HospitalInspections.org

Based on document review, and interview, the Governing Body failed to ensure that the medical staff bylaws rules and policies were approved and current. This deficient practice created the
potential failure of determining, implementing, and monitoring policies that provide quality health care in a safe environment. The findings are:

A. Review of the the medical staff bylaws indicated that the bylaws were last approved on 12/01/10, to be effective on 01/01/11.

B. On 08/12/14 at 11:00 am, during interview, the Chief of Staff and the Medical Staff Administrative Assistant confirmed that the medical bylaws were last approved on 12/01/10. The Chief of Staff stated that the bylaws were legally approved each year by the corporation.

C. Review of the Medical Staff Bylaws policy Section 9 titled "Review, Revision, Adoption, and Amendment" revealed the following:
"9.1 Medical Staff Responsibility a. The medical staff shall have the responsibility to formulate, review at least biennially, and recommend to the Board any medical staff bylaws, rules, regulations, policies, procedures, and amendments as needed."

This is a repeat Condition of Participation deficiency from a survey completed on 09/28/04.

Based on observation and interview, the hospital's Surgical Services failed to have a tracheotomy set available for emergencies in the operating suite. The operating room staff were unaware that the tracheotomy set needed to be in the surgery department. This deficient practice resulted in the potential for a tracheotomy set to be unavailable if a patient was to experience a respiratory emergency in the operating suite and the tracheotomy set was needed immediately. The findings are:

A. On 08/13/14 at 3:30 pm, during the tour of the operating room suites, the operating room staff member was asked to locate the tracheotomy set. He stated that there are two tracheotomy sets in the hospital, one set kept in the emergency room and the other set kept in the intensive care unit. When asked how long the tracheotomy sets have been kept in those areas, he stated that the sets had been there a long time.


Based on observations and interviews, the facility failed to provide and maintain a clean and sanitary environment in the operating rooms and procedural room, by not following standards of practice for terminal cleanings. This deficient practice has the potential for germs to be spread from one patient to the next. It also increased the amount of germs in the environment and increased the risk to patients obtaining a hospital acquired infection during surgery. The findings are:

A. On 08/12/14 at 4:45 pm, during the time that the hospital staff designated as the terminal cleaning of the operating rooms the following was observed:
1. The housekeeping staff member was cleaning the operating rooms, she was accompanied by her supervisor, the Manager of Housekeeping. They were both wearing a scrub uniform and gloves, as if they were cleaning the operating room between surgery cases. The staff member of housekeeping was cleaning the surfaces in the operating room (OR) with "Clorox Broad Spectrum Quaternary Disinfectant Cleaner." When asked when they clean the walls and ceilings in the OR, they stated that the OR rooms, including the walls and ceilings, are cleaned once a week, on Thursdays.
2. The "Clorox Broad Spectrum Quaternary Disinfectant Cleaner" indicates the following on the bottle: "Personal Protection: When handling items soiled with blood or body fluids, use disposable impervious gloves, gowns, masks and eye coverings..."

B. On 08/13/14 at 10:30 am, during interview, the Infection Control Nurse (ICN) was asked when the OR suites are cleaned. She stated that the OR suites are deep cleaned at the end of the day after surgery cases on Mondays, Tuesdays, Wednesdays and Fridays and that the terminal cleaning of the OR suites takes place on Thursdays. When asked how long has this been going on, she stated since April 2014, when she had an informal conversation with the Manager of Housekeeping. The ICN stated that she had done some research and that the Association of periOperative Registered Nurses (AORN) recommended terminal cleanings once a week. The AORN defines terminal cleaning as the "thorough environmental cleaning that is performed at the end of each day when the area is being used" and turnover clean as "cleaning and disinfecting done to a room between patients throughout the day."

C. On 08/13/14 at 2:45 pm, during interview, the Director of Patient Care Services, when asked if she was aware that the OR suites were only terminially cleaned once a week on Thursdays, stated that she was not aware of this.

D. On 08/13/14 at 2:50 pm, during interview, the Manager of Housekeeping confirmed that the OR suites were terminally cleaned once a week on Thursdays.

E. On 08/15/14 at 10:40 am, during interview, the Manager of the OR, when asked if he was aware that terminal cleaning of the OR suites was performed once a week, stated, "Yes, I am." When asked how long has this been going on, he stated that the terminal cleaning once a week had been going on for a couple of years. When asked if he was aware that the hospital policy regarding the terminal cleaning indicated that it was daily, he replied, "No."

F. Review of the hospital policy effective date 06/27/11 titled "[Name of hospital] - Surgical Services/Operating Room" indicated the following: "Those entering the restricted area of the surgical suite shall wear scrub clothes...Shoes - all personnel entering the surgical suite must wear clean or covered shoes. Shoe covers are optional and are used to protect shoes in case of splashing with body fluids. Hair - all personnel entering the surgical suite must have hair covered by surgical cap or hood.
Terminal cleaning will be performed daily. These areas include surgical suites, autoclave rooms, utility rooms, work rooms, scrub sinks, and sterile corridors...Clean all furniture, including casters, kick buckets. Fixed and ceiling-mounted equipment and tracks. Wall-mounted boxes and equipment. Cabinet handles, light switches. Walls and ceilings..."