HospitalInspections.org

Based on observation and staff interview, the hospital facility did not ensure that 1) Sterile Supply Room had positive air-pressure; 2) Ceiling tiles of special rooms meet requirements specified in the Facility Guidelines Institute (FGI) 2010 to permit cleaning and disinfection of these tiles; 3) A scrub sink in the OR had clean running water.

These failures may place patients at risk for infection.

Findings include:

During the tour of the Operating Suites on 6/7/2021 between 11:30 AM and 12:30 PM, the following findings were identified in the presence of Staff J (OR Assistant Manager) and Staff N (Director of Engineering):

1- The sterile supply room on the 10th floor was found to have a negative air pressure relative to the adjoining spaces instead of the required positive air pressure for sterile supply rooms.

2- The ceiling tiles of the sterile supply room B of the Operating Room Suite on 10th floor were regular ceiling tiles instead of the washable and scrubbable type of ceiling that is required for this type of room as per FGI 2010.

-The ceiling tiles of the sterile supply room M10108 in the Operating Room Suite on 10th floor were the regular ceiling tiles instead of the washable and scrubable type of ceiling that is required for this type of room as per FGI 2010.

As per 'FGI 2010: 2.1-7.2.3.4, (2) Ceilings'
"(2) Semi restricted areas
(a) Ceiling finishes in semi restricted areas (e.g., airborne infection isolation rooms, protective environment rooms, lean corridors, central sterile supply spaces, specialized radiographic rooms, and minor surgical procedure rooms)
shall be smooth, scrubbable, nonabsorptive, nonperforated, capable of withstanding cleaning with chemicals, and without crevices that can harbor mold and bacterial growth."

3- The water at scrub sinks located at sub-sterile areas that served Operating Rooms #s 8, 16 and 17 was discolored and turbid. The discolored/turbid water is a potential source for transmission of infections.

The above findings were acknowledged by Staff J and Staff N during the tour of the Operating Suites and was brought to the attention of the hospital leaders at the exit conference on 6/7/2021 at approximately 4:00 PM.