HospitalInspections.org

Based on random observations, staff interviews, review of facility policies and procedures, and review of nationally recognized guidelines, it was determined that the facility failed to ensure: 1) shared equipment is cleaned and disinfected between patients in accordance with the facility's "Cleaning: Environment, Patient Equipment and Medical Devices" policy; 2) manufacturer's Instructions for Use (IFU) for germicidal detergent is followed in accordance with the facility's "Routine Daily Cleaning and Disinfection" policy; 3) hand hygiene is performed in accordance with the facility's "Hand Hygiene" policy and Center for Disease Control (CDS) guidelines.

Findings include:

1. At 11:15 AM, during a tour of the "Clean" wing, in the presence of Staff (S) 3, S10, was observed in patient room 204-B auscultating Patient (P) 2's lungs with a stethoscope. S10 then placed the stethoscope around his/her neck, performed hand hygiene and exited the patient room. S10 failed to clean and disinfect the stethoscope after auscultating P2's lungs, and prior to placing the stethoscope around his/her neck and exiting the patient room. Upon interview, S10 stated "I forgot."

The policy regarding Cleaning and disinfection of medical equipment was requested. The policy titled "Cleaning: Environment, Patient Equipment and Medical Devices" Revised July 2021, was provided and states, "...II. Procedure: Equipment can serve as a vehicle for transmitting pathogens. This policy specifies a process for reducing that risk. A. Whenever possible, there will be no shared equipment. ...B. When not possible...the equipment will be disinfected after use by the clinical staff, immediately after use. ..."

Failure to clean and disinfect shared equipment between patients can potentially lead to cross contamination and spread of infections.

2. At 11:38 AM, in the presence of S3, S12 was observed cleaning and disinfecting occupied Patient Room 233. S12 was observed wiping the door jam with PDI Super Sani-Cloth Germicidal Disposable Wipes, with gloves on. S12 discarded the wipes, then proceeded to the Environmental Services (EVS) cart located directly outside the patient room, where there was a container of PDI Super Sani-Cloths Germicidal Wipes with the entire lid off. S12 reached into the container with his/her potentially soiled gloves on and retrieved additional wipes.

The policy regarding cleaning and disinfection of patient rooms was requested. The policy titled "Routine Daily Cleaning and Disinfection" was provided and reviewed. The policy states, "...II. General Principles: ... C. All surfaces will be cleaned with a hospital grade germicidal detergent as indicated by manufacturer. ... III. Procedure: A. Prepare the germicidal detergent solution per manufacturer' specifications. ..."

The PDI Super Sani-Cloth Germicidal Wipes manufacturer's IFU was requested and reviewed. The IFU states, "... Directions For Use ...To Dispense wipes: Remove lid and discard inner seal from canister. Find center of wipe roll, remove first wipe for use, twist corner of next wipe into a point and thread through the hole in the canister lid. Pull through about one inch. Replace lid. Dispense remaining wipes as necessary by pulling out at an angle. When not in use keep the center cap of lid closed to prevent moisture loss. ..."

S12 failed to dispense the wipes through the center cap of the lid per the IFU, cross contaminating the wipes within the container with his/her potentially soiled gloves.

3. Reference: CDC Guideline for Hand Hygiene in Health Care Settings: Recommendation of the Healthcare Infection Control Practices Advisory Committee[HICPAC] and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force, published in the CDC (Centers for Disease Control and Prevention) Morbidity and Mortality Weekly Report at MMWR 2002; 51 (No. RR-16) page 32 states, Recommendations 1. Indications for handwashing and hand antisepsis A. When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids, wash hands with either a nonantimicrobial soap and water or an antimicrobial soap and water... . B. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations described in items 1C-J ... . Alternatively, wash hands with an antimicrobial soap and water in all clinical situations described in items 1C-J ... . ... I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the
immediate vicinity of the patient ... . J. Decontaminate hands after removing gloves... ."

At 11:38 AM, in the presence of S3, S12 was observed cleaning and disinfecting occupied Patient Room 233. S12 was observed wiping the door jam with PDI Super Sani-Cloth Germicidal Disposable Wipes, with gloves on. After cleaning and disinfecting the door jam, S12 doffed (removed) his/her gloves and failed to perform hand hygiene, prior to reaching into the box of clean gloves, to obtain a new pair of gloves.

The policy addressing hand hygiene was requested. The policy titled "Hand Hygiene" states, "... II. Policy: ... B. When ... 9. Between glove changes and after removing gloves ... " The policy titled "Routine Daily Cleaning and Disinfection" states, "... III. Procedure: ... E. Remove protective gloves and wash hands thoroughly ..."

The facility failed to ensure hand hygiene was performed in accordance with facility policy and CDC guidelines.

S3 immediately re-educated S12 on the importance of performing hand hygiene after doffing soiled gloves. S12's personnel file was later reviewed. S12's competency dated 1/17/23, indicated that he/she was competent in basic cleaning and disinfecting practices, donning (putting on) and doffing PPE [Personal protective Equipment] correctly, performing hand hygiene before and after gloves and as needed, and using cleaning supplies and chemicals according to manufacturer's guidelines.