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 observation, staff interview, and policy and procedure review, it was determined the facility staff failed to ensure practices related to the cleaning of brushes used in reprocessing and the storage of nebulizer equipment were done in a manner to decrease the risk of infection.

The findings include:

1. A surveyor observed the central sterile reprocessing area on 8/1/12 at approximately 9:20 a.m. The assistant manager for the reprocessing accompanied the surveyor. In the decontamination room, the surveyor asked about the process for cleaning instruments/equipment. The manager explained some of the brushes used for cleaning were not disposable. These brushes were cleaned at the end of the shift.

The survey team met with the chief nursing officer (CNO) on 8/1/12 at approximately 3:20 p.m. The discussion included the re-usable brushes used in decontamination. The CNO stated the current practice was to clean the brushes daily and discard them weekly. She acknowledged the brushes were not being cleaned after each use. She stated there was no policy and procedure related to the cleaning of the brushes.

2. During observations in the intensive care unit (ICU) on 8/1/12, one surveyor interviewed the respiratory therapist (RT) assigned to that unit at 10:25 a.m. When asked how the nebulizer equipment such as masks/mouthpieces and cups were handled following treatments on the same patient, the RT stated the equipment was put in a patient specific bag with a label. The RT said the equipment is used for a period of time on the same patient before it would be replaced and that usually the patient was not in the hospital long enough for the equipment to be replaced.

The survey team met with the Director of Respiratory Therapy on 8/1/12 at approximately 3:00 p.m. The Director stated their practice for handling equipment between treatments on the same patient was to "shake out the medication and hang it upside down." When asked about rinsing the mask/mouthpiece or cup out and drying it thoroughly between uses on the same patient, the director acknowledged that was not their practice.

The survey team reviewed the facility's policy and procedure titled, "Medication Nebulizer Treatment Policy and Procedure." The policy did not include how to maintain the equipment between treatments on the same patient.