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CHEYENNE REGIONAL MEDICAL CENTER 214 EAST 23RD STREET CHEYENNE, WY 82001 Jan. 10, 2013
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation, staff interview, and review of nationally recognized standards for infection prevention, the facility failed to maintain a sanitary environment for patient care. The failure was evident in the accumulation of dust and debris observed in 1 of 10 surgery suites, 1 of 3 clean storage rooms, and 2 of 4 patient rooms; and was further evident in the surgical staff's failure to clean injection ports and maintain sanitary conditions during 2 of 2 surgical procedures observed. The facility also failed to ensure staff properly disinfected point-of-care diagnostic devices during 1 of 2 random observations of blood glucose screening. The findings were:

1. Observation of selected areas on the 5th floor (obstetrics, pediatrics, labor & delivery, and neonatal nursery units) on 1/8/13 from 8:35 AM through 9:50 AM revealed the following concerns:
a. The ventilation grills and horizontal surfaces (carts, shelving, anesthesia machine) in the emergency Caesarian-section (C-section) surgical suite (room 5045) showed significant accumulation of dust and debris. The environmental services manager stated, in subsequent interviews on 1/9/13 at 1:10 PM and again on 1/10/13 at 9:40 AM, his expectation was all surgical suites, including room 5045, should be terminally cleaned after each case, daily if not used, and "deep cleaned" (cleaned and disinfect on all surfaces, floors, walls, and ceilings) each week. He acknowledged in the 1/10/13 interview the dust and debris found in the initial observation was more than would be reasonably expected to accumulate if the quality and frequency of cleaning was performed as scheduled.
b. Room 3041 was observed to contain storeage of clean linens, medical supplies, baby clothing, and infant formula. Further observation revealed the ceiling-mounted air vents and an overhead sprinkler head were coated with dust and debris. In particular, the air return duct was about 20% occluded from a build-up of debris on the louvers. Immediately beneath the dirty vents and sprinkler head were open packages of baby clothing, linens, and infant formula removed from its outer-wrapping. The hospital infection preventionist acknowledged in an interview on 1/9/13 at 9:45 AM that the accumulation of dust and debris in room 5031 was not appropriate for an area used to store clean medical supplies, opened linens, and infant formula.
c. Of 4 patient rooms observed, 2 (rooms 5048 and 5058) were observed with significant accumulations of dust and debris on air vents and horizontal surfaces. Interview with hospital employee #5 on 1/8/13 at 9:10 AM revealed these rooms had been cleaned and were considered ready for patient occupancy.

2. Observation of perioperative care on 1/8/13 showed anesthesiologist #1 failed to cleanse the tops of medication vials prior to inserting needles through the rubber septum and withdrawing medication into syringes. Further observation showed the anesthesiologist also failed to cleanse the intravenous injection ports prior to injecting medications during the procedure. This practice was observed from 12:23 PM to 1:11 PM during the care of patient #22 and at 2:49 PM during the care of patient #27. In an interview on 1/8/13 at 2:56 PM, the director of perioperative services who was present during these observations verified that the failure to cleanse vials and intravenous ports was not an acceptable standard of practice.

According to Elkin, Perry and Potter, "Nursing Interventions and Clinical Skills," "Administration of Parenteral Medications " , chapter 23, Fifth Edition, Mosby, Inc., 2012: Intravenous ports and vial tops should be cleansed with an antiseptic swab. Ports and tops should be firmly swabbed and allowed to dry before accessing. This prevents the transfer of microorganisms during needle or blunt cannula insertion.

3. On 1/8/13 from 3 PM to 3:20 PM, the director of perioperative services and anesthesia technician #1 showed the surveyor the anesthesia carts in the storage room. Observation of the anesthesia carts revealed 3 of 4 anesthesia carts ready for use had drawers that contained multiple opened sterile packaged oral tracheal tubes (OT) tubes. Stylets had been placed in the OT. The insertion end of the OT was in the lower half of the package with the upper half extending above the opened edges of the package. Once packages were opened and the contents exposed to a non-sterile area, such as a drawer on the anesthesia cart, the contents were no longer sterile. The anesthesia technician stated the carts were placed in the storage room at end of the day and she was responsible for preparing the carts for the next time they were to be used by the anesthesiologists. She further stated her preparatory tasks did not include removing the opened sterile packaged OT with stylets that were routinely left in the carts. She and the director of perioperative services verified 5 of the 17 anesthesiologists themselves routinely opened the sterile packages in preparation for future use. The anesthesia technician stated one of the carts had been prepared in this manner four days ago. She further acknowledged the drawers inside the anesthesia carts were not routinely cleaned.

4. On 1/8/13 at 5:30 PM, CNA #1 was observed performing blood glucose screening with a point-of-care glucose meter (glucometer) for patient #40. After the test was completed, the CNA used an alcohol preparation pad to clean and disinfect the device. At that time the CNA stated using the alcohol preparation pad was her usual practice for cleaning the device between patient use. The infection preventionist stated in an interview on 1/9/13 at 9:45 AM that staff were instructed to use a disinfecting wipe on point-of-care devices after each use.

The CDC publication "Guideline for Disinfection and Sterilization in Healthcare Facilities", 2008, does not recommend the use of alcohol to disinfect equipment when bloodborne pathogens, such as hepatitis viruses, are a concern. The Association for Professionals in Infection Control & Epidemiologist (APIC) recommendations for disinfecting point-of-care devices are published in the American Journal of Infection Control, April 2010. The APIC guideline recommends glucometers be disinfected with a dilute bleach solution or an Environmental Protection Agency (EPA)-registered disinfectant effective against hepatitis and human immunodeficiency viruses. Alcohol is not an EPA-registered disinfectant for bloodborne viral pathogens.