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Based on interview and record review, the facility failed to analyze two of three sampled incident reports (Patients 2 and 3) for potentially preventable causes, and failed to implement hospital-wide preventive measures when a third incident (Patient 4) was found to have a preventable cause. Refer to A-286. The cumulative effect of these systemic problems resulted in the facility's inability to ensure the provision of quality health care in a safe environment.

Based on interview and record review, the facility's governing body failed to adopt a protocol for collecting its handwashing data, failed to ensure data regarding Clostridium difficile infections (CDI, a bacterium that can cause fatal diarrhea) were collected according to specifications, and failed to ensure CDI rates were computed by nursing unit in order to identify problem-prone areas. The deficient practices limited the accuracy of and follow-up to infection control data, and had the potential to hinder the facility's infection control efforts.

Findings:

1. Review of the facility's Hand Hygiene Observation Tally Sheet dated 7/13-7/17 (no year specified) indicated it included 5 observations on each of 10 nursing units. Each observation had columns labeled "DONE" and "NOT DONE" with either no check marks, one check mark, or two check marks in each column. Several observations had check marks in both the "DONE" and "NOT DONE" columns; some observations had two check marks in one column and a single check mark in the other column. The number of check marks in each column was totaled for the five observations on each unit. No additional information was present explaining how a single observation could be both done and not done, or why in some cases there were two check marks in a column. Comparison of the tally sheet to the facility's "Weekly HHO [hand hygiene observations] Data by Unit" dated 7/15 and 8/15 indicated the total of "DONE" and "NOT DONE" check marks on each unit was entered from the tally sheet, and the number of "DONE" check marks was divided by the total number of check marks to calculate the percent done.

In an interview on 8/18/15 at 2:46 p.m., the Infection Control Manager (ICM) stated the handwashing observations were made by unlicensed observers, there was no protocol for them to follow, and the methods varied from observer to observer.

Review of the minutes of the Board of Directors of Kaiser Foundation Hospitals dated 9/11/14, 10/28/14, 12/1/14-12/3/14, 3/10/15-3/12/15, 5/5/15-5/7/15 indicated there was no mention of handwashing. Review of the minutes of the Quality and Health Improvement Committee of the Board of Directors of Kaiser Foundation Hospitals (QHIC) dated 9/10/14, 10/23/14, 10/27/14, 12/1/14, 12/3/14, 3/11/15, 4/22/15 as well as draft QHIC minutes for a meeting on 6/24/15 all indicated there was no mention of handwashing. Review of the Northern California Region Quality Oversight Committee (QOC) minutes dated 9/10/14, 10/8/14, 12/2/14, 12/10/14, 1/14/15, 2/11/15, 3/11/15, 4/8/15, 5/13/15, 6/10/15, as well as draft minutes dated 8/12/15 all indicated there was no mention of handwashing. Review of the QOC minutes dated 7/8/15 indicated the committee approved the facility's annual report to QHIC which in turn indicated a next step to controlling CDI was to "Reinforce vital behaviors for hand hygiene". No detail was present, however, regarding how the facility would collect its handwashing data.

Review of the facility's Quality & Utilization Executive Oversight Committee (QUEOC) minutes dated 4/8/15 indicated, "Hand Hygiene... Our local secret shopper program, though limited, is still in place. We conduct 5 observations in selected units every few weeks. During rounds, the leadership teams observe hand hygiene and conduct immediate coaching when necessary." No further detail was present regarding how the observations would be conducted. Review of the QUEOC minutes dated 5/13/15 indicated, "...we continue to use our local secret shopper program and leadership rounding to make hand hygiene observations and provide feedback... we need to commit more resources to local hand hygiene education and data collection." No additional detail was present specifying the details of how or how often the hand hygiene data would be collected.

2. Review of the facility's Infection Prevention Services presentation to QUEOC dated 8/12/15 indicated effective 6/1/15 the facility had adopted a policy to test the first loose or liquid stool for CDI. Review of an undated line listing of CDI cases indicated Patient 1 had loose stool on 8/15/15 at 10:59 p.m., but no specimen was sent for CDI until 8/17/15 at 8:24 a.m. Review of an e-mail dated 8/17/15 at 6:41 a.m. indicated the facility had begun generating a daily listing of all patients with documented loose stool 2.5 hours prior to the survey, and there were 17 patients who had loose stool on 8/16/15 but had no CDI testing found.

In an interview on 8/18/15 at 12:57 p.m., the ICM stated the facility drilled down on positive CDI cases, and identified opportunities for education, but did not keep track of the time between the first loose stool and CDI testing.

3. Review of the facility's Infection Prevention Services presentation to QUEOC dated 8/12/15 indicated it included hospital-wide CDI rates. No rates by nursing unit were present. Review of a line listing of positive CDI lab results dated 8/18/15 indicated it specified on which unit each positive specimen had been collected but did not compute CDI rates by nursing unit. Review of an undated line listing containing analysis of CDI cases indicated it identified each nursing unit on which each CDI case had been located, but did not calculate CDI rates by nursing unit. In an interview on 8/18/15 at approximately 12:55 p.m., the ICM stated she did not like to calculate rates by nursing unit based on the location of specimen collection because she was concerned the results would deter the units from sending specimens. The ICM stated she did not calculate CDI rates by nursing unit, but identified them by color on her line listing and did terminal cleaning and education in the affected units.

Based on interview and record review, the facility failed to analyze two of three sampled incident reports (Patients 2 and 3) for potentially preventable causes, and failed to implement hospital-wide preventive measures when a third incident (Patient 4) was found to have a preventable cause. The deficient practice eliminated opportunities to prevent adverse events.

Findings:

Review of the facility's policy, "RESPONSIBLE REPORTING OF MEDICAL ERRORS, ADVERSE EVENTS, AND NEAR MISSES" (revised 11/12) indicated, "Medical errors, adverse events, and near misses will be analyzed through a multi-disciplinary process... with the objective to identify opportunities to change current procedures and systems to reduce errors."

1. Review of a line listing of incident reports dated 8/14 indicated Patient 2 fell and hit his head on 8/25/14. No indication was present whether or not the facility had identified preventable causes of the fall or taken any follow-up action. Review of excerpts of Patient 2's medical record provided by the facility indicated he had abnormal coagulation studies and platelet counts (lab results indicating an increased risk of bleeding) so the doctor ordered a CT (computed tomography) scan of Patient 2's head which was normal. No indications were present in the medical record excerpts regarding whether the facility had identified a preventable cause of the fall or taken follow-up action.

In an interview on 8/20/15 at 2:49 p.m., the Clinical Adult Services Director (CASD) stated Patient 2 was not injured so the case was closed and no analysis for preventable causes of Patient 2's fall had been done. In an interview on 8/20/15 at 3:37 p.m., the CASD stated falls in 2014 were only analyzed if there had been moderate injury but "now each fall has an in-depth assessment." The CASD stated she would return with evidence to support her statement that the facility had changed its follow-up to falls. At the conclusion of the survey on 8/21/15 the CASD had not provided additional documentation.

2. Review of a line listing of incident reports dated 8/14 indicated two suture needles were missing at the end of Patient 3's surgery on 8/18/14 and the surgeon declined to perform an x-ray because the needles were too small to be seen on x-ray. Review of excerpts of Patient 3's medical record presented by the facility indicated the closing and final counts both noted 2 missing needles and that the surgeon declined to perform an x-ray. No notations were present describing what other efforts had been taken to locate the missing needles or if they were ultimately found.

In an interview on 8/20/15 at 12:58 p.m., the Perioperative Services Director (PSD) stated the needles in question were less than 10 mm (millimeters) long, that the facility's policy did not require an x-ray for missing needles that small, and that the incident report was closed without further action since not taking an x-ray was according to the facility's policy. The PSD stated she knew that other efforts had been taken to locate the missing needles because that was the facility's policy, but that she did not have documentation of what else had been done. In an interview on 8/21/15 at approximately 11:00 a.m., the PSD stated the facility's policy was based on AORN (Association of periOperative Registered Nurses Guidelines).

Review of the facility's policy, "Prevention of Retained Foreign Items" (revised 6/14) indicated, "Incorrect Count... The Surgeon will immediately explore the wound... The RN [registered nurse] Circulator and Scrub Person will search drapes, trash & linen receptacles & OR suite... An x-ray is taken when the needle count is incorrect, only considered exception is if the needle is <10 mm or smaller."

Review of the AORN Guideline for Prevention of Retained Surgical Items (effective 7/15/10) indicated, "Even small needles left in the patient may cause injury. Needles less than 10 mm, however, may be difficult to see radiographically when retention is suspected... Standardized measures for investigation and reconciliation of count discrepancies should be taken during the closing count and before the end of surgery. When a discrepancy in the count(s) is identified, the surgical team should carry out steps to locate the missing item. Rapid intervention when an incorrect count is identified may reduce procedural time. Assessing the surgical site before closure decreases the time a patient remains under anesthesia and the risk of extended surgical time if the wound has to be reopened. Early identification of RSIs decreases the likelihood that a surgical wound would need to be reopened and reduces or eliminates the need for radiographs to detect an RSI... A count discrepancy is a potential RSI incident... The RN circulator should visually inspect the area surrounding the surgical field, including the floor, kick buckets, and linen and trash receptacles in an effort to locate the missing surgical item... The scrub person should assist with visual inspection of the area surrounding the sterile field when there is a count discrepancy... When a discrepancy in the count is identified, the surgeon(s) should suspend closure of the wound if the patient's condition permits, perform a methodical wound examination by actively looking for the missing item, cooperate in the attainment of radiographs or other modalities as indicated to find the missing item, and remain in the OR until the item is found or it is determined with certainty not to be in the patient... If a missing item is not recovered, intraoperative imaging should be performed to rule out a retained item before final closure of the wound if the patient's condition permits... A radiograph to locate a possible retained item may be waived under certain circumstances as defined in the health care organization's policy and procedure. There are situations when it may be medically appropriate for the surgeon to determine it is not in the individual patient's best interest to perform an intraoperative radiograph to locate a potential RSI... Health care organizations should define needle size limit criteria where radiographs will effectively assist in identifying retained needles. There is no definitive evidence to indicate how effective radiographs are in detecting small suture needles. Recent studies have demonstrated that needles 10 mm and smaller may not be consistently visible on a radiograph. There is conflicting evidence regarding the visibility of 10-mm to 13-mm needles on radiographs."

3. Review of the facility's Pharmacy and Therapeutics (P&T) Committee minutes dated 11/4/14 indicated a preventable adverse drug event (ADE) had occurred in the 2nd quarter of 2014. The committee decided the preventable ADE should be submitted to the hospital's incident reporting system. No additional detail was present regarding the nature of the preventable ADE or the follow-up that the facility would take in response.

Review of the facility's Quality & Utilization Executive Oversight Committee (QUEOC) minutes dated 12/10/14 indicated there had been a preventable ADE in the 2nd quarter of 2014. The minutes did not provide further detail regarding the nature of the incident or what follow-up had been taken.

In an interview and record review on 8/19/15 at 3:02 p.m., the Inpatient Pharmacy Director (IPD) stated the preventable ADE involved Patient 4, who had tonic-clonic movements during a time when labs showed levels of one of her anti-seizure medications (phenytoin) had been getting lower. He stated perhaps increased monitoring could have prevented the event. He stated the event had been discussed at P&T and QUEOC and the committees felt no follow-up was needed. Review of a redacted line listing of ADE's dated 8/19/15 provided by the IPD indicated Patient 4 was an inpatient who had a "spastic episode with outstretched arm and jerking movements of her head. Unclear if this was a true seizure. Adjustment of phenytoin dosing was made... Phenytoin level measured subtherapeutic at 4 mcg/I (micrograms per liter) on 5/26/14. Phenytoin levels trended down very quickly from 22 mcg/l on 4/21/14 to 9 mcg/l on 5/3/14. A lab should have been redrawn prior to 5/26/14 to see if the levels were still decreasing, or whether a constant level was reached."

Based on observation, interview, and record review, the hospital failed to implement, and maintain an active hospital-wide program for the prevention and control of infections and communicable diseases; and failed to provide a sanitary environment to avoid sources and transmission of infections as evidenced by:

1. One facility staff (Operating Room - OR Staff 1) retrieved a supply that fell inside a used sharps container and put the contaminated supply with other clean supplies available for use in the operating room (OR). The deficient practice put the staff at risk of sharps injury and cross-contamination in the operating room.

2. Sterile field was not maintained and monitored constantly when distance between unsterile area and sterile table was less than 12 inches, a facility staff was leaning on the sterile table, and the back of a facility staff's surgical gown touched the sterile table. The deficient practice had the potential for cross-contamination.

3. One facility staff (OR Staff 5) did not perform hand hygiene after touching contaminated item in the operating room, and one staff (Registered Nurse - RN 1) did not perform hand hygiene after removing gloves and putting on a new sterile gloves and gown during a PICC (Peripherally Inserted Central Catheter - a sterile procedure to insert a catheter on a patient's vein for medications and/ or fluid administration) procedure. The deficient practices had the potential for cross-contamination.

4. Three facility staff (OR 6, OR 7 and Sterile Processing Technician - SPT) did not wear proper PPE (personal protective equipment) while performing tasks which required PPE to prevent cross-contamination and prevent staff from contact with contaminated items and body fluids.

5. One facility staff (RN 3) did not clean blood glucose meter in between patient's use, creating cross-contamination.

6. The cleaning of operating room in between surgery cases were not done according to the disinfectant manufacturer's recommendation for contact time (time from when the equipment or surface got wet with disinfectant to kill the microorganisms, up to the time the disinfectant dried up) of 5 minutes to kill hepatitis B and C (bloodborne pathogens that could be transmitted from one patient to another). The EVS (Environmental Services) staff (Environmental Services Staff - EVS 1, 2 and 3) used cleaning technique of wiping from bottom to top in the operating room which created cross-contamination.

7. Four of six facility staff (OR Staff 1, RN 1, EVS 1 and EVS 4) did not have annual Infection Control training. This had the potential for facility staff not to have knowledge of new disinfectant product's instructions for use and update on facility's Infection Control policies and procedures.

The cumulative effect of these systemic problems would compromise the health and safety of all patients in the facility.

Findings:

1. During an observation and interview on 8/18/15 at 11:20 AM, Perioperative Director stated OR 7 had a bloody case and we should wait to have the bloody linens and trash to be taken out of the room before we enter and observe the in-between cases cleaning. While waiting outside OR 7, OR Staff 1 came in the room holding multiple packaged supplies in his hands. While OR Staff 1 was restocking supplies of a cell saver machine (a machine used to suction, wash, and filter blood from a patient during surgery so the blood could be given back to the patient's body instead of throwing the blood away), a packaged supply fell inside the sharps container near the cell saver machine. OR Staff 1 immediately put his whole hand and arm inside the sharps container and retrieved the packaged supply. OR Staff 1 put the retrieved supply together with other supplies on top of the cell saver that were available for use. The Perioperative Director who was also observing outside OR 7, stated, "He (OR Staff 1) should not have done that. I hope the sharps container was empty."

On continued observation on 8/18/15 at 11:20 AM, Perioperative Director and the surveyor entered OR 7 to observe the cleaning procedures. The Perioperative Director verified the sharps container where OR Staff 1 retrieved a supply was 1/4 full and had bloody sharps and other unidentified bloody items.

During an interview on 8/18/15 at 11:30 AM, OR Staff 1 stated, "I realized what I did was wrong. I should not have done that. The supply that fell inside the sharps container was a suction line."

During an interview on 8/18/15 at 11:35 AM, Perioperative Director stated the supply that fell inside the sharps container was contaminated and might have been punctured so it will be thrown away. When asked about the other supplies that touched the contaminated supply, Perioperative Director stated that as long as the packaging was not punctured and intact, the supplies can be used.

Review of the facility's Bloodborne Pathogens Exposure Control Program policy and procedure (P&P), dated 8/11, indicated, "This Exposure Control Plan is developed pursuant to the requirements of the Cal-OSHA bloodborne pathogens regulations - 8 CCR 5193... the purpose of the plans is to provide guidelines to assist in protecting our health care workers against occupational transmission of viral hepatitis B (HBV), Human Immunodeficiency Virus (HIV), Hepatitis C and other bloodborne diseases... (page 18 of 63)... 9) The contents of the sharp container must not be accessed unless properly reprocessed or decontaminated. Never place fingers into opening of sharps container. 10) Sharps container must not be opened, emptied or in any manner which could expose health care workers to the risk of sharps injury.

Review of the facility's Cleaning, Disinfection and Sterilization P&P, revised 6/13, indicated, "5.5 Dirty/contaminated equipment will be separated from equipment that is clean or sterile... 5.7 Sterile supplies will be stored in a safe clean place."

2. During an observation and interview on 8/18/15 at 10:30 AM at OR 5, three facility staff (OR Staff 2, 3 and 4) had their backs against a sterile table with multiple sterile instruments. OR Manager stated the current surgery was a minimal invasive procedure but had to be done in OR just in case the patient needed surgery. OR Manager stated a sterile table had to be prepared in case of complications like cardiac arrest. During the observation, OR Staff 2 put his hand down and gently leaned on the sterile table behind him with his sterile gloved hand. OR Staff 2's back of surgical gown touched the side of the sterile table. Perioperative Director who was also observing stated, "OR Staff 2 should not have leaned on the sterile table. The back of the surgical gown should not be touching the sterile field." When asked what should be the distance between the unsterile (back of OR staff) and sterile table, Perioperative Director stated, the facility was following the AORN (Association of Perioperative Registered Nurses) guidelines of "12 inches". The perioperative Director verified the distance of the sterile table and the unsterile area did not look like it was 12 inches. Perioperative Director stated the OR was challenged with space because of the number of equipment inside the room, the number of staff and the size of sterile table that needed to be prepared.

Review of the facility's Aseptic Technique P&P, dated 1/09, indicated, "4. A sterile field is maintained and monitored constantly... c. The application of the principles of sterile technique depends on the surgical team's vigilance to breaches in sterility. Event related sources of contamination of a sterile field include, but is not limited to: 1) Personnel... 5. All personnel moving within or around the sterile field will do so in a manner that maintains the sterile field... c. Scrub personnel will keep their arms and hands within the sterile field at all times. They should avoid changing levels and be seated only when the entire surgical procedure will be performed at that level."

Review of the AORN 2015 Perioperative Standards and Recommended Practices, Guidelines for Sterile Technique state that sterile fields should be constantly monitored ...unscrubbed personnel should face the sterile field on approach, should not walk between sterile fields or scrubbed persons, and should maintain a distance of at least 12 inches from the sterile field and scrubbed persons at all times.

3. a. During an observation and interview on 8/18/15 at 10:00 AM, OR Staff 5 was assisting the nurse in cleaning the patient's surgical site with betadine (skin disinfectant), when a sterile towel fell on the floor. OR Staff 5 picked the towel and put it in the linen hamper. OR Staff 5 did not remove his gloves and did not do hand hygiene before he took another sterile towel to hold the patient's foot while the nurse was cleaning the surgical site. OR Manager stated, "He (OR Staff 5) should have changed his gloves and disinfect hands after picking something from the floor."

3. b. During an observation on 8/18/15 at 1:25 PM, RN 1 was preparing to do a PICC line insertion. RN 1 put on sterile gloves and prepared the sterile supplies on the patient bedside table. After RN 1 had prepared all the sterile items, she removed the gloves, and without doing hand hygiene, RN 1 put on a sterile gown and put on sterile gloves.

During an interview on 8/18/15 at 2:35 PM, PICC Team Nurse Leader who was also present during the observation of PICC line insertion, stated, "RN 1 should have done hand hygiene before putting on sterile gown and gloves."

Review of the facility's Hand Hygiene P&P, revised 5/11, indicated, "3.1 The KPNC (Kaiser Permanente Northern California) region follows the Word Health Organization (WHO) 5 Moments of Hand Hygiene. The 5 moments are: (a) Before touching a patient, (b) Before clean/aseptic procedures, (c) After body fluid exposure/risk, (d) After touching a patient, and (e) After touching patient surroundings."

The World Health Organization Guidelines for Hand Hygiene in Health Care: A Summary (2009) states to perform hand hygiene: a) before and after touching the patient b) before handling an invasive device for patient care, regardless of whether or not gloves are used c) after contact with body fluids or excretions, mucous membranes, non-intact skin, or wound dressings d) if moving from a contaminated body site to another body site during care of the same patient e) after contact with inanimate surfaces and objects (including medical equipment) in the immediate vicinity of the patient f) after removing sterile or non-sterile gloves

4. a. During an observation and interview on 8/18/15 at 10:00 AM, OR Staff 6 was preparing a sterile table. OR staff 6's hair was exposed on the back of his head and his facial hair was partially covered with a facial mask. OR Manager verified OR Staff 6 was not wearing proper PPE while preparing a sterile table. The OR Manager was asked who should check if OR staff was wearing proper PPE, OR Manger stated any of the surgical team in the room could say to the staff, "You're not wearing proper PPE."

4b. During an observation and interview on 8/18/15 at 10:45 AM, OR Staff 7 was preparing a sterile table for the next case. OR Staff 7 was wearing a short sleeve scrub suit. The Perioperative Director stated OR staff could wear short sleeve scrubs if they are preparing sterile table as long as they were not reaching into the sterile field.

Review of the facility's Surgical Attire P&P, revised 10/12, indicated, "1. All persons who enter the semi-restricted or restricted area of the surgical suite must be in surgical attire...G. A warm up jacket is encouraged to reduce cellular skin sloughing... 2. All possible head and facial hair, including sideburns and neckline, must be covered when entering the semi-restricted and restricted areas of the surgical suite."

4. c. During an observation on 8/19/15 at 11:30 AM, SPT (Sterile Processing Technician) was wearing a gown, mask and chin-length face shield while he was cleaning a used endoscope (a flexible instrument used to examine the interior of a hollow organ or cavity of the body). SPT soaked the endoscope in a cleaning solution and started brushing the internal parts of the endoscope. SPT touched his mask three times with the gloved hand he was using to clean the dirty endoscope.

During an interview on 8/19/15 at 11:35 AM, Scope Processing Coordinator stated, cleaning of the used endoscope was a dirty procedure and SPT should not be touching his facial mask.

Review of the facility's Bloodborne Pathogens Exposure Control Program policy and procedure (P&P), dated 8/11, indicated, "This Exposure Control Plan is developed pursuant to the requirements of the Cal-OSHA bloodborne pathogens regulations - 8 CCR 5193... The purpose of the plan is to provide guidelines to assist in protecting our health care workers against occupational transmission of viral Hepatitis B (HBV), Human Immunodeficiency Virus (HIV), Hepatitis C and other bloodbrone diseases... (page 29 of 63)... 4. Face shields / Masks/ Eye protection/ Other - Masks in combination with eye protection such as goggles or glasses or chin-length face shield must be worn to prevent splashes, sprays, splatter, or droplets of blood or infectious materials if there is a potential for eye, nose, or mouth exposure." The policy did not indicate the mask must be replaced when contaminated or becomes wet.

5. During an observation and interview on 8/20/15 at 11:20 AM, RN 3 brought the blood glucose meter and strips container in the patient's room. RN 3 took a strip from the container and inserted it on the blood glucose meter and brought the meter to the patient sitting on a chair. After she collected a small amount of blood, she told the patient the blood sugar reading. RN 3 took the blood glucose meter to the docking area in the nursing station without cleaning or disinfecting the meter. RN 3 put back the strip container in the blood glucose meter case without cleaning or disinfecting the strip container. When asked how often the blood glucose meter and the strip container are cleaned, RN 3 stated it was cleaned "at least once a day." When asked how many blood sugar she usually check, RN 3 stated she usually check blood sugar of 2-3 patients.

Review of the blood glucose meter manufacturer's instructions for use, indicated, "Cleaning: Since meter will always be used at bedside, clean after every use in pt (patient) room with 10% bleach followed by damp cloth with water."

6. a. During an observation and interview on 8/18/15 at 11:15 AM, three EVS staff were cleaning OR 8 for the next surgery case with the use of rags soaked in Oxycide solution. EVS 3 wiped the operating table pads and armrest pads, and it was observed the disinfectant dried up in three (3) minutes which was verified by the Perioperative Director. EVS 1 wiped all the equipment and it was observed that the disinfectant dried up in 3 minutes on the equipment surfaces. EVS 3 cleaned the rolling chairs and intravenous (IV) poles by wiping it from top to bottom. EVS 3 used the same rag she used for cleaning the bottom parts of the chair and IV pole to clean the top of a small table. The Perioperative Director stated cleaning should be from top to bottom and change the rag if needed. The Perioperative Director was informed EVS 1 and 3 used one rag each to clean the entire OR 8 and used rag from bottom to top creating cross-contamination. EVS 2 was mopping the floor while EVS 1 and 3 were moving around the room to clean the equipment. The floor that EVS 2 have mopped and cleaned were stepped on by EVS 1 and 3. The Perioperative Director stated the mopping of the floor should be done last.

During an observation and interview on 8/18/15 at 11:35 AM, two EVS staff were cleaning OR 3 for the next surgery case. EVS 3 wiped the pillows and put it on top of a clean table. EVS 2 came in the room and cleaned the operating table pads and it was observed the disinfectant dried up in 3 minutes, verified by Perioperative Director. EVS 2 removed the uncleaned armrest and put it on table with clean pillows. EVS 2 was not aware the pillows have already been cleaned by EVS 3. EVS 2 finished cleaning the operating table but have forgotten the other armrest he put on the table with pillows. EVS 3 cleaned the rolling chairs and IV poles from top to bottom and used the same rag to clean a small table. EVS 2 and 3 used one rag each to clean the entire room and used the rags from cleaning bottom to top creating cross- contamination. EVS 2 mopped the floor after all the equipment were cleaned. EVS 2 and 3 went out of the room and told the Perioperative Director and the surveyor that they finished cleaning the room. The surveyor informed EVS 2 and 3 the armrest that was put on the table with pillows was not cleaned, and there was no communication between them which items or equipment have been cleaned and which were not cleaned. The Perioperative Director stated EVS staff should communicate with each other when cleaning the operating room so they would not miss anything.

During an interview on 8/18/15 at 1:10 PM, EVS Manager stated cleaning of the operating room should be from top to bottom and floor mopping should be done last. EVS Manager stated there was no P&P on how many times the rag should be used but it should be changed when used in wiping bottom parts of equipments. When asked if there was an audit done regarding the disinfectant manufacturer's instruction for use for contact time, EVS Manager stated, the facility started using the Oxycide in April 2015 but have not done audits on contact time of 3 and 5 minutes.

During an interview on 8/20/15 at 10:25 AM, Infection Control Manager stated the audits of contact time should be done by EVS.

Review of the Oxycide Daily Disinfectant Cleaner information sheet indicated a lists of bacteria, bacterial endospores like Clostridium difficile (bacteria which causes diarrhea and life-threatening inflammation of the bowels), viruses and yeast were killed within "3 minutes contact time". The information sheet indicated, "Oxycide is effective against a broad spectrum of organisms when used as directed:.. 5 MINUTE CONTACT TIME Viruses Hepatitis B, Hepatitis C."

Review of the Cleaning Procedure: OR and L&D (Labor and Delivery) Room Terminal P&P, dated 5/13, indicated, "General Instructions 3. Cleaning/disinfectant products must be used according to the manufacturer's instructions regarding use and required contact time... 4. All items that have in contact with he patient or the surgical field area should be considered contaminated... Procedure - Daily... 5. Operating Rooms (Clean form top to bottom)."

According to the AORN, Perioperative Standards and Recommended Practices, Recommended Practices for Environmental Cleaning (2015), Recommendation II: The patient should be provided with a clean, safe environment: Disinfectants should be applied and reap-plied as needed, per manufacturers ' instructions, for the dwell time required to kill the targeted microorganism (e.g., Clostridium difficile).

According to the CDC / HICPAC, Guidelines for Environmental Infection Control in Health-Care Facilities (2011), Cleaning and Disinfecting Strategies for Environmental Surfaces in Patient-Care Areas: Cleaning and Disinfecting Strategies for Environmental Surfaces in Patient-Care Areas: Select EPA-registered disinfectants ...and use them in accordance with the manufacturer's instructions.

According to the AORN, Perioperative Standards and Recommended Practices, Recommended Practices for Environmental Cleaning (2015), Standard VI states that cleaning and disinfection activities should be performed in a methodical pattern that limits the transmission of microorganisms. Cleaning an area in a methodical pattern establishes a routine for cleaning so that items are not missed during the cleaning process. The method for cleaning may limit the transmission of microorganisms to reduce the risk of cross contamination of environmental surfaces.1. Cleaning should progress from clean to dirty areas. 2. Cleaning should progress from top to bottom areas. During cleaning of top areas, dust, debris, and contaminated cleaning solutions may contaminate bottom areas. If bottom areas are cleaned first, these areas could potentially be recontaminated with debris from the top areas. 3. Clockwise or counter-clockwise cleaning may be performed when used in conjunction with clean-to-dirty and top-to-bottom methods.

6. b. During an observation on 8/18/15 at 2:40 PM, EVS 4 was cleaning the bathroom of Room 4324 on the inpatient unit. EVS 4 wiped the door knob, paper towel dispenser and the sink. EVS 4 went to the patient bed and with the same rag she used in the bathroom, wiped the suction canister and the headboard panel with oxygen connection.

Review of the Cleaning Procedure: Patient Room P&P, dated 5/13 indicated, "The Environmental Services Department shall provide the Medical Center with effective, safe and sanitary cleaning services to minimize health care workers' and patients' exposure to potentially infectious microorganisms..." The policy and procedure did not indicate how the cleaning should be done to avoid cross-contamination like disposing the rag used in cleaning the bathroom.

7. During personnel record review on 8/19/15 and 8/20/15, The Director of Quality verified there were four of six facility staff (OR Staff 1, RN 1, EVS 1 and EVS 4) did not have an annual Infection Control training.

Review of the facility's Environmental Health and Safety Training P&P, revised 11/12, indicated, "C. Annual Refresher Safety Training - Annual safety training (including Infection Control training) will be completed on-line through KP Learn (or equivalent classroom training) during the second quarter of each year."