HospitalInspections.org

Based on observation, interview, and review of policies and procedures, it was determined that the hospital failed to develop and implement policies and procedures for infection prevention in the following areas:
* A water-borne pathogens program had not been developed and implemented.
* Not all surfaces were in good repair and cleanable in the ORs.

Findings include:

1.a. During an interview with the IP, DQ and FM on 08/16/2018 at 1330, they stated the hospital had not developed and implemented waterborne pathogens policies and procedures. The FM stated "We haven't put our water program together yet. It's a work in progress." The IP and DQ stated that a waterborne pathogens risk assessment had been conducted for the hospital by a contractor, but the hospital had not determined what information in it they were going to use. Regarding water monitoring and control measures, the FM stated "We haven't even determined what the control measures will be, and where we should be monitoring."

b. The policy and procedure provided titled "Water Management Program to Reduce Legionella Risk (ASANTE)," was reviewed. It was water marked "DRAFT" and the "Approval:" section reflected only "(Date of Signature Approval)." The "Effective Date:" section reflected "(Submitted by Date)." There was no documentation to reflect that the policy and procedure had been fully developed, approved and implemented.

2.a. The Surgical Services department was toured and interviews were conducted on 08/16/2018 beginning at approximately 1130 with hospital staff that included the IP and SSM. Not all surfaces were in good repair and cleanable in the ORs.
* Observations in OR2 included:
- Peeling laminate and dark colored areas on the edges of a built in work desk.
- A piece of irregular shaped peeling black tape approximately 4 inches by 1 inch applied to the wall near the room entry.
- A piece of black Velcro applied to the wall near the built in supply cabinet.
* Observations in "Open Heart" OR8 included:
- Chipped paint on the door frame at the room entry.
- Chipped paint on the top and side edges of a blue metal work cart.
* Observations in "Open Heart" OR9 included:
- Chipped paint on the ante room door frame.
- Pieces of black tape applied to the floor under the OR table/gurney. At the time of the observation, the IP stated "We don't generally advocate for using tape."

b. The policy and procedure provided titled "Building Maintenance Program (ARRMC)," dated as approved 05/19/2016 was reviewed. It stipulated:
* "...It is the policy of this hospital's Engineering Department to regularly inspect the interior of all areas of the building and to paint as necessary on an ongoing basis." The policy and procedure did not include any other information to ensure environmental surfaces in the ORs were maintained in good repair and cleanable.

c. The policy and procedure provided titled "Environmental Cleaning of the Perioperative Areas (ARRMC)," dated as approved 07/23/2018 was reviewed. It stipulated:
* "...processes outlined in this policy should be followed to ensure a clean environment...All hard surfaces to be disinfected...Perioperative staff will perform cleaning between surgical procedures within the OR Suite/Procedure Room...Horizontal surfaces in the OR Suites (e.g. furniture...) should be cleaned...with the standard hospital disinfectant (SHD) before the first scheduled surgical procedure of the day...Terminal cleaning will be done once every 24 hours..."

The policies and procedures provided did not include information that ensured environmental surfaces in the ORs would be kept in good repair and cleanable in order to ensure appropriate cleaning and disinfection of those surfaces.