HospitalInspections.org

Based on review of facility policies and procedures, observations and staff interviews, it was determined that the facility lacked an effective system to:
a) maintain a sanitary hospital environment;
b) mitigate the risks contributing to healthcare-associated infections (HAIs);
c) perform/provide active surveillance of the hospital's environment;
d) Assess and monitor aseptic technique practices used in surgery and in invasive procedures performed outside the operating room; and
e) monitor compliance with facility infection control policies, procedures, protocols.

Findings were:

A) A tour of the Hospital's Operating Room (OR) was conducted with the Specialty Director of Perioperative Services (OR Director- employee #20) and the OR's Clinical Nurse Specialist (CNS- employee #5) at 11:00 a.m. on 8/14/2012. Inspection of OR #22 revealed a coating of gray-colored dust on the surface and in crevices of the anesthesia cart, the air vents and on the window ledge. When shown to the CNS, the CNS explained that OR staff cleaned all equipment related to the surgery itself, that Anesthesia staff were responsible to clean the anesthesia equipment, and housekeeping cleaned the other surfaces of the room. During a subsequent interview in OR #22 at 12:30 p.m. on 8/14/2012, the Coordinator of Anesthesia Services (employee #21) acknowledged the dust located on the anesthesia machine, and related that anesthesia staff cleaned all anesthesia equipment between surgical cases, and performed a more in-depth cleaning (terminal cleaning) of the equipment once per week.

Perioperative Services policy entitled, Post-Procedure Clean Up, last reviewed 09/11/2008, described the isolation and disposal of contaminated items following a surgical procedure, but did not direct staff in how to clean and disinfect individual ORs between cases and at the close of the surgical day.

B) A tour of the Hospital's Cardiac Catheterization Lab (Cath Lab) with the Director of Invasive Cardiology (DIC- employee #19) and the Associate Chief Nurse for the Cardiac Services (ACN- employee #18) at 10:30 a.m. on 8/15/2012 revealed the following:
1) Observations in Cath Lab #3 at 11:00 a.m. revealed a Cardiovascular Lab Technician (employee #6) set up a table with sterile drapes, instruments and supplies for use during a heart catheterization procedure. The lower ties of the Technician's surgical mask had been removed and the lower portion of the mask protruded from the Technician's face exposing his/her lower face and beard. When questioned, the Technician explained that he/she removed the ties to provide ventilation under the mask and prevent his/her goggles from fogging up. The Registered Nurse (RN- employee #7) who circulated the room did not wear a mask. During the heart catheterization procedure, the surveyor observed the Technician pass behind the physician- the front of the Technician's sterile garb was next to and inches from the unsterile back of the physician's gown.
2) Observation in Cath Lab #1 at 11:50 a.m. revealed that the surgical hat worn by the Cath Lab Technician (employee #23) failed to cover the front and sides of the Technician's hair. The physician Fellow (physician undergoing additional training in a specialty area) was observed to assist the patient's physician and to perform portions of the heart catheterization procedure. The Fellow was observed to wear a gold-colored ring under his/her sterile gloves during the procedure.
3) During application of the surgical drape (covering/drape applied over the patient and surrounding table to protect sterile instruments, needles and supplies from contamination) in Cath Labs #3 and #1, the Technician in each room was observed to "fluff" the drape open. In each case, the lower edges of the drape, which were contaminated during the application, were observed to fly back over the sterile drape.

Facility policy entitled, Attire in the Cardiac Cath Lab, last approved 07/07/2012, required that all head and facial hair be covered while in the restricted areas (surgical/procedure areas) of the Cardiac Cath Lab, that staff wear masks to cover the nose and mouth where open sterile supplies or scrubbed staff are located, and that all rings and watches be removed prior to handwashing. The Cardiology Services' policy entitled, Infection Control Policy, last approved 08/04/2003, also stipulated that staff who were to touch the sterile field, sterile instruments or wound were to remove all jewelry from their fingers and wrists, and scrub their hands with an anti-microbial surgical hand-scrub preparation. The Cardiology Services' policy entitled, Asepsis, last approved 08/14/2012, stipulated that sterile staff pass either back-to-back or front-to-front when changing positions in a sterile field.

During an interview in the ACN's office at 12:30 p.m. on 8/15/2012, the DIC confirmed that while in areas where sterile procedures were being set up and/or performed, staff were to wear masks to cover their mouth, nose and facial hair, and that all hair was to be covered. Persons who participated in the actual procedure were to remove all jewelry from their hands and wrists prior to washing their hands, then don their sterile gown and gloves. The DIC also confirmed that portions of the sterile drapes that fell below the level of the surgical field were considered contaminated, and in order to prevent those portions from contaminating the sterile field, drapes should be applied without fluffing.

C) During a tour of the Emergency Department (ED) at 2:45 p.m. on 8/15/2012, a thick layer of dust was observed on the facility's emergency Crash Carts (carts containing drugs and equipment for use during medical emergencies), the rails in the hallways, and on respiratory and other equipment located throughout the department. The overhead lights and equipment located in one of the ED's examination rooms (room not numbered), and the equipment attached to the wall behind a patient in one of the other examination rooms (also not numbered) were also observed to be dusty. During the tour, the Director of Nursing Operations (employee #26), the ED's Unit Director (employee #27) and the ED's Clinical Nurse Specialist (employee #28) confirmed the above findings and related that the housekeeping staff were responsible to clean all non-medical equipment which was cleaned by the nursing staff.

D) During a tour of the Mother/Baby unit on 8/14/2012, thick dust was noted on the door plates of the clean and soiled utility rooms. The floor in the clean utility room appeared dirty and dusty. Two (2) transport incubators had dust on control panels and did not appear clean. The Clinical Specialist (employee #11) and the ICP (employee #24) were present during the tour and acknowledged the findings.

E) During a tour on the Respiratory Department on 8/15/2012 and review of the departments high level disinfection documentation revealed that the department failed to follow the manufacture's instructions for use. Documentation revealed that the Cidex OPA solution temperature was not monitored and that the length of the submersion time of the instruments was not documented. Additionally, the Cidex OPA test strips container was not dated as to when it had been opened. The label indicated that the test strips were to be discarded after 90 days after the container was opened. The Respiratory manager (employee #25) was present during the tour and acknowledged the listed findings.