HospitalInspections.org

Based on Observation and Interview the facility failed to follow their infection prevention and control plan to prevent the spread of hospital acquired infection and maintain a clean and sanitary environment in 4 of 4 operating rooms (OR) observed (OR #1, 2, 3, 4).

Findings Include:

Review of Facility Policy, "Infection Prevention and Control Plan 2022," reference number RF-INF-003, effective date, 03/2022 revealed, "The (facility name) Hospital Infection Prevention and Control Program is an integrated program designed to reduce the risks of acquiring and transmitting hospital acquired infections (HAI) associated with provision of care, unprotected measures, medical procedures, and the use of medical equipment and medical devices. .....The infection detection, analysis, monitoring, and evaluation activities of the surveillance program are based on nationally recognized systems and best practice guidelines....Core activities of the program include.....Integrating the infection control function and processes with other organization-wide functions and activities including....pertinent environmental controls....The infection preventionist, with the assistance of members of the Environment of Care Committee.....conduct tracer surveys and environmental audits to assure that the hospital is maintained in a sanitary manner. Areas that are monitored include.....surgical and other procedural areas....in accordance to federal, Wisconsin, and local regulations, codes, guidelines, recommendations and current standards of practice."

During a tour and observation of the 4 operating rooms on 05/03/2022 from 09:35 AM to 10:00 AM with Surgery Manager A and Infection Preventionist B and Supervisor C, observed multiple spots of chipped paint and exposed sheet rock present in the corners of all 4 operating room suites and paint chips/nicks and exposed sheet rock present in the OR hallway by the dirty utility room and by the prep and pack room.

In an interview with Surgery Manager A on 05/03/2022 at 9:50 AM, when asked Surgery Manager A if the observations of OR rooms # 1, 2, 3, 4 and hallways were correct, Manager A stated, "It certainly looks like it."

In an interview with EVS (Environmental Services) Day Lead Staff F, when asked about how the OR (Operating Rooms) are cleaned, Staff F stated, "We start in one area and clean the bed and work our way out." When asked about the chips noted in all 4 of the OR rooms, Staff F stated, "For the chips, we'd put a work order in, I'm not aware of any current work orders. I do know the rooms need to be painted....a lot of the nicks are from our mops when we mop the walls."

In an interview with IP (Infection Preventionist) Manager O on 05/03/2022 at 2:55 PM when asked about the paint chips noted in the OR, IP Manager O stated, "We follow the FGI (Facility Guidelines Institute) standards for OR Construction and the walls and floors, everything has to be cleanable and wipeable. Our policy is that surfaces should be cleanable and wipeable, we follow AORN (Association of Operating Room Nursing) guidelines and it should be a smooth surface."

In an interview with Surgery Manager A on 05/04/2022 at 8:55 AM when asked about the paint chips and nicks in the OR, Manager A stated, "I would have expected this to be reported, we do safety rounds and I'm kicking myself for not knowing."