HospitalInspections.org

Based on observations and review of policy and procedure and interview, it was determined the facility failed to ensure the staff followed the facility's infection control policies, as evidenced by:

1. Two hospital employees touched the water faucet with their bare hands prior to drying their hands with paper towels. As a result, their hands were potentially contaminated during the provision of direct patient care. This effected Patient Identifier (PI) # 1, one of one same day surgery observations.

2. Operating Room (OR) staff failed to contain a blood spill in the OR during the postoperative cleaning process by walking without shoe covers or with shoes dedicated exclusively to use in the OR. The blood spill was not cleaned and contained prior to mopping the entire floor. As a result, potentially contaminated blood was tracked outside of the OR room on the shoes of staff. By failing to spot clean the blood spill and using a mop to clean the blood spill, the remainder of the floor was potentially contaminated. This had the potential to effect all patients in the Operating Room.

Findings include:

Facility Policy and Procedure:

Policy and Procedure: Hand Hygiene and Surgical Scrub
Number 951973, Effective: 3/1/91; Approved: 7/1/14.

"Purpose: Hand-washing has been recognized as the single most important preventative measure in decreasing the transmission of infection."

All areas of the hospital performing General Hand-washing as follows:

...C. Use plenty of soap and vigorously scrub all hand surfaces...

E. Rinse thoroughly and dry well...

G. Use a paper towel to turn off the faucet.


Facility Policy:

Policy: Sanitation, Number 1575799. Effective: 11/1/98; Approved: 5/29/15.

Purpose: To define cleaning techniques that control and reduce microorganism in the Operating Room (OR), and ensure the OR is thoroughly cleaned before and after each case.

Policy: ...Every case will be treated as potentially contaminated. Cleanup techniques are designed to confine and contain organic debris to prevent contamination of the operating suite...

B. Intraoperative Cleaning:

1. Areas contaminated by organic debris (blood/body fluids) during the operation will be wiped up by the circulator or designee.


During observations of hospital staff providing direct patient care in the Same Day Surgery area on 8/4/15:

At 08:30 Employee Identifier (EI) # 1/ Patient Care Assistant (PCA), was observed washing his/her hands prior to collecting blood from a patient in the patient's room. EI # 1 washed his/her hands with soap and water. EI # 1 turned off the faucet with his/her bare left hand before drying hands with paper towels.

On 8/4/15 at 08:32, EI # 1 left the patient's room for supplies and returned at 08:33. EI # 1 washed his/her hands with soap and water and turned off the faucet with his/her bare left hand prior to drying hands with paper towels.

EI # 2, Registered Nurse (RN) washed his/her hands with soap and water and turned the faucet off with his/her bare hand prior to drying his/her hands with paper towels on 8/4/15 at 08:35.

During an observation of cleaning the OR suite between cases, the surveyor observed the following:

Two areas of bright red blood were seen on the floor near the operating table during an observation on 8/4/15 at 11:30 of Surgical Patient Care Assistants (PCA) cleaning an Operating Room (OR) between surgical cases. A PCA, not wearing shoe covers, walked directly on the blood spill and out of the room into the hall. Another PCA, who was mopping the floor of the OR, used the mop to clean the blood spill and continued to use the same mop to clean the remainder of the floor.

During an interview on 8/4/15 at 11:35, EI # 3, Administrative Director - Surgical Services, said shoe covers are not required if the employee's shoes are dedicated (worn exclusively) to the Operating Room (OR). EI # 3 stated the PCA is new and he/she did not know if the employee's shoes were dedicated for use in the OR. EI # 3 was asked if the blood spill on the floor should have been isolated and cleaned prior to mopping. According to EI # 3, the hospital policy and procedure does not specify cleaning of the spill before mopping.