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WEST OAKS HOSPITAL 6500 HORNWOOD HOUSTON, TX 77074 Sept. 12, 2014
VIOLATION: INFECTION CONTROL OFFICER(S) Tag No: A0748
Based on observation, interview, and record review, the facility failed to implement infection control measures to ensure staff wash their hands after removing gloves;

Failed to ensure staff do not use single dose vials of medication for multiple patients use; and

Fail to ensure staff keep clean and dirty equipment and supplies separate to prevent cross contamination. This failed practice has the potential for the spread of infections to patients and staff. Citing random observation made in the Electroconvulsive Therapy (ECT) suite.

Findings:

During observation on 9/12/2014 at 9:15 am in the ECT Suite with the Chief Nursing Officer and the Director of Quality the following observations were made:

Five patients care staff were observed in the suite caring out multiple tasks including cleaning used patient bed, monitoring patients vital sign ,intra venous fluids and preparing medication for intra venous use. The staff wore gloves to carry out their task.

All observed staff removed their gloves after completing their tasks and did not wash/sanitize their hands.

Physician (D) Anestheologist was observed in the patient preparation area giving intravenous propofol medication to patients. The Physician was administering propofol to multiple patients from a single patient dose vial containing 200 mg/per 20 ml, five (5) patients (#s 10-14) were each given 100 mg of propofol in 10 milliliter from single dose vial containing 200 mg/20 ml.

There was an opened vial of propofol on the medication counter, the Surveyor asked Physician (D) what he did with the remaining medication he said 20 milliliter vials were the smallest amount of propofol in the facility do you expect me to throw the balance away?

The Physician was observed placing used oxygen mask and used syringe with needle on the table with clean supplies.
The physician attended two patients, putting mask on the and administering medication in their IV and never wash his hands between patients.

There was only one available sink in the suite and it was located in an ante room with housekeeping supplies.

During an interview on 9/12/2014 at 11:25 am with the Infection Control Officer she stated the staff would be in-serviced in good infection control practices and a hand washing sink would be provided.