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ADVENTHEALTH WESLEY CHAPEL 2600 BRUCE B DOWNS BLVD WESLEY CHAPEL, FL 33544 Sept. 2, 2015
VIOLATION: OPERATING ROOM POLICIES Tag No: A0951
Based on record review, facility policy review and interview it was determined the facility failed to ensure surgical services met the needs and resource for two (#5, #7) of fourteen sampled surgical records reviewed.

Findings include:

A review of the surgical log for 07/17/2015 revealed nine surgical cases.

A review of record #7 revealed an invasive knee arthroscopy was performed outside the restricted surgical suite in endoscopy room #2. The patient was brought into the room at 7:46 a.m., the procedure started at 8:34 a.m. and ended at 8:52 a.m. The patient left the room at 8:56 a.m. and was transferred to the PACU (post anesthesia care unit).

A review of record #5 revealed an invasive knee arthroscopy was performed outside the restricted surgical suite in endoscopy room #2. The patient was brought into the room at 9:10 a.m., the procedure started at 9:30 a.m. and ended at 9:53 a.m. The patient left the room at 10:00 a.m. and was transferred to the PACU.

A review of the facility policy titled "Surgical Services Scope of Service" #SS.305-01, page #8 Heading: Endoscopy: Type of patient served: item #1, Read: The Endoscopy procedure unit is a 2 room unit designated to meet the needs of adolescent, adult and geriatric patients. The market served are those patients requiring inpatient or outpatient endoscopy procedures and care. Approved procedures and treatments include EGD, Colonoscopy, Bronchoscopy and ERCP procedures.

Interview on 08/31/2015 at approximately 10:00 a.m. with the director of surgical services revealed she opened endoscopy room #2 for the knee arthroscopies. She stated she did not get approval from the chief of surgery or inform risk management or the chief nursing officer if the decision.

An interview on 09/02/2015 at approximately 9:00 a.m. with the chief of surgery revealed he did not authorize the procedure room to be used for an invasive surgical procedure. He did not know the room had been used until this interview. He stated he did not see an issue with the use of the room for an arthroscopy of the knee as it was a scope procedure.

An interview on 09/02/2015 at approximately 8:30 a.m. with the chief nursing officer, risk manager and the quality analyst/infection control nurse confirmed the above findings. It revealed they were unaware of the endoscopy room being used for invasive surgical procedure (knee arthroscopy) until the time of the survey.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on record reviews, facility policy reviews and interviews it was determined the infection control officer failed to ensure policies related to infection control in operating rooms were implemented for two (#5, #7) of fourteen sampled records reviewed.

Findings Include:

A review of record #7 revealed an invasive knee arthroscopy was performed outside the restricted surgical suite in endoscopy room #2 on 7/17/15. The patient was brought into the room at 7:46 a.m., the procedure started at 8:34 a.m. and ended at 8:52 a.m. The patient left the room at 8:56 a.m. and was transferred to PACU (post anesthesia care unit).

A review of record #5 revealed an invasive knee arthroscopy was performed outside the restricted surgical suite in endoscopy room #2 on 7/17/15. The patient was brought into the room at 9:10 a.m., the procedure started at 9:30 a.m. and ended at 9:53 a.m. The patient left the room at 10:00 a.m. was transferred to PACU.

An interview on 08/31/2015 at approximately 10:00 a.m. with the director of surgical services revealed the procedure rooms are used for Bronchoscopy, Urology and Gastroenterology. When questioned if those were the only types of procedures performed within the procedure rooms, the director stated a knee arthroscopy had been performed in the procedure room a while back but could not remember the date. The director stated the room was terminally cleaned prior to and following the surgery. When the director was asked for the terminal cleaning log, she stated she was not aware of a log. She stated the instruments used for the procedure were transported on a covered cart from surgery to the endoscopy rooms and back.

The procedure rooms were not within a restricted access hallway. There was no scrub sink outside the room or within the room. There was a small hand washing sink outside the procedure rooms on the opposite side of the hallway. Each room did have a small hand sink within the room.

An interview on 09/01/2015 at approximately 10:30 a.m. with the Director of Environmental Services revealed terminal cleaning logs for Operating Rooms 1-5. The Director stated the endoscopy rooms as well as the cath lab were terminally cleaned after the last procedure of day was completed but was not currently recorded. He stated there were no log to show terminal cleaning was performed prior to arthroscopies being done in Endoscopy room #2 before or after each procedure or after the last case performed.

On 09/02/2015 at 9:30 a.m. an interview with the Chief of Surgery revealed he did not authorize the procedure room to be used for an invasive surgical procedure. He did not know the room had been used until this interview. He stated he did not see an issue with the use of the room for an arthroscopy of the knee as it was a scope procedure.

A review of the inspection of the Air Exchanges performed on 07/13/2015 revealed Endoscopy room # 2 was at negative pressure with an ACH (air change per hour) of 22.2.

09/02/2015 at 9:45 a.m. an interview with the Director of Engineering revealed Endoscopy room #2 changed to negative pressure on 07/08/2015 per the log book. It changed to positive pressure on 07/17/2015, however no time was logged. It was not able to be confirmed negative or positive pressure was present in Endoscopy #2 at time of surgical procedures of 2 separate knee arthroscopies.

A review of facility policies titled "Infection Prevention Plan 2015" #IC.000-01A; "Surgery Cleaning" #9.01; "Standard Precautions and Transmission-Based Precautions" #IC.000.02; "Cleaning of the Operating Room Suites", #SS.305-17 and "Surgical Services Scope of Service" #SS.305-01 revealed the facility failed to follow facility policies by not informing the chain of command of potential increased risk of surgical site infection.

An interview on 09/02/2015 at approximately 8:30 a.m. with the chief nursing officer, risk manager and the quality analyst/infection control nurse confirmed the above findings. They revealed they were unaware of the endoscopy room being used for invasive surgical procedure (knee arthroscopy) until the time of the survey.