HospitalInspections.org

The hospital reported a census of two patients with 20 medical records reviewed. The data base worksheet completed by the hospital identified the hospital staffed 10 of 10 beds with an average daily census of one, and 4 operating rooms.

Based on observation, documentation, and staff interview, the hospital failed to implement systems to achieve and then maintain a sanitary environment in the surgical suite area when the infection control officer failed to ensure hospital staff followed infection control policies, manufacturer's guidelines and acceptable infection control standards of practice.

The cumulative effect of the hospital staff's failure placed all patients at risk for healthcare acquired infections (HAI).

Findings include:

- The hospital failed to provide a functional and sanitary environment for the provision of surgical services by adhering to professionally acceptable standards of practice. See evidence at A0749, 42 CFR 482.42(a)(1).

The hospital reported a census of two patients with 20 medical records reviewed. The data base worksheet completed by the hospital identified the hospital staffed 10 of 10 beds with an average daily census of one, and 4 operating rooms.

Based on observation, review of hospital policy and manufacturer's guidelines, and staff interview, the hospital and the infection control officer:

- failed to establish traffic patterns for the transport of contaminated supplies and instruments away from clean/sterile supplies;
- failed to follow AORN guidelines for the wearing of surgical mask and hair covers;
- failed to ensure staff followed hospital policy regarding cleaning of one operating room (OR) following a surgical procedure;
- failed to follow hospital policy regarding terminal cleaning of three ORs; and
- failed to ensure hospital staff followed infection control policies and manufacturer's guidelines for two single use enzymatic instrument sponge cleaning brushes.

These failures indicate lack of systems in place to minimize the potential for hospital-acquired infections for patients who have a surgical procedure at the hospital.

Findings include:

- Association for PeriOperative Registered Nurses (AORN) "Recommended Practices for Traffic Patterns in the Perioperative Setting", reviewed on 3/14/13 at 1:00pm, revealed, "The movement of clean and sterile supplies and equipment should be separated from contaminated supplies, equipment, and waste by space, time, or traffic patterns...the movement of supplies should be from the clean core, through the operating or procedure room to the peripheral corridor...soiled supplies, instruments, and equipment should not re-enter the clean core area."

Hospital policy "Clinical-Opening of Sterile Supplies and Instruments", reviewed on 3/13/13 at 4:30pm, revealed, "Sterile supplies will be stored in both the OR rooms and the sterile supply area in the OR corridor...."

Observation on 3/13/13 at 10:15am revealed a hallway that linked OR #3 to the decontamination area. The hospital designed the hallway as the storage area for sterile supplies where operating room staff stored sterile supplies on movable racks with dust covers. (Dust covers are typically used to prevent dust from accumulating on the sterile supplies since dust is considered a source of potential infection.) However, the dust covers on the racks were propped open and the supplies were visible. Operating room staff transported soiled instruments and equipment past sterile supplies through this corridor to the decontamination room.

DON staff B interviewed on 3/13/13 at 10:15am acknowledged the hospital staff moved the soiled supplies and equipment past the sterile supplies in the corridor to the decontamination room. Observation at this same time revealed a stainless steel movable table in the hallway directly outside of the decontamination room. DON staff B indicated staff moved surgical instruments from the clean supply room to the table in the hallway for staff to wrap and staff moved soiled supplies and equipment past this table to the decontamination room.


- Hospital policy "Clinical-Surgical Dress Code", reviewed on 3/13/13 at 4:20pm revealed, "All hair is to be completely covered including beards and sideburns while in the OR Suite...."

AORN is the national organization recognized as a source of standards of practice for surgical staff.

AORN 2012 Recommendation IV reads, "All personnel should cover their head and facial hair when in the semi-restricted and restricted areas. Hair coverings should cover facial hair, sideburns and the nape of the neck ...Skulls caps are not recommended because they do not completely cover the wearer's hair and skin: they fail to cover the side hair above and in front of the ears and the hair at the nape of the neck."

(Hair is a potential source of potentially-infectious microorganisms.)

However, observation on 3/13/13 from 9:00am to 12:30pm revealed staff who wore hair covers which failed to cover their hair at the nape of their neck, around their ears and their sideburns.

- Observation of surgeon staff G on 3/13/13 at 9:30am revealed they wore a surgical "skull" cap that failed to cover all the hair on their head, the hair at the nape of their neck, and around their ears and sideburns.
- Observation of scrub tech F on 3/13/13 at 9:55am found him/her wore a surgical "skull" cap that failed to cover all the hair on their head, hair at the nape of their neck, around their ears and sideburns.

Infection Control Officer and Chief Operations Officer staff C, interviewed on 3/13/13 at 5:30pm, acknowledged the hospital failed to follow their policy and AORN 2012 recommendations for surgical staff to cover all head hair and sideburns.


- Hospital policy "Infection control: Operating Room " reviewed on 3/13/13 at 4:20pm revealed, "...surgical masks are changed between cases...."

AORN 2012 at VI.b. reads, "A fresh clean surgical mask should be worn for every procedure."

AORN 2012 at VI.b.1 reads, "Surgical masks should not be worn hanging down from the neck. The filter portion of a surgical mask harbors bacteria collected from the nasopharyngeal [nose and mouth] airway. The contaminated mask may cross-contaminate the surgical attire top."

AORN 2012 at VI.c. reads, "Surgical masks should be discarded after each procedure."

However, observations on 3/13/13 from 9:30:00am to 11:30am revealed multidisciplinary staff members (operating room nursing staff, Certified Registered Nurse Anesthetist and Physicians failed to discard their single use disposable masks after each procedure).

- Administrative/Physician's Assistant B on 3/13/13 at 10:00am entered the first floor hallway from the stairwell with a single use disposable mask tucked under their chin.
- Random observation on 3/13/13 at 10:02am revealed a female staff member clad in scrubs and an x-ray apron exited the pre-operative and post-anesthesia care unit into the unsterile hallway with a mask dangling around their neck. They went to the Business Office/Patient Registration area then re-entered the pre-op/post-op units still wearing the same mask dangling around their neck.

Administrative staff interviewed on 3/13/13 at 3:30pm verified the hospital followed AORN guidelines and recommendations. Administrative staff acknowledged surgical staff should not tuck their mask under chins or let the surgical mask dangle around their necks.


- Hospital policy "Equipment Cleaning, Disinfection, and Sterilization", reviewed on 3/13/13 at 4:30pm, revealed, "E. Equipment is wiped with hospital approved disinfectant used according to manufacturer's recommendations. All products list contact times...follow manufacturer's instructions for contact time."

Hospital policy "Infection Control: Operating Room", reviewed on 3/13/13 at 4:20pm, revealed, "OR Cleaning: following every surgical procedure 1. Clean gloves must be worn during cleanup process, 2. Horizontal surfaces of all tables and equipment will be washed with a disinfectant solution, 3. Operating room table mattress pads will be washed 4. Casters of mobile furniture will be cleaned by pushing them through disinfectant solution...10. Floors will be cleaned a perimeter of several feet surrounding the focus point or patient area between cases...."

However, observation of scrub tech staff F on 3/13/13 at 9:56am found they entered OR #3 wearing single use disposable gloves and used Super-Sani disposable cloth to wipe the pillow and surgery bed. The surgical bed dried in 1 minute at 9:57am, which meant a wet contact time of 1 minute instead of the manufacturer's required 2 minutes. Scrub tech staff F failed to clean other equipment on wheels stored in OR #3.

When interviewed, at this time, scrub tech staff F stated directions on the back of the canister of Super-Sani disposable cloths read environmental surfaces should have a wet contact time of 2 minutes for disinfection.

DON staff B, interviewed on 3/13/13 at 10:30, acknowledged the hospital failed to ensure staff followed the manufacturer's instructions for wet contact time for Super-Sani cloths.


- Hospital policy "Infection Control: Operating Room", reviewed on 3/13/13 at 4:20pm, revealed, "Daily Terminal Cleaning 1. At the completion of the days schedule each OR...should be terminally cleaned. "

Hospital policy "Environmental Services Terminal Cleaning the OR", reviewed on 3/13/13 at 4:20pm, revealed, "The OR suites will be terminally cleaned at the end of the day and biweekly."

However, when interviewed on 3/13/13 at 11:30am, scrub tech staff D, scrub tech staff F, and scrub tech staff H (responsible for clean the ORs) stated operating rooms are "deep cleaned" each day they are used and are "terminally cleaned" once a week.

DON Staff B, interviewed on 3/13/13 at 11:30am, verified hospital staff terminally clean the operating rooms only once per week.


- The manufacturer's guidelines for Endozime InstruSponge observed in use on and reviewed on 3/13/13 at 10:30am directed "for medical use only, single use" and showed an expiration date of May 2011 (the date after which the product should not be used).

Observation in the decontamination room on 3/13/13 at 10:30am revealed two enzymatic instrument sponge cleaning brushes (a single use cleaning brush) draped over the top of the water faucet. The manufacturer's guidelines stated each item is for single use only. When interviewed at this time, scrub tech staff D explained staff reused the Endozime InstruSponge Cleaning brushes to clean surgical instruments prior to sterilization.

Director of Nursing (DON) staff B, interviewed on 3/13/13 at 10:45am verified OR staff failed to ensure staff followed the manufacturer's guidelines for cleaning and disinfecting of the surgical instruments with single use brushes.

Infection Control Officer and Chief Operations Officer Staff C, interviewed on 3/13/13 at 4:20, verified the hospital followed AORN and Association for Professionals in Infection Control and Epidemiology (APIC).

The hospital reported a census of two patients with 20 medical records reviewed. The data base worksheet completed by the hospital identified the hospital staffed 10 of 10 beds with an average daily census of one, and 4 operating rooms.

Based on observation, documentation, and staff interview, the hospital failed to implement systems to achieve and then maintain a sanitary environment in the surgical suite area when the infection control officer failed to ensure hospital staff followed infection control policies, manufacturer's guidelines and acceptable infection control standards of practice.

The cumulative effect of the hospital staff's failure placed all patients at risk for healthcare acquired infections (HAI).

Findings include:

- The hospital failed to provide a functional and sanitary environment for the provision of surgical services by adhering to professionally acceptable standards of practice. See evidence at A0749, 42 CFR 482.42(a)(1).

The hospital reported a census of two patients with 20 medical records reviewed. The data base worksheet completed by the hospital identified the hospital staffed 10 of 10 beds with an average daily census of one, and 4 operating rooms.

Based on observation, review of hospital policy and manufacturer's guidelines, and staff interview, the hospital and the infection control officer:

- failed to establish traffic patterns for the transport of contaminated supplies and instruments away from clean/sterile supplies;
- failed to follow AORN guidelines for the wearing of surgical mask and hair covers;
- failed to ensure staff followed hospital policy regarding cleaning of one operating room (OR) following a surgical procedure;
- failed to follow hospital policy regarding terminal cleaning of three ORs; and
- failed to ensure hospital staff followed infection control policies and manufacturer's guidelines for two single use enzymatic instrument sponge cleaning brushes.

These failures indicate lack of systems in place to minimize the potential for hospital-acquired infections for patients who have a surgical procedure at the hospital.

Findings include:

- Association for PeriOperative Registered Nurses (AORN) "Recommended Practices for Traffic Patterns in the Perioperative Setting", reviewed on 3/14/13 at 1:00pm, revealed, "The movement of clean and sterile supplies and equipment should be separated from contaminated supplies, equipment, and waste by space, time, or traffic patterns...the movement of supplies should be from the clean core, through the operating or procedure room to the peripheral corridor...soiled supplies, instruments, and equipment should not re-enter the clean core area."

Hospital policy "Clinical-Opening of Sterile Supplies and Instruments", reviewed on 3/13/13 at 4:30pm, revealed, "Sterile supplies will be stored in both the OR rooms and the sterile supply area in the OR corridor...."

Observation on 3/13/13 at 10:15am revealed a hallway that linked OR #3 to the decontamination area. The hospital designed the hallway as the storage area for sterile supplies where operating room staff stored sterile supplies on movable racks with dust covers. (Dust covers are typically used to prevent dust from accumulating on the sterile supplies since dust is considered a source of potential infection.) However, the dust covers on the racks were propped open and the supplies were visible. Operating room staff transported soiled instruments and equipment past sterile supplies through this corridor to the decontamination room.

DON staff B interviewed on 3/13/13 at 10:15am acknowledged the hospital staff moved the soiled supplies and equipment past the sterile supplies in the corridor to the decontamination room. Observation at this same time revealed a stainless steel movable table in the hallway directly outside of the decontamination room. DON staff B indicated staff moved surgical instruments from the clean supply room to the table in the hallway for staff to wrap and staff moved soiled supplies and equipment past this table to the decontamination room.


- Hospital policy "Clinical-Surgical Dress Code", reviewed on 3/13/13 at 4:20pm revealed, "All hair is to be completely covered including beards and sideburns while in the OR Suite...."

AORN is the national organization recognized as a source of standards of practice for surgical staff.

AORN 2012 Recommendation IV reads, "All personnel should cover their head and facial hair when in the semi-restricted and restricted areas. Hair coverings should cover facial hair, sideburns and the nape of the neck ...Skulls caps are not recommended because they do not completely cover the wearer's hair and skin: they fail to cover the side hair above and in front of the ears and the hair at the nape of the neck."

(Hair is a potential source of potentially-infectious microorganisms.)

However, observation on 3/13/13 from 9:00am to 12:30pm revealed staff who wore hair covers which failed to cover their hair at the nape of their neck, around their ears and their sideburns.

- Observation of surgeon staff G on 3/13/13 at 9:30am revealed they wore a surgical "skull" cap that failed to cover all the hair on their head, the hair at the nape of their neck, and around their ears and sideburns.
- Observation of scrub tech F on 3/13/13 at 9:55am found him/her wore a surgical "skull" cap that failed to cover all the hair on their head, hair at the nape of their neck, around their ears and sideburns.

Infection Control Officer and Chief Operations Officer staff C, interviewed on 3/13/13 at 5:30pm, acknowledged the hospital failed to follow their policy and AORN 2012 recommendations for surgical staff to cover all head hair and sideburns.


- Hospital policy "Infection control: Operating Room " reviewed on 3/13/13 at 4:20pm revealed, "...surgical masks are changed between cases...."

AORN 2012 at VI.b. reads, "A fresh clean surgical mask should be worn for every procedure."

AORN 2012 at VI.b.1 reads, "Surgical masks should not be worn hanging down from the neck. The filter portion of a surgical mask harbors bacteria collected from the nasopharyngeal [nose and mouth] airway. The contaminated mask may cross-contaminate the surgical attire top."

AORN 2012 at VI.c. reads, "Surgical masks should be discarded after each procedure."

However, observations on 3/13/13 from 9:30:00am to 11:30am revealed multidisciplinary staff members (operating room nursing staff, Certified Registered Nurse Anesthetist and Physicians failed to discard their single use disposable masks after each procedure).

- Administrative/Physician's Assistant B on 3/13/13 at 10:00am entered the first floor hallway from the stairwell with a single use disposable mask tucked under their chin.
- Random observation on 3/13/13 at 10:02am revealed a female staff member clad in scrubs and an x-ray apron exited the pre-operative and post-anesthesia care unit into the unsterile hallway with a mask dangling around their neck. They went to the Business Office/Patient Registration area then re-entered the pre-op/post-op units still wearing the same mask dangling around their neck.

Administrative staff interviewed on 3/13/13 at 3:30pm verified the hospital followed AORN guidelines and recommendations. Administrative staff acknowledged surgical staff should not tuck their mask under chins or let the surgical mask dangle around their necks.


- Hospital policy "Equipment Cleaning, Disinfection, and Sterilization", reviewed on 3/13/13 at 4:30pm, revealed, "E. Equipment is wiped with hospital approved disinfectant used according to manufacturer's recommendations. All products list contact times...follow manufacturer's instructions for contact time."

Hospital policy "Infection Control: Operating Room", reviewed on 3/13/13 at 4:20pm, revealed, "OR Cleaning: following every surgical procedure 1. Clean gloves must be worn during cleanup process, 2. Horizontal surfaces of all tables and equipment will be washed with a disinfectant solution, 3. Operating room table mattress pads will be washed 4. Casters of mobile furniture will be cleaned by pushing them through disinfectant solution...10. Floors will be cleaned a perimeter of several feet surrounding the focus point or patient area between cases...."

However, observation of scrub tech staff F on 3/13/13 at 9:56am found they entered OR #3 wearing single use disposable gloves and used Super-Sani disposable cloth to wipe the pillow and surgery bed. The surgical bed dried in 1 minute at 9:57am, which meant a wet contact time of 1 minute instead of the manufacturer's required 2 minutes. Scrub tech staff F failed to clean other equipment on wheels stored in OR #3.

When interviewed, at this time, scrub tech staff F stated directions on the back of the canister of Super-Sani disposable cloths read environmental surfaces should have a wet contact time of 2 minutes for disinfection.

DON staff B, interviewed on 3/13/13 at 10:30, acknowledged the hospital failed to ensure staff followed the manufacturer's instructions for wet contact time for Super-Sani cloths.


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