HospitalInspections.org

Based on a tour of the facility and staff interview (EMP), it was determined that the facility failed to follow the facility policy for hand hygiene and terminal cleaning of the operating room (OR) to prevent infections.

Findings include:

Review of policy "Hand Hygiene" revised August 2014, revealed, "... A. Policy Statement. Handy hygiene (either traditional hand washing with soap and water or hand sanitizer use) is the most important practice for preventing the spread of infection and must be performed by all employees and healthcare workers when entering and exiting the patient's room, even when gloves have been worn. ... It is the policy to ' wash in and wash out ' C. After contact with patient care equipment, medical devices or other inanimate objects, blood, body fluids or excretions, mucous membranes or non-intact skin F. After situations during which microbial contamination of hands is likely, especially those involving contact with mucous membranes, blood/body fluids, secretions or excretions (if hands are not visibly soiled)...."

Review of facility policy "Environmental Cleaning in the Perioperative Services Area" dated July 15, 2014, revealed, "... E. At the conclusion of the day's schedule - Terminal cleaning will be performed on the night shift by the Environmental Services department. 1. Areas to be cleaned daily include: a. ORs (operating rooms). ..."


1) Observation on the Surgical Intensive Care Unit (SICU), on March 18, 2015, at approximately 10:15 AM revealed a physician assistant (PA) and a PA student in a patient room removing a Jackson Pratt (JP) drain and removing cardiac pacer wires. The student left the room and later re-entered the room without washing in or out. The PA removed the JP drain, and then proceeded to remove the cardiac pacer wires without performing hand hygiene between procedures. At the time of the observation EMP5 confirmed that the student and PA should have performed hand hygiene upon exiting and entering the room and between procedures.

2) Further observation of SICU on March 18, 2015, at approximately 11:00 AM, revealed a patient in a room with signage indicating gloves and a mask must be worn upon entering the room. A PA exited the room without performing hand hygiene. An anesthesiologist entered the room without performing hand hygiene or donning a mask. At the time of the observation EMP7 confirmed that the health care workers did not follow the hand hygiene.

3) Observation of a procedure in OR #24 on March 19, 2015 at approximately 7:30 AM revealed an anesthesia resident exit and return to the OR twice without performing hand hygiene.

4) Observation of a procedure in OR #24 on March 19, 2015 at approximately 7:30 revealed a large amount of dust particles on top of two different monitors.

At the time of the observations EMP14 confirmed the findings and stated, "I see that."