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Based on observation during a tour of the 3rd floor in-patient floor the facility did not ensure that proper ventilation is provided as required.

Findings:

1. The materials management room, where clean and sterile supplies are stored, lacked ventilation of any kind.

2. The IV room, used as a clean work room, was provided with an air conditioner but did not take in outside air. This finding was confirmed in interview with Staff # 2.

3. Based on interview with Staff #s 1 and 2 the endoscope processing room, where Peracetic Acid is used as the disinfectant, is not provided with 10 exhaust air changes per hour. According to the the manufacturer's Product Safety Data Sheet peracetic acid is a toxic chemical.

4. The janitor closet on the 3rd floor in-patient floor was not provided with exhaust ventilation.
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Based on observation and interview the facility did not ensure a safe environment consistent with infection control practices and prevention of cross contamination or providing adequate ventilation to prevent the spread of infection.

1. On the morning of 4/18/11 during a tour of the in-patient unit on the third floor the following infection control issues were identified:

a. Based on observation and interview the flow of surgical instruments from dirty to sterile presents the opportunity for cross contamination because the flow is not in one direction. In interview with the sterilization technician (tech) it was revealed that surgical instruments are washed on the 2nd floor then brought to the IV room, a clean work room, on the 3rd floor in-patient suite. The tech then proceeds to the sterilization equipment room (a room with negative air flow) approximately 20 feet away to collect the wraps used for the sterilization process. The tech then returns to the IV room to wrap the surgical instruments. The tech then returns to the sterilization equipment room to place the instruments in the autoclave. When the sterilization process is completed the sterilized instruments are brought across the corridor to the materials management room. No ventilation was available in this room. The IV room is provided with an air conditioner (AC) but this unit does not provide outside air. Therefore no air changes are provided in this room. Interview with Staff # 2 confirmed that the AC unit does not provide air changes.

b. The hospital policy and procedure for the sterilization of surgical instrument does not provide a comprehensive description of the sterilization process. The policy includes only the inspection and use of the autoclave itself and not a description of the flow of instruments after use of the surgical instrument to decontamination, disinfection, sterilization and storage.

c. Cardboard shipping boxes were noted stored on shelving in the clean supply room adjacent to open boxes of sterile and clean supplies for patient use. No ventilation whatsoever was available in this room

d. During observation of the tech who processes endoscopes two stainless steel containers used for transporting scopes were noted stored one on top of the other on the counter in the decontamination room located off the procedure room. On interview the tech indicated that one container is used to transport the washed scope from the decontamination room to the scope processing room and the the second container is used to transport the scope that has undergone high level disinfection from the scope processing room to the storage cabinet. The storage of this container in the decontamination room could contaminate the transport container and thus contaminate the endoscope when placed in this container for transport to the storage cabinet.

e. Although the endoscopy tech stated that it is the policy to use a cart to transport the washed scope from the decontamination room to the scope processing room the tech did not demonstrate that policy. The tech carried the container by hand to the processing room. The container has a perforated bottom which could drip liquid along the way.

f. Based on interview with Staff #s 1 and 2 the sterilization processing room, where Peracetic Acid is used as the disinfectant, is not provided with 10 changes per hour. According to the the manufacturer's Product Safety Data Sheet peracetic acid is a toxic chemical.
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