HospitalInspections.org

Based on review of medical records, policy review and staff interview it was determined the facility failed to ensure the consent for surgery was completed indicating informed consent was obtained for one (#1) of thirty patient records sampled.

Findings included:

Review of the medical record for patient #1 revealed the patient presented to the Emergency Department on 04/23/17 after a fall.

Documents provided by the Adult Living Facility indicated patient #1 had a Health Care Surrogate (HCS) and list contact names and phone numbers.

Review of the admitting physician's History and Physical dated 04/24/17 at 4:37 a.m. revealed a history of dementia and psychiatric illness. The note stated the patient was a poor historian and had expressive aphasia. Orthopedic Surgeon consultation note dated 04/24/17 at 7:25 a.m. noted the patient's history included Dementia and psychiatric illness.

Orthopedic surgeon documentation, approximately 1 hour and 33 minutes later, dated 04/24/2017 at 8:58 a.m. stated the surgical treatment options were discussed with the patient, the patient voiced understanding and agreed to surgery. There was no documentation in the medical record that indicated the surgery was emergent.

Facility policy titled "Informed Consent" dated 01/24/17 indicated a signed consent will be obtained from every competent adult or person authorized to sign for a minor or incompetent adult for major and minor surgery that involves entry into the body. If the patient has not been declared incompetent, but there is serious question as to their competency, the physician must initiate measures for legal declaration of incompetence in order to proceed and that will be documented in the chart. The policy states attempts will be made to notify the family and secure a consent.

Review of the medical record included a consent for surgery form dated 04/24/17 at 6:45 a.m. The form listed the patient's name, the surgeon's name and the procedure to be performed. There was no signature from the patient or the Health Care Surrogate consenting to the surgery. On the line for the patient's signature were hand written words, "unable to sign". There was no documentation on the consent form or in the medical record indicating why the patient or the patient's Health Care Surrogate did not sign the consent form. There was no documentation in the medical record an attempt was made to contact the patient's Health Care Surrogate to obtain consent for surgery or to provide the designated individual the information required to make informed decisions about the patient's care. There was no documentation in the medical record regarding the competency status for patient #1. The medical record revealed the patient had surgery on 04/24/17 at 8:58 a.m. without a signed consent form.

An interview with the Nurse Leader on 04/26/17 at 12:00 p.m. confirmed the above findings.

Based on observation and interview it was determined the facility failed to protect patients [past and present] personal and protected health information for greater than 530 past and present patients.

Findings included:

On 04/26/2017 at 7:47 a.m. the conference room assigned by facility for surveyors to conduct the validation survey was unlocked on arrival. All documents containing patients' personal and PHI [protected health information] had been moved, rearranged and placed in different folders. The Vice President of Quality and Patient Safety was immediately notified. She stated she was not sure what happened and had heard a children's community meeting had been held in the room.

The surveyor requested the facility investigate due to the personal and PHI breach of the following information:
1. List containing current Inpatient census of fifty-four [54] patient names admit date, unit and diagnosis
2. The restraint death record log with eight [8] patient names
3. The Surgery Schedule log with two-hundred sixty-one [261] patient names, date of procedure, and procedure to be performed.
4. The list of Returns to OR [operating room] with one hundred fifty-six [156] patient names, date and procedure
5. The list of patients who received blood/blood products containing eleven [11] patient names, number of infusions and type of blood product administered and date of administration.
6. The list of surgical patients with positive wound cultures with fifteen [15] patient names
7. The facility's emergency room Transfer Out log for 2017 included ninety-five [95] patient names, reason for transfer, where they were transferred and the Transfer In log for 2017 included twenty-five [25] patient names and reason for transfer.
8. The first quarter EMTALA [emergency medical treatment and labor act] log contained patient names, time seen, reason for seeking emergency care, too numerous to count.
9. The confidential Peer Review Committee Minutes for January, February and March 2017 containing multiple patients too numerous to count.
10. The facility Grievance logs for year 2015 to 2017 containing patient names too numerous to count.

On 04/27/2017 a request for information on the breech investigation throughout the day was made. The Vice President of Quality and Patient Safety stated "they were working on it". No information was received to confirm an investigation, report of breach or action plan was being conducted.

Based on record review and staff interview it was determined the facility failed to ensure safety of patients during investigation of an allegation of sexual misconduct made against a member of the facility's personnel.

Findings included:

A review of the facility's log of sexual abuse/misconduct revealed an allegation of sexual abuse/misconduct was reported in April 2016. A patient in the BHU [behavioral health unit] complained a staff member rubbed up against her and exposed himself to her. A review of the alleged sexual misconduct investigation revealed. The alleged incident happened on 04/20/2016.

Review of facility documents revealed the staff member alleged of the sexual misconduct was moved from the BHU to the ARU [Addiction Recovery Unit] while the facility conducted an investigation. The staff member was assigned and continued to work in patient care areas providing direct patient care. Documentation revealed the staff member alleged of the sexual misconduct continued to work in patient care areas and returned to the BHU on 04/23/2016. The patient involved in the alleged incident was not discharged from the BHU until 04/29/2016.

Review of an email dated 04/26/2016 from the Vice President of Quality and Patient Safety to the Executive staff stated "I received a call this morning they [DCF] are closing the case with no substantiation".

Interview with the Vice President of Quality and Patient Safety and the Director of Human Resources on 04/27/2017 at 9:10 a.m. revealed the above findings were confirmed. There was no explanation why the staff member remained in patient care activities while the allegation of sexual misconduct was investigated.

Based on medical record reviews and staff interviews it was determined the facility failed to ensure medical staff rules and regulations were followed for three [#3, #4, #14] of thirty sampled patient records and the policy for verbal and telephone order verification was followed for two [#11, #15] of thirty sampled patient records.

Findings included:

1. Medical Staff Rules and Regulations Page 6 of 22 [regarding discharge summary] Item #19 "The patient's medical record shall be complete within thirty days following discharge, including progress notes, final diagnosis and clinical resume.

A review of patient # 3's medical record documented the patient was admitted on 12/01/2016 and discharged home on 12/06/2016. A review of the discharge summary showed the summary was dictated on 03/09/2017 and authenticated by the physician on 03/10/2017, three months and four days after discharge.

A review of patient # 4's medical record documented the patient was admitted on 03/11/17 and discharged home on 03/13/17. A detailed review of the medical record on 04/27/17 for patient # 4, with the director of surgical services, showed no documentation of a discharge summary, 45 days after discharge.

A review of patient #14's medical record documented the patient was admitted on 03/08/2017 and discharged home on 03/12/2017. A detailed review of the medical record on 04/26/2017 for patient #14, with the director of clinical care, showed no documentation of a discharge summary, 44 days after discharge.

2. Facility policy titled "Verbal and Telephone Order Verification" approved by the quality council and medical executive committee on 03/2017, stated on page 1 item B: Documentation of verbal and or telephone orders shall include (but not limited to) the following elements:
Date and Time of the order for treatment or medication, . . .on page 2 item C. Standard verbal and or telephone orders are to be signed by the Prescriber within forty-eight hours. Hazardous orders must be signed within twenty-four hours (for example: Chemotherapy, Investigational Drugs, DNR [do not resuscitate], CMO [comfort measures only], Restraints).

A review of patient #11's medical record documented a telephone order received on 04/19/2017 at 9:00 a.m. for hemodialysis. A detailed review on 04/26/2017 with the director of critical care confirmed the order was not verified/validated or signed by the ordering physician within the forty-eight hour time frame specified in the facility policy.

A review of patient #15's medical record documented a telephone order for restraints received on 11/24/2016 at 2:10 a.m. A detailed review of the order on 04/26/2017 with the director of critical care showed the physician evaluation, signature, date and time section was left blank.

A continued review documented a telephone order for restraints received on 11/25/2016 at 2:00 a.m. A detailed review of the order on 04/26/2017 with the director of critical care showed the physician evaluation, date and time section was left blank.

An interview with the director of critical care confirmed she was unable to determine if the order was verified/validated within twenty-four hours per policy.

A continued review of medical record documented a physician signed order for restraints on 11/26/2016. It showed the time of restraint order left blank. A detailed review of the order on 04/26/2017 with the director of critical care showed the section of the order for clinical justification was blank, time limit was blank, criteria for release was blank, physician evaluation was blank and time the order was signed by the physician was blank.

An interview with the director of critical care on 04/26/2017 at 3:00 p.m. confirmed the above findings.

Based on review of medical records and staff interview it was determined the registered nurse failed to supervise and evaluate nursing care to ensure care was provided according to physician orders for two (#11, #27) of thirty patients sampled.

Findings included:

1. A review of patient #11's hemodialysis physician orders and dialysis treatment flow sheets documented a physician's order for Hemodialysis with a DFR (Dialysate Flow Rate) of 700. A review of the dialysis treatment flow sheet for 04/21/2017 revealed the DFR ran at 800 as set by the RN (Registered Nurse).

A detailed review of the patient's medical record with the director of critical care on 04/26/2017 confirmed the above findings and stated there was no evidence of physician order to increase DFR.

A review of patient #11's medication orders showed an order for Calcium Acetate 1334 mg [milligrams] by mouth three times a day. A review of the medication administration record documented the patient was administered the phosphate binder on the following dates and times:
04/19/2017 at 8:35 a.m. and 8:26 p.m.
04/20/2017 at 8:48 a.m.; 2:47 p.m. and 9:53 p.m.
04/21/2017 at 8:35 a.m.; 4:50 p.m. and 8:11 p.m.
04/22/2017 at 9:54 a.m.; 3:54 p.m. and 10:03 p.m.
04/23/2017 at 9:38 a.m. and 8:34 p.m.
04/24/2017 at 9:11 a.m. and 2:22 p.m.
04/25/2017 at 11:42 a.m.
04/26/2017 at 8:56 a.m. and 1:49 p.m.

A review of the medication indications and usage using the 2017 Physician's Desk Reference 71st edition: www.pdr.net/ and Epocrates Online: https://online.epocrates.com documented calcium acetate, brand name PhosLo was to be given orally with food.

An interview with the facility pharmacist on 04/26/2017 at 1:00 p.m. confirmed the medication was to be given with food to be effective.

An interview with the director of critical care noted nurses were to know the medications they were giving as part of patient safety.

An interview with the director of dietary services on 04/26/2016 at 2:00 p.m. revealed meal tray delivery to the unit the patient was on were Breakfast at 8:30 a.m.; Lunch at 12:30 p.m. and Dinner at 5:30 p.m.

On 04/26/2017 at 3:00 p.m. a detailed review of the medication administration record with the director of critical care and the facility pharmacist confirmed the medication was not administered appropriately to be effective.

2. Review of the medical record for patient #27 revealed an order for hemodialysis three times per week on Monday, Wednesday, Friday. Review of the hemodialysis orders dated 4/10/2017 at 11:00 a.m. revealed no ordered rate for the DFR. Review of the hemodialysis treatment flowsheets revealed the RN ran the DFR at the following rates:
4/10/2017 DFR 800
4/12/2017 DFR 600
4/13/2017 DFR 700
4/15/2017 DFR 700
4/17/2017 DFR 700
4/19/2017 DFR 800
4/21/2017 DFR 700
4/24/2017 DFR 600

Interview and review of the record with the Director of Critical Care on 4/27/17 at 3:30 p.m. confirmed the above findings.

Based on review of medical records and policy and staff interview it was determined the nursing staff failed to develop and keep current an individualized care plan for two (#1, #2) of thirty patients sampled.

Findings included:

1. Review of the medical record for patient #1 revealed the patient was admitted on 04/23/17 with a right femoral neck fracture.

Review of the Pain Assessment completed in the Emergency Department on 04/23/17 at 4:48 p.m. revealed a pain score of five out of ten (zero was no pain and a ten was the worst possible pain).

Review of the History and Physical dated 04/23/17 at 4:59 by the Emergency Department physician revealed the patient complained of right hip pain. The history indicated the patient was cognitively impaired and had impaired communication.

The admitting physician's History and Physical dated on 04/24/17 at 04:37 a.m. revealed patient #1 had pain in the right hip at the time of the assessment. On 4/23/17 an order was initiated for Morphine Sulfate, 2 milligrams (mg) intravenously every two hours as needed for pain.

Review of the document "Patient's Plan of Care" created on 04/23/17 revealed the identified problems were Impaired Musculoskeletal Function, Impaired Physical Function and Impaired Neurological Function. There was no plan of care developed to address pain prior to or after surgery.

2. Review of the triage record for patient #2 revealed the patient presented to the emergency department on 04/17/17 at 6:27 a.m. for perforated appendicitis. At the time of triage, Patient #2 reported a pain score of ten out of ten (Zero was no pain and a ten was the worst possible pain).

According to the Nursing Admission Assessment dated 04/17/17 at 11:23 a.m. patient #2 complained of left lower quadrant abdominal pain.

Review of the pain assessment documentation revealed Patient #2 continued to experience intermittent pain from the time of admission until 04/26/17 at 12:00 p.m.

Review of the document "Patient's Plan of Care" created on 04/17/17 revealed the problems identified were Impaired Gastrointestinal Function, Impaired Skin Integrity and Knowledge Deficit. There was no plan of care developed to address pain from 04/17/17 to 04/26/17.

Review of the facility policy titled "Assessment-Reassessment" dated 01/24/17 revealed the Registered Nurse will determine and set priorities on the patient's nursing care needs during the initial assessment phase. Upon completion of the initial assessment, an individualized, prioritized plan of care shall be developed in consultation with the patient/significant other. Any change in the patient's condition shall require an immediate reassessment with changes in the plan of care reflecting the change in condition. The plan of care shall be reviewed regularly in consultation with the patient/significant other and revised as patient's condition or diagnosis changes.

An interview with the Nurse Leader on 04/26/17 at 12:00 p.m. confirmed the above findings.

Based on review of medical records, staff interview and review of policy and procedures it was determined the facility failed to ensure medications were timely administered and administered in accordance with orders for two (#27, #28 ) of thirty sampled patients.

Findings included:

Review of policy and procedure "Medication Administration", effective date 5/24/16, under section, Procedure III "Standard Medication Administration Times" indicated timed medications ordered more than once a day will be given no more than one hour before or one hour after the scheduled time.

1. Patient #28 was admitted on 4/8/17 to the Intensive Care Unit with sepsis. Review of physician admission orders dated 4/8/17 at 8:00 p.m. included orders for Zosyn 2.75 grams every eight hour. Physician order dated 4/8/17 at 9:50 p.m. ordered Bactroban twice a day.

Review of the Electronic Medication Administration Record noted the Zosyn was given on 4/8/17 at 10:32 p.m. and on 4/9/17 at 4:43 a.m. The medication was due at 6:00 a.m., approximately one hour and fifteen minutes later. There was no documentation as to why the medication was given earlier than one hour. Review of the Electronic Medication Administration Record revealed no evidence the Bactroban was administered.

Interview with the Director of Critical Care during the record review on 4/27/17 indicated Bactroban had been faxed to the pharmacy but not placed on Electronic Medication Administration Record. The Director of Critical Care stated medications that are timed are given one hour before or one hour after the due time.

Record review and interview with the Director of Critical Care on 4/27/17 at approximately 3:00 p.m. confirmed the above findings.

2. Review of the medical record for patient #27 revealed a physician order for Epogen 4000 units with each hemodialysis treatment. Review of the medical record revealed the patient received hemodialysis on 4/10/2017 beginning at 2:21 p.m. Review of the MAR (Medication Administration Record) dated 4/10/2017 revealed no evidence the Epogen was administered as ordered.

Review of the medical record revealed the patient received hemodialysis on 4/12/2017 beginning at 11:45 a.m. Review of the physician orders revealed an order on 4/11/2017 to change the Epogen to 8000 units with each hemodialysis treatment. Review of the MAR dated 4/12/2017 revealed Epogen 8000 units was administered at 12:14 p.m. At 12:15 p.m. Epogen 4000 units was administered. Review of the MAR revealed the Epogen was administered once by the primary care nurse and also administered by the hemodialysis nurse.

Review of a physician order indicated Zemplar 2 mcg (micrograms) was to be given with each hemodialysis treatment. Review of the medical record revealed the patient received hemodialysis on 4/10/2017 at 2:21 p.m. Review of the MAR dated 4/10/2017 revealed no evidence the Zemplar was administered as ordered.

Review of the medical record revealed the patient received hemodialysis on 4/12/2017 beginning at 11:45 a.m. Review of the MAR dated 4/12/2017 revealed Zemplar was administered at 12:13 p.m. and at 12:15 p.m. Review of the MAR revealed the Zemplar was administered once by the primary care nurse and also administered by the hemodialysis nurse.

Review of the MAR revealed on 4/15/2017 at 10:45 a.m. Albumin was administered to the patient by the hemodialysis nurse. Review of the physician orders revealed no evidence of an order to administer Albumin. On 4/21/2017 at 9:45 a.m. and 11:30 a.m. Albumin was administered to the patient by the hemodialysis nurse. Review of the physician orders revealed no evidence of an order to administer Albumin.

Based on record review and staff interviews it was determined the facility failed to keep accurate medical records for three (#4, #6, #14) of thirty sampled records.

Findings included:

On 04/26/2016 a review of Patient # 4's medical record revealed the patient was discharged on 03/13/2017. A detailed review showed no evidence of a physician discharge summary.

On 04/27/17 a review of Patient #6's surgical record revealed the patient had a surgical procedure performed on 02/17/17. Review of nursing documentation revealed the surgery was performed in operating room [OR] #3. Review of the anesthesia record revealed the surgery was performed in OR #2.

On 04/26/2017 a review of patient #14's medical record revealed the patient was discharged on 03/12/2017. A detailed review showed no evidence of a physician discharge summary.

On 04/27/17 at approximately 2:25 p.m. an interview conducted with the Director of Critical Care and the Director of Surgical Services confirmed the above findings.

Based on record review and staff interview it was determined the facility failed to ensure medication orders were reviewed by the pharmacist for appropriateness of the drug, dose, frequency, route and method of administration for one [#11] of thirty records.

Findings included:

A review of patient #11's physician order revealed an order for Calcium Acetate [Trade name: PhosLo] 1334 mg [milligrams] by mouth three times daily. A review of patient #11's medication profile revealed the medication was reviewed by a pharmacist, however the need to administer the medication with food was not entered.

During an interview with the facility's Director of Pharmacy on 04/26/2017 at approximately 1:30 p.m. he confirmed the medication was a phosphate binder that needed to be given with food to be effective.

Based on observation and staff interview it was determined the facility failed to ensure routine and preventive maintenance, inspections, testing and repair activities were performed.

Findings included:

On 04/24/2017 at approximately 10:00 a.m. accompanied by the Life Safety Code surveyor and the Maintenance Director a tour of the facility was conducted on the 3rd Floor. It was noted:
1. Observation of 3-prong electrical beds with no documentation of preventative maintenance or electrical safety tests.
2. Observation and inspection of the 3rd floor revealed patient restrooms in rooms 333, 335, 363, 365, 361 and 387 revealed all exhaust vents not working and clogged with fuzzy lint.
3. Patient nutrition room's ice dispenser drain and tray covered in brown slimy substance.

Observation of the 2nd floor revealed a locked Behavioral Health Unit [BHU] and an Adult Rehabilitation Unit [ARU]. It revealed:
1. Observation of the BHU revealed a clogged sink drain in the staff lounge with approximately 2 inches of greenish brown liquid confirmed by the Maintenance Director
2. Observation of the BHU showed fire extinguishers stored within locked cabinets. Interview of staff member [A] during the tour stated she did not have a key. An interview with the BHU charge nurse on 04/24/2017 stated all staff should have a key to the fire extinguishers.
3. Observation of patient room 219 revealed restroom exhaust vent not working and with fuzzy lint on grate covering.
4. Observation of the air conditioning unit in patient room 219 with copious amounts of brown sticky substance and fuzzy lint. Per the maintenance director, housekeeping did not have a key to the unit cabinet and stated "maintenance checks, cleans and changes filters once per month and this one is due".
5. Observation of the BHU and ARU patient laundry rooms revealed dryer with copious amount of lint in the dryer vent behind the cleaning screen.

Observation of the 1st floor revealed the Intensive Care Unit, Emergency Department, Laboratory Department, Pharmacy, Radiology and Dietary. It revealed:
1. Observation during tour of the Intensive Care Unit (ICU) on 4/27/17 at 12:30 p.m. with the Director of Critical Care revealed in the nourishment room next to the refrigerator a grape fruit size area of paint peeling down to the wood work. Interview with the Director of Critical Care during the observation indicated she had no knowledge of how it occurred or when it occurred.

An interview with the maintenance director during the tours confirmed the above findings.

Based on review of facility policy, observation and staff interview it was determined the facility failed to follow the infection control policies related artificial nails, nail polish and nail length.

Findings included:

On 04/25/17 at 9:00 a.m. review of the facility surgical services policy titled "OR-Scrub Technique", revised 02/14/17 revealed the following: keep fingernails trimmed neatly and short ...fingernail polish should not be worn ...no artificial nails of any type allowed.

Review of a human resources policy titled "Professional Dress Standards" revealed artificial nails may not be worn by employees providing direct patient care, in food services, environmental services or sterile processing.

Review of an infection control policy titled "Hand Hygiene", effective 01/16/16 revealed a house wide clinical policy indicating no artificial nails are allowed.

Review of an infection control policy titled "OSHA Bloodborne Pathogen Exposure Control Plan" effective 01/11/16 revealed a house wide policy requiring nails to be short enough to allow thorough cleaning under nails and to avoid damage to gloves ...artificial nails or tips on employees providing direct patient care is not permitted since these can become colonized with microorganisms that cannot be removed by routine hand washing.

The Association of peri-Operative Registered Nurses (AORN) recommended the following: Fingernail tips should be no longer than 2 mm (millimeters) (0.08 inch). Studies found fingernails at a length shorter than 2 mm were less likely to harbor bacteria when compared to nails longer than 2 mm. (Guideline for hand hygiene. In: Guidelines for Preoperative Practice. Denver, CO: AORN, Inc.)

On 04/25/17 at approximately 9:55 a.m. a tour was conducted, accompanied by the Director or Surgical Services, of the Sterile Processing and Peri-operative Departments. During the tour of the Operating Room the RN Supervisor was observed wearing finger nail polish with an approximate length of 5 mm.

An interview conducted with the RN supervisor revealed she performed direct patient care. The nails were not artificial. Additionally, the RN supervisor stated "scrub techs cannot wear artificial nails, but the Registered Nurses (RNs) can".

At approximately 11:00 a.m. a tour was conducted of the Sterile Processing Department (SPD) where the sole Sterile Processing Technician was observed wearing artificial nails with an approximate length of 10 mm. The SPD technician stated she performed all of the functions related to the sterile processing of surgical instruments for the facility. Additionally, the SPD technician stated she was aware the policy for her position did not allow wearing of artificial nails.

On 04/25/7 at approximately 11:07 a.m. the Director of Surgical Services confirmed the above findings with the OR RN Supervisor and Sterile Processing Technician nails.

Based on record review, review of policy and procedure and staff interviews it was determined the facility failed to ensure a patient's right to chose a home health agency for post hospitalization care per facility policy was maintained for one (#19) of thirty records reviewed.

Findings included:

Review of patient #19's record with the Nurse Director of the Behavioral Health Unit (BHU) and the Nurse Manager of the BHU on 4/24/17 and 4/25/17 noted the patient was admitted to the BHU on 4/15/17. Review of the admission assessment and physician progress notes, nursing documentation and case management notes from the date of admission to 4/23/17 did not reveal evidence the patient was receiving home health care prior to admission.

Patient interview on 4/24/17 at 2:25 p.m. revealed the patient was going home that day with home health care. The patient stated no choice of a home health agency was provided. The patient stated the physician ordered the prior home health care agency.

Review of physician orders dated 4/24/17, no time, indicated to discharge home with home health agency A. Review of case management documentation dated 4/24/17 indicated home health care agency A was contacted for in home assessment.

Interview with the Nurse Director of the BHU and Nurse Manager of the BHU on 4/26/17 at 2:26 p.m. revealed no documentation of a choice list for home health agencies being provided to the patient or prior information related to home health agency A could be located.

Review of policy and procedure "Discharge Planning" issued 3/3/17, no number, under policy 2b. indicated the evaluation of the patient's post discharge needs is identified in the first stage of discharge planning. Number 13 indicated a list of home health agencies available to the patient will be presented for a patient's choice.

Based on review of facility policy, review of documents and staff interview it was determined the facility failed to follow the policy related to terminal cleaning and disinfection of the surgical department operating rooms for 18 of 90 days reviewed.

Findings included:

On 04/25/17 at approximately 11:10 a.m. review of the facility surgical services policy titled "Cleaning Sanitation Surgical Procedure Areas", revised 02/02/17, revealed the objective of the policy was to re-establish a clean safe environment after each surgical procedure ...cleaning procedures done within the Surgical Suite will be according to the Association Of periOperative Registered Nurses (AORN) recommend guidelines. Further review of the policy revealed terminal cleaning will be performed at the conclusion of the day's schedule, operating rooms, scrub/utility areas, corridors, furnishings and equipment should be terminally cleaned ...mechanical friction and a hospital-approved disinfectant/detergent are used to clean equipment and areas that should include:
1) Surgical lights and tracks,
2) Fixed and ceiling mounted equipment
3) All furniture, including wheels and casters
4) Handles of cabinets and push plates
5) Face plated of vents
6) Horizontal surfaces (e.g. tops of counters & fixed shelving)
7) Entire floor
8) Kick buckets
9) Scrub sinks

On 04/25/17 at approximately 10:30 a.m. review of the facility documents for the months of February, March, and April 2017 titled with the following: Team Member: By initialing the following spaces, you are indicating that the suite has been terminally cleaned and disinfected to AORN and Joint Commission Standards ...Manager/Supervisor: By providing your signature, you are indicating cleaning has been in compliance. Further review of the document revealed multiple days in this three month period that did not have staff or Manager/Supervisor initials indicating the OR suite had been terminally cleaned.

On the following dates the facility performed surgical procedures and terminal cleaning was not performed:
02/20/17-Review of the surgical log revealed surgical procedures were performed in OR #2 and #6. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #2 and #6.
02/22/17-Review of the surgical log revealed surgical procedures were performed in OR #3. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #3.
02/26/17-Review of the surgical log revealed surgical procedures were performed in OR #4. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #4.
03/03/17-Review of the surgical log revealed surgical procedures were performed in OR #1. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #1.
03/07/17-Review of the surgical log revealed surgical procedures were performed in OR #3. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #3.
03/19/17-Review of the surgical log revealed surgical procedures were performed in OR #1 and #4. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #1 and #4.
03/20/17 - Review of the surgical log revealed surgical procedures were performed in OR #6 and #7. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #6 and #7.
03/24/17-Review of the surgical log revealed surgical procedures were performed in OR #3 and #4. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #3 and #4.
03/25/17-Review of the surgical log revealed surgical procedures were performed in OR #6. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #6.
03/29/17-Review of the surgical log revealed surgical procedures were performed in OR #3. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #3.
04/02/17-Review of the surgical log revealed surgical procedures were performed in OR #2. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #2.
04/04/17-Review of the surgical log revealed surgical procedures were performed in OR #6. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #6.
04/08/17-Review of the surgical log revealed surgical procedures were performed in OR #1 and #4. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #1 and #4.
04/09/17 - Review of the surgical log revealed surgical procedures were performed in OR #1. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #1.
04/13/17-Review of the surgical log revealed surgical procedures were performed in OR #1. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #1.
04/15/17-Review of the surgical log revealed surgical procedures were performed in OR #4. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #4.
04/16/17-Review of the surgical log revealed surgical procedures were performed in OR #1. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #1.
04/21/17-Review of the surgical log revealed surgical procedures were performed in OR #1, #2 and #3. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #1, #2 and #3.

On 04/25/17 at 10:25 a.m. an interview conducted with the Director of Surgical Services and the Director of Environmental Services confirmed the above findings.