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Based on observations, interviews and document review, the facility failed to monitor and mitigate infection risks. Specifically, the facility failed to monitor and correct operating room (OR) floor defects. The failure was identified in two of five ORs which were in use by the facility while awaiting installation of new flooring (OR #6 and OR #9).

Findings include:

Facility policies:

Turnover Cleaning for Sterile Procedure Rooms dated 60/20/20 read, clean and disinfect the sterile procedure rooms, such as surgery rooms, after each case in accordance with AORN and joint Commission practices and standards. During surgery, open wounds are very susceptible to infection by harmful bacteria. Adhering to cleaning and disinfecting procedures in the surgical rooms can help save lives by minimizing risk of exposure to patients and hospital staff.

Terminal Cleaning for Sterile Procedure Rooms dated 6/20/20 read, clean and disinfect the sterile areas in a sterile procedure room, such as surgery rooms, upon completion of all scheduled surgeries at the end of the day in accordance with industry (e.g., AORN) standards and CDC recommendations. Patients in surgery are vulnerable to infection. The level of cleanliness in sterile areas is vital to keeping our patients safe. Record any maintenance issues and notify your manager.


References:

The Association for periOPerative Registered Nurses (AORN), Guidelines for Perioperative Practice, 2019: Guideline for Design and Maintenance, Recommendation XII and XII. a (page 96) read, the health care organization should create and implement a systemic process for monitoring and maintaining structural surfaces and Heating, Ventilation and Air Conditioning (HVAC) system performance. The integrity of structural surfaces (doors, floors, walls, ceiling and cabinets) should be maintained and surfaces should be repaired when damaged.

The AORN, Guidelines for Perioperative Practice, 2019: Guidelines for Environmental Cleaning, Recommendation II (page 178) read, the patient should be provided with a clean, safe environment. Recommendation III and III.c.5 (pages 180-182) read, a clean environment should be reestablished after the patient is transferred from the area. Reestablishing a clean environment after the patient leaves the area decreases the risk of cross-contamination and disease transmission. The floors and walls of operating and procedure rooms should be cleaned and disinfected after each surgical or invasive procedure if soiled or potentially soiled by splash, splatter or spray. Recommendation IV and IV. b (page 183) read, perioperative areas should be terminally cleaned. Terminal cleaning and disinfection of the perioperative environment decreases the number of pathogens and the amount of dust and debris. All floors in the perioperative and sterile processing area should be disinfected.

The Facility Guidelines Institute (FGI), Guidelines for Design and Construction of Hospitals, 2018: Common Elements for Hospitals, 2.1-7.2.3 Surfaces (pages 107-110) read, reduction of surface contamination linked to health care-associated infections (HAI's) by selection of surfaces and furnishings which would be easy to clean, with no surface crevices, rough textures, joints or seams. Floor and wall base assemblies shall be monolithic (consisting of one piece, solid and unbroken).

1. The facility failed to monitor operating room surfaces for defects.

a. Observations revealed floors in the operating rooms had tears and breaks in the surface.

i. On 7/1/21 at 3:15 p.m., observations in OR #9 revealed an area of the floor was warped and had slits cut around the area. Staff were observed to turn over the room (the process in which staff cleaned and disinfected the OR environment after a patient left the room to decrease risk of spread of infectious disease to the next patient). Staff mopped the floor from the furthest corner of the room towards the door.

While on tour, Perioperative Manager (Manager) #4 stated she were unaware of the defect and the plan for repair.

ii. On 7/7/21 at 1:54 p.m., observations in OR #6 revealed an area of the floor was warped with a tear in the flooring material. The floor was a different color than the main floor.

While on tour, Manager #4 stated the area was patched in the past. Manager #4 stated she was unaware of the defect.

Observations were in contrast with AORN guidelines which stated the integrity of structural surfaces, such as floors, were to be maintained and repaired when damaged. Additionally, observations were in contrast with FGI guidelines in which floors were monolithic and without surface crevices.

b. Interviews with leadership revealed they were unaware of the floor defects and if the patch used was approved for use in the ORs.

i. On 7/7/21 at 11:08 a.m., an interview was conducted with Infection Prevention Manager (Manager) #1. Manager #1 stated the facility followed AORN guidelines for prevention of infection in the ORs. She stated she was unaware of the damaged floors in OR #6 and OR #9. Manager #1, she stated the risk of a damaged floor was more pathogens (organisms which caused disease) on the floor.

ii. On 7/7/21 at 2:20 p.m., an interview was conducted with Director of Facilities (Director) #3. He stated the flooring in the ORs was older and required maintenance. Director #3 stated some of the OR floors were replaced and others were scheduled as the flooring materials were received. Director #3 stated he was unaware of the holes and defects in the floors of OR #6 and OR #9. Director #3 stated if floors were not sealed or were damaged, staff was unable to clean the floors for infection prevention. He stated the ORs with floor damage were not closed due to the floor damage and planned to patch the holes with tape.

On 7/8/21 at 2:37 p.m., a subsequent interview was conducted with Director #3. Director #3 stated the recommended repair for vinyl flooring was a seam welded patch. He stated the Condor tape used by the facility was a quick fix to mitigate the risk of infection. Director #3 stated the damage to the OR floors was a concern for at least five years. Director #3 stated the tape was purchased from an industrial supply company and was unsure if it was intended for use in the OR. He stated it was vinyl and cleanable, and if the tape edges rolled up, it was replaced. Director #3 stated an infection control risk assessment was not done for the use of the tape. He stated the facility followed FGI guidelines and flooring in ORs was required to be monolithic. Director #3 stated the facility planned to replace all OR flooring with Terrazzo which was monolithic. He stated the tape was temporary and used for quick fix until the entire floor was replaced or a seam welded patch was placed.

iii. On 7/7/21 at 2:58 p.m., Regulatory Standards Manager (Manager) #2 stated the Director of Environment of Care was unable to provide environmental rounds for the OR completed in the last year. She stated the rounds did not occur due to the pandemic.

c. On 7/8/21 at 2:55 p.m., an interview was conducted with Surgical Technologist (Tech) #6. Tech #6 stated one of the roles of the surgical techs and OR assistance was to turnover the rooms between surgical cases. Tech #6 stated staff was not instructed to report floor defects for repair.

This was in contrast with facility policy which required staff to report maintenance issues to managers.

The facility was unable to provide national guidelines or documentation for the use of the tape to patch damaged floors in the operating rooms.