HospitalInspections.org

Based on observation and interview the hospital failed to maintain adequate airflow for the surgery department. This failure had the potential to effect all patients having surgery. On 10-1-2012= 5, 10-2-2012 = 6, and 10-3-2012= 10.

Findings include:

Tour of the surgical area with Director Medical Services H, Facilities Manager A, Nursing Director Hospital Division C on 10-1-2012 from 10:30 AM through 2:30 PM revealed the following:

The cooridor between the Surgery Control Station and the PACU was found by white tissue sampling to have airflow from dirty to clean.

Clean equipment storage room #1516 was white tissue tested, the test showed air from the cooridor (dirty) was flowing into the clean equipment storage area.

Based on staff observation, staff interview and Policy & Procedure (P&P) review the hospital failed to develop systems to prevent the spread of infections throughout the surgical area. This failure had the potential to effect all patients having surgery. On 10-1-2012= 5, 10-2-2012= 6, and 10-3-2012= 10.

Findings include:

On 10-2-2012 at 3:35 PM the Mosby's Skills document on medication administration for Intravenous Bolus was reviewed. As Interim Survey Coordinator, S explained, the hospital doesn't have a P&P for IV medications administration instead they refer to Mosby's. The document states in part, "Intravenous Push- 10. clean injection port with antiseptic swab. Allow to dry."

On 10-1-2012 from 10:30 AM through 2:30 PM a tour of the surgical area was completed with Nursing Director, C and Director of Medical Staff, H.

Operating rooms #1, 2, 4, and 5 were noted to have wall paper on the walls that was separating at the seams making the surface uncleanable. Chair rail was noted around the surgical suites with multiple areas where the ends do not approximate, making the surface unclean able.

The corridor outside rooms #1 and #2 had gouges in the wall making the surface uncleanable.

The air supply ceiling vent in the clean corridor outside OR rooms #1 and #2 had two red stains resembling blood.

The surgery corridor was observed to have a vinyl wall covering that was separating at the seams in several areas. The wall covering was also damaged in numerous areas making the surface uncleanable.

The anesthesia work room #1511 was observed to have 5 anesthesia carts with dust and
debris on horizontal surfaces of the carts, Anesthesia Technician P explained the carts are cleaned once a month. Two endoscope cases were noted on the floor next to the medication refrigerator. Broken vial glass was noted on the floor between two Pixus machines.

The Tissue Bank room #1513 was noted to have a layer of dust on the horizontal surface of the electrical outlet and cord itself. Paper in binders is stored on the shelves next to sterile implants.

Central sterile office room #1522A was observed while in the Central Sterile Supply area (#1522). The office is considered dirty to the sterile supply storage. The office contains paper, personal items, borrowed surgical devices (not sterilized), carpeted floor. Manager of Processing J explained the office is J's space and non-sterile items are brought in and out of the office through the sterile supply area because there is only one way in and out. This door is also frequently left open to the sterile supply. A work counter was observed to have delamination, exposing the wood underlayment leaving the surface uncleanable.

Sub sterile storage area #1523 is a Steris machine used for high level disinfection of EGD scopes. Surgery Manager F explained after the scopes are used they go to a room for testing and removal of bioburden. Then the scopes are brought to the machine located in the back of the room, past sterile and clean items to be processed. Bare drywall is noted around door #1523, on the hallway side.

Doors #1524, 1525, 1526, 1529, 1532, and 1527 were observed to be in porous condition leaving them uncleanable.


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On 10-1-2012 from 11:15 a.m. through 2:00 p.m. a tour of the surgical area was completed with Surgery Manager C and RN Coordinator B.

Operating room #2 was noted to have wall paper on the walls that was separating at the seams making the surface uncleanable. A chair rail was noted around the entire room with multiple areas where the ends do not approximate, making the surface uncleanable. Noted gouges in the wooden doors, and the metal door frames had chipped and peeling paint.

Operating room #3 had gouges in the wooden doors. 2 small areas where the dry wall had been damaged removing the paint exposing dry wall.

Operating room #4 was noted to have wall paper on the walls that was separating at the seams making the surface uncleanable. A chair rail was noted around the entire room with multiple areas where the ends do not approximate, making the surface uncleanable. Noted gouges in the wooden doors, and the metal door frames had chipped and peeling paint.

Operating room #6 noted to have gouges in the wooden doors.

Operating room #7 noted gouges in the wooden doors, gouges in the dry wall and the metal door frames had chipped and peeling paint.

Room 1507 was a shared stored room holding office supplies including paper, binders, folders, pens, pencils, and high lighters along with clean surgical supplies such as Light sources, Stryker pumps, Brain lab, Radiofrequency generator, Arthro care and Mako-robotic arm, all covered with plastic.

Room 1513 was the Tissue Bank which had a ceiling made up of porous ceiling tiles with a few damaged tiles which made the surface uncleanable.

Per observation on 10/2/12 at 9:45 a.m. Anesthesiologist E was observed removing the caps from the medication vials of 3 medications and did not clean the membranes prior to inserting needles to draw up the medication. When injecting medication in the IV line, Anesthesiologist E did not wipe the port with alcohol for the administration of the medications into the intravenous tubing.

Based on staff interview and policy and procedure review, the facility management failed to develop surgical policies and require staff in the surgical department to follow practices to ensure a high standard of medical practice. This systemic failure had the potential to affect all patients having surgery during the survey, 10-1-2012 = 5, 10-2-2012= 6, 10-3-2012 = 10.


On 10-2-12 at 8:39 AM observations were made in the surgical area with Nursing Director Hospital Division C, and RN Coordinator B. Housekeeping closet #1512 was observed when RN O moved a Neptune 2 machine into the room and attached to the docking station to empty, and left. The Error message was on the screen and RN N was called over to address. RN N explained the machine was not locked into place. RN N was not wearing gloves or eye protection. The machine emptied blood and red solid into a drain on the floor, a slop sink for housekeeping. A small amout of water drains from a faucet approximately 2 feet above the drain and splatters when it hits the slop sink. Nursing Director Hospital Division C, and RN Coordinator B were asked about staff wearing proper PPE and the P&P for the machines. Nursing Director Hospital Division C, and RN Coordinator B were unsure if the hospital had either in place.

On 10-2-12 at 11:54 AM a review of documents titled "Neptune 2 Waste Management System" and "Neptune 2 Ultra" were reviewed. Per Interim Survey Coordinator S, "Neptune 2 Ultra" is what was used for training staff on the use on the Neptune 2 system. The in service log is dated June 15 & 16, 2011. The document titled "Neptune 2 Ultra" used for training staff doesn't contain direction on wearing of proper PPE, proper use in attaching of device, warnings regarding injury and improper use. Document titled, "Neptune 2 Waste Management System" stated in part on page 4, "Always wear gloves and protective eye wear when performing the docking procedure."
On 10-2-2012 at 2:22 PM Surgery Manager F, confirmed training for the use of the Neptune machines did not include wearing PPE, infection control guidelines and safe use. F, also confirmed there is not a P&P for the Neptune machines.

On 10-11-12 a review of the following U.S Food and Drug Administration alert was completed.
FOR IMMEDIATE RELEASE September 25, 2012 - On June 5, 2012, Stryker initiated a Class 1 recall of the Neptune Waste Management System. The devices are being recalled because Stryker has received two reports of serious injury as a result of tissue damage associated with the use of the Neptune 2, including an event in which one customer connected the Neptune 2 System to a passive chest drainage tube post operatively, resulting in a fatality.
On 10-3-2012 at 9:54 AM a interview with Surgery Manager F, was completed regarding staff wearing designated shoes in the surgical suites. Surgery Manager F, explained it is a practice the hospital follows but the hospital does not have a policy or procedure to follow to ensure the practice is conducted in a manner consistent with proper infection control or surgical standards.

Based on review of operating room log and staff interview the facility failed to include all required information on the operating room log. This deficient practice could potentially affect all patients receiving this service. On 10-1-2012 = 5, 10-2-2012= 6, and on 10-3-2012= 10.

Surveyors requested surgery log upon entrance to facility, on 10/2/12 a log was provided by Interim Survey Coordinator, S. The log included the following information: date of surgery, patient name, date of birth, procedures, anesthesia type, discharge date, log number and patient age on procedure date. During interview with Clinical Informatics (CI)- T on 10/2/12 regarding information that is missing on the surgery log, CI -T stated that there was a log in EPIC (electronic medical record software) which was more inclusive to the information required.

On 10/2/12 at 4:00 p.m. a second surgical log was provided by Interim Survey Coordinator, S. Per review by surveyor on 10/3/12 at 8:20 a.m. revealed a log which included all the required information except the pre and post diagnosis. This was confirmed by CI-T in an interview on 10/3/12 at 10:20 a.m.