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AIA, (American Institute of Architects) Guidelines for Design and Construction of Health Care Facilities 2.1 General Hospitals 8.2 General Standards for Details and Finishes 8.2.3.4 Ceilings

(3) Semirestricted areas

(a) Ceiling finishes in semirestricted areas such as airborne infection isolation rooms, protective environment rooms, clean corridors, central sterile supply spaces, specialized radiographic rooms, and minor surgical procedure rooms shall be smooth, scrubbable, nonabsorptive, non perforated, capable of withstanding cleaning with chemicals, and without crevices that can harbor mold and bacterial growth.

(b) If lay-in ceiling is provided, it shall be gasketed or clipped down to prevent the passage of particles from the cavity above the ceiling plane into the semirestricted environment. Perforated, tegular, serrated, or highly textured tiles shall not be used.

Based on tour of the surgical suite on 6/12/12 with Staff A (Director of Surgical Services) it was observed that the facility failed to maintain an environment that is safe for the patient's well-being.

Findings include:


During tour of the surgical suite on 6/12/12 it was observed and shown to Staff A that the ceiling tiles located in the semi-restricted corridors between operating rooms 1, 2 and 3, and central sterile supply room failed to be clipped down ceiling tiles. Interview with Staff B (Plant Supervisor) on 6/12/12 confirmed finding, telling surveyor that all the ceiling tiles have been replaced just recently but were not clipped down.

"AORN (Association of periOperative Registered Nurses) 2009 Edition Page 439. Recommended Practices for Environmental Cleaning in the Perioperative Setting. Recommendation 1 The patient should be provided a clean, safe environment.

1.b All horizontal surfaces in the OR (eg, furniture, surgical lights, booms, equipment should be damp dusted before the first scheduled surgical procedure of the day. Plasma and monitor screens should be cleaned according to manufactures' instructions.

Dust is known to contain human skin and hair, fabric fibers, pollens, mold, fungi, insect parts, glove powder, and paper fibers among other things. Airborne particles range in size form 0.001 microns to several hundred microns. Contamination for particles can come from an external source (eg, ventilation, doors) or an internal source..."


Based on observation with Staff A (Director of Surgical Services) it was found that the horizontal surfaces failed to be fully cleaned.

Findings include:

During tour on 6/12/12 of all three surgical suites it was observed by surveyor and shown to Staff A that the horizontal surfaces through out the operating rooms had build up of dust on multiple horizontal surfaces.

Based on tour of the facility's food preparation area it was found that the facility failed to have proper lighting and failed to maintain a refrigerators inner walls.

Findings include:

During the initial tour of the facility's kitchen on 6/12/12 with Staff C (Director of Food Services) it was observed and shown to Staff C that the produce walk-in refrigerator walls were pitted and rusted and unable to be fully cleaned.

Also during tour it was difficult to see products on the back wall of all three coolers (walk-in refrigerator, produce cooler, and freezer). Staff C also was asked about the lighting who agreed that the lighting in all three coolers, is poor and it was difficult to see.

CDC (Centers for Disease Control and Prevention) (http://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html) 6/18/12 pg 2 of 8 States "Unsafe Practices during Blood Glucose Monitoring and Insulin Administration".

"Unsafe practices during assisted monitoring of blood glucose and insulin administration that have contributed to transmission of HBV or have put persons at risk for infection include:

1) Using fingerstick devices for more than one person

2) Using a blood glucose meter for more than one person without cleaning and disinfecting it in between uses

3) Using insulin pens for more than one person

4) Failing to change gloves and perform hand hygiene between fingerstick procedures"


Based on observation and interview it was determined that the facility failed to provide laboratory services to meet manufactures recommendation with the use of glucose blood testing.

Findings include:

On tour of the Medical Surgical Unit on 6/12/12 it was observed that Staff D (Staff Laboratory personal) was doing glucose testing going from room to room and failing to wash the glucose meter with any disinfectant. On review of the product instruction manual dated 2010 states: "WARNING: Healthcare professionals and others using this system on multiple patients should be aware that all products or objects that come into contact with human blood should be handled as if capable of transmitting viral diseases, even after cleaning".