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On 1/10/10 between the hours of 0900 and 1100 a tour of the Surgical Services Unit with the Plant Operations Director revealed the following:

The aisles, corridors and related Means of Egress in the Surgical Services Unit did not provide "a continuous and unobstructed way of travel" and was not clear and unobstructed. The means of egress to exit access was reduced from that which was originally designed and constructed due to the storage of carts and equipment along the corridor walls.\
19.2.3.3*
Any required aisle, corridor, or ramp shall be not less than 4 ft (1.2 m) in clear width where serving as means of egress from patient sleeping rooms. The aisle, corridor, or ramp shall be arranged to avoid any obstructions to the convenient removal of nonambulatory persons carried on stretchers or on mattresses serving as stretchers.
Exception No. 1: Aisles, corridors, and ramps in adjunct areas not intended for the housing, treatment, or use of inpatients shall be not less than 44 in. (112 cm) in clear and unobstructed width.
Exception No. 2: Exit access within a room or suite of rooms complying with the requirements of 19.2.5.
3.3.121* Means of Egress.
A continuous and unobstructed way of travel from any point in a building or structure to a public way consisting of three separate and distinct parts: (1) the exit access, (2) the exit, and (3) the exit discharge.
4.5.3.2 Unobstructed Egress.
In every occupied building or structure, means of egress from all parts of the building shall be maintained free and unobstructed. No lock or fastening shall be permitted that prevents free escape from the inside of any building other than in health care occupancies and detention and correctional occupancies where staff are continually on duty and effective provisions are made to remove occupants in case of fire or other emergency. Means of egress shall be accessible to the extent necessary to ensure reasonable safety for occupants having impaired mobility.

On 1/10/10 between the hours of 1230 and 1330 a tour of the Surgical Services Unit of the Surgical Hospital with the Plant Operations Director revealed the following:

Extension Cords with multiple outlet adapters with an integrated switch/overload breaker were found in the Operating Rooms. Cords for lamps or portable electrical appliances shall have cords long enough to plug into fixed approved receptacles.

NFPA 101, 2000 Ed.
19.3.2.3 Anesthetizing Locations.
Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, 1999 Ed. Chapter 7, Electrical Equipment
7-5.1.2.5 Line Voltage Equipment - Anesthetizing Locations.
Flexible cord for portable lamps or portable electric appliances operating at more than 12 V between conductors, intended for use in anesthetizing locations, shall be continuous and without switches from the appliance to the attachment plug and of a type designated for extra-hard usage in accordance with Section 501-11 of NFPA 70, National Electrical Code. Cords shall be protected at the entrance to equipment by a suitable insulating grommet. The flexible cord shall be of sufficient length to reach any position in which the portable device is to be used, and the attachment plug shall be inserted only in a fixed, approved receptacle. For correct use and maintenance of adapters, the provisions of 7-6.2.1.5 shall apply.

On 1/10/10 between the hours of 0900 and 1100 a tour of the Surgical Services Unit with the Plant Operations Director revealed the following:

Supplies were stored in a manner that endangered patient safety. The corridors through the Unit providing access to and from the operating rooms had the storage of a significant quantity of cabinets and carts with surgical equipment and supplies in them. The area within the corridors with supplies and equipment was in excess of 50 square feet. It is the opinion that the quantity and character of the supplies and equipment is of the nature of being flammable with paper and plastic packaging and is in a quantity deemed to be hazardous as provided by NFPA 101, 2000 Edition, 19.3.2.1 (7).

Life Safety:
NFPA 101, 2000 Edition
19.3.2 Protection from Hazards.
19.3.2.1 Hazardous Areas.
Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:

(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction.

Based on observation, review of policies and procedures, inservices records and interview, it was determined the facility failed to assure staff followed procedures and practices related to the storage, removal of expiration items and environmental sanitation and cleaning between surgery cases. Failure to assure procedures were established and followed created a potential for increased risk of infection. The failed practice had the potential to affect the 18 patients on the surgery schedule and an average of 17 surgical cases per day of the Main OR (Operating Room) on 10/01/10. Findings follow:

A. Observation of "CV Instrument Storage Area" revealed 7 of 12 sterilized items without dust covers that were expired and stored stacked on top of each other Expiration dates: Radial Pack and Long Clip Applicators , expired 09/23/10. Life Pack, expired 09/10/10 . Chest Bar, expired 07/04/10, CV Electronic Retra Blade expired 09/04/10, Life Pack defibrillator. two with an expiration date of 09/16/10. The items were stored stacked on top of each other on shelving in an alcove area of the surgical hallway. The main surgical corridor had a collection of sterile and clean items stored on shelving along the walls and alcoves. The findings were confirmed by the Director of OR 10/01/10 at 1100, she stated The Central Sterile rejprocessing staff and each nurse is responsible for checking for expiration dates on sterile packs.
B. On 10/01/10 from 1025 - 1045, the breakdown and between case cleaning was observed of OR #3. The OR technician used a spray bottle with a solution of CDC 10 Spartan, sprayed the surface of each item and immediately wiped the surface with a cloth. The solution was not allowed to remain wet on the surfaces to be disinfected, but immediately wiped dry. The process was repeated on the top flat surfaces of the OR table, side table top surfaces. The technician them wiped the lower legs and sides of tables then the top. The same cloth for cleaning was used on the upper, lower, then upper surfaces of the OR table, side table, suction equipment, top surface of the anesthesia cart, keyboard, and side support arms and transfer board.
1) In an interview with the OR Educator and the Infection Preventionist on 10/01/10 at 1530, they confirmed the products used for surface disinfection in the OR. The"Clean on the Go" is surface cleaning only and has no disinfection properties. Also confirmed the CDC 10 is a product with"five minute disinfection action." The CDC 10 product has the following manufactures' guidelines for use: The five minute infectant action against the listed bacteria and viruses. "Spray Area until covered with foam, allow to wet surface for five minutes. Wipe off with clean damp cloth or sponge
2) Hospital policy #NEA/Surgery 041 "Housekeeping Routine for the OR" stated "All OR Suites and Surgical Services Department areas will be cleaned with hospital approved germicidal and disinfectant cleaners." "Clean all equipment and furniture where direct patient contact occurs with a hospital approved germicidal agent at the end of each surgical procedure. Use a pre-moistened wipe or a clean low-lint cloth wet with germicidal solution and water. Once a cloth has been used, it is never placed back into the germicidal solution, it should be placed in a dirty linen receptacle."
3) In an interview 10/01/10 at 1600, with the Director of Surgery and the Director of Medical Review/ Quality, confirmed no training had been provided for staff related to the environmental cleaning between cases in the OR. She stated the process changed approximately one month ago that Environmental services staff was no longer providing the cleaning of the OR suites, that it now was surgery staff.