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Based on observation during the survey walk-through, staff interview, and document review during the Life Safety code portion of the Full Survey Due to a Complaint conducted on April 24 - 25, 2023, the surveyors find that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety code portion of the Full Survey Due to a Complaint conducted on April 24-25, 2023, the surveyors find that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

Based on observation, document review, and interview, it was determined that for 2 of 2 (E #1 and E #2) staff observed cleaning operating rooms (OR) after procedures, the Hospital failed to maintain infection control practices by ensuring that the equipment was properly disinfected between surgical cases. This has the potential to affect the remaining patients having surgery in these ORs on 04/25/2023.

Findings include:

1. During an observational tour of the Operating Room Suites on 04/25/2023 between 9:25 AM - 9:50 AM, OR #8 wasobserved being cleaned after a procedure. The following was observed:

- At approximately 9:27 AM, an environmental service staff (E #1) was observed disinfecting a Stryker operating bed (orthopedic surgical bed), but residual tape was not removed fully from the bedprior to disinfection.
-At approximately 9:40 AM, an OR Monitor Technician (E #2) was observed placing an unused/unopened rebreather mask
and tubing on an uncleaned monitor cart and proceeded to clean and disinfect the cart while the unused packaged remained on the surface. E #2 was then observed removing a full trash bag from a bin and walked the garbage bag outside of OR #8 and proceeded to take clean syringes and supplies out of a cart and brought them to OR #8 without removing dirty gloves and performing hand hygiene.
- On 4/25/2023 at 9:45 AM, in OR suite #3, tape and/or tape residue was found on 1 craniotomy table and on 3 "line holders" (devices used to secure intravenous lines to the OR table), after the room had been cleaned and was ready for use.

2. The Hospital's policy titled, "Surgery Cleaning" (revised 2/1/22) was reviewed and required, "To maintain a sterile environment ... when leaving the surgery area ... PPE (personal protective equipment) should be removed ... Between Case Cleaning (AORN/Association of perioperative Registered Nurses) Wash O.R. table, lights and furniture with germicidal solution."

3. The Hospital's policy titled , "Hand Hygiene Policy" (revised 10/18/2021) was reviewed and required, "All health care workers, physicians... support staff... are required to comply with this hand hygiene policy... before donning gloves (non-sterile or sterile) and after removing gloves. before accessing clean or sterile supplies."

4. On 04/25/2023 at approximately 9:55 AM, an interview was conducted with the EVS (E #1). E #3 stated that the adhesive should be removed from the surface of the surgical table, and equipment, however it does not come off with the product that is supplied.

5. On 04/25/2023 at approximately 10:00 AM, an interview was conducted with OR Monitor Technician (E #2). E #4 stated that it was not appropriate to place unused clean supplies on a dirty surface. E #2 stated that E #2 should have changed his gloves after handling the garbage bag and obtaining new supplies.