HospitalInspections.org

Based on record reviews, observations, and interviews, the hospital failed to ensure its system for controlling infections and communicable diseases of patients and personnel was implemented as evidenced by failing to ensure policies and procedures for surgical services were implemented to mitigate risks contributing to healthcare-associated infections by:
1) failure to ensure staff adhered to acceptable standards of professional practice in surgical attire in the restricted areas as evidenced by multiple observations of surgical attire breaches on 06/13/18 from 10:25 a.m. to 11:45 a.m., and
2) failure to ensure ORs were cleaned after each use according to policy as evidenced by observations in 3 of 19 ORs, reported to be clean and ready for the next procedure, with a large clump of long blonde hair on the floor, and ORs with dust collected on the air return vents located in the walls.
Findings:


1) Failure to ensure staff adhered to acceptable standards of professional practice in surgical attire in the restricted areas as evidenced by multiple observations of surgical attire breaches on 06/13/18 from 10:25 a.m. to 11:45 a.m.

Review of the hospital policy titled "Dress Code in the Operating Room", (SURG Policy 37, Dress Code in the OR) provided as current. revealed, in part the following: Surgical attire and appropriate personal protect equipment were worn to promote worker safety and a high level of cleanliness and hygiene in the perioperative environment. The expected outcome was that the patient would be free from signs and symptoms of infection. . Further review revealed the following:" II Policy- It is the policy of University Medical Center New Orleans (UMCNO) that:...B. Individuals who enter semi-restricted and restricted areas must wear scrub attire that has been laundered at a UMCNO-approved laundry facility or wear single-use scrub attire provided by UMCNO and intended for use within the perioperative areas... 2. Reusable head coverings will be completely covered by a disposable bouffant...IV. Procedure, Head Coverings-A. Wear a clean surgical head cover or hood that confines all hair and completely covers the ears, scalp skin, sideburns, and nape of the neck." Review of section VI. References revealed references used included AORN, Guidelines for Perioperative Practice, Guideline for Surgical Attire.


Review of AORN Guidelines for Perioperative Services, 2018 Edition revealed, under Surgical Attire, Recommendation III, "Personnel entering the semi-restricted and restricted areas should cover the head, hair, ears, and facial hair


Observations were made of 19 ORs and the sterile cores on 05/15/18 from 10:25 a.m. to 11:45 a.m. Present for these observations were, in part, S3RN, S1CNO, and S2SurgDirector. These observations revealed the following breaches in surgical attire:
-S5CRNA was observed with the front section of a reusable fabric head cover partially uncovered by the disposable bouffant head cover in an OR during a surgical procedure.
-S4RN was observed wearing a reusable fabric head cover partially uncovered by a disposable bouffant head cover in an OR during a surgical procedure.
-S6MD was observed in an OR, with a surgical procedure in progress, with his ears and sideburns uncovered.
-S7MD was observed to exit an OR with a surgical procedure in progress, and walk down the sterile corridor with his side burns and beard not completely covered.
-S9CRNA was observed in an monitoring anesthesia during a surgical procedure with facial hair exposed at the sides of his mask.
-S10CRNA was observed in an OR during a surgical procedure with the front section of her reusable fabric head covering exposed from under a disposable bouffant cap.
-S11MS and S12MD were observed performing a surgical prep on a patient in an OR. Both staff had beards exposed/uncovered at the sides of their surgical masks.
-S13MD and S14MD were observed in an OR during a surgical procedure with their ears and sideburns exposed from their disposable bouffant caps.
-S15CRNA was observed in an OR during a surgical procedure with his beard exposed at the sides of his surgical mask.

S3RN, present throughout these observations verified each one. S3RN reported the surgical services department followed AORN guidelines. She verified that reusable head coverings were not laundered by the hospital and should have been completely covered. S3RN reported that ears and all hair, including side burns and beards should have been completely covered. She reported that she was not sure if the hospital had any covering for beards and sideburns.

2) Failure to ensure ORs were cleaned after each use according to policy as evidenced by an observation of an OR, reported to be clean and ready for the next procedure, with a large clump of long blonde hair on the floor, and ORs with dust collected on the air return vents located in the walls.

Review of the hospital policy SURG Policy 50 titled, "Environmental Cleaning of Operating Rooms", provided as current policy, revealed "clean" was defined as absence of visible dust, soil, debris, blood, or other potentially infectious material. The procedure included preoperative cleaning before the first case of the day, which included, in part, damp dusting before case carts, supplies, and equipment were brought into the room. Damp dusting from top to bottom was part of the cleaning before the first case of the day. Further review revealed the Postoperative cleaning included, in part, reestablishing a clean environment after the patient was transferred from the OR. ORs were to be cleaned after each patient. AORN was documented as reference for this policy.

Observations were made of 19 ORs on 05/15/18 from 10:25 a.m. to 11:45 a.m. Present for these observations were, in part, S3RN, S1CNO, and S2SurgDirector. The following observations were made of ORs not cleaned completely.
-In OR 14 dust was noted to be on the air vent located in the wall by the door to the corridor.
-In OR 19 the air vent in the wall by the door had spots of light brownish-red in a splatter pattern
-In OR 20 the air vent in the wall by the door had dust on it. 2 empty 1-liter sized plastic bottles with saline labels on them sat on top of an anesthesia cart. A large clump of blond hair approximately 12 inches long was noted on the floor between the anesthesia cart and a wall.
When asked if the room had been cleaned after the last surgery and was ready for the next surgery, S3RN reported that it was supposed to ready for the next surgical procedure. She confirmed the observations, and confirmed the rooms were not clean and ready for use.