HospitalInspections.org

Based on findings from observation and interview, the hospital did not maintain a clean and sanitary environment in central sterile services department. Failure to maintain a clean and sanitary environment could lead to contamination of instruments that were undergoing sterilization.

Findings include:

-- Per observation on 5/9/17 at 8:56 am, the area under and immediately surrounding the main sterilizers was not clean and properly sealed to prevent communication with an adjacent room at the rear of the sterilizers.

-- Per observation on 5/9/17 at 9:20 am, the temporary air conditioning unit installed in the central services department was not clean.

-- During interviews on 5/9/17 at 8:56 am and 9:20 am, Staff A (Infection Control Practitioner) and Staff B (Supervisor of the Sterile Processing Department) observed and confirmed the above findings.

Based on findings from observation, interview and document review, the facility did not provide surgical services in accordance with acceptable standards of practice. Specifically, in 6 of 6 operating rooms observed, facility staff failed to follow facility policy and procedure (P&P) regarding surgical attire. This could lead to increased risk of infection.

Findings include:

-- During tour of the hospital's main operating suite (5E) on 5/8/17 numerous medical providers (i.e., physicians, anesthesia providers, residents, physician extenders and medical students) were observed wearing a skull cap (type of head covering) with exposed hair in back of head and neckline. Additionally, medical providers were observed with facial hair exposed with no beard covering. Also, medical providers and a vendor did not wear appropriate eye protection. These observations were verified with Staff C (Nurse Manager OR) at the time of observation.

For example:

-OR #2 at 10:10 am - 1 medical provider wore a skull cap with exposed hair in back of head and neckline. Another medical provider had a full beard without a beard covering.
-OR #1 at 10:30 am - 4 medical providers wore skull caps with exposed hair in back of head and neckline. Another medical provider had a full beard without a beard covering.
-OR #6 at 10:45 am - 1 medical provider wore a skull cap with exposed hair in back of head and neckline. Another medical provider had a full beard without a beard covering.
-OR #10 at 10:50 am - 1 medical provider wore a skull cap with exposed hair in back of head and neckline and a vendor did not wear eye protection.
-OR #11 at 11:00 am - 1 medical provider did not wear eye protection
-OR #12 at 11:05 am - 1 medical provider had a beard without a beard covering.

-- Per interview of anesthesiologists with facial hair (Staff D and Staff E) on 5/8/17 at 10:55 am and 11:10 am, respectively, when asked if they wore facial hair protection, both indicated they did not.

-- Per review of the hospital's P&P titled "Surgical/Procedural Attire," last revised 11/30/16, it indicated within the restricted area (operating rooms) a disposable surgical head cover or hood that covers the head and confines all hair (including facial hair) must be worn. Also, all personnel in the OR where procedures and/or surgery are being performed, must wear eye protection.

-- Per review of New York State Department of Health "Dear Chief Executive Officer" letter, dated 3/18/16, "If a hospital chooses to provide surgical services, the services must be well organized and provided in accordance with acceptable standards of practice." It further indicates that compliance with standards and recommendations promoted by, or established by, nationally recognized professional organizations (e.g., Association of Operating Room Nurses, Association for Professional in Infection Control and Epidemiology, etc.) compromise acceptable standards of clinical practice.