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Based on record review and interview, the facility's Infection Control officer failed to participate in the active surveillance of the facility's Sterile Processing Department, when it failed to maintain a sanitary environment, and did not monitor all Surgical Patients for Post-operative surgical site infections.

Findings include:

Observations made on 10/18/17, during a tour of the Hospitals Sterilization Processing Department revealed,
- residue and debris was noted on horizontal surfaces of (2) surgical instrument carts and debris fell out of a disassembled washer sprayer arm when handled.
- a handwashing sink in the decontamination room was blocked by two large metal carts containing soiled operating room instruments.
- (3) three Clean Endoscope storage cases had webbing material handles touching the floor, when opened the webbing material could swing and touch the clean scopes.

During an interview on 10/18/17, during the tour of the facility's Sterile Processing Department Staff #5 and Staff #9 confirmed the findings.

During an interview on 10/18/17 in the Facility's Sterile Processing department Staff #8, SPT (Sterile Processing technician) when asked about the cleaning of the facility's Surgical instrument washers stated, "We wipe them down daily...we remove the sprayer cap ends and check them..." When asked to demonstrate how he disassembled the sprayer arms, as the manufacturer instructed, Staff #8 was not able to perform the task.

During an interview on the morning of 10/18/17 in the Facility's Sterile Processing Department Staff #5, Surgery Director stated, "I made a guide, following the manufacturer's instructions for the equipment....I made it easier to read, the manual would be too much to read....We have very hard water and get calcium build-up....we should be wiping the carts daily..."

Review of the facility provided Sterile Processing Routine Maintenance Guide Single Chamber/Disinfector with Conveyor reflected Daily Cleaning of the Chamber Bottom filter and Spray Arms....Weekly spray Arms Functionality Test..." The guide did not detail how the washer was to be cleaned. The facility was not able to provide documentation of the routine maintenance.

Review of the facility provided STERIS Corporation Washer maintenance documents reflected a service date on:
1/24/17- Spray Arm Issue
1/12/17- Spray Arms Not Moving
03/2/17- Spray Arm Issue
08/1/17- Insufficient water through rack, needle, cleaning spray jet
8/22/17- Replacement of 3 elbow, lower spray arm

Review of the facility provided document Steris Surgical Instrument Washer's Operator Manual Routine Maintenance reflected,"...6.3 weekly Cleaning...
3. Clean wash chamber rotary spray arm assembly as follows:
a. Remove screw securing rotary spray arm assembly on top of chamber and lower rotary spray arm assembly.
b. Remove locking pin securing each spray arm on rotary spray arm hub.
c. Rinse each spray arm under running water to clean out sediment.
d. Use a fine wire (approximately wire gauge of a paper clip) to clean sediment from spray nozzles. Rinse under running water...
4. remove bottom rotary spray arm assembly and clean in same way as top rotary spray arm assembly...."

During an interview on 10/18/17, in the facility conference room, Staff #9, Director of Infection Prevention stated, "...The surgery department does not report to me..." Staff #9 confirmed she was not conducting tours of the Sterile Processing Department.

Review of the facility's post-surgical surveillance program for 2017 reflected the facility could not provide evidence that all patients had been monitored for post-operative surgical infections.

During an interview on 10/18/17, in the facility conference room, Staff #9, Director of Infection Prevention confirmed the facility did not check for 30-day post-operative infections on all patients having surgery. "We check for readmissions and check for blood cultures in the system....We wouldn't know if they went to another hospital...."