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Based on observation and interview, it was determined staff failed to assure stethoscopes and blood glucometers were disinfected between patient uses. Failure to disinfect stethoscopes and blood glucometers between patient use did not assure cross contamination did not occur from staff using those devices between patients without disinfecting them. The failed practices were likely to affect all diabetic patients and patients undergoing respiratory treatments in the Facility. Findings follow:
A. On observation 06/24/15 at 0950, Registered Nurse #1 disinfected a blood glucometer after testing the blood glucose level for a patient in their room. She then laid the glucometer on the patient's over bed table, re-contaminating it. She did not disinfect the glucometer again after removing if from the patient's room. Findings were verified at the time of observation with the Director of Imagining.
B. On observation 06/24/15 at 1430, Respiratory Therapist #1 listened to the heart and lungs of a patient on a ventilator in the Intensive Care Unit. She then placed the stethoscope around her neck. At 1450, Respiratory Therapist #1 entered a second patient's room and at 1500 took the stethoscope from around her neck and listened to a second patient's heart and lungs. She did not sanitize the stethoscope between the two patients. Findings were verified at the time of observation with the Director of Imagining.

Based on review of policies and procedures, review of surgical mask package labeling, observation and interview, it was determined staff failed to assure surgical masks were discarded after use; failed to assure used masks did not hang around the neck; and failed to assure masks covered the nose and mouth when worn during surgical procedures. Failure to discard surgical masks after use did not assure a clean mask was used for each surgical procedure; failure to assure used masks did not hang around the neck did not assure contamination did not occur from the used mask coming in contact with patients or supplies used for patient care; and failure to cover the nose and mouth did not assure droplet contamination did not occur from venting during a surgical procedure. The failed practices were likely to affect all surgical staff and patients undergoing surgical procedures in the Facility. Findings follow:
A. On observation 06/24/15 at 1110 in the Surgical Services Department, the following staff were observed with surgical masks hanging around their necks which did not assure a clean mask was worn for each procedure or that contamination to patients or supplies did not occur from coming in contact with a used mask:
1) Certified Registered Nurse #1;
2) Perfusionist #1;
3) Certified Surgical Technician #2; and
4) Attendant #1.
Findings were confirmed at the time of observation with the Operating Room Director.
B. During interview with the Operating Room Director on 06/24/15 at 1115, she explained there were no masks outside the operating rooms, that all masks were located in the central core of the Surgery Department.
C. On observation 06/24/15 at 1415, while performing a Cesarean Section procedure, Physician #1 wore a surgical mask which did not cover her nose. Findings were confirmed with the Director of Imagining at the time of observation.
D. Review of Policy, "Surgical Attire" revealed "All personnel entering the restricted areas will wear a surgical mask when open sterile supplies and equipment are present. The mask will cover the mouth and nose and be secured in a manner to prevent venting. A fresh, clean surgical mask will be worn for every procedure".
E. Review of surgical mask package labeling revealed, "single use" and was verified with the Operating Room Director on 06/24/15 at 1120.



Based on review of policies and procedures, observation and interview it was determined staff failed to assure all hair was covered in one of one (Surgery Department) restricted areas. Failure to assure all hair was covered in a restricted area did not assure contamination did not occur from hair or flakes of exfoliated epidermis falling onto clean or sterile areas. This failed practice was likely to affect all staff and patients in the Surgical Department. Findings follow:

A. On observation 06/24/15 at 1040, Certified Registered Nurse Anesthetist #2 wore a skull cap which exposed approximately two inches of hair on the back of his head during a cystoscopy procedure.
B. On observation 06/24/15 at 1040, Circulating Nurse #2 wore a cloth hat which exposed approximately two to three inches of hair on the back of her head during a cystoscopy procedure.
C. Findings listed as A and B were verified with the Director of Imaging at the time of observation.
D. Review of policy, "Surgical Attire" revealed "All personnel will cover head and facial hair, including sideburns and the nape of the neck, when in the semi-restricted and restricted areas".


Based on review of policies and procedures, observation and interview it was determined Physician #1 failed to maintain sterility of her gloves during a surgical procedure by assuring the gloves did not come in contact with the back of her gown in one of one (Cesarean Section) procedure. Failure to maintain sterility of gloves during a surgical procedure did not assure contamination did not occur to instruments or to the patient during the surgical procedure. The failed practice was likely to affect all patients undergoing surgical procedures by Physician #1. Findings follow:

A. On observation 06/24/15 at 1410, Physician #1 stood at side of the operating room table for a patient undergoing a Cesarean Section. She was dressed in sterile attire which included a gown and gloves. She placed her fisted hands which were donned in sterile gloves, on the back of her hips (unsterile area) and stood for approximately 3-5 minutes prior to beginning a Cesarean Section. Findings were verified with the Director of Imagining at the time of observation.
B. Review of policy, "Surgical Gown: Donning Gown and Maintaining Sterility (Perioperative)" revealed, "Be aware that the back of the gown is not considered sterile".



Based on observation and interview it was determined staff failed to clean operating room equipment and furnishings between procedures in a manner which assured a top to bottom cleaning technique for the prevention of cross contamination in one of one (Cystoscopy Room) area. Failure to assure cleaning techniques did not promote contamination did not assure patients were not exposed to contaminants and was likely to affect all surgical patients in the Facility. Findings follow:

A. On observation 06/24/15 at 1010, Attendant #1 wiped the operating room table (top) with disinfectant. Next, she wiped a kick bucket (bottom) on the floor with the same cloth. She then wiped a leg holder (top) attached to the side of the bed which did not assure it was not contaminated from debris cleaned from the kick bucket.
B. Findings were verified with the Operating Room Director at the time of observation.



Based on observation and interview, it was determined staff failed to assure cross contamination did not occur from not removing gloves in a contaminated area (Cesarean Section procedure room) before going into a clean area (sterile supply room) for patient care supplies. Failure to remove contaminated gloves prior to going into a clean area for supplies, did not assure supplies and supply dispensing machines remained clean. The failed practice was likely to affect all patients undergoing surgical procedures in the Facility. Findings follow:

On observation 06/24/15 at 1400, Circulator #1 wore blue exam gloves during a Cesarean Section procedure (contaminated). At 1405, she entered an adjacent sterile supply room (clean), pushed buttons on the supply dispensing machine, reached in and retrieved supplies. She then returned to the procedure and opened the supplies onto the sterile field. She did not remove her gloves prior to entering the supply room. Findings were verified with the Director of Imaging at the time of observation.

Based on review of sterile water product labels, observation and interview it was determined the Facility failed to follow package labels to discard unused portions of sterile water after opening in one of one (Room 2209) areas. Failure to follow package labels to discard unused sterile water after opening did not assure the product would remain sterile and was likely to affect all patients in the Facility. Findings follow:

A. On 06/24/15 at 1500, a half empty 1000 ml (milliliter) bottle of Sterile Water was observed sitting on the bedside table in Room 2209. Respiratory Therapist #1 confirmed the sterile water was used for humidifying oxygen to the patient.
B. Review of the Sterile Water product label revealed, "Single Use. Discard unused portion".
C. Findings listed as A and B were confirmed with the Director of Imagining at the time of observation.