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Based on observation and staff interview, the hospital failed to ensure the Operating Room (OR) department was arranged and maintained to provide adequate space for provision of surgical services.

See Conditon of Participation: 485.639 Surgical Services

Based on observation and staff interview, the facility failed to ensure the Operating Room (OR) department was arranged and maintained to provide adequate space and facilities for the provision of surgical services.

Findings:

~ On the morning of June 20, 2016, administrative staff told surveyors the facility had plans to renovate the OR department and had submitted plans of renovation for approval.

~ On the morning of June 20, 2016, surveyors toured the OR department.

The OR department did not contain adequate space or adequate support areas for the provision of surgical services.


The following observations were made:


The OR department did not contain clearly defined areas of semi-restricted, un-restricted, and restricted space as required.

The OR department did not contain a control station to permit observation of all traffic into the OR suite.

The OR department did not contain an office space for the OR director.

The OR department contained 2 dressing rooms, a men's dressing room and a women's dressing room. Both dressing rooms had only 1 employee entrance and exit. One entrance and exit door would not allow for a one-way traffic flow as required for an OR department.

The OR department had 2 OR suites. One OR suite served as an equipment storage room not an OR suite. There was no space for equipment storage.

The OR department did not contain a medication station for storage and distribution of drugs and routine medications.

The OR department had one corridor that served as the main OR corridor and a substerile area. The corridor contained 4 scrub sinks. The scrub sinks were not recessed into an alcove and were not out of the main traffic area.

The OR department did not contain an enclosed soiled workroom for the collection and disposal of soiled material.

The OR did not contain a clean workroom/supply room equipped with a work counter, handwashing sink, and storage facilities for clean supplies.

The OR department did not contain adequate space to prevent cross traffic of supplies and staff from the sterile/clean areas to the soiled/decontaminated areas.

The OR department did not contain provisions for medical gas storage.

The OR department did not contain an anesthesia workroom for cleaning, testing, and storing anesthesia equipment.

The OR department did not contain a staff lounge.

The OR department did not contain a dictation and report area for staff.

~ On the morning of June 20, 2016, the OR director told surveyors the facility performed approximately 100 - 200 surgical procedures a month. The OR director told surveyors the majority of the surgical procedures were performed on an outpatient basis.

The OR department did not contain service areas specific for outpatient surgical procedures such as; a phase II recovery area equipped with handwashing sinks, a nurse's station, a clinical sink, provision for bedpan cleaning and storage space for supplies and equipment.

The OR department did not contain an outpatient surgery changing area equipped with lockers and toilets.

The OR department did not contain provisions for patient examinations, interviews, preparation, testing, and obtaining vital signs of patients for outpatient surgery.

The OR department did not contain a patient holding area to accommodate stretcher patients waiting for surgery.

The OR department did not contain a housekeeping closet that had a service sink and provisions for storage of supplies and housekeeping equipment.

The OR department did not contain an area for preparation and examination of frozen sections.

The OR department did not contain an ice machine for treatments and patient use.

~ On the morning of June 20, 2016, surveyors toured the Post Anesthesia Care Unit (PACU).

The following observations were made:

The PACU did not contain adequate spacing for equipment and patient beds.

The PACU did not contain provisions for isolation of infectious patients.