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The facility failed to ensure the Condition of Participation: Governing Body (GB) was met when:

The Contracted Environmental Services (EVS) terminal cleaning (cleaning and disinfectant) was performed daily in the Operating Room (OR) and in the Sterile Processing Department (SPD). (Refer to A-084)

The cumulative effect of this systemic practice resulted in the facility's failure to deliver care in compliance with the Condition of Participation for Governing Body.

Based on observation, interview and record review, the Governing Body (GB) was unaware the contracted Environmental Services (EVS) terminal cleaning was not performed daily. This failure resulted in the Operating Rooms (OR) and the SPD (Sterile Processing Department - an area in the hospital where cleaning and sterilization of used and reused instruments and devices for medical procedures take place) not being terminally cleaned to maintain cleanliness and sterilization to prevent risk of infection.

Findings:

During a concurrent observation and interview on 10/19/2023 at 3 PM, with Associate Director of Perioperative services (ADPOS), on the Sterile Processing Department (SPD) Decontamination Area (where scrubbing/cleaning of reusable surgical instruments was performed), the following concerns were identified: a cobweb with a spider was identified in the corner of the back area of SPD, multiple ceiling vents and registers (openings where airflow is delivered to the unit) contained build-up of grey fuzzy substance, on the floor beneath scope washers were multiple black loose substance and build-up of grey fuzzy substance, multiple surgical instrument case trays were beneath the sink and beneath work tables, and approximately 20 laminated papers were taped to a wall above the table used to perform cleaning of scopes. ADPOS stated that terminal cleaning was supposed to be performed daily.

During an interview on 10/19/2023 at 3:15 PM, with Environmental Technician 1 (EVS 1) and the Director of Environmental Services (EVSD), the observations made during the tour of SPD and Operating Room (OR) were discussed. EVSD stated that terminal cleaning was not performed daily in SPD. EVSD also stated that for the OR, terminal cleaning was performed on some Saturdays if needed and only on Sundays after a trauma case.

During an interview with the Chief Medical Officer (CMO) on 10/20/2023 at 11:48 AM, the CMO stated, the governing body were not aware that terminal cleaning was not performed daily in the OR or in the SPD.

During a review of the Governing Body's, also known as Safety Quality and Service Committee (SQC), meeting minutes approved on 9/26/2023, there was no documented evidence to show the facility identified the terminal cleaning was not performed daily.

During a review of the facility's Quality Assessment & Performance Improvement (QAPI) Plan, dated 9/26/2023, indicated, "... Page 4. Governance and Leadership... Quality and safety in daily practice is the responsibility of the Chief Executive Officer, the Chief Nursing Officer, and the Chief Medical Officer. Each works with executive and clinical leaders at (name of facility) to develop and successfully deploy activities to maintain, sustain and spread improvements for quality, safety and service..."

The facility failed to ensure the Condition of Participation: Quality Assessment and Performance Improvement Program (QAPI) was met by failing to ensure:

1. The facility's Infection Control Prevention Program had oversight. (Refer to A-0283, Finding 1)

2. The Infection Control Program performed active surveillance in the Sterile Processing Department (SPD) and in the Operating Room (OR) to ensure the department and staff performed surgical services in a safe manner. (Refer to A-0283, Finding 2)

The cumulative effect of these systemic practices resulted in the facility's failure to deliver care in compliance with the Condition of Participation for QAPI.

Based on observation, interview and record review the facility failed to maintain an effective Quality Assessment and Performance Improvement (QAPI) Program when the facility was unable to provide evidence to indicate effective Infection Control Program oversight. These failures resulted in unsafe infection control practices.

Findings:

During multiple observations throughout the survey, the following were identified:

1. In the Sterile Processing Department (SPD), a cobweb with a spider was identified in the corner of the back area of SPD, multiple ceiling vents and registers (openings where airflow is delivered to the unit) contained build-up of grey fuzzy substance, on the floor beneath scope washers were multiple black loose substance and build-up of grey fuzzy substance, multiple surgical instrument case trays were beneath the sink and beneath work tables, and approximately 20 laminated papers were taped to a wall above the table used to perform cleaning of scopes.

2. Three (3) of 3 storage cabinets contained procedural scopes were stored in Operating Rooms (ORs). The storage cabinets were not cleaned and maintained.

3. Two (2) surgical instrument tray sets contained multiple instruments with brown, reddish orange stains and pitting (rough tiny holes).

4. Multiple surgical instruments were not cleaned and disinfected. In addition, single-use syringes (used to flush instrument lumens) were reused throughout the day, and brushes (used to clean soiled surgical instruments) were not cleaned in between each use.

During an interview with the Infection Control Prevention Manager 1 (ICPM 1) on 10/23/23 at 8 AM. the above infection control concerns were discussed. ICPM 1 stated that she oversees five (5) Infection Control Preventionists (ICPs), two (2) of which oversee the OR and SPD. ICPM 1 stated, "ICPs do not perform specific infection control surveillance rounds in SPD and OR."

During a review of the facility's Job Description titled, "Manager, Infection Prevention and Control," dated 3/1/2020, it indicated that ICPM "Responsible for the assessment, analysis, planning, implementation and evaluation of Infection Prevention interventions, programs, data, working with relevant staff. Manages activities of daily surveillance and reporting of infection data..."

Based on observation, interview, and record review, the facility failed to implement their policy of initiating care plan (an individualized plan that provides direction on the type of care a patient needs) timely for one (1) of 16 sampled patients (Patient 10). This failure had the potential to prevent staff caring for the patient from having the necessary information to provide consistent care.

Findings:

During a concurrent observation and interview on 10/19/2023 at 9:38 AM, in front of Patient 10's room, an enclosed (a tent-like enclosure entirely covering a hospital bed) transparent bed was observed. Supervising Registered Nurse 5 (SRN 5), SRN 5 stated an enclosed beds were considered restraints.

During a concurrent interview and record review on 10/20/2023 at 8:52 AM, with Registered Nurse 7 (RN 7), RN 7 stated the initial Physician Order for an enclosed bed was ordered on 9/26/2023 at 10:40 PM.

During the review of Patient 10's "Safety, Reduction in Harm 'Restraint'" IPOC (interprofessional plan of care) care plan, the care plan was initiated on 10/13/2023 (a total of 17 days after the initial Physician Order).

During an interview on 10/20/2023 at 9:34 AM, with RN 7, RN 7 stated the staff have 24 hours to initiate the care plan.

During a review of the facility's policy and procedure (P&P) titled, "Restraint Policy," dated 11/01/2021, the (P&P) indicated, " ... IV. Plan of Care B. Upon initiation of restraints, plan of care should be reviewed and modified to reflect current intervention during the shift in which the changes occurred."

Based on observation, interview, and record review, the facility failed to ensure one (1) of 16 sampled patients' (Patient 9) medications were not left in the room unattended by nursing staff. These failures had the potential to compromise the safety of patients during medication administration.

Findings:

During a concurrent observation and interview on 10/18/2023 at 10 AM, with Patient 9 and his mother in his room. Patient 9's mother was observed giving Patient 9 medications in a clear plastic medication cup which he took.

During a concurrent observation and interview on 10/18/2023 at 10:28 AM, with Registered Nurse 4 (RN 4), RN 4 stated she told Patient 9 that she would leave the medication in the room. RN 4 stated that it was not a normal practice to leave medication by the bedside.

During a review of Patient 9's Medication Administration Record (MAR), the MAR indicated the following medications were administered to Patient 9 at 9:36 AM: rivaroxaban (medication to treat and prevent blood clots) 20 mg (milligram) tablet and voriconazole (medication to treat fungal infection) 300 mg tablet.

During an interview on 10/18/2023 at 10:49 AM, with Supervising Registered Nurse 5 (SRN 5), SRN 5 stated it was against the facility's policy to leave medications at bedside.

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration and Documentation," dated 4/25/2020, the P&P indicated, " ... II. Administration: ... B. h. Administer the medication, remaining with the patient until all medications... C. Medications (even those administered by parent or self-administered by the patient) must be under the direct observation by a licensed staff member... G. Medications may not be left at bedside."

The facility failed to ensure the Condition of Participation: Infection Prevention and Control and Antibiotic Stewardship was met when:

1. Bleach disinfectant (used to clean hemodialysis machines) bottles had a black, brown, and orange substance around the top. (Refer to A-0750, Finding 1).

2. Three (3) of 3 storage cabinets contained procedural scopes were stored in Operating Rooms (ORs). The storage cabinets were not cleaned and maintained. (Refer to A-0750, Finding 2).

3. Two (2) surgical instrument tray sets contained multiple instruments with brown, reddish orange stains and pitting (rough tiny holes). (Refer to A-0750, Finding 3).

4. Multiple surgical instruments were not cleaned and disinfected. In addition, single-use syringes (used to flush instrument lumens) were reused throughout the day, and brushes (used to clean soiled surgical instruments) were not cleaned in between each use. (Refer to A-0750, Finding 4).

5. Multiple corrugated supply boxes were stored in the Sterile Processing Department (SPD: a restricted area used to clean, prepare, sterilize, and store reusable medical and surgical instruments). (Refer to A-0750, Finding 5).

The cumulative effect of these systemic practices resulted in the facility's failure to deliver care in compliance with the Condition of Participation for Infection Prevetion and Control and Antibiotic Stewardship.

Based on observation, interview, and record review, the facility failed to implement and maintain a clean and sanitary environment to avoid the transmission of infections. This failure had the potential for cross-contamination (transfer of harmful bacteria from one person, object, or place to another) and placed the patients at risk for infections.

Findings:

1. During a tour of the Hemodialysis Unit on 10/17/2023 at 3:50 PM, ten (10) white plastic bottles with yellow tops were observed to have black, orange substance and black particles.

During a concurrent interview with a Registered Nurse Dialysis Supervisor (RNDS) who stated that the bottles were filled with bleach and used to disinfect the hemodialysis machines. RNDS further stated the bottles should probably be replaced.

2. During a concurrent observation and interview on 10/18/2023 at 1:20 PM, with the Director of Perioperative Services (DPS) in the Operating Rooms (OR). The following concerns were identified:
a. OR #15 had two (2) storage cabinets that contained flexible endoscopes (device used to look inside a body cavity or organ).
b. OR #6 had one (1) storage cabinet that contained four (4) laryngoscopes (device used to look inside a patient's voice box). The bottom of the scope cabinet had visible black stains, tape adhesive, loose black particles and grey fuzzy matter.

During an interview on 10/18/2023 at 2:15 PM with a Registered Nurse Ear Nose and Throat Coordinator (RNENT) and DPS, RNENT stated she cleans the cabinet while the scopes are in the cabinet and cleans around the scopes. RNENT and DPS were unable to provide documented evidence to show the cabinet was cleaned on a regular basis. In addition, the DPS stated she was aware that the cabinets containing the procedural scopes should not have been stored in the OR procedure rooms.

During a review of the facility document titled, "AORN (Association of Perioperative Registered Nurses) Guidelines for Perioperative Practice: Flexible Endoscopes," Copyright 2012-2023 AORN Inc., the document indicated, "13.4 store flexible endoscopes in cabinets that are situated in a secure location in the clean workroom of the endoscopy processing room in a two-room design or in a separate clean area close to, but not within, the endoscopy procedure room."

During a review of the facility document titled, "ANSI (American National Standard Institute)/AAMI (Advancement of Medical Instrumentation) ST 91:2021 Flexible and semi-rigid endoscope processing in health care facilities," copyright 2022, the document indicated, "Cabinets and endoscopes shall be visually inspected to ensure cleanliness when the endoscope is placed into the storage cabinet... Storage cabinets should be cleaned in accordance with manufacturer's instructions for use (IFU), or at least weekly and when visibly soiled."

3. During a concurrent observation and interview on 10/19/2023 at 10:42 AM, in the Sterile Processing Department (SPD), with Associate Director of Perioperative Services (ADPOS) and Sterile Processing Department Technician 1 (SPDT 1), two (2) sterilization containers (a major and a minor tray with previously cleaned and ready to use reusable patient surgical instruments) were inspected. The following concerns were identified upon observation of the surgical instruments: eight (8) had brown, reddish orange stains, two (2) had brown, reddish orange stains and were rough to touch, and one (1) had brown staining and was rough to touch. The ADPOS stated that the brown/orange spotting was "probably rust" and should have been pulled before packaging to be recleaned or replaced if needed, and the rough area was "pitting" and should have been replaced.

According to AAMI (Advancement of Medical Instrumentation) ST 79 titled, "Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities," indicated, "7.6.1 General considerations... (g) Devices should be inspected for flaws, damage, debris, detergent residue, and completeness, then dried... 7.6.4.5 Verification of the cleaning process... Instruments should undergo an inspection for proper function and cleanliness. 1. Instruments should be inspected for a) cleanliness ..."

4. During a concurrent observation and interview on 10/19/2023 at 1:55 PM, at the Sterile Processing Department's (SPD) Decontamination Room, a Sterile Processing Department Technician 2 (SPDT 2) was manually cleaning soiled surgical instruments. SPDT 2 did not scrub/brush the surgical instruments. SPDT 2 used a single use syringe to flush surgical instrument's lumens. SPDT 2 stated that we do not brush unused surgical instruments. SPDT 2 also stated that we use the brush and single-use syringe throughout the day, and the brush used to clean the surgical instruments does not get cleaned in between each use.

During a concurrent observation and interview on 10/19/2023 at 2:37 PM, at the SPD's Decontamination Room, a SPDT 1 was manually cleaning soiled surgical instruments. SPDT 1 brushed approximately 10 immersible soiled surgical instruments at once, above the water level. SPDT 1 used a single-use syringe to flush lumens of instruments. SPDT 1 stated that unused open sugical instruments do not get brushed, only the used ones with a lot of blood. In addition, SPDT 1 stated that the single-use syringe used to flush lumens gets used throughout the day.

According to Association for the Advancement of Medical Instrumentation (AAMI) ST 79, indicated: "7.4.1 General considerations for all devices and utensils ...single-use cleaning instruments should be discarded after each use...

During a review of facility's document titled, "AORN (Association of Perioperative Registered Nurses) Guidelines for care and cleaning of surgical instruments," the document indicated: "9.3 Clean and decontaminate all instruments that were open in the OR or procedure room." "9.4.6 Perform brushing under the surface of the water during manual cleaning."

During a review of facility's document titled, "Brush Instructions for use," the document indicated "...Clean brushes after each use and disinfect between cases or daily ..."

5. During the concurrent observation and interview on 10/19/2023 at 3:35 PM, with the Associate Director of Perioperative Services (ADPOS), in the Sterile Processing Department (SPD), 59 corrugated supply boxes were stored on the floor of SPD near the Sterile Storage Room, and three (3) corrugated supply boxes were stored in the Clean Room. ADPOS stated that the supply boxes should not be kept in SPD.

During a review the facility's policy and procedure (P&P) titled, "Sterile Supplies from Outside Manufacturers," dated 4/26/2021, the P&P indicated, "No outside shipping cartons will be stored in the clean or sterile supply area. Storage of sterile supplies in cartons that are made from corrugated cardboard will be avoided at all times."

6. During a concurrent observation and interview on 10/20/2023 at 2:57 PM with a Perioperative Core Technician 1 (PCT1), PCT 1 was observed to have long fingernails. PCT 1 stated her nails were a little long and should be short.

During an interview on 10/20/2023 at 3:10 PM with the Interim Operating Room Manager (ORM), the ORM stated the expectation was that staff fingernails should be short.

During a review of the facility's policy and procedure (P&P) titled, "Hand Hygiene, dated 4/27/2023, the P&P indicated, " 7. Nails: The following policy statements apply to staff who engage in patient care, food service staff, clean patient rooms, handle sterile supplies, or restock in patient rooms: a. Natural nail tips should be kept short and no longer than ½ inch in length."

7. a. During a concurrent observation and interview on 10/17/2023 at 3:35 PM, with Cardiovascular Acute Manager (CVAM), Cardiovascular Acute Supervisor (CVAS), and Clinical Practice Leader Patient Care Services (CPL), a fingerstick blood glucose meter (device used to check blood sugar) located at 2W Nurse's Station #2 had dried brownish red stain by the strip port. CVAM, CVAS, and CPL confirmed that the meter was not cleaned properly.

b. During a concurrent observation and interview on 10/17/2023 at 3:50 PM, with CVAM, Cardiothoracic Supervisor (CTS), and CPL, a fingerstick blood glucose meter located at 2E Nurse's Station #5 had dried brownish red stain on the barcode area. CVAM, CTS, and CPL confirmed the meter was not properly cleaned.

c. During a concurrent observation and interview on 10/17/2023 at 3:56 PM, with Registered Nurse 2 (RN 2), a fingerstick blood glucose meter located at 2E Nurse's Station #2 had dried brownish red stain by the strip port. RN 2 stated that fingerstick blood glucose meter should be cleaned after each patient use with Sani-cloth wipes and bleach if needed. RN 2, CVAM, CTS, and CPL confirmed the meter was not properly cleaned.

During a review of "Nova biomedical Glucose Hospital Meter System Instruction for Use (IFU) Manual," Reference 55848K 2023-05, the IFU indicated the glucose meter "should be cleaned and disinfected after each patient use to minimize the risk of transmission ..." The IFU also indicated "to ensure proper disinfection, it is important to clean (with a fresh germicidal wipe) prior to disinfecting (with a fresh germicidal bleach wipe) the meter."

8. a. During an observation on 10/17/2023 at 3:53 PM, in 2E Nurse's Station #3, there was a portable transport ventilator (machine that helps you breathe) left unattended and uncovered.

During an interview on 10/17/2023 at 3:53 PM, with Respiratory Therapist 1 (RT 1), RT 1 stated that uncovered equipment would be assumed dirty.

b. During a concurrent observation and interview on 10/17/2023 at 3:58 PM, with RT 2, an uncovered Nitric Oxide machine (used along with a breathing machine) was found in 2E Clean Utility Room.

During an interview on 10/19/2023 at 4:15 PM, with Associate Director of Respiratory Care Services (ADRC), ADRC stated that any uncovered respiratory machine meant that the equipment was dirty.

During a review of facility's policy and procedure (P&P) titled, "Equipment Cleaning and Assembly," dated 7/06/2021, the P&P indicated, "All dirty reusable respiratory equipment will be bagged and placed in the unit's designated dirty utility room."

9. During a concurrent observation and interview on 10/20/2023 at 2:50 PM, with Supervisor of Surgical Center (SSC), there were multiple sterile supplies (such as gloves, instruments, and sutures) found near the sink in clean room between Operating Room (OR) #3 and #12. SSC stated, "They should not be stored here."

During an interview on 10/23/2023 at 9 AM, with Associate Director of Perioperative Services (ADPOS), ADPOS stated the sterile supplies should not be stored in the clean area.

During a concurrent observation and interview on 10/20/2023 at 3:20 PM, with SSC, in a recessed area by OR #10, a wide-open storage cabinet (labeled "OR 10 Peel Packs") containing sterile instruments was found next to non-sterile supplies. SSC stated that the storage cabinet should have been kept closed.

During a review of the facility's policy and procedure (P&P) titled, "Aseptic Practice in the Operating Room (Maintaining a Sterile Field)," dated 5/17/2018, the P&P indicated, "Other situations that could raise doubt about the sterility of an item include: 2. A sterile appearing package found in a non-sterile work area or with non-sterile items... Sterile and unsterile items are not stored together (i.e., on the same shelf or in the same drawer)."

10. During an observation of the Hemodialysis Center on 10/17/2023 at 3:16 PM, with the Dialysis Nurse Manager (DNM), the Registered Nurse Dialysis Supervisor (RNDS), and the Dialysis Lead Nurse (DLN). Nine (9) Patient Stations (#1, #2, #3, #4, #5, #6, #7, #8, and #9) had damaged, discolored, and stained reusable fluid proof pillows.

During a concurrent observation and interview, on 10/17/2023 at 3:33 PM, conducted with Certified Hemodialysis Technician 1 (CHT 1), in Patient Station #7, CHT 1 was observed to wiping the pillow and applied the pillowcase while the pillow was still wet. CHT 1 stated he did not follow the manufacturer's instructions for use (IFU) because the surface of the pillow did not completely air dry.

During an interview on 10/18/2023 at 9:25 AM, with the Infection Control Prevention Manager 2 (ICPM 2), the ICPM 2 stated that the staff should have followed the germicidal manufacturer's instructions for cleaning and disinfecting the pillows. The ICPM 2 stated if the pillows were stained and/or damaged, the pillows should have been removed from the patient care area because damaged pillows "cannot be properly cleaned and disinfected."

A review of the germicidal manufacturer's guidelines titled, "Super Sani-Cloth General Guidelines for Use," dated 2021, indicated, "... Let air dry."

Based on observation, interview, and record review, the hospital failed to provide evidence that adequate training for decontamination cleaning process of surgical instruments were provided and ongoing competency validation were completed for four (4) of 4 sampled Sterile Processing Department Technicians (SPDT 1, SPDT 2, SPDT 3, and SPDT 4). This failure had the potential to negatively impact the patient's safety.

Findings:

During a concurrent interview and record review on 10/23/2023 at 10:45 AM, with the Sterile Processing Department Manager (SPDM), employee files were reviewed on unit specific orientation and ongoing annual competency for the SPD staff.

The following employee files were reviewed.

a. For SPDT 1, SPDT 1 was hired on 07/02/2018. There was no documentation of competency-based training, education or orientation on the cleaning and care of instruments used in surgery.

b. For SPDT 2, SPDT 2 was contracted to the hospital on 11/14/2022. There was no documentation of competency-based training, education or orientation on the cleaning and care of instruments used in surgery. There was no documentation of performance evaluation in SPD.

During an interview on 10/23/2023 at 11:55 AM, with SPDT 3, SPDT 3 stated that during her new hire process there were no signed competencies required for instrument decontamination. SPDT 3 stated there was "not enough training" for the decontamination cleaning process.

During an interview with SPDT 4 on 10/23/2023 at 12:08 PM with SPDT 4, SPDT 4 stated "there is no sign off sheet for that" when discussing the instrument cleaning decontamination process. SPDT 4 stated there are "no annual competencies" in the Sterile Processing Department (SPD).

There was no documentation of competency-based training, education, and/or orientation on the cleaning and care of instruments used in surgery for SPDT 1 or SPDT 2. The SPDM stated she was responsible for ensuring staff were provided surgical instrument decontamination and cleaning training. The SPDM confirmed ongoing competency-based training was not provided and stated the hospital did not currently have a decontamination and cleaning training tool or checklist. The SPDM stated a decontamination and cleaning checklist was needed and ongoing competency-based training should have been provided to prevent avoidable hospital acquired infections.

A review of the Association of PeriOperative Registered Nurses (AORN) Guidelines for Perioperative Practice (2020), Guidelines for Instrument Cleaning indicated the following recommendation: "15. Education. 15.1 Provide education and verify competency of team members with responsibilities for cleaning and care of instruments used in surgery... Rationale: It is the responsibility of the health care organization to provide initial and ongoing education and to verify the competency of perioperative team members. Initial and ongoing education of perioperative personnel about cleaning and care of instruments facilitates the development of knowledge, skills, and attitudes that affect safe patient care."

The hospital failed to comply with the Condition of Participation: Surgical Services when:

1. Terminal cleaning (to clean and disinfect) was not performed in the Operating Rooms (OR) and in the Sterile Processing Department (SPD) daily. (Refer to A-0951, Finding 1).

2. Parts of one (1) slush and warmer system (use to warm solutions and make cold slush during transplant) and 1 solution warmer were corroded. (Refer to A-951, Finding 2).

The cumulative effect of these systemic practices resulted in the facility's failure to deliver care in compliance with the Condition of Participation Surgical Services.

Based on observations, interviews, and record reviews, the hospital failed to provide surgical services in a well-organized manner and in accordance with acceptable standards of practice. These failures had the potential to increase risk of hospital infections.

Findings:

1. During a concurrent observation and interview on 10/19/2023 at 3 PM, with Associate Director of Perioperative Services (ADPOS), on the Sterile Processing Department (SPD) Decontamination Area (where scrubbing/cleaning of reusable surgical instruments was performed), the following concerns were identified: a cobweb with a spider was identified in the corner of the back area of SPD, multiple ceiling vents and registers (openings where airflow is delivered to the unit) contained build-up of grey fuzzy substance, on the floor beneath scope washers were multiple black loose substance and build-up of grey fuzzy substance, multiple surgical instrument case trays were beneath the sink and beneath work tables, and approximately 20 laminated papers were taped to a wall above the table used to perform cleaning of scopes. ADPOS stated that terminal cleaning was supposed to be performed daily.

During an interview on 10/19/2023 at 3:15 PM, with Environmental Technician 1 (EVS 1) and the Director of Environmental Services (EVSD), the observations made during the tour of SPD and Operating Room (OR) were discussed. EVSD stated that terminal cleaning was not performed on weekends in SPD. EVSD also stated that for the OR, terminal cleaning was performed on some Saturdays if needed and only on Sundays after a trauma case.

According to the Association of Perioperative Registered Nurses (AORN: evidence-based guidelines which define the standards that help keep healthcare workers and surgical patients safe), infection control standards the hospital followed, defines terminal cleaning as "Thorough environmental cleaning that is performed at the end of each day when the area is being used."

During a review of the facility's document titled, "Environmental Services Cleaning Procedures Manual," Copyright 2011 Sodexo, indicated, "This procedure covers the terminal or end-of-day cleaning instructions for surgical/invasive areas and delivery rooms and meets AORN requirements. Surgical and invasive procedure rooms and scrub/utility areas should be terminally cleaned daily."

2. During a concurrent observation and interview on 10/20/2023 at 3:30 PM, with Supervisor of Surgical Center (SSC) in Operating Room (OR) #12, a slush and warmer system called Hush Slush machine (use to warm solutions and make cold slush during transplant) was found with corrosion inside the basins and the outer part of the machine.

During a concurrent observation and interview on 10/20/2023 at 3:35 PM, with SSC, one (1) of 2 stand-alone solution warmer machine being stored by an alcove (recess opening off a room) was found with corroded basin.

During an interview on 10/20/2023 at 5:05 PM, with Director of Perioperative Services (DPS), DPS stated they still use the corroded Hush Slush machine found in OR #12 and the solution warmer found by an alcove. DPS agreed that the corrosive part cannot be properly cleaned.

During an interview on 10/23/2023 at 9:45 AM, with Infection Control Prevention Manager 1 (ICPM 1), ICPM 1 stated that they should have not used the Hush Slush machine because you can not properly clean and disinfect corrosion.

During a review of Operator's Manual (OM) titled, "Hush Slush 2.0 Ecolab Slush & Warmer System (E Series: ESW7L)," Copyrighted 2021 by Microtek Medical Inc., the OM indicated that when basin(s) has corrosion, "Hush Slush 2.0 was not cleaned as frequently as instructed." The OM also indicated that "9.1 Routine Cleaning After Each Use ... a. Clean the Hush Slush 2.0 as follows: ...ii. Clean and dry the basins after each use... to prevent corrosion... 9.2 Monthly Maintenance a. Clean Hush Slush 2.0... every month. ii. This prevents the buildup of corrosion or staining in the basin..."