The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

KANSAS SURGERY & RECOVERY CENTER 2770 NORTH WEBB ROAD WICHITA, KS 67226 May 4, 2012
VIOLATION: INFECTION CONTROL Tag No: A0747
Based on observations, policy/document review and staff interview the infection control officer failed to ensure staff used single use surgical masks per policy, followed manufacturer's instructions for "flash" sterilization and high level disinfection, followed the hand hygiene policy, used disinfectants in accordance with manufacturer's instructions, and designated multi-dose vials as single dose vials when used in the Operating Room (OR) and failed to maintain a sanitary environment. Non-compliance with these requirements has the potential to cause Healthcare Acquired Infections (HAI) in all surgical patients.

The cumulative effect of non-compliance with infection control policy and practices resulted in the hospital's inability to ensure a safe and sanitary environment for all surgical patients receiving services at the hospital.

Findings include:

- The infection control officer failed to ensure staff used single use surgical masks per policy, followed manufacturer's instructions for "flash" sterilization and high level disinfection, followed the hand hygiene policy, used disinfectants in accordance with manufacturer's instructions, and designated multi-dose vials as single dose vials when used in the Operating Room (OR) and failed to maintain a sanitary environment. For further evidence see A-0749, 42 CFR 482.42(a)(1).
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observations, policy/document review and staff interview the infection control officer failed to ensure staff used single use surgical masks per policy, followed manufacturer's instructions for "flash" sterilization and high level disinfection, followed the hand hygiene policy, used disinfectants in accordance with manufacturer's instructions, and designated multi-dose vials as single dose vials when used in the Operating Room (OR) and failed to maintain a sanitary environment. Non-compliance with these requirements has the potential to adversely affect all surgical patients at the hospital.

Findings include:

- Review of the Hospital's Infection Management Program and Exposure Plan approved on 11/3/10 directed the following:

1. The Hospital Board has final accountability for the infection management program.

2. The Administration and the Director of Nursing Service support the infection management program.

3. The Infection Control Practitioner developed plans for routine activities and responsibilities of surveillance, prevention and control of infection, carried out periodic inspections to ensure that procedures for the control of infections are being followed correctly and conducted environmental surveillance monitoring through direct observation in these areas: proper hand washing, respiratory etiquette, cleaning/sterilization of equipment using the hospital approved disinfectant/sterilization processes.

- Observation on 4/30/12 at 11:35am revealed staff S, a CRNA (Certified Registered Nurse Anesthetist) stood in the hospital cafeteria with a used surgical mask dangling around their neck picking up food to go.

Random observation on 4/30/12 at 12:35am of the OR breakroom/lounge revealed a female OR staff member sat and ate their lunch with a surgical mask dangling around their neck.

Observation on 4/30/12 at 12:45pm revealed staff O, an anesthesiologist walked into an OR with a used surgical mask dangling around their neck.

Random observation on 4/30/12 at 1:32pm revealed two OR staff wheeled a patient up the hall and into an OR with their surgical masks dangling around their necks.

Random observation on 4/30/12 at 1:35pm revealed two OR staff walked out of the OR surgery suite into the post-operative area with their surgical masks dangling around their necks.

Random observation on 4/30/12 at 1:36pm revealed a male OR staff person walked into the OR surgery area from the pre-operative area and entered OR #3 with their surgical mask dangling around his neck.

Random observation on 4/30/12 at 1:37pm revealed a male OR staff member stood by the pre-operative nursing station with a surgical mask on over their face, with gloved hands touching lying on the nursing station counter. The OR staff member walked into the OR surgery suite walked up the OR corridor and entered OR #5.

Random observation on 4/30/12 at 1:41pm revealed a male OR staff exited OR #4 as they tucked their surgical mask under their chin.

Random observation on 4/30/12 at 1:42pm revealed a female OR staff moved in and out of the OR surgery suite to the pre-operative area with their surgical mask dangling around their neck.

Random observation on 4/30/12 at 1:45pm revealed a female CRNA walked in the hall of the surgery suite area with her used surgical mask hanging around her neck. The CRNA sneezed into her surgical mask and left it hanging around her neck. The CRNA then entered OR #7 were the housekeeping staff was performing a terminal cleaning of the room. The CRNA then walked out of the surgical suite area into the pre-op and post-op area with the same surgical mask hanging around her neck. The CRNA failed to perform hand hygiene or change their surgical mask after they sneezed in it.

Random observation on 4/30/12 at 1:45pm revealed an OR nurse and a CRNA wheeled at patient on a gurney out of the OR area into the post-operative area with their surgical masks dangling around their necks.

Observation on 4/30/12 at 2:30pm revealed staff O, an anesthesiologist, walked off of the OR area with their surgical mask dangling around their neck.

Random observation on 4/30/12 at 2:31pm revealed a CRNA stood at the pre-operative nursing station with their surgical mask dangling around their neck.

Observation on 4/30/12 at 3:30pm revealed staff O, an anesthesiologist walked out of the surgery area into the hospital's lobby waiting area with a surgical mask dangling around their neck. Staff O left the lobby area and went back into the surgery area.

Random observation on 5/1/12 at 8:10am revealed a CRNA walked onto the inpatient unit and made rounds to patients on the unit with their surgical mask dangling around their neck.

Patient #11's clinical record reviewed on 5/1/12 at 8:20am revealed an admission date of [DATE] for left knee arthroscopy and repair of meniscus tear. Observation in patient #11's pre-operative cubicle on 5/1/12 at 8:37am, 8:42am, and 8:45am revealed staff G, an anesthesiologist, staff H, an anesthesiologist, and staff I, a physician assistant, all visited patient #11 with their used surgical masks hanging around their necks.

Random observations on 5/1/12 between 8:00am and 11:00am of surgical staff entering and exiting the surgical suite area revealed 18 female surgical staff and 5 male staff exited the surgical suite area into the pre-op and post-op areas and re-entered the surgical suite area with their used surgical masks hanging around their necks.

Random observation on 5/1/12 at 11:26am revealed three CRNA staff stood at the pre-operative nursing station area with their surgical mask dangling around their necks.

Random observation on 5/1/12 at 12:00pm revealed three female OR staff and one male OR staff stood in line at the hospital's cafeteria with their surgical masks dangling around their necks.

Random observation on 5/2/12 at 8:15am revealed a male OR staff member stood at the pre-operative nursing station then walked into the OR surgery suite with their surgical mask dangling around their neck. Two other OR staff sat at the nursing station with their surgical mask dangling around their necks.

Random observation on 5/2/12 at 8:22am revealed two female OR staff wheeled a patient from the pre-operative area into the OR surgery suite with their surgical masks dangling around their necks.

Random observation on 5/2/12 at 12:00pm revealed four OR staff members in the hospital's cafeteria with their surgical masks dangling around their necks.

Random observation on 5/3/12 at 8:38am revealed multiple OR staff moved in and out of the OR suite with their surgical masks dangling around their necks.

Hospital policy titled "Surgical Attire" reviewed on 5/2/12 at 4:00pm directed staff "...masks will be discarded as soon as it is removed from the face. Masks are not to be worn hanging around the neck...All masks should be removed when leaving the semi-restricted area...".

Staff A, RN/DON interviewed on 5/2/12 at 4:45pm verified staff failed to follow hospital policy regarding not wear their surgical masks dangling around their necks.

- Observation on 4/30/12 at 12:45pm revealed OR staff picked up a pan of uncovered and unwrapped instruments from a "flash" sterilizer with sterile thongs. They carried the pan across the hall to OR #3. There was traffic in the hallway of OR staff and patient's being wheeled on gurneys to other ORs. Another OR staff went to a different "flash" sterilizer near OR #5 picked-up a pan of uncovered/unwrapped instruments and walked up the OR hallway.

Staff B, RN/OR Nurse Manager interviewed on 4/30/12 at 1:30pm shared she does not track the amount of items flashed sterilized.

Observation on 4/30/12 at 1:50pm revealed an OR technician placed a pan of instruments into a "flash" sterilizer. The technician called the instrument a "Ronjuer" and it was going to be "flashed" sterilized for 15 minutes.

Staff N, Lead Instrument Technician interviewed on 4/30/12 at 2:25pm verified the instrument that was "flashed" sterilized at 1:50pm was a "Ronjuer". Staff N shared that they also "flash" sterilized batteries for the Stryker Power. They cleaned the batteries with detergent and placed them in the battery charger. Staff "flash" sterilized the battery prior to each surgery case. Staff N explained "flash" was the same as regular sterilization.

Observation on 5/1/12 at 10:15am revealed staff Q, an OR nurse placed batteries in the sterilizer #5 for 10 minutes on the "flash" cycle.

Observation during the patient #11's tracer surgery case on 5/1/12 at 11:30am revealed the Circulating nurse carried into the OR a pan of Arthroscopic bites that staffed had "flashed" sterilized. The Scrub nurse stated they have two sets, so when one set was in use the other set they cleaned in the ultra-sonic washer and then "flashed" sterilize them for the next case.

Staff A, RN/DON interviewed on 5/2/12 at 11:00am provided for review the manufacturer's direction for use of the AMSCO sterilizer's express cycle. Staff A also provided for review information on the Ronjuer surgical instrument, the power batteries and laparoscopic instruments.

Review of this information revealed the following:

1. For the AMSCO sterilizer: "...Special information regarding the Express Cycle: The Express cycle is an abbreviated prevacuum flash cycle that is available on small (16 inch and 20 inch) Vacamatic sterilizers. Appropriate parameters for sterilization are preset by AMSCO. The sterilizer is designed to permit flash sterilization using a single wrapper (non-woven or textile) on the instrument tray. Rationale: The single wrapper serves to confine and contain the sterilized items from environmental contaminants that may be encountered enroute from the sterilizer to the point of use...".

2. For laparoscopic instruments: From Smith & Nephew laparoscopic instruments these have been approved for "flash prevac steam" sterilization.

3. For the Stryker batteries: Stryker information regarding battery packs directed staff to "store the batteries in the charger after cleaning and to sterilize them prior to use". The instructions contained methods for sterilization: "Under one of the approved method for sterilization: "...Hi Vac, Pre-vacuumed sterilizer, 270-272 degrees Fahrenheit, 4-minute exposure time" was approved. The instructions directed staff that the batteries could be "wrapped or unwrapped" during the sterilization process..

4. For the Ronjuer surgical instrument: This surgical instrument was part of the Buxton Shoulder Repair Set. Review of a test report conducted by Myoscience Inc., specialists in microbiology and regulatory affairs, dated 10/06/08 regarding 270 degree Fahrenheit sterilization of the Buxton Instrument Set revealed "...selected instruments were wrapped in a single layer of sterilization wrap and autoclaved at 270 degrees Fahrenheit and 30-32 PSIG (pound-force per square inch gauge) for 5 minutes...was sufficient to sterilize the selected instruments...This validated time should encompass both gravity and pre-vacuum cycles, wrapped or unwrapped...Following proper cleaning procedures, applicable hospital and AAMI (Association for the Advancement of Medical Instrumentation) guidelines, and the sterilizer's instruction manual are essential to successful sterilization...".

The hospital OR staff on 5/2/12 during the surgery schedule documented items they "flashed" sterilized. They "flashed" sterilized the following:

In autoclave #9 they flashed sterilized power batteries and a physician's special instrument sets. The MD had two sets of instruments and three cases scheduled.

In autoclave #10 they flashed sterilized batteries.

Staff A, RN/DON interviewed on 5/3/12 at 10:40am verified the OR staff do not wrap any equipment or instruments when they "flashed" sterilized them using the AMSCO sterilizer's express cycle. Staff A acknowledged the written information from AMSCO about the express (flash) cycle indicated the cycle was designed to use a single wrapper (non-woven or textile) on the instrument tray. Staff A stated they talked with Staff N, the Lead Instrument technician. Staff A indicated they followed an affiliate hospital's practice who did not wrap or cover items flashed. Staff A reported OR staff followed AAMI standards.

Staff A, RN/DON interviewed on 5/3/12 at 11:00am provided excerpts from the 2011 and 2012 AAMI manual regarding "flash" sterilization. Review of these excerpts revealed the following:

1. From the 2011 AAMI standards: Flash sterilization: General considerations related to wrapped or unwrapped loads directed staff "...The stated parameters are only intended to be general guidelines. The sterilizer manufacturer's written IFU (instructions for use) and the device manufacturer's written IFU should always be followed...".

2. From the 2012 AAMI standard related to "flash" sterilization directed staff "...The items to be processed are usually unwrapped, although a single wrapper may be used in certain circumstances if the sterilizer or packaging manufacturer's written IFU permit...".

Hospital policy titled "Sterilization and Disinfection" reviewed on 5/2/12 at 4:30pm directed staff "...Steam Sterilization-High Speed: The High Vac instrument sterilizer is adjusted at 270 degrees F. and 32 pounds of pressure for three minutes, four or ten minutes depending on type and volume of load. The manufacturer's directions are filed in the workroom...".

Staff B, RN/OR Nurse Manger interviewed on 5/3/12 at 11:48am acknowledged they re-checked with staff N, the lead instrument technician. The instrument technician was adamant they do not have or supposed to wrap anything when they "flash" sterilizer.

Staff A, RN/DON interviewed on 5/3/12 at 11:48am verified OR staff failed to follow the sterilizer's written instructions for use to single wrap items when using the express cycle.

- Observation on 4/30/12 at 1:30pm revealed two metal tables along the OR main corridor. Each of the metal tables had two blue plastic tubs with lids that contained a liquid. OR staff had dated the tubs with 5/10/12. The tables also had other blue plastic tubs with lids, no date and some with a clear liquid in them.

Staff B, RN/OR Nurse Manager interviewed on 4/30/12 at 1:30pm explained these two metal tables with the blue plastic tubs were where staff conducted high level disinfection using Cidex OPA. OR staff would soak arthroscopes in the Cidex OPA for 12 minutes. She stated the Cidex OPA was in the tubs that were dated 5/10/12. The other blue tubs were used by staff to rinse the arthroscopes in fresh sterile water after the Cidex OPA soak.

Observation on 4/30/12 at 1:35pm revealed a OR staff member gloved and retrieved an arthroscope after it soaked in the Cidex OPA for 12 minutes. The OR staff rinsed the arthroscope one time in sterile water then carried the scope into an OR.

Staff R, an OR RN interviewed on 5/1/12 at 9:00am explained they cleaned the scopes in the back de-contamination room and then placed them in a cabinet. The next morning they soaked the scopes in the Cidex OPA for 12 minutes and then rinsed them and took the scopes to the OR where it was needed.

Hospital policy titled "Othro-Phythaladehyde Solution Disinfection Cidex OPA" instructed staff to "...Thoroughly rinse the equipment with sterile water...".

Cidex OPA manufacturer's written instructions for use reviewed on 5/2/12 at 4:15pm directed staff "...Following removal from the Cidex OPA solution , thoroughly rinse the semi-critical medical device by immersing it completely in a large volume of water...Use sterile water unless potable water is acceptable...totally immerse for a minimum of one minute...remove the device and discard the rinse water...repeat the procedure TWO (2) additional times, for a total of THREE (3)RINSES with large volumes of fresh water to remove Cidex OPA solution residues...".

Staff A, RN/DON interviewed on 5/2/12 at 4:45pm verified OR staff failed to follow the Cidex OPA manufacturer's written instructions for rinsing equipment/instruments three times with fresh sterile water each time.

- Random observation on 5/1/12 at 11:00am revealed a CRNA exited from surgery room #2 with gloved hands carrying a laryngoscope blade. The CRNA proceeded to clean the laryngoscope blade with a pre-packaged brush (used to for surgical hand scrubs) in a surgical hand scrub sink. The CRNA after cleaning, rinsing, and drying the laryngoscope blade, walked back into surgery room #2 with the laryngoscope blade.

Staff A, RN/DON interviewed on 5/2/12 at 4:00pm provided the hospital's two types of pre-packaged surgical hand scrub brushes/sponges for review:

1. The Chlorhexidine Gluconate (an antiseptic) pre-packaged scrub brush directed staff that it significantly reduced the numbers of micro-organisms on the hands and forearms prior to surgery or patient care.

2. The Povidine/Iodine (an antiseptic) pre-packaged scrub/sponge directed staff that it significantly reduced the numbers of micro-organisms on the arms and hands prior to surgery.

Review of the manufacturer's labels regarding their use revealed neither type of surgical hand scrubs indicated that staff may use them to scrub/clean laryngoscope blades.

Hospital policy titled "Processing of Laryngoscope Blade" reviewed on 5/2/12 at 4:00pm directed staff "...All semicritical items will undergo a high-level disinfection process. Laryngoscopes blades are "semicritical" items...".

Staff A, RN/DON interviewed on 5/3/12 at 9:00am verified the CRNA should not use the surgical hand scrub sink to clean the laryngoscope blade. The CRNA failed to clean the blade in the de-contamination room. Staff A verified the CRNA failed to do a high level disinfection process of the blade per policy

- Random observation on 4/30/12 at 1:45pm revealed a female CRNA walking in the hall of the surgery suite area with her used surgical mask hanging around her neck. The CRNA sneezed into her surgical mask and left it hanging around her neck. The CRNA then entered surgical room #7 were the housekeeping staff was performing a terminal cleaning of the room. The CRNA then walked out of the surgical suite area into the pre-op and post-op area with the same surgical mask hanging around her neck. The CRNA failed to do any hand hygiene or change their mask after they sneezed in it.

- Observation on 5/1/12 at 8:19am during a medication administration revealed staff T, RN prepared to pass medications to patient #12's room #206. The nurse used alcohol gel as they entered the room. Staff T encountered computer difficulties and had to leave the room to call the IT (Information Technology) technician. The technician arrived and they went back into the patient's room. Staff T, RN failed to do hand hygiene as they re-entered the patient room.

- Observation on 5/1/12 at 8:45am revealed anesthesia staff anesthetized patient's #11 left hand they injected the site with Lidocaine (a local anesthetic) and attempted to start an IV (intravenous) site. The anesthesia staff failed at their first attempt to start the IV. Staff cleaned a new IV site and used the same needle and syringe to inject the new site with Lidocaine. Staff failed to conduct hand hygiene before or after applying gloves during the IV stick.

- Observations conducted on 5/1/12 from 9:52am to 11:06am staff L, Housekeeping as she terminally cleaned room 204 post-discharged of a patient revealed the following:

Staff L gloved and dust mopped the room floor and then the bathroom floor. Staff L dragged the dirt/debris with the dust mop into the hallway and up to the soiled utility room; where they swept the dirt/debris up and discarded it in a trash container.

Staff L re-entered the room without changing their gloves or doing /hand hygiene and collected the trash bags; once they collected the trash staff L carried them to the soiled utility room and discarded it.

The housekeeper returned to their housekeeping cart and changed gloves without any hand hygiene. Staff L picked up a spray bottle and explained it contained a bleach solution and went into the bathroom where they sprayed the bleach solution on the sinks and the toilet. Staff L went back to their cart and retrieved another container of liquid and a toilet bowl swab/brush. Staff L swabbed/scrubbed the inside of the toilet bowl, around the rim, then cleaned the outside of the toilet and the toilet seat. The housekeeper returned the toilet bowl swab/brush and liquid to the cart. Staff L dipped a clean rag into a "Virex" solution and re-entered the bathroom without changing their gloves or doing hand hygiene and washed the sink, the mirror, the handrail and the call light. They used a clean dry rag to dry off all of these surfaces and explained that the "Virex" only had to set for "several minutes".

Staff L changed gloves without any hand hygiene and used a clean rag with the Virex to clean the bathroom door and handles. After that staff L grabbed their mop and mopped the bathroom floor. Staff L placed the mop back in the mop water after they completed the bathroom floor.

Staff L changed gloves (no hand hygiene), picked up multiple clean rags and a bucket of Virex solution and water and carried them into the main part of the room and placed them on an over-the-table. She cleaned the flat surfaces in the room, the chairs/recliner, vital sign equipment and so on. Observations revealed two vinyl seated chair and the recliner remained visibly wet up to five minutes or less. They cleaned the bed, bed frame and mattress twice and it stayed wet 10 minutes. At 10:50am, staff L mopped the floor with the same mop head and water they used to mop the bathroom.

Staff L, Housekeeping interviewed on 4/30/12 at 11:06 stated that they normally changed the mop water every two to three rooms, but when doing a terminal cleaning of a room, they changed the mop head and mop water after each terminally cleaned room.

Hospital policy titled "Hand Hygiene" reviewed on 5/2/12 at 4:00pm instructed staff "...hand hygiene with either waterless hand sanitizer or soap and water is required...upon entering and leaving a patient room environment...And any time as needed such as after sneezing or coughing..."and "...before donning and after removing gloves...".

Staff A, RN/DON interviewed on 5/2/12 at 4:45pm verified staff failed to follow hospital policy regarding hand hygiene.

- Observation on 4/30/12 at 1:10pm to 1:30pm of staff C, housekeeping staff as they performed a terminal cleaning of operating room #6 revealed, staff C obtained a wet cloth from a bucket of "Virex" solution, wiped a slide board, back table, mayo stand, laundry bag hamper, and garbage bag hamper. These surfaces remained wet from 1 minute 30 seconds to 2 minutes 30 seconds. Staff C took the slide board outside of the surgical room and stood it up on the floor then leaned it against the wall in the hall.

Staff C then picked up the bag of trash and set it in the hall outside of the room. Using the same gloves they took a wet rag from the bucket of "Virex" solution and wiped the pads on the operating room table, and the operating room table frame. These surfaces remained wet for two minutes. The housekeeper then cleaned the rest of the flat surfaces which remained wet for three minutes. The floor was wet mopped with "Virex" solution that remained wet between six to eight minutes.

Staff C, housekeeper failed to assure the surfaces remained wet for ten minutes to achieve disinfection according to the manufacturer's guidelines.

Observation on 4/30/12 at 1:51pm revealed staff K, Housekeeping terminally cleaned OR #2 after a surgery case where the patient had a known infection of their shoulder. Staff K gloved and put on new shoe covers to do the terminal clean. The housekeeper mopped up the OR first because it had blood on it. Staff K took the mop and the bucket to the housekeeping closet and dumped the bloody solution and changed the mop head.

Staff K proceeded back to OR #2 without changing their gloves or shoe covers and began to disinfect all flat surfaces, the lights, the walls, the OR table and then the OR floor. These flat surfaces stayed visibly wet for seven to eight minutes. Staff K finished the OR at 2:40pm and without changing their gloves proceeded to OR #4 to clean it.

Observation on 5/1/12 at 8:19am in the pre-op area revealed staff D, RN cleaned a discharged patient cart and equipment. Using a cloth wet with a pink solution from an unlabeled spray bottle they wiped all surfaces of the cart and a chair. The surfaces remained wet for six minutes. Staff D was unable to identify the pink liquid in the spray bottle. Staff E, the director of pre and post operative areas confirmed the solution in the spray bottle was "Virex".

Observation on 5/1/12 at 9:49am in the post-op area revealed staff F, CNA cleaned patient carts (2) using a spray bottle with pink solution in it labeled OASIS 499. Staff F sprayed the surfaces with the Oasis 499 solution than wiped them with a cloth sprayed with the same solution. They stated the bottle contained a "Virex" solution. The surfaces remained wet for four to six minutes. Staff F was unaware of how long the surfaces need to remain wet for disinfection.

Observation on 5/1/12 at 10:30am in the pre-operative area revealed administrative staff staff E, RN/Pre and Post operative Nurse Manager placed labels titled "OASIS 499" on unlabeled spray bottles that contained a pink solution.

Administrative staff A, RN/DON interviewed on 5/2/12 at 10:00am revealed the spray bottles of pink solution were mislabeled and/or not labeled with the correct label indicating what was in the spray bottles. They verified with materials management that "Virex" is the only solution they use for cleaning surfaces. The hospital does not have the "OASIS 499" and does not know were the labels for this product came from.

Observations conducted on 5/1/12 from 9:52am to 11:06am staff L, Housekeeping as she terminally cleaned room 204 post-discharged of a patient revealed the following:

Staff L gloved and dust mopped the room floor and then the bathroom floor. Staff L dragged the dirt/debris with the dust mop into the hallway and up to the soiled utility room; where they swept the dirt/debris up and discarded it in a trash container.

Staff L re-entered the room without changing their gloves or doing /hand hygiene and collected the trash bags; once they collected the trash staff L carried them to the soiled utility room and discarded it.

The housekeeper returned to their housekeeping cart and changed gloves without any hand hygiene. Staff L picked up a spray bottle and explained it contained a bleach solution and went into the bathroom where they sprayed the bleach solution on the sinks and the toilet. Staff L went back to their cart and retrieved another container of liquid and a toilet bowl swab/brush. Staff L swabbed/scrubbed the inside of the toilet bowl, around the rim, then cleaned the outside of the toilet and the toilet seat. The housekeeper returned the toilet bowl swab/brush and liquid to the cart. Staff L dipped a clean rag into a "Virex" solution and re-entered the bathroom without changing their gloves or doing hand hygiene and washed the sink, the mirror, the handrail and the call light. They used a clean dry rag to dry off all of these surfaces and explained that the "Virex" only had to set for "several minutes".

Staff L changed gloves without any hand hygiene and used a clean rag with the Virex to clean the bathroom door and handles. After that staff L grabbed their mop and mopped the bathroom floor. Staff L placed the mop back in the mop water after they completed the bathroom floor.

Staff L changed gloves (no hand hygiene), picked up multiple clean rags and a bucket of Virex solution and water and carried them into the main part of the room and placed them on an over-the-table. She cleaned the flat surfaces in the room, the chairs/recliner, vital sign equipment and so on. Observations revealed two vinyl seated chair and the recliner remained visibly wet up to five minutes or less. They cleaned the bed, bed frame and mattress twice and it stayed wet 10 minutes. At 10:50am, staff L mopped the floor with the same mop head and water she used to mop the bathroom.

Staff L, Housekeeping interviewed on 4/30/12 at 11:06 stated that they normally changed the mop water every two to three rooms, but when doing a terminal cleaning of a room, they changed the mop head and mop water after each terminally cleaned room.

Staff A, RN/DON interviewed on 5/2/12 at 11:15am provided for review the disinfectants the hospital staff used to disinfect surfaces.

From the label of "Crew" a clinging toilet bowl cleaner the manufacturer's written instructions of use directed staff to clean toilet bowls they must do the following:

1. Remove the water from the bowl by forcing over the trap with an applicator.
2. Remove the excess water from the applicator by pressing it against the side of the bowl. 3. Pour one ounce of the product onto the applicator.
4. Scrub the entire unit especially under the rim, at water outlets.
5. Wait one minute, then flush.

Allow surfaces to remain wet for one minute.

From the label of "Virex" II 256, a disinfectant the manufacturer's written instructions of use directed staff to disinfect surfaces they must do the following:

All surfaces must remain wet for 10 minutes. Wipe surfaces and let air dry.

Hospital policy titled "Policy for Operating Room Sanitation" reviewed on 5/2/12 at 4:00pm directed staff during terminal cleaning of the ORs to "...use mechanical friction and use a facility-approved agent to clean...".

Hospital policy titled "Policy for Room Cleaning Post Patient Discharge" directed staff "...gloves must be worn when cleaning patient rooms...empty trash and bio from patient room and bathroom..Disinfect using Virex-256, start with the bed and let stand (up to 15 minutes)...Patient room high dust counter clockwise...Disinfect the bathroom...re-spray the mattress with Virex-256 if it is dry...Dust mop...Disinfect doors and doors handles...Gloves should be removed at this time...Restock the patient room...Make Bed...Move furniture back in place...Damp mop room...Post wet floor sign...Wash your hands and forearms thoroughly with soap".

Staff A, RN/DON interviewed on 5/2/12 at 4:45pm verified staff failed to ensure when disinfecting surfaces that the surfaces remained visibly wet per manufacturer's written instructions of use.

- Observation on 5/3/12 at 10:15am revealed each CRNA was assigned to an OR. The CRNAs each procure a silver metal tray of medications from a cupboard in the pre-operative area. These trays contained single-dose vials and multi-dose mediation vials.

Staff J, RN/Inpatient Nurse Manager/Pharmacy Nurse interviewed on 5/3/12 at 10:15am verified the CRNAs take the tray to their assigned OR and keep the tray in the OR throughout the surgery schedule. They might return the tray and get another one if they run out of a medication. The used trays are re-stocked by Pharmacy.

Review of the Medication tray labeled #7 on 5/3/12 at 10:20am revealed it contained the following multi-dose vials:

A bottle of Lidocaine 2% opened and dated
A bottle of Phenylenephrine 1% opened and dated
A bottle of Neostigmine 1:1000 opened and dated
A bottle of Labetalol 5mg/cc opened and dated
A bottle of Succinylcholine not opened
Three bottles of Rocuonium two opened and dated.

Staff H, an anesthesiologist interviewed on 5/3/12 at 10:30am verified the CRNAs keep the tray in the OR and use the multidose vials for multiple patients all day.

Staff A, RN/DON and Staff Ml, CEO interviewed on 5/3/12 at 11:48am lacked awareness that multi-dose vials must be designated as single-dose vials if they enter patient care areas.

Review on 5/3/12 at 4:00pm of CDC (Centers for Disease Control and Prevention) "Safe Injection Practices to Prevent Transmission of Infections to Patients" last updated 4/01/11 under Recommendations IV.H.7 directed "Do not keep multidose vials in the immediate patient treatment area and store accordance with the manufacturer's recommendations; discard if sterility is compromised or questionable 453, 1003. Category IA".

- Observation on 5/1/12 at 10:05am revealed OR staff placed six "slideboards" (used to transfer patients to and from the gurney to the operating table) against the walls outside of OR's #3, 4, 5, 6, 10 and 11. One end of the "slideboards" sat di