HospitalInspections.org

Based on observation, interview and record review, the facility's Infection Control Nurse failed to develop, implement, and evaluate a system for infection control in the operating rooms. This failed practice could create possible preventable surgical infections for patients. The findings are:

A. On 07/26/16 at 10:20 am during interview, Staff #2, who identified herself as a scrub nurse, and Staff #3, who identified herself as a circulating nurse, were asked when the Infection Control Nurse had last visited a surgery. Both stated they had never seen her in any operating room.

B. On 07/26/16 at 10:15 am -- five minutes before the interview at 10:20 am -- the surveyor conducted an observation of an orthopedic procedure. During the observation of the procedure, Staff #1, a surgeon, while gloved and gowned and operating in a sterile field, reached up and touched the plastic cover over the fluoroscope to adjust the position of the fluoroscope. No other operating staff called the infraction on the surgeon. Staff #3 left the operating room suite with gloves on and returned with supplies. She had the same gloves on when she returned. No other staff called the infraction on the nurse.

C. On 07/26/16 at 8:45 am during interview, the Dietary Director was asked when the Infection Control Nurse had visited the kitchen. He stated, "The only time I have seen her in dietary [the kitchen] is during environmental rounds, once a quarter."

D. On 07/27/16 at 11:00 am during interview, the facility's Infection Control Nurse was asked when she did infection control observations. She stated she did them quarterly during environmental rounds. She also stated she had not yet observed a surgery or observed food preparation. She further stated that she did not keep a log of her infection control rounds, an accepted process of documentation of surveillance activities for hospital infection control nurses as recommended by the Centers for Disease Control and Prevention's National Health Safety Net (NHSN).

E. Record review of the facility's infection control policy revealed that the "Infection Prevention Program Manager is responsible for the operation of the Infection Prevention Program," and that the "purpose of the Infection Prevention Program is to improve patient care by preventing and controlling infection." The policy further stated the following:
"An effective surveillance plan is a key element in the infection control program. Infection Prevention Surveillance:
· Improves outcomes
· Obtains baseline data
· Identifies problems or trends
· Investigates perceived problems
· Evaluates control interventions
· Monitors quality of current infection control practices
· Educates healthcare providers....

Perform periodic informed observation of patient care areas to assure
maintenance of standard precautions on all patients and adequate hand washing
by patient care staff. Establish an IP rounding calendar."

Based on record review and interview, the facility failed to appoint a physician as Director of Anesthesiology and approve that person by the governing body. The lack of qualified leadership of anesthesia services exposes patients to potential harm. The findings are:

A. Record review of the facility's governing body minutes for the past three years indicated no qualified, designated, and approved physician directing the Anesthesiology Department at the facility.

B. On 07/26/16 at 3:10 pm during interview, the facility's interim Director of Quality confirmed the facility did not have a physician appointed or approved by the governing body to manage the Anesthesiology Department. She stated, "We are in the process of contracting anesthesiology services."

C. On 07/26/15 at 3:40 pm during interview, a member of the Quality Staff (Staff #4) stated that the facility had purchased policies from an online vender regarding anesthesiology since the facility's policies were "long out of date." She also confirmed that the policies had not been adopted by the governing body.