HospitalInspections.org

35968


Based on observation, staff interview, and document review the Critical Access Hospital (CAH) failed to ensure there was a system in place for preventing, identifying, reporting and investigating infections in the facility as evidenced by a lack of monitoring of Air Exchanges in the Central Processing and Sterile supply areas, by failing to ensure the instrument table in the Central Processing Room was properly cleaned, by failing to follow proper operating room attire in the Central Processing Room, and by failing to separate the clean and dirty areas in the Central Processing Room. This deficient practice had the potential to expose all patients and healthcare workers to infectious diseases.

Findings include:

Maintenance Staff C interviewed on 2/29/2015 at 1:20 PM indicated Airflow was tested in the Operating Room (OR) area only. Staff C indicated they would request verification from the testing company to ensure the air exchanges were appropriate.

Chief Nursing Officer Staff A interviewed on 3/1/2016 at 9:00 AM revealed the results of the testing was appropriate for the OR air exchanges. Staff A acknowledged the CAH failed to ensure the company tested the air exchange rates in the Central Processing and Sterile Supply areas.

Record review of the AORN (Association of PeriOperative Registered Nurses) Journal dated June 2009 given by CNO B revealed the following recommendations: "Humidity, temperature, and air exchanges in the OR ... A relative humidity level that is too low can result in excessive bacteria-carrying dust in the surgical environment or static electricity ...Log should be maintained on humidity, temperature, and air exchanges. "The recommended settings were in a table and were as follows for the American Institute of Architects (AIA):Temperature OR, decontamination: 68 - 73degrees F Preparation and packaging: 75degrees F Humidity in all areas: 30 to 60%Air Exchanges per hour: OR 15; Decontamination10; Prep and packaging 4.

Plan of Correction document reviewed on 3/1/2016 at 9:30 AM revealed "...The Air Flow Rate rates will be checked by Central Mechanical Wichita, LLP on 02/17/2016. The Air Flow rates will then be checked by Plant Op Director as advised by the specialist and will be added to the OA Maintenance list. A policy will be developed to address the Air Exchanges in the surgery area ..."


- OR (Operating Room) Central Processing Room observed on 3/1/2016 at 9:30 AM revealed the Licensed Practical Nurse (LPN) Staff B had no shoe covers on while in the Clean Processing Room.


LPN Staff B interviewed on 3/1/2016 at 9:45AM acknowledged they should have had on shoe covers. LPN Staff B stated they usually wear their designated shoes but they were in the other room.


- Policy title "Operating Room Attire" reviewed on 3/1/2016 at 10:45 AM directed staff "...Proper Operating Room (OR) attire consists of: Surgical Scrub Clothes, Cap, Mask, Shoe Covers ..."


- OR Central Processing Room observed on 3/1/2016 at 9:55 AM revealed the LPN Staff B failed to disinfect the sides of the instrument table properly.


Chief Nursing Officer (CNO) Staff A interviewed on 3/1/2016 at 11:00 AM to let them be aware the LPN Staff B failed to clean the sides of the instrument table properly during the observation in the OR Central Processing Room.


- Policy title "Operating Room Sanitation" reviewed on 3/1/2016 at 10:45 AM directed staff "...The OR table, horizontal surfaces and all other pieces of furniture or equipment that have been soiled are wiped clean with a disinfectant solution ..."


- OR Central Processing Room observed on 3/1/2016 at 9:30 AM revealed the dirty and clean areas were very close in proximity, shared the same counter, no type of partition to prevent splattering into the clean area.


CNO Staff A interviewed on 3/1/2016 at 12:30 PM to inform them regarding the close proximity of the clean and dirty areas in the OR Central Processing Room that has the potential of contaminating the clean side since there was no partition separating the two areas.


- Policy review on 3/1/2016 at 10:45 AM revealed the CAH failed to develop a policy to ensure clean items in the OR Central Processing Room were protected from potential contamination.