HospitalInspections.org

On 11/8/11 at 10:30 AM, Patient #13 was observed and followed for a right total hip arthroplasty.

During the procedure in operating suite #4, four staff members were observed without shoe coverings: the anesthesiologist, and Employees #24, #25, and #26.

During the procedure, significant blood spatter appeared on the floor around the foot of the operating table and on the non-operative side. Employees #24, #25, and #26 were observed walking in and around the blood spatter.

At 12:55 PM, Patient #13's Foley catheter bag fell into the blood spatter and was placed back atop the patient.

At 12:58 PM, a pillow fell in the blood spatter and was placed back atop Patient #13.

Employees #17 and #18 were observed cleaning the operating suite post procedure. Employee #17 wore shoe coverings and Employee #18 did not. Employee #26 indicated Employee #18 would wash over her shoes with the mop after exiting. Employee #18 did not do so and left the area.

After cleaning, the surveyor inspected the operating suite floor and found areas of minute blood spatter missed by housekeeping. One area was raised from the floor vs. a spot on the floor, indicating bio-waste of some sort. The housekeepers were called back in to remove the spatter/waste.

At 1:13 PM, Employee #26 indicated shoe coverings were optional, but staff avoided walking in blood/bio-waste on the floor. If they did; however, Employee #26 agreed there was no way to prevent transfer of bio-waste to surrounding hallways, etc.

The hospital did not have a written policy governing the wearing of shoe covers. Instead, Employees #21 and #26 presented a section of the 2011 Perioperative Standards and Recommended Practices. On page 59, under section II.d., the manual referred to dedicated shoes for the operating suite and operative areas. The hospital did not keep track of whose shoes were dedicated for these areas only. The anesthesiologist wore open back clogs, which the manual advised against.

At 1:55 PM, Employees #22 and #23 were asked about the use of shoe coverings, since Employee #22 wore them and Employee #23 did not. Both agreed without hesitation that shoe coverings were supposed to be worn in the operating suites and surrounding halls within the red zone. Employee #22 indicated she did so to make it easier for housekeeping to clean.




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Based on observation, interview and document review, the facility failed to ensure safe injection practices and the maintenance of a sanitary physical environment to control infections and diseases of patients and personnel.

Findings include:

On 11/08/2011 at 10:37 AM during an endoscopy procedure, Employee #13 was observed entering a medication vial with a needle. The rubber septum on the medication vial was not disinfected with alcohol prior to piercing.
On 11/08/2011 at 10:40 AM, Employee #14 was asked about safe injection practices. She stated the rubber septum of a medication vial must be disinfected using an alcohol wipe before inserting a needle.
The facility policy titled "Safe Injection Practices", dated 01/2011, read:
"...Use aseptic technique to avoid contamination of sterile injection equipment".
On 11/08/2011 at 1:59 PM, Employee #18 was observed cleaning and disinfecting one of the operation rooms after a procedure. She placed the cleaning cart inside of the operation room. She cleaned several items with the same cloth wipe and removed her gloves several times without performing hand hygiene. Employee #18 cleaned blood on the floor using a mop, and then disposed of it in the regular trash can, not a biohazard container. A sharps container was overfilled with a sharp instrument pointing out of the container.
At 2: 02 PM, Employee #18 was observed changing the trash bag of the cleaning cart in the hallway closed to the operation room. She hand carried the bag to the soiled room using gloves. She opened the soiled room door with gloves and put the trash bag in a container. She removed her gloves and did not perform hand hygiene.
A 2:05 PM, the soiled room was inspected. There were visible blood spots on the wall, floor and sink. It was also observed several regular trash bags contained items with blood. Two containers with single use devices to be reprocessed were found overfilled with bloody instruments without covers.
At 2: 07 PM, Employee # 11 was interviewed about the items with blood in the regular trash bags. She stated trash with blood was disposed in a biohazard container and not in the regular trash can.
At 2; 20 PM, the Sterile Process department was inspected. Employee #20 explained the whole process since the surgical instruments were transported from the operation room. During the inspection of the decontamination room, it was found six containers with single use devices to be reprocessed, five of them were uncovered. The floor and walls around the containers were visibly soiled with blood. Employee #20 was interviewed about the containers with single use devices to be reprocessed. She stated the containers were stored in this area until the reprocessing company picked them up. She affirmed the reprocessing company picked up the containers daily.
The facility policy titled "Bloodborne Pathogens Exposure Control Plan", dated 01/2011, indicated:
- "... All contaminated surfaces will be decontaminated after completion of procedure and immediately or as soon as feasible after any spill of blood or other potentially infectious materials, as well as at the end of the work shift if the surface may have become contaminated since the last cleaning".
- "...Reusable sharps that are contaminated with blood or other potentially infectious materials shall not be stored or processed in a manner that requires employees to reach by hand into the containers where these sharps have been placed".
- "... The containers shall be maintained upright throughout use and replaced routinely and not be allowed to overfill. (not to exceed 3/4 full)".
The facility policy titled "Cleaning Blood and Body Fluids", dated 10/01/2009, read:
"... 7. Place material soaked with blood or body fluid into red infectious wasted liner and tie closed".