HospitalInspections.org

Based on facility record review and staff interviews the Hospital failed to implement policy for environmental sanitation in the Operating room to minimize patients ' exposure to potentially infectious microorganisms as evidenced by lack of documented evidence to substantiate weekly terminal cleaning for 16 of 17 Operating Rooms on 10/31/2011 to 12/09/2011.

The findings include:


Review of the hospital policy titled " Environmental Sanitation in the Operation room " revealed the policy requires weekly terminal cleaning of the operation rooms. The policy specifies " Operating rooms, in which procedures may be performed, regardless of whether they are used, will be terminally cleaned once during the regular work week by Environmental Service personnel in accordance with the Environmental Department's " Cleaning Surgical Department " policy and procedures. Equipment is cleaned to prevent growth of microorganisms during storage and to prevent subsequent contamination of the surgical practice setting".

Observation in the Operation room Department on 12/13/11 beginning at 9:50 AM revealed seventeen (17) operating rooms where procedure may be performed.
The Hospital environmental services record dated 10/31/11 through 12/09/11 was provided and verified to be the terminal cleaning records of the Operating rooms. Review of the environmental service record provided revealed findings as follows:
On 10/31/11 to 11/05/11 no terminal cleaning record for six (06) operation rooms #s 07, 08, 09, 10, 11 and 14.
On 11/06/11 to 11/12/11 no terminal cleaning record for two (02) operating rooms #s 09 and 17.
On 11/13/11 to 11/19/11 no terminal cleaning record for three (03) Operating rooms #s 09,12 and 16.
On 11/20/11 to 11/26/11 no terminal cleaning record for six (06) operating rooms #s 04, 05, 14, 16, 17 and 18.
On 11/27/11 to 12/03/11 no terminal cleaning record for ten (10) Operating rooms #s 02, 03, 04, 05, 07, 09, 14, 15, 17 and 18.
On 12/04/11 to 12/09/11 no terminal cleaning record for three (03) Operating rooms # 01, 16 and 18.

During interview with the Operating room (OR) manager on 12/13/11 at 9:30 AM, the Manager states she was unaware the terminal cleaning was not documented or that the above operating rooms had not been terminally cleaned at least weekly. The Manager stated about a year ago, an efficiency process review identified multiple processes using the same disinfectant when cleaning operating room surfaces. One standard process was created, the process was broken down step by step to improve efficiency in the operating room; it was not a sanitation issue. Staff education and competency were verified. Upon inquiry, the manager stated there is no written cleaning schedule for the operating rooms. The nurses usually inform environmental service personnel when a OR room is available for terminal cleaning.
In an interview with the Director of Environmental services on 12/13/11 at 9:15 AM, the Director stated the written schedule for terminal cleaning the OR was discontinued , he acknowledged the current record keeping practice is inadequate. The manager stated he is investigating an electronic record keeping process for managing the OR.
In an interview with the Environmental supervisor of the second and third shift on 11/13/11 at approximately 2:30 PM, the manager stated he usually checks the OR environment once or twice a week, speaks to the OR supervisors or nurses and asks if there are any environmental concerns. If the Supervisor is busy he would do a walk through. The terminal cleaning record is kept in the OR central room. The environmental supervisor makes copies of the record from the previous week, scans the record but he does not do a thorough review. The supervisor stated they had terminal cleaning schedules for a year but the previous OR Director discontinued the terminal cleaning schedule citing it was too complicated.
Interview with an environmental Technician who is assigned to perform terminal OR cleaning on 12/13/11 at approximately 2:40 PM, revealed the Technician stated he is frequently assigned to clean the operation rooms. The OR nurse tells him what rooms are to be cleaned. The book/record is kept in the central room. At times the room is locked and the record in not available for him to document the cleaning. If the book is not available, he usually writes it in when he arrived on the next day. Upon inquiry regarding OR room #18 that had not been terminally cleaned since 11/16/11 per the terminal cleaning log, the Technician stated OR room #18's terminal cleaning was done on 12/08/11, but he had forgotten to document it.