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A. Based on observation, document review and interview, it was determined for 12 of approximately 25 people present in the surgical department (Z #1, 2, 3, 4, 5, MD #1, 2, 3, 4, and E # 3, 4, and 8), the Hospital failed to ensure staff adhered to the OR dress code policy.

Findings include:

1. On 8/18/15 between approximately 9:00 AM and 10:00 AM an observational tour was conducted in the Hospital's surgical department. During the tour the following observations were made:

In OR #5:
- 9:15 AM an anesthesia student (Z #1) was observed entering the room while tying his mask and a surgical technician ( E #3) had approximately 1 inch of hair exposed from the back of her head cover.
- 9:20 AM an anesthesiologist (MD #1) entered the room with approximately 1 to 1.5 inches of hair exposed from the back of his surgical cap;

Hall (semi-restricted):
- 9:05 AM, a nursing anesthesia student (Z #5) wore a mask around the neck (dangling).
- 9:30 AM a visitor (following a PA) (Z #2) was observed with facial hair exposed and a medical student (Z #3) observed with 1 to 1.5 inches of hair exposed from the back of his surgical cap.
- 10:10 AM, an OBGYN (Obstetric Gynecological) Physician (MD #3) wore a dangling mask.
-10:55 AM, an Anesthesiologist (MD #4) wore a dangling mask and left the OR into an unrestricted corridor.

In OR #3:
- 9:44 AM a product representative (Z #4) was observed with facial hair exposed.

In the catheterization laboratory (CL):
- 8:35 AM, a surgical scrub technician (E #4) wore a loose mask, allowing venting, in a CL room, where sterile supplies were open.
- 8:50 AM, a Rockford Cardiology Associate (MD #2) wore a loose mask, allowing venting, in a CL room, where sterile supplies were open.

2. On 8/18/15 at approximately 8:30 AM, at the beginning of the observational tour, the Director of Perioperative (E #8) raised her dangling mask to cover her nose and mouth. E #8 stated she would keep the mask up.

3. Hospital policy entitled, "Surgical Attire: Dress Code for OR and SSA," (reviewed date 1/20/2014) required, "...V. Practice...A. Hats: All head and facial hair is to be covered while in the restricted and semi-restricted areas of the surgical suite...B. Masks: Masks shall be worn at all times in the pods, operating rooms and other areas where open sterile supplies or scrubbed personnel are located. Masks shall fully cover the nose and mouth and shall be secured in a manner that prevents venting...8: Masks shall be worn at all times in the pods, operating rooms and other areas where open sterile supplies or scrubbed personnel are located. Masks shall fully cover the nose and mouth and shall be secured in a manner that prevents venting... Masks should not be saved by hanging around the neck..."

4. The Director of Perioperative Services stated during an interview on 8/18/15 at approximately 10:00 AM that she saw the personnel with hair exposed and untied mask.


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B. Based on document review, observational tour, and interview, it was determined for 2 of 10 staff (E #1 & 6), the Hospital failed to ensure staff washed/cleansed their hands, as required by policy.

Findings include:

1. On 8/17/15 at 11:30 AM, policy # 30.0205.0, titled, "Hand Hygiene, Handwashing, and Lotions" dated 1/27/10, was reviewed. The policy required, "I. When to Wash Hands... B. Before and After... gloving for patient contact... C. After... contact with soiled linen or trash..."

2. On 8/17/15 from 10:30 AM to 11:20 AM, an observational tour was conducted in critical care unit (CCU). At 10:40 AM, a Chaplain (E #1) removed his gown and gloves, and exited a contact isolation room (room 207), but did not wash his hands.

3. On 8/17/15 at 10:45 AM, an interview was conducted with E #1. E #1 stated he forgot to wash his hands. The Manager of CCU (E #2) was present during the interview with E #1.

4. On 8/18/15 from 9:10 to 11:00 AM, an observational tour was conducted in the operative area. At 9:30 AM, a surgical scrub technician (E #6), with ungloved hands, picked up a tube holder off the floor, placed it on a table, did not cleanse hands, and then tied the sterile gown of another scrub technician.

5. On 8/18/15 at 9:40 AM, the Manager of Surgery (E #7) stated she observed the same finding.

C. Based on document review, observational tour, and interview, it was determined for 2 of 2 surgical scrub technicians (E #4 & 6), the Hospital failed to ensure uncovered hands and arms did not extend over sterile fields.

Findings include:

1. On 8/18/15 at 1:55 PM, the Association of Perioperative Registered Nurses (AORN) 2015 Edition Guidelines for Perioperative Practice was reviewed. The Guidelines required, "Sterile Technique... Recommendation VI. Items introduced to the sterile field should be opened, dispensed, and transferred by methods that maintain the sterility and integrity of the item and the sterile field... VI.b. Items should be delivered to the sterile field in a manner that prevents unsterile objects or unscrubbed team members from leaning or reaching over the sterile field... Microorganisms are shed from the skin of Perioperative personnel..."

2. On 8/18/15 from 8:30 AM to 9:00 AM, an observation tour was conducted in the catheterization laboratory (CL). At 8:35 AM, a surgical scrub technician (E #4) placed her uncovered hands and arms over the sterile field of the back table while placing sterilized supplies and instruments on the sterile field.

3. On 8/18/15 at 8:40 AM, an interview was conducted with the Manager (E #5) of the catheterization laboratory. E #5 stated they follow AORN guidelines and "have been opening [sterile supplies] this way".

4. On 8/18/15 from 9:10 to 11:00 AM, an observational tour was conducted in the operative area. At 9:30 AM, a surgical scrub technician (E #6) placed her uncovered hands over the sterile field to place a sterile supply on the sterile field.

5. On 8/18/15 at 9:40 AM, during an interview with the the Manager of Surgery (E #7), the observation was discussed and E #7 had no comment.

D. Based on document review, observational tour, and interview, it was determined for 2 of 2 concentrated surgical instrument cleaning solutions, the Hospital failed to ensure surgical instrument cleaning solutions were properly concentrated, potentially affecting 32 surgical patients on the 8/18/15 schedule.

Findings include:

1. On 8/19/15 at 11:20 AM, policy No. 20.674.021.8, titled, "Decontamination of Instruments", reviewed by the Hospital on 1/20/14, was reviewed. The policy required, "E. Instruments to be manually washed and soaked/cleaned with an enzymatic solution".

2. On 8/19/15 at 11:25 AM, policy No. 20.674.022.5, titled, "Decontamination, Cleaning, Inspection, Lubrication of Powered Surgical Instruments", reviewed by the Hospital on 1/20/14, was reviewed. The policy required, "D. Power equipment will be scrubbed with a high-suds disinfecting detergent..."

3. On 8/18/15 at 1:55 PM, the Association of Perioperative Registered Nurses (AORN) 2015 Edition Guidelines for Perioperative Practice was reviewed. The Guidelines required, "Sterilization... Recommendation III Items to be sterilized should be cleaned... Effective sterilization cannot take place without effective cleaning. The process of sterilization is negatively affected by the amount of bioburden and the number, type, and inherent resistance of microorganisms, including biofilms, on the items to be sterilized. Soils, oils, and other materials may shield microorganisms on items from contact with the sterilant or combine with and inactivate the sterilant."

4. On 8/18/15 at 10:15 AM, an observational tour was conducted in the Perioperative reprocessing and decontamination area. At 10:40 AM, a sterile processing technician (E #9) was placing dirty surgical instruments into cleaning baths. The first bath contained Medical Enzyme Detergent (to soak instruments with attached blood) and the second was Manual Detergent High Foam (for cords and other sensitive instruments). Both detergents required mixing with water to achieve the correct concentration.

Neither the pan containing Medical Enzyme Detergent nor the bowl containing Manual Detergent High Foam solution had measurement indicators for the containers. The only measuring device found was a 10 cc syringe.

5. On 9/18/15 at 10:40 AM, an interview was conducted with a Sterile Processing Technician (E #9). E #9 stated 30 cc of Medical Enzyme Detergent are added with water in the pan. The pan had a tape marker to show how much water to pour into the pan, but the tape was removed approximately 2 weeks ago.

6. E #9 stated 1 squirt of Manual Detergent High Foam is added to a half filled bowl of water. The bowl did not have a measurement indicator.

7. On 9/18/15 at 10:50 AM an interview was conducted with the Director of Perioperative Services (E #8). E #8 stated the OR follows AORN guidelines and could not explain why the solution concentrations were not being measured.

Based on document review and interview, it was determined for 2 of 4 (Pt #6 and 7) clinical records reviewed for discharge planning, the Hospital failed to ensure all discharge planning was documented in the patients' clinical record, to include home health and hospice agency information.

Findings include:

1. Hospital policy entitled, "Discharge Planning," (effective date 8/1/15) was reviewed on 8/19/15. The policy failed to include the documentation requirement when a list of home health and/or hospice companies was provided to the patient.

2. The clinical record of Pt #6 was reviewed on 8/19/15. Pt #6 was a 63 year old female admitted on 6/9/15 with a diagnosis of adrenal insufficiency and discharged on 6/12/15. Case Management notes dated 6/10/15 included that Pt #6 lived independently in her own home. Case Management documentation dated 6/12/15 included Pt #6 was discharged home with OSF Home Care (Order of St Francis). Pt #6's clinical record lacked documentation that Pt #6 was provided a list of available home care agencies.

3. The clinical record of Pt #7 was reviewed on 8/19/15. Pt #7 was an 85 year old female admitted on 6/11/15 with a diagnosis of chronic kidney disease and discharged on 6/17/15. Case Management notes dated 6/16/15 included, "Met with pt and family per RN call to assist getting pt connected with hospice. Met with pt and daughter...Pt agreeable to hospice, but daughter assisting with choices...Per family request referral made to Northern Ill Hospice..." Pt #7's clinical record lacked documentation that Pt #7 was provided a list of available hospice agencies.

4. The Director of Case Management stated during an interview on 8/19/15 at approximately 10:30 AM the records did not include documentation that the list had been provided to the patients.