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Based on review of facility tour findings, staff interview, policies and procedures and facility documents, it was determined that the facility lacked an effective system to ensure the cleanliness and sanitation of its surgical areas, thereby increasing the risk of surgical site infection to its patients.


Findings were:

Facility policy entitled, Infection Control Policy/Operating Room (OR) Suite, lll.B. Sanitation of Operating Rooms and Equipment, Part 1, last revised 11/2017, directed that "Prior to Start of Day OR Staff will ensure that:
a. Horizontal surfaces of furniture, surgical lights and equipment are damp dusted with the approved hospital germicide prior to opening of sterile supplies.
b. Equipment not stored in the operating room but required for a procedure is cleaned with the hospital approved germicide prior to being taken into the room.
c. A visual inspection of the room and equipment for cleanliness is done before case carts, supplies and instrument sets are brought into the room."

Infection Control Policy entitled Equipment and Environment Cleaning, revised 12/2018, Section lll A. Assigned Responsibilities, revealed that "Maintaining the equipment and the environment in a sanitary manner is a team effort that includes cooperation between department managers, Clinical Engineering and Environmental Services" and assigns responsibility for assuring that environmental cleaning practices comply with "the standards established for the practice setting". The policy references Appendix B entitled, OR Equipment Cleaning Responsibilities, which delineates responsibility for cleaning the various equipment in the OR rooms as follows:
--Anesthesia cart, anesthesia equipment, anesthesia monitor is to be cleaned by Anesthesia Staff;
--Fixed and ceiling mounted equipment, OR furniture, surgical lights, OR specialty equipment is to be cleaned by OR Staff and Environmental Services (EVS); and
--X-Ray Equipment is to be cleaned by OR Radiology Technicians.

The facility's EVS manual entitled Environmental Services Cleaning Procedures Manual, © Sodexo v 17.1, Chapter 8, pgs 288-289 and 294-296 documented that, in order to minimize the exposure risk of healthcare personnel and patients to potentially infectious microorganisms, all horizontal surfaces (furniture, surgical lights, booms and equipment) should be damp dusted with a disinfectant solution prior to the first case of the day and during Terminal Cleaning at the end of each day. Pages 290-291 directed that Surgical/Invasive Areas and Delivery Rooms be cleaned between cases.

Tours of the main OR, located on 6K, the Endoscopy Suite, and the smaller OR suite on 4K (6 rooms, including three designated Gynecology (GYN)/Caesarean Section rooms) were conducted with the OR Executive Director (OOO), the OR Director of PACU, Outpatient Surgery and 4KGYN (JJJJJ), and the Chief Anesthetist on 6/11/19 at 7:45 am and 6/12/19 at 2:10 pm. During the tours, layers of dust, some of which were ropey and floated into the air when touched, were observed on the anesthesia equipment, overhead OR light arms (placed over the patient during surgery to illuminate the surgical site), the anesthesia electrical and gas boom, the PAX wall monitor (integrated radiology viewing system), and horizontal ledges located within OR rooms #4K064, 4KOR5, Cysto Room, OR 5. The OR Executive Director acknowledged the findings as they were observed. NOTE- Upon observation of the findings in the Cysto Room, the OR Executive notified anesthesia and anesthesia technicians arrived and began cleaning the equipment in the Cysto Room.

During inspection of the 4K064, staff present (a staff nurse and the Director of L&D, Mother and Baby and 4A/4B) reported that Operating Room (OR) staff cleaned rooms between each case (contact-surfaces wiped and floors mopped with disinfectant solutions) and that all surfaces were thoroughly cleaned at the end of each day ("terminal cleaning") by environmental services staff. When asked, staff reported that surfaces were not wiped prior to the first case of the day because the rooms were run 24 hours/day and it would be difficult to determine when the first case of the day would be.

Based on review of facility tour findings, staff interview, policies and procedures and facility documents, it was determined that the facility lacked an effective system to ensure the cleanliness and sanitation of its surgical areas, thereby increasing the risk of surgical site infection to its patients.


Findings were:

Facility policy entitled, Infection Control Policy/Operating Room (OR) Suite, lll.B. Sanitation of Operating Rooms and Equipment, Part 1, last revised 11/2017, directed that "Prior to Start of Day OR Staff will ensure that:
a. Horizontal surfaces of furniture, surgical lights and equipment are damp dusted with the approved hospital germicide prior to opening of sterile supplies.
b. Equipment not stored in the operating room but required for a procedure is cleaned with the hospital approved germicide prior to being taken into the room.
c. A visual inspection of the room and equipment for cleanliness is done before case carts, supplies and instrument sets are brought into the room."

Infection Control Policy entitled Equipment and Environment Cleaning, revised 12/2018, Section lll A. Assigned Responsibilities, revealed that "Maintaining the equipment and the environment in a sanitary manner is a team effort that includes cooperation between department managers, Clinical Engineering and Environmental Services" and assigns responsibility for assuring that environmental cleaning practices comply with "the standards established for the practice setting". The policy references Appendix B entitled, OR Equipment Cleaning Responsibilities, which delineates responsibility for cleaning the various equipment in the OR rooms as follows:
--Anesthesia cart, anesthesia equipment, anesthesia monitor is to be cleaned by Anesthesia Staff;
--Fixed and ceiling mounted equipment, OR furniture, surgical lights, OR specialty equipment is to be cleaned by OR Staff and Environmental Services (EVS); and
--X-Ray Equipment is to be cleaned by OR Radiology Technicians.

The facility's EVS manual entitled Environmental Services Cleaning Procedures Manual, © Sodexo v 17.1, Chapter 8, pgs 288-289 and 294-296 documented that, in order to minimize the exposure risk of healthcare personnel and patients to potentially infectious microorganisms, all horizontal surfaces (furniture, surgical lights, booms and equipment) should be damp dusted with a disinfectant solution prior to the first case of the day and during Terminal Cleaning at the end of each day. Pages 290-291 directed that Surgical/Invasive Areas and Delivery Rooms be cleaned between cases.

Tours of the main OR, located on 6K, the Endoscopy Suite, and the smaller OR suite on 4K (6 rooms, including three designated Gynecology (GYN)/Caesarean Section rooms) were conducted with the OR Executive Director (OOO), the OR Director of PACU, Outpatient Surgery and 4KGYN (JJJJJ), and the Chief Anesthetist on 6/11/19 at 7:45 am and 6/12/19 at 2:10 pm. During the tours, layers of dust, some of which were ropey and floated into the air when touched, were observed on the anesthesia equipment, overhead OR light arms (placed over the patient during surgery to illuminate the surgical site), the anesthesia electrical and gas boom, the PAX wall monitor (integrated radiology viewing system), and horizontal ledges located within OR rooms #4K064, 4KOR5, Cysto Room, OR 5. The OR Executive Director acknowledged the findings as they were observed. NOTE- Upon observation of the findings in the Cysto Room, the OR Executive notified anesthesia and anesthesia technicians arrived and began cleaning the equipment in the Cysto Room.

During inspection of the 4K064, staff present (a staff nurse and the Director of L&D, Mother and Baby and 4A/4B) reported that Operating Room (OR) staff cleaned rooms between each case (contact-surfaces wiped and floors mopped with disinfectant solutions) and that all surfaces were thoroughly cleaned at the end of each day ("terminal cleaning") by environmental services staff. When asked, staff reported that surfaces were not wiped prior to the first case of the day because the rooms were run 24 hours/day and it would be difficult to determine when the first case of the day would be.