HospitalInspections.org

Based on document review and staff interview it was determined the hospital failed to ensure the surgical staff was competent to clean the Phillips Transesophegeal Echocardiography Transducer (TEE) properly. This failure led to a chemical fire that had the potential to lead to serious harm or possible death of any patient or staff receiving the services of the hospital.

Findings include:

1. A review of the hospital's root cause analysis findings states, "The fire started in the scope decontamination room at approximately 3:15 a.m. on 1/19/21. The sprinkler doused the fire and it was contained in that room. It appeared to have been a chemical fire that started in the container containing a high-level disinfectant and a TEE scope. The TEE scope was to be placed in the container with high level disinfectant and left to soak for 8 minutes and then removed."

2. An interview was conducted with the Director of Surgical Services on 2/2/21 at approximately 9:40 a.m. While discussing the above allegations he stated, "From what I have been able to find out, an Ultrasound (US) Tech went to a patient's bedside to do the TEE ultrasound at around 9:00 a.m. on 1/13/21. He came back to the scope room and put the scope in the cleaning solution. Usually one of the surgical techs will get the scope out of the solution, however that day both of my surgical techs were off with COVID. So instead of the TEE scope being taken out of the solution like it should have been, it was left in the solution." He stated the normal time frame for the scope to be placed in the solution was for eight (8) minutes but the scope was left in the cleaning solution for five (5) days (1/19/21).

3. A review of the hospital document entitled, 'Important Information for TEE Transducer Care' states, "Limit the time that the transducers are soaked in the solution to the minimum recommended by the manufacturer." The document goes on to further read, "Do not soak the transducer for extended periods of time." Manufacturer instructions for use or normal sterilization / high level disinfection practices were not followed resulting in the flash fire.

4. A review of the hospital document entitled, 'Revital-Ox Resert High-Level Disinfectant' states, "Once the instrument has been immersed and all surfaces in contact with the disinfectant solution, soak the instrument for eight (8) minutes at 20 degrees Celsius."

5. A review of the hospital document entitled 'Resert HLD Solutions Processing Form' revealed on 1/13/21 the TEE scope was placed in the cleaning solution and the time frame for exposure time in the cleaning solution was eight (8) minutes. The document was signed by the US Tech.

6. An interview was conducted with the US Tech and Director of Radiology on 2/2/21 at 9:50 p.m. They concurred that the US Tech did not have a competency in the proper use of high level disinfectant solution.

7. A interview was conducted with Surgical Technician #1 on 2/2/21 at 11:05 a.m. During the interview she stated that she was off with COVID on 1/3/21. She stated she normally would have taken the scope out of the solution if she had been there but she was not working at that time. She stated that you normally leave the TEE scope in the solution for eight (8) minutes and then hang it to dry.

8. A interview was conducted with the Coordinator of Surgical Services on 2/2/21 at approximately 11:10 a.m. She stated she normally provides the education for employees in the surgical department. When questioned if she had been trained for high-level disinfectant cleaning she stated she had been trained in the past.

9. A review of the competency for the Coordinator of Surgical Services revealed that she was only trained for cleaning and disinfecting of surgical equipment. The competency does not show she has been trained in high level disinfectant cleaning. The competency also revealed that Surgical Tech #1 signed off on her training.

10. An interview was conducted with the Chief Nursing Officer (CNO) on 2/2/21 at approximately 1:20 p.m. When questioned about Surgical Tech #1 signing off on the competency for the Coordinator of Surgical Services, she stated that she did not realize that the Surgical Tech was signing the competency of the Coordinator. When questioned why no one had noticed in five (5) days that the scope was in the solution she stated, "Normally the Coordinator would be making the rounds in the department but most of the department was off with COVID. The responsibility should have fallen to the Director of the unit." When asked what her expectation was when doing rounding in the department she stated to check the equipment and supplies.

11. A re-interview was conducted with the Director of Surgical Services on 2/2/21 at approximately 3:45 p.m. He stated that he could not find the competency for the Coordinator of Surgical Services for high level disinfectant cleaning. He concurred that she was the educator for the surgical department. He concurred that she had educated all staff and was checked off on her competency by a surgical technician. He concurred that he now understands that the surgical technician was not validated to competency someone in a higher position. He further concurred that the US Tech did not follow procedure and remove the TEE scope from the solution at the completion of the eight (8) minute time frame.

12. A re-interview was conducted with the CNO on 2/2/21 at approximately 4:55 p.m. She concurred they were unable to prove the Coordinator of Surgical Services was competent in cleaning with high level disinfectant. She concurred that this made all surgical staff that had had competencies for high level disinfectant cleaning by the coordinator non-valid.