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Based on on clinical record review, review of hospital policies and procedures, and interviews, the facility failed to ensure 1 of 36 sampled patients (28) was free of restraints when there were no comprehensive, behavior-specific, consistent, and ongoing assessments for the use of wrist restraints on Patient 28. This failure infringed on Patient 28's right to be free from inappropriate use physical restraints.

Findings:

Patient 28 was admitted on 10/17/12 with diagnoses including severe respiratory failure. While in the emergency room, Patient 28 had a breathing tube placed through her mouth and into her trachea to help her breathe and multiple intravenous (vein or artery) lines inserted. At approximately 7:30 p.m., Patient 28 was transferred to the intensive care unit after being stabilized.

A review of Patient 28's clinical record disclosed a preprinted order set dated 10/17/12 at 9 p.m. and signed by a physician, titled, "Medical (Non-Violent) Restraint Orders." The order set had check marks beside the following printed indicators:
- "Reason to Restraint: Prevent unplanned discontinuance of medical device or therapy - other alternatives not effective
-Early Release Criteria: Cooperative with care
-Type of Restrain: soft wrist restraints"

Further review of Patient 28's clinical record disclosed a form titled, "Medical Restraints Documentation." The printed form indicated it was used for assessment of patients and necessitated that a registered nurse (RN) check applicable indicators, which included following:
- "Active Physician Order present"- was not checked.
- "Interventions attempted prior to applying restraints: Pain medication; Reduce noise/activity"
There was no patient name or date on the form.

An area on the form, "Implementation (initial boxes), had areas of assessment which included, "RN evaluation of ongoing need for continued restraint," Q2H (every 2 hours). Patient 28's RN had initialed the Q2H boxes from 7 p.m. through 2 a.m. The boxes from 3 a.m. through 6 a.m. were blank of any type of assessment, nor were there any RN's initials. There were no notations in the "Comments" section of the form.

Another Medical Restraints Documentation form was reviewed. Patient 28's name was stamped on the form and dated 10/18/12. The form had no indicators for the following:
- there an "Active Physician Order present" for restraints,
- "Reason to Restrain,
- Interventions attempted prior to applying restrains,
- Type of restraint:"
The "Implementation" boxes for assessments were also blank and un-initialed by an RN. The form indicated the restraints were discontinued at 10 a.m. because Patient 28 was "Cooperative with care" and "Therapy/medical device was discontinued." A handwritten "Comment" at 10 a.m., noted "restraints (discontinued after) extubation."

A review of nurse's "Narrative Note" disclosed the following:
- on 10/17/12 there were no entries;
- on 10/18/12 at 1:30 a.m. there was an entry which indicated Patient 28 opened her eyes in response to "voice";
- on 10/18/12 at 6:45 a.m. there was an entry that noted Patient 28 was "very agitated"; there was no description of how Patient 28's agitation manifested nor were there any comments related to her wrist restraints.

The hospital's policy and procedure (P&P), titled, "Restraints, Medical/Non Violent (Adult and Pediatric)" was reviewed. The policy statement established the following:
- "Restraints shall be used only where other, less restrictive alternatives are not sufficient to protect patients or others from injury;
- Before restraining a patient, there needs to be a clear rationale for the use of restraints, and all other solutions to the problem must be considered;
- All patients will have an assessment performed by an RN to determine the safety and protective needs of the patient prior to the application of the restraint."

The hospital's P&P also explained that an "initial assessment of a patient in restraints must be done by an RN within 15 minutes of application:
a. to evaluate the appropriate use of restraints.
b. To ensure that restrains are properly applied.
c. to ensure that there is no respiratory or circulatory compromise.
d. To determine patient's response to restraints."
The P&P explained that "Nursing Interventions" while a patient was restrained should include:
- "Release and/or adjust position of all restraints;
- Perform passive or active (range of motion) on the released extremities ...."

Review of the clinical record disclosed no documentation of the following:
- Patient 28's specific need for wrist restraints; what behaviors or actions necessitated initial and ongoing need for wrist restraints,
- specifically when the wrist restraints were applied to Patient 28;
- that an initial assessment was performed by an RN prior to or within 15 minutes of application of the restraints;
- that a release of or adjustment to the restraints after application had been done; nor,
- that any type of range of motion on Patient 28's arms and/or wrists was performed to keep her circulation to her arms and hands intact.

During concurrent interviews on 12/28/12 at approximately 1230 p.m. with a Clinical Nurse Specialist (CNS) and Nurse Manager (NM) 2, they both agreed there was no documentation related to a specific reason for Patient 28 to be restrained nor when the wrist restraints were applied. The CNS and NM 2 also agreed that the ongoing assessment for the need for continuing the restraints was inadequate.

Based on interview and document review, the hospital failed to assure restraint orders were written in compliance with hospital standards for 2 of 36 sampled patients (Patients 16, 19).

Findings:

During a 12/27/12 medical record review of Patient 16's "Medical (Non-Violent) Restraint Orders," it was noted that the 7:30 a.m., 12/25/12 order sheet did not specify "Type of Restraint" to be used. Patient 16's 12/25/12 "Medical Restraints Documentation" form reflected the use of soft wrist restraints on both arms from 7 a.m., 12/25/12 to 7 a.m., 12/26/12. In a 4:25 p.m., 12/27/12 interview, Nursing Director (ND) 1 confirmed the type of restraint had not been indicated in the 12/25/12 order.

During a 12/28/12 medical record review of Patient 19's "Medical (Non-Violent) Restraint Orders," an 8:15 a.m., 12/23/12 order for "Side rails x 4 [all 4 of bed's siderails to be kept raised]" was noted. No other type of restraint was ordered.

Patient 19's 12/23/12 "Medical Restraints Documentation" form reflected the use of soft wrist restraints on both arms from 7 a.m., 12/23/12 to 7 a.m., 12/24/12. In a 7:34 a.m., 12/28/12 interview, the Coordinator Auality/Risk Management (CQRM) stated, "The order is incomplete. Technically there is no order for the wrist restraints."

Review of the hospital's "Patient Care Standard: Restraints, Medical/Non-Violent (Adult and Pediatric," revised June, 2012 revealed, "Obtain physician order for restraint. This order must include the reason for the restraint, the type of restraint to be used...."

Based on observation, interview, and policy review the facility staff failed to clean a glucometer (machine used to test blood sugar levels) between patient use. This was found for 1 of 36 samples patients (21). This created a potential infection control risk for the patients.

The findings.

On 12/26/12 at 9 a.m. Licensed Nurse 2 used a hand held glucometer to test a drop of blood obtained from Patient 21. The nurse used a small lancet to prick the patient's finger. The drop of blood was placed on a test strip which had been inserted into the glucometer. After obtaining the blood glucose reading, the nurse changed her gloves and washed her hands. She then picked up the glucometer and walked to the nursing station and placed it into a docking station. She stated the results would be transmitted to the laboratory and the glucometer was then available for use for another patient. She stated that glucometer was thoroughly clean each shift.

Nurse Manager 1 provided a copy of the facility policy regarding glucometer use entitled "Glucose INFORM Meter Competency." Review of the policy found that the top line on the first page read, " CLEAN the METER after each patient use! Careful cleaning protects your patients , the meter, and you." Nurse Manager #1 stated that it was the policy for the nurse to clean the glucometer after use.

Based on interview, and document review, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of 1 of 36 patients (36) when a nutrition consult was not entered into the hospital computer system. This failure had the potential of compromising the patients care.

Findings:

On 12/28/12 at 9:17 a.m., Patient 36's medical record was reviewed. Patient 36 was admitted to the hospital on 12/17/12 with a right hip fracture after a fall. Review of the Patient Profile Adult dated 12/17/12, indicated under the Nutrition Screen that they were "unable to assess". Review of the 24 hour Patient Care Record, dated 12/17/12, indicated under the Braden risk assessment scale (The Braden Scale for Predicting Pressure Sore Risk is a clinically validated tool that allows nurses and other health care providers to reliably score a patient/client's level of risk for developing pressure ulcers) that the Nutrition subscale was 2 (2 indicates "probably inadequate").

Review of the physician's pre-printed orders dated 12/17/12, indicated a Nutrition Consult for Braden subscale of 1-2 or any wound. Review of the physician's orders dated 12/26/12, indicated a stage II pressure ulcer (The stage II ulcer is an open wound: The outer layer of skin (epidermis) and part of the underlying layer of skin (dermis) is damaged or lost) in the gluteal fold. Review of the physician's pre-printed orders dated 12/26/12, indicated a Nutrition Consult for Braden subscale of 1-2 or any wound.
Review of the patient graphic record, indicated oral meal intake was either nothing by mouth (NPO order) or 50% or less since time of admission of 12/17/12. Only one meal was 75% for breakfast on 12/19/12. This indicated overall poor oral intake for 10 days and a stage II pressure ulcer had developed during this time.
Review of the Nutrition Assessment dated 12/27/12, indicated the meal intake was refused to 50% of meals and the RN reported to RD 4 Patient 36 had a poor appetite. The RD indicated the patient had edema and stage II pressure ulcer. RD 4's goals for Patient 36 were to meet needs, heal tissue, and dry weight. The RD Recommendations were for a multi-vitamin with minerals daily, patient needs to be fed, risk of poor healing. RD 4 indicated a re-assessment would be done on 12/29-12/31. This follow up time indicated Patient 36 was at a high nutrition risk (or Priority 1).
On 12/28/12 at 9:17 a.m. an interview was conducted with RD 4. RD 4 stated she felt like they should have been consulted before they saw the patient especially since the diet went from regular to puree. The RD 4 stated they picked up the patient because the length of stay was 10 days. The RD 4 stated the hospital's policy is if identified at nutrition risk on the admission nutrition screen then they won't see them until the length of stay of 7-10 days.
On 12/28/12 at 10:00 a.m. an interview was conducted with RN 10. RN 10 stated when they read the pre-printed orders and the nutrition consult is pre-checked the nurse should check the nutrition subscale and if it is a 1 or 2, then the nurse needs to order a RD consult.
On 12/28/12 at 10:05 a.m. an interview was conducted with the Assistant Nurse Manager (ANM 5). The ANM 5 stated if at any point in time, the nutrition subscale is a 1 or 2 then the nurse should check to see if a RD consult was ordered and if not then they need to order one. The ANM 5 acknowledged that a consult should have been ordered for Patient 36. The ANM 5 acknowledged there was no consult ordered in the computer.
Review of the hospital's policy titled Pressure Ulcers, Prevention of Hospital-Acquired dated 8/08 and revised 1/11, indicated if inadequate nutritional intake (Nutrition score on the Braden Scale 1 or 2), then to obtain a RD consult.

Based on observation, record review, and interview the facility staff failed to safely give medications as ordered for 3 of 36 sampled patients (22, 23,and 24). This placed the residents at risk for prolonged hospitalization.

The findings:

1. The facility accepted Patient 22 for observation on 12/24/12 at 2 p.m. due to chest pains. The medication administration record (MAR) showed that a physician order dated 12/25/12 at 9 a.m. indicated 100 mg ( milligrams) of Desvenlafaxine ( an antidepressant) to be given daily. The MAR showed that the medication was to be given from the patient's personal supply after it had been examined and identified by the pharmacy. The MAR showed that the medication was circled and noted to be "not available." There was no record that the facility staff notified the physician of the unavailability of the medication or took actions to obtain the medication from the pharmacy.

The manufacturer of the drug warned of problems related to dosage reductions on their web page, www. Pristiq.com. The manufacturer stated, "Discontinuation symptoms may occur when stopping or reducing PRISTIQ [ Desvenlafaxine] , so talk to your health care professional before stopping or changing your dose."

2. The facility admitted Patient 23 to the facility on 12/27/12 with multiple medical problems and the physician ordered 5 oral medications to be administered daily. The patient was ordered : carvedilol (for high blood pressure) 6.25 mg ( milligrams); aspirin (a blood thinner) 325 mg; famotidine (an antiacid) 20 mg; guaifenesin ( to thin mucous) 600 mg; and hydrochlorothiazide (for high blood pressure) 25 mg. On 12/27/12 at 9 a.m. Licensed Nurse 1 administered the 5 oral medication by picking up each tablet with an ungloved hand and dropping it in the patients mouth. Interview with Nurse Manager 1 immediately following the medication administration indicated that the nurse should have used a gloved hand.

3. The facility admitted Patient 24 to the facility on 10/18/12 with multiple medical problems and ordered laboratory blood test to monitor the patient. On 10/18/12 at 1 p.m. the physician ordered the magnesium (MG) replacement protocol on order 153418. Magnesium is an essential electrolyte (chemical) in the blood and helps regulate the heart and nervous system. The order stated that if the MG level was between 1.5 - 1.9 mg/dl (milligrams per deciliter) the patient should receive 2 GM (grams) of magnesium sulfate by IV (intravenously, directily into a vein). The medical record showed the MG level on 10/19/12 at 5:45 a.m. was 1.5 mg/dl. There is no record that the patient received the magnesium sulfate as ordered by the protocol. On 12/27/12 at 3 p.m. Nurse Manager 1 reviewed the medical record and could find no evidence that the medication was given according to the protocol.

Based on interview and record review, the hospital failed to assure physicians timed orders and progress notes for 2 of 36 sampled patients (Patients 16 & 17).

Findings:

12/27/12 medical record reviews revealed an untimed 12/24/12 physician order for "Argatroban [a medication to prevent blood clotting]...CXR [chest x-ray]...Use [of] dialysis catheter..." [tube inserted into a blood vessel through which a machine can filter waste products when the kidneys are not working] for Patient 17 and an untimed 12/25/12 physician order for "Respiratory aerosol protocol [set of doctor's orders for breathing treatments]...Lasix [a medication to treat fluid retention]...and Hydrocortisone cream [a steroid cream for itching or inflammation]..." for Patient 16. One12/18/12, two 12/24/12 and two 12/26/12 physician progress notes for Patient 17 were also untimed.

During a 4:15 p.m., 12/27/12 interview, the Coordinator Quality/Risk Management (CQRM) was unable to locate the 12/24/12 physician order time and the12/18/12, 12/24/12 and 12/26/12 physician progress note times in Patient 17's medical record. During a 4:30 p.m., 12/27/12 interview, Clinical Manager (CM) 1 confirmed the physician had not timed Patient 16's 12/25/12 order.

A 12/28/12 review of the "Medical Staff Rules," revised 5/14/12, revealed, "All entries placed in the medical record...by the responsible Practitioner shall be signed and dated and timed by the responsible Practitioner."

Based on observation and interview, the hospital failed to ensure that two expired bottles of Tuberculin Purified Protein for testing, stored in the medication refrigerator in Ambulatory Surgery Services (ASS), were discarded after the November 2012 expiration date. This failure had the potential for use of the medication beyond the recommended use by date.
Findings:
In a tour of the ASS on 12/27/12 at 10 a.m. with the Director of Ambulatory Services (DAS) and the Interim Assistant Nurse Manager (IANM) two expired bottles of Tuberculin Purified Protein for testing were found in a medication refrigerator in the Post Anesthesia Recovery area of the ASS. The unopened vials had no labeling to indicate when or to whom they were issued. The DAS and the IANM acknowledged the medication was outdated and should not have been present. The DAS and the IANM stated the Pharmacist was responsible for stocking medications stored in the medication room during daily rounds and this included checking for expired or outdated medications.
On 12/27/12 at 1:38 p.m. the Pharmacy Director (PD), was interviewed regarding the expired medications. When asked about the medication's availability in the ASS medication refrigerator he said "We missed it. It was an error. It shouldn't have been available."
In a review of a hospital policy titled Expiration Dates/Beyond Use Dates, reviewed 4/25/12, there was no reference to the responsibility of the Pharmacist to monitor the expiration dates on medications stored in the medication cabinet or refrigerator.

Based on observation, interview and record review the hospital failed to ensure that nutritional needs were met for 3 of 36 sampled patients (14, 21, 36) when:
1) the hospital's nutrition screening system was effective to identify two patients who were at nutritional risk, in order to have a nutrition assessment completed by a registered dietitian to evaluate whether the diet met the individual's nutrition needs (Patient 36, Patient 21);
2) Hydration status data that was collected as part of the nutrition screening system resulted in a meaningful action plan or referral, and that a registered dietitian included an assessment of patient fluid needs in a nutrition assessment in accordance with hospital policy. (Patient 14) Failure to implement timely and effective systems for evaluation of medical nutrition therapy may result in further compromising nutritional and medical status for at risk patients.

Findings:

1.a. On 12/28/12 at 9:17 a.m., Patient 36's medical record was reviewed. Patient 36 was admitted to the hospital on 12/17/12 with a right hip fracture after a fall. Review of the Patient Profile Adult dated 12/17/12, indicated under the Nutrition Screen that they were "unable to assess". Review of the 24 hour Patient Care Record, dated 12/17/12, indicated under the Braden risk assessment scale (The Braden Scale for Predicting Pressure Sore Risk is a clinically validated tool that allows nurses and other health care providers to reliably score a patient/client's level of risk for developing pressure ulcers) that the Nutrition subscale was 2 (2 indicates "probably inadequate").

Review of the physician's pre-printed orders dated 12/17/12, indicated a Nutrition Consult for Braden subscale of 1-2 or any wound. Review of the physician's orders dated 12/17/12, indicated a regular diet was ordered. Review of the physician's orders dated 12/18/12, indicated a NPO (nothing by mouth) after midnight. Review of the physician's orders dated 12/19/12, indicated ensure one can by mouth three times a day. Review of the physician's orders dated 12/20/12 revealed orders for meal one clear liquids, meal two full liquid and meal three regular diet. Review of the physician's orders dated 12/21/12, indicated level one dysphagia diet (puree diet) with nectar thick liquids. Review of the physician's orders dated 12/23/12, indicated NPO per speech therapy. Review of the physician's orders dated 12/24/12, indicated puree diet with honey thick liquids. Review of the physician's orders dated 12/26/12, indicated a stage II pressure ulcer (The stage II ulcer is an open wound: The outer layer of skin (epidermis) and part of the underlying layer of skin (dermis) is damaged or lost) in the gluteal fold.

Review of the patient graphic record, indicated oral meal intake was either nothing by mouth (NPO order) or 50% or less since time of admission of 12/17/12. Only one meal was 75% for breakfast on 12/19/12. This indicated overall poor oral intake for 10 days.
Review of the Nutrition Assessment dated 12/27/12, indicated the meal intake was refused to 50% of meals and the RN reported to RD 4 Patient 36 had a poor appetite. The RD indicated the patient had edema and stage II pressure ulcer. RD 4's goals for Patient 36 were to meet needs, heal tissue, and dry weight. The RD Recommendations were for a multi-vitamin with minerals daily, patient needs to be fed, risk of poor healing. RD 4 indicated a re-assessment would be done on 12/29-12/31. This follow up time indicated Patient 36 was at a high nutrition risk (or Priority 1).

On 12/28/12 at 9:17 a.m. an interview was conducted with RD 4. RD 4 stated she felt like they should have been consulted before they saw the patient especially since the diet went from regular to puree. The RD 4 stated they picked up the patient because the length of stay was 10 days. The RD 4 stated the hospital's policy is if not identified at nutrition risk on the admission nutrition screen then they won't see them until the length of stay of 7-10 days.
On 12/28/12 at 10:00 a.m. an interview was conducted with RN 10. RN 10 stated when they read the pre-printed orders and the nutrition consult is pre-checked the nurse should check the nutrition subscale and if it is a 1 or 2, then the nurse needs to order a RD consult.
On 12/28/12 at 10:05 a.m. an interview was conducted with the Assistant Nurse Manager (ANM 5). The ANM 5 stated if at any point in time, the nutrition subscale is a 1 or 2 then the nurse should check to see if a RD consult was ordered and if not then they need to order one. The ANM 5 acknowledged that a consult should have been ordered for Patient 36. The ANM 5 acknowledged there was no consult ordered in the computer.
Review of the hospital's policy titled Pressure Ulcers, Prevention of Hospital-Acquired dated 8/08 and revised 1/11, indicated if inadequate nutritional intake (Nutrition score on the Braden Scale 1 or 2), then to obtain a RD consult.

Review of the Adult Nutrition Priority/Timing of Care policy, revised 3/12, indicated Nursing/care team referral, unintentional weight loss of 5 pounds or 5%, and Braden nutrition subscale score of 1 or 2, the RD would perform a nutrition assessment within 72 hours of notification or identification.

On 12/28/12 at 12:40 p.m. an interview was conducted with the Nutrition Services Manager (NSM) regarding the nutrition policy and time frames. The NSM stated the regional staff had a conversation about time frames within the last 6-7 months. The NSM stated she did not know what the average length of stay was for the inpatients at the hospital. The Assistant Administrator (AA) stated the hospital average length of stay was 3.8 days. It is unclear why a patient identified at nutrition risk would be assessed within 3 days (72 hours) when the average patient is only in the hospital for 3.8 days.

b. On 12/27/12 at 9:15 a.m., Patient 21's medical record was reviewed. According to a Consultation report, dated 12/23/12 which was the day of Patient 21's admission to the hospital, the patient's diagnosis included end stage renal [kidney] disease on hemodialysis [use of a machine to clean the blood], and the patient was found to have diabetic ketoacidosis (a dangerous complication of diabetes mellitus in which the chemical balance of the body becomes too acidic). Patient 21 also had a coronary bypass graft surgery previously.

On 12/27/12 at 9:15 a.m., the NSM stated that the hospital's nutrition screening system had not identified Patient 21 as a nutritionally high risk patient, and therefore a registered dietitian would not complete a nutrition assessment until 7 - 10 days after admission.

On 12/28/12 at 10:32 a.m., RD 3 reviewed Patient 21's medical record per surveyor's request. RD 3 stated that Patient 21 was at nutritional high risk due to state of diabetic ketoacidosis at time of admission and due to hemodialysis. RD 3 verified that Patient 21 could benefit from diet education and a nutrition assessment by a registered dietitian. RD 3 verified that the hospital's nutrition screening system failed to identify Patient 21 as a nutritionally high risk patient in order for a registered dietitian to complete a comprehensive nutrition assessment and evaluation of Patient 21's diet order, in a timely manner.

On 12/28/12 at 2:00 p.m., the NSM acknowledged that a nutrition screening system should have been developed to capture a patient who was in diabetic ketoacidosis status and had end stage organ disease, in order for an RD to have been triggered to conduct an evaluation of the diet and complete an individualized patient nutrition assessment.
According to the hospital's policy entitled Nutritional Assessment/Reassessment of the Acute 'At Risk' Patient, "It is the policy of the Nutrition and Food Service Department that a Registered Dietitian assess "at risk" patients based on their clinical status and reassess ...purpose; To provide timely nutrition assessments and reassessments."

2 . On 12/28/12 at 9:50 A.M., Patient 14's medical record was reviewed. Patient 14 was admitted to the hospital on 12/22/12 with a diagnosis that included congestive heart failure per a consultation report, dated 12/22/12. According to the Patient Profile Adult form completed by an RN at time of Patient 14's admission, under the Nutrition screening category was a category for "Hydration" in which an X was located in the box that indicated "excess". RD 3 reviewed the Patient Profile Adult form an stated that a nutrition referral was not indicated for the RD on 12/22/12 since the patient had not had unintentional weight loss prior to admission. RD 3 verified that hydration status was a factor that registered dietitians took into consideration when assessing patients nutritional status. RD 3 stated that when hydration status was identified as a deficit or excess on the nutrition screening section of the form, under hydration, that it did not result in a referral to the RD. At that time, the Nutrition Services Manager (NSM) stated, "That information is just gathered to meet Joint Commission." The NSM verified that the hydration section under the nutrition screening category was for data gathering only and did not result in triggering a next step approach.

On 12/24/12 an RD completed a nutrition consult per the RN referral for Patient 14. The RD documented that Patient 14 had an estimated caloric need for 2,300 calories per day, and 60 - 75 grams of protein per day. There was no documented assessment of the patient's fluid needs, or fluid status. At that time, the NSM acknowledged that assessing fluid needs was part of a nutrition assessment, and was expected.

According to the hospital's policy on Nutritional Assessment/Reassessment of the Acute 'At Risk' Patient indicated, "...comparative standards to estimate energy, protein, fluid, and micronutrient needs."

Based on observation, interview and record review, for 2 of 36 sampled patients (14, 21), the hospital failed to ensure nutritional needs were met when:
a) One patient did not receive a therapeutic diet order as prescribed by the practitioner responsible for the care of the patient (Patient 21) and, b) One patient's nutritional needs were not addressed timely when poor intake was identified (Patient 14).

Findings:

a.On 12/27/12 at 9:15 A.M., Patient 21's medical record was reviewed. CN 1 viewed the electronic computer system that stored the diet data entry based on physician orders for Patient 21. According to the order screen Patient 21 was prescribed a cardiac diet on 12/25/12 via a pre-printed order form with a check mark next to cardiac diet. According to CN 1, on 12/26/12 a nurse entered electronically another diet order based on a physician's order and entered, "Renal diet, 80 gm pro, 2 gram K+, 60 g per meal; 1500 mls". CN 1 stated that the cardiac diet portion was dropped off during that data entry but should have continued to be part of the order as it was not discontinued by a physician.

On 12/27/12, Patient 21's physician wrote another diet order of "cardiac & renal [diet for kidney disease] & carb [carbohydrate] control diet [a diabetic diet]." CN 1 verified that the cardiac, renal and carb control diet remained the current diet order.

The Nutrition Services Manager (NSM) stated that the food and nutrition services department was providing Patient 21 a renal and carb control diet. The NSM verified that the food and nutrition services department was unaware of a physician's order of a cardiac diet.

CN 1 viewed the electronic data entry record for Patient 21's diet order and stated that a nurse entered the diet order, but had not entered the cardiac portion of the physician's diet order. The food and nutrition services department had not received accurate communication for Patient 21's therapeutic diet order.

Patient 21 had not received a therapeutic diet as prescribed by the physician.
The hospital's policy entitled Patient Tray Tickets and Tray Identification indicated, "All diet orders and related information are sent by Nursing Services via computerized order entry and transferred to CBORD using an interface." The hospital's policy entitled Alterations in Diets and Diet Schedules indicated, "To ensure that the nutritional needs of the patients are met in regard to their diet prescriptions, as ordered by the physician."

b. On 12/28/12 at 9:50 A.M., Patient 14's medical record was reviewed. Patient 14 was admitted to the hospital on 12/22/12 with a diagnosis that included congestive heart failure per a consultation report, dated 12/22/12.

On 12/23/12, a nurse (RN) entered an electronic referral for a registered dietitian (RD) referral for Patient 14 for "poor appetite."

On 12/24/12 an RD completed a nutrition consult per the RN referral. The RD documented that Patient 14 had an estimated caloric need for 2,300 calories per day. The RD documented, "Goals: Meet need soon with po [by mouth] intake for weight stability as some gradual weight loss acceptable. Will reassess 12/27-28, if intakes remain low - add incr cal/prot supplements [increase calorie/protein]." There was no documented evidence that a nutrition intervention was recommended in response to Patient 14's nurse identifying that the patient was not eating well.

On 12/28/12 at 9:50 A.M., RD 3 reviewed Patient 14's medical record, including the nutrition assessment that was completed on 12/24/12 and po intake since admission. RD 3 verified that Patient 26 had continued with poor po intake. Patient 14 had not met his estimated nutritional needs for seven consecutive days.

RD 3 and the Nutrition Services Manager (NSM) acknowledged that a nutrition intervention recommendation to address Patient 14's poor po intake that had been identified by a nurse would have been appropriate, and a more timely manner to address Patient 14's nutritional needs.

The hospital's policy on Nutritional Assessment/Reassessment of the Acute 'At Risk' Patient indicated, "Purpose A. To provide timely nutrition assessments and reassessments, B. To facilitate communication between multidisciplinary team members regarding nutritional concerns..."

The hospital's policy entitled Nutritional Screening of the Patient indicated, "To ensure that Physicians, Nursing, and other support services recognize the efficacy of early nutritional screening services, To ensure timely provision of Medical Nutrition Therapy (MNT) to those patients identified at nutritional risk ..."

According to the hospital's document entitled Patient Care Services/Departments, "The Registered Dietitians work with Nursing Services to identify patients at nutritional risk through a screening process. Potentially at risk patients are assessed, a nutritional care plan is developed for those at risk, and these patients are closely monitored."

Based on observation, interview, testing, and document review, the hospital failed to be maintained safely to insure the safety of the patients. This was evidenced by:
1. The failure of the fire alarm system in the Emergency Department to provide visual and audible warning to staff and patients in the event of a fire emergency. (Refer to K51)

2. The hospital failed to have a detailed plan that included an adequate water supply for patients and staff in the event of an emergency or disaster. This failure put patients and staff at risk of dehydration in the event of a disaster that required the hospital to shelter in place with no outside resources available. (Refer to A 703)

The cumulative effects of these systemic problems identified during the Life Safety Code (LSC) portion of the certification survey resulted in the General Acute Care Hospital's inability to insure the provision of quality health care in a safe environment. As a result of the findings, the Condition of Participation for Physical Environment is out of compliance.

Based on observation, staff interviews and review of hospital documents the hospital failed to have a detailed plan that included an adequate water supply for patients and staff in the event of an emergency or disaster. This failure put patients and staff at risk of dehydration in the event of a disaster that required the hospital to shelter in place with no outside resources available.

Findings:

This hospital consists of two separate campus approximately 25 city blocks apart. Campus 1 is located near the freeway and Campus 2 is located in a residential neighborhood. On 12/27/12 beginning at 9:40 a.m. the disaster food and water plan was reviewed. There was 10,080 four-ounce pouches (315 gallons) of disaster water stored in the Capitol Pavilion Parking Structure (near Campus 1). Review of the Nutrition and Food Service Disaster Meal Plan, indicated the plan for Hospital Campus 1 included 330 patients and 1,000 staff for four days. When the four day disaster menu was reviewed, it indicated water to be given for lunch and dinner for the regular and cardiac diets. There was no water indicated on the carbohydrate controlled diet (CCD), renal, puree, full liquid or clear liquid diets. At approximately 10:00 a.m. an interview was conducted with the Executive Chef. The Executive Chef stated he was not sure how much water would be given but he thought the Nutrition Services Manager (NSM) would know.

On 12/28/12 at 11:53 a.m. an interview was conducted with the NSM regarding the disaster water. The NSM stated the plan is to include all fluids not just water. The NSM stated they were in the middle of coming up with a tool for fluids. The NSM stated they were using the Recommended Dietary Allowances (RDA) for fluid as their reference and were not using any other nationally accepted references or calculations when determining the need for water. For example, one source for information on water is the Federal Emergency Management Agency (FEMA) which indicates at least 1 gallon per person per day. The NSM stated they planned for 106 ounces per person per day. Review of all juices, water and sodas, there was only enough water for the planned 1,330 people for 1 day not the 96 hours (4 days) according to their plan. On 12/28/12 at 12:35 p.m. an interview was conducted with the NSM. The NSM acknowledged there was not adequate water on site.

Review of the Emergency Operations Plan for water, updated 12/22/08, indicated there was 801 gallons of water throughout Hospital Campus 1 that would be available. It indicated there is a well located at Hospital Campus 1 and Campus 2, but those will not be available within the next couple of years due to construction. On 12/28/12 at 1:20 p.m. an interview was conducted with the POM regarding the well. The POM confirmed there was not access to the well at Hospital Campus 1 due to all the construction and there was only water in the 5 gallon locations and the pouches.

Based on observation, interview, testing, and document review, the hospital failed ensure the life safety from fire requirements were met. This was evidenced by the failure of the fire alarm system in the Emergency Department to provide visual and audible warning to staff and patients in the event of a fire emergency. This deficient practice could potentially result in a delay in response by staff and the spread of smoke and/or fire in both the Emergency Department and the rest of the hospital.

Findings:

Refer to Life Safety Code survey findings at tag K-51.

Based on observation, facility documentation and interview the facility failed to maintain humidity levels within acceptable standards of 30-60% (Association of Operating Room Nurses Perioperative Standards and Recommended Practices) and greater than 35% (National Fire Protection Association) for 11 of 12 operating rooms (ORs) on 12/21/12 and 5 of 12 ORs on 12/24/12. In 1 of 12 OR rooms (room 3) the temperature was below acceptable standards of 68F to 73F degrees on 12/21/12 and 12/24/12. Low humidity increases the risk of electrostatic charges, which pose a fire hazard in an oxygen-enriched environment or when flammable agents are in use and increases the potential for dust accumulation.

Findings:

This hospital consists of two separate campus approximately 25 city blocks apart. Campus 1 is located near the freeway. On 12/27/12 a tour of the Physical Environment in the Surgical area at Campus 1 was conducted. The Department was accompanied by the Plant Operations Manager (POM) and the Assistant Manager for Surgical Services (ANM 1). The Department observed, in an surgical suite, that the temperature and humidity was indicated on a wall mounted gauge with a constant reading. The POM stated that there was no direct wiring from the gauges to Plant Operations for monitoring. The ANM 1 stated that the surgical technicians and/or nurses were responsible for checking the temperature and humidity in each surgical suite and noting it on the Daily OR Temperature/Humidity Log. A copy of the most recent weekly log was requested and provided by ANM 1.

Review of the log showed that across the top were the surgical suites numbered 1-12. Down the left side were spaces for 7 days and the temperature/humidity for daily checks. Down the right side was a column for range marked H & L and next to that another column marked "POM called" with a check mark. Another column identified the staff performing the check. At the bottom of the log were identified target temperature ranges of 68-73 degrees and humidity ranges of 35%-60%.

The log showed, for 12/21/12, 11 of 12 surgical suites (rooms 1, 2, 4, 5, 6, 7, 8, 9, 10, 11, 12) had humidity less than 35 % (ranging from 21% to 34%). Room 3 had a temperature of 58.6 degrees. On the 12/24/12, 5 of 12 rooms (rooms 4, 5, 6, 11, 12) had humidity below 35% (ranging from 22% to 24%). On 12/24/12 the temperature in Room 3 was 59 degrees.

On the part of the log identifying high and low temperatures there were no check marks to indicate that the POM was notified. There were staff names noting who did the temperature and humidity checks.

On 12/28/12 at 1:30 p.m. an interview was conducted with the POM regarding these out of range environments. The POM acknowledged that the humidity and temperature entries were out of range and they should have been notified by the surgical staff. It was acknowledged that there were surgical cases ongoing in the affected rooms on those days.

Review of the AORN (Perioperative Standards and Recommended Practices 2012 edition), "Recommended Practices for a Safe Environment of Care" in part indicated, "Recommendation V. Potential hazards associated with HVAC systems in the practice setting should be identified, and safe practices should be established. V.b. Relative humidity should be maintained between 30% and 60% within the perioperative suite, including operating rooms, recovery area, ... instrument processing areas, and sterilizing areas and be maintained below 70% in sterile storage areas. Low humidity increases the risk of electrostatic charges, which pose a fire hazard in an oxygen-enriched environment or when flammable agents are in use and increases the potential for dust. High humidity increases the risk of microbial growth in areas where sterile supplies are stored or procedures are performed." Section V.b.2. indicated "Humidity should be monitored and recorded daily using a log format or documentation provided by the HVAC system. Section V.c. indicated "Temperature should be monitored and recorded daily using a log format or documentation provided by the HVAC system.V.c.1. Temperature should be maintained between 68 F to 73 F (20 C to 23 C) within the operating room suite and general work areas in sterile processing (autoclave room)."

National Fire Protection Association (NFPA) 99, "6.4.1.1: The mechanical ventilation system supplying anesthetizing location shall have the capability of controlling the relative humidity at a level of 35 percent or greater.'

Based on observation, staff interviews and review of hospital documents, the hospital's Infection Prevention coordinator failed to develop an effective system for:
1. Identifying staff practices for storage of dirty tray carts and clean dishes.
2. Identifying ice machines that were not maintained in a sanitary manner.
3. Identifying dirty microwaves in the nourishment rooms.

Failure to ensure a hospital wide infection control program that serves the patient and hospital wide staff has the potential of microorganism growth.

Findings:

This hospital consists of two separate campus approximately 25 city blocks apart. Campus 1 is located near the freeway and Campus 2 is located in a residential neighborhood.

1. On 12/26/12 at 1:00 p.m., inside the kitchen at the Hospital Campus 2, there were meal delivery carts that contained dirty dishes pushed up against the side of the dish machine where clean dishes were located. The Food Service Supervisor stated that since lunch trayline [a process in which patient meal trays were assembled] was still in process, dietary staff brought down the patient meal delivery carts that contained the dirty dishes and brought them into the entry of the clean side of the dish machine area. The Director of Food and Nutrition Services (DFNS) acknowledged that dirty dishes should not be stored in the same area that clean dishes were stored as it was a potential for cross-contamination. According to the Director of Food and Nutrition Services job description, "The Director provides leadership and managerial support in planning, organizing, staffing and controlling the day to day operational functions related to the department."

2. a. On 12/27/12 at 1:30 p.m. an interview with the Senior Facilities Manager (POM) was conducted along with an observation of the ice machine in kitchen at Hospital Campus 1. The POM stated they do a semi-annual cleaning and sanitizing of the ice machines throughout the hospital. The ice machine chute was observed to have a brown substance. The Food Service Supervisor stated the bin is cleaned monthly by the food service staff.

On 12/27/12 at 1:35 p.m. an observation of the ice machine in the cafe at Hospital Campus 1 was conducted with the POM. The ice machine tubes where the water flowed through were observed to have brownish-pinkish substance. The POM stated it should not look this way. The POM stated he only has documentation from the cleanings from 3/2012.

b. On 12/27/12 at 12:50 p.m., the following observation was made in the presence of the DNFS and the Food Service Supervisor, in the 5 north nourishment room at the Hospital Campus 1, the ice machine chute was observed with a white substance. Review of the monthly log of Refrigerator and Ice Machine Cleaning located in the nourishment room, indicated they were cleaned on 12/26/12 and initialed.

On 12/27/12 at 12:55 p.m., the following observation was made in the presence of the DNFS and the Food Service Supervisor, in the 5 east nourishment room at the Hospital Campus 1, the ice machine chute was observed with a brown substance. The Food Service Supervisor acknowledged it was dirty. Review of the monthly log of Refrigerator and Ice Machine Cleaning located in the nourishment room, indicated they were cleaned on 12/26/12 and initialed.

On 12/27/12 at 1:50 p.m. an interview was conducted with an environmental services tech (EVS 2) regarding the cleaning of the nourishment rooms. The EVS 2 stated they clean the nourishment room daily. The EVS 2 stated they clean the floor, sink, counters daily and the refrigerator and ice machine monthly. The EVS 2 stated they sanitize the trays with bleach and have to keep on for 5 minutes in order for the bacteria to be killed.

Review of the Hospital Campus 1's Preventive Mantenance checklist for ice machines, indicated the frequency is March and September. Review of the ice machine manufacturer's directions, indicated the recommend cleaning and sanitizing at least once a year. More frequent cleaning and sanitizing, however, may be required in some existing water conditions.

3. a. On 12/27/12 at 10:05 a.m., in the 5 north nourishment room at the Hospital Campus 2, the inside of the microwave contained thick dried food debri, and the door of the microwave was in disrepair. An environmental services employee (EVS 1) acknowledged the microwave was dirty.

b. On 12/27/12 at 12:50 p.m., the following observation was made in the presence of the DNFS and the Food Service Supervisor, in the 5 north nourishment room at the Hospital Campus 1, the inside of the microwave contained brown spots and dried food debri.
Review of the monthly log of Refrigerator and Ice Machine Cleaning located in the nourishment room, indicated they were cleaned on 12/26/12 and initialed.

c. On 12/27/12 at 12:55 p.m., the following observation was made in the presence of the DNFS and the Food Service Supervisor, in the 5 east nourishment room at the Hospital Campus 1: the inside of the microwave contained thick dried white food debri and yellow and orange dried food debri on the top. The Food Service Supervisor acknowledged it was dirty. Review of the monthly log of Refrigerator and Ice Machine Cleaning located in the nourishment room, indicated they were cleaned on 12/26/12 and initialed.

On 12/27/12 at 1:50 p.m. an interview was conducted with an environmental services tech (EVS 2) regarding the cleaning of the nourishment rooms. The EVS 2 stated they clean the nourishment room daily. The EVS 2 stated they clean the floor, sink, counters daily and the refrigerator and ice machine monthly. The EVS 2 stated nursing cleans the microwaves.
The hospital's policy and procedure entitled Cleaning of Nursing Unit Support Rooms, indicated, "The following procedures shall be observed by Environmental Services personnel when cleaning nursing floor utility areas: ...Counter and sink areas, including inside and outside of microwave ovens, are cleaned daily using a germicidal solution ..."

Based on observation, interviews and record review, the hospital failed to a) follow established surgical policies and procedures and b) acceptable standards of professional practice, including those of the Association of PeriOperative Registered Nurses to ensure a well organized and safe surgical suite when:

1. The hospital failed to follow established policies and nationally recognized guidelines for the cleaning of the surgical suites between cases and terminal cleaning each day. (Refer to A 0951)

2. The facility failed to maintain humidity levels within acceptable standards of 30-60% (Association of Operating Room Nurses Perioperative Standards and Recommended Practices) and greater than 35% (National Fire Protection Association) for 11 of 12 operating rooms (ORs) on 12/21/12 and 5 of 12 ORs on 12/24/12. In 1 of 12 OR rooms (room 3) the temperature was below acceptable standards of 68F to 73F degrees on 12/21/12 and 12/24/12. (Refer to A 0701)

3. The hospital failed to provide a well organized surgical suite consistent with standards of practice when traffic patterns, including environmental controls and requirements for surgical attire, were not clearly defined or enforced to delineate non-restricted, semi-restricted and restricted areas of the surgical suite.

These failures put surgical patients at risk for harm, including injury, infection and death.

The cumulative effect of these systemic failures resulted in the failure of the hospital to comply with the Condition of Participation: Surgical Services.

Findings:

On 12/27/12 at 1:45 p.m. a tour of the hospital Surgical Suite was conducted by the Interim Operations Director (IOD) and two Surgical Services Assistant Nurse Managers (ANM 1 and ANM 2). An entrance door to the Surgical Suite was described as a temporary door and labeled Alternate Access Door. The signage did not designate this as an entrance to a semi-restricted or restricted area. The IOD stated this door to the Surgical Suite had been in place since February 2012 as the original entrance was under construction. The IOD acknowledged that hospital followed the AORN (Association of Operating Room Nurses) Perioperative Standards and Recommended Practices as a clinical resource for establishing operating room standards of practice.

A second door approximately 30 feet down the corridor opened into an area with a nursing station and two small surgical suites. The IOD stated one of these rooms was used for endoscopy procedures (procedures to view internal organs of the body) and the other for storage. There was no signage to indicate whether this was a non-restricted or semi-restricted area. Several staff were observed entering or exiting this area some in scrub attire and some wearing street clothes.

Another door opened into an area with a nursing station, across from the wall grease board used to post the surgeries scheduled in each room for the day. Staff from the operating rooms were standing at or around the grease board reviewing cases. Multiple staff members in surgical attire were at the nursing station with a scheduling clerk in street clothes. Some had their hair covered, others did not. In the same general area were two workrooms, one designated as an anesthesia workroom (storage room for mediations and equipment used during surgery to put patients to sleep) and one identified as a soiled utility room where instruments were taken prior to sending to Central Supply for cleaning. There was no signage to indicate the appropriate environmental control for this area.

In a concurrent interview ANM 1 stated Surgical Services was under construction and it would be difficult to define the traffic patterns distinctly. ANM 1 acknowledged this phase of the construction and the temporary door had been in place since February. Both ANM 1 and ANM 2 were unable to verbally define the boundaries for the non-restricted and semi-restricted areas.

On 12/27/12 at 10 a.m., a tour of the hospital Surgical Suite was conducted with the Infection Control Preventionist (ICP), the Assistant Administrator (AA), ANM 1 and ANM 2. Multiple staff members were convened in the area around the grease board and in the nursing station adjacent to the dressing room, an anesthesia workroom and a soiled utility room. Approximately 50% of the surgical staff present in scrubs did not have hair coverings. Two surgical staff members present were not in scrubs. During a fifteen minute period of traffic observation in this area the following was noted:

1. A dietary aide in personal black scrubs brought a large dietary cart into the area. The IOD stated the trays were being brought to the physicians in their break room.
2. A bioengineering staff person in street clothes brought in a cart with a piece of equipment and took it into the anesthesia work room.
3. One vendor checked in to the nursing station, another vendor came into this area from the dressing room in street clothes.

In a concurrent interview with ANM 2, he stated this area was semi-restricted and surgical attire was only required in restricted areas.

In a review of a policy titled Traffic Patterns in Surgical Services, approved January 2010, there was stipulation "Clearly defined and enforced traffic control practices protect personnel, patients, supplies and equipment from potential sources of cross contamination....". The policy mandated the surgical suite be divided into three designated areas with signs posted that indicate where semi-restricted and restricted areas are. The policy further directed the following for the semi-restricted area:

1) Scrub and hair coverings are required.
2) Traffic is limited to authorized personnel and patients.
3) Includes storage areas, sterile storage areas, scrub sink areas, hallway and instrument processing.

In addition, the policy directed: "Persons entering the semi-restricted or restricted area for a brief period of time for a specific purpose (e.g. Nursing staff from other departments...bio engineers) should cover all head and facial hair and will don fresh scrub attire or use a single use coverall suit (bunny suit) to totally cover all outside apparel."

In a review of this policy with ANM 2, he stated "I never read this policy" and he was in disagreement with the definition of a semi-restricted area.

In review of AORN Standards, 2012 Edition, Recommended Traffic Patterns in the Perioperative Practice Setting, Recommendation I, page 95, there was stipulation:

"Traffic patterns should be designed to facilitate movement of patients and personnel into, through, and out of defined areas within the surgical suite. Signs should clearly indicate the appropriate environmental controls and surgical attire required.

The surgical suite should be divided into three designated areas that are defined by the physical activities performed in each area. Increasing environmental controls and surgical attire as progression is made from unrestricted to restricted areas decreases the potential for contamination.

1. The semi-restricted area includes the peripheral support areas of the surgical suite. It has storage areas for clean and sterile supplies, work areas for storage and processing of instruments, scrub sink areas, and corridors leading to the restricted areas of the surgical suite. Traffic in this area is limited to authorized personnel and patients. Personnel are required to wear surgical attire and cover all head and facial hair.
2. Movement of personnel from unrestricted areas to either semi-restricted or restricted areas should be through a transition zone. A transition zone exists where one can enter the area in street clothing and exit into the semi-restricted or restricted zone in surgical attire. Locker rooms serve as transition zones between the outside and inside of a surgical suite and may serve as a security point to monitor people admitted to the suite."

In further review, Recommendation V stipulated: "During construction and renovation, specific traffic patterns should be established and maintained in accordance with applicable state regulations.

3. A multidisciplinary assessment should be completed to determine the infection control and safety risks involved in a construction, renovation or maintenance project. A multidisciplinary team performing the assessment should include infection control, safety and project personnel.

Both the Assistant Administrator (AA) and the ICP stated the multidisciplinary committee had not addressed traffic patterns in the various phases of the construction project. Both the AA and the ICP agreed that established hospital and professional practice standards must be followed throughout each phase of construction.

Based on observation, interviews and record review, the hospital failed to follow established policies and nationally recognized guidelines for the cleaning of the surgical suites. This failure resulted in the potential for cross-contamination and subsequent infection.

Findings:

A tour of Surgical Services was conducted on 12/27/12 at 10 a.m. with two Assistant Nurse Managers (ANM 1, ANM 2). During this tour observations were made in Operating Room (OR) 1, the only unoccupied surgical suite at the time.

In a concurrent interview with ANM 1, he stated OR 1 was used for "larger" cases, for example brain, spine and orthopedic surgery and a case had been done in the room that day. At the side wall of the room was a large metal table approximately 5 feet long, 3 feet wide and 3 feet tall with a shelf along the bottom. ANM 1 stated this "table" was placed over the operating room table to hold instruments and supplies most specifically for brain surgery.

Viewing the edge of the shelf, dust and lint particles were observed. Reaching under the table and swiping the bottom shelf, large amounts of dust, lint, paper scraps and string were evident. In a concurrent interview, ANM 1 stated it was the responsibility of the Surgical Attendant to clean all equipment in the room between cases. ANM 1 added each operating room was terminally cleaned (thoroughly washed and disinfected) every 24 hours during the night.

In addition, the following observations were made:

1. In the rear of the room, there was a large container, approximately 2 feet high and 9 inches wide, labeled Sharps Pharmaceutical Waste Container (SPWC). The lid to the container was open, exposing multiple used intravenous bags (bags of fluid given into a patient's vein or artery) and syringes covered in blood and clear fluid. ANM 1 stated the lid could not be closed until the container was full or it would seal. ANM 1 stated the waste was not disposed of after each case or at the time of daily terminal cleaning. In a second observation of a SPWC in an adjacent room the next day, the lid to the container was closed and could be opened for placement of materials.

2. An IV pole ( a pole that holds intravenous solutions) appeared to have dark material on the extended legs. When wiping this with a sharp object, the material appeared to be dirt imbedded into the metal.

Both ANM 1 and ANM 2 acknowledged the room had not been thoroughly cleaned.

In an interview with the Operations Supervisor for Environmental Services (OSES) on 12/28/12 at 9:30 a.m., she stated there were presently two full time ES employees cleaning the operating rooms at night (previously there had been three). The OSES stated the rooms were terminally cleaned every night and each night two room floors were thoroughly machine scrubbed and polished. The OSES stated the staff were trained to wash walls from the top to bottom and clean all vertical and horizontal surfaces including equipment and the removal of waste. The OSES stated equipment included all equipment used except as designated, for example the anesthesia monitors. The OSES acknowledged the brain table should have been cleaned each night.

In review of a policy titled Patient Care Standard for Surg: Cleaning and Disinfection in the Operating Room, approved November 2012, there was reference to the use of AORN Standards and Recommended Practices, 2011 for professional standards for cleaning. The policy gave specific instructions on standards for cleaning between cases and terminal cleaning. This included the following:
A. Prior to the First Scheduled Procedure
1. Damp dust horizontal surfaces...
2. The Perioperative Nurse will visibly inspect the operating room for cleanliness....
C. Between Case Cleaning
4. Dispose of medical waste according to patient standard....
5. Clean and disinfect all equipment....
D. Terminal Cleaning is performed at the completion of surgical practice setting's daily surgery. At the end of the da8ily surgery achedule, terminal cleaning will be performed once within a 24 hour period during the regular work week in the operating rooms used that day. Staff shall use mechanical friction with Environmental Protection Agency (EPA)-registered hospital disinfectants to clean and disinfect equipment and areas that should include but not limited to:
3. All furniture and equipment....
7. All horizontal surfaces...
15. Document in cleaning log.

A separate schedule was included for scheduled cleaning done daily, weekly or monthly which included removing all furniture from the room to machine scrub and mop and wax the floor.

In review of a document titled Weekly Work Schedule, provided by the OSES, there were nightly assignments for cleaning. Each night Monday through Thursday two OR rooms were scheduled, Friday indicated surgery floors would be done. Each night this schedule was signed by both ES staff. The OSES stated this was only the floor cleaning schedule but was unable to produce a schedule or document to reflect the terminal cleaning of each OR every 24 hours.

In an interview with two Surgical Attendants (SA 1, SA 2) on 12/28/12 at 1 p.m., they stated it was their responsibility to clean the operating rooms between cases and this included wiping down all equipment. SA 1 and SA 2 stated three rooms are terminally cleaned by ES staff each night. Both SA's were unable to state why the equipment in OR 1 had been so dirty.