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Based on observation, interview, and document review, the facility failed to ensure expired disinfectants were disposed of or removed from use.

The failure created the potential for patient harm and increased risk of infection to patients by employees using disinfectant solutions past the manufacturer's efficacy date. The disinfectants were used during high level disinfection of equipment between patients.

FINDINGS:

POLICY

The policy, Cleaning and Disinfecting Bronchoscopes, instructs that manual reprocessing using high level disinfection (HLD) requires the disinfecting solution be tested prior to each use.

The policy, Infection Control: High Level Disinfection, stated that all high level disinfection solutions must be tested for efficacy before use and/or daily and the results of the tests should be maintained in a log in the department.

REFERENCE

According to Cidex OPA manufacturer directions for use (DFU), the high level disinfectant may be reused for up to a maximum of 14 days regardless of efficacy testing of the solution prior to use.

1. The facility failed to ensure the HLD used for the disinfection of bronchoscopes was within its efficacy for use.

a) During a facility tour in the reprocessing room on 6/16/15 at approximately 10:35 a.m., a blue, rubber type container with a top was observed on a counter. The Respiratory Therapy Supervisor (RTS) #6 identified the container as the soak tub used to hold the HLD solution during manual reprocessing of bronchoscopes. S/he stated the solution in the container was Cidex OPA.

b) In an interview with RTS #6 on 6/16/15 at approximately 10:35 a.m., s/he explained the process for manual HLD and stated the Cidex OPA solution should be changed every 14 days. RTS #6 stated the date the solution was initially placed in the disinfecting soak tub should be recorded on a tracking log.

c) On 6/16/15 at 1:00 p.m., a review of the sterile processing log book was performed. The log book contained the document, Cidex Log, which included the statement Cidex must be changed every 14 days. Focused review of the document revealed the last documented date of replacement of the Cidex OPA disinfectant was on 5/17/15. The current solution in the disinfecting soak tub was 16 days past the manufacturer's stated effective date.

Based on observations, interviews, and document review, the facility failed to ensure a clean and sanitary environment.

This failure created the potential for transmission of infection, cross contamination, insect infestation, and negative patient outcomes.

FINDINGS:

POLICY

According to policy, General-Specimen Collection, all biological specimens should be treated as potentially infectious.

According to policy, Environmental Services Role in Infection Control, the hospital must maintain a clean and sanitary environment.

According to policy, Material Management Role in Infection Control, all supplies will be transported in an uncontaminated condition and stored at least four inches above the floor.

The policy, Safety-Environmental Rounds, defines a procedure for scheduling and conducting environmental rounds to identify environmental hazards and unsafe practices in all areas of the hospital, to include formal inspections conducted by the Safety Officer and designated safety committee members and informal inspections consisting of "Facility Walk Through" conducted on a regular basis by department managers.

1. The facility did not separate biological specimens and biohazard waste from the same area that clean supplies were stored.

a) A tour of the 2nd floor Intensive Care Unit (ICU) on 06/16/15 at 9:50 a.m., revealed a room located across from ICU Room 2. The door to the room was labeled "Clean Utility." A second door in a parallel hallway of the ICU was labeled "Dirty Utility." Both doors led to the same room.

A centrifuge and refrigerator were located on a counter inside the room. A sign on the counter listed "Routine Lab Pickup Times." Clean lab supplies, including specimen cups and supplies for collecting blood, were stored in close proximity to potentially infectious biological specimens located within the same room.

An interview at the same time with the Chief Nursing Officer (CNO) in the ICU revealed the counter in the clean utility room where the centrifuge and refrigerator were located was used to prepare specimens for a courier to collect and take to a contracted laboratory for processing.

b) An interview with Registered Nurse (RN) #5, on 6/16/15 at 10:17 a.m. in the ICU, revealed both doors were used to access the clean/dirty utility room. S/he stated staff used the closest door of the utility room, depending on which hall staff was in when they needed to access the room. This could mean that staff would use the clean utility door when processing biological specimens for courier pickup, or staff could use the dirty utility door to gain access to clean supplies for specimen collection.

c) A tour of the 2nd floor "pre-op" area on 06/16/15 at 10:52 a.m., revealed a red biohazard container located on the floor of a room labeled "Clean Storage/Clean Utility." Further, soiled shoe covers, a face shield, and multiple face masks were located inside the biohazard container.

An interview with the Chief Nursing Officer (CNO) at the same time revealed the room was used only to store clean supplies and the biohazard container should not have been located within the clean storage room.

2. The facility allowed patient belongings, and supplies to be stored directly on floor, increasing the risk of contamination to these items.

a) On 06/16/15, at 9:50 a.m., during a facility tour, the dirty/clean utility room, located on the 2nd floor across from ICU room #2 was observed. Six insulated blood transport boxes were observed stored directly on the floor.

b) On 06/16/15, at 10:05 a.m., during a facility tour, the "Dirty Utility" room on the 2nd floor was observed. One insulated blood transport box was observed stored directly on floor.

c) On 06/16/15, at 11:00 a.m., during a facility tour, the "Clean Utility" room located on the 2nd floor outside the ICU was observed. Several bags labeled "Patient Belongings," multiple various bags containing clothing, a gym-type bag, and two cardboard boxes were observed stored directly on the floor. One small bag of biohazard was observed on top of a patient belonging bag, which contained a cell phone, phone cord, phone charger, and pair of socks. The biohazard bag had an affixed patient label which was soiled with a dried, rust-colored substance, and the inside of the biohazard bag contained a small amount of light red liquid.

d) On 06/16/15, at 11:05 a.m., an interview was conducted with the Director of Quality Management who stated per policy and expectations, all items including boxes, bags, and patient belongings were to be "stored at least six inches" above the surface of the floor. When asked what substance was located on the label and inside the biohazard bag containing the cell phone and accessories, the Director of Quality Management stated, "I don't know."

3. The facility allowed visible dust to accumulate on horizontal surfaces, specifically the tops of doorframes, in 2 of 3 doorframes observed.

a) On 06/16/15, at 10:20 a.m., thick dust was observed by 2 surveyors, on 2 of 3 horizontal doorframe surfaces in the Intensive Care Unit (ICU).

b) On 06/16/15, at 10:21 a.m., an interview was conducted in the ICU with the Director of Quality Management who stated routine environmental services (EVS) cleaning included dusting of environmental surfaces in all patient care areas. The Director stated surface cleaning was the responsibility of EVS personnel and noted the presence of visible dust on the doorframes as unacceptable.

c) On 06/17/15, at 2:10 p.m., an interview was conducted with Environmental Services employee #7 (EVS #7) who stated cleaning of all horizontal surfaces in patient care areas was the responsibility of housekeeping and EVS staff had procedures on how to clean different areas. S/he stated, "There is an extra person who cleans above the doors and the hallways. My job is to clean inside the room and the extra person will clean outside the rooms."