HospitalInspections.org

Based on policy review, observations, and staff interviews, the facility failed to implement an infection control program that minimized the potential of cross contamination for 2 (#s 6 and 7 ) of 9 patients observed in Same Day Surgery during the admission process. Findings include:

1. During review of the facility's policies for Hand Hygiene on 5/20/13 at 2:00 p.m., surveyors understood that, "All personnel will perform hand hygiene in the following situations (but not limited to these situations):
-Before and after direct contact with patients
-Before and after contact with blood or body fluids or secretions, mucous membranes, or non-intact skin.
-Before and after contact with objects likely to be contaminated or in the vicinity of the patient.
-Before eating and or drinking.
-Before donning sterile gloves when inserting in-dwelling/invasive catheters.
-After using the rest room.
-After removing gloves.
-When going from a dirty site to a clean site, hands shall be washed or an alcohol hand rub applied between sites."


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On 5/21/13 at 9:20 a.m., the surveyor observed the out patient surgery center. Patient #6 was in the surgical suite. During the observation a nurse drew blood, inserted the IV and then removed her gloves. She threw away the supply packaging and typed on the computer. The nurse did not sanitize/wash her hands after she removed her gloves.

On 5/21/13 at 9:50 a.m., the surveyor observed a nurse sanitize her hands as she entered the room for patient #7. The nurse had a lead apron on her torso. She pushed back her hair, pushed up her glasses, and then crossed her arms and rested her arms on the lead apron. The nurse was unable to insert the IV into the right arm. She removed her gloves, wiped her hair away from her face and again pushed up her glasses on her nose. With her bare hands she rubbed the left arm for a vein, opened the supply cart, retrieved the IV supplies, and placed a new set of gloves on the bed. She raised the bed rail, opened the supplies and then placed the arm band on the left arm. The nurse failed to sanitize/wash her hands prior to donning the new set of gloves.

On 5/21/13 at 9:00 a.m., the surveyor noticed multiple physicians enter the pre-op rooms with face mask hanging down their necks. The physicians would enter a clean surgery suite, talk to the patient, take vitals and then leave the suite and enter another suite. One unidentified physician had the face mask draped around the back of her neck so that the face mask was touching her neck and hair. The physicians were observed to be behind the nurse desk charting, in the medication room, and up and down the hall ways. At this time the manager stated that face masks were to be removed after the physicians left the surgery room.

On 5/21/13 at 9:15 a.m., staff member C stated the hospital policy was to wash/sanitize as going in the patient's room and leaving the room.

On 5/21/13 at 10:00 a.m., staff member C stated the facility educated the physicians and staff members to remove the face mask as they are leaving the operating room.

Based on surveyor review of the ARON Standards provided on 5/21/13 at 1:00 p.m., "Masks should not be worn hanging down from the neck. The filter portion of a surgical mask harbors bacteria collected from the nasopharyngeal airway. The contaminated mask may cross-contaminate the surgical attire top. Surgical masks should be discarded after each procedure. Masks should be removed carefully by handling only the mask ties. Hand hygiene should be preformed after removal of the masks...."