HospitalInspections.org

Based on observation, interview and policy review the facility failed to provide a safe environment for all patients by ensuring that staff maintain supply package integrity for 63 of 63 intravenous (IV) line tubings in the anesthesia supply room and failed to maintain the medical asepsis (condition of the environment - free from infecting organisms) free from dust for the top of crash carts for 3 of 3 crash carts in the Operating Room (OR) hallway, this practice places all OR patients at risk for an infection. Facility census was 188 on the first day of survey.

Findings include:

1. Review of the facility's policy titled "Aseptic Technique", Policy #SUR 1010.0308 dated 3/08 and reviewed on 12/01/10 directs staff in part the following:

Policy: All personnel working in the operating room environment must have basic knowledge and appreciation of aseptic technique and contamination control to facilitate patient safety.

Purpose: To direct personnel in maintaining cleanliness and eliminating infectious agents.

Action Directives:
3. A. All items are to be inspected immediately before presentation to the sterile field for proper packaging, processing, seal, package container integrity, and inclusion of sterilization indicator.

8. Control of Contamination is Maintained By:
d. Cleaning OR Suites furniture, fixtures and floors daily, on an interval and terminal basis with approved disinfectant germicide solution.

Review of AORN (Association of Operating Nurses) 2010 Edition of Perioperative Standards and Recommended Practices on 12/02/10 directs staff in part to:

Recommendation VI - Potential hazards associated with the use of medical equipment in the practice setting should be identified, and safe practices should be established.

VI.e. A written plan should be developed describing the processes to be implemented to effectively manage medical equipment including selection, purchase, inspection, and maintenance.

Review of Administrative Policy titled: Cardiopulmonary Resuscitation dated July 2010 and reviewed on 12/01/10 directs staff in part:
V. Routine Checking Procedure
A. Emergency Cart contents will be checked and documented on the Emergency Cart Check Sheet as follows:
1. Unit staff will check the integrity of the Emergency Cart.

2. Observation on 12/01/10 at 1:15 PM, of the anesthesia supply room showed 63 IV administration tubing sets hanging in a corner on 3 different hooks. Review of the IV administration tubing package shows a manufacturer statement of: "sterile unless package open".

During an interview on 12/01/10 at 1:30 PM, Staff D, registered nurse (RN) manager of Sterile Processing, stated that this needs to be stopped, he/she didn't think it had been caught before. It should not happen. Staff D stated that the standard would be to set-up the IV package and immediately use. Staff D stated that the facility does not really have a policy for this.

3. Observation on 12/01/10 at 2:30 PM, of crash carts #2 and #3 in the OR hallway showed the tops of the crash carts with visible dust, dust that rolled up on staffs hand. Staff C, RN manager of OR stated that the crash carts were just checked today and they should have been cleaned at this time, looks like they forgot to clean the crash carts.

4. Observation on 12/01/10 2:45 PM, of the crash cart in the post anesthesia care unit (PACU) showed visible dust on the top of the crash cart.

During an interview on 12/01/10 at 2:50 PM, Staff E, RN manager of Same Day surgery and PACU stated that they don't know of any procedure for cleaning the tops of the crash carts.

Based on review of facility documentation of infection control activities and interview, the facility failed to ensure the Infection Control Practitioner maintains a current log of staff related to infections and communicable diseases in the facility. This had the potential to affect all patients in the facility. The facility census was 188.

Findings included:

1. Review of Infection Control activities on 11/30/10 at 10:30 AM, showed no current log of staff incidents related to infections and communicable diseases, including those identified through employee health services.

2. During an interview on 11/30/10 at 10:30 AM, Staff P, registered nurse (RN) manager of occupational health and workers' compensation confirmed that no current log of staff with infections/illness is kept in the facility.