HospitalInspections.org

Based on record reviews and interview the hospital failed to inquire from patients upon admit if patients wanted the hospital to notify their own physician of their admission to the hospital. This failed practice was evidenced in 5 of 5 (#1-#5) medical records reviewed for physician notification upon admit. The hospital had a census of 8 patients out of a total capacity of 37.

Findings:
A review of the demographic facesheets for Patients #1- #5 revealed that the PCP (Primary Care Physician) listed on each patient's facesheet was the same physician's name as listed for the Admit Physician and the Attending Physician.

In an interview on 04/12/16 at 2:00 p.m. with S26Adm (Lead Admissions Clerk), she indicated that the admission department personnel were responsible for obtaining the information from the patients for the demographic facesheet. S26Adm indicated that the admission department personnel did not inquire or ask about a patient's PCP since some patients did not visit their PCPs regularly. S26Adm further indicated that it was the hospital's practice to list the Admit/Attending physician as the patient's PCP.

Based on record reviews and interviews, the hospital failed to ensure that the nursing staff developed and kept current a nursing care plan for each patient as evidenced by failing to individualize the patient's nursing care plan to include all the patient's medical diagnoses for which the patient was being treated for 5 (#1-#5) of 5 patient medical records reviewed for nursing care plans. The hospital had a census of 8 patients out of a total capacity of 37.

Findings:

Patient #1
The patient was a 59 year old male admitted to the hospital on 04/11/16 for a Laparoscopic Gastric Sleeve (LGS) surgical procedure. The admit diagnosis was morbid obesity. Other diagnoses included in part: peripheral vascular disease, high cholesterol, diabetes and chronic obstructive pulmonary disease. A review of the medical record revealed a bariatric care plan, which included care plans for pain, skin integrity, nutrition and activity related to postoperative care. A further review of the patient's nursing care plan revealed no documented care plans for peripheral vascular disease, high cholesterol, diabetes and chronic obstructive pulmonary disease.
Patient#2
The patient was a 41 year old female admitted to the hospital on 04/12/16 for a Laparoscopic Gastric Sleeve (LGS) surgical procedure. The admit diagnosis was morbid obesity. Other diagnoses included in part: high cholesterol, urinary stress incontinence and diabetes. A review of the medical record revealed a bariatric care plan, which included care plans for pain, skin integrity, nutrition and activity as related to postoperative care. A further review of the patient's nursing care plan revealed no documented care plans for high cholesterol, urinary stress incontinence or diabetes.
Patient #3
The patient was a 41 year old male admitted to the hospital on 01/26/16 for a Laparoscopic Gastric Sleeve (LGS) surgical procedure. The admit diagnosis was morbid obesity. Other diagnoses included in part: hypertension, high cholesterol, coronary artery disease and atrial fibrillation. A review of the medical record revealed that no care plans had been initiated for the patient.
Patient #4
The patient was a 66 year old male admitted to the hospital on 04/12/16 for a right Total Hip Arthroplasty (THA) surgical procedure. The admit diagnosis was osteoarthritis. Other diagnoses included in part: gout and a history of kidney stones. A review of the medical record revealed a THA care plan, which included care plans for tissue perfusion, pain, skin integrity and activity related to postoperative care. A further review of the patient's nursing care plan revealed no documented care plans for gout or urological concerns.
Patient #5
The patient was a 66 year old female admitted to the hospital on 04/12/16 for a Laparoscopic Gastric Sleeve (LGS) surgical procedure. The admit diagnosis was morbid obesity. Other diagnoses included in part: hypertension, hypothyroidism, arthritis and urinary stress incontinence. A review of the medical record revealed a bariatric care plan, which included care plans for pain, skin integrity, nutrition and activity as related to postoperative care. A further review of the patient's nursing care plan revealed no documented care plans for hypertension, hypothyroidism, arthritis and urinary stress incontinence.
In an interview on 04/13/16 at 3:30 p.m. with S6ClinMgr and S3RM, they indicated that the patients are here at the hospital for such a short time that they concentrate the care plans on the more immediate postoperative needs and they do not care plan for all the patients medical diagnoses. S6ClinMgr indicated that the patient's nursing care plan should be more comprehensive.

Based on record reviews, observations and interviews the hospital's Infection Control program failed to identify, prevent, and control infection control issues and/or breaches by failing to implement an effective infection control plan consistent with acceptable professional standards governing surgical services and acceptable infection control standards of practice by:
1) failing to ensure that staff adhered to acceptable standards of professional practice in surgical attire in the restricted and semi-restricted surgical areas and
2) failing to ensure that Surgical Services followed the hospital's infection control policy in the terminal cleaning of the surgical suites

Findings:
1) failing to ensure that staff adhered to acceptable standards of professional practice in surgical attire in the restricted and semi-restricted surgical areas and

A review of the hospital policy titled "Surgery/Room Attire" provided by S4IC, as the most current, revealed in part: All personnel entering the restricted/semi-restricted areas of the surgical suite should wear appropriate attire. Circulators may wear buttoned cover jackets. All possible head and facial hair including sideburns and necklines should be covered while in the restricted/semi-restricted areas. Masks are either on or off. They are not to be saved by hanging around the neck and masks should fit to prevent venting.
A review of the AORN (Association of periOperative Registered Nurses) Guidelines for Perioperative Practice, 2015 edition - Guideline for Surgical Attire-
Recommendation I revealed in part: All individuals entering the restricted surgical area (O.R. suite) should wear a surgical mask when scrubbed personnel, sterile supplies and/or sterile equipment are present. A surgical mask protects the patient from transfer of microorganisms. The mask should cover the mouth and nose and be secured in a manner to prevent venting. A mask that is securely tied at the back of the head and behind the neck decreases the risk of staff transmitting nasopharyngeal and respiratory microorganisms to patients. Surgical masks are intended to contain and filter droplets from the nasopharynx. The filter portion of the surgical mask harbors bacteria collected from the nasopharyngeal airway. Surgical masks should be tied securely and discarded after each procedure or when soiled and should not be worn hanging from the neck. When in the semi-restricted or restricted surgical areas, all non-scrubbed personnel should wear a freshly laundered or single use long sleeved warm up jacket snapped closed with the cuffs down to the wrists. Wearing the warm up jacket snapped closed prevents the edges of the front of the jacket from contaminating a skin prep area or the surgical sterile field. Long sleeved attire helps contain skin squames shed from bare arms. All personal clothing should be completely covered by the surgical attire. Undergarments such as T-shirts with a V-neck, and shirts with sleeves which can be contained underneath the scrub top, may be worn; personal clothing that extends above the scrub top neckline or below the sleeve of the surgical attire should not be worn.
Recommendation III revealed in part: All personnel should cover head and facial hair, including the sideburns, the ears and the nape of the neck, when in semi-restricted and restricted areas. Human hair can be a site of pathogenic bacteria such as MRSA. Hair acts as a filter when it is uncovered and collects bacteria. A clean, low-lint surgical head covering or hood that confines all hair and covers scalp skin and ears should be worn. The head covering or hood should be designed to minimize microbial dispersal. Skull caps (surgeon caps) fail to contain the side hair above and in front of the ears and hair at the nape of the neck and the ears and should not be worn. Reusable head coverings (cloth head coverings) should be laundered in a health care-accredited laundry facility or completely covered by a disposable bouffant hat.

Recommendation IX revealed in part: Restricted areas in a surgical suite includes the OR (operating room) and procedure rooms, the clean core and the scrub sink areas. People in the restricted areas are required to wear full surgical attire (scrub attire, head coverings, masks, and shoe covers as applicable). The Semi-Restricted areas include the peripheral support areas of the surgical suite, the storage areas, the work areas, and corridors leading to the restricted areas of the surgical suite.

Observations on 04/12/16, from 3:20 p.m. to 4:30 p.m. with S4IC and S5DirOR revealed the following surgical attire breaches in the restricted and semi-restricted surgical suite area:
S14RN/OR during a surgical procedure with a personal cloth cap not completely covered by the disposable bouffant hat
S15RN/OR during a surgical procedure not having her warm-up jacket buttoned/snapped
S16Rep during a surgical procedure wearing a skull cap that did not completely cover the hair and ears and wearing a T-shirt that was not completely covered by the surgical attire and not wearing a buttoned down warm up jacket in the O.R. during a surgical procedure.
S17Rep with his surgical mask worn hanging from the neck
S18CRNA during a surgical procedure with the bottom string of her mask not tried securely and causing venting of the mask and her bouffant hat not covering her ears
S19CRNA with his mask worn hanging from the neck and during a surgical procedure wearing a skull cap that did not completely cover the hair and ears
S20CRNA during a surgical procedure with the bottom string of his mask not tried securely and causing venting of the mask and his bouffant hat not covering her ears and wearing a T-shirt that was not completely covered by the surgical attire.
S21MD/Anes with his mask worn hanging from the neck
S22MD/Anes with his mask worn hanging from the neck and during a surgical procedure wearing a skull cap that did not completely cover the hair and ears
S23Student observing in a surgical procedure with her warm up jacket sleeves pushed up above her elbows.
S24MD wearing a skull cap that did not completely cover the hair and ears
In an interview on 04/12/16 at 4:30 p.m. with S5DirOR and S4IC, S5Dir/OR indicated that the Surgical Services followed the professional standards of practice established by the AORN Guidelines. S4IC further indicated that the AORN Guidelines and acceptable infection control practices regarding O.R. surgical attire were not being followed by staff.

2) failing to ensure that Surgical Services followed the hospital's infection control policy in the terminal cleaning of the surgical suites

A review of the hospital policy titled "Environmental Cleaning" provided by S4IC, as the most current, revealed in part: Operating Rooms will be end of day cleaned after the last case by the O.R. staff. Terminal daily cleaning will include the entire room - floor, lights, bed, moving equipment, and all surfaces. Operating Room staff will clean between cases to include all flat surfaces and removing soiled linen and trash and mopping.
A review of the AORN (Association of periOperative Registered Nurses) Guidelines for Perioperative Practice, 2015 edition - Guideline for Environmental Cleaning: Recommendation IV revealed in part: Surgical and Invasive Procedure Rooms and scrub/utility areas should be terminally cleaned daily when used. Terminal cleaning and disinfection of the perioperative environment decreases the number of pathogens, dust, and debris that is created during the day. Terminal cleaning and disinfection of operating and invasive rooms should be done when the scheduled procedures are completed for the day for each used operating room.

An observation on 04/12/16 at 4:30 p.m. was made of staff cleaning an O.R. after a surgical procedure was completed.
In an interview on 04/12/16 at 4:30 p.m. with S5DirOR she indicated that the O.R. staff were responsible for cleaning the O.R. after a surgical case was completed and at the end of the day ' s schedule. S5DirOR indicated that O.R. staff were also responsible for terminal cleaning of the O.R.s each week and indicated that terminal cleaning was performed once a week and used rooms were not terminally cleaned daily. S5DirOR indicated that she was not aware that used O.R.s had to be terminally daily at the end of the day ' s schedule. S5DirOR indicated that the Surgical Services followed the professional standards of practice established by AORN Guidelines.

Based on record reviews, observations and interviews the hospital failed to ensure acceptable professional standards of practice governing surgical services and infection control were adhered to as evidenced by:
1) failing to ensure that staff adhered to acceptable standards of professional practice in surgical attire in the restricted and semi-restricted surgical areas and
2) failing to ensure that Surgical Services followed the hospital's infection control policy in the terminal cleaning of the surgical suites

Findings:
1) failing to ensure that staff adhered to acceptable standards of professional practice in surgical attire in the restricted and semi-restricted surgical areas and

A review of the hospital policy titled "Surgery/Room Attire" provided by S4IC, as the most current, revealed in part: All personnel entering the restricted/semi-restricted areas of the surgical suite should wear appropriate attire. Circulators may wear buttoned cover jackets. All possible head and facial hair including sideburns and necklines should be covered while in the restricted/semi-restricted areas. Masks are either on or off. They are not to be saved by hanging around the neck and masks should fit to prevent venting.
A review of the AORN (Association of periOperative Registered Nurses) Guidelines for Perioperative Practice, 2015 edition - Guideline for Surgical Attire-
Recommendation I revealed in part: All individuals entering the restricted surgical area (O.R. suite) should wear a surgical mask when scrubbed personnel, sterile supplies and/or sterile equipment are present. A surgical mask protects the patient from transfer of microorganisms. The mask should cover the mouth and nose and be secured in a manner to prevent venting. A mask that is securely tied at the back of the head and behind the neck decreases the risk of staff transmitting nasopharyngeal and respiratory microorganisms to patients. Surgical masks are intended to contain and filter droplets from the nasopharynx. The filter portion of the surgical mask harbors bacteria collected from the nasopharyngeal airway. Surgical masks should be tied securely and discarded after each procedure or when soiled and should not be worn hanging from the neck. When in the semi-restricted or restricted surgical areas, all non-scrubbed personnel should wear a freshly laundered or single use long sleeved warm up jacket snapped closed with the cuffs down to the wrists. Wearing the warm up jacket snapped closed prevents the edges of the front of the jacket from contaminating a skin prep area or the surgical sterile field. Long sleeved attire helps contain skin squames shed from bare arms. All personal clothing should be completely covered by the surgical attire. Undergarments such as T-shirts with a V-neck, and shirts with sleeves which can be contained underneath the scrub top, may be worn; personal clothing that extends above the scrub top neckline or below the sleeve of the surgical attire should not be worn.
Recommendation III revealed in part: All personnel should cover head and facial hair, including the sideburns, the ears and the nape of the neck, when in semi-restricted and restricted areas. Human hair can be a site of pathogenic bacteria such as MRSA. Hair acts as a filter when it is uncovered and collects bacteria. A clean, low-lint surgical head covering or hood that confines all hair and covers scalp skin and ears should be worn. The head covering or hood should be designed to minimize microbial dispersal. Skull caps (surgeon caps) fail to contain the side hair above and in front of the ears and hair at the nape of the neck and the ears and should not be worn. Reusable head coverings (cloth head coverings) should be laundered in a health care-accredited laundry facility or completely covered by a disposable bouffant hat.

Recommendation IX revealed in part: Restricted areas in a surgical suite includes the OR (operating room) and procedure rooms, the clean core and the scrub sink areas. People in the restricted areas are required to wear full surgical attire (scrub attire, head coverings, masks, and shoe covers as applicable). The Semi-Restricted areas include the peripheral support areas of the surgical suite, the storage areas, the work areas, and corridors leading to the restricted areas of the surgical suite.

Observations on 04/12/16, from 3:20 p.m. to 4:30 p.m. with S4IC and S5DirOR revealed the following surgical attire breaches in the restricted and semi-restricted surgical suite area:
S14RN/OR during a surgical procedure with a personal cloth cap not completely covered by the disposable bouffant hat
S15RN/OR during a surgical procedure not having her warm-up jacket buttoned/snapped
S16Rep during a surgical procedure wearing a skull cap that did not completely cover the hair and ears and wearing a T-shirt that was not completely covered by the surgical attire and not wearing a buttoned down warm up jacket in the O.R. during a surgical procedure.
S17Rep with his surgical mask worn hanging from the neck
S18CRNA during a surgical procedure with the bottom string of her mask not tried securely and causing venting of the mask and her bouffant hat not covering her ears
S19CRNA with his mask worn hanging from the neck and during a surgical procedure wearing a skull cap that did not completely cover the hair and ears
S20CRNA during a surgical procedure with the bottom string of his mask not tried securely and causing venting of the mask and his bouffant hat not covering her ears and wearing a T-shirt that was not completely covered by the surgical attire.
S21MD/Anes with his mask worn hanging from the neck
S22MD/Anes with his mask worn hanging from the neck and during a surgical procedure wearing a skull cap that did not completely cover the hair and ears
S23Student observing in a surgical procedure with her warm up jacket sleeves pushed up above her elbows.
S24MD wearing a skull cap that did not completely cover the hair and ears
In an interview on 04/12/16 at 4:30 p.m. with S5DirOR and S4IC, S5Dir/OR indicated that the Surgical Services followed the professional standards of practice established by the AORN Guidelines. S4IC further indicated that the AORN Guidelines and acceptable infection control practices regarding O.R. surgical attire were not being followed by staff.

2) failing to ensure that Surgical Services followed the hospital's infection control policy in the terminal cleaning of the surgical suites

A review of the hospital policy titled "Environmental Cleaning" provided by S4IC, as the most current, revealed in part: Operating Rooms will be end of day cleaned after the last case by the O.R. staff. Terminal daily cleaning will include the entire room - floor, lights, bed, moving equipment, and all surfaces. Operating Room staff will clean between cases to include all flat surfaces and removing soiled linen and trash and mopping.
A review of the AORN (Association of periOperative Registered Nurses) Guidelines for Perioperative Practice, 2015 edition - Guideline for Environmental Cleaning: Recommendation IV revealed in part: Surgical and Invasive Procedure Rooms and scrub/utility areas should be terminally cleaned daily when used. Terminal cleaning and disinfection of the perioperative environment decreases the number of pathogens, dust, and debris that is created during the day. Terminal cleaning and disinfection of operating and invasive rooms should be done when the scheduled procedures are completed for the day for each used operating room.

An observation on 04/12/16 at 4:30 p.m. was made of staff cleaning an O.R. after a surgical procedure was completed.
In an interview on 04/12/16 at 4:30 p.m. with S5DirOR she indicated that the O.R. staff were responsible for cleaning the O.R. after a surgical case was completed and at the end of the day ' s schedule. S5DirOR indicated that O.R. staff were also responsible for terminal cleaning of the O.R.s each week and indicated that terminal cleaning was performed once a week and used rooms were not terminally cleaned daily. S5DirOR indicated that she was not aware that used O.R.s had to be terminally daily at the end of the day ' s schedule. S5DirOR indicated that the Surgical Services followed the professional standards of practice established by AORN Guidelines.

Based on record reviews and interview the hospital failed to to maintain a complete Operating Room Register that included at least the following information: name of patient, age of patient or date of birth, patient's hospital identification number, date of procedure, operating room times, names of surgeons, anesthesia and staff, type of anesthesia, procedure performed, and pre and post diagnosis as specified in the regulation. This failed practice was evidenced by no documentation of the patient's hospital identification number or the patient's age or date of birth on the Operating Room Register log

Findings:
A review of the Operating Room Register log revealed no documentation of any patient's hospital identification number or the patient's age or date of birth.

In an interview on 04/13/16 at 1:30 p.m. with S3RM she indicated that patient's hospital identification numbers and the patient's age or date of birth were not documented in the Operating Room Register log and patient's hospital identification numbers and age were not a part of the Operating Room Register log.

Based on record reviews, observations and interviews the hospital's Infection Control program failed to identify, prevent, and control infection control issues and/or breaches by failing to implement an effective infection control plan consistent with acceptable professional standards governing surgical services and acceptable infection control standards of practice by:
1) failing to ensure that staff adhered to acceptable standards of professional practice in surgical attire in the restricted and semi-restricted surgical areas and
2) failing to ensure that Surgical Services followed the hospital's infection control policy in the terminal cleaning of the surgical suites

Findings:
1) failing to ensure that staff adhered to acceptable standards of professional practice in surgical attire in the restricted and semi-restricted surgical areas and

A review of the hospital policy titled "Surgery/Room Attire" provided by S4IC, as the most current, revealed in part: All personnel entering the restricted/semi-restricted areas of the surgical suite should wear appropriate attire. Circulators may wear buttoned cover jackets. All possible head and facial hair including sideburns and necklines should be covered while in the restricted/semi-restricted areas. Masks are either on or off. They are not to be saved by hanging around the neck and masks should fit to prevent venting.
A review of the AORN (Association of periOperative Registered Nurses) Guidelines for Perioperative Practice, 2015 edition - Guideline for Surgical Attire-
Recommendation I revealed in part: All individuals entering the restricted surgical area (O.R. suite) should wear a surgical mask when scrubbed personnel, sterile supplies and/or sterile equipment are present. A surgical mask protects the patient from transfer of microorganisms. The mask should cover the mouth and nose and be secured in a manner to prevent venting. A mask that is securely tied at the back of the head and behind the neck decreases the risk of staff transmitting nasopharyngeal and respiratory microorganisms to patients. Surgical masks are intended to contain and filter droplets from the nasopharynx. The filter portion of the surgical mask harbors bacteria collected from the nasopharyngeal airway. Surgical masks should be tied securely and discarded after each procedure or when soiled and should not be worn hanging from the neck. When in the semi-restricted or restricted surgical areas, all non-scrubbed personnel should wear a freshly laundered or single use long sleeved warm up jacket snapped closed with the cuffs down to the wrists. Wearing the warm up jacket snapped closed prevents the edges of the front of the jacket from contaminating a skin prep area or the surgical sterile field. Long sleeved attire helps contain skin squames shed from bare arms. All personal clothing should be completely covered by the surgical attire. Undergarments such as T-shirts with a V-neck, and shirts with sleeves which can be contained underneath the scrub top, may be worn; personal clothing that extends above the scrub top neckline or below the sleeve of the surgical attire should not be worn.
Recommendation III revealed in part: All personnel should cover head and facial hair, including the sideburns, the ears and the nape of the neck, when in semi-restricted and restricted areas. Human hair can be a site of pathogenic bacteria such as MRSA. Hair acts as a filter when it is uncovered and collects bacteria. A clean, low-lint surgical head covering or hood that confines all hair and covers scalp skin and ears should be worn. The head covering or hood should be designed to minimize microbial dispersal. Skull caps (surgeon caps) fail to contain the side hair above and in front of the ears and hair at the nape of the neck and the ears and should not be worn. Reusable head coverings (cloth head coverings) should be laundered in a health care-accredited laundry facility or completely covered by a disposable bouffant hat.

Recommendation IX revealed in part: Restricted areas in a surgical suite includes the OR (operating room) and procedure rooms, the clean core and the scrub sink areas. People in the restricted areas are required to wear full surgical attire (scrub attire, head coverings, masks, and shoe covers as applicable). The Semi-Restricted areas include the peripheral support areas of the surgical suite, the storage areas, the work areas, and corridors leading to the restricted areas of the surgical suite.

Observations on 04/12/16, from 3:20 p.m. to 4:30 p.m. with S4IC and S5DirOR revealed the following surgical attire breaches in the restricted and semi-restricted surgical suite area:
S14RN/OR during a surgical procedure with a personal cloth cap not completely covered by the disposable bouffant hat
S15RN/OR during a surgical procedure not having her warm-up jacket buttoned/snapped
S16Rep during a surgical procedure wearing a skull cap that did not completely cover the hair and ears and wearing a T-shirt that was not completely covered by the surgical attire and not wearing a buttoned down warm up jacket in the O.R. during a surgical procedure.
S17Rep with his surgical mask worn hanging from the neck
S18CRNA during a surgical procedure with the bottom string of her mask not tried securely and causing venting of the mask and her bouffant hat not covering her ears
S19CRNA with his mask worn hanging from the neck and during a surgical procedure wearing a skull cap that did not completely cover the hair and ears
S20CRNA during a surgical procedure with the bottom string of his mask not tried securely and causing venting of the mask and his bouffant hat not covering her ears and wearing a T-shirt that was not completely covered by the surgical attire.
S21MD/Anes with his mask worn hanging from the neck
S22MD/Anes with his mask worn hanging from the neck and during a surgical procedure wearing a skull cap that did not completely cover the hair and ears
S23Student observing in a surgical procedure with her warm up jacket sleeves pushed up above her elbows.
S24MD wearing a skull cap that did not completely cover the hair and ears
In an interview on 04/12/16 at 4:30 p.m. with S5DirOR and S4IC, S5Dir/OR indicated that the Surgical Services followed the professional standards of practice established by the AORN Guidelines. S4IC further indicated that the AORN Guidelines and acceptable infection control practices regarding O.R. surgical attire were not being followed by staff.

2) failing to ensure that Surgical Services followed the hospital's infection control policy in the terminal cleaning of the surgical suites

A review of the hospital policy titled "Environmental Cleaning" provided by S4IC, as the most current, revealed in part: Operating Rooms will be end of day cleaned after the last case by the O.R. staff. Terminal daily cleaning will include the entire room - floor, lights, bed, moving equipment, and all surfaces. Operating Room staff will clean between cases to include all flat surfaces and removing soiled linen and trash and mopping.
A review of the AORN (Association of periOperative Registered Nurses) Guidelines for Perioperative Practice, 2015 edition - Guideline for Environmental Cleaning: Recommendation IV revealed in part: Surgical and Invasive Procedure Rooms and scrub/utility areas should be terminally cleaned daily when used. Terminal cleaning and disinfection of the perioperative environment decreases the number of pathogens, dust, and debris that is created during the day. Terminal cleaning and disinfection of operating and invasive rooms should be done when the scheduled procedures are completed for the day for each used operating room.

An observation on 04/12/16 at 4:30 p.m. was made of staff cleaning an O.R. after a surgical procedure was completed.
In an interview on 04/12/16 at 4:30 p.m. with S5DirOR she indicated that the O.R. staff were responsible for cleaning the O.R. after a surgical case was completed and at the end of the day ' s schedule. S5DirOR indicated that O.R. staff were also responsible for terminal cleaning of the O.R.s each week and indicated that terminal cleaning was perfor

Based on record reviews, observations and interviews the hospital failed to ensure acceptable professional standards of practice governing surgical services and infection control were adhered to as evidenced by:
1) failing to ensure that staff adhered to acceptable standards of professional practice in surgical attire in the restricted and semi-restricted surgical areas and
2) failing to ensure that Surgical Services followed the hospital's infection control policy in the terminal cleaning of the surgical suites

Findings:
1) failing to ensure that staff adhered to acceptable standards of professional practice in surgical attire in the restricted and semi-restricted surgical areas and

A review of the hospital policy titled "Surgery/Room Attire" provided by S4IC, as the most current, revealed in part: All personnel entering the restricted/semi-restricted areas of the surgical suite should wear appropriate attire. Circulators may wear buttoned cover jackets. All possible head and facial hair including sideburns and necklines should be covered while in the restricted/semi-restricted areas. Masks are either on or off. They are not to be saved by hanging around the neck and masks should fit to prevent venting.
A review of the AORN (Association of periOperative Registered Nurses) Guidelines for Perioperative Practice, 2015 edition - Guideline for Surgical Attire-
Recommendation I revealed in part: All individuals entering the restricted surgical area (O.R. suite) should wear a surgical mask when scrubbed personnel, sterile supplies and/or sterile equipment are present. A surgical mask protects the patient from transfer of microorganisms. The mask should cover the mouth and nose and be secured in a manner to prevent venting. A mask that is securely tied at the back of the head and behind the neck decreases the risk of staff transmitting nasopharyngeal and respiratory microorganisms to patients. Surgical masks are intended to contain and filter droplets from the nasopharynx. The filter portion of the surgical mask harbors bacteria collected from the nasopharyngeal airway. Surgical masks should be tied securely and discarded after each procedure or when soiled and should not be worn hanging from the neck. When in the semi-restricted or restricted surgical areas, all non-scrubbed personnel should wear a freshly laundered or single use long sleeved warm up jacket snapped closed with the cuffs down to the wrists. Wearing the warm up jacket snapped closed prevents the edges of the front of the jacket from contaminating a skin prep area or the surgical sterile field. Long sleeved attire helps contain skin squames shed from bare arms. All personal clothing should be completely covered by the surgical attire. Undergarments such as T-shirts with a V-neck, and shirts with sleeves which can be contained underneath the scrub top, may be worn; personal clothing that extends above the scrub top neckline or below the sleeve of the surgical attire should not be worn.
Recommendation III revealed in part: All personnel should cover head and facial hair, including the sideburns, the ears and the nape of the neck, when in semi-restricted and restricted areas. Human hair can be a site of pathogenic bacteria such as MRSA. Hair acts as a filter when it is uncovered and collects bacteria. A clean, low-lint surgical head covering or hood that confines all hair and covers scalp skin and ears should be worn. The head covering or hood should be designed to minimize microbial dispersal. Skull caps (surgeon caps) fail to contain the side hair above and in front of the ears and hair at the nape of the neck and the ears and should not be worn. Reusable head coverings (cloth head coverings) should be laundered in a health care-accredited laundry facility or completely covered by a disposable bouffant hat.

Recommendation IX revealed in part: Restricted areas in a surgical suite includes the OR (operating room) and procedure rooms, the clean core and the scrub sink areas. People in the restricted areas are required to wear full surgical attire (scrub attire, head coverings, masks, and shoe covers as applicable). The Semi-Restricted areas include the peripheral support areas of the surgical suite, the storage areas, the work areas, and corridors leading to the restricted areas of the surgical suite.

Observations on 04/12/16, from 3:20 p.m. to 4:30 p.m. with S4IC and S5DirOR revealed the following surgical attire breaches in the restricted and semi-restricted surgical suite area:
S14RN/OR during a surgical procedure with a personal cloth cap not completely covered by the disposable bouffant hat
S15RN/OR during a surgical procedure not having her warm-up jacket buttoned/snapped
S16Rep during a surgical procedure wearing a skull cap that did not completely cover the hair and ears and wearing a T-shirt that was not completely covered by the surgical attire and not wearing a buttoned down warm up jacket in the O.R. during a surgical procedure.
S17Rep with his surgical mask worn hanging from the neck
S18CRNA during a surgical procedure with the bottom string of her mask not tried securely and causing venting of the mask and her bouffant hat not covering her ears
S19CRNA with his mask worn hanging from the neck and during a surgical procedure wearing a skull cap that did not completely cover the hair and ears
S20CRNA during a surgical procedure with the bottom string of his mask not tried securely and causing venting of the mask and his bouffant hat not covering her ears and wearing a T-shirt that was not completely covered by the surgical attire.
S21MD/Anes with his mask worn hanging from the neck
S22MD/Anes with his mask worn hanging from the neck and during a surgical procedure wearing a skull cap that did not completely cover the hair and ears
S23Student observing in a surgical procedure with her warm up jacket sleeves pushed up above her elbows.
S24MD wearing a skull cap that did not completely cover the hair and ears
In an interview on 04/12/16 at 4:30 p.m. with S5DirOR and S4IC, S5Dir/OR indicated that the Surgical Services followed the professional standards of practice established by the AORN Guidelines. S4IC further indicated that the AORN Guidelines and acceptable infection control practices regarding O.R. surgical attire were not being followed by staff.

2) failing to ensure that Surgical Services followed the hospital's infection control policy in the terminal cleaning of the surgical suites

A review of the hospital policy titled "Environmental Cleaning" provided by S4IC, as the most current, revealed in part: Operating Rooms will be end of day cleaned after the last case by the O.R. staff. Terminal daily cleaning will include the entire room - floor, lights, bed, moving equipment, and all surfaces. Operating Room staff will clean between cases to include all flat surfaces and removing soiled linen and trash and mopping.
A review of the AORN (Association of periOperative Registered Nurses) Guidelines for Perioperative Practice, 2015 edition - Guideline for Environmental Cleaning: Recommendation IV revealed in part: Surgical and Invasive Procedure Rooms and scrub/utility areas should be terminally cleaned daily when used. Terminal cleaning and disinfection of the perioperative environment decreases the number of pathogens, dust, and debris that is created during the day. Terminal cleaning and disinfection of operating and invasive rooms should be done when the scheduled procedures are completed for the day for each used operating room.

An observation on 04/12/16 at 4:30 p.m. was made of staff cleaning an O.R. after a surgical procedure was completed.
In an interview on 04/12/16 at 4:30 p.m. with S5DirOR she indicated that the O.R. staff were responsible for cleaning the O.R. after a surgical case was completed and at the end of the day ' s schedule. S5DirOR indicated that O.R. staff were also responsible for terminal cleaning of the O.R.s each week and indicated that terminal cleaning was performed once a week and used rooms were not terminally cleaned daily. S5DirOR indicated that she was not aware that used O.R.s had to be terminally daily at the end