HospitalInspections.org

1. Based on observation, review of hospital documentation, interview with hospital personnel and review of hospital policy, the hospital failed to ensure that terminal cleaning of the operating rooms was documented in accordance with hospital policy. The findings include:

During tour of Bliss Rooms 418, 420 and 423 on 1/25/2012 from 5:30 AM to 6:10 AM, with the Charge Nurse of the Operating Room, a cavi wipe (cleaning cloth) was utilized to wipe down furniture and several machines including cell savers, heater/coolers (Sarns) and bypass (Terumo) machines. The following was observed:

a. The waterline tubing of the heater/cooler in Room 418 was observed to have a small to moderate amount of black and yellowish material when wiped with the cavi wipe. A wipe of the base and underside of the OR table produced a moderate amount of brownish material and a moderate amount of the same material was observed on the OR floor. A moderate amount of black material was removed from a cord extending from the OR table to the base when wiped with the cavi wipe. A chair was observed to have torn vinyl.

b. Upon request, the centrifuge of the cellsaver in Room 420 was removed by the Perfusionist. A slight amount of brownish, red material was observed after wiping the area with a cavi wipe.

The heater/cooler located in room 420 was observed to have visible splatters of a red material at the left front of the machine. The waterline of the heater/cooler was observed to have a moderate amount of brownish-black material present when wiped down with a cavi wipe.

c. In Room 423, a moderate amount of brownish, black material was removed when a cavi wipe was used to wipe down the water lines of the heater/cooler. A large amount of brownish, black material was observed on the floor at the head of the OR table and a small amount of a yellowish brown material was removed from the underside of the OR table when wiped with the cavi wipe. A sharps container was observed to be overflowing with syringes protruding out from the sharps protective cover. A stool in Room 423 was observed to have multiple cuts in the vinyl allowing threads from the seat material to break through.

Dust and darkened debris was observed at the top of pumps attached to the IV poles located at the head of the OR tables in each room.

Review of the Terminal cleaning of surgical rooms policy, identified the directive to provide total room cleaning every twenty-four (24) hours. Review of the terminal cleaning logs for October, November, December 2011, and January 2012 for three rooms in the Bliss wing (Rooms 418, 420 and 423) utilized for cardiac surgeries, identified that although the policy stipulated cleaning every 24 hours, several consecutive days passed without documentation that the room was cleaned as directed. Review of the cleaning logs identified gaps in cleaning that occurred over weekends, on random days during the week, and in November 2011, from the 1st through the 6th, each room was terminally cleaned once. Additionally, log documentation, directed to include the time the room was cleaned and the initials of the person who cleaned the room. The logs included the words "OK" and a slash across two days that failed to indicate that the time the room was cleaned.

During interview on 1/25/12 at 10:05 AM, the Director of Environmental Services stated that he could not answer who was responsible to review the terminal cleaning logs for policy compliance and/or what the aberrant documentation meant.


2. Based on observation, interview with hospital personnel, review of hospital documentation, policies, and manufacturer directions, the hospital failed to document daily cleaning of machines and/or develop policies based on manufacturer's directions for disinfection and/or maintenance of machines utilized during heart procedures. The findings include:

a. Review of the cell saver cleaning log reflected that for the four (4) identified cell savers located in the hospital, the last documented cleaning occurred in September 2011.

b. Review of the heater/cooler (Sarns) machine cleaning and descaling log reflected that for the five machines identified within the hospital, each machine was listed as being randomly cleaned throughout the year.

During interview on 1/25/12 at 6:10 AM, the Chief Perfusionist stated that although there was no formal log that documented the daily cleaning of the machines, the machines were disinfected daily after use.

Review of the manufacturer's directions for the heater/cooler machines directed a daily sanitation procedure with a chlorine check as well as a cleaning and sanitizing procedure that should occur at a minimum of weekly, with descaling every six (6) months, and decontaminated when biofilm was present according to manufacturer's direction.

The hospital failed to provide documentation that the manufacturer's direction were followed.

c. Review of the cleaning log for the heart/lung (Terumo) machines identified that there were five machines in place within the OR. The log failed to reflect any documented cleaning of machines #1-4 during the year 2011. During interview with the Chief Perfusionist on 1/25/12 at 6:00 AM, identified that machine #5 was on loan with documentation that the machine was last cleaned on 10/17/11. The Chief Perfusionist stated that although there was no formal log for daily cleaning of the machines, the machines were disinfected daily after use.

Review of manufacturer's directions provided by the hospital reflected equipment care directions that stipulate that the machine be cleaned and inspected after each use, inclusive of cleaning system surfaces, pump head, occlusion rollers, tube clamp assemblies and the water trap filters. Manufacturer's directions further directed monthly maintenance would occur to check the air filter and gas flow.

Review of the hospital cleaning log documentation for all the above referenced machines failed to reflect that manufacturer's directions were followed.

During interview on 1/25/12 at 6:10 AM, the Chief Perfusionist stated that the hospital did not have a policy that directed the daily cleaning and maintaining of the machines but that manufacturer's directions were followed.