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.

Based on observation, document review and interview, the facility did not ensure access to patient information was restricted and not easily accessible.

This lapse in the protection of patient information placed patients at risk for the accidental disclosure of their private information to unauthorized individuals.

Findings included:

During observations of the cleaning of Operating Room (OR) #4 on 2/26/20 at 1:45PM, Patient #4's medical record (MR) information was observed on the computer previously utilized by anesthesia, visible to facility staff not involed in the patient's care.

This observation was made in the presence of Staff D (Assistant Vice President of peri-operative Nursing Services) who confirmed Patient #4's MR information should have been secured.

During observations in the cleaning of (OR) #4 on 2/26/20 at 1:45PM, Patient #5's MR information was found visible, unattended and accessible on a portable computer in the OR.

This observation was made in the presence of Staff D (Assistant Vice President of peri-operative Nursing Services) who confirmed Patient #5's MR information should not have accessible to unauthorized individuals.

The facility policy and procedure (P&P) titled "Patient Health Information Privacy Policy," last revised 11/9/16, contained the following statements: "Every inpatient and outpatient of the facility is guaranteed by law to the right of privacy. All facility staff must respect this right and treat all protected health information properly or in the most confidential manner possible. Protected health information can be written or oral, it can be recorded on paper, computer or other media."
Based on observation, document review and interview, the facility failed to ensure that staff followed standards of infection control practices to reduce the potential for transmission of infections, in

(a) the cross-contamination of equipment and supplies in four (4) of four (4) observations of Operating Room (OR) cleanings;

(b) the failure of facility staff to disinfect the rubber diaphragm tops in of 2 (two) of 2 (two) IV (intravenous) medication vials prior to withdrawing and administering the medications.


(c) the failure of nursing staff to ensure intravenous (IV) tubing's were labeled as per facility policy in three (3) of six (6) observations.

These breaches in infection control practices placed patients and staff at increased risk for infections.

Findings pertinent to (a)

Observations of a Terminal cleaning {a method used to control the spread of infections where items in the room are disinfected, sanitized, and/or decontaminated} and the cleanings in between procedures in the facility's operating rooms (ORs) on 2/26/20, 2/27/20, and 2/28/20, identified the following:

On 2/26/20, at 12:35 PM, Staff L (Environmental Services Aide), was observed during an in-between procedure cleaning of OR# 9. The staff member removed the suction canisters and basin containing bloody secretions and placed them on a surgical table. Then without changing his contaminated gloves, he retrieved bottles of solidifier, multiple times from his pockets.

The same staff member was later observed failing to clean all surfaces of a Bear Hugger, surgical table, and a standing circular tray, then cross contaminating a surgical table by placing a dirty pillow on the previously cleaned table surface.

These observations were made in the presence of Staff D (Assistant Vice President of Peri-operative Services), who confirmed the findings.

Additional observations of the cleaning of the OR's revealed there was no specific order for the cleaning of OR's.

On 2/26/20 between 12:35 PM, Staff M (Environmental Services) was observed during the in-between procedure cleaning of (OR) #9. Staff M removed equipment on a dirty OR table, cleaned the equipment, and then placed them back onto the same table contaminating them.

On 2/26/20 between 12:35 PM and 12:55 PM, Staff O (Environmental Services), was observed terminally cleaning OR #4 (a room vacated by a patient on Contact precautions for MRSA and VRE). The staff member cleaned the peg boards on a partially cleaned surgical table contaminating them.

The same staff member was again observed cleaning an IV pole with a machine on it. He wiped the pole from the top to the base of the legs with the rag touching the floor, then with the same contaminated rag he proceeded to wipe the electrical cord for the machine then hung the contaminated cord on the cleaned IV pole contaminating it.

These observations were made in the presence of Staff C (Environmental Service Supervisor) and Staff D who acknowledged the findings.

Similar findings of cross contamination of OR surfaces and equipment were observed during the cleanings of OR #5 and OR #6 by EVS staff members P and Q .

Additional, observations of the staff cleaning the OR's revealed there was no specific order in which the OR's are cleaned.

Per interview of Staff C at the time of the observations. When asked about the facility's process for ensuring the EVS staff cleans the OR's correctly, he stated that he occasionally observes the EVS staff and responds to any complaints made by nursing, but he has no active surveillance process ensuring staff cleans the rooms correctly.

The facility policy and procedure (P&P) titled "Operating Room Cleaning" last reviewed August 2016, lacked clear instructions for the EVS staff on how to clean the OR's.

The facility's policy and procedure titled "Procedure for Terminal Cleaning in the Operating Rooms", last reviewed 6/1/19, listed the following steps:
"A. Clean-up procedure after a case
1. Pick up trash, sutures, papers on the floor, then use treated cloth for sweeping.
2. Discard trash into the red plastic waste bags and tie securely.
3. Pick up all soiled and non-soiled linen, discard into the impermeable linen bag and tie securely.
4. Pick up used disposable suction bottles and tubing.
5. Take waste bags, linen and suction canisters to Soiled Utility Room.
6. Damp wipe horizontal surfaces of operating room table, instrument tables with germicide.
7. Dispose all contaminated wastes according to the hospital Policy: "Disposal of Infectious Wastes".
8. Mop the floor with a fresh, clean mop head with Germicidal solution.
9. Do not leave the floor too wet, to prevent falls of personnel. Use floor signs at all times.
10. Spot clean walls and ceilings, as necessary.
11. Line all buckets and garbage cans with clean plastic bags.
12. Replace hampers with clean bags.
13. Replace clean suction canisters and connect to wall unit.
14. Inspect, remove and replace, if needed, sharp containers.
15. Remove all cleaning equipment and send mops to laundry to be cleaned as per policy."

"B. Terminal Cleaning Procedure at the end of the day (after last case):
1. At the end of the day, the same cleaning techniques described in A (Clean up after case) should be repeated.
2. Clean and disinfect thoroughly all furniture with detergent/germicide solution.
3. Clean and disinfect legs and casters of OR tables, kick bucket holders and IV stands.
Remove all debris, blood and sutures that might be present.
4. Clean and disinfect all kick buckets with a fresh germicide solution.
5. Clean walls, doorknobs and windows with detergent/germicide solution.
6. Damp wipe light tracks nightly. Vacuum light tracks weekly.
7. Vacuum and wash air-conditioning grills weekly.
8. Damp wipe x-ray view boxes, surgical lights, ceiling and vents.
9. Clean and disinfect OR bed thoroughly including base.
10. Wash scrub-sink ledges and walls around sink to remove soap splashes during the day.
11. Clean and disinfect faucet head.
12. Scrub sink with germicidal detergent.
13. Mop floor using fresh mop heads and germicidal detergent."

However, the policy lacks the order and directions for how these tasks should be completed.

Findings pertinent to (b):

Observations in the facility's OR suite #5 on 2/27/20 during a tour between 11:50 AM and 2:35 PM identified the following:

Staff J (Registered Nurse) was observed removing the cap on a vial containing Lidocaine and Epinephrine. Without cleansing the rubber diaphragm, she inserted a pour device intended to be utilized on the sterile field.

This was observed in the presence of Staff B (Clinical Nurse OR Manager) who confirmed Staff J should have cleansed the rubber diaphragm with alcohol prior to inserting the device.

Staff K (Anesthesiologist) was observed administering Zofran (a medication for nausea) to Patient #3. The Staff member removed the cap on the medication vial and without cleansing the rubber diaphragm, he drew up the medication and administered it to the patient intravenously.

The facility policy and procedure (P&P) titled, "Administration of medications onto a sterile field," last revised March 2019, contained the following statement: "when using a transfer device, remove cap and spike the medication vial." The policy lacked instruction for nursing staff to cleanse the rubber diaphragm prior to accessing the medication vial.

Per interview of Staff A and Staff B around the time of this observation, they both acknowledged medication vials should be cleansed prior to needle entry.

A facility policy and training for accessing of IV medication vials was requested for both Nursing and Medical staff but was not available.

The Institute for Safe Practice Medication Practice's "Safe Practice Guidelines for Adult IV Push Medications," dated 2015 stated, "Practitioners may not be aware that the "pop-off" vial caps from manufacturers are considered "dust covers" and are not intended to maintain sterility of the vial diaphragm or access point. Thus, the diaphragm must always be
disinfected after removing the cap of a new vial."

Findings pertinent to (c) include:

The facility policy and procedure (P&P) titled, "Venipuncture/ Insertion Peripheral Short Catheter for Continuous or Intermittent Infusion, including Site and Tubing Change," last revised 10/2017, instructed staff to "...attach to the tubing a color coded 'Change Label' for the day of the week to be changed, along with the due date [for changing]."

Observations in the facility's Surgical intensive Care Unit (SICU) on 2/28/20 identified the following:

On 2/28/20 at 11:00AM, Patient #6, was observed in Room (RM) #356 with Intravenous (IV) tubing used to administer Zosyn, Precedex and Normal Saline not labeled with dates indicating when they needed to be changed.

On 2/28/20 at 11:02 AM, Patient #7, was observed in RM #354 with (IV) tubing used to administer Propofol and Normal Saline not labeled with dates indicating when they needed to be changed.

On 2/28/20 at 11:05AM, Patient #8, was observed in RM #352 with (IV) tubing used to administer Potassium not labeled with dates indicating when they needed to be changed.

These observations were made in the presence of Staff A (Vice President of Performance Improvement and Care Management), Staff G (Nurse Manager of SICU) and Staff F (Registered Nurse) who confirmed the tubing should have been labeled for each patient.