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272 HOSPITAL ROAD

CHILLICOTHE, OH 45601

INFECTION CONTROL PROGRAM

Tag No.: A0749

Based on observations made during tour, facility policy review, and staff interview, the facility failed to follow it's current facility policies related to weekly cleaning of sterilization equipment and gowning prior to set up of a sterile field. This had the potential to affect all surgical patients. The facility census was 89.

Findings include:

The Surgical Suites were toured on 09/15/14 at 04:30 PM. Surgery staff in OR #1 were beginning to prepare for a surgery and the scrub technician was observed opening up a surgical tray on a sterile surgical field. The scrub technician was observed wearing gloves but not wearing a gown.

The facility policy titled Roles and Duties of the Surgical Technician was reviewed on 09/16/14 at 10:30 AM. According to the policy staff are instructed to gown and glove prior to preparing the back table and mayo stand.

Staff E, the Operating Room Educator, was interviewed on 09/16/14 at 11:00 AM. According to Staff E Surgery staff are instructed to gown and glove prior to preparing the back table in order to prevent any microorganisms from contaminating the sterile field. It was confirmed with Staff E and Staff F that the staff member observed setting up the back table should have been wearing a gown on 09/16/14 at 11:15 AM.

The Sterile Processing Department was toured on 09/15/14 at 03:45 PM. During the tour of the Sterile Processing Department, Staff B was asked how often staff clean the sterilization equipment. Staff B stated the equipment is cleaned weekly. The facility policy for cleaning the sterilizers was reviewed on 09/16/14 at 10:50 AM. According to the policy, sterile processing technicians are responsible for cleaning sterilizers every week. Documentation of the weekly cleaning was requested. Staff B reported there was no documentation of the required weekly cleaning. He/She stated: "I know the staff do the weekly cleaning, we just have to start keeping a log of it." It was confirmed with Staff B on 09/16/14 at 11:30 AM that the facility lacked documentation of ever having completed the required weekly cleaning.