Observations:
Based on observations, review of facility documents, and staff interviews (EMP), it was determined the facility failed to ensure a sanitary environment was maintained to protect surgical patients by not using new oxygen extension tubing for each patient in the facility's procedure rooms.
Findings include:
Observation tour of procedure room one (1) on November 30, 2023, at approximately 2:15 PM, revealed oxygen extension tubing connected to the oxygen nut stem adapter on the wall of the procedure room. Further observation revealed no patient in the room.
Observation tour of procedure room two (2) on November 30, 2023, at approximately 2:19 PM, revealed oxygen extension tubing connected to the oxygen nut stem adapter on the wall of the procedure room. Further observation revealed no patient in the room.
Review on November 30, 2023, of facility document, "Hudson RCI 7ft (2.1m) Star Lumen Tubing... Reference number 1115" package insert revealed, the tubing is single patient use only.
Interview with EMP1 on November 30, 2023, at 2:22 PM confirmed the facility does not change the oxygen extension tubing between patients.
| | Plan of Correction - To be completed: 01/08/2024
Oxygen extension tubing will be removed from the oxygen set-up. The 7 ft oxygen cannula that attached to the extension tubing will be replaced with a 14 ft oxygen/end tidal CO2 cannula (SunMed, Product # 4114F).
All staff shall be re-trained on changing tubing between patients and in-serviced on the new 14-foot tubing before completion of corrective action.
The Director of Nursing is responsible for monitoring the continued implementation of this plan of correction. To ensure compliance, a standing order for 14 ft tubing has been placed with Respitech Medical. Each weekly shipment will be checked by the Director of Nursing to ensure that the correct tubing has been shipped. Oxygen/end tidal CO2 cannulas are for single patient use.
Corrective action will be completed by 1/8/2024. The above corrective actions will be reported to the Board of Directors, MAB, Patient Safety and Infection Control Committees in January, 2024.
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