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Based on observation and interview the facility failed to identify, report, and investigate infection control issues regarding maintenance of a sanitary hospital environment. The facility failed to insure operating room table pads were cleansed of all residues, the integrity of the pads were maintained, and integrity of wooden doors and walls in the operating room department were maintained. The census was 259 patients.
Findings include:
1. Observations, on the afternoon of 7/13/10 during a tour of the inpatient surgical suite, revealed the following:

-The wooden door to operating room (OR) #9 was splintered and jagged on one edge, the corner of one wall adjacent to the cabinets was chipped and cracked and another wall was gouged in two places.

-The wooden door to operating room #1 was splintered and jagged in two locations and three wall tiles were broken with jagged edges on one wall.

-The wooden door to operating room #7 was splintered and jagged in two locations, the wall covering in one area was chipped exposing a metal corner guard underneath the wall, there was a small hole in the wall adjacent to the fire extinguisher, the wall covering was peeled away in numerous areas above the floor vent and a section of baseboard approximately five feet long was pulled away from the wall adjacent to the fire extinguisher.

-Staff L OR Clinical Specialist and Staff M Service Leader Medical Services confirmed the observations at that time.

2. During an observation on 07/13/10 at 2:30 P.M. in operating room # 9 showed adhesive residue and a small wet area on the operating table pad.
In an interview immediately following the observation Staff I, Team Leader for the OR (operating room), and Staff E, Service Leader for Cardio-Pulmonary and Vascular Services verified that the adhesive residue and wet area was noted on the operating table pad.
3. During an observation on 07/13/10 at 2:37 P.M. in operating room # 7 showed white, raised and not raised areas and approximately 18 inches of grey duct tape along the side of the operating table pad.
In an interview immediately following the observation Staff I, Team Leader for the OR (operating room), and Staff E, Service Leader for Cardio-Pulmonary and Vascular Services verified that the white areas and the duct tape were noted on the operating table pad.
In an interview on 07/13/10 at 2:40 P.M. Staff I, Team Leader of OR, said the duct tape was a temporary fix and not appropriate. A new one should be ordered.
4. During an observation on 07/13/10 at 2:45P.M. in operating room # 1 showed a piece of tape and a wet area on the operating table pad.
In an interview immediately following Staff I, Team Leader for the OR(operating room), and Staff E, Service Leader for Cardio-Pulmonary and Vascular Services verified that tape and a wet area was noted on the operating table pad.
5. In an interview on 07/13/10 at 2:45 P.M. Staff I, Team Leader of OR, said
-A table is made up with a blue warming blanket that has warm water flowing through it, a gel pad on top of the warming blanket, and then an impervious pad goes over both of the pads and is tucked in around the entire pad.
-The wet areas on the table are from condensation between the warming blanket and the gel pad.
-The impervious pad will not allow water to absorb through to
the sterile drapes.

6. During an observation on 07/14/10 at 10:20 A. M. in operating room # 8 the anesthesia cart showed:
-In the bottom drawer, six different types of caps and lids
- In the fifth drawer, a dried, raised, yellow substance

In an interview immediately following this observation Staff I, Team Leader OR; Staff J, Quality Analyst; and Staff K Service Leader Human Motion Institute verified the caps and lids and the dried, yellow substance in the drawers.

7. During an observation on 07/14/10 at 1:25 P.M. in the surgery center operating room # 4 four showed adhesive residue on the operating table pad.

In an interview immediately following this observation Staff N, Team Leader Surgery Center; Staff O, RN (Registered Nurse); Staff J,Quality Analyst; and Staff K, Service Leader Human Motion Institute verified the adhesive residue was present on the operating table pad.

8. During an observation on 07/14/10 at 1:40 P.M. in the surgery center operating room # 2 two showed adhesive residue on the operating table pad.

In an interview immediately following this observation Staff N, Team Leader Surgery Center; Staff O, RN (Registered Nurse); Staff J, Quality Analyst; and Staff K, Service Leader Human Motion Institute verified the adhesive residue was present on the operating table pad.

9. During an observation on 07/14/10 at 1:58 P.M. in the surgery center operating room # 3 three showed adhesive residue on the operating table arm board pad.

In an interview immediately following this observation Staff N, Team Leader Surgery Center; Staff O, RN (Registered Nurse); Staff J, Quality Analyst; and Staff K, Service Leader Human Motion Institute verified the adhesive residue was present on the operating table pad..