HospitalInspections.org

Based on record review and interview, the hospital failed to implement a system for controlling infections and maintaining a sanitary hospital environment by failing to ensure hospital staff followed the hospital policy for disposal of infectious waste as evidenced by patient care staff discarding blood and body fluids from wound drains into the patient's bathroom sink.

Findings:

Review of the hospital's policy titled: Infection Control - Management of Infectious Waste, updated September 2011, reviewed October 2017, and presented as the current policy by S1DON revealed the following, in part:
Infectious Waste Plan for Specialists Hospital Shreveport is followed as required by the State Department of Health.
A. Infectious waste is defined as: ...
B. D. Blood and blood products.
To prevent exposure and transmission of infectious disease, to meet regulatory requirements - C. Bulk blood, regulated body fluids, suctioned fluids, excretions and secretions may be carefully poured down a drain connected to a sanitary sewer (hopper).

On 02/20/19 at 10:10 a.m., an interview with patient #3 revealed the staff emptied her Jackson Pratt drain every 4 hours, measured it in a cup, and discarded the contents into her bathroom sink.

On 02/20/19 at 10:20 a.m., an interview with patient #4 revealed the staff emptied her Davol drain every 4 hours, measured it in a cup, and discarded the contents into her bathroom sink.

On 02/20/19 at 10:30 a.m., an interview with patient #5 revealed the staff emptied her Davol drain every 4 hours, measured it in a cup, and discarded the contents into her bathroom sink.

On 02/20/19 at 12:20 p.m., an interview with S2RN, staff nurse on the nursing unit confirmed that the procedure for discarding the wound drainage from the above drains was to pour it into the patient's bathroom sink or toilet.

On 2/20/19 at 3:00 p.m., an interview with S1DON confirmed the procedure the staff was using to dispose of the drainage was not consistent with hospital policy.

Based on observation, interview and record review, the hospital failed to ensure that staff in the perioperative surgical suite's restricted and semi-restricted areas followed acceptable professional standards of practice, acceptable infection control practices and/or hospital policy as evidenced by staff in the OR suites observed wearing sport jackets over their scrubs.

Findings:

Review of the hospital policy titled "Infection Control" last updated June 2016, and confirmed by S2DON as the current policy, revealed in part that all individuals who enter the semi-restricted and restricted areas of the surgical suite should wear freshly laundered surgical attire intended for use only within the surgical suite. The policy outlined some suggestions for home laundering. Resource: AORN, "Standards and Recommended Practices," 2015. 2015 AORN stance: 'Surgical attire should be laundered in a healthcare accredited laundry facility.' Specialists Hospital Shreveport stands with the above policy and allows home laundered scrubs present in the OR suite."

Review of "AORN 2018 Edition Guidelines for Perioperative Practice" revealed in part: Surgical Attire, Recommendation I- Clean surgical attire should be worn in the semi-restricted and restricted areas of the perioperative setting. The collective body of evidence supports wearing clean surgical attire in the perioperative setting to reduce the number of microorganisms in the environment and the patient's risk for developing an SSI. Clean scrub attire has been laundered in a health care-accredited laundry facility and has not been previously worn. Recommendation II: All individuals who enter the semi-restricted and restricted areas should wear scrub attire that has been laundered at a health care-accredited laundry facility or disposable scrub attire provided by the facility and intended for use within the perioperative setting.

On 02/20/19 at 9:20 a.m., observation of the surgical suites with S6SurgMgr revealed the following:
-in OR "a" S4CRNA was wearing a sports jacket over her scrubs while setting up for a surgical procedure. A patient was transported into the OR during the observation.
-In OR "b" S5CRNA was wearing a sports jacket over her scrubs while setting up for a surgical procedure. A patient was being prepped in the OR during the observation.
S6SurgMgr confirmed the jackets were not appropriate attire for the surgical suites.

In an interview on 02/20/19 at S1DON verified that the jackets worn by S4CRNA and S5CRNA were not of lint-free material, were not professional attire, and were not appropriate for use in the surgical suites.