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Based on observation, staff interview and document review conducted on 4/19/11, the facility failed to construct and maintain the hot water system of the hospital in a way that ensure the health and safety of the patients who receive surgical services in the Operating Rooms Suite (OR).

The hospital failed to ensure that the hot water of the scrub sinks in Operating Rooms Suite (OR) is clean, sanitary and free of contaminants. Six out of six (6 of 6) of the OR scrub sinks were observed by the state and the RO surveyors to have discolored, brown and turbid water that was observed to be dirty with black sediments. During this observation three (3) patients were undergoing surgical procedures and two (2) patients were awaiting surgery.

The hospital's failure to:
1- recognize the presence of the problem of the hot water at the scrub sinks of the OR suite;
2- have a mechanism in place to prevent and control the potential patient harm during surgery due to surgical personnel scrubbing using turbid water;
3- maintain the hospital 's hot water system to ensure the safety and well being of the patients.
The above failure showed a lack of compliance with the Condition of Participation at 42 CFR 482 Physical Environment.

Findings include:

During a tour of the Operating Room Suites on 4/19/2011 at 2:20 PM, the state surveyor turned on the hot water faucets of the scrub sinks outside Operation Rooms #3 and #4 and the hot water of those faucets was observed to be dirty, discolored, with brownish color, and they had an unclean, unsanitary appearance. These sinks are used for scrubbing before surgery.

The State surveyors and the RO surveyor asked the facility staff to check all the faucets of all the scrub sinks outside all the Operation Rooms in the OR Suite.

Six out of six of the scrub sinks that were checked were found to have dirty, unsanitary, turbid and discolored water with black sediments as follows:
1- All the faucets of the scrub sink between OR # 3 and OR # 4.
2- All the faucets of the two scrub sinks between OR #2 and OR #1.
3- All the faucets of the two scrub sinks between OR #11 and OR #12.
4- All the faucets of the scrub sink between OR #5 and OR #6.

These observations were found in the presence of the Director of Anesthesiology SP#26, the Director of Surgery SP#27, the Associate Executive Director - Facility Management SP#30, the OR Head Nurse SP#28, Infection Control Senior Associate Director SP#29 and several OR nurses who stated that they were not aware of when the discoloration of the water started or what caused the discoloration of the hot water.

The Director of Anesthesiology, the Director of Surgery, the OR Head Nurse and the nurses who were accompanying the surveyors when the above observations were made stated that they observed dirty and discolored hot water was not good for cleaning hands and was not good for scrubbing before surgery.

When asked, and after confirming with the plumbers of the hospital, the Associate Executive Director - Facility Management said that the facility did not have any recent purging or maintenance of the water system that might have caused the above problem of the hot water at the scrub sinks. Also, the staff member said that the only maintenance and cleaning of the hot water system is the cleaning of the hot water tank and that that is done annually.

Moreover, the Associate Executive Director - Facility Management stated that the facility will have to open the ceiling in multiple areas and check for possible failure of one or more of the pressure reducing stations of the hot water system that feed OR Suite which has multiple hot water feeds.

Review of the hospital records of the hot water tank, revealed that the hot water tank was cleaned in June 2010 and is cleaned once a year by an outside vendor. The next scheduled cleaning of the hot water tank is in June of 2011.
At 3:40 PM the hot water system in the boiler room on the 1st floor was checked by the hospital plumber and the water boiler was found to have no sediments in the tank, no water or steam leak.

The OR suite is located on the 5 th floor of the building and according to the Associate Executive Director - Facility Management and after he reviewed the blue print of the plumbing, the hot water supply of the 5 th floor has multiple hot water feeds.

The hot water of other floors (4 th floor, 8 th floor and 9 th floor) were checked and was found to have no problem. Also, the hot water system of the Dialysis Unit on the 17 th floor was checked and was found to have no problem.

Based on observation, staff interview and document review conducted on 4/19/11, it was revealed that the hospital failed to ensure that the hot water of the scrub sinks in Operating Rooms Suite (OR) is clean, sanitary and free of contaminants. Six out of six (6 of 6) of the OR scrub sinks were observed by the state and the RO surveyors to have discolored, brown and turbid water that was observed to be not clean with black sediments. During this observation three (3) patients were undergoing surgical procedures and two (2) patients were awaiting surgery.

The hospital's failure to:
1- recognize the presence of the problem of the hot water at the scrub sinks of the OR suite;
2- have a mechanism in place to prevent and control the potential patient harm during surgery due to surgical personnel scrubbing using turbid water;
3- implement appropriate infection control interventions in order to prevent and control infections showed a lack of compliance with the Condition of Participation at 42 CFR 482.42 Infection Control. As a result, these deficient practices posed an immediate and serious threat to patients health and safety.

Findings include:

During a tour of the Operating Room Suites on 4/19/2011 at 2:20 pm, the state surveyor turned on the hot water faucets of the scrub sinks outside Operation Rooms #3 and #4 and the hot water of those faucets was observed to be dirty, discolored, with brownish color, and they had an unclean and unsanitary appearance. These sinks are used for scrubbing before surgery.

The State surveyors and the RO surveyor asked the facility staff to check all the faucets of all the scrub sinks outside all the Operation Rooms in the OR Suite.

Six out of six of the scrub sinks that were checked were found to have dirty, unsanitary, turbid and discolored water with black sediments as follows:
1- All the faucets of the scrub sink between OR # 3 and OR # 4.
2- All the faucets of the two scrub sinks between OR #2 and OR #1.
3- All the faucets of the two scrub sinks between OR #11 and OR #12.
4- All the faucets of the scrub sink between OR #5 and OR #6.

These observations were found in the presence of the Director of Anesthesiology SP#26, the Director of Surgery SP#27, the Associate Executive Director - Facility Management, the OR Head Nurse SP# 28, Infection Control Senior Associate Director SP# 29 and several OR nurses who stated that they were not aware of when the discoloration of the water started or what caused the discoloration of the hot water.

The Director of Anesthesiology, the Director of Surgery, OR Head Nurse and the nurses who were accompanying the surveyors when the above observation was made stated that the observed dirty and discolored hot water was not good for cleaning hands and was not good for scrubbing before surgery.

When asked, and after confirming with the plumbers of the hospital, the Associate Executive Director - Facility Management said that the facility did not have any recent purging or maintenance of the water system that might caused the above problem of the hot water at the scrub sinks. Also, the staff member said that the only maintenance and cleaning of the hot water system is the cleaning of the hot water tank and that that is done annually.

Review of the hospital records of the hot water tank, revealed that the hot water tank was cleaned in June 2010 and is cleaned once a year by an outside vendor. The next scheduled cleaning of the hot water tank is in June of 2011.
At 3:40 pm the hot water system in the boiler room on the 1st floor was checked by the hospital plumber and the water boiler was found to have no sediments in the tank, no water or steam leak.

The OR suite is located on the 5th floor of the building and according to the Associate Executive Director - Facility Management and after he reviewed the blue print of the plumbing, the hot water supply of the 5th floor has multiple hot water feeds.

The hot water of other floors (4th floor, 8th floor and 9th floor) was checked and was found to have no problem. Also, the hot water system of the Dialysis Unit on the 17th floor was checked and was found to have no problem.

The hospital Administration was contacted regarding the above finding and was informed of an Immediate Jeopardy (IJ) situation at 4:09 PM, and was informed that an immediate plan of correction had to be submitted before the IJ would be abated.

On 4/19/11 at 7:35PM, the immediacy was corrected based on an acceptable plan of correction. However the Condition of Participation at 42 CFR 482.42 Infection Control remains out.