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A. Based on observation, document review and interviews it was revealed the Infection Control Officer failed to ensure housekeeping staff followed the facility infection control program. Staff failed to take measures to identify, report, prevent and control potential transmission of infections and communicable diseases of patients and personnel. This failure has the potential to expose all surgical patients to risk of infection.

Findings include:

1. An observation was conducted in OR #11 on 7/24/19 at approximately 6:50 a.m. The corner next to the rear entrance door had black discoloration on the floor and a layer of black debris was on top of the floor molding along the wall. The main entrance door jambs had black buildup and debris on the floor.

2. An interview was conducted with Regulations and Patient Safety Manager (RPSM) on 7/24/19 at approximately 6:50 a.m. When asked about the black discoloration and black debris on the floor molding and if the area was cleaned by housekeeping, the RPSM verbalized the black discoloration was wax build up. She then took a pencil and moved the layer of debris on the molding and concurred this area in the OR was not cleaned.

3. A review of the Environmental Services Department (EVS) Duty List for "Area Cleaner 2'nd Floor O.R. 3'rd shift" was conducted. The EVS Duty List states in part: "Floor Care: 1. Corners & Edges, 2. Damp mop, 3. Scrub floors ..." and further states in part: "Detail Cleaning ... 3. Baseboards."

B. Based on observation, document review and interviews it was revealed the Infection Control Officer failed to ensure operating room (OR) staff followed the facility infection control program. Staff failed to take measures to identify, report, prevent and control potential transmission of infections and communicable diseases of patients and personnel. This failure has the potential to expose all surgical patients to risk of infection.

Findings include:

1. An observation was conducted in OR #11 on 7/24/19 at approximately 8:30 a.m. Certified Registered Nurse Anesthetist (CRNA) #1 dropped the telemetry leads with attached electrodes on the OR floor, picked up the leads, removed the backing from the electrodes and attached them to the chest of patient #30.

2. A review of facility policy by the Department of Anesthesia titled Infection Control Responsibilities, effective date 1/12, approved date 1/18 was conducted. The policy states in part: "All OPS (outpatient services), OR and PACU (post-anesthesia care unit) personnel will perform patient care activities in a manner that decreases the possibility of cross contamination."

3. A review of facility policy by the Department of Anesthesia titled Infection Control Procedures During Anesthesia, effective date 1/12, approved date 1/18 was conducted. The policy states in part: "Standard Precautions will be strictly adhered to and OR personnel will use proper infection control measures to contain any infectious materials during and at the completion of the procedure."

Based on clinical record review and interviews it was revealed the facility failed to ensure an operative report describing techniques, findings and tissues removed or altered was written or dictated immediately following surgery and signed by the physician. This failure was identified in one (1) out of thirty (30) patient medical records (patient #1). This failure has the potential to delay continuity of patient care for all surgical patients.

Findings include:

1. A review of clinical record for patient #1 was conducted on 7/23/19. The operative note written by physician #1 documents in part: "Date of Service: 05/15/19." Physician #1 completed and signed the operative note four (4) days later as documented, 5/19/2019 and an addendum was documented, Status: Addendum ... filed at 05/27/19.

2. An interview with physician #1 was conducted on 7/22/19 at approximately 3:23 p.m. When discussing when the operative report is completed after surgery, physician #1 verbalized the operative report is done within the same day or within twenty-four (24) hours.

3. An interview with the Chief Quality Officer (CQO) and the Regulations and Patient Safety Manager (RPSM) was conducted on 7/23/19 at approximately 11:40 a.m. When discussing how soon operative reports are expected to be completed, the CQO and RPSM both concurred the Operative Report is expected to be completed immediately.