The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

Based on observations of 10 patient tracers, interview and document review it was determined the hospital failed to ensure the development and implementation of infection control policies that include following manufacturers' guidelines for disinfectants, hospital isolation related cleaning policies, manufacturer's guidelines for equipment cleaning, aseptic technique for intravenous (IV) access, sharps disposal and use of personal protective equipment (PPE) by staff and visitors. This practice does not ensure the prevention of cross contamination.

Findings include:

1. On 7/23/12 a sign posted on a wall in the surgical holding area read "Sani wipes: clean, leave five minutes!!! That's the rule".

On 7/23/12 at 1:55 p.m., after a surgical procedure, surgical technician #17 was observed to wipe down the surgical table in Operating Room (OR) #3 with Sani-Cloth disinfectant. The surgery table began to dry in 2-3 minutes.

Review of manufacturer's guidelines for Sani-Cloth Plus revealed the recommended contact time (wet time) was 5 minutes. The container instructed "treated surface must remain visibly wet for a full 3 minutes. Use additional wipes if needed to assure continuous 3 minute wet contact time..." for TB "a 5 minute contact time."

On 7/23/12 at 4:35 p.m., after a tuberculosis (TB) isolation patient was discharged , housekeeper #9 was observed to spray Dispatch disinfectant on the bed and allowed to dry. Approximately 10-15 minutes later she wiped the bed with Virex solution and allowed it to dry.

An interview was conducted on 7/23/12 at 4:43 p.m. with housekeeper #9. The housekeeper explained for isolation rooms she was given the Dispatch and followed it with the Virex. She said she must wait 8-10 minutes for dry time. She does not make the bed while it was still wet. She said the disinfectants stayed wet for about 5 minutes. She was unaware of the isolation patient's diagnosis.

Review of manufacturer's guidelines for Dispatch revealed disinfection procedure: "Spray 6"-8" from surface until surface is completely wet. Let stand for 5 minutes."

On 7/24/12 at 9:20 a.m. housekeeper #10 was observed to wipe surface areas in room 202 with a cloth dampened with Virex solution. The surfaces were dry in a few minutes.

An interview was conducted on 7/24/12 at 9:22 a.m. with housekeeper #10. She stated she waited 15 minutes for the Virex solution to dry but indicated that it "dries in a couple seconds."

On 7/24/12 at 11:55 a.m. OR aide #13 was observed to wipe down a gurney in the surgical holding room #8 with Quat disinfectant. The gurney was mostly dry after 5 minutes.

An interview was conducted on 7/24/12 at 11:55 a.m. with surgical technician (ST) #17. The ST was unaware of the "wet time" for the Quat disinfectant he was using.

Review of manufacturer's guidelines for Quat revealed "contact time for the viruses, fungi, and bacteria listed on this label is 10 minutes except for Polio virus which is 30 minutes.

The wet contact times observed, were less than the manufacturers' guidelines and the hospital staff was unaware of these guidelines.

2. On 7/23/12 at 4:43 p.m. housekeeper, #9 was observed terminally cleaning isolation room 301. She sprayed Dispatch disinfectant on the bed. She wiped the pillow 3 times on each side with a cloth wet with Virex disinfectant and set aside to dry. About 2/3 of the pillow surface was wet.

An interview was conducted on 7/23/12 at 4:43 p.m. with housekeeper #9. The housekeeper stated she was leaving the pillow in the room after the cleaning.

Review of policy "Isolation Terminal Cleaning" #14 revealed cleaning and/or disposition of the pillow was not addressed. Supplemental procedures for Clostridium difficil (C-diff) instructed to use disinfecting product such as Dispatch in a pail and use cleaning rags.

The interview on 7/23/12 at 4:43 p.m. with housekeeper #9 revealed that for isolation rooms she was given the Dispatch by her supervisor. She said she was not aware of patient's diagnoses (the patient from room 301 had TB, not C-diff).

An interview was conducted on 7/24/12 at 9:06 a.m. with the Environmental Services Director. The Director indicated they "use Dispatch for terminal cleaning on isolation rooms. Some (housekeepers) have preferences, some use the spray and some use liquid, I don't think we have a policy".

The isolation terminal cleaning policy was inadequate and not followed.

3. On 7/23/12 at 11:45 a.m. Respiratory Therapist #7 was observed to clean the pulse oximeter with Sani-Cloth after using it for patient #9.

Review of hospital policy for "Measurement of SaO2 (oxygen saturation)" #CP-58 revealed "Before and after each use wipe probe and surfaces with mild detergent or 10% bleach solution, may use alcohol or Sani-Wipe."

Review of the oximeter manufacturer's cautions revealed "Do not use caustic or abrasive cleaning agents or any cleaning agent containing ammonium Chloride or isopropyl alcohol.

Sani-Cloth Plus active ingredients include ammonium chloride. The hospital policy and practice failed to follow the equipment instructions.

4. On 7/23/12 at 1:12 p.m. during a surgical procedure on patient #1 the Certified Registered Nurse Anesthetist (CRNA) was observed to administer several injections into the patient's intravenous (IV) line without swabbing the access port. At 1:40 p.m. the CRNA injected Toradol into the IV line, again without swabbing port.

In an interview on 7/23/12 at 2:08 p.m. the CRNA confirmed he did not swab ports on the IV line before administering the medications. He explained he did not swab ports if the IV tubing was placed new in the OR. The Director of Surgical Services interjected there had been a recent emphasis on always swabbing the hubs.

The hospital was aware of best practice for aseptic IV access but may not be utilizing it.

5. On 7/24/12 at 11:18 a.m. sharps container in the decontamination room was observed to be over-filled. The lid would not close because material exceeded the fill line as well as the opening on the top of the container.
Shortly before the observation the Director of Surgical Services (DSS) said the sharps containers are emptied by a contract service. When the over-filled sharps container was pointed out, the DSS attempted to close the container. She admitted "I guess it's full." The service was due to come in 2 days.
The facility failed to dispose of sharps container in a safe manner.

6. On 7/23/12 at 2:10 p.m. a patient tracer observation was conducted in the Intensive Care Unit (ICU) for patient #4. Registered Nurse (RN) #1 obtained a pre-filled 10 milliliter (ml) syringe of sterile normal saline to conduct an IV flush. The RN swabbed the connector, opened the hub and performed the flush without wearing gloves. The surveyor asked the RN when she would utilize gloves while working with open IV lines. She responded "only if I see visible blood".

The Infection Control/Nursing Policy was reviewed with the Infection Control Officer. It stated that gloves are to be worn during injections and IV line insertions.

7. On 7/23/12 at 12:55 p.m. tracer observations were conducted for infection control precautions and PPE(Personal Protective Equipment) usage. A sign was posted on the door for patient #10 for contact precautions. The precaution sign instructed to see the nurse and to wear gloves, gown and mask for direct contact with the patient, linen or equipment.

Observation noted 4 visitors were in the room with the patient. One visitor was sitting on a chair wearing only gloves. One visitor was sitting on the patient's bed without any PPE. One visitor was sitting in a chair without any PPE. The other visitor was standing close to the patient and touching him without wearing any PPE.

Review of patient #10's medical record revealed a positive culture on 7/21/12 for Staphylococcus Aureus, MRSA, of the nasal nares.