HospitalInspections.org

Based on observations and interviews it was determined the facility failed to ensure the patients were cared for in a safe environment and clean environment free of pests and insects in all patient's area of the facility especially in the Operating Room.

1. A complaint was received on 8/13/18 stating that a fly landed on the surgeon's sterile field (open incision) during surgery on 7/31/18. The complainant further stated that there were flies and other insects in and around the operating room and ancillary rooms.

During an interview conducted on 8/14/18 at 8:00 AM with Employee Identifier (EI) # 1, Chief Nursing Officer confirmed a fly did land on the sterile filed during the surgical procedure but added that she/ he, EI # 10 Director of Nursing responsible for the Operating Room (OR) , Central Instrument Processing Department (CIPD), 3 West and Coronary Intensive Care Unit (CICU) and EI # 9, OR Manager were not informed of the incident until it was discussed in the Department of Surgery/ Operating Room Committee Meeting on 8/1/18 at 7:00 AM by EI # 12, Cardiovascular (CV) Surgeon.

EI # 1, EI # 2, Chief Medical Officer, EI # 11, Chairman, Surgery and EI # 10 informed the surveyor that as soon as they found out about the issue, the started discussing and planning on a corrective action.

On 8/6/18 The Employee Identifier (EI) # 11, Chairman of the Surgery Committee, EI # 2, Chief of Medical Staff, EI # 1, Chief Nursing Officer and EI # 10, Director of Nursing with the EI # 9, Operating Room Nurse Manager reached a to close the operating room and cancel all surgical cases and do a thoroughly cleaning of the Operating Room (OR), Recovery Room (RR), Pre-Op and all ancillary rooms in the OR. EI # 10 further stated that he/ she met with all the staff and discussed the plan of action to clean the whole area including stretchers, OR table , etc. thoroughly.

EI # 10 further stated that on 8/7/18, after inspection by EI # 2, EI # 11, EI # 10 and EI # 9, all agreed to re-open the OR and begin surgery.

EI # 10 stated that on 8/7/18, additional changes were made and that is to move the employee lounge (break room) outside of the main operating room areas. The physicians, allied personnel and anesthesia were to take eating breaks and meals in their respectively lounges outside of the operating room areas. This arrangement also affected the Recovery Room (RR) Pre-operative and CIPD staffs.

A tour of the OR, RR and Pre-Op was conducted on 8/14/18 at 8:30 AM with EI # 1, EI # 9, and EI # 10. The surveyor observed that all ice machine were removed from the Operating Room areas except for 2 that were located at the Recovery Room which were for patient's use and for emergency such as malignant Hyperthermia care. The surveyor also noted that all dirty utility rooms including inside x 2 and outside of the OR were mopped clean and no garbage in the garbage bins. EI # 9 stated that all the doors to the 16 OR rooms are kept close whether not in use or in use to lessen the in and out movement of staff.

8/14/18 at 4:30 PM, the surveyor together with EI # 1, # 9 and # 10 observed 3 EVS ( Environmental Services) staff perform terminal cleaning of OR 12. The surveyor asked one of the EVS staff on how they start preparing the room for terminal cleaning. EVS staff # 1 stated they move all movable equipment to the center of the room then mop the walls and ceiling, the OR table, all other equipments are wiped down, and then the floor using the Oxivir solution. An ultraviolet light was then turned after the terminal cleaning was done for 45 minutes.

In an interview with EI # 7, EVS Director conducted on 8/15/18 at 3:50 PM. The surveyor asked EI # 7 what changes have been implemented to address the complaint issues, presence of flies, insects and overstuffed garbage bins in the Soiled Utility Room. EI # 7 stated after the 8/6/18, EVS changed the EVS staffing pattern from 2 to 5 EVS staff on the first shift, 2 on the second shift and one part time (4 hours shift on the third shift), to pick up garbage throughout the hospital. There is 1 dedicated EVS staff to pick up garbage in the Operating Room. Each EVS staff are to round throughout the hospital and OP to check the soiled utility room to pick u garbage. Garbage are to be taken to the incinerator for, hazardous waste such as contaminated and bloody linens, etc. are stored in a dedicated room and is picked daily by the hazardous waste company. EI # 7 further stated that he/ she ordered new garbage bins that have a cover and are lined with plastic liner prior to delivery. Garbage bins are to be cleaned, dried and lined prior to delivery to the designated areas (soiled utility rooms). EI # 7 informed the surveyor that this changes except for the new garbage bins with cover is in effective now. The garbage bins have been ordered.

An interview conducted on 8/16/18 at 1:30 PM with EI # 1, and EI # 2 who confirmed the above mention findings.

Based on review of the National Healthcare Safety Network (NHSN) of Centers for Disease Control And Prevention (CDC) document and interview with the staff, it was determined the facility staff failed to ensure:

1. Patient Care areas including the Operating Rooms (OR) are free from contamination and insects.

2. Documentation of surveillance, observation and rounding on high risk areas especially the OR are in place.

Findings include:

THE NHSN ( National Healthcare Safety Network) STANDARDIZED INFECTION RATIO (SIR) A Guide to the SIR Updated March 2018.

The Standardized Infection Ratio (SIR) is the primary summary measure used by the National Healthcare Safety Network (NHSN) to track healthcare associated infections (HAIs). As NHSN grows, both in its user-base and surveillance capability, the SIR continues to evolve. Highlighting the SIR and changes resulting from an updated baseline, this document is intended to serve both as guidance for those who are new to this metric as well as a useful reference for more experienced infection prevention professionals.

What is the SIR? The standardized infection ratio (SIR) is a summary measure used to track HAIs at a national, state, or local level over time. The SIR adjusts for various facility and/or patient-level factors that contribute to HAI risk within each facility. The method of calculating an SIR is similar to the method used to calculate the Standardized Mortality Ratio (SMR), a summary statistic widely used in public health to analyze mortality data.

In HAI data analysis, the SIR compares the actual number of HAIs reported to the number that would be predicted, given the standard population (i.e., NHSN baseline), adjusting for several risk factors that have been found to be significantly associated with differences in infection incidence. In other words, an SIR greater than 1.0 indicates that more HAIs were observed than predicted; conversely, an SIR less than 1.0 indicates that fewer HAIs were observed than predicted. SIRs are currently calculated in NHSN for the following HAI types: central line-associated bloodstream infections (CLABSI), mucosal barrier injury laboratory-confirmed bloodstream infections (MBI-LCBI), catheter-associated urinary tract infections (CAUTI), surgical site infections (SSI), Clostridium difficile infections. (CDI), methicillin-resistant Staphylococcus aureus bloodstream.


In an interview conducted with Employee Identifier (EI) # 3, Director of Quality to discuss the facility's infection rate and the department plans for correction related to the findings from the Infection Control Committee meeting last July 26, 2018.

EI# 3 informed the surveyor the facility's SSI baseline is 2-3%.

Review of the Infection Control Committee Meeting dated 7/26/18 revealed the following surgical site infections (SSI) for Quarter 2 and Year-To-Date (YTD) for 2018

Open Heart Surgery - SSI Rate for March was 10.71 % (percent), April 2018 was 9.68 %, May 2018 was 8.70%= Year To Date (YTD) 2018 was 6.49 (%) percent.

Abdominal Surgery - SSI Rate for April 2018 was 33.33 % = YTD 2018 was 6.67 %
Total Surgical Infection YTD was 18.

SSI Action Plan

4. Monthly OR observations: Skin preparation, room set-up, cleaning between cases, and hand hygiene.

During the interview with EI # 3, conducted on 8/16/18 at 10:20 AM, the surveyor asked EI # 3 if the SSI for Q2 % YTD 2018 was shared with all the physicians that performed surgeries. EI # 3 stated the report was presented to the Infection Control Committee on July 26, 2018

The surveyor asked EI # 3 if there have been any procedure changes in the surveillance/ observation process in the OR that the Infection Control/ Quality Department had implemented. EI # 3 stated that an IC Preventionist (ICP) have started rounding in OR to check for the presence of insects, etc. The surveyor asked to see the ICP's documentation, EI # 3 informed the surveyor there are documentation or forms filled during surveillance. EI # 3 further stated that the ICPs sends her/ him and email with no problems observed documented. When asked what do the ICP do while in OR, EI # 3 stated the ICP was to check for any insects and do environmental rounding .

On 8/16/18 at 1:45 PM, EI # 3 presented a printed report by the ICP who was assigned to the OR, regarding her/ his observation to the surveyor. The form was entitled OR Environmental Rounding by Infection Preventionist and had the following documentation:
" 8/6/18 Rounded in OR and no issues found. OR closed for terminal cleaning and pesticide treatment ".
" 8/7/18 OR checked and no issues found " - " 8/8/19 OR checked and no issues found ".
" 8/9/18 OR checked and no issues found ". - " 8/10/18 OR checked and no issues found ".
" 8/13/18 Rounded in the OR and no issues found ".
" 8/14/18 On back hall where case carts are housed, the general case cart had the door partially opened. Amanda was informed. She stated case cart will be sent to CIPD.
" 8/15/18 Rounded in OR, GI Lab and CIPD. No issues found " .
" 8/16/18 Rounded in OR. No issues found ".

This form was dated and signed by the ICP on 8/16/18.

An interview was conducted on 8/16/18 at 1:45 PM with EI # 3 who confirmed the above mentioned findings.