HospitalInspections.org

Based on observation, interview, and record review, the hospital did not ensure that the infection control policies were implemented and enforced. Infection control practices were not adhered to by:
A) 2 of 3 physicians (anesthesiologist) in the postoperative unit;
B) 2 of 3 circulators in the OR (operating room); and
C) 1 of 1 employee who worked in the surgical department and was wearing disposable shoe covers in the cafeteria.

Findings included:

During a tour on 04/23/13 in the postoperative unit with the facility's CNO (Chief Nursing Officer/ Personnel #1) the following were observed:

A) 1. At approximately 9:12 AM in the postoperative unit/bay #5 Physician #19 had a mask hanging around his neck which was previously worn in the OR. Physician #19 was conversing with a postoperative nurse (Personnel #24). The CNO was informed of the above findings. She confirmed the findings.

2) At approximately 9:54 AM Physician #20 was observed to come out from OR #1 with the OR circulator rolling the patient on the gurney towards the postoperative unit. Physician #20 was wearing a mask previously worn in the OR. He was observed talking to the postoperative nurse then proceeded to go to the nursing station and use a computer. Physician #20 still had his mask on while using the computer. The CNO was informed of the findings and she confirmed the findings.

B) 1. At approximately 9:51 AM in OR #4 Personnel #23 (the OR circulator) took off her soiled gloves and stepped out of the OR. She came back with a small sterile package and opened the sterile package for the scrub technician. Personnel #23 did not wash her hands or apply alcohol rub after taking off her gloves. The CNO was informed of the above findings and confirmed the findings.

2) At approximately 10:00 AM in OR #6 Personnel #25 (the OR circulator) was assisting the physician in repositioning the "Hanna table." Personnel #25 laid the "Hanna table" on the floor. She proceeded to open a sterile package for the scrub technician. She did not wash her hands or apply alcohol rub after repositioning the "Hanna table" on the floor.

C) At 11:19 AM in the cafeteria Personnel #25 was observed wearing blue scrubs (top and bottom) and disposable blue shoe covers. Personnel #25 was asked for his name and the department he worked. The CNO was informed of the above findings. After verification of policy and AORN guidelines (Association of Perioperative Nurses) which the facility had adopted, the CNO confirmed the findings.

The Provisions of Care policy and procedure #35: "surgical Attire" reviewed 2/2013 required "4...Shoe covers should be removed before leaving the OR suite...6...Masks are to be removed before leaving the OR suite. Masks are not to be saved by hanging around the neck..."

The Infection Control policy and procedure #11: "Hand Hygiene" required "Procedure: A. Indications for use...4. Before and after using gloves...9. After touching contaminated surfaces..."