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Based on observations, document review, and interview, the Environmental Service Department did not ensure that cleaning of the Operating Room was consistent with generally accepted standards of practice. Specifically, in two (2) out of three (3) observations, while cleaning the Operating Rooms, the Operating Room (OR) Housekeepers did not clean all of the equipment and surfaces according to the facility's Policy. Additionally, the facility's Policy lacked instructions for changing soiled cleaning wipes and disinfecting all surfaces.

These lapses in cleaning technique and adherence to facility Policy could lead to the Operating Room equipment remaining contaminated.

Findings:

Observations in the facility's Operating Room (OR) Suite during a tour between 10:35AM and 11:00AM on 07/29/16 identified the following:

In OR #2, Staff C, OR Housekeeper, was observed cleaning step stools on the floor with a cleaning wipe, then using the same cleaning wipe to clean the Cautery Machine.

Staff A, OR Housekeeper, was observed cleaning a step stool and Sequential TEDS Machine on the floor, then used the same cleaning wipe to clean the IV Pole.

These observations were made in the presence of Staff O, Perioperative Director, who acknowledged that the Housekeeping Staff should have changed cleaning wipes after cleaning the equipment on the floor and before cleaning the other equipment in the room.

Observations of the cleaning procedures in OR #6 on 07/29/16 at 12:20PM identified the following:

Staff C, OR Housekeeper, did not sanitize or clean the Anesthesia Cart. The staff member partially wiped the surfaces of the OR table and lead shields worn by the staff, and failed to mop the floor under the OR bed and Lithotripsy equipment.

These observations were made in the presence of Staff O, Perioperative Director, who acknowledged the findings.

During interviews with Staff P, Director of Environmental Services, and Staff B, Lead OR Housekeeper on 08/01/16 at 1:30PM, when asked about the Operating Rooms cleaning procedures and when staff should change cleaning wipes during cleaning of the OR. Staff B stated that "Housekeeping Staff should change cleaning wipes after cleaning equipment on the floor and before cleaning other equipment in the room". This was confirmed by Staff P.

When asked about the facility's Policy regarding the cleaning of Anesthesia equipment and the mopping of the floors under the OR table, Staff B stated "The Anesthesia Cart should be cleaned after every patient and the floors under the OR table should be mopped after each patient."

The facility's Policy and Procedure titled "Surgical Cleaning Area" last revised 10/01/15 directs Housekeeping Staff, under "Between Case Cleaning" to "wet mop the floor of the OR Suite with a germicidal solution" and "disinfect items that are used during patient care (Anesthesia Cart, Intravenous Pumps and OR Beds) after each patient use." However, the Policy lacked instructions on when to change cleaning wipes between highly soiled surfaces.

The facility's current Training Manual titled "Surgical Area Training Guide" instructs Housekeeping Staff to damp mop floors, sanitize surgical tables, and sanitize all horizontal surfaces with germicidal solution", but does not include directions on when to change cleaning wipes.