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Based on observations, staff interviews, and policy reviews, the hospital failed to maintain a sanitary hospital environment regarding hand hygiene, multi-dose medication vials, insulin pens were not labeled or stored appropriately, the changing or protecting of surgical attire when leaving the designated surgical area was not monitored, sterile brushes were not washed appropriately, single use cleaning sponges in central sterile were used more than once, and not maintaining acceptable humidity in the operating rooms (OR) and allowing surgeries to be performed with high humidity. Findings include:

OR Attire:

On 8/6/12 at 1:00 p.m., multiple medical personnel were observed entering in and out of the OR, Pediatric Acute Care Unit (PACU), break room, and from the main hospital with cloth caps, disposable hair caps, disposable facial masks draped around their necks, and OR scrubs not covered. The hospital's dress code required for the OR staff was not being monitored when staff were leaving and re-entering the OR area. A registered nurse (RN) in the surgical area had a cloth cap on her head and a surgical mask was draped around her neck. The RN was asked what the hospital's policy was on washing the cloth hats. The RN stated once a week she took the hat home to wash it.

At 4:00 p.m., on 8/6/12, the OR Manager and Director were interviewed. They both stated the facility followed Centers for Disease Control (CDC) and Association of Operating Room Nurses (AORN) guidelines for the OR.? Both RN's had cloth caps on their heads, had been in and out of surgery all day, walked out side, and were not wearing a protective cover over their scrubs. The manager stated that surgical masks should be changed when leaving the OR. The manager stated she could not say that it happened all the time and there were OR employees that kept the mask draped around their necks throughout the day. The manager stated she did not monitor this. The director was asked what was the monitoring and policy for the cloth hats for the surgery personnel. She stated that daily the caps were to be taken home and washed. She stated that the cloth caps and the disposable caps are worn all day, in and out of the surgery area, into the other rooms of the hospital, break room, bathrooms, and outside. She stated she did not monitor employees regarding washing their own personal cloth caps or if a disposable cap was replaced. At this time, the infection control officer stated that all masks, and caps must be removed when the employee was leaving the patient area. Surgical scrubs should be covered when leaving the area.

On 8/7/12 at 8:15 a.m., the Chief Medical Officer stated that the practice of employees washing their own hats was a fiscal savings, but was not aware that it was not occurring as often as needed. He also stated there was no way to monitor if the caps were laundered correctly regarding detergent and water temperature and how the cap was transported back to the facility.

Handwashing:

Patient #1 was admitted on 8/6/12 for a scheduled ceaserean section. On 8/16/12 at 1:35 p.m., the following was observed in an OR during a surgery:

The surveyor observed RN had gloves on and placed a catheter for patient #1. Once the catheter was in place, the RN removed her gloves, removed the sterile pad and packaging off the patient, and then placed the items in the garbage. The RN with her bare hands in the garbage, pushed the pile of garbage down. The RN then continued through out the OR, to retrieved items for the delivery of the baby, and placed a new set of gloves on her hands with out sanitizing or washing. The RN did not wash her or sanitize her hands after she removed her gloves or after she placed her hands in the garbage can.

On 8/6/12 at 4:00 p.m., the surgical manager and the director, during an interview, stated the hands should be washed or sanitized before or after gloves were placed on the hands.

On 8/7/12 at 8:30 a.m., the infection control officer stated that hands should be sanitized prior and after glove removal.

On 8/7/12 at 9:00 a.m., the infection control policy was reviewed and documented that hands must be washed or sanitized prior and after glove removal.

Medications:

On 8/7/12 at 9:30 a.m., with the infection control officer, and pharmacist, the surveyor observed the medication room on the rehabilitation unit. The medication room refrigerator contained a multi-dose vial of insulin which lacked an open date. There was one insulin pen that was used that did not contain an expiration date. The instructions on the pen stated must be discarded after 28 days. The pharmacist stated that the pen should have an expiration date sticker on it and that the multi-dose vial of insulin needed to be marked with an open date. The open insulin pen was available to be used on the patient.

On 8/7/12 at 9:40 a.m., the medical floor in the medication rooms were observed with the infection control officer. The surveyor noted there were three insulin pens without an expiration date. The pharmacist on the medical floor stated that the pens needed to be marked with an expiration date of 28 days and usually the nurses will check for these dates. The pens were available to be used on the patients.

Catheter care:

During a tour of the medical floor at 9:45 a.m., a catheter bag was observed with the infection control officer to be lying flat on the floor. The catheter bag contained urine. The infection control officer stated that catheter bags should not be on the floor.

Single use items:

On 8/6/12 at 2:30 p.m., the manager of central sterilization (CS) stated that sponges used to pre-clean surgical items were single use and that the brushes used to clean surgical items were to be washed in the machine at the end of the day. The CS room was observed at this time and there were two single use sponges in the sink. The manger stated it did not appear the sponges were thrown away after single use or that the brushes were washed at the end of the shift.


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Isolation:

During a tour of the medical floor at 8:45 a.m., on 8/7/12, an isolation cart was observed outside of patient #2's room. The top drawer of the isolation cart was observed to have two open insulin pens.

Patient #2's medical record was reviewed at 9:00 a.m. on 8/7/12. Patient #2 was in contact isolation for Methicillin-resistant Staphylococcus aureus (MRSA). The patient had diabetes and was on insulin per physician order.

During the meeting on 8/7/12 at 1:00 p.m., the Infection Control Officer stated the insulin pens had been used on the isolated patient and should not have been left on the clean isolation cart.

Operating Room Humidity:

During review of the OR humidity logs at 11:00 a.m., on 8/7/12, it was noted that the humidity was out of range 16 times within the past 19 days. The out of range levels were between 61% - 70%.

On 8/7/12 during the meeting at 11:00 a.m., the maintenance manager stated he checked the humidity levels daily. He further stated he was unable to control the humidity in four operating rooms. He did not notify the OR when the humidity levels were out of range.

On 8/7/12 during the meeting at 11:00 a.m., the OR Director, stated surgery was performed in the operating rooms during the time the humidity levels were out of range.

? AORN Updates Recommendations on Surgical Attire
2/21/2011 Vol. 2, Issue 1 Pillar 7: Environmental Safety and Emergency Operations Planning
Source: Briefings on Infection Control, www.hcpro.com January 2011 Vol 9. No 1

Based on observations, staff interviews, and policy reviews, the hospital failed to maintain a sanitary hospital environment regarding hand hygiene, multi-dose medication vials, insulin pens were not labeled or stored appropriately, the changing or protecting of surgical attire when leaving the designated surgical area was not monitored, sterile brushes were not washed appropriately, single use cleaning sponges in central sterile were used more than once, and not maintaining acceptable humidity in the operating rooms (OR) and allowing surgeries to be performed with high humidity. Findings include:

OR Attire:

On 8/6/12 at 1:00 p.m., multiple medical personnel were observed entering in and out of the OR, Pediatric Acute Care Unit (PACU), break room, and from the main hospital with cloth caps, disposable hair caps, disposable facial masks draped around their necks, and OR scrubs not covered. The hospital's dress code required for the OR staff was not being monitored when staff were leaving and re-entering the OR area. A registered nurse (RN) in the surgical area had a cloth cap on her head and a surgical mask was draped around her neck. The RN was asked what the hospital's policy was on washing the cloth hats. The RN stated once a week she took the hat home to wash it.

At 4:00 p.m., on 8/6/12, the OR Manager and Director were interviewed. They both stated the facility followed Centers for Disease Control (CDC) and Association of Operating Room Nurses (AORN) guidelines for the OR.? Both RN's had cloth caps on their heads, had been in and out of surgery all day, walked out side, and were not wearing a protective cover over their scrubs. The manager stated that surgical masks should be changed when leaving the OR. The manager stated she could not say that it happened all the time and there were OR employees that kept the mask draped around their necks throughout the day. The manager stated she did not monitor this. The director was asked what was the monitoring and policy for the cloth hats for the surgery personnel. She stated that daily the caps were to be taken home and washed. She stated that the cloth caps and the disposable caps are worn all day, in and out of the surgery area, into the other rooms of the hospital, break room, bathrooms, and outside. She stated she did not monitor employees regarding washing their own personal cloth caps or if a disposable cap was replaced. At this time, the infection control officer stated that all masks, and caps must be removed when the employee was leaving the patient area. Surgical scrubs should be covered when leaving the area.

On 8/7/12 at 8:15 a.m., the Chief Medical Officer stated that the practice of employees washing their own hats was a fiscal savings, but was not aware that it was not occurring as often as needed. He also stated there was no way to monitor if the caps were laundered correctly regarding detergent and water temperature and how the cap was transported back to the facility.

Handwashing:

Patient #1 was admitted on 8/6/12 for a scheduled ceaserean section. On 8/16/12 at 1:35 p.m., the following was observed in an OR during a surgery:

The surveyor observed RN had gloves on and placed a catheter for patient #1. Once the catheter was in place, the RN removed her gloves, removed the sterile pad and packaging off the patient, and then placed the items in the garbage. The RN with her bare hands in the garbage, pushed the pile of garbage down. The RN then continued through out the OR, to retrieved items for the delivery of the baby, and placed a new set of gloves on her hands with out sanitizing or washing. The RN did not wash her or sanitize her hands after she removed her gloves or after she placed her hands in the garbage can.

On 8/6/12 at 4:00 p.m., the surgical manager and the director, during an interview, stated the hands should be washed or sanitized before or after gloves were placed on the hands.

On 8/7/12 at 8:30 a.m., the infection control officer stated that hands should be sanitized prior and after glove removal.

On 8/7/12 at 9:00 a.m., the infection control policy was reviewed and documented that hands must be washed or sanitized prior and after glove removal.

Medications:

On 8/7/12 at 9:30 a.m., with the infection control officer, and pharmacist, the surveyor observed the medication room on the rehabilitation unit. The medication room refrigerator contained a multi-dose vial of insulin which lacked an open date. There was one insulin pen that was used that did not contain an expiration date. The instructions on the pen stated must be discarded after 28 days. The pharmacist stated that the pen should have an expiration date sticker on it and that the multi-dose vial of insulin needed to be marked with an open date. The open insulin pen was available to be used on the patient.

On 8/7/12 at 9:40 a.m., the medical floor in the medication rooms were observed with the infection control officer. The surveyor noted there were three insulin pens without an expiration date. The pharmacist on the medical floor stated that the pens needed to be marked with an expiration date of 28 days and usually the nurses will check for these dates. The pens were available to be used on the patients.

Catheter care:

During a tour of the medical floor at 9:45 a.m., a catheter bag was observed with the infection control officer to be lying flat on the floor. The catheter bag contained urine. The infection control officer stated that catheter bags should not be on the floor.

Single use items:

On 8/6/12 at 2:30 p.m., the manager of central sterilization (CS) stated that sponges used to pre-clean surgical items were single use and that the brushes used to clean surgical items were to be washed in the machine at the end of the day. The CS room was observed at this time and there were two single use sponges in the sink. The manger stated it did not appear the sponges were thrown away after single use or that the brushes were washed at the end of the shift.


27823


Isolation:

During a tour of the medical floor at 8:45 a.m., on 8/7/12, an isolation cart was observed outside of patient #2's room. The top drawer of the isolation cart was observed to have two open insulin pens.

Patient #2's medical record was reviewed at 9:00 a.m. on 8/7/12. Patient #2 was in contact isolation for Methicillin-resistant Staphylococcus aureus (MRSA). The patient had diabetes and was on insulin per physician order.

During the meeting on 8/7/12 at 1:00 p.m., the Infection Control Officer stated the insulin pens had been used on the isolated patient and should not have been left on the clean isolation cart.

Operating Room Humidity:

During review of the OR humidity logs at 11:00 a.m., on 8/7/12, it was noted that the humidity was out of range 16 times within the past 19 days. The out of range levels were between 61% - 70%.

On 8/7/12 during the meeting at 11:00 a.m., the maintenance manager stated he checked the humidity levels daily. He further stated he was unable to control the humidity in four operating rooms. He did not notify the OR when the humidity levels were out of range.

On 8/7/12 during the meeting at 11:00 a.m., the OR Director, stated surgery was performed in the operating rooms during the time the humidity levels were out of range.

? AORN Updates Recommendations on Surgical Attire
2/21/2011 Vol. 2, Issue 1 Pillar 7: Environmental Safety and Emergency Operations Planning
Source: Briefings on Infection Control, www.hcpro.com January 2011 Vol 9. No 1