HospitalInspections.org

Based on review of the Association of Perioperative Registered Nurses, Environmental Cleaning-Intraoperative Areas policy for "Enhanced Environmental Cleaning, pest control report review, observation and interviews, the hospital failed to provide a sanitary environment to avoid sources and transmission of infections in 1 (#13) of 17 surgery suites.

The findings include:

Review of the Association of Perioperative Registered Nurses, Environmental Cleaning-Intraoperative Areas Including Operating and Procedure Rooms policy for "Enhanced Environmental Cleaning" published 2016 showed," Implement enhanced environmental cleaning procedures following the care of patients who are infected or colonized with multidrug-resistant organisms. In addition to standard precautions, wear gowns and gloves when performing enhanced environmental cleaning procedures. Clean and disinfect all high-touch objects, in addition to objects cleaned as part of routine cleaning, as part of enhanced environmental cleaning procedures after the patient leaves the OR including storage cabinets, supply carts, and furniture; light switches; door handles and push plates; telephones and mobile communication devices; computer accessories (eg, keyboard, mouse, touchscreen); chairs, stools, and step stools; and trash and linen receptacles. Clean and disinfect floors and walls of operating and procedure rooms after each surgical or invasive procedure if soiled or potentially soiled."

Review of the pest control provider's report dated 2/4/2025, revealed "...targeted pest...Boric acid... American Cockroach...treated sub-basement for American cockroach..."

Interview with the Regulatory Compliance Officer on 2/4/2025 at 3:50 PM, revealed she was unaware of any event involving insects in the surgical suite and she was unaware of the cockroach had landed on a sterile field during surgery. She stated this information should have been reported to her immediately.

Interview with the Interim Administrator on 2/4/2025 at 3:50 PM, revealed he was unaware of any incident involving insects in the surgery suites or that a cockroach had landed on a sterile field during surgery. He stated this information had not been reported to him immediately as would be expected.

During an interview on 2/4/2025 at 4:00 PM, surgical registered nurse (RN) C stated on 2/3/2025, in surgical suite #13, during a thyroidectomy (removal of the thyroid gland) approximately halfway through the surgery, she heard Surgical Tech (technician) B scream. RN C observed a large cockroach jump from Surgical Tech B's right arm onto the sterile field containing the surgical instruments. Interview continued and revealed a second surgical nurse, RN E removed the cockroach from the sterile field, placing it in a plastic container. Surgical Tech B had to re-gown, re-scrub (hand washing process to reduce the risk of infection) and re-glove before the surgery could be resumed. Interview revealed the surgeon, Physician A, had another surgery to follow. Interview confirmed there was no terminal cleaning performed in surgical suite #13 following the cockroach incident and before another patient was brought into surgical suite #13 for surgery.

During an interview on 2/4/2025 at 4:05 PM, the Environmental Services Director stated he was made aware on 2/3/2025 at 10:00 AM, a cockroach was observed in surgical suite #13. He notified the hospital's pest control provider immediately. Interview revealed the pest control provider arrived at the facility on 2/4/2025 at 11:00 AM and a picture of the cockroach was provided. Interview revealed the pest control technician identified the insect as an American cockroach and indicated the cockroach most likely entered the facility through the sewage system.

During an interview on 2/4/2025 at 4:20 PM, the Director of Surgery stated a thyroidectomy was being performed by Physician A on 2/3/2025. Interview revealed she was told midway through the surgery a large cockroach landed on the back of Surgical Tech B, crawled down the right arm of Surgical Tech B, and landed onto the mayo table (a table with a sterile field which holds the sterile surgical instruments). Interview revealed the mayo table was positioned directly over the patient's abdomen when the cockroach fell onto the table. Interview revealed the hospital has 17 surgery suites and the previously scheduled surgery for suite #13 was conducted after the usual cleaning between surgery cases. She stated prior to the next surgery case, any other cockroaches were looked for but not observed in surgery suite #13. The interview confirmed the Director of Surgery had contacted the Environmental Services Director immediately, but had not reported the incident to Infection Control or her supervisor.
Interview continued and revealed a cockroach was found in the employee break room refrigerator, adjacent to the surgery suites, on 1/23/2025. Interview continued and revealed there were open food containers in the refrigerator. She stated the staff cleaned out both refrigerators and initiated a policy that food left in the refrigerator had to be placed in a sealed container.

An observation of the two breakroom refrigerators was conducted on February 5, 2025, at 11:45 AM, revealed several lunch boxes of employees in the two refrigerators with food in sealed containers.

During an interview on 2/5/2025 at 9:20 AM, Physician A stated she was performing a thyroidectomy on 2/3/2025 and about halfway through the surgery, while the surgical site was open, Physician A heard a scream from Surgical Tech B. Surgical Tech B was standing at Physician A's right side and she turned to see why Surgical Tech B screamed and observed a large cockroach jump from Surgical Tech B's right arm onto the mayo table. She stated the cockroach did not come in contact with the patient at any time. The mayo table was moved away from the patient, the surgical instruments were replaced, and Surgical Tech B replaced her surgical gown and re-scrubbed before the surgery could continue. There was approximately a 15-minute delay but Physician A stated this did not have any effect on the patient.

During an interview on 2/5/2025 at 10:15 AM, surgical RN D stated on 2/3/2025, when Surgical Tech B screamed and RN D observed a large cockroach crawl down Surgical Tech B's right arm onto the mayo table. Interview revealed Surgical Tech B replaced the surgical gown, re-scrubbed, and the surgery resumed. Interview revealed another surgery was scheduled for surgery suite #13 and the suite was cleaned, but not terminally cleaned after the cockroach was observed in the surgery suite.