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Based on observation, interview, and document review, the facility failed to maintain a system for controlling sources of infections in accordance with internal policies and procedures, nationally recognized infection control practices and guidelines, and regulations, when:

1. Staff did not adhere to policy and procedures and standards of practice related to Surgical Attire.
2. Floors in perioperative services were in a state of disrepair or made of materials which prevented the process of disinfection.
3. There was no evidence to support the terminal cleaning in decontamination, sterile processing, sterile storage, and endoscopy processing and storage rooms.
4. Employee Health requirements were not being met.

Findings:

1. On February 12, 2019 at 10:10 a.m., during a tour of the semi-restricted and restricted areas of the perioperative department, RN 1 did not have any covering over a substantial amount of facial hair. When interviewed he stated that he did not have a beard and did not require a facial hair cover.

According to the facility policy entitled OR Attire, dated April 2017, disposable scrub hats or surgical hoods that completely cover all possible head and facial hair are to be worn by all personnel entering the OR restrictive area.

On February 12, 2019 at 10:10 a.m., during an interview with Adm RN 2, she stated that the facility has adopted AORN (Association of peri-Operative Registered Nurses) and AAMI (Association for the Advancement of Medical Instrumentation) as the guidelines for their infection control program.

According to AORN Guidelines for Perioperative Practice (2019), Guideline for Surgical Attire: Personnel entering the semi-restricted and restricted areas should cover the head, hair, ears, and facial hair. A clean surgical head cover or hood that confines all hair and completely covers the ears, scalp skin, sideburns, and nape of the neck should be worn.

2. On February 12, 2019 at 10:30 a.m., during a tour of Trauma OR Room 1, the floor was observed to have many open penetrations, which could harbor bacteria. These observations were validated by Adm RN 1 and Adm RN 2.

On February 12, 2019 at 10:45 a.m., during a tour of the endoscopy processing room, the floor was observed to have a linoleum-like tile floor with space between the tiles and visible penetrations in the tile in front of the sink. These observations were validated by Adm RN 1 and Adm RN 2.

On February 12, 2019 at 10:10 a.m., during an interview with Adm RN 2, she stated that the facility has adopted AORN (Association of peri-Operative Registered Nurses) and AAMI (Association for the Advancement of Medical Instrumentation) as the guidelines for their infection control program.

According to ANSI/AAMI ST79: 2017 Comprehensive Guide To Steam Sterilization and Sterility Assurance in Health Care Facilities, 3.3.5 General facility design requirements: All surfaces (e.g., floors, walls, ceilings, cabinets) should be durable, smooth, and cleanable. Unless otherwise stated ...all processing work areas should conform to the following recommendations. Surfaces that are durable, smooth, and cleanable allow for ease of cleaning and assist in preventing buildup of dirt and debris in crevices. Floors should be level (i.e., should have no ridges or bumps); be constructed of non-particulate or non-fiber shedding materials that will withstand daily or more frequent wet cleaning and the application of chemical cleaning agents.

3. On February 12, 2019 at 10:45 a.m., during a tour of the endoscopy processing room, the floor was observed to have a porous mat in front of the sink that covered a soiled floor underneath. In the corners of the room there was visible debris. This observation was validated by Adm RN 1 and Adm RN 2.

On February 12, 2019, during an interview with EVS Mgr, a log of terminal cleaning was requested. He presented a log for Operating rooms 1-6, and Endoscopy Procedure Rooms 1-2. There was no evidence of terminal cleaning for decontamination, sterile processing, sterile storage, and endoscopy processing and storage rooms.

On February 12, 2019 at 10:10 a.m., during an interview with Adm RN 2, she stated that the facility has adopted AORN (Association of peri-Operative Registered Nurses) and AAMI (Association for the Advancement of Medical Instrumentation) as the guidelines for their infection control program.

According to AORN Guidelines for Perioperative Practice, Environmental Cleaning (2019): Terminal cleaning and disinfection of perioperative areas, including sterile processing areas, should be performed daily when the areas are being used. All floors in the perioperative and sterile processing areas should be disinfected. Terminal cleaning of operating and procedure rooms should include cleaning and disinfecting of all exposed surfaces ... Policies and procedures for environmental cleaning processes and practices should be developed, reviewed periodically, revised as necessary, and readily available in the practice setting ... Completion of terminal and scheduled cleaning procedures should be documented on a checklist or log sheet.

4. On February 13, 2019 at 9:00 a.m., during a review of employee files, one (EE 3) out of 5 employee files (EE 1, EE 2, EE 3, EE 4, Admin RN 1) did not show evidence of mumps immunity status; one (EE 4) out of 5 employee files (EE 1, EE 2, EE 3, EE 4, Admin RN 1) did not show evidence of Tdap (Tetanus, Diphtheria, Pertussis) status. These omissions were validated by RN 1.

According to the facility policy entitled Employee Immunization Program, Employees will be screened and may be vaccinated for Mumps immunity if they lack evidence of seropositivity of documentation of two MMR (Measles, Mumps, and Rubella) vaccines. An employee whose Tdap status is unknown may receive a single dose of Tdap.

For current California requirements, "Cal. Code Regs. tit. 8, § 5199, relating to "aerosol transmissible diseases". Cal. Code Regs. tit. 8, § 5199(h)(5) requires employers to make available to all susceptible healthcare workers with occupational exposure all vaccine doses listed in Appendix E. Doses listed in Appendix E include seasonal influenza vaccine, measles, mumps, and rubella vaccine, varicella vaccine, and tetanus-diphtheria-acellular pertussis (Tdap) vaccine. Employers are required to ensure that employees who decline to accept a recommended and offered vaccination sign the declination statement in Appendix C1 for each declined vaccine. Cal. Code Regs. tit. 8, § 5199 applies to hospitals, skilled nursing facilities, clinics, medical offices and other outpatient medical facilities, among others.