HospitalInspections.org

A. Based on document review, observation, and interview, it was determined, for 2 of 2 Physicians (MD #3 & 5), the Hospital failed to ensure physicians followed the hand hygiene policy and AORN (Association of Perioperative Registered Nurses) Standards and Recommended Practices when working in the Perioperative Area (OR).

Findings include:

1. On 8/29/17 at 3:05 PM, Hospital policy titled, "Hand Hygiene", reviewed 6/13/14, was reviewed. The policy required, "Hand hygiene should be performed before and after every patient/ resident contact, as in the following, but not limited to... 8. Upon removing sterile or non-sterile gloves... 12. After handling contaminated material or waste..."

2. On 8/29/17 at 3:10 PM, the Association of Perioperative Registered Nurses Perioperative Standards and Recommended Practices, 2014 Edition was reviewed. The Standards included, "Hand Hygiene, Recommendation II, Standard procedure for hand washing should be followed... before putting gloves on and after removing gloves... any time there is a possibility that there has been contact with blood or other potentially infectious material or surfaces..."

3. On 8/29/17 at 11:20 AM, an observational tour was conducted in the Perioperative and decontamination areas. At 1:10 PM, in OR suite #7, an Anesthesiologist (MD #5), with a gloved hand, adjusted the lid of the red sharps bucket so the lid would remain open. MD #5 touched the sharps bucket lid a second time to open it further. MD #5 did not change gloves or disinfect his hands. MD #5 proceeded to adjust Pt. #1's nasal oxygen tube, the anesthesia machine, Pt. #1's blood pressure cuff, and prepare the antibiotic piggy back intravenous tubing. MD #5 did not disinfect his hands or change gloves after touching the contaminated red sharps bucket lid.

4. At 2:14 PM, Pt. #1 laying on her left side with her buttocks exposed, had an explosive bowel movement, with some of the fecal matter landing on the floor. The Surgeon (MD #3), wearing gloves, placed towels over the fecal mater, wiped up the fecal matter, and placed the soiled towels in a waste container. MD #3 did not change his gloves or disinfect his hands. MD #3 placed clean towels under Pt. #1, adjusted the cautery pad line, and raised the table. MD #3 changed his gloves but did not disinfect his hands. MD #3 adjusted the surgical lamps and then left OR suite #7 to scrub in.

5. On 8/29/17 at 2:20 PM, an interview was conducted with the OR Manager (E #5). E #5 stated the OR follows AORN Standards and MDs #3 & 5 should have removed their gloves and disinfected their hands after touching contaminated items.


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B. Based on document review, observation and interview, it was determined, that the Hospital failed to ensure proper surgical attire was worn in the Perioperative Area (OR) for 4 out of 10 employees (E #3, E #4, MD #3, & MD #4).

Findings include:

1. On 8/29/17 at 2:00 PM, the Hospital policy titled, "Surgical Attire" revised 2/17/2016 was reviewed. The "Surgical Attire" policy indicated, "Purpose...to delineate appropriate attire for prevention and transportation of microorganisms into the surgical suite...Rings, and bracelets, are to be removed."

2. On 8/29/17 at 2:15 PM, the Association of Perioperative Registered Nurses' (AORN) Perioperative Standards and Recommended Practices 2014 Edition was reviewed. The Perioperative Standards and Recommended Practices indicated "...Jewelry including earrings, necklaces, watches, and bracelets that cannot be contained or confined within the surgical attire should not be worn... A clean, low-lint surgical head cover or hood that confines all hair and cover scalp skin should be worn. Hair acts as a filter when it is uncovered and collects bacteria in proportion to its length...Masks should not be worn hanging down from the neck..."

3. An observational tour of the Perioperative Area was conducted on 8/29/17 between 12:30 PM and 1:30 PM. At 12:55 PM, in the semi-restricted OR corridor, an Anesthesiologist (MD #5) was observed with his mask hanging from his neck.

4. At 1:00 PM, the Manager of Quality Assurance and Performance Improvement (E #3), in OR suite 7, where sterile instruments and supplies were open, had 2 gold chains around her neck and 1 gold bracelet and watch on her left wrist. The Quality Data Analyst (E #4) was wearing a gold chain around her neck.

5. At 1:05 PM, in OR suite 7, the Surgeon's (MD #3) beard was exposed approximately 1 inch between the mask and head cover.

6. On 8/29/17 at 2:20 AM, an interview was conducted with the OR Manager (E #5). E #5 stated the OR follows AORN Standards and Practices. E #5 stated that "Dangling masks should be removed... There should not be jewelry worn in the operating room... E #3's beard should have been covered. "