HospitalInspections.org

As directed by Centers for Medicare & Medicaid Services (CMS), an unannounced on-site survey was conducted on 11/01/10 to 11/05/10 at the University of Missouri Health Care System, Columbia, Missouri. As a result the hospital was found to be out of compliance with 42 CFR Part 482.41, Condition of Participation-Physical Environment.

Based on observation, interviews, and review of facility policies, the hospital:
- failed to clean and maintain walls, floors, ceilings and equipment to ensure a clean, safe and sanitary environment for patient care services in surgical suites, procedure rooms, kitchens and cooking facilities where food is stored, prepared and served daily, potentially affecting staff, visitors and patients;
- failed to ensure expired or unusable supplies were not available for patient use; and
- failed to ensure mattresses and armboard's were replaced when the integrity was compromised (ripped, frayed, cut or tape residue).

(Refer to A0701 and A0724)

The cumulative effect of these systemic practices has the potential to affect all patients in the hospital. The cumulative patient census of all facilities under this provider was 272.

Based on observation and interview, the facility failed to clean and maintain walls, floors, ceilings and equipment to ensure a clean, safe and sanitary environment for patient care services in surgical suites, procedure rooms, kitchens and cooking facilities where food is stored, prepared and served daily, potentially affecting staff, visitors and patients. The cumulative patient census of all facilities under this provider was 272.

Findings include:

1. Observation on 11/01/10 at 2:00 P.M., at the University Hospital's Same Day Surgery Suite #1 showed approximately 100 black, sticky areas on the floor, varying in size. A layer of thick dust coated the top horizontal surfaces of an anesthesia cart and a fluoroscopic camera (a camera used during procedures which shows x-rays in video) located above the surgical table. When the surfaces were wiped, dust particles fell to the floor and onto the surgical table, witnessed by Staff J.

During an interview on 11/01/10 at 2:00 P.M., Staff J stated that the anesthesia technician was responsible for cleaning the anesthesia cart and the cart should be cleaned between patient procedures as well as during the terminal cleaning of the room.

2. Observation on 11/02/10 at 6:00 P.M., at the University Hospital's Same Day Surgery Suite #1 showed a thick layer of dust covered the horizontal base of a portable ultrasound machine. When wiped with a bare hand, thick rolls of dust collected, which was witnessed by Staff B, Manager of Regulatory Affairs.

3. Observation on 11/02/10 at 9:20 A.M., at the University Hospital's main operating room (OR) suite #10 showed thick dust covering the top horizontal surface of a monitor. Wiping the surface caused thick clumps of dust to fall to the floor, which was witnessed by Staff C, Director of Surgical Services.

4. Observation on 11/02/10 at 9:42 A.M., at the University Hospital's main OR suite #6 showed dust on the top horizontal surface of an anesthesia cart. Wiping the surface caused dust particles to fall to the floor, which was witnessed by Staff C. A short time later, the room had been cleaned; however, sticky adhesive residue from a partially removed sticker remained on an instrument table used to set up a sterile field for procedures.

5. Observation on 11/02/10 at 5:30 P.M., at the University Hospital's main OR suite #7 showed debris (paper and plastic), on the floor after the room had been cleaned.

During an interview on 11/02/10 at 5:30 P.M., Staff C stated that he/she would expect the debris found on the floor to be removed during room cleanings.

6. Observation on 11/03/10 at 2:10 P.M., at the Women's and Children's Hospital OR suite #10 showed the floor around the head of the surgical table (after cleaning) had debris (plastic and paper) and was dry. The remainder of the floor was wet from mopping.

During an interview on 11/03/10 at 2:10 P.M., Staff UUU, Women's and Children's Hospital Preoperative (Peri-Op) Assistant stated that he/she had mopped the floor in suite #10 in preparation for another patient procedure. Staff DDD, Women's and Children's Hospital OR Supervisor stated that he/she expected the floor to be cleaned, removing debris and mopping, in-between patient procedures.

7. Observation on 11/02/10 at 10:20 A.M., at the University Hospital's pre-operative (pre-op) room #2 showed supplies such as sterile gloves, suction tubing, and yankauers (a plastic tool used to suction a patient's mouth) in a storage bin located at the head of a patient cart. When these supplies were pulled out of the storage bin, clumps of dust were clinging to the bottom of the packaging. Observation of the adjacent pre-op room #3 showed clumps of dust in the bottom of the storage bin where patient supplies were stored.

During an interview on 11/02/10 at 10:20 A.M., Staff P, University Hospital's Post Anesthesia Care Unit Supervisor said, "We'll work on that", (when the dusty supplies were shown to him/her).

Record review of University Hospital's Infection Control Environmental Rounds dated 04/23/10 and 10/04/10, revealed storage bins were clean in the Recovery and Holding area (which includes pre-op) (page 1). However, documentation on 10/04/10 by an unknown source showed, "I have spoken to staff and will continue to reinforce dusting."

8. Observation on 11/04/10 at 3:00 P.M., at the Missouri Orthopedic Center's Post Anesthesia Recovery Unit (PACU) clean storage area showed two infusion pumps with dark red/brown dry spots (pencil eraser sized). The spots were easily removed with a wet cloth by Staff YYY, OR Supervisor.

During an interview on 11/04/10 at 3:00 P.M., the Missouri Orthopedic Center's Supervisor YYY stated that the pumps had been cleaned by housekeeping and the spots on the pumps appeared to be either dried blood or betadine (an antiseptic).

9. Observation on 11/01/10 at 3:20 P.M., at the University Hospital's Same Day Surgery Suite #3 showed the surgical table mattress arm and leg extensions (attached to the table) were covered with sticky type residue, which appeared to be from adhesive tape.

10. Observation on 11/02/10 at 9:20 A.M., at the University Hospital's general OR suite #10 showed surgical table residue, which appears to be from adhesive tape, over multiple areas covering arm and leg rests, which was witnessed by Staff C.

11. Observation on 11/02/10 at 9:42 A.M., at the University Hospital's general OR suite #6 showed two red cabinets with laminate missing, exposing chipped particle board.

During an interview on 11/02/10 at 9:42 A.M., the University Hospital's Surgical Services Director stated that the facility was in the process of removing the red cabinets from the OR suites.

12. Review of Policy #2062 titled, "Cleaning Procedure: Term Clean of OR rooms", with a revision date of 01/05/09 revealed in part, under items to be cleaned:
-thoroughly clean and disinfect all flooring (page 1, #4);
-all stains and black marks are to be scoured (page 1, #5.5).
-thoroughly clean and disinfect all equipment (page 1, #6)
-visually inspect the room to insure all items have been cleaned (page 2, #9).

Review of Policy #2035 titled, "Operating Room between Case Cleanings", with a revision date of 01/01/09 revealed in part:
-remove all trash from the area (page 1, #2);
-disinfect all items located throughout the room, including horizontal surfaces (page 1, #4)
-thoroughly dust mop the floor (page 2, #8);
-thoroughly wet mop all areas of the floor (page 2, #9).

13. Record review of University Hospital's Infection Control Environmental Rounds dated 06/29/10 and 10/01/10, revealed high level dust was found in the Same Day Surgery Department (page 1). Documentation on 06/29/10 showed dust findings were discussed with Staff PPP, Operating Room Registered Nurse.

14. During an interview on 11/05/10 at 9:45 A.M., Staff YY, University Hospital's Infection Control Nurse said, "Floors are not a source of infection, it is an aesthetic issue." He/she stated that dust "is a concern of ours", it is a problem they have seen before, and that high level dusting is monitored by infection control staff. He/she stated that tape residue on the surgical tables is something "we watch for" and address when residue is found. He/she said the residue should be removed.

15. Review of the Infection Control Manual showed in part:
6. Cleaning of Equipment:
Equipment can become an important reservoir for pathogens. It is necessary to make sure that equipment used on multiple patients is cleaned based on degree of infection risk involved in the use of these items. All equipment should be cleaned according to manufacturer's directions.
-Noncritical items are those that come into contact with intact skin. Low level disinfection is necessary to prevent secondary transmission of infectious agents by noncritical items. Computer keyboards, glucose meters, blood pressure cuffs, and other small equipment taken from patient to patient must be wiped with a sani-cloth or other quaternary ammonia spray prior to use on another patient. If the manufacturer's guidelines do not recommend cleaning with a quaternary ammonia compound then 70% isopropyl alcohol may be substituted.
##. Review of Policy #2035 titled, "Operating Room between Case Cleanings", with a revision date of 01/01/09 revealed in part to thoroughly clean the OR table (see OR table cleaning for specific instruction) (page 2, #7).
Review of Policy #2051 titled, "Cleaning Procedure: OR Tables", with a revision date of 02/23/09 revealed in part to thoroughly clean the table (page 1, #3).



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16. Observation of the monitor for the C-arm (portable fluoroscopy device) located in the procedural room at the Ellis Fischel campus on 11/04/10 at 3:00 P.M. showed a significant amount of dust on the top surface of the machine.

Staff BBBB, Director of Ellis Fischel confirmed the dust on the monitor on 11/04/10 at 3:05 P.M., and stated that the technicians were responsible for wiping down the equipment.

Staff MMMM, Manager of Infection Control stated during an interview on 11/05/10 at 10:50 P.M. that the C-arm monitor should not be used if dusty, and should have been cleaned.

17. Observation of the defibrillator during a tour of the Burn Intensive Care Unit (BICU) at the main campus on 11/03/10 at 3:00 P.M., showed a significant amount of dust on the top surface of the defibrillator.

Staff CCCC, Manager of BICU verified the dust on the defibrillator on 11/03/10 at 3:05 P.M., and stated that the unit attendant was responsible for wiping down the crash cart.


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18. Observation on 11/02/10 at 9:20 A. M. of the Inpatient Operating Room #10 showed the Cauter-CMC III Mates Bipolar Electrosurgical System Machine (machine used for cauterization [burning of tissue for cutting open or closing off] in surgery) last maintained 03/10 and next date due for maintenance 09/10.

During an Interview on 11/02/10 with Staff C, Director of Surgical Services confirmed the outdated Cauter-CMC III Mates Bipolar Electrosurgical System Machine. Staff C then called Clinical Engineering Department and was told the machine was checked on 09/20/10 but was never labeled as being maintained.

19. Observation on 11/02/10 at 9:45 A. M. of the Inpatient Operating Room #6 showed a Symphony II Machine that was outdated for maintenance 04/15/10.

During an interview with Staff C, Director of Surgical Services confirmed the Symphony II Machine was outdated for maintenance.


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20. Observation on 11/3/10 at 3:15 PM on the campus of the Women's and Children's hospital revealed debris and dust on the floor behind the preparation counter in the kitchen area .
21. Observation on 11/4/10 at 2:36 P.M. in the main kitchen food preparation area of the Missouri Orthopedic Institute revelaed debris and dust underneath a counter used for storage of condiments and food preparation under the entire length of the table. The area near the small refrigerator next to this area had dried/colored stains on the floor. There were dried water stains next to the dish cleaning area on the floor.
22. During an interview at the Women's and Children's campus on 11/3/10 at 4:04 PM Staff NNNN (infection control professional) stated that he/she does not spend time in the kitchen other than checking the temperature logs for the refrigerator. He/she thought that Staff YY might monitor the kitchen areas
23. During an interview at the main campus of the hospital on 11/5/10 at 10:27 AM Staff YY (manager infection control) stated that the infection control practitioners use environmental rounding sheets for the areas they visit to determine if there are associated infection control risks. Staff YY stated that there was no rounding sheet for the kitchen areas of the multiple campuses, however, the city sanitarian does inspections of these areas.


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24. Observation of University Hospital's dry food storage area on 11/3/10 at 1:40 P.M. revealed a large room with tiled floor deeply pitted, gouged and marked with two and four inch wide black marks from pallet trucks and pallet skid damage. Most of the cuts and pits in the floor were partially filled with black dirt, tile adhesive and other unidentified debris.

25. Observation of the adjacent kitchen area at 2:40 P.M. on the same date revealed food debris, dirt and large crumbs accumulated in the corners of doors and between ramps leading up to the walk-in refrigerators and freezers. Dirt, food crumbs and dust blackened the corners, borders and tile grout around the perimeter of the kitchen; along all walls, including behind the cook line and next to the food prep areas. The wall grout color was white; however the eight inch high area below the vinyl bumper the wall grout was completely obscured and blackened. There was a film of grease on the floor below the deep fat fryers and spills had gelled to form brown deposits on the internal bracing around burner areas.

26. During interviews on 11/3/10 at 2:40 P.M., the day Food Service Supervisor, Food Service Assistant Manager, and Manager of Dining and Nutrition Services, stated that the kitchen employees clean up after each meal and a terminal mop and clean is done in the evenings with an enzymatic floor cleaner. They stated that equipment and tables not on wheels are moved every month for cleaning behind and around the station. The Food Service Supervisor stated that they had submitted a formal request in June for replacement or renovation of the ceiling, wall and floor covering that would include significant updating and improvement of the overall kitchen environment.

Based on observation and interview, the facility failed to ensure expired or unusable supplies were not available for patient use and failed to ensure mattresses and armboards were replaced when the integrity was compromised (ripped, frayed, cut or tape residue). This had the potential to affect all patients. The cumulative patient census of all facilities under this provider was 272.

Findings included:

1. Observation on 11/01/10 at 1:55 P.M. of Operating Room (OR) #7 (room used for open heart, cardio/thoracic cases) showed four opened tracheal tubes of various sizes in the anesthesia cart. The packaging of one of the open tracheal tubes was soiled. During an interview upon the observation, Staff C Director of Surgical Services stated that there was no way to tell how long the endotracheal tubes had been opened.

2. Observation on 11/01/10 at 2:35 P.M. of the anesthesia cart in OR #8 (trauma room) showed five opened endotracheal tubes of various sizes.

During an interview on 11/01/10 at 2:40 P.M., Staff TTTT Anesthesia Technician, stated that Certified Registered Nurse Anesthetists (CRNA) opened the endotracheal tubes and the anesthesia technician's were responsible to dispose of them.

3. Observation on 11/01/10 at 3:05 P.M. of the anesthesia cart in OR #16 showed seven opened endotracheal tubes of various sizes. During an interview upon the observation Staff QQQQ anesthesia technician stated if anesthesia staff opened the endotracheal tubes, the anesthesia technicians put the open, unused endotracheal tubes back.

During an interview on 11/01/10 at 3:15 P.M., Staff O Registered Nurse Educator stated staff should dispose of opened endotracheal tubes.

4. AORN Perioperative Standards and Recommended Practices
May 2009
Recommended Practices for Environmental Cleaning in the Perioperative Setting:

Recommendation II (in part)
A safe, clean environment should be reestablished after each surgical procedure.
Routine cleaning and disinfection reduces the amount of dust, organic debris and microbial load in the environment. Following scientifically based recommendations for cleaning and disinfection practice in health care organizations helps to reduce infections associated with contaminated items.
11. b. Mattresses and padded positioning device surfaces (e.g., OR beds, arm boards, patient transport carts) should be moisture-resistant and intact.
11. b. 3. Damaged or worn coverings should be replaced.


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5. Observation on 11/01/10 at 2:54 P.M., University Hospital Same Day Surgery Suite #1 showed an outdated Pediatric Bovie Pad (a pad used to ground electrical currents that "cut" in surgical procedures), Lot #148709, expired 09/10.
6. Observation on 11/02/10 at 9:20 A.M., University Hospital main OR suite #10 showed an outdated capnographer (checks for proper breathing tube placement), Lot #7208118, expired 04/10. A sterile introducer bougie (used to assist with a breathing tube insertion), Lot #MD020, was found open on the anesthesia cart. Both findings were witnessed by Staff C, Director of Surgical Services.

7. Observation on 11/02/10 at 10:35 A.M., University Hospital pre-op room #3 showed the following outdated supplies:
-Nasopharyngeal airway (a tube placed in a patient's nostril to assist with breathing), Lot #00G05, expired 06/05;
-Nasopharyngeal airway, Lot #00K01, expired 10/05;
-Nasopharyngeal airway, Lot #04B06, expired 01/09;
-Nasopharyngeal airway, Lot #03G04, expired 06/08;
-cardiac (heart) monitoring patches, Lot #2008-04, expired 04/08;
-sterile gloves, size 7 ?, Lot #0309071521, expired 09/08;
-three sterile butterfly needles (needle and tubing used to draw blood) 23 gauge (size) by ? inch, Lot #A027, expired 09/02; Lot #A008, expired 01/04, and Lot #A020, expired 03/04;
-blue top blood tube (used to store blood for testing), Lot #9G027, expired 01/01;
-needle 21 gauge by 1 ? inch, Lot #416057, expired 05/09;
-sterile intravenous (IV) catheter (a needle and plastic tube placed in the vein to administer fluids or medication), Lot #5139124, expired 05/08.

Observation on 11/02/10 at 10:47 A.M. in the University Hospital pre-op room #12, showed an outdated nasopharyngeal airway, Lot #04B06, expired 1/09.

Note: Record review of University Hospital Infection Control Environmental Rounds dated 04/23/10 and 10/04/10, revealed there were no expired sterile supplies found in the Recovery and Holding area (which includes pre-op).

8. Observation on 11/02/10 at 1:45 P.M., at the University Hospital Emergency Department (ED) room #16 showed two outdated sterile Iodaform packing strips:
-Lot #82870301, expired 10/10;
-Lot #82620302, expired 09/10.

9. Observation on 11/02/10 at 1:55 P.M., at the University Hospital ED room #15 showed the following outdated supplies:
-sterile gonorrhea culture swab, Lot #694101, expired 02/15/10;
-sterile gonorrhea culture swab, Lot #670519, expired 12/08/09;
-sterile Iodaform packing strips, Lot #81220301, expired 05/10.

10. Observation on 11/02/10 at 2:20 P.M., at the University Hospital ED room #6 showed an expired Pediatric Capnographer, Lot #7253143, expired 06/10.

11. Observation on 11/02/10 at 2:35 P.M., at the University Hospital ED room #2 showed three expired sterile culture swabs:
-Lot #T5QV09, expired 08/10;
-two of Lot #NFBE09, expired 10/10.

12. Observation on 11/02/10 at 2:55 P.M., at the University Hospital ED room #5 showed seven outdated sterile culture swabs:
-Lot #OMQV00, expired 06/07;
-Lot #ILMJ00, expired 07/07;
- four of Lot #505715, expired 02/10;
-Lot #NFSE09, expired 10/10.

Note: Record review of University Hospital Infection Control Environmental Rounds dated 09/21/10, revealed there were no sterile expired supplies in the ED.

13. . Observation on 11/03/10 at 1:35 P.M., at the Women's and Children's Hospital OR suite #9 showed a mobile cart with two outdated Betasept (an antiseptic solution) bottles:
-Lot #0712-0359, expired 05/10;
-Lot #0801-0368, expired 06/10.

14. Observation on 11/03/10 at 2:40 P.M., at the Women's and Children's Hospital OR suite #10 showed an outdated thin prep pap test kit (used to obtain tissue samples to test for cancer cells), Lot #TCK-162, expired 03/10.

During an interview on 11/03/10 at 2:40 P.M., Staff CCC, Women's and Children's Hospital OR Manager stated that a physician must have brought the expired pap test kit in from a private office, as the facility does not use that particular brand of Pap test.

Note: Record review of Women's and Children's Hospital Infection Control Environmental Rounds dated 06/16/10 and 09/29/10, revealed there were no expired solutions in the OR.

15. Observation on 11/04/10 at 9:20 A.M., at the Women's and Children's Hospital Intensive Care Unit (ICU) showed the storage supply closet contained the following outdated supplies:
-27 yellow top blood containers (used to store blood for testing), Lot #9240380, expired 08/10;
-50 steri-strips (used to "tape" wounds closed), size ? inch by 4 inches, Lot #2010-07 and #2010-10, expired 07/10 and 10/10.
-19 steri-strips, size ? inch by 4 inches, Lot #2009-08, expired 08/09;
-Ventriculostomy kit (used to drain fluid from the brain and monitor pressures in the brain), Lot #A57045, expired 09/09.

During an interview on 11/04/10 at 9:20 A.M., Staff XXX, Women's and Children's Hospital ICU Manager stated that the nursing staff were responsible for removing the outdated blood tubes, Central Supply was responsible for removing the steri-strips on the par level (floor stock maintained by Central Supply), and that ventriculostomy patients are no longer managed at the Women's and Children's Hospital.

16. Observation on 11/04/10 at 10:50 A.M., at the Women's and Children's Hospital Neonatal ICU storage room showed the following outdated sterile butterfly needles:
-Lot #07E14, expired 01/10;
-two of Lot #04E31, expired 04/09;
-Lot #04F07, expired 05/09;
-Lot #07I16, expired 08/10;
-Lot #07E14, expired 04/10.

During an interview on 11/04/10 at 10:50 A.M., Staff VVVV, Women's and Children's Hospital Neonatal ICU Manager stated that the outdated butterfly needles are rarely used because the staff did not like them.

During an interview on 11/05/10 at 9:45 A.M., Staff YY, Women's and Children's Hospital Infection Control Nurse stated that when environmental rounds are completed by infection control staff and outdated supplies are found, it was addressed immediately with the responsible party. The unit where the outdated supplies were found was then re-checked in one week to ensure the expired supplies had been removed.


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17. Observation on 11/01/10 at 2:26 P. M. of the Same Day Surgery Operating Room #2 anesthesia cart (cart where anesthesia supplies are stored in Operating Room)lower drawer showed an Endotracheal Tube (tube placed in patients throat to help with breathing), size 8.5, lot number 045000366 opened.

18. Observation on 11/04/10 at 1:30 P. M. of the Digestive Health Center's storage cabinet located across from nurses desk showed one 18 gauge Intravenous (IV) autoguard winged set (used to start Intravenous access on patient's) outdated 05/2010.
Note: as a result of the damaged areas listed above, the object cannot be effectively sanitized.


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19. Observation during tour of Operating Room #7 on 11/1/10 at 2:10 P.M. showed tape residue with rough adhesive areas and small holes penetrated the sealed cover exposed white frayed edges of internal fabric cover on two arm boards staged in the east hallway. Sticky silicone gel leaked from an open break in the sealed surface of a support cushion.
Note: as a result of the damaged areas listed above, the object cannot be effectively sanitized.

20. Observation during tour of Operating Room #8 on 11/1/10 at 2:30 P.M. showed a one half inch long tear near the foot of the mattress exposed white threads and interior cushion. Tape residue was on two arm boards, and a stainless steel IV pole was scratched, bent and dented.
Note: as a result of the damaged areas listed above, the object cannot be effectively sanitized.

21. Observation during tour of Operating Room #16 on 11/1/10 at 3:00 P.M. showed tape residue on both sides of an arm board attached to the table. Tape residue was also on two arm boards staged for use with other equipment. Chips of the rubberized vinyl surface coating missing from the surface and corners of a positioning cushion exposed white threaded cloth.
Note: as a result of the damaged areas listed above, the object cannot be effectively sanitized.

22. Observation on 11/1/10 at 3:30 P.M. in the sterile corridor outside of Operating Rooms #15 and #16 revealed two operating room tables and a hospital bed staged for transporting the patient to recovery. One of the three mattresses had tape residue on one side, another had a one half inch diameter hole in the mattress showing white threads and interior foam cushion, and the third had scratches which cut through the protective surface and exposed the white cloth base material.
Note: as a result of the damaged areas listed above, the object cannot be effectively sanitized.

As directed by Centers for Medicare & Medicaid Services (CMS), an unannounced on-site survey was conducted on 11/01/10 to 11/05/10 at the University of Missouri Health Care System, Columbia, Missouri. As a result the hospital was found to be out of compliance with 42 CFR Part 482.42, Condition of Participation-Infection Control.

Based on observation, interviews, and review of facility policies, the hospital:
-failed to identify and mitigate residue and debris in the sterile surgical containers and carts used to transport sterile instruments;
-failed to ensure the integrity and cleanliness of surgical suites, procedure rooms and sterile processing department;
-failed to ensure the cleanliness of surgical instruments free from residue;
-failed to perform adequate hand hygiene; and
-failed to ensure proper disposal of potentially infectious wastes.
(Refer to A0749)

The cumulative effect of these systemic practices has the potential to affect all patients in the hospital. The cumulative patient census of all facilities under this provider was 272.

Based on observation, interview and policy review, the facility failed to identify and mitigate residue and debris on sterile instruments in sterile surgical containers, and on a sterile cart used to transport sterile instruments; failed to ensure the integrity and cleanliness of surgical suites and procedure rooms; failed to ensure surgical table mattresses, arm boards and positioning devices were repaired, replaced, or cleaned when the integrity was compromised; failed to ensure staff follow the facility Hand Hygiene policy; failed to follow facility policy and standard of practice regarding handling and processing potential infectious waste; and failed to ensure equipment was kept clean in patient care areas. This deficient practice potentially affects all staff, visitors and patients of the hospital complex. The cumulative patient census of all facilities under this provider was 272 patients.

Findings included:

1. Observation on 11/01/10 at 10:00 A.M. of a lamboty set (set of surgical instruments) showed there was a dark residue which wiped off of the bottom of the metal container holding the instruments.

During an interview on 11/01/10 at 10:05 A.M., Staff C, director of Surgical Services stated that approximately one month prior, a staff member complained a canula had a rust like discoloration that could be wiped off. Staff was unable to determine if it was body fluid or not.

2. Observation on 11/01/10 at 11:20 A.M. of a clean metal cart (used to hold surgical packs in the sterilizer) showed a dark residue on the cart. The residue could be wiped off. During an interview upon the observation Staff H, Sterile Processing Department (SPD) Supervisor stated that the cart had been through the sterilizer and was clean.

During an interview on 11/01/10 at 11:25 A.M., Staff H SPD Supervisor stated that there was a possibility of potential contamination to the surgical instruments and the facility needed to find out which sterilizer machine had been used for the cart and the instrument container with the residue. Staff H stated that there was a potential the same residue on the cart could transfer to the sterile surgical instruments.

During an interview on 11/01/10 at 11:15 A.M., Staff I Manager of SPD stated that the steam that goes to the sterilizer system was not a dedicated steam pipe and it had to travel across campus from the power plant to reach the sterilizer.

During an interview on 11/02/10 at 10:35 A.M. the Pipe Fitter Supervisor stated that the facility did not do any testing of the quality of the steam and they only tested the water softener for the softness and checked the copper and silver amounts. Staff VV stated he/she did not receive any water reports and he/she was unsure if anyone else received them.

During an interview on 11/03/10 at 9:40 A.M., Staff YY, Infection Control Nurse stated that plant engineering staff monitored the quality of the steam.

3. Observation on 11/01/10 10:20 A.M. of Stairwell C (direct route from surgical floor to the ground floor) showed dirt, debris and dried spills from the third floor landing to the ground floor exit. Staff C Director of Surgical Services stated that staff used the stairwell and housekeeping staff were responsible for cleaning. Note: staff leaving and entering the surgical suites and/or units utilize Stairwell C which could potentially compromise the cleaniness and the integrity of the surgical suites.

4. Observations of Sterile Supply where sterile surgical instrument sets are stored showed in the clean storage area the floor was dirty with lint, dust and debris throughout the area. There was a thick layer of dust and debris under the storage racks where sterile surgical instruments are stored.

During an interview on 11/01/10 at 10:40 A.M., Staff H SPD Supervisor stated that Environmental Services cleaned the area twice a day.

During an interview on 11/01/10 at 10:45 A.M. Staff G Custodian, stated he/she did not clean the area where sterile surgical instruments are stored but another environmental services staff that worked from 5 A.M. to 1:00 P.M. was responsible to clean the area.

5. Observation on 11/01/10 at 10:50 A.M. of the Sterile Processing Department showed multiple areas of plaster residue from the walls and pieces of plastic on the floor.

During an interview on 11/01/10 at 10:55 A.M., Staff C Director of surgical Services stated that the cleanliness of the floor was not acceptable.

6. Observation on 11/01/10 at 11:30 A.M. showed a dirty and grimy sink in the Sterile Processing Department work area where SPD staff checks the instruments. The grime could be wiped off with a paper towel. During an interview upon the observation, Staff C Director of Surgical Services stated that the staff used the sink for hand hygiene.

During an interview on 11/02/10 at 10:15 A.M., Staff I, Manager of Sterile Processing Department (SPD) stated that the housekeeping staff were supposed to clean the floor between the movable storage racks the sterile surgical items are stored on but were not. The Manager of SPD stated that four housekeepers had cleaned the area yesterday evening.

During an interview on 11/02/10 at 10:55 A.M. the Assistant Director of Support Services (housekeeping/environment) stated that he/she had not received any maintenance requests regarding the floors. He/she stated that they had started a new process for cleaning the OR floors by having a person assigned to clean the OR floors between 10:30 P.M. and 7A.M. said
-He/she did not keep a record of floors that had been cleaned but said, "need to start".

During an interview on 11/02/10 at 2:10 P.M. Staff YY Infection Control Nurse stated that he/she or members of the Infection Control Committee do quarterly environmental rounds in patient care areas, OR and sterile processing. The Infection Control Nurse stated that environmental rounds included looking at high level dusting, expired supplies, clean and dirty items were separated, in addition to other areas.

During an interview on 11/03/10 at 9:40 A.M. Staff YY stated that he/she did not feel the dirty floors in the operating rooms or sterile storage area in the Sterile Processing Department posed an increased risk of infections as anything dropped on the floor would be disposed of. The infection Control Nurse stated that they had identified some issues with high level dusting during environmental rounds.

7. Review of the Infection Control Environmental Rounds, showed in part, the following:

-On 09/30/10 in Cardiac Rehab workout area-work out equipment dusty, same as June rounds.
-On 09/30/10 in SICU-cables from TV are lined with dust also on space labs wall mount hardware.
-On 10/01/10 in the Same Day Surgery-light dust on tops of monitors noted in several areas.
-On 10/04/10 in the Recovery/Holding area bays #2 and #8, light dust on tops of space labs monitor, ceiling tiles adjacent to air vents on pre-op side are very dust lined.

8. Review of the CDC (Centers for Disease Control) "Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008, showed, in part, the following;
-Hospital floors become contaminated with microorganisms from settling airborne bacteria: by contact with shoes, wheels, and other objects; and occasionally by spills. The removal of microbes is a component in controlling health-care-associated infections.

9. Review of the policy Functions of Sterile Processing #1-3, dated 12/8/2008 showed in part:
-Provide materials which contribute to better technique of patient care and assist in decreasing the spread of contamination.
-Process and/or sterilize instruments and trays for use throughout the hospital.
-Monitor all sterilization processing and biological or mechanical tests and test results for sterilizers throughout the hospital.

10. Review of the policy Interdepartmental Functions of Sterile Processing #1-5, dated 12/8/2008 showed in part:
Environmental Services:
-Floors in the department will be cleaned on a routine basis.

Infection Control:
-Ensure that items are sterilized effectively.

Infection Control will:
-Report any problems to Sterile Processing/Central Service.

11. Review of the facility policy Employee Work Assignments Sterile Processing 2-1, dateed 12/08/08 showed in part:
-The cleaning and maintaining of all areas in the department is the responsibility of all Sterile Processing personnel. Storage area shall be as clean as the item being stored.
-Sterile area must be cleaned.


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12. Observation on 11/4/10 at 9:35 A.M. showed Registered Nurse (RN) JJJ enter Patient # 4's room, put on non-sterile gloves and:
-checked the patient's identification bracelet which was on the ankle
-documented in the patient's medical chart
-opened the fridge door and poured liquid into a cup and gave it to the patient
-left the patient's room
No hand cleansing was done before leaving the room.

13. Observation on 11/4/10 at 9:50 A.M. showed RN JJJ enter Patient #5's room without cleansing his/her hands. The RN removed the patient's intravenous lock (IV) without wearing gloves. The RN left the room without cleansing his/her hands. The RN went into another patient's room and opened a drawer getting a flashlight and brought it back into Patient #5's room.

During an interview on 11/4/10 at 10:15 A.M., Clinical Improvement Specialist GGG said, "It's (hand washing and gloves) so basic. I don't know why this happens."

14. Record review of the Infection Control Manual (no date) provided by the facility in part stated the following:
f. Remove gloves when the task is finished or if touching public items or areas that others may contact.
Hand Hygiene
Wash hands before and after patient contact. Wash hands or use hand sanitizer prior to performing invasive procedures. Hand hygiene must also be performed immediately after removing gloves.
When should you wash your hands?
a. Wash hands before:
Patient contact
Putting on gloves
Performing invasive procedures
b. Wash hands after:
Patient contact
Touching beds or bedside objects
Removing gloves


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15. The facility Infection Control Manual revised 2010 stated in part under the heading of Infectious Waste Management, "Many institutionalized patients have infectious diseases, which have not been diagnosed; therefore, it is prudent for health care personnel to handle the blood, blood products, excretions and secretions of all patients as infectious. Bulk blood, suctioned fluids, excretions, and secretions are considered as infectious waste; however, they may be carefully poured down a drain connected to a sanitary sewer".

Observation of removal of a Jackson Pratt (JP) drain from the abdomen of Patient #10 on 5 West on the main campus on 11/03/10 at 1:15 P.M. showed Staff EEEE, physician, removed the drain and bulb. The bulb contained a moderate amount of serosanguineous (drainage containing blood) drainage. Staff EEEE did not empty the device, and placed it in a trash can in the patient's room. (A Jackson-Pratt drain is used to remove fluids that build up in areas of the body after surgery or when there is an infection. The JP drain is made up of 2 parts: A thin rubber tube and a soft round squeeze bulb. The rubber tube is placed in the area of the body where fluids may build up. The other end comes out through a small incision. A squeeze bulb is attached to this end which collects the fluids)

Staff MMMM, Manager of Infection Control stated during an interview on 11/05/10 at 10:55 P.M. that JP drains should be emptied prior to discarding in the trash.

16. Observation on 11/4/10 at 3:00 P.M. showed a significant amount of dust on the top surface of the monitor for the C-arm (portable fluoroscopy device) located in the procedural room at the Ellis Fischel campus. Staff BBBB, Director of Ellis Fischel confirmed the dust on the monitor on 11/04/10 at 3:05 P.M., and stated during an interview at that time that the technicians are responsible for wiping down the equipment.

Staff MMMM, Manager of Infection Control stated during an interview on 11/05/10 at 10:50 P.M. that the C-arm monitor should not be used if dusty, and should have been cleaned.

17. Observation of the defibrillator during a tour of the Burn Intensive Care Unit (BICU) at the main campus on 11/03/10 at 3:00 P.M., showed the defibrillator with a significant amount of dust on the top surface of the machine.

Staff CCCC, Manager of BICU verified the dust on the defibrillator on 11/03/10 at 3:05 P.M., and stated during an interview that the unit attendant is responsible for wiping down the crash cart.


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18. Observation on 11/01/10 at 10:05 A.M., the University Hospital's Same Day Surgery clean storage area showed a Sterrad Sterilization basket (a basket used to hold instruments, which is sterilized with the instruments) with gray discoloration (appeared to be corrosion) in the tray. A white gauze wiped along the inside of the sterilization basket turned grey with gentle pressure.
During an interview on 11/01/10 at 10:05 A.M., Staff J, University Hospital's Assistant Manager of Surgical Services confirmed the discoloration inside the tray, but stated that he/she did not know what caused it.
19. Observation on 11/01/10 at 10:30 A.M., showed the University Hospital's Same Day Surgery clean storage area contained multiple, packaged, sterile instruments banded with yellow and red tape. The tape was used to determine what department the instruments belong to.
During an interview on 11/01/10 at 10:30 A.M., Staff J stated tape should not be on instruments, the facility had stopped taping instruments "a year ago or more", that all staff are responsible for removing tape on instruments, and instruments with tape remaining on them should not be used. Staff J then directed an unknown staff member to remove the instruments from use which had tape on them.
20. Observation on 11/01/10 at 10:45 A.M., in the University Hospital's Same Day Surgery surgical hall of, showed a metal storage rack with sterile, packaged, biopsy snares (instrument used to remove tissue during a procedure) banded with yellow and red tape. After opening the packaging, the tape was found to be dry, brittle, and easily removed.
During an interview on 11/01/10 at 11:00 A.M., Staff M, University Hospital's Surgical Technician stated that the hospital had been working on removing tape from the surgical instruments for three or four months, that everyone is responsible for removing the tape, but the taped instruments are still being used in the operating room because the facility has not had the time to remove all of the tape from the instruments.
During an interview on 11/01/10 at 1:15 P.M. Staff I, University Hospital's Manager of Sterile Processing, provided photocopies from a book titled "Inspecting Surgical Instruments: An Illustrated Guide", dated 2008. The information provided addressed surgical marking tape on instruments but did not provide any guidelines or recommendations for removal of deteriorating surgical marking tape. Staff I said the information was not an actual policy but did not provide a policy regarding removal of deteriorating surgical instrument tape prior to the exit conference on 11/05/10.
21. Observation on 11/01/10 at 3:20 P.M., the University Hospital's Same Day Surgery area showed a sterile instrument pack containing ocular (eye) scissors. When the sterile pack was opened, a silicone mat which holds the sterile instruments in place had black smears and black debris between the silicone teeth (or nubs). Another sterile instrument pack containing a Reverse Sinskey (a hook used in surgery on the eye) showed three small particles (yellow/orange, red, and black in color), which were removed from between the silicone mat teeth by pressing a cotton tipped applicator on the particles and lifting. Both findings were witnessed by Assistant Manager J and by Staff PPP, Operating Room Registered Nurse.
During an interview on 11/05/10 at 9:45 A.M., Staff YY, University Hospital's Infection Control Nurse stated that he/she did not know what the particles found in the sterile tray were from or if there was a concern if these particles became a foreign body (something that does not belong in a patient's body) during surgery. Staff YY stated that the particles were "definitely something that warrants investigation".
22. Observation on 11/03/10 at 2:55 P.M. in the Women's and Children's Hospital's Sterile Processing clean storage, an instrument set (when opened and the basket of instruments were removed from the metal casket) showed a thick and powdery residue (the diameter of a golf ball) on the bottom of the metal casket.
During an interview on 11/03/10 at 3:02 P.M., Staff VVV, Women's and Children's Hospital Sterile Processing Department (SPD) Supervisor stated that he/she did not know what the powdery residue in the surgical casket was from, but believed it to be soap. Staff VVV stated that the washer, which is used to clean the metal caskets, did not always rinse the soap off in one rinse cycle. When soap residue was found, the staff sent the caskets through a second rinse cycle. Staff VVV stated that he/she did not know if the presumed soap residue would be harmful to tissue if the steam sterilization process (which takes place after the casket is washed) transferred the residue to the instruments.
23. Observation on 11/04/10 at 8:45 A.M., the Women's and Children's Hospital Emergency Department (ED) showed a sterile instrument tray, used for suturing (stitches), contained two metal cups used to place sterile water or antiseptics in. Both of the cups showed a dry white film (quarter sized) which could be easily wiped away with a wet gauze.
24. Record review of Women's and Children's Hospital Infection Control Environmental Rounds in the main OR, dated 06/16/10, revealed several comments had been made about dirty instruments in sterile trays, specifically orthopedic (bone) trays. In the documentation, it was reported, "Three out of three trays in one day had instruments with bone or cement on them" (page 3).
25. Review of Policy #2062 titled, "Cleaning Procedure: Term Clean of OR rooms", with a revision date of 01/05/09 revealed in part, under items to be cleaned:
-thoroughly clean and disinfect all flooring (page 1, #4);
-all stains and black marks are to be scoured (page 1, #5.5).
26. Observation on 11/01/10 at 2:00 P.M., University Hospital's Same Day Surgery Suite #1 showed approximately 100 black, sticky areas on the floor, varying in size. A layer of thick dust coated the top horizontal surfaces of an anesthesia cart and a fluoroscopic camera (a camera used during procedures which shows x-rays in video) located above the surgical table. When the surfaces were wiped, dust particles fell to the floor and onto the surgical table, witnessed by Staff J.

During an interview on 11/01/10 at 2:00 P.M., Staff J stated that the anesthesia technician were responsible for cleaning the anesthesia cart and the cart should be cleaned between patient procedures as well as during the terminal cleaning of the room.

27. Observation the following day on 11/02/10 at 6:00 P.M., University Hospital's Same Day Surgery Suite #1 showed a thick layer of dust covered the horizontal base of a portable ultrasound machine. When wiped with a bare hand, thick rolls of dust collected, which was witnessed by Staff B, Manager of Regulatory Affairs.

28. Observation on 11/02/10 at 9:20 A.M., University Hospital's main operating room (OR) suite #10 showed thick dust covering the top horizontal surface of a monitor. Wiping the surface caused thick clumps of dust to fall to the floor, which was witnessed by Staff C, Director of Surgical Services.

29. Observation on 11/02/10 at 9:42 A.M., University Hospital's main OR suite #6 showed dust on the top horizontal surface of an anesthesia cart. Wiping the surface caused dust particles to fall to the floor, which was witnessed by Staff C. A short time later, the room had been cleaned; however, sticky adhesive residue from a partially removed sticker remained on an instrument table used to set up a sterile field for procedures.

30. Observation on 11/02/10 at 5:30 P.M., University Hospital's main OR suite #7 showed debris (paper and plastic), on the floor after the room had been cleaned.
During an interview on 11/02/10 at 5:30 P.M., Staff C stated that he/she would expect the debris found on the floor to be removed during room cleanings.

31. Observation on 11/03/10 at 2:10 P.M., Women's and Children's Hospital OR suite #10 showed the floor around the head of the surgical table (after cleaning) had debris (plastic and paper) and was dry. The remainder of the floor was wet from mopping.

During an interview on 11/03/10 at 2:10 P.M., Staff UUU, Women's and Children's Hospital Preoperative (Peri-Op) Assistant stated that he/she had mopped the floor in suite #10 in preparation for another patient procedure. Staff DDD, Women's and Children's Hospital OR Supervisor stated that he/she expected the floor to be cleaned, removing debris and mopping, in-between patient procedures.

32. Observation on 11/02/10 at 10:20 A.M., University Hospital's pre-operative (pre-op) room #2 showed supplies such as sterile gloves, suction tubing, and yankauers (a plastic tool used to suction a patient's mouth) in a storage bin located at the head of a patient cart. When these supplies were pulled out of the storage bin, clumps of dust were clinging to the bottom of the packaging. Observation of the adjacent pre-op room #3 showed clumps of dust in the bottom of the storage bin where patient supplies were stored.

During an interview on 11/02/10 at 10:20 A.M., Staff P, University Hospital's Post Anesthesia Care Unit Supervisor said, "We'll work on that", when the dusty supplies were shown to him/her.

Record review of University Hospital's Infection Control Environmental Rounds dated 04/23/10 and 10/04/10, revealed storage bins were clean in the Recovery and Holding area (which includes pre-op) (page 1). However, documentation on 10/4/10 by an unknown source shows, "I have spoken to staff and will continue to reinforce dusting."

33. Observation on 11/04/10 at 3:00 P.M., the Missouri Orthopedic Center's Post Anesthesia Recovery Unit (PACU) clean storage area showed two infusion pumps with dark red/brown dry spots (pencil eraser sized). The spots were easily removed with a wet cloth by Staff YYY, OR Supervisor.

During an interview on 11/04/10 at 3:00 P.M., Missouri Orthopedic Center's Supervisor YYY stated that the pumps had been cleaned by housekeeping and the spots on the pumps appeared to be blood or betadine (an antiseptic).

34. Observation on 11/01/10 at 3:20 P.M., University Hospital's Same Day Surgery Suite #3 showed the surgical table mattress arm and leg extensions (attached to the table) were covered with residue, which appeared to be from adhesive tape.

35. Observation on 11/02/10 at 9:20 A.M., University Hospital's general OR suite #10 showed surgical table residue, which appears to be from adhesive tape, over multiple areas covering arm and leg rests, which was witnessed by Staff C.

36. Observation on 11/02/10 at 9:42 A.M., University Hospital's general OR suite #6 showed two red cabinets with laminate missing, exposing chipped particle board. During an interview on 11/02/10 at 9:42 A.M., University Hospital's Surgical Services Director stated that the facility was in the process of removing the red cabinets from the OR suites.

37. Review of Policy #2062 titled, "Cleaning Procedure: Term Clean of OR rooms", with a revision date of 01/05/09 revealed in part, under items to be cleaned:
-thoroughly clean and disinfect all flooring (page 1, #4);
-all stains and black marks are to be scoured (page 1, #5.5).
-thoroughly clean and disinfect all equipment (page 1, #6)
-visually inspect the room to insure all items have been cleaned (page 2, #9).

38. Review of Policy #2035 titled, "Operating Room between Case Cleanings", with a revision date of 01/01/09 revealed in part:
-remove all trash from the area (page 1, #2);
-disinfect all items located throughout the room, including horizontal surfaces (page 1, #4)
-thoroughly dust mop the floor (page 2, #8);
-thoroughly wet mop all areas of the floor (page 2, #9).

39. Record review of University Hospital's Infection Control Environmental Rounds dated 06/29/10 and 10/01/10, revealed high level dust was found in the Same Day Surgery Department (page 1). Documentation on 06/29/10 showed dust findings were discussed with Staff PPP, Operating Room Registered Nurse.

40. During an interview on 11/05/10 at 9:45 A.M., Staff YY, University Hospital's Infection Control Nurse stated that, "Floors are not a source of infection, it is an aesthetic issue." He/she stated that dust "is a concern of ours", it is a problem they have seen before, and that high level dusting is monitored by infection control staff. He/she stated that tape residue on the surgical tables is something "we watch for" and address when residue is found. He/she said the residue should be removed.

41. Review of the Infection Control Manual showed in part:
6. Cleaning of Equipment:
Equipment can become an important reservoir for pathogens. It is necessary to make sure that equipment used on multiple patients is cleaned based on degree of infection risk involved in the use of these items. All equipment should be cleaned according to manufacturer's directions.
-Noncritical items are those that come into contact with intact skin. Low level disinfection is necessary to prevent secondary transmission of infectious agents by noncritical items. Computer keyboards, glucose meters, blood pressure cuffs, and other small equipment taken from patient to patient must be wiped with a sani-cloth or other quaternary ammonia spray prior to use on another patient. If the manufacturer's guidelines do not recommend cleaning with a quaternary ammonia compound then 70% isopropyl alcohol may be substituted.

42. Review of Policy #2035 titled, "Operating Room between Case Cleanings", with a revision date of 01/01/09 revealed in part to thoroughly clean the OR table (see OR table cleaning for specific instruction) (page 2, #7).
Review of Policy #2051 titled, "Cleaning Procedure: OR Tables", with a revision date of 02/23/09 revealed in part to thoroughly clean the table (page 1, #3).


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43. Observation on 11/01/10 at 10:45 A.M., of Staff K, Certified Registered Central Service Technician (CRCST) showed her/him washing dirty surgical instruments with gloves on then opened door of decontamination room (room in the surgery suite where dirty surgical instruments are taken for cleaning) and answered the phone in the clean hallway of the Same Day Surgical Operating Room Suite without removing wet gloves.

44. Observation on 11/01/10 at 2:25 P.M., of Same Day Surgery Operating Room #2 showed two operating room tables and the mattresses had several small cuts and some areas with threads exposed.

45. Observation on 11/02/10 at 3:15 P.M., of Staff MMMM, Registered Nurse (RN) on Medical and Neuro Intensive Care Unit (ICU) showed no hand hygiene (hand sanitizing or hand washing) prior to administering an Intravenous Piggy Back (IVPB [IV medication to infuse through main IV tubing]) Medication.

46. Observation on 11/03/10 at 10:20 A.M., of Staff FF, Licensed Practical Nurse (LPN) during preparation for a Peripherally Inserted Central Catheter (PICC) Line showed she/he wearing the same gloves for the following:
-preparing area for procedure
-getting clean supplies from cart
-picking up trash that had fallen on the floor
-assisting Registered Nurse (RN) with sterile field
-scrubbing area of insertion site of Patient 17.

47. Observation on 11/03/10 at 3:00 P.M., of Staff NN, Registered Nurse (RN) inserting an Intravenous Line (IV) into Patient 24's left hand showed Staff RN changed gloves in middle of procedure and did not use hand hygiene before putting on second pair of gloves.

48. Observation on 11/03/10 at 3:00 P.M., revealed Staff NN, Registered Nurse (RN) washed hands, and turned faucet off with clean wet hands, then dried hands.

49. Record Review of Medication Management Policy, revised 10/01/08 showed on page 1, "POLICY: 1. General Principles, A. Perform appropriate hand hygiene prior to sterile product preparation and administration (refer to "Hand Hygiene" section of the Infection Control Manual)".

Record review of Hand Washing Policy, effective date 02/17/09 showed, "All personnel will use the hand-hygiene of washing their hands with warm soapy water". Fifth bullet states, "Before applying gloves and inserting indwelling catheters, peripheral vascular catheters, and other invasive devices that do not require a surgical procedure." Bullet 11 states, "Always after removing gloves".

Record Review of Hand Hygiene procedure, page 54 of the Infection Control Manual, states, "#2.e. Dry hands thoroughly from the fingers down to the forearms and wrists with a paper towel; if available, use a clean paper towel to turn off water". Page 55, b., "Wash hands after: bullet four states, removing gloves".

50. Observation on 11/03/10 at 1:45 P.M., of the East Medical-Oncology-Surgical Oncology floor showed Room 41, Bed 1 with urinal containing urine sitting on the overhead table where the patient's personal items were and where patient eats.

51. Observation on 11/01/10 at 9:50 A. M., of the Same Day Surgery supply room showed a sterile package of large Weite Landers Abdominal forceps (instrument used for large abdominal incision to hold open) had colored tape that was dry, brittle and easily removed.

52. Observation on 11/01/10 at 9:50 A. M., of the Same Day Surgery supply room showed a sterile package of small Weite Landers Abdominal forceps (instrument used for small abdominal incision to hold open) had colored tape that was dry, brittle and easily removed.

53. Observation on 11/02/10 at 9:20 A.M., of the Inpatient Operating Room #10 anesthesia cart (cart where anesthesia supplies are stored in the Operating Room) showed a size 8.0 millimeters (mm) Endotracheal Tube (tube placed in patient ' s throat to facilitate breathing) was torn open and placed in the bottom drawer readily available for patient use.

54. Observation on 11/04/10 at 3:45 P.M., of the Breast Imaging Center located at the Ellis Fischel Facility showed a sterilized peel package of a surgical scalpel handle with tape that was dry, brittle and easily removed with handling.

55. Record review of policy Assuring Sterility of Patient Care Items, revised date 03/2001, states, in part, "These items may be used as long as the integrity of the package is not compromised by becoming torn, wet, damaged or otherwise suspected of being contaminated. "DAMAGE" is defined as visual evidence of compromised packages. 1. Holes/torn, with the change in policy, it is imperative to assess the integrity of the items to ensure quality care to patients".


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56. During an interview at the main campus of the hospital on 11/5/10 at 10:27 A.M., Staff YY (manager infection control) stated that the infection control practitioners use environmental rounding sheets for the areas they visit to determine if there are associated infection control risks. Staff YY stated that there is no rounding sheet for the kitchen areas of the multiple campuses but the sanitarians from the city do inspect these areas. For hand washing or hand hygiene compliance for staff persons, only the intensive care units get direct observations. For the other types of patient care units the amount of usage of hand sanitizers and soaps is analyzed by looking at the amounts ordered or used by each unit.


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57. Observation during tour of Operating Room #7 on 11/1/10 at 2:10 P.M., revealed the following:
scratched paint and exposed bare metal on a wheeled stand;
large amounts of dust on a 36 inch long by 12 inch high wall air intake vent, tape and tape residue on two of three ceiling mounted electrical service units;
large milky-white spots on the base two IV poles and yellow stains on the floor around the OR table;
black and brown residue had accumulated in cracks where heat sealed vinyl floor strips had separated;
gouges and marks on the floor, some as large as three inches long by one-quarter inch wide provided a resting place for unidentified debris that could not be easily cleaned between procedures;
peeled paint around the edges and a scorched heat basin on a fluid warmer;
tape and tape residue on the door and drawer facing left sticky white residual;
two unfilled one quarter-inch d