HospitalInspections.org

Based on document review, observation and interview, the facility failed to ensure policies, procedures and standards of practice were followed by surgery department personnel related to dress code, failed to ensure housekeeping personnel, in terminal cleaning, used disinfectants on all surfaces, failed to ensure staff followed isolation policies related to droplet and contact isolation, failed to ensure staff followed its policy for central catheters related to dressing changes, failed to ensure that air flow monitoring of a transplant positive pressure room and a negative pressure isolation room were monitored on a daily basis when patient present and failed to ensure staff cleaned a nebulizer after patient use.

Findings include:

1. Review of policy/procedure POS 1.07, Dress Code: Preoperative Practice Domain, indicated the following:
"V. Policy Statements
8. All hospital provided preoperative attire is laundered between uses by a designated professional laundry, and is not to be laundered at home.
C. Head/Face
1. Head and facial hair including sideburns and neckline will be covered. Standard, disposable bouffant and hood style covers are preferred.
2. Cloth hats are optional and should consist of a standard OR polyester/cotton blend, and should cover all hair. Cloth hats should be laundered when visibly soiled. Wearing disposable bouffant hats over cloth hats is optional.
4. Masks are to cover the mouth and nose completely and will be secured to prevent venting from occurring at the sides. Masks will be worn either on or off, rather than hanging around the neck, and must be changed at minimum between cases or more often when soiled. Masks are not to be worn outside the preoperative area."
This policy/procedure was last reviewed/revised on 02-2012.

2. Review of the AORN Journal dated August 2010 indicated the following:
"Fabric head coverings should cover the hair and scalp completely. Fabric head coverings should be laundered daily in a health care-approved or accredited laundry."

3. On 07-10-12 at 0910 hours with staff #47 & 48 in the Surgery Department, the following was observed in Operating Room 20: 2 operating room staff wearing personal cloth caps without disposable bouffant caps, 1 staff was wearing a black colored cap with hair exposed at the back of head. The 2 staff with masks on left Operating Room #20 with a patient to the Post Anesthesia Care Unit (PACU). In the PACU the 2 staff had the masks hanging around the neck. The 2 staff then went to the Preoperative area with the masks still on the neck. The staff member wearing the black colored cap changed his/her mask prior to returning to OR #20 for the next operative case. The other staff member wore the same mask to OR#20 for the next operative case.

4. On 07-10-12 at 0910 hours, staff #47 & 48 confirmed that the facility does not launder the OR staff's personal cloth caps. On 07-10-12 at 1000 hours, staff #47 confirmed that the staff member wore the surgical mask from OR #20 to PACU, then to Preoperative area and back to OR #20.

5. On tour of the transplant unit at 12:15 PM on 07/10/12, rooms were identified as positive pressure. Two rooms were tested and showed positive pressure.

6. In interview at 12:15 PM on 07/10/12, staff member #N2 indicated they check rooms with smoke tubes on monthly basis.

7. In interview on 07-10-12 at 1505 hours, staff #50 confirmed that patient rooms on the Transplant Unit 7N are positive air flow and are not checked on a daily basis when a patient is assigned to the unit.



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8. Facility policy titled "STANDARD AND TRANSMISSION-BASED ISOLATION PRECAUTIONS" last reviewed/revised 10/11 states on page 7, E.1.b: "Facilities will check the room at daily intervals to ensure that negative pressure is maintained...."

9. Review of document titled "ISOLATION ROOM NEGATIVE AIR FLOW MONITORING FORM" indicated a patient in room 6040 was in isolation 12/21/11-1/6/12. The form states under directions: "2. Record daily smoke test results on the table below....." The form lacked evidence that the room was checked on 12/22/11-12/24/11, 12/26/11, and 1/2/12.

10. Staff member #N1 verified the missing dates on the form at 11:55 a.m. on 7/11/12.

11. Facility policy titled "DISCHARGE/TRANSFER CLEANING" last reviewed/revised 4/16/12 states "Follow the daily cleaning steps procedure as outlined in ES #1. In addition, perform the following..........Wipe down the shower with Sanimaster 4...." ES #1 policy titled "DAILY CLEANING STEPS" last reviewed/revised 4/16/12 indicates that Sanimaster 4 is to be used for bathroom cleaning. The policy indicates that light duty cleaner can be used to clean the floor.

12. Facility policy titled "ISOLATION ROOM CLEANING" last reviewed/revised 4/16/12 states on page 1: "Follow the general cleaning procedures. You do not need to clean an isolation room any differently than any other patient room....."

13. Observation of terminal cleaning of a discharge room beginning at 3:20 p.m. on 7/9/12 indicated the following:
(A) Housekeeper #1 used "scrub and shine" toilet bowl cleaner for the toilet bowl, "light duty floor cleaner" on the floors, and "all purpose cleaner" on the shower walls and floor. Per review of product label for each, the products are not a disinfectant.
(B) Housekeeper #1 indicated in interview at 3:30 p.m. on 7/9/12 that they do not use the "Sani master" product.

14. Staff member #N1 verified at 9:00 a.m. on 7/10/12 that the products used by housekeeper #1 (5.A above) are not disinfectants.

15. Facility policy titled "PERIPHERALLY INSERTED CENTRAL CATHETERS (PICC) MAINTENANCE AND REMOVAL" last reviewed/revised April 2009 states on page 6 of 14 under dressing change: "....4. Take precautions to avoid contaminating site with airway secretions. Place mask on patient or have patient turn head away from site."

16. Observation of a PICC line dressing change at 11:55 a.m. on 7/10/12 indicated the following:(A) RN #1 changed a PICC line dressing on patient #N2.
(B) The RN did not place a mask on the patient or instruct the patient to keep his/her head turned. The patient moved their head freely during the procedure.

17. Facility policy titled "SMALL VOLUME NEBULIZER" last reviewed/revised October 2009 states on page 2: "I. Turn off air compressor or flowmeter, disconnect oxygen tubing, and place nebulizer back into treatment bag."

18. Observation of nebulizer treatments on 7/9/12 per respiratory therapy (RT) indicated the following:
(A) R.T. #1 completed a nebulizer treatment on patient #N3 at 1:00 p.m. He/she placed the nebulizer in a plastic bag. He/she did not clean the equipment.
(B) R.T. #2 completed a nebulizer treatment on patient #N4 at 2:10 p.m. He/she placed the nebulizer in a plastic bag once completed. He/she did not clean the equipment.

19. R.T. #1 indicated in interview at 1:00 p.m. on 7/9/12 that R.T. does not clean the equipment after use.

20. R.T. #2 indicated in interview at 2:10 p.m. on 7/9/12 that R.T. does not clean the equipment after use.

21. Facility policy titled "STANDARD TRANSMISSION-BASED ISOLATION PRECAUTIONS" last reviewed/revised October 2011 states on page 6 of 11: "C. CONTACT Precautions..............2. Before entering a patient's room, don a gown. Use a surgical mask if needed for Standard Precautions at this time. 3. Perform hand hygiene. 4. Put on gloves 5. Provide care......"

22. During observations on 7/9/12, the following was observed:
(A) At 1:15 p.m., RN #2 was observed going into a contact isolation room with no gown or gloves. Supplies were available outside the patients door.
(B) At 4:15 p.m. RN #3 was observed going into a contact isolation room without gown or gloves. Supplies were available outside the patient's door.

23. Facility policy titled "STANDARD AND TRANSMISSION-BASED ISOLATION PRECAUTIONS" last reviewed/revised October 2011 states on page 7 of 11: "D. Droplet precautions............ 2. Put on surgical mask.................5. Remove mask and discard mask inside the room and perform hand hygiene....." Page 9 states "1. Isolation signs must be maintained in each patient care area. 2. The signs must not be obscured by other signage."

24. Review of patient #N5 medical record indicated the following:
(A) He/she had an order dated 7/2/12 for Droplet isolation.

25. Observation of patient #N5 room at 12:15 p.m. indicated that there was no signage on the door and there were no mask outside the door for staff to utilize.

26. Staff member #N1 verified there was no signage or PPE outside the patient's door at the time of observation.