HospitalInspections.org

Based on policy and procedure review, observation, and staff interview, the facility failed to sustain a safe and sanitary environment.

Findings:

On the afternoon of 12/30/14, surveyors toured the surgical department with administrative staff, the director of surgery and a surgical consultant.
Surveyors observed a room connected to the surgical department's central sterile room. Administrative staff told surveyors the room was considered "unrestricted" the room was connected to the central sterile room by automatic opening doors that contained an approximate 1 inch gap in between the doors. The "unrestricted" room contained many corrugated boxes. Administrative staff told surveyors the corrugated boxes are brought to this room directly from the hospital's receiving department.
Surveyors observed a room labeled, "equipment storage" that was within the operating room department. This room contained 4 corrugated boxes being utilized for equipment storage.
Surveyors reviewed a policy titled, "Corrugated Boxes." The policy documented "...No corrugated boxes are permitted to be stored in a patient care, sterile or clean storage area..."
The policy further documented "...When corrugated boxes are opened, it is preferable to have all the contents transferred to a separate plastic or metal container that is easily cleanable-prior to transport of items..."
Surveyors observed a male employee with facial hair uncovered in semi restricted areas of the surgical department (central sterile department and corridors leading to the restricted area of the surgical suites).
On the morning of 12/30/14, the director of quality provided surveyors with a copy of "Keep Calm and Get Back to Basics Surgical Services" educational information that had been provided to all employees as well as a copy of "Surgical attire policy and practice." The educational handout and Surgical attire policy documented "...Personnel are required to wear surgical attire and cover all head and facial hair..."
Administrative staff verified there was a male employee with facial hair uncovered in semi restricted areas in the surgical department on 12/30/14.
Administrative staff told surveyors that the educational handout and surgical attire policy were part of their plan of correction for all surgical department employees and all education and training was completed by 10/8/14.
Administrative staff verified that the male employee in the surgical department was not following the surgical attire policy that was instituted as part of the hospital's plan of correction.