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Based on observation, record review, and interview, this facility failed to follow its policies and procedures and the recommendations of nationally recognized professional standards of practice evidenced by failing to maintain an environment that was free from potential contaminants to patients in 1 out of 10 departments observed (OR). Failure to maintain an environment free from potential contamination has the potential to affect all surgical patients, including the 6 patients scheduled for surgical procedures on the day of the survey (10/14/2014).

Findings include:

During the previous Recertification survey, in an interview with IPC E on 8/25/2014 at 9:30 a.m. regarding which standards of practice this facility follows for infection control, IPC E stated that the facility follows the recommendations from APIC, CDC, and AORN.

The facility's policy titled, "Handling Soiled Linen," dated 10/7/2014, was reviewed on 10/14/2014 at 1;10 p.m. The policy does not address laundering surgical attire and indicates the only laundry that continues to be done on site at the facility are mop heads.

Per the CDC guidelines for Environmental Infection Control in Health Care Facilities,
"Laundry equipment should be used and maintained according to the manufacturer's instructions to prevent microbial contamination of the system." The guideline goes on to state, "The antimicrobial action of the laundering process results from a combination of mechanical, thermal and chemical factors."

The facility's policy titled, "Attire in the Operating Room," dated 10/21/2013, was reviewed on 10/14/2014 at 1:00 p.m. The policy states in part, "All reusable attire shall be laundered after each use by a laundry facility approved and monitored by [the facility]."

In an interview with QA Dir A on 10/14/2014 at 1:10 p.m. Dir A stated that the facility continues to use a residential-grade washer, dryer and detergent for internal laundering of surgical scrubs and cloth head coverings and that the water temperature of the washer still cannot be measured. Without the ability to monitor water temperature during the wash cycles the facility cannot determine the temperature of the water is adequate to affect antimicrobial levels during washings.

Dir A also stated that the reason the facility is still laundering the surgical scrubs was because of concern they would run short for procedures until more could be ordered.

An invoice with a price quote for surgical scrubs was produced by Purchasing Manager F on 10/14/2014 at 12:30 p.m. This invoice has a date of 10/15/2014 at the top of the page which is scribbled out to be almost unreadable. At 2:21 p.m. on 10/14/2014 Purchasing Manager F confirmed that the invoice is just a quote and the surgical scrubs have not been ordered yet.

AORN Recommended Practices from 2012 regarding masks in the OR: "The mask should cover the mouth and nose and be secured in a manner to prevent venting. A two-tie mask that is securely tied at the back of the head and behind the neck, or a mask that is secured at the crown of the head, helps to prevent infectious particles from reaching the wearer ' s nose and mouth by passing through leaks at the mask-face seal."
AORN 2014 Surgical Attire Recommendation III.b. "When in the semirestricted or restricted areas, all nonscrubbed personnel should wear a freshly laundered or single-use long sleeved warm-up jacket snapped closed with the cuffs down to the wrists. Wearing the warm-up jacket snapped closed prevents the edges of the front of the jacket from contaminating a skin prep area or the sterile surgical field. Long-sleeved attire helps contain skin squames shed from bare arms."
AORN 2012 Recommendation IV: "All personnel should cover their head and facial hair when in the semirestricted and restricted areas. Hair coverings should cover facial hair, sideburns, and the nape of the neck. Perioperative nurses can help minimize the risk of surgical site infections by covering head and facial hair, which prevents skin squames [cells] and hair shed from the scalp from falling onto the sterile field. Skull caps are not recommended because they do not completely cover the wearer's hair and skin. Personal, reusable head coverings are acceptable for perioperative personnel to wear if they are covered with a single-use disposable head covering or if they are laundered daily in a health care-accredited laundry facility."

Observations in OR:
At 11:31 a.m. on 10/14/2014 a tour of the Surgical Suite was conducted accompanied by Surgery Manager B. It was observed that the open shelving units above the anesthesia area in OR 1 and OR 3 have not been replaced with closed units to enclose the contents on the shelf. Surgery Manager B stated that the shelving unit in OR 2 has also not been replaced. The contents on the shelves are not able to be cleaned during the terminal clean process.

In an interview with Manager B during the tour, B stated that the shelving units were ordered but had not yet arrived. A purchase order was produced by Purchasing Manager F at 11:45 a.m. The shelving units were not ordered until 10/1/2014 (Recertification survey ended 8/28/2014, plan of correction due date was 10/11/2014.) In an interview with QA Dir A on 10/14/2014 at 1:10 p.m., Dir A stated A was not aware the shelving units were not yet replaced.

In the OR at 12:15 p.m.on 10/14/2014, RN D was observed assisting to open sterile packs for a total knee replacement surgery. RN D did not have a cover jacket over RN D's scrubs and RN D's arms were exposed while opening the sterile supplies. RN D also wore a cloth surgical bonnet without a surgical bouffant covering.

At 12:40 p.m. CRNA C entered the OR where sterile equipment had been set up on the equipment tables for the surgery. CRNA C did not have the top strings of the surgical mask tied and the bottom strings were loosely tied allowing for a gap between the skin and the mask. CRNA C also did not have a cover jacket to cover C's exposed arms and wore a skull cap style head covering without a surgical bouffant covering.

These findings were discussed and confirmed with Surgery Manager B and QA Dir A on 10/14/2014 at 12:50 p.m.