HospitalInspections.org

Based on review of the Association of Perioperative Registered Nurses' (AORN), hospital documents and staff interviews, it was determined the Administrator failed to require that:

1. immediate use sterilization was properly implemented; and

2. a safe environment was maintained in the surgical suite according to nationally recognized standards of practice.

Findings include:

1. AORN Perioperative Standards and Recommended Practices For Inpatient and Ambulatory Settings 2014 Edition; Recommendation VII.a.2. pg. 582 requires: "...Immediate use steam sterilization should not be used as a substitute for sufficient instrument inventory...."

Hospital policy titled "Immediate Use Steam Sterilization (IUSS) Operating Practice" requires: "...IUSS should be kept to a minimum and should be used only in selected clinical situations...."

Review of the hospital "Sterilization Logs for Emergent Sterilization" labeled "Autoclave between operating rooms 1-2" revealed the patella clamp was sterilized in the pre-vac cycle because there was only one (1) clamp on the following dates: 03/11/14 and 03/26/14.

Review of the hospital "Sterilization Logs for Emergent Sterilization" labeled "Autoclave between operating rooms 3-5" revealed the patella clamp was sterilized in the pre-vac cycle because there was only one (1) clamp on the following dates: 02/04/14, 02/11/14 and 03/25/14.

Physician #2 confirmed during an interview conducted on 04/01/14, the patella clamp mentioned is no longer manufactured and the physician does not like to use any other clamp, therefore, the patella clamp is sterilized using the immediate use cycle.

The Director of Nursing confirmed the above findings during the same interview.

2. AORN Perioperative Standards and Recommended Practices For Inpatient and Ambulatory Settings 2014 Edition; Recommendation II.h. pg. 52 requires: "...Fanny packs, backpacks, and brief cases should not be taken into the semi restricted or restricted areas...Pathogens...shown to survive on fabrics and plastics.... "

Observation of Operating Room #6 on 04/01/14 at 1300 hours, revealed a brown colored bag on a metal stand located near the anesthesia machine. The nurses in the room stated the bag belonged to the anesthesiologist.

The Director of Nursing confirmed the location of the brown bag in the restricted area of the operating room during an interview conducted on 04/01/14.