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ADVENTIST HINSDALE HOSPITAL 120 NORTH OAK ST HINSDALE, IL 60521 Oct. 2, 2012
VIOLATION: INFECTION CONTROL Tag No: A0747
Based on record review, observation, and interview, it was determined that the Hospital failed to investigate and take corrective action for reported infection control problems in the Operating Room (OR) (A-749 A).

The cumulative effect of these systemic practices resulted in the Hospital's inability to ensure surgical procedures were performed in an infection controlled environment.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


A. Based on record review and interview, it was determined, that for 1 of 9 clinical records reviewed (Pt. #1), the Hospital failed to investigate and take corrective action for reported infection control problems in the Operating Room (OR).

Findings include:

1. The Nurse Manager job description was reviewed and required, the Nurse Manager "Facilitates resolution of issues involving staff/ patients/ families/ physicians, as needed... Conducts regular staff meetings with employees to discuss problems, new procedures, etc. Facilitates the timely resolution of problems..."

2. The clinical record of Pt. #1 was reviewed and indicated that Pt. #1 was a [AGE] year old male, admitted on [DATE], with a diagnosis of Left Vestibular Schwannoma. Pt. #1's anesthesia record dated 9/12/12, included a 6 1/2 hour procedure (7:00 AM to 1:30 PM) and Pt. #1's operative report dated 9/12/12, included a routine procedure and " There were no complications of surgery." However, discussion with Hospital staff involved in Pt. #1's procedure indicated infection control problems were experienced during the procedure.

3. On 10/2/12 at 10:00 AM, an interview was conducted with a Certified Scrub Technician (E #6) who provided care to Pt. #1 on 9/12/12. E #6 stated that blood fell on the floor and chair and a Nurse (E #1) brought in a mop to clean up the blood. Another CST (E #19) informed E #1 that a mop should not be brought into the room during the procedure and E #1 disagreed.

4. Hospital policy # (RG) INC.252, revised 1/19/12, titled, "Cleaning Up Blood Spills/Other Body Fluids", required, "Cleaning up blood spills requires special procedures and disinfectant ... small blood spill ... blot up spill ... large blood spill ... protect the area from traffic ..."

5, An interview was requested with E #1. However, E #1 was not at work and could not be contacted by phone.

6. E #6 stated that there was a Neuro-physiology Technician (E #4) who was not wearing a mask and was coughing during the procedure.

7. E #6 stated that a probe instrument dropped off the sterile field into the drape and out of sight. The Neurologist (E #5) ordered E #6 to give him the probe and used it on Pt. #1.

8. On 10/2/12 at 10:10 AM, an interview was conducted with the OR Manager, who was present during the interview with E #6. The OR Manager stated that she became involved in Pt. #1 case because a CST (E #19) left Pt. #1's case during the procedure and went to the Manager's office to complain about infection problems. The OR Manager stated that she counseled E #1 about the mop, but had not documented the counseling. The OR Manager stated that she had not followed up on the Neuro-physiology Technician's (E #4) lack of wearing a mask and had not contacted the Neurology Surgeon (E #5) regarding the fallen probe.

B. Based on record review, observation, and interview, it was determined that for 6 of 14 staff (E #8, 18, 20, 21, 22, & 23) in restricted area, OR suite 2 and in the semi-restricted corridor on 10/1/12, the Hospital failed to ensure infection control attire policies were followed.

Findings include:

1. Pt. #2's clinical record was reviewed and included a [AGE] year old female, admitted on [DATE], to undergo "Removal of Spine Implant and Interbody Cage; Extension of Fusion and Fixation to Sacrum and Pelvis; Osteotomy L4, L4 - L5, and L5 - S1; and Transforaminal Lumbar Interbody Fusion and Grafting".

2. Hospital policy, # (HH) 32.147, effective 5/12, titled, "Infection Control: Surgical Attire" required"... Jewelry that cannot be contained within the surgical attire will not be worn... All personnel will cover head and facial hair, including sideburns and the nape of the neck, when in the semi-restricted and restricted areas... All individuals entering the restricted area will wear a surgical mask when open sterile supplies and equipment are present... Masks will not be worn hanging down from the neck..."

3. On 10/1/12, between 9:30 AM and 11:30 AM, an observational tour was conducted in the OR. Pt. #2 was scheduled for surgery in OR Suite 2. The following was observed during Pt. #2's procedure:

- Several staff members (E #18, & 20, 21) had sideburns and/or hair exposed below their caps.

- One Circulating Nurse (E #8) entered the room, holding an untied mask to his face.

- A Heritage Medical Group Manufacturer's Representative (E #23) wore a ring on her left hand.

4. When leaving OR Suite 2 at 11:30 AM, a Registered Nurse (E #22) was wearing a dangling mask in the semi-restricted corridor.

5. On 10/1/12, at 11:31 AM, an interview was conducted with the Regional Director of Regulatory Compliance and Patient Safety. The findings were reviewed.

C. Based on record review, observation, and interview, it was determined that for 1 of 2 registered nurses (E #9) who prepped the patient's surgical site, the Hospital failed to ensure surgical preparation of the skin was done according to policy.

Findings include:

1. Hospital policy, # (HH) 32.046, reviewed 8/11, titled, "Surgical Preparation of the Skin" required "... Utilize the surgical principle of progression from the cleanest area to the least clean area, the prep begins at the line of intended incision and progresses to the periphery..."

2. On 10/1/12, between 9:30 AM and 11:30 AM, an observational tour was conducted in the OR. In OR Suite 2, Pt. #1, a [AGE] year old female, admitted on [DATE], underwent "Removal of Spine Implant and Interbody Cage; Extension of Fusion and Fixation to Sacrum and Pelvis; Osteotomy L4, L4 - L5, and L5 - S1; and Transforaminal Lumbar Interbody Fusion and Grafting".

3. At 10:52 AM, a Registered Nurse (E #9) applied Chloraprep to the operative area, then reapplied the Chloraprep applicator to the proximal incision area after applying the solution to a more distal area.

4. When leaving OR Suite 2 at 11:30 AM, an interview was conducted with E #17. E #17 agreed that E #9 had returned the prep applicator to the cleaner area.