HospitalInspections.org

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Based on record review, interview and observation, the facility failed to ensure that staff complied with the facility's Infection Control Practices, including the use of Personal Protective Equipment (PPE), handwashing, environmental cleaning and appropriate surgical attire.

This failure of non-compliance for proper hand washing, proper PPE and cleaning practices places the patients at risk for potential infection.

Findings:

See Tag A 748.

See Tag A 749.
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Based on document review and interview, the Infection Control Officer failed to implement and ensure the facility's Environmental Services Specialist Housekeeper and Environmental Services Housekeeping Workers received Unit Specific training and competencies for cleaning the Operating Room (OR). This was found in five (5) of five (5) OR Housekeeping Staff Personnel Files reviewed.

This failure places all patients at risk for potential infections.

Findings:

Personnel Files for Staff V, an Environmental Services Specialist Housekeeper in the OR, revealed an employment date of 11/07/05. The file lacked documented evidence of any Operating Room specific training for cleaning the Restricted OR Suites or adjacent Semi-Restricted Hallways.

Personnel Files for Staff U, an Environmental Services Housekeeping Worker in the OR, revealed an employment date of 11/21/11. The file lacked documented evidence of any Operating Room specific training for cleaning the Restricted OR Suites or adjacent Semi-Restricted Hallways.

Similar findings were noted in the Employee Files of Staff Members T and AA, both Environmental Services Housekeeping Workers in the OR.

Per interview with Staff S (Environmental Supervisor) on 07/06/16 at 11:30AM during a tour of the OR, the staff member stated that these Housekeeping staff were designated specifically for the OR.

Review of the Environmental Services Competencies for the Housekeeping staff revealed that they lacked Unit Specific instruction and skill observations for staff working in the OR areas, including Cycle Cleaning between patients and Terminal Cleaning at the end of the shift to ensure the sterility of the environment.

During interviews with Staff Z (Director of Environmental Services) on 07/08/16 at 11:00AM and 1:45PM respectively, the staff member stated that no one is dedicated as OR specific and that staff can rotate all over the hospital. He advised that the Housekeepers all received the same orientation by the Housekeeping Supervisors and no one receives OR specific training and competencies.
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Based on observation, document review and interview, the facility failed to ensure that staff provided care in accordance with the acceptable standards of Infection Control Practices. This was evident in the observations of widespread breaches of Infection Control Practices including use of Personal Protective Equipment (PPE), Handwashing, and Operating Room Cleaning by Professional and Non-Professional staff members in various Units throughout the facility.

The pattern of ineffective Infection Control Precautions places all patients at risk for exposure to Infectious Diseases.

Findings:

Review of the facility's Policy and Procedure titled "Peri-Operative and Invasive Procedures with Implants: Surgical Attire", implemented on 03/17/16, contained the following statements:

In the Semi-Restricted Area "All hair should be covered, including beards and moustaches", and "In addition to the requirements for Semi-Restricted Areas, masks are worn by all personnel in the Restricted Area".

Observations of surgical procedures in the facility's Surgical Unit during a tour between 10:00AM and 11:30AM on 07/06/16 identified the following:

In OR #15 Staff C, a Plastic Surgeon, had approximately two (2) to three (3) inches of hair showing under his cap above the nape of the neck while performing surgery. Staff D, a Resident, had approximately one (1) inch of hair showing under his cap. Staff E, a Certified Registered Nurse Anesthetist, had hair hanging out both sides of her cap, and Staff F, a Circulating Nurse, had approximately one (1) inch of hair showing out of the front of her cap.

In OR #1 Staff G, a Circulating Nurse, had approximately one (1) inch of hair showing out of the front of her cap. Staff H, a Resident, had uncovered sideburns and approximately two (2) inches of hair showing under his cap.

In OR #2 Staff I, a Surgeon, had uncovered sideburns showing under his cap during surgery.

In OR #4 Staff J, an X-Ray Technician, had a full beard showing face mask while performing an x-ray during surgery. His beard cover was noted hanging around his neck, not on his face as required.

In OR #8 Staff M, an Anesthesia Resident, had a face mask on without a beard cover and facial hair showing outside of his mask.

In OR #20 Staff N, a Medical Student, had sideburns and approximately one to two (1-2) inches of hair showing from under his cap.

In OR #21 four (4) Surgeons, Staff Members O, P, Q and R, all had hair showing under their caps, and three (3) of them had sideburns showing while performing surgery.

Similar observations were made in five (5) additional Operating Rooms, with a total of twenty-four (24) staff observed wearing their PPE improperly in twelve (12) out of twenty-one (21) Operating Rooms observed.

These observations were made in the presence of Staff A (Director of Quality Management) and Staff B (Vice Chairman of Surgery), who were present during the tour and acknowledged that staff are required to have their hair and facial hair covered.

Observations of the cleaning procedures for facility Operating Room #24 on 07/06/16 at 11:05AM - 11:30AM, identified the following:

Staff U (Environmental Service Worker {ESW}), was observed removing garbage from the Operating Room into the Semi-Restricted Area.

After removing the garbage, Staff U was noted removing his dirty gloves, retrieving supplies from the cleaning cart and applying clean gloves, two (2) times, without performing hand hygiene.

Staff T (ESW) was observed pushing the garbage down into the garbage receptacle with his gloved hands. Then with the same dirty gloves on, he removed dusting cloths from his back pocket and handed them to Staff V, (ESW).

Staff V then placed the contaminated dusting cloths on a metal tray that had just been sanitized. He then removed his dirty gloves, and applied clean gloves without performing hand hygiene in between glove changes.

Staff V was also noted during two (2) separate observations to touch the garbage with his gloved hands and walked into the Semi-Restricted Area without changing gloves and performing hand hygiene.

Staff V was later observed cleaning the Bear Hugger Machine (patient warmer machine), then wheeling the clean Bear Hugger through the dirty field under the OR table where a bloody gauze was observed lying on the floor.

Observations of the cleaning procedures for facility Operating Room #7 on 07/07/16 at 11:35AM - 12:10PM, identified the following:

Staff M (Anesthesia Tech), was observed cleaning the anesthesia equipment, applying new cardiac leads, and placing them on the cardiac monitor with the leads hanging towards the floor.

Two (2) of the leads were noted touching the dirty floor when the Tech then rolled up the leads and placed them on the cardiac monitor.

This was observed in the presence of Staff A (Director of Quality Improvement), who acknowledged that the cardiac leads should have been cleaned after touching the floor prior to placing them onto the monitor.

Staff V was observed pulling the disposable lap belt from the OR table and tossing it across the room into the garbage where it landed on the edge of the pail hanging out of the garbage. This garbage pail was noted next to the anesthesia cart.

The dirty garbage pail, with soiled materials and the contaminated lap belt, was observed touching the sterile supplies in baskets on the side of the anesthesia cart.

This was observed in the presence of Staff A (Director of Quality Management) who acknowledged the finding.

Staff V was then observed moving metal tables, sterile trays, garbage bins and an IV pole that had just been sanitized, with the dirty gloves he was using while mopping the floors.

Staff V was then observed cleaning the perimeter of the OR room, then dragging the mop through the dirty field under the OR table and then went back over the just cleaned perimeter of the OR room with the same dirty mop.

This was observed in the presence of Staff S (Environmental Supervisor) who acknowledged the finding.

The facility's Policy and Procedure titled "Perioperative Area: Minimizing the Risk of Infection within the Surgical Practice Setting", last revised December 2013, lacks the following instructions:

When to change gloves between dirty and clean tasks.

To perform hand hygiene between glove changes.

How to mop the OR floors from the cleanest areas first to the dirtiest areas last.

Similar lack of instructions were noted in the undated facility Procedure Manual titled "Daily Operating Room In-Between Case Cleaning and Terminal Cleaning".

During interviews with Staff Z (Director of Environmental Services) and Staff W (Assistant Executive Director) on 07/08/16 at 1:45PM they acknowledged these findings.

During observations of the facility's 5 North Unit at 11:20AM on 07/07/16 Staff BB (Patient Care Aide) was observed providing care for a patient on Contact Isolation. He was then observed removing paper towels from the towel dispenser with the same contaminated gloves that he used to care for the patient.

At 11:25AM the Aide was then observed removing the dirty gloves and donning clean gloves without performing hand hygiene in between glove changes.

This was observed in the presence of Staff A (Director of Quality) who acknowledged the finding.

On 07/07/16 at 12:20PM Staff CC (Registered Nurse) was observed performing glucose testing. During the observation, Staff CC removed her dirty gloves and donned clean gloves two (2) times without performing hand hygiene between glove changes.

Staff CC was then observed removing her dirty gloves and accessing clean supplies from the bottom draw of the supply cabinet without performing hand hygiene before entering the cabinet.

On 07/08/16 at 10:26AM Staff DD (Registered Nurse) was observed performing a Foley catheter insertion in the Labor and Delivery (L& D) Operating Room. While preparing the patient for the procedure Staff DD positioned the patient's feet on the OR table.

Staff DD touched the socks the patient was wearing while ambulating the hallway with her gloved hands while positioning her. Staff DD then removed cleansing wipes from Foley catheter kit and proceeded to wipe the patient's vaginal area without changing gloves.

This was observed in the presence of Staff EE (Nurse Manager) who acknowledged the Nurse should have removed her dirty gloves after touching the patient's feet, cleaned her hands, and re-gloved prior to cleaning the patient.

The facility's Policy and Procedure titled "Placing Patients on Precautions" last revised May 2012 instructs staff to "Change gloves between task and procedures on the same patient after contact with material that may contain a high concentration of microorganisms; before touching non-contaminated items and environmental surfaces".

The facility's Policy and Procedure titled "Hand Hygiene", revised August 2013, states "Hand hygiene should be done before donning gloves and after removing them".

On 07/08/16 at 11:45AM Staff FF (Patient Care Aide) was observed performing glucose testing. During the observation Staff FF removed dirty gloves two (2) times and performed hand hygiene for only approximately five (5) seconds both times.

This finding was acknowledged by Staff GG (Coordinator of Quality Improvement).

The facility's Policy and Procedure titled "Hand Hygiene", revised August 2013, states that hands should be washed for "at least 15-20 (fifteen to twenty) seconds".