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Based on observation, interview, record review and nationally-recognized standards review, the facility failed to perform fire-risk assessments prior to surgical procedures. These failures placed the surgical patients and staff at an elevated fire risk.The hospital census was two Acute Care patients, two Swing Bed patients and two Observation (Observation - outpatient services provided to a patient while the patient's physician decides whether to admit the patient to Acute Care services or discharge the patient) patient for a total patient census of six.

Findings included:

1. Observation on 1/31/24 at 9:05 AM, for surgical Patient #8, in the Gastrointestinal Operating Room Suite, showed no surgical staff performed a fire-risk assessment prior to a colonoscopy.

2. During an interview on 1/31/24 at 1:50 PM, Staff K, Director of Surgical and Outpatient Services, stated staff were expected to perform fire-risk assessments verbally prior to surgical procedures and document them.

3. Review of Patient #5's medical record on 10/25/23, showed no documentation of a fire-risk assessment prior to a colonoscopy with lesion removal.

4. Review of Patient #6's medical record on 08/07/23, showed no documentation of a fire-risk assessment prior to a left knee scope with menicotomy.

5. Review of Patient #7's medical record on 11/13/23, showed no documentation of a fire-risk assessment prior to a laporoscopy chole.

6. Review of the Association of PeriOperative Registered Nurses (AORN) "Guideline for Fire Prevention Practices," dated 2023, showed the direction for staff to:
- Perform a fire-risk assessment as part of the preprocedural briefing process, to include ignition, fuel, and oxidizer sources present in the OR.
- Include cognitive aids (eg, algorithms, checklists).
- Collaborate on and implement interventions based on the fire-risk assessment.
- Document the fire-risk and the actions taken to address them.
- Prevent contact between fuel sources (eg, drapes, skin antisepsis agents) and ignition sources (eg, electrosurgical devices).
- Prevent pooling of flammable skin antiseptic agents under, on, or near the patient.
- Prevent the pooling of flammable antiseptic agents by:
o placing sterile or clean towels near the surgical preparation site to absorb excess solution from pooling;
o using sterile towels to absorb excess solution from the prepped site;
o removing materials (eg, sterile or clean towels) that become wet with the skin preparation solution before draping; and
o moving flammable antiseptic soaked materials away from ignition sources and outside of the patient care vicinity (ie, at least 6 ft away).
- Allow the skin antiseptic agent to dry before applying surgical drapes. Follow the manufacturer's IFU for dry time.
- Use a water-soluble gel for the patient's head and hair when performing procedures that involve the head of neck.
- Use moistened radiopaque sponges near oxidizer and ignition sources during airway procedures.
The operating room contains several elements of the fire triangle, including oxygen (oxidizer), lasers and electrosurgical devices (ignition sources), and alcohol-based skin antiseptics and surgical drapes (fuel). The perioperative team can help reduce the risk of fire by performing a fire risk assessment and implementing interventions (eg, preventing contact between fuel sources and ignition sources) based on that assessment.

7. Review of the facility's policy titled, "Fire In The Operating Room," dated 09/2023, showed the direction for staff to perform fire-risk assessments before each operative or other invasive procedures.

Based on record review and interview the facility failed to ensure physicians who supervise Certified Registered Nurse Anesthetists (CRNA) had approved privileges.The facility census was two Acute Care patients, two Swing Bed (Swing Bed - a Medicare program in which a patient can receive acute care services, then if needed Skilled Nursing Home Care) patients and two Observation (Observation - outpatient services provided to a patient while the patient's physician decides whether to admit the patient to Acute Care services or discharge the patient) patients for a total patient census of six.

Findings included:

1. Review of the credentialing packets for Physician #1 and #10 showed privileges requested for surgery. The privilege for supervision of the CRNA did not appear on the sheet as an option.

2. Review of the facility's undated policy titled, "Scope of Services for Anesthesia," showed anesthesia administered by a CRNA is done under the supervision of the operating practitioner.

3. During an interview on 01/31/24 at 9:30 AM, Staff I, Chief Nursing officer confirmed the privilege sheet lacked an option to select supervision of the CRNA and neither physician had that on the privilege sheet.

Based on observation, interview, policy review and nationally-recognized standards review, the hospital failed to ensure staff followed infection control policies and infection prevention standards of practice when staff failed to:
- Provide a separation between the clean laundry and dirty laundry to ensure containment to prevent cross-contamination;
- Maintain cleanliness in the Endoscope cabinet;
- Maintain repairs and cleanable drop ceilings in the Central Sterile rooms; and
- Provide maintenance and a rust (reddish-brown oxidation of metal that can harbor bacteria) -free kitchen.

These failed practices had the potential to expose all patients, visitors and staff to cross-contamination and increased the potential to spread infection. The facility census was two Acute Care patients, two Swing Bed (Swing Bed - a Medicare program in which a patient can receive acute care services, then if needed Skilled Nursing Home Care) patients and two Observation (Observation - outpatient services provided to a patient while the patient's physician decides whether to admit the patient to Acute Care services or discharge the patient) patients for a total patient census of six.

Findings included:

Laundry Separation

1. Observation on 1/31/24 at 8:10 AM, in the laundry department, showed no door between the dirty laundry and the clean laundry failing to keep the laundry contained.

2. During an interview on 1/31/24 at 8:10 AM, Staff H, Environmental Services Manager, stated the dirty side is a negative pressure room and hadn't had a door for 23 years.

3. Review of the AORN "Guidelines for Laundry," dated 2023, showed handling contaminated laundry with a minimum of agitation avoids contamination of air, surfaces and personnel.

4. Review of the facility's policy titled, "Infection Prevention and Control - Laundry," undated, showed clean linen and soiled linen shall be strictly separated and contact between clean linen and soiled linen shall not occur at any time.


Endoscope Storage

5. Observation on 1/31/24 at 9:40 AM, in the Endoscope storage room, showed inside the Endoscope cabinet multiple tape (harbors bacteria) labels on the back wall of the cabinet, two sticky notes (harbors bacteria) on the side wall and an unclean towel in the bottom of the cabinet.

6. Review of the AORN "Guideline for Flexible Endoscopes," dated 2023, showed visible soil in the storage cabinet may contaminate endoscopes stored in the cabinet. Areas and equipment that are not cleaned according to a schedule may be missed during routine cleaning procedures and become environmental reservoirs for dust, debris, and microorganisms.


Central Sterile and Surgical Hallway

7. Observation on 1/31/24 at 9:45 AM, in the surgical hallway, showed six scrapes on the wall with exposed drywall (particle shedding that harbors bacteria).

8. Observation on 1/31/24 at 9:50 AM, in the Central Sterile Clean room, showed:
- A drop uncleanable ceiling;
- Two paper calendars (particle shedding); and
- Multiple papers and tissue box (particle shedding) on a desk.

9. Observation on 1/31/24 at 10:00 AM, in the Instrument Decontamination room, showed:
- A drop uncleanable ceiling;
- A floor seam cracked, open and unclean; and
- Two wall seams broken away from the wall leaving unclean areas.

10. Observation on 1/31/24 at 10:15 AM, in the Endoscope Decontamination room, showed a drop uncleanable ceiling.

11. Review of the APIC "Infection Preventionists Guide to the Operating Room," dated 2018, showed the OR environment requires surfaces which are smooth, cleanable, non-absorptive, and capable of withstanding cleaners and disinfectant solutions. There should be no cracks and crevices where dirt can become trapped. Other materials (e.g., vinyl) can rip or wear in ways which create environmental reservoirs for microorganisms.

12. Review of the AORN "Guideline for Environmental Cleaning," dated 2023, showed the Sterile Processing Areas were to be terminally cleaned each day the areas were used.


Kitchen

13. Observation on 1/29/24 at 2:00 PM, in the kitchen, showed:
- Four holes in the wall to the left of the window;
- Ceiling cracks with drywall exposed above the cook stove;
- Rust under the dishwasher;
- Rust under the lid of the ice machine;
- Rust on legs below the ice machine; and
- One hole in the wall to the left of the café door.

14. During an interview on 1/31/24 at 1:50 PM, Staff K, Director of Surgical and Outpatient Services, stated they expected staff to place work orders for any repairs needed, remove all paper products and terminally clean the Central Sterile area.

15. During an interview on 1/31/24 at 2:10 PM, Staff J, Infection Preventionist, stated they expected:
- Dirty laundry to be contained;
- Paper products to be removed from the Central Sterile Clean room;
- The central sterile staff to keep the endoscope cabinet clean;
- Ceilings in the Central Sterile rooms to be cleanable; and
- Staff in the kitchen and surgical areas to report any needed repairs to maintenance and Infection Control.

16. Review of the facility's policy titled, "Infection Prevention and Control Program Policy," last reviewed on 3/03/14, showed environmental rounding was to be performed monthly of patient care units and ancillary departments by the Infection Preventionist.

17. Review of the facility's log titled, "Quality Assurance Monitoring Evaluation - Walk Around Hospital Cleanliness," for the last six months, showed no observation of the kitchen or surgery areas.

Based on interview and record review and nationally-recognized standards review, the facility failed to provide a current Infection Control Plan approved by the Governing Body. This failure had the potential to effect all patients and staff that presented to the hospital for treatment.The hospital census was two Acute Care patients, two Swing Bed (Swing Bed - a Medicare program in which a patient can receive acute care services, then if needed Skilled Nursing Home Care) patients and two Observation (Observation - outpatient services provided to a patient while the patient's physician decides whether to admit the patient to Acute Care services or discharge the patient) patients for a total patient census of six.

Findings included:

1. During an interview on 1/31/24 at 2:10 PM, Staff J, Infection Preventionist, stated they didn't have an Infection Control Plan approved by the Governing Body.

2. Although requested, the facility failed to provide a current Infection Control Plan approved by the Governing Body.

3. Review of the Centers For Disease Control and Prevention (CDC), titled, "Core Infection Prevention and Control Practices for Safe Healthcare Delivery", dated 11/29/22, showed the required ensurance of the Governing Body's accountability for the success of infection prevention activites in a health care facility.