HospitalInspections.org

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ITEM #1 - Transesophageal Echocardiography Reprocessing

Based on observation, interview, and record review, the hospital central processing staff failed to use high-level disinfectants according to manufacturer's instructions for use when cleaning transesophageal echocardiography (TEE) probes.

Failure to use high-level disinfectants according to manufacturer's specifications risks inadequate disinfection of patient care equipment that could risk patient infection.

Findings included:

1. Record review of the manufacturer's instructions for use for Cidex OPA (ortho-phthalaldehyde), a high-level disinfectant, showed that manually reprocessed equipment must be soaked in disinfectant solution for a minimum of 12 minutes at 20 degrees Celsius.

2. Record review of the hospital policy titled, "Echocardiography Department TEE Transducer Cleaning," no policy number, revised 05/17, showed that the policy did not reflect the current cleaning protocol for TEE probes.

3. On 01/30/19, Surveyor #2 observed the reprocessing procedure for TEE probes in the central processing department. The surveyor did not observe a thermometer for measuring the temperature of Cidex OPA during reprocessing. The log sheet for documenting reprocessing steps did not have a section to record the temperature.

4. At the time of the observation, Surveyor #2 reviewed the manufacturer's instructions for use with the Chief Medical Officer (Staff #201) and the Central Processing Department manager (Staff #202). The staff members acknowledged that the instructions for use indicated that the disinfection temperature must be measured at 20 degrees Celsius or higher.

ITEM #2 - Hand Hygiene

Based on observation, interview, and document review, the hospital failed to ensure that hospital staff performed hand hygiene (HH) according to hospital policy and accepted standards of practice in 3 of 3 observations of patient care (Patient #901, #902, #903).

Failure to perform hand hygiene places patients and staff at risk of infection.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Infection Control and Prevention, Hand Hygiene," no policy number, revised 08/17, showed that hand hygiene is required before and after entering a patient's room or bedside, after patient contact, before and after putting on gloves.

2. On 01/30/19 at 12:45 PM, Surveyor #9 observed ophthalmic surgery on Patient #901. During preparation for the surgery, Surveyor #9 observed the following:

a. Staff #901, the clinical coordinator entered the operating room (OR) suite at 12:55 PM and 1:05 PM. He did not perform HH upon entering the room or leaving the room.

b. Staff #902, the surgeon, entered and exited the OR suite prior to starting surgery at 1:10 PM without performing HH.

c. At the time of the observation, the CNO (Staff #903), confirmed that hospital policy regarding HH had not been followed.

3. On 01/30/19 at 1:45 PM, Surveyor #9 observed care given to Patient #902 who was in Contact Isolation on the 4th floor. Surveyor #9 observed the following:

a. Staff #904, the registered nurse changed gloves twice without performing HH when donning and doffing gloves.

b. Staff #905, the certified nurse's aide (CNA) changed gloves twice without performing HH when donning and doffing gloves.

c. At the time of the observation, the CNO (Staff #903), confirmed that hospital policy regarding HH had not been followed.

4. On 01/31/19 at 8:30 AM, Staff #9 observed podiatric surgery on Patient #903. During the preparation for surgery, Surveyor #9 observed the following:

a. Staff #906, the anesthesiologist, put on gloves twice without performing HH when donning and doffing gloves.

b. Staff #907, the physician's assistant (PA), entered and left the OR suite without performing HH at 8:39 AM, 8:40 AM, 8:44 AM and 8:46 AM. Additionally the PA touched the patient's foot, leg, and arm and did not perform HH after these contacts.

c. At 8:45 AM, the surgeon (Staff #908) exited the OR suite after touching the patient's foot and did not perform HH.

d. At the time of the observation, the Chief Medical Officer for Patient Safety and Quality (Staff #909) confirmed that the hospital policy regarding HH was not followed.

ITEM #3 - Radiology Apron Cleaning
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Based on observation, interview, and document review, the hospital failed to ensure that radiology leaded aprons were cleaned once a month and logged onto a "cleaning log" of recorded data in 2 of 2 areas surveyed.

Failure to ensure cleaning of radiology leaded aprons could lead to risk of infections for patients and staff during procedures.

Findings included:

1. Document review of the hospital's policy titled, "Apron Care and Treatment," no policy number, reviewed 09/18, showed that lead aprons are to be cleaned once a month and that the data was to be recorded on a monthly basis. Additionally, document review showed that each department is responsible for the cleaning of the lead aprons.

2. On 01/30/19 at 1:30 PM during a tour of the Operating Room (OR) suites, Surveyor #9 noted an area where a number of lead aprons were hanging on a wall. Above the lead aprons, there was a paper labeled, "Cleaning Check Off Monthly" Surveyor #9 noted that there were no cleanings documented after November 2017 and prior to that both September 2017 and October 2017 the documentation did not show that the lead aprons were cleaned.

3. At the time of the observation, Surveyor #9 asked the Surgery Manager (Staff #910) if cleaning information for the lead aprons was stored elsewhere. She stated she thought it was stored electronically.

4. At 3:30 PM, Surveyor #9 asked the Quality Director (Staff #911) if there was an electronic record of the lead apron cleaning. She stated that she thought it was electronic; however, upon her further review, she found that there were no cleaning records after 2017.

5. On 01/31/19 at 10:00 AM, during a tour of the Endoscopy Unit, Surveyor #9 noted several lead aprons hanging on the wall and asked the Quality Director (Staff #911) if she would locate the records that showed monthly cleaning. At 11:00 AM, Staff #911 stated that she was unable to locate cleaning records for the lead aprons in Endoscopy.