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Based upon observation, staff interview and record review, the hospital failed to ensure performance improvement actions, previously implemented for infection control deficient practice, were sustained. Findings include:

A deficient practice was identified during a complaint survey on 7/31/12, related to failure of all OR (operating room) staff to wear head coverings and masks in a manner that covered all areas appropriately during surgical procedures. During interview, on 7/31/12 at 4:00 PM the Infection Control Nurse stated that per hospital policy and standard of care, PPE (Personal Protective Equipment), including head covers that completely cover all hair, and facial masks, completely covering nose and mouth, should be worn by anyone entering an OR in which an active case is in progress. However, during a tour of the perioperative area on 10/9/12 at 11:20 AM with the VP of Medical Affairs and the Director of Ambulatory Nursing Services, in OR #3 the scrub nurse, circulating nurse and anesthesiologist were all observed wearing PPE (hair coverings) that failed to completely cover their hair and jewelry while actively involved in a surgical procedure. Although the Director for Ambulatory Nursing Services confirmed frequent auditing/surveillance of staff in the operating rooms had been conducted, the deficient practice had not been corrected as of 10/9/12, improvement actions associated with this plan to correct this deficient practice and breach of infection control policy had not been sustained.

Refer to Tag A-0749

During a follow up survey on 12/10/12 and based on observations and staff interviews, the hospital failed to ensure performance improvement actions, previously implemented for infection control deficient practice were sustained. Findings include:

Based on observations, staff interview and record review the hospital failed to assure that infection control measures were implemented in an ongoing and consistent manner to assure sterile technique was adhered to by perioperative staff in accordance with standards of practice. Findings include:

While observing operating room # 4 on 12/10/12 at 10:55 A.M., accompanied by the Director of Ambulatory Nursing Services ( DANS )and another Surveyor, a surgeon broke sterile technique during a tonsillectomy for Patient # 5. After sanitizing his/her hands, the surgeon touched a headlamp light source box and the headlamp device with ungloved hands. The surgeon then turned to the scrub tech who assisted the surgeon to gown and glove. The surgeon then proceeded with the tonsillectomy without rescrubbing or sanitizing his/her hands. A circulating Registered Nurse (RN), an anesthesiologist and a scrub technician were present in the operating room and failed to bring the break in technique to the surgeon's attention or stop the procedure. Immediately after making the observation, the DANS stated that the surgeon should have sanitized his/her hands after touching the light source and headlamp prior to gowning and gloving. The DANS also stated that neither the light source box nor the headlamp was sterile. In a 1:05 P.M. interview on 12/10/12 with the scrub technician and the RN, the Scrub Technician confirmed the break in sterile technique, stating " I missed that". Both the RN and the scrub technician stated that the surgeon should have been notified of the break in technique prior to beginning the procedure. A hospital policy entitled " Maintaining a sterile field", section D, 2, states " Do not be afraid to call attention to a break in technique on the part of the surgeon or any other member of the operating room team". Per review of the operative note dictated by the above surgeon on 12/10/12 at 11:29 A.M., the surgeon stated " a break in sterile technique was done where the headlight was put on after scrub but before the gloves were put on". Although the Director for Ambulatory Nursing Services confirmed frequent auditing/surveillance of staff in the operating rooms had been conducted, the deficient practice had not been corrected as of 12/10/12, improvement actions associated with this plan to correct this deficient practice and breach of infection control policy had not been sustained.

Based on staff interview and record review during a follow-up survey conducted on 12/10/12 the hospital failed to assure that a properly executed anesthesia consent form was obtained for 1 of 4 patients in the applicable sample undergoing a surgical procedure (Patient # 11) Findings include:

Per record review on 12/10/12 at 10:25 A.M., Patient # 11 underwent a Myringotomy on 12/10/12. The anesthesia consent form was not signed, dated or timed by a physician as required. This was confirmed by the Director of Ambulatory Nursing Services at 10:30 A.M. on 12/10/12.

Based on observations, staff interview and record review the hospital failed to assure that infection control measures were implemented in an ongoing and consistent manner to assure sterile technique was adhered to by perioperative staff in accordance with standards of practice. Findings include:

While observing operating room # 4 on 12/10/12 at 10:55 A.M., accompanied by the Director of Ambulatory Nursing Services ( DANS ) and another Surveyor, a surgeon broke sterile technique during a tonsillectomy for Patient # 5. After sanitizing his/her hands, the surgeon touched a headlamp light source box and the headlamp device with ungloved hands. The surgeon then turned to the scrub tech who assisted the surgeon to gown and glove. The surgeon then proceeded with the tonsillectomy without rescrubbing or sanitizing his/her hands after making contact with unsterile surgical equipment. A Registered Nurse (RN) whose role was as the circulating nurse, an anesthesiologist and a scrub technician were present in the operating room and failed to bring the break in technique to the surgeon's attention or stop the procedure. Immediately after making the observation, the DANS stated that the surgeon should have sanitized his/her hands after touching the light source and headlamp prior to gowning and gloving. The DANS also confirmed that neither the light source box nor the headlamp was sterile. Per Interview on 12/10/12 at 1:05 PM the Scrub Technician confirmed the break in sterile technique, stating "I missed that". The RN who was the circulating nurse during the surgical procedure and present during interview agreed with the scrub technician that the surgeon should have been notified of the break in technique prior to beginning the surgical procedure. A hospital policy entitled " Maintaining a sterile field", section D, 2. revised 4/12/12 states " Do not be afraid to call attention to a break in technique on the part of the surgeon or any other member of the operating room team". Per review of the operative note dictated by the above mentioned surgeon on 12/10/12 at 11:29 A.M., the surgeon stated " a break in sterile technique was done where the headlight was put on after scrub but before the gloves were put on". Per interview with the hospital Infection Control Nurse and the Vice President of Medical affairs on 12/10/12 at 11:20 A.M., the Infection Control Nurse confirmed the aforementioned breach in sterile technique.










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