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Based on observation, interview, and the review of document, it was determined the facility failed to (1) develop and implement policies to ensure appropriate surgical attire is worn in surgical suites; (2) maintain isolation precaution for patients on contact isolation; (3) provide a sanitary environment to avoid sources and transmissions of infectious and communicable diseases.

Findings include:

See Tag A-0749
See Tag A-0941

Based on observation, interview, and review of document, it was determined the facility failed to (1) develop and implement policies to ensure appropriate surgical attire is worn in the surgical suites in two (2) of three (3) Operating Rooms observations; (2) maintain isolation precaution for patients on contact isolation in two (2) of five (5) observations; (3) provide a sanitary environment to avoid sources and transmissions of infectious and communicable diseases.

Findings include:

The following was observed during a tour of the Operating Room (OR) Suite on 9/15/15, at approximately 12:35 PM. The surveyor was accompanied by the Staff #1, Director of Perioperative Service:

1. In Operating Room #2, an orthopedic surgery was in progress. The surgeon and two resident physicians wore "Blue Surgeon's cap with ties" with their hair exposed around the edges. The surgeon and the two resident physicians were in close proximity to the sterile field.

In OR Room #3, at approximately 1:10 PM, vascular surgery was in progress.
The resident physician assisting the surgeon had facial hair that was exposed and was positioned within a foot of the sterile field. A medical student positioned within two feet of the sterile field wore a "Blue Surgeon's cap with ties" with her hair exposed around the edges.

Review of the facility's policy and procedure titled "Surgical Attire/Hand Hygiene," last reviewed and revised December 2014 notes appropriate attire for head covering includes (a) disposable cap or freshly laundered cloth, and (b) disposable hood for personnel with facial hair. The facility did not implement the Center for Disease guideline for prevention of Surgical Site Infection, 1999; it notes intraoperatively, " wear a cap or hood to fully cover hair on the head and face when entering the operative room " .

At interview with Staff #2, Director of Perioperative Services on 9/15/15 at 1:15 PM, she stated the personnel with facial hair should have worn a disposable hood. She stated the facility stock for head covering includes "Blue surgeon's cap with ties", disposable bouffant hats and disposable hoods for personnel with facial hair. She added that the choice of head covering depends on individual preference.

There was no effective measures in place to ensure Operating Room personnel wore the appropriate surgical attire.


2. (a) During the tour of the ED on 9/15/15 at 2:45 PM, Patient A was observed in an isolation room with no isolation sign posted at the entrance of the room.

Patient A is an 87-year-old male who was triaged in the Emergency Department on 9/15/15 at 5:24 AM with complaints of urinary symptoms. The Infection Control log for 9/15/15 notes the patient was positive for Clostridium Difficile toxin in stool on 8/24/15 and requires contact isolation for which gown, gloves and hand hygiene are indicated.


(b) During ED tour on 9/15/15 at 2:50 PM, Patient B was observed being transferred by Staff #3 and Staff #4, Patient Care Associates to another location in the ED without the use of gown and gloves. There was no isolation precaution sign posted by the patient's room.

Patient B, a 53-year-old male was triaged on 9/15/15 at 00:25 AM with chief complaint of shortness of breath. The Infection Control log for 9/15/15 notes the patient was positive for Methicillin Resistant Staphylococcus Aureus (MRSA) in sputum on 4/25/15 and requires contact isolation for which gown and gloves are indicated.

The facility's policy and protocol titled "Isolation Precaution/Transmission Based Precaution" last revised March 2015 notes "Gown and Glove/Contact Precautions apply to specified patients known or suspected to be infected or colonized (presence of microorganism in or on patient but without clinical signs and symptoms of infection) with epidemiologically important microorganisms that can be transmitted by direct or indirect contact. The policy noted the duration of Gown and Glove precautions should be six (6) months except in the case of Clostridium Difficile patients who should be removed from isolation when one culture is negative.

At interview with Staff #3 during the observation of Patient B on 9/15/15 at 2:50 PM, she stated Patient B was not on isolation. However, orders were noted in the medical record for isolation precaution (Gown and Gloves) on 9/15/15 at 5:46 AM.

At interview with Staff #5, Assistant Nurse Manager on 9/15/15 at 3:05 PM, he stated patients requiring isolation are identified at triage and are immediately isolated. He stated Patient A and Patient B should have had isolation signs posted by the nurse upon admission to the Emergency Department and prior to physician written order for isolation.


3. On 9/15/15, between 11:15 AM and 11:30 AM the following observations were made in the Emergency Department in the presence of Staff #6, Director of Nursing for Emergency Department:

a) In the soiled utility room;
- The floor of the room was heavily soiled.
- The clinical sink was filled with dirty water.
- The airflow between the room and the adjacent ED corridor was not negative as required. Improper airflow may allow contaminants from the soiled utility room to travel to areas in close proximity to this room.

b) In the clean utility room;
- Eight (8) plastic bins used for storage of syringes, needles and intravenous catheters were
found to be dusty and had dirt particles.
- A dirty stylet (A thin wire probe) that had been bagged for reprocessing was found on top of a cart.


c) In the Pediatric ED suite;
- Two big (2) packs of gauze for multiple patient use were opened and stored in the patient
care area which exposes them to dust and possible contamination by patients.


d) On 9/15/15 between 12:20 PM and 12:40 PM, the following observations were made in the Operating Room Suite in the presence of Staff #2.

- In the clean workroom of the second floor operating room suite, surgical scrubs were
observed to be stored in the cabinet underneath a sink, which exposes these supplies to soil,
and water leaks.

- In the Post Anesthesia Care Unit, stacks of clean towels were noted to be stored at the head of multiple patient beds. The clean towels were not covered to ensure cleanliness and
protection from dust and soil.



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Based on observation, interview, and review of document, it was determined the facility failed to (1) develop and implement policies to ensure appropriate surgical attire is worn in the surgical suits in two (2) of three (3) Operating Rooms observations.

Findings include:

See Tag A-0749