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Based on observation and staff interview, the CAH failed to ensure the PPS Excluded Psych unit was maintained and properly equipped for the scope of services provided to ensure the safety and well being of patients who reside on the unit. In addition, the facility failed to ensure that adequate private space was provided for the provision of direct care services for patients utilizing the ED (Emergency Department)). Findings include:

During a tour of the PPS Excluded Psychiatric Unit on 7:50 AM on 6/22/10 the following observations were made:

1. The bathroom doors in rooms 229 and 230 did not have the ability to provide a two-way access creating a potential opportunity for a patient to barricade themselves in the bathroom. All other bathroom doors in patient rooms had the capability of two-way access.

2. The ceiling exhaust fan in the handicap bathroom was rusty, soiled and presented potential as a loopable device.

3. The faucets in patient bathrooms have a reversed "J" shape, creating a potential loopable device.

4. The patients' telephone located in the hallway had a detachable cord which was approximately 36 inches long when stretched.

The observations were verified with the Co-Director of the PPS Excluded Psychiatric Unit.

5. During tour of the ED, with the Nurse Manager, on the morning of 6/22/10, and while entering the ED from outside the facility through the ambulance entrance, a patient was observed sitting on a stretcher in an open area just inside the entry way, and receiving medical care to an injured extremity. Although all other bed spaces within the department were occupied by patients at the time of the observation, the patient was not provided any privacy and was in full visual view of ambulance staff or anyone else entering through that entrance. The Nurse Manager stated that because of the volume of patients presenting to the ED, the space and two stretchers located just inside the ambulance entrance, is frequently utilized to accommodate patient census and provide direct services. S/he also stated that the ambulance entrance is frequently utilized by the general public for entry into the ED as it is easily accessible and unsecured during the day.

Based on observation and interview, the CAH failed to maintain the operating rooms and surgical equipment in a manner to ensure the safety and well being of patients and failed to conduct surveillance and inspections of the Peri-Operative environment and equipment. Findings include:

1. During a tour on 6/23/10 at 11:05 AM with the Director of Engineering, the Director of Housekeeping and the Infection Control nurse the following observations were made and confirmed:

a. In Operating Room (OR) #2 cracks with gaps (measuring approximately 1/8 th to 1/4 inch) were noted on the outside edge of one side of the operating room floor extending approximately 5 feet.
b. A metal panel located on the floor in front of a stainless steel cabinet in OR #2 was stained with rust.
c. Dust was observed on the metal grates of the air supply vent in OR #2.
d. Chipped paint was noted on the walls of OR #1, exposing under wall surface.
e. Four bowl stands were heavily soiled with rust on the wheel bases.

Per interview with the Director of Engineering during the time of observations confirmed routine maintenance/housekeeping surveillance rounds have not been conducted in the Peri-Operative area for an undisclosed period of time, however confirmed the interdisciplinary rounds must resume and include both the Director of Housekeeping and the Infection Control nurse.

Based on observation and confirmed by staff interview, the CAH failed to ensure all drugs were properly stored and secured. Findings include:

1. Per observation during a tour of Operating Room #2 on 6/23/10 at 11:10 AM, medications including Bupivacaine 30 ML vial, 2 Methylene Blue 1 mg vials and iothalamate Meglumine 60% 30 cc vials were stored in a unlocked cabinet. Per interview on 6/23/10 at 11:45 AM, the Nurse Manager for Peri-Operative services confirmed no medications should be stored in the unlocked cabinet and staff should be utilizing the Pyxis medication station to access any medications.

2. Per observation during visual inspection of the code carts in the CBC (Childbirth Center), with a pharmacy aide at 9:45 AM on 6/22/10, both the Adult and Neonatal code carts, located in the C-Section area, and each containing emergency medications including; Atropine Sulfate, Epinephrine, Sodium Bicarb, Metoprolol and Procainamide, were unsecured.

During interview, at the time of observation, the CBC Nurse Manager confirmed that both the code carts, which had been opened during inspection by the surveyor at approximately 1:40 PM the previous afternoon on 6/21/10, had remained unsecured since that time and that the carts should have been locked.

3. Per observation, during visual inspection of medication refrigerators with a pharmacy aide, on the morning of 6/23/10, the temperature logs used by nursing to document the temperature of the refrigerators, although directing staff to notify pharmacy for any temperature out of range, did not clearly define what the acceptable temperature range was.

During interview, at the time of the separate observations in the ED and ICU (Intensive Care Unit), RNs #1 and #2 both stated that, although they were responsible for monitoring the temperatures, they did not know what the appropriate temperature range was for the medication refrigerators in each of their respective units.

Per review of the original Medication Refrigerator Temperature Log, provided by the pharmacy following the observations, the acceptable temperature range was clearly defined by color and identified as between 3 and 7 degrees C (centigrade). Although the temperature logs for both the ED and ICU for the month of June 2010 revealed temperatures documented between 2-8 degrees C on more than one occasion, there was no evidence that pharmacy had been notified of temperatures outside the acceptable range.

Per record review, on 6/23/10, a discrepancy was noted between the acceptable temperature range identified on the Medication Refrigerator Temperature Log utilized by staff for monitoring the temps (3-7 degrees C) and the facility's policy, "Refrigeration (Medication)", dated 9/10/09, which states; "A thermometer that will indicate the normal range (2-8 degrees centigrade) shall be kept in each drug refrigerator"............"Standard refrigerator temperature is 2 degrees C to 8 degrees C...".

During interview, on the morning of 6/23/10, the Director of Pharmacy Services confirmed that the Medication Refrigerator Temperature Logs, which had been copied in black and white form, for staff use in monitoring temperatures, did not clearly define the acceptable temperature range (identified on the original, by color, as 3-7 degrees C). S/he further confirmed that there was no evidence that staff had reported any temperatures outside the acceptable range for the month of June to pharmacy staff and that, although there was a process for Pharmacy to monitor the Medication Refrigerator Temperature Logs on a monthly basis, these issues had not been identified. The Pharmacy Director also confirmed, during a subsequent interview, at 9:05 on 6/24/10, that s/he had not been aware of the discrepancy between the acceptable temperature range for the medication refrigerators identified on the Medication Refrigerator Temperature Log and the facility's Refrigeration (Medication) policy until informed by the surveyor. In addition, s/he confirmed that all drugs stored in the medication refrigerators in both the ED and ICU would remain stable at any and all temperatures that had been documented on the respective monitor logs for the month of June.

Based on observation and staff interview the CAH failed to ensure there was an ongoing Infection Control surveillance and monitoring of the physical environment to include the Peri-Operative area and failed to ensure staff maintained standards of practice for infection prevention and control. Findings include:

1. During a tour on 6/23/10 at 11:05 AM with the Director of Engineering, the Director of Housekeeping and the Infection Control nurse the following observations were made and confirmed:

a. In Operating Room (OR) #2 cracks with gaps (measuring approximately 1/8 th to 1/4 inch) were noted on the outside edge of one side of the operating room floor.
b. A metal panel located on the floor in front of a stainless steel cabinet in OR#2 was stained with rust.
c. Dust was observed on the metal grates of the air supply vent in OR #2.
d. Chipped paint was noted on the walls of OR #1, exposing under wall surface.
e. Four bowl stands were heavily soiled with rust on the wheel bases.

As per AORN (Association of Peri-Operative RNs) and CDC (Center for Disease Control) Standards of Practice recommend OR walls, floors and ceilings must be kept in good repair with no plaster exposed and OR floors should be seamless. The Infection Control nurse confirmed the areas of disrepair created an obstacle for maintaining a sanitary and safe environment.

Per interview with the Infection Control nurse at the time of the tour, it was also confirmed, despite the necessity to ensure strict standards of practice for infection prevention and control, active surveillance rounds and monitoring with both housekeeping and maintenance in the Peri-operative area had not been conducted for an undisclosed period of time. The nurse stated "It dropped off and I know we should".

2. On 6/21/10 at 2:15 PM during a tour with the Nurse Manager for Peri-Operative Services of the Decontamination Room (a receiving area for the cleaning of soiled, contaminated and reusable equipment and instruments) a hospital employee, identified to be an ultrasound technician, was observed wearing gloves while rinsing a high level chemical disinfectant off of a ultrasound probe at the decontamination sink, the technician failed to wear personal protective equipment (PPE) to include face mask/shield and fluid repellant gown. The ultrasound technician was then observed exiting the room with the probe (which was for patient use) wearing the same gloves and failed to cover the probe from contamination during transport to the radiology department. When confirming the observation and infection control breach with the Infection Control nurse on 6/23/10 at 9:35 AM, it was also confirmed that a policy, initiated on 12/13/06 and approved by the Infection Control nurse on 3/29/10, titled "High Level Chemical Disinfection", discussed the use of PPE when handling the chemical disinfectant. Per interview on 6/23/10 at 9:50 AM, the ultrasound technician confirmed s/he had failed to maintain appropriate infection control standards when handling the probe and did not take the necessary precautions when in contact with the high level disinfectant.

3. On 6/23/10 at 11:25 AM a surgical aide was observed transporting uncovered contaminated surgical instruments used during eye surgery from the OR to the decontamination room. When asked why s/he did not cover the contaminated surgical instruments when transporting from the OR, the aide stated s/he was not trained to cover eye instruments, but was aware other surgical case instruments should always be covered during transportation. The Infection Control nurse, who was present during the observation, confirmed all instruments required appropriate coverings during transport from the operating rooms to the decontamination room to prevent contamination of personnel or the environment. Per interview on 6/24/10 at 8:15 AM the Nurse Manager for Peri-Operative Services also confirmed all contaminated instruments used in any surgical case must be covered during transport to the decontamination room.

4. Per observation of the inpatient rehabilitation space, at 3:26 PM on 6/23/10, there was a cart containing dressing supplies including; packages of gauze pads, cling wrap and clear adhesive dressings stored in a location directly in front of a wall with a large hole that revealed exposed pipes and was littered with plaster dust and debris. Although the dressing supplies stored on top of the cart were covered with a sheet, other supplies, located on shelves below were not covered. The Physical Therapist who was present during the observation stated that the dressing cart was used by staff to dress patient wounds.

During interview at the time of observation the Staff Educator agreed that the cart should not be stored in that location because of the potential for contamination of supplies from the existing plaster dust and debris.

Based on observation, staff interview and record review, the Radiology ultrasound technician failed to maintain infection control practice and failed to follow CAH policy and procedure regarding high level chemical disinfection. Findings include:

On 6/21/10 at 2:15 PM during a tour with the Nurse Manager for Peri-Operative Services of the Decontamination Room (a receiving area for the cleaning of soiled, contaminated and reusable equipment and instruments) a hospital employee, identified to be an ultrasound technician, was observed wearing gloves while rinsing a high level chemical disinfectant off of a ultrasound probe at the decontamination sink, the technician also failed to wear personal protective equipment (PPE) to include face mask/shield and fluid repellant gown. The ultrasound technician was then observed exiting the room with the probe (which was for patient use) without changing gloves or washing their hands and failed to protect the probe from contamination during transportation to the radiology department. When confirming the observation and infection control breach with the Infection Control nurse on 6/23/10 at 9:35 AM, it was also confirmed that a policy, initiated on 12/13/06 and reviewed and approved by the Infection Control nurse on 3/29/10, titled "High Level Chemical Disinfection", discussed the use of PPE when handling the chemical disinfectant. Per interview on 6/23/10 at 9:50 AM, the ultrasound technician confirmed s/he had failed to maintain appropriate infection control standards when handling the probe and did not take the necessary precautions when in contact with the high level disinfectant.

Based on observation and staff interview, nursing staff failed to ensure consistent monitoring of dated laboratory blood sampling tubes. Findings include:

During a tour of the Intensive Care Unit on 6/23/10 at 10:10 AM, the pediatric code card contained the following expired blood tubes (used to obtain blood samples for testing): 6 blue tops expired on 11/09; green tops expired 01/10 and lavender tops expired 05/10. The observation was confirmed by the nurse manager for ICU.

Based on record review and confirmed by staff interview, the CAH failed to obtain and include in the medical record consultive screening and findings conducted in the ED for 1 applicable patient and failed to ensure a complete history and physical was conducted for 3 of 6 applicable patients admitted to the PPS Excluded Phychiatric Unit. (Patients #24, 25, 26, 27) Findings include:

1. Per review, on 6/23/10, the medical record for Patient #24 lacked documentation of a mental health screening evaluation conducted in the ED on 4/1/10. The patient, who presented to the ED on 4/1/10 with a chief complaint of "Depression and Suicidal Thoughts", had a mental health screening conducted by staff from HCRS (Healthcare and Rehabilitation Services) during the course of treatment. The patient was subsequently discharged home, however there was no record of the mental health consult conducted to reflect the decision regarding disposition.

During interview, on the afternoon of 6/23/10, the Chief of Patient Care Services, confirmed the lack of documentation of the mental health screening and received a faxed copy of the document after contacting and requesting same from HCRS.

The ED Nurse Manager stated, during interview on the morning of 6/24/10, that staff from HCRS are expected leave a copy of their mental health evaluations with the medical record upon completion of the consult, but "that doesn't always happen."

2. Per record review on 6/22/10, and confirmed by the the co-director of the PPS Excluded Psychiatric unit, the CAH Emergency Department medical screening exam was being substituted for the history and physical for Patients # 25, 26 and 27 who were recently admitted to the unit. Per interview on 6/22/10 at 11:15 AM, the co-director stated the unit had an "arrangement" with the ED to provide the history and physical however there is no assurance the history and physicals are consistently complete or adequate to meet the requirement for both CAH regulations and the regulations for the PPS Excluded Distinct Part additional requirements (? 412.27). In addition, the Rules and Regulations of the Medical Staff (revised 3/2009) state: Medical Records B-6 "The admitting physician shall be held responsible for the history and physical if the admitting physician has not transferred that patient to another physician's care within twenty-four hours of the patient's admission to the hospital". In the case of the 3 records reviewed, care was not transferred to another physicians care.

Based on observation and staff interview, the CAH's medical staff failed to complete medical records in a timely manner. Findings include:

During the afternoon of 4/22/10 incomplete medical records were observed stored in a dictation room. Per interview with the Medical Records manager, a deficiency count is done weekly and a report is provided to the Chief of Quality and Systems Improvement. The manager stated records which remain incomplete for greater then 30 days are considered delinquent. Per review of the report, as of 6/24/10 110 records were delinquent. In addition, the "Rules and Regulations of the Medical Staff" (revised 3/2009) Medical Records: B-9 states: "Medical records must be completed within thirty days. Compliance with record completion will be assessed on a weekly basis in accordance with the approval of Hospital Policy on medical Record Completion".

(Based on observation, interview and record review, the CAH failed to assure that surgical procedures were performed in an environment and manner that promoted patient safety and well-being as evidenced by the facility's failure to ensure the following: a.) that access to the preoperative, central sterile decontamination room and surgical and perioperative area is limited to authorized personnel only; b.) that equipment and floors in the perioperative area were cleaned and maintained in accordance with acceptable standards of practice; c.) that all staff utilizing the decontamination room consistently adhered to proper infection control practices; d.) that the policy and procedure pertaining to the disinfectant utilized for reprocessing endoscopes went through the proper review and approval process prior to its implementation; e.) that all personnel accessing the OR are appropriately attired; and f.) that all staff received appropriate relevant training. Findings include:

1. During a tour on 6/21/10 at 1:00 PM with the Nurse Manager for Peri-Operative Services and on 6/23/10 at 11:05 AM with the Director of Engineering, the Director of Housekeeping and the Infection Control nurse the following observations were made and confirmed:

a. In Operating Room (OR) #2 cracks with gaps (measuring approximately 1/8 th to 1/4 inch) were noted on the outside edge of one side of the operating room floor.
b. A metal panel located on the floor in front of a stainless steel cabinet in OR#2 was stained with rust.
c. Dust was observed on the metal grates of the air supply vent in OR #2.
d. Chipped paint was noted on the walls of OR #1, exposing under wall surface.
e. Four bowl stands were heavily soiled with rust on the wheel bases.

As per AORN (Association of Peri-Operative RNs) and CDC (Center for Disease Control) Standards of Practice recommend OR walls, floors and ceilings must be kept in good repair with no plaster exposed and OR walls, floors and ceilings should be seamless. The Infection Control nurse confirmed the areas of disrepair created an obstacle for maintaining a sanitary and safe environment.

2. On 6/21/10 at 2:15 PM during a tour with the Nurse Manager for Peri-Operative Services of the Decontamination Room (a receiving area for the cleaning of soiled, contaminated and reuseable equipment and instruments) a hospital employee, identified to be an ultrasound technician, was observed wearing gloves while rinsing a high level chemical disinfectant off an ultrasound probe at the decontamination sink. The technician failed to wear personal protective equipment (PPE) to include face mask/shield and fluid repellant gown. The ultrasound technician was then observed exiting the room wearing the same gloves, and continued to transport the probe uncovered, increasing the risk for contamination, to the radiology department for patient use. When confirming the observation and infection control breach, the Nurse Manager for Peri-Operative Services stated, although s/he was responsible for oversight of all Peri-operative areas, s/he had limited control of employees who utilized the decontamination room s/he had limited control of employees who utilize the decontamination room, although s/he is responsible for all Peri-Operative areas.

3. On 6/23/10 at 11:25 AM a surgical aide was observed transporting uncovered contaminated surgical instruments used during eye surgery from the OR to the decontamination room . When asked why s/he did not cover the contaminated surgical instruments when transporting from the OR (required to prevent contamination of personnel or environment) to the soiled area in the decontamination room, the aide stated s/he was not trained to cover eye instruments, but was aware other surgical case instruments should always be covered during transportation after use. Per interview on 6/24/10 at 8:15 AM the Nurse Manager for Peri-Operative Services confirmed all contaminated instruments used in any surgical case must be covered during transport to the decontamination room. In addition, the manager was unable to provide proof of the orientation and training for the surgical services aide.

4. On 6/23/10 at 11:30 AM clean covergowns worn by the housekeeping staff when cleaning the operating rooms were observed stored in the housekeeper closet, where tasks, including the emptying of mop buckets, occured, increasing the risk for potential contamination of the clean gowns. The Infection Control nurse, present during the observation, confirmed the storage of the gowns in the closet was a breach in infection control standards of practice and should be stored in a clean environment

5. Per observation on the afternoon of 6/21/10, the CAH failed to ensure access to the preoperative, central sterile decontamination room and the operative area is limited to only authorized personnel. There was limited signage or floor markings to alert the public, who also utilize part of connecting corridors in the Peri-Operative area, of the unauthorized and restricted access to these specific areas. In addition, there was an unsecured door between the preoperative area and the emergency department facilitating the potential for unauthorized access to preoperative area.

6. Per record review and staff interview, the CAH staff failed to follow their own policy for review of policies and procedures used by Endoscopy staff for the disinfecting and reprocessing of endoscopes. During a tour of the Endoscopy suites on 6/21/10, the RN in charge stated the nurses are responsible for disinfecting and reprocessing of the endoscopes. When asked for the policy for this process the Nurse manger for Peri-Operative Services provided a document which was represented only as a guideline for hospitals to use to developed their own institutional policies, procedures and protocols. Per interview on the morning of 6/24/10 the Chief of Patient Care Services and the Infection Control nurse were unaware of the use of the document "Guidelines for Use of High Level Disinfectants and Sterilants for Reprocessing Flexible Gastrointestinal Endoscopes" as a facility policy for surgical services. They confirmed that the development of a policy or procedure for disinfecting and reprocessing endoscopes would require review and approval by the VP of Patient Services, Surgical services and Infection controlprior to it's initiation and implementation as a CAH.

Based on staff interview and record review Anesthesia services failed to ensure a post-anesthesia evaluation report was conducted by a practitioner qualified to administer anesthesia for each patient receiving anesthesia for 4 of 9 applicable patients. (Patients #14, 16, 19, 22 ) Findings include:

1. Per record review Patient #22, who underwent 2 separate surgical procedures during the same hospital admission did not have evidence of a post anesthesia follow up evaluation following either procedure. The patient, who received general anesthesia during an operative procedure performed on 5/5/10, did not have evidence of a post-anesthesia follow up evaluation to determine adequate recovery from the anesthesia. The patient developed post -operative complications and underwent a second surgical procedure, on 5/13/10, also requiring the administration of general anesthesia for which there was no evidence of post anesthesia follow-up report.

During interview, at 8:30 AM on 6/24/10, the Medical Director for Anesthesia Services confirmed the lack of post anesthesia follow up for each of the surgical procedures, and stated that they had not been as "diligent " as they should be in completing the post anesthesia evaluations of patients.

2. Per record review on 6/23/10 there was no evidence in the record of a post-anesthesia follow-up evaluation/report for Patient #14, who had a surgical procedure requiring general anesthesia on 11/24/09. This was confirmed with the Medical Director of Anesthesia on 6/24/10 at 3:15 PM.

3. Per record review on 6/23/10, Patient #19 underwent surgery requiring general anesthesia on 6/1/10. No post-anesthesia follow up evaluation/report was conducted, as required. This omission was confirmed by the Chief of Patient Services on 6/23/10 at 4:30 PM.

4. Per record review on 6/23/10, there was no evidence in the record of a post-anesthesia follow-up evaluation/report for Patient #16 who was administered spinal anesthesia during childbirth. Per telephone interview on 6/23/10 at 4:30 PM, the Medical Director for Anesthesia stated, regarding post-anesthesia evaluations/report following spinal anesthesia, "Sometimes we do and sometimes we don't, it depends of the OR schedule and availability......". The physician also confirmed there was no specific policy to meet this requirement.

Based on observations, staff interviews and record review the CAH failed to ensure all patient care services and other services affecting patient health and safety had an effective and responsive Quality Assurance Program.

Refer to Tags C 0222, 278, 320, 337

Based on staff interview and record review, the CAH Quality Assurance programs for Pharmacy, Infection Control, Maintenance/Housekeeping and Surgical Services failed to identify the following deficient practices. Findings include:

1. Per staff interview and record review, pharmacy failed to identify a deficient practice related to identification and reporting of refrigerator temperatures outside the acceptable range. In addition there was a failure to identify a discrepancy in acceptable temperature range as defined in the facility's policy for monitoring medication refrigerator temperatures and the monitor log utilized by staff.

Per observation, during visual inspection of medication refrigerators with a pharmacy aide, on the morning of 6/23/10, the temperature logs used by nursing staff to document the temperature of the refrigerators, did not clearly define the acceptable temperature range. Although the log instructed staff to notify Pharmacy for any temperature outside the accepted range, it was printed in black and white and did not clarify the acceptable temperature range.

During interview, at the time of separate observations in both the ED and ICU (Intensive Care Unit), RNs #1 and #2 both stated that, although they were responsible for monitoring the temperatures, they did not know what the appropriate temperature range was for the medication refrigerators in each of their respective units.

Per review of the original Medication Refrigerator Temperature Log, provided by the pharmacy following the observations, the acceptable temperature range was clearly defined by color and identified as between 3 and 7 degrees C (centigrade). Although the temperature logs for both the ED and ICU for the month of June 2010 revealed temperatures documented between 2-8 degrees C on more than one occasion, there was no evidence that pharmacy had been notified of temperatures outside the acceptable range.

Per record review, on 6/23/10, a discrepancy was noted between the acceptable temperature range identified on the Medication Refrigerator Temperature Log utilized by staff for monitoring the temps (3-7 degrees C) and the facility's policy, "Refrigeration (Medication)", dated 9/10/09, which states; "A thermometer that will indicate the normal range (2-8 degrees centigrade) shall be kept in each drug refrigerator"............"Standard refrigerator temperature is 2 degrees C to 8 degrees C...".

During interview, on the morning of 6/23/10, the Director of Pharmacy Services confirmed that the Medication Refrigerator Temperature Logs, which had been copied in black and white form, for staff use in monitoring temperatures, did not clearly define the acceptable temperature range (identified on the original, by color, as 3-7 degrees C). S/he further confirmed that there was no evidence that staff had reported any temperatures outside the acceptable range for the month of June to pharmacy staff and that, although there was a quality assessment process in place for Pharmacy to monitor the Medication Refrigerator Temperature Logs on a monthly basis, these issues had not been identified. The Pharmacy Director also confirmed, during a subsequent interview, at 9:05 on 6/24/10, that s/he had not been aware of the discrepancy between the acceptable temperature range for the medication refrigerators identified on the Medication Refrigerator Temperature Log and the facility's Refrigeration (Medication) policy until informed by the surveyor.

2. Based on observation, interview and record review, Surgical Services Quality Assurance Program failed to identify that access to the preoperative, central sterile decontamination room and surgical and perioperative area should be limited to only authorized personnel; failed to conduct ongoing monitoring and survailence to ensure there was appropriate cleaning and maintenance of OR floors and equipment used during surgery; failed to ensure conformance of proper infection control practice by all staff utilizing the decontamination room; failed to ensure polices and procedures pertaining to disinfectant for reprocessing endoscopes was reviewed and approved prior to practice; failed to ensure staff who accessed the OR utilized clean surgical coverings and failed to maintain ongoing documentation of staff orientation and training for tasks assigned.

Refer to Tag C-0320

3. Per interview with the Director of Engineering on 6/23/10 at 11:15 AM confirmed routine maintenance/housekeeping surveillance rounds have not been conducted in the Peri-Operative area for an undisclosed period of time, however confirmed interdisciplinary rounds must resume and include both the Director of Housekeeping and the Infection Control nurse.

Refer to Tag C-0222

4. Per interview on 6/23/10 at 11:30 AM, the Infection Control nurse confirmed despite the necessity to ensure strict standards of practice for infection prevention and control, a quality assurance program for the active surveillance rounds and monitoring with both housekeeping and maintenance in the Peri-operative area had not been conducted for an undisclosed period of time. The nurse stated "It dropped off and I know we should".

Refer to Tags C-0222, 0278