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Based on observation and interview, the facility failed to ensure the maintenance of infection prevention standards in the surgical department. Specifically, the facility failed to ensure contaminated shoe covers were not worn from 1 of 1 decontamination room into a designated clean area of the surgical department.

Findings included:

During an observation on 01/22/2024 at 3:45 PM of the decontamination room, while accompanied by the Sterile Processing Manager (SPM), significant amounts of water in multiple puddles on the floor of the room were identified. Sterile Processing Department (SPD) Technician #14 was observed removing instruments from a rinse sink, placing them into a wire tray, and placing the tray onto a cart used to transfer items to a washing machine. In the process of transferring the tray from the sink to the cart, water was observed dripping onto the floor. Additionally, water was observed draining off the top of the cart onto the floor. Thereafter, the SPM directed the surveyor to exit the decontamination room via a doorway that opened to a short hallway in an operating room (OR) suite behind a red line, which indicated that the space was a clean area. At that time, the shoe covers worn by the surveyor and SPM were soaked in water from the decontamination room, which had now contaminated the floor in the clean OR area.

On 01/23/2024 at 3:40 PM, the surveyor conducted an interview with the Patient Safety Manager, the Manager of Infection Prevention and the Infection Preventionist. The Manager of Infection Prevention stated the observation in question represented a coaching moment.