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Based on observations and interviews, the facility failed to ensure staff were trained in infection control practices to prevent the risk of introducing contaminants into the surgery suites.

The failure created the potential for increased risk of surgery-related infections for patients.

FINDINGS:

POLICY

According to the policy, Surgical Services Infection Control Guidelines, care of the patient during surgery requires movement of patients, personnel and material within the surgical suite. Planning and controlling these movements assists in the containment of contamination. The practice setting should be designed to facilitate movement of patients and personnel through, into and out of defined areas within the surgical suite while containing and decreasing the risk of contamination that might contribute to infection.

Environmental requirements: cleaning will be performed on a scheduled basis. Environmental cleaning measures are required after each individual patient. Environmental cleaning is a team effort (e.g., anesthesia care providers, surgeons, OR assistants) and Perioperative Services Environmental Services personnel. The ultimate responsibility for ensuring a clean environment rests with perioperative nurses. Administrative personnel must ensure that environmental cleaning practices comply with the standards established for the practice setting.

Equipment and furniture will be cleaned with a facility-approved agent after each patient use.

1. The facility failed to ensure all equipment, furniture and trash receptacles were cleaned and emptied after each patient use and that contaminated surfaces from the previous case were sanitized prior to the start of cataract surgery for Patient #6.

In addition, the facility failed to prevent inadvertent transfer of contaminants to work surfaces, medications vials and equipment in the surgical suite by a pharmacy technician, who entered the room to re-stock medications during the cleaning of the room.

a) On 09/02/15 at 9:20 a.m. observation was conducted in Operating Room (OR) #2. The surveyor entered the room after the previous surgical patient exited to observe the cleaning of the room prior to the surgery for Patient #6. Numerous staff were cleaning the room from the previous case. Staff were wiping down equipment, furniture and work surfaces to sanitize them, as required, prior to the next surgery. The Circulating Nurse (Registered Nurse #14, RN), Certified Registered Nurse Anesthetist (CRNA) #15, and Pharmacy Technician (PT) #5 were in the room.

PT #5 placed a rectangular plastic bin containing medications, which s/he brought into the OR, on the dirty anesthesia machine and proceeded to fill various drawers of the medication dispensing unit. At one point, a medication vial dropped onto the floor. PT #5 picked up the contaminated vial and proceeded to place it in the medication dispensing machine.

The technician moved the plastic bin and set it on a large kitchen-sized gray waste basket which contained trash from prior surgical cases. PT #5 continued to fill the medication dispensing machine.

Subsequently the technician moved the bin, which had been sitting on the open trash container, to another anesthesia storage cart and placed it on a flat work-surface covered with a white towel. The towel had 6-8 small plastic syringes that had been taken out of their wrappers in preparation for the next case. The syringes and white towel were not replaced, nor was the storage cart disinfected after it had been contaminated by PT #5, prior to the next surgery.

b) During the surgery, the CRNA utilized at least one of the syringes from the white towel-covered anesthesia storage cart, to administer medications to Patient #6. The CRNA acknowledged the syringe s/he had used was from the pile of syringes on the storage cart. The CRNA picked up the syringes and placed them down on the contaminated towel where PT #5 had previously placed the contaminated plastic bin with medications.

c) During an interview, on 09/02/15 at approximately 11:00 a.m., RN #14 stated the OR trash was not routinely emptied between a series of cataract cases, because there was not much contaminated waste. RN #14 stated the anesthesia cart was not wiped down nor was the towel on the anesthesia cart changed between cases. S/he stated they were only changed and cleaned at the end of the day unless they were obviously dirty or contaminated in some way.

d) On 09/02/15, after the surgery and cleaning of the room, the Director of Perioperative Patient Care Services (RN #10), stated the plastic bin, used by PT #5, should have been wiped down before it was brought into the surgical suite and wiped down again after it was removed to prevent cross-contamination of surfaces. RN #10 acknowledged the pharmacy technician's process of placing the plastic bin on multiple surfaces, as observed, created problems with cross-contamination of surfaces. Further, s/he stated the anesthesia storage cart should be wiped down between cases and the towel should be changed.

On 09/02/15 at 1:30 p.m., RN #9 (Director of OR and Sterile Processing) and RN #10 were interviewed about the expectations for cleaning the operating room between cases. RN #9 and RN #10 acknowledged the sequence of events with PT #5 moving the plastic bin to multiple contaminated surfaces created an infection control risk in the surgical area and indicated a need for staff education and process changes. They stated it had been their understanding and expectation that all surfaces, including the anesthesia supply cart, would be wiped down and sanitized between cases.

e) On 09/03/15 at 8:40 a.m., an interview was conducted with PT #5. PT #5 acknowledged s/he had not really been given any real training about what was okay and what was not okay in the operating room, other than knowing when to wear a mask. PT #5 stated s/he had not been given specific training about infection control expectations in the surgical suite so s/he relied on staff for direction in the surgery area.

f) On 09/03/15 at 9:00 a.m., the Director of Pharmacy (Employee #6) was interviewed about the cross-contamination incidents observed on 09/02/15. S/he stated there had been significant discussion of the sequence of events and they had identified the need for additional training for pharmacy staff working in the surgery areas. S/he stated there had been productive discussion with staff about the need for better training and possibly process changes. S/he stated the only training pharmacy technicians received for working in the surgery area was one-on-one training they received from another pharmacy technician they shadowed during orientation