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Based on staff interview, record review, document review, and policy review the hospital failed to ensure housekeeping staff (Staff K) was trained and knowledgeable of the hospital's cleaning solutions, equipment, and cleaning procedures during one of one observed terminal cleaning (Operating Room (OR) two). This deficient practice has the potential to cause ineffective cleaning of the sterile surgical environment which could lead to patient harm. The hospital failed to ensure a crack in the wall of one of eight ORs (Room two) was immediately repaired or closed for used until the crack could be repaired. This deficient practice has the potential to allow harmful bacteria and other infectious materials to collect and contaminate the OR's sterile environment and could cause surgical site infection. The hospital failed to ensure paper signs that are taped to the walls are contained in a manner that the surface could be cleaned in seven of eight ORs (OR one through three, and five through eight). This deficient practice has the potential to allow bacteria and other infectious materials to remain in the OR's sterile environment which could lead to surgical site infections. The hospital failed to ensure hazardous waste containers in one of eight ORs (OR two) were removed when or prior to them reaching the full line. This deficient practice has the potential to allow hazardous items to spill from the container and contaminate the surrounding areas. The hospital failed to ensure all operating room staff (Staff L, R, and three unidentified staff) covered their hair completely during five random observations in the operating room suites between 05/14/18 and 05/15/18.

Findings include:

- Document review of the hospital's policies showed the hospital had no policy directing the training and surveillance of housekeeping staff performing terminal cleanings of the ORs.

Document review of the manufacturer's guidelines for the use of "Oxivir" disinfecting solution read, Apply to hard non-porous surfaces. Allow to remain wet for 5 minutes.

During an observation on 05/14/18 between 3:38 PM and 4:30 PM, Staff K, housekeeper, performed a terminal cleaning of OR room two. Staff K, using a microfiber mop pad wet with the disinfecting solution "Oxivir" wiped the walls in a V type pattern and missed cleaning sections of the walls, then cleaning the floor, and going back to the wall with the same mop. Thus, moving from a less contaminated area (the wall) to a more contaminated area (the floor) and back, potentially causing cross contamination. Staff K used the same microfiber mop for three of the walls that remained wet between two to four minutes not the five minutes per the manufacturer's guidelines. Failing to keep the walls wet for the required time has the potential for ineffective removal of infectious agents. Staff K failed to change her gloves after changing from a dirty mop or cloth to a clean mop or cloth; causing potential cross contamination. Staff K continued to wipe the equipment (three stools, back table, mayo stand, and cushions for the operating room table) with a cloth wet with the "Oxivir" disinfecting solution but failed to completely wipe all the surfaces down. Failing to disinfect all surfaces has the potential for contamination with residual infectious agents.

During an interview on 05/14/18 at 4:00 PM, Housekeeping Staff K, stated that she thought the surfaces should remain wet about ten minutes because she did not know what surgeries were done in that room.

During an observation on 05/14/18 at 4:25 PM in operating room (OR) two, Staff K, Housekeeper, performed a terminal clean of the OR room with a floor scrubbing machine that she lacked sufficient knowledge to operate. While Staff K, Housekeeper, was suctioning the wet floor a hose disconnected and dumped water all over the floor.

During an interview on 05/14/18 at 4:30 PM, Staff K, Housekeeper, stated that she was not very sure how to use the machine. Staff K, Housekeeper stated she was told the water tube often comes off this machine, so she needed to be careful.

During an interview on 05/16/18 at 11:30 AM Staff Q, Environmental Services (EVS) Manager, stated Staff K, Housekeeper, has only been on second shift and training to do terminal OR room cleaning for ten days and had not done a OR room independently until the observation on 05/14/18. Staff Q stated that a supervisor had not checked off Staff K's ability to properly clean an OR. Staff Q stated that Staff K was not familiar with the floor scrubbing machine she was instructed to use for the observation. Staff Q identified the following deficient practices that occurred during the terminal cleaning: failed to use a top to bottom cleaning technique, failed to use a systematic cleaning method and therefore missed several surfaces, failed to change microfiber mops frequently enough, failed to change gloves as frequently as is required, failed to clean the glass window per policy, wiped the floor with the mop and then used the same mop to clean a lower portion of the wall, failed to know what the proper dwell time of the chemical cleaner was, and failed to ensure the surfaces cleaned remained wet for the required amount of time.


- Document review of the hospital's policies showed the hospital had no policy directing staff to immediately repair all surface cracks or tears immediately and suspend services in that OR room until the repair is verified.

During an observation on 05/14/18 at 3:40 PM in operating room (OR) two showed a crack in the wall extending from the ceiling to the chair rail. The crack made the surface non-cleanable.

During an interview on 05/15/18 at 3:50 PM Staff B, Registered Nurse, stated that she was unaware of a crack in the wall but agreed that would make it a non-cleanable surface.

During an interview on 05/16/18 at 11:25 PM Staff B, Registered Nurse, stated that environmental rounds are conducted every two weeks with environmental services, Infections control staff, maintenance staff, and the Accreditation Coordinator. Staff B indicated that OR room two was closed upon identifying the crack during survey observation on 05/14/18 and was not reopened until it was confirmed completed on 05/16/18 at 11:55 AM.

During an interview on 05/16/18 at 11:45 AM Staff G, maintenance, stated that they identified a crack in the middle of the wall and in a corner about three weeks ago and assigned his engineer (Staff P) to fix the cracks. Staff G stated that he failed to ensure that both cracks were repaired immediately. Staff G reported that Staff P repaired the crack with an acrovent vinyl patch which does not require sanding or painting and is a cleanable surface and Staff G confirmed the crack was repaired on 05/16/18 at 11:55 AM.


- Document review of the hospital's policies showed the hospital had no policy directing staff to ensure all paper items mounted to the OR walls are required to be in a plastic sleeve.

During an observation on 05/14/18 at 1:30 PM in operating room (OR) two showed an unprotected paper sign taped to a wall cabinet. Unprotected paper products are non-cleanable and could harbor bacteria and/or infectious materials.

During an interview on 05/14/18 at 1:40 PM Staff I, Registered Nurse stated, "Paper items should be in a plastic sleeve."

During an observation on 05/14/18 at 4:39 PM in OR rooms one, three, five, six, seven, and eight showed paper signs taped to the walls. Unprotected paper products taped to operating room walls are non-cleanable and could harbor bacteria and/or infectious materials.


- Document review of the hospital's policy titled, "EVS General Cleaning of Patient Area 007" dated 02/2016 showed, Staff are to remove any sharps containers which are ¾ full or fuller and replace with a new empty box.

During an observation on 05/14/18 at 3:40 PM in operating room (OR) two, a Kendall Hazardous waste container filled above the full line with used needless syringes at the level of the container's opening. Staff K, housekeeper, reported to her supervisor that the hazardous waste container was above the full line and she would need a new one. This deficient practice has the potential to allow hazardous items to spill from the container and contaminate the surrounding areas or cause an accident with a dirty sharp.

During an interview on 05/14/18 at 4:20 PM Staff Q, Environmental Services Director, stated that hazardous waste and sharps containers should be removed as soon as they get to the ¾ full line marked on the container. Staff Q stated they had a problem because the vendor was picking up during the afternoon so all container in the OR rooms were not accessible. Staff Q stated the EVS staff have been instructed to remove the ¾ full containers from the OR's as needed and put them in a central location for the vendor to pick up.


- Document review of the hospital's policy titled "SS Surgical Attire Policy" dated 02/2018 showed, All hair must be covered by a cap or hood.

During the tour of the surgical suite area on 05/14/18 between 1:30 PM to 2:30 PM showed four operating room staff (Staff L, R, and two unidentified staff members) wearing disposable skull caps with exposed hair at the nape of their neck and around the ears.

During an observation on 05/14/18 at 3:40 PM in the operating room area by OR room eight showed an unidentified staff member wearing a skull cap with hair exposed at the nape of their neck.

During an interview on 5/15/18 at 10:00 AM Staff D, Infection Control Officer, stated that it is a problem with the operating room staff not covering all their hair. The hospital has ordered new hair covers and will no longer use the skull caps.