HospitalInspections.org

Based on review of facility contracts, facility policies, Board of Trustees meeting minutes, observations during a tour, and staff interview, it was determined that the Governing Body failed to ensure that services provided by its contracted cleaning company were compliant with facility policy requirements and regulatory requirements.

Findings were:

Facility policy entitled, "Sanitation of Surgical Services", dated 2/2015, documented that a patient had the right to "be provided with a safe, clean, environment, free from dust and organic debris."

A tour of the facility was conducted on 10/06/15 at 12:15 pm with the Operating Room Director (employee #13).

Observed in the Operating Room (OR) Suite:
A sawdust-like material was observed on the floor of the soiled instrument room (room where used/contaminated instruments are cleaned and disinfected in preparation for sterilization), and was observed on the bottom of the surveyors' shoe covers.

Dirty/utility room findings included: The room had two doors- one led into the OR suite, and the other opened to a narrow concrete ramp outside of the building. A water-filled hopper was located inside the room on the wall nearest the interior door. There was a strong, foul odor of moisture and mold. A three (3) feet by four (4) feet area of heavily-populated, medium brown "spots and patches" was observed on the room's outer perimeter wall. A more sparsely populated amount of the spots and patches was observed to be distributed over the the remainder of the wall (approximately 8 feet high by 8-10 feet wide). Damage was observed on the interior walls around the door frame.

Recovery Room findings included: Multiple hanging ceiling panels with spaces noted between the panels and the metal suspension grid. The room's five (5) ceiling grates were covered in dust. The grate in the room's bathroom was very dusty.

During a subsequent tour of the facility with the Chief Nursing Officer (CNO- employee #15), the Surgery Technician (employee #5), and the OR Director (employee #13) at 10:30 a.m. on 10/08/15, surveyors were informed that there had already been a surgical case performed that day. The surveyors observed the following:

ORs #1and #2- Large amounts of "ropey-like" dust were found on top of the x-ray light boxes and on the anesthesia carts. When disturbed, particles of the dust broke away and floated into the air. Inspection of the anesthesia carts revealed dust on the anesthesia gas tanks, the hoses leading from the tanks to the machine, and on the various ledges along the back of each cart.

Dirty instrument room- The sawdust-like material remained on the floor.

During the tour, the Surgery Technician stated that the technicians had previously been required to "terminally clean" (process where entire room is cleaned, all surfaces wiped down with a disinfectant and floors mopped with a disinfectant) but that the process was now performed by the facility's contracted cleaning company. This was confirmed by the OR Director. However, this was in conflict with both the Housekeeping contract, dated 3/8/12, which did not include terminal cleaning of the OR as part of its contracted services, and with facility policy entitled, "Duties of a Surgical Technologist" last updated 2/2015, which directed surgery staff to terminally clean the Operating Rooms at the end of each day.

During an interview in the OR hallway on 10/08/15 just prior to commencement of surgery, the contracted cleaning company's Supervisor (identified as "employee" #16) stated that the person assigned to clean the OR had not been trained appropriately to perform this duty, and would either be re-assigned or re-trained. The Supervisor also stated that assessments of the staff's quality of work had not been performed.

During a tour on October 8, 2015 at 11:45 a.m. with the CNO and the Director of Maintenance (employee #17), surveyors observed that the facility's pharmacy fluid storage room contained multiple layers of dust and grime on and surrounding the window sills, baseboards, corregated cardboard boxes which stored the fluids, and the floor.

During the survey's closing conference at 3:15 pm on 10/08/15 with the hospital's administrative staff and the Supervisor of the facility's contracted cleaning company, the facility's Chief Executive Officer (CEO- employee #14) related that the hospital had decided to terminate its contract with its current cleaning company and contract with another one. The CEO also stated that he/she relied on the hospital's infection rate to determine whether the hospital was clean enough or not. However, review of the Board of Trustees meeting minutes for the year beginning January 01, 2015 failed to show documented evidence that the governing body had reviewed infection control reports/data.

Based on review of facility contracts, policies, observation during facility tours and staff interviews, it was determined that the facility failed to protect the patients' right to receive care in a safe environment.

Findings were:

A copy of an email dated 10/14/15 sent from the facility's Chief Operating Officer to the Chief Nursing Officer (CNO- employee #15) documented that 975 patients underwent surgery in the facility's Operating Room (OR) suite from October 2014 through September 2015.

A. Review of Patients' Rights documents dated 9/17/13 failed to reveal a statement regarding the right of a patient to receive care in a safe manner. However, a policy entitled "Sanitation of Surgical Services", dated 2/2015, related that a patient had the right to "be provided with a safe, clean, environment, free from dust and organic debris".

A tour of the facility's Operating Room (OR) suite was conducted on 10/06/15 at 12:15 pm with the OR Director (employee #13). Observations in the OR Suite during the tour revealed the following:

A sawdust-like material was observed on the floor of the soiled instrument room (room where used/contaminated instruments are cleaned and disinfected in preparation for sterilization), and was easily picked up by staff shoes and was observed on the bottoms of the surveyors' shoe covers.

Inspection of the Recovery Room revealed multiple dislodged hanging ceiling panels with spaces noted between the panels and the metal suspension grid. The room's five (5) ceiling grates were covered in dust, and the grate in the room's bathroom was very dusty.

During a subsequent tour of the facility with the Chief Nursing Officer (CNO), the Surgery Technician (employee #5), and the OR Director at 10:30 a.m. on 10/08/15, surveyors were informed that there had already been a surgical case performed that day. The surveyors observed the following:

ORs #1and #2- Large amounts of "ropey-like" dust were found on top of the x-ray light box and on the anesthesia carts. When disturbed, particles of the dust broke away and floated into the air. Inspection of the anesthesia carts revealed dust on the anesthesia gas tanks, the hoses leading from the tanks to the machine, and on the various ledges along the backs of each cart.

Dirty instrument room- The sawdust-like material remained on the floor.

During the tour, the Surgery Technician stated that the technicians had previously been responsibe to "terminally clean" (process where entire room is cleaned, all surfaces wiped down with a disinfectant and floors mopped with a disinfectant) but that the process was now performed by the facility's contracted cleaning company. This was confirmed by the OR Director. However, this was in conflict with both the Housekeeping contract, dated 3/8/12, which did not include terminal cleaning of the OR as part of its contracted services, and with facility policy entitled, "Duties of a Surgical Technologist" last updated 2/2015, which directed surgery staff to terminally clean the Operating Rooms at the end of each day.

During an interview in the OR hallway on 10/08/15 just prior to commencement of surgery, the contracted cleaning company's Supervisor stated that the person assigned to clean the OR had not been trained appropriately to perform this duty, and would either be re-assigned or re-trained. The Supervisor also stated that assessments of the staff's quality of work had not been performed.

During a tour on October 8, 2015 beginning at 11:45 a.m. with the CNO and the Director of Maintenance, surveyors observed that the facility's pharmacy fluid storage room contained multiple layers of dust and grime on and surrounding the window sills, baseboards, corrugated boxes which stored the fluids, and the floor.

During the survey's closing conference with the hospital's administrative staff and the Supervisor of the facility's contracted cleaning company, the facility's Chief Executive Officer (CEO- employee #14) related that the hospital had decided to terminate its contract with its current cleaning company and contract with another one. The CEO also stated that he/she relied on the hospital's infection rate to determine whether the hospital was clean enough or not. However, review of the Board of Trustees meeting minutes for the year beginning January 01, 2015 failed to show documented evidence that the governing body had reviewed infection control reports/data.

B. During a telephone interview on 10/7/15 at 1:30 p.m., the Registered Nurse Infection Control Practitioner (ICP) verified that the hospital utilized the Association of periOperative Registered Nurses (AORN) recommendation guidelines to monitor temperature and humidity in ORs #1 and #2.

The Association of periOperative Registered Nurses (AORN) guidelines (2015) document that to decrease the risk of contamination to sterilized surgical instruments and reduce the risk of surgical site infection, the temperature of each OR should be maintained between 68-75 degrees Farenheit, and that the humidity should be maintained between 20 - 60 percent.

Review of the OR Temperature and Humidity Logs from January 2015 through October 2015 revealed documentation of 170 days of recorded testing. According to the log, the temperatures were outside the recommended range in OR #1 for 24 days and in OR #2 for 44 days (total of 68 incidents). The log also documented that the humidity was outside the recommended range in OR #1 for 59 days, and in OR #2 for 18 days (total of 77 incidents). There was no documentation of notification of anyone or that corrective measures had been implemented when the ranges were found to be too high or too low.

During the tour of the facility on 10/06/15 at 12:15 pm with the Chief Nursing Officer (CNO- employee #15), surveyors observed that the Operating Room's (OR's) dirty/utility room had two doors- one led into the OR suite, and the other opened to a narrow concrete ramp outside of the building. Surveyors observed that the door to the outside did not sit flush with the floor, and light was seen coming into the room from the outside through a 1/2 to 1-inch space at floor level. A water-filled hopper was located inside the room on the wall nearest the interior door. There was a strong, foul odor of moisture and mold with moisture damage on the interior walls around the door frame. A three (3) feet by four (4) feet area of heavily-populated, medium brown "spots and patches" was observed on the room's outer perimeter wall. A more sparsely populated amount of the spots and patches was observed to be distributed over the the remainder of the wall (approximately 8 feet high by 8-10 feet wide). Rust was observed on the door frame and on the hanging ceiling frame. The walls had exposed and deteriorated drywall with multiple cracks. Tissue-testing of the room's air pressure revealed a very slight negative pressure when tested from the outside (inside the OR suite). However, when tested from the inside of the room, the tissue's position did not shift at either door, which did not indicate either a positive or a negative air pressure. AORN guidelines require that the airpressure in this room be maintained as "negative" in order to reduce the risk of contaminated air escaping into the clean OR environment. On 10/08/15 at 10:30 am in the OR suite, the Chief of Maintenance (employee #17) informed the surveyors that the fan that pulled air into the room to create the negative pressure had been disabled to help control the humidity in the room.

Based on observation, interviews and policy reviews, the facility failed to maintain the Operating Room (OR) suite and the pharmacy fluid storage room in such a manner that patient safety was ensured.


Findings include:

On 10/6/15 in Operating Room (OR) #1 beginning at 12:16 p.m., the surveyor observed the following:
A loose faceplate was seen next to the anesthesia area where the suction device was plugged in. No electrical outlet face plates were marked "emergency" either by color or writing in the room to indicate that they would run on generator during a power outage. Cracked paint with partial peeling about 1.5 inches in length by 1/8th inches in width was noted in the ceiling. The air handling intake vent was dusty.

Observation on 10/6/15 at 12:20 p.m. with the Operating Room Director (employee #13) included:
1) In the autoclave/fluid /blanket warmer room, an open drain was observed in the floor (drain cover was moved to the side), an opening in the ceiling where copper pipe comes through, small holes in the wall around electrical panel boxes, uncapped pipe coming from floor, the copper pipes had corrosion, and multiple cracks were observed in the paint on the walls.
2) Surveyors observed five (5) cabinets used for storing sterile supply/instruments. The cabinets were located in an alcove-like section of the OR suite which was not closed off from the rest of the OR. Surrounding these was a multitude and variety of stored unsterile products. A thermometer and humidity sensor was observed in one (1) of the five (5) cabinets, and the staff present explained that the facility's accrediting organization had instructed them to make certain that the temperature and humidity was maintained in the cabinets to assure that the requirements related to appropriate temperature and humidity were met to reduce the risk of contamination to the stored, sterilized surgical instruments. (Higher temperature and humidity levels increase the risk of moisture entering the instrument packages and contaminating the instruments inside.)
3) OR#2 findings include: on the outer perimeter wall there was a receptacle, about seven (7) feet high on the wall, which looked as if it had gotten too hot or had shorted out. Emergency electrical outlets were not identified by either label or color. The control box for the OR table (bed that the patient lies on during surgery) in OR #1 was held together with silk tape and was very dirty and coming apart.
4) The dirty/utility room had a strong odor of moisture and mold; the walls had moisture damage around the door frame; the door frame was rusted and the wall had exposed and deteriorated drywall. There were multiple cracks on the walls, the hanging ceiling frame was rusted, and a mold-like substance (medium-brown spots and patches) was observed on the perimeter wall. A tissue test conducted at the outside base of the door by the surveyor during the tour revealed that the room had a slight negative pressure. (The room should have negative pressure to keep contaminated air from entering the OR).
5) The pre-op room had multiple scraped/scuffed areas in the wall with drywall exposure and multiple areas of paint peeling from the wall.
6) In the Recovery Room, surveyors observed that multiple hanging ceiling tiles were dislodged leaving open areas. Five (5) of the ventilation grates were covered in dust, and the patient bathroom's grate was also very dusty.

During an interview at 1:10 p.m. in the recovery room, the Director of Surgical Services (employee #13) confirmed of the above findings.

During an interview on 10/6/15 at 2:00 p.m. in the main conference room, the Chief Executive Officer employee #14) related that there had been work in progress on the lower part of the cabinets in the dirty utility room (where instruments are cleaned in preparation for steam sterilization) since last week, and that that was probably what resulted in the dust found on the floor.

During a repeat tour of the OR Suite with the Chief Nursing Officer (employee #15), the OR Director (employee #13) and the Chief of Maintenance (employee #17) beginning on 10/8/15 at 10:30 a.m., surveyors observed that the area where the immediate use sterilizer is located was still dusty with the sawdust-like material still on the floor. The dirty/soiled utility room for housekeeping no longer had a foul odor. A tissue test of the air pressure was conducted by the surveyor while inside the room by holding a tissue at the inside-bottom of each door. The tissue did not move, which revealed that the air pressure was neutral. The Association of periOperative Registered Nurses (AORN) guidelines require that the airpressure in this room be maintained as "negative" in order to reduce the risk of contaminated air escaping into the clean OR environment. The Chief of Maintenance stated that the fan pulling air into the room had been disabled because of the humidity and mold problem in that room. In Operating Room (ORs) #1 and #2, ropey-like dust was observed on top of the radiology lights in each room, rust on the wheels of the anesthesia carts, I. V. poles (for hanging bags of fluid to be placed in the use of anesthesia), and the surgical field tables in both rooms, and inspections of the anesthesia carts in both ORs #1 and #2 revealed dust on the carts, anesthesia gas tanks, the gas tubing leading from the tanks to the carts, and the horizontal ledges of both carts.

The dirty instrument room for re-sterilization still had sawdust-like material in the floor. Outside of Central Sterile, there was a portion of wall across the hall which was bubbled and painted over (measuring approximately 12 inches in height by 36 inches in height.

Observation on October 8, 2015 at 11:45 a.m. by one surveyor and one surveyor supervisor, while accompanied by the CNO, revealed that the entrance to the facility's decontamination room/sterile room, located in the main hallway was unlocked, which allowed unrestricted access to the OR's contaminated instruments and sterile items stored therein. The facility's pharmacy supply sterile room contained multiple layers of dust and grime in and surrounding the window sills, baseboards, and on the floor. The facility's pharmacy fluid storage room contained multiple corregated cardboard boxes resting on the bare floor.

During an interview and observation with the central sterile technician (CST- employee #5) on 10/6/15 at 1:15 p.m. in various parts of the suite, the CST related that the out-of-service steam autoclave was sometimes used for sterilization of instruments for immediate use on patients. The dirty instrument room (for cleaning instruments prior to re-sterilization) had negative flow and the current arthroscopy instrument (a lighted instrument for looking inside and treating joints) could not be cleaned at that time because another set of instruments was already in the sink of enzymatic cleaner. Therefore, the CST verbally return-demonstrated/explained the cleaning and inspection of the scopes prior to sterilization. The CST also explained that the OR used to clean/process the reusable respiratory therapy equipment but stopped this last Thursday. The CST related that use of disposable equipment was to begin as soon as possible.

Facility policy entitled, "Duties of a Surgical Technologist", last updated 2/2015, directed that the technologists were to terminally clean the Operating Rooms at the end of each day.

During a tour of the facility with the CNO, the Surgery Technician, and the OR Director at 10:30 a.m. on 10/08/15, the Surgery Technician stated that the technicians had been required to "terminally clean" the OR (process where entire room is cleaned, all surfaces wiped down and floors mopped with a disinfectant) at the end of the surgical day, but that the process was now performed by the facility's contracted cleaning company. This was confirmed by the OR Director. The housekeeping contract and the policy regarding terminal cleaning were in conflict, as follows- The housekeeping contract, dated 3/8/12, did not include terminal cleaning of the OR as part of its contracted services, and facility policy entitled, "Duties of a Surgical Technologist" last updated 2/2015, directed surgery staff to terminally clean the Operating Rooms at the end of each day.

The facility failed to maintain the OR environment in such a manner that the safety and well-being of the patients was assured as evidenced by failing to assure who was responsibe to mainain a safe, clean OR environment that was free from dust and organic debris as stated in policy entitled, "Sanitation of Surgical Services", dated 2/2015, which documented that a patient had the right to "be provided with a safe, clean, environment, free from dust and organic debris".

Based on tour of the facility and staff interview, the facility failed to ensure that requirements for emergency power were met.

Findings include:

On 10/6/15 in Operating Rooms (OR) #1 and #2, beginning at 12:16 p.m. with the OR Circulator (employee #6) present, the surveyor observed a loose faceplate located next to the anesthesia area where the suction device was plugged in. No electrical outlet face plates were marked "emergency" either by color or writing in the rooms to indicate that they would run on generator during a power outage.

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Based on review of facility documentation related to temperature and humidity control, observations during facililty tour(s) and staff interview, the facility failed to ensure that temperature, humidity and airflow were maintained in the facility's anesthetizing locations (the Operating Room).

Findings include:

During a telephone interview on 10/7/15 at 1:30 p.m., the Registered Nurse Infection Control Practitioner (ICP) verified that the hospital utilized the Association of periOperative Registered Nurses (AORN) recommendation guidelines to monitor temperature and humidity in Operating Rooms (ORs) #1 and #2.

The Association of periOperative Registered Nurses (AORN) guidelines document that to decrease the risk of contamination to sterilized surgical instruments and reduce the risk of surgical site infection, the temperature of each Operating Room (OR) should be maintained between 68-75 degrees Farenheit, and that the humidity should be maintained between 20 - 60 percent.

Review of the operating room Temperature and Humidity Logs from January 2015 through October 2015 revealed documentation of 170 days of recorded testing. According to the log, the temperatures were outside the recommended range in OR #1 for 24 days and in OR #2 for 44 days (total of 68 incidents). The log also documented that humidity was outside the recommended range in OR #1 for 59 days, and in OR #2 for 18 days (total of 77 incidents). There was no documentation of notification of anyone when the ranges were found to be too high or too low and no actions were noted.

During a tour of the facility on 10/06/15 at 12:15 pm with the Chief Nursing Officer (CNO- employee #15), surveyors observed that the Operating Room's (OR's) dirty/utility room had two doors- one led into the OR suite, and the other opened to a narrow concrete ramp outside of the building. Surveyors observed that the door to the outside did not sit flush with the floor, and light was seen coming into the room from the outside through a 1/2 to 1-inch space at floor level. A water-filled hopper was located inside the room on the wall nearest the interior door. There was a strong, foul odor of moisture and mold with moisture damage on the interior walls around the door frame. Rust was observed on the door frame and on the hanging ceiling frame. The walls had exposed and deteriorated drywall with multiple cracks. Tissue-testing of the room's air pressure revealed a very slight negative pressure when tested from the outside (inside the OR suite). However, when tested from the inside of the room, the tissue's position did not shift at either door, which did not indicate either a positive or a negative air pressure. AORN guidelines require that the airpressure in this room be maintained as "negative" in order to reduce the risk of contaminated air escaping into the clean OR environment. On 10/08/15 at 10:30 am in the OR suite, the Chief of Maintenance (employee #17) informed the surveyors that the fan that pulled air into the room to create the negative pressure had been disabled to help control the humidity in the room.

Based on review of facility contracts, facility policies, governing body meeting minutes, observations during tour(s), and staff interview, it was determined that the Infection Control Program:
A. failed to implement measures to maintain a sanitary hospital environment,
B. failed to develop and implement infection control measures related to hospital staff and contracted workers (housekeeping), and to monitor compliance with all policies, procedures, protocols and other infection control program requirements.

Findings were:

A. Failed to implement measures to maintain a sanitary hospital environment:

During a tour of the facility on 10/06/15 at 12:15 pm with the Chief Nursing Officer (CNO- employee #15), surveyors observed that the Operating Room's (OR's) dirty/utility room had two doors- one led into the OR suite, and the other opened to a narrow concrete ramp outside of the building. Surveyors observed that the door did not sit flush with the floor, and light was seen coming into the room from the outside through a 1/2 to 1-inch space at floor level. A water-filled hopper was located inside the room on the wall nearest the interior door. There was a strong, foul odor of moisture and mold with damage on the interior walls around the door frame. Rust was observed on the door frame and on the hanging ceiling frame. The walls had exposed and deteriorated drywall with multiple cracks. Tissue-testing of the room's air pressure revealed a very slight negative pressure when tested from the outside (inside the OR suite). However, when tested from the inside of the room, the tissue's position did not shift at either door, which did not indicate either a positive or a negative air pressure (the room should have negative pressure to keep contaminated air from entering the OR). On 10/08/15 at 10:30 am in the OR suite, the Chief of Maintenance (employee #17) informed the surveyors that the fan that pulled air into the room to create the negative pressure had been disabled to help control the humidity in the room.

Tours of the OR on 10/6/15 and 10/08/15 with the CNO and OR staff revealed multiple layers of dust and debris on the horizontal surfaces in both of the facility's two (2) ORs (#s 1 and 2), and on the floor of the autoclave room and the soiled instrument room. Cabinets in the scope rooms and the soiled instrument room had a swollen appearance as if from repeated exposure to moisture, and the cabinets' laminated surfaces were cracked and peeling. Rust was also observed on the ceiling tile tracks and on the surfaces and wheels of the furniture in both ORs. Cracked/peeling/rusted surfaces prevents effective cleaning and disinfection of those surfaces. Dust, debris and dead insects were observed in the Pharmacy's fluid storage room.

During an interview at 12:51 pm on 10/08/15, the Infection Control Practitioner (ICP-employee #9) explained that the hospital conducted environmental rounds twice a year in clinical areas, and once a year in non-clinical areas. These tours were usually conducted by the managers of the departments being toured, but that sometimes the ICP performed them as well. Problems identified with the physical condition of the areas were sent to the Engineering department as work orders.

Review of a document entitled, "Infection Control Plan, Including Program, Role and Scope", not dated, revealed that the Infection Control Program's goals included limiting unprotected exposure to pathogens, limiting the transmission of infections associated with procedures, limiting the transmission of infections associated with the use of medical equipment, devices and supplies, and improving compliance with hand hygiene guidelines. The document related that the Infection Control Committee met monthly during the Performance Improvement/Peer Review meeting. However, documentation related to regular inspection of the facility for cleanliness and implementation of infection control measures was not provided. Documented evidence of review of the infection control data/reports by the either the performance Improvement/Peer Review committee or the Governing Body was not provided, and the ICP confirmed that no documented evidence of the review by either committee had been made.

B. Failed to develop and implement infection control measures related to hospital staff and contracted workers (housekeeping), and to monitor compliance with all policies, procedures, protocols and other infection control program requirements:

On 10/6/15 in Operating Room (OR) #1 beginning at 12:16 p.m., the surveyor observed a certified registered nurse anesthetist fail to clean his/her hands after removing gloves. An alcohol dispenser was not in the room. The physician's assistant who helped the surgeon discarded his/her gloves and donned new ones without washing/disinfecting his/her hands prior to touching the patient again.

During observation of a blood draw by a phlebotomist (staff #12) on 10/7/15, the phlebotomist did not wash/sanitize hands before donning gloves, failed to verbally identify the patient's identification, (although the arm/wrist band was checked), and failed to perform hand-sanitation activities following completion of the blood draw.

During interviews on 10/07/15 with the OR circulator (employee #6), the CNO, the LPN/Scrub Tech (employee #2) and with the OR Director (employee #13) at 10:15 am, 10:15 am, 10:45 am and 10:57 am respectively, each stated that training in infection control techniques was provided on hire, then staff were required to read infection control information and answer a questionnare annually thereafter. Each staff member related that infection control training related to their specific job was not provided. The CNO added that the training on 10/06/15 was the first time that there had been a scope manufacturer to give them a class on the cleaning and reprocessing of the scopes. Each staff member interviewed related that he/she did not know of any projects conducted in the OR related to infection control.

During an interview in the OR hallway on 10/08/15 just prior to commencement of surgery, the contracted cleaning company's Supervisor stated that the person assigned to clean the OR had not been trained appropriately to perform this duty, and would either be re-assigned or re-trained. The Supervisor also stated that assessments of the staff's quality of work had not been performed.

During a tour of the facility with the CNO, the Surgery Technician, and the OR Director at 10:30 a.m. on 10/08/15, the Surgery Technician stated that the technicians were previously responsible to "terminally clean" the OR (process where entire room is cleaned, all surfaces wiped down and floors mopped with a disinfectant at the end of the surgical day) but that the process was now performed by the facility's contracted cleaning company. This was confirmed by the OR Director. However, facility policy entitled, "Duties of a Surgical Technologist" last updated 2/2015, continued to direct surgery staff to terminally clean the Operating Rooms at the end of each day, and the Housekeeping contract, dated 3/8/12, did not include terminal cleaning of the OR as part of its services.

Additionally, facility policy entitled, "Sanitation of Surgical Services", dated 2/2015, documented that a patient had the right to "be provided with a safe, clean, environment, free from dust and organic debris." The policy directed staff to damp dust all furniture, surgical lights and equipment with an approved disinfectant. As stated earlier, tours of the OR revealed surfaces covered with dust and debris which would indicate that this required cleaning was not being performed.

Based on review of policies, quality reports, observation and staff interview, it was determined that the facility failed to ensure that policies related to Maintenance of the environment in the Operating Room (OR) were implemented and enforced.

Findings include:

While walking to the conference room on 10/6/15 at 11:00 am to begin the entrance conference, the CNO advised the surveyor that the facility's accrediting organization had just left the facility on 10/02/15 and that the AO had found some problems. The CNO did not elaborate on what the problems were.

Review of a document entitled, "Infection Control Plan, Including Program, Role and Scope", not dated, revealed that the Infection Control Program's goals included limiting unprotected exposure to pathogens, limiting the transmission of infections associated with procedures, limiting the transmission of infections associated with the use of medical equipment, devices and supplies, and improving compliance with hand hygiene guidelines. The document related that the Infection Control Committee met monthly during the Performance Improvement/Peer Review meeting. However, documentation related to regular inspection of the facility for cleanliness and implementation of infection control measures was not provided.

Facility policy entitled, Operating Room Infection Control Standards, effective 9/02, directed that all OR staff were responsible to insure that the room was clean prior to the start of the first surgical case of the day, and then between subsequent cases.

Facility policy entitled, Sanitation in the Surgical Practice Setting, effective 8/12, specified that prior to the start of the surgical day, furniture, surgical lights and equipment should be damp-dusted with an approved chemical disinfectant applied to a lint-free cloth, and at the end of the surgical cases, the ORs, scub/utility areas, corridors, furnishings and equipment should be terminally cleaned. This would include fixed and ceiling mounted equipment, all furniture, horizontal surfaces, and floor, as well as other equipment located in the OR.

During a tour of the facility on 10/06/15 at 12:15 pm with the Chief Nursing Officer (CNO- employee #15), surveyors observed that the Operating Room's (OR's) dirty/utility room had two doors- one led into the OR suite, and the other opened to a narrow concrete ramp outside of the building. Surveyors observed that the door did not sit flush with the floor, and light was seen coming into the room from the outside through a 1/2 to 1-inch space at floor level. A water-filled hopper was located inside the room on the wall nearest the interior door. There was a strong, foul odor of moisture and mold with moisture damage on the interior walls around the door frame. Rust was observed on the door frame and on the hanging ceiling frame. The walls had exposed and deteriorated drywall with multiple cracks. Tissue-testing of the room's air pressure revealed a very slight negative pressure when tested from the outside (inside the OR suite). However, when tested from the inside of the room, the tissue's position did not shift at either door, which did not indicate either a positive or a negative air pressure. (The Association of periOperative Registered Nurses (AORN) requires that the airpressure in this room be maintained as "negative" in order to reduce the risk of contaminated air escaping into the clean OR environment.) On 10/08/15 at 10:30 am in the OR suite, the Chief of Maintenance (employee #17) informed the surveyors that the fan that pulled air into the room to create the negative pressure had been disabled to help control the humidity in the room.

Tours of the OR and the hospital on 10/6/15 and 10/08/15 with the CNO and OR staff revealed multiple layers of dust and debris on the horizontal surfaces in both of the facility's two (2) ORs, and on the floor of the autoclave room and the soiled instrument room. Cabinets in the scope rooms and the soiled instrument room had a swollen appearance as if from repeated exposure to moisture, and the laminated surfaces were cracked and peeling. Rust was also observed on the ceiling tile tracks and on the surfaces and wheels of the furniture in both ORs. Cracked/peeling/rusted surfaces prevents effective cleaning and disinfection of those surfaces.

On 10/07/2015, surveyors were provided with documentation of staff training in cleaning and disinfection of endoscopes (lighted tubes inserted through the mouth or rectum to visually inspect the gastro-intestinal tract). Surveyors were also provided with copies of new facility policies, dated 10/07/2015, regarding the use and quality control of the facility's selected solution used to disinfect endoscopes and respiratory equipment, temperature and humidity monitoring, and storage of sterile packs (surgical instruments wrapped then sterilized) which was dated 10/08/2015. Documentation related to staff training and verification of competency regarding the cleaning and disinfection of endoscopes was provided; however, documentation related to staff training and competency verification regarding the other new policies and procedures was not provided.

Based on review of facility contracts, facility policies, Board of Trustees meeting minutes, observations during tour(s), and staff interview, it was determined that the facility's leadership (chief executive officer, medical staff and director of nursing) failed to implement measures to maintain a sanitary hospital environment, failed to develop and implement infection control measures related to hospital staff and contracted workers (housekeeping), and failed to monitor compliance with all policies, procedures, protocols and other infection control program requirements.

Findings were:

Tours of the facility's Operating Room (OR) suite revealed multiple areas of dust and debris located on and in various surfaces within the individual ORs and the OR suite.

During a telephone interview on 10/7/15 at 1:30 p.m., the Registered Nurse Infection Control Practitioner (ICP) verified that the hospital utilized the Association of periOperative Registered Nurses (AORN) recommendation guidelines to monitor temperature and humidity in Operating Rooms (ORs) #1 and 2. The guidelines document that to decrease the risk of contamination to sterilized surgical instruments and reduce the risk of surgical site infection, the temperature of each Operating Room (OR) should be maintained between 68-75 degrees Farenheit, and that the humidity should be maintained between 20 - 60 percent.

Review of the operating room Temperature and Humidity Logs from January 2015 through October 2015 revealed documentation of 170 days of recorded testing. According to the log, the temperatures were outside the recommended range in OR #1 for 24 days and in OR #2 for 44 days (total of 68 incidents). The log also documented that humidity was outside the recommended range in OR #1 for 59 days, and in OR #2 for 18 days (total of 77 incidents). There was no documentation of notification of anyone when the ranges were found to be too high or too low and no actions were noted.

The soiled utility room held evidence of moisture, dust, dirt, mold and rust. Although the Association of periOperative Registered Nurses (AORN) requires that the airpressure in this room be maintained as "negative" in order to reduce the risk of contaminated air escaping into the clean OR environment, the Chief of Maintenance (employee #17) stated that the fan pulling air into the room had been disabled because of the humidity and mold problem in that room. Surveyors observed it to be neutral in pressure during multiple tours of the OR from 10/06 through 10/08/2015.

Tours of the facility's Operating Room Suite revealed evidence of peeling and cracked paint, dislocated ceiling tiles, and collections of dust and debris throughout.

During an interview at 12:51 pm on 10/08/15, the Infection Control Practitioner (ICP-employee #9) explained that the hospital conducted environmental rounds twice a year in clinical areas, and once a year in non-clinical areas. These tours were usually conducted by the managers of the departments being toured, but that sometimes the ICP performed them as well. Problems identified with the physical condition of the areas were sent to the Engineering department as work orders.

Review of a document entitled, "Infection Control Plan, Including Program, Role and Scope", not dated, revealed that the Infection Control Program's goals included limiting unprotected exposure to pathogens, limiting the transmission of infections associated with procedures, limiting the transmission of infections associated with the use of medical equipment, devices and supplies, and improving compliance with hand hygiene guidelines. The document related that the Infection Control Committee met monthly during the Performance Improvement/Peer Review meeting. However, documentation related to regular inspection of the facility for cleanliness and implementation of infection control measures was not provided. During interviews with Infection Control Practitioner (ICP- employee #9) on 10/08/2015 at 11:30 a.m. and 10/08/2015 at 1:45 p.m., he/she confirmed that the facility reports of infections were sent to the infection control committee which reported through Quality Assurance and then Board of Trustees Minutes. The ICP confirmed that while the infection control information is presented to the Board of Trustees every other month, the items reported are not on the agenda and are not documented as having been reviewed in the meeting. Documented evidence of review of the infection control data/reports by the either the Quality Assurance/Performance Improvement (QAPI)/Peer Review committee or the Governing Body was not provided, and the ICP confirmed that no documented evidence of the review by either committee had been made.

Review of the employee files for seven of the facility's OR staff responsible for maintaining the overall maintenance of the OR environment and for providing care to patients undergoing surgical procedures and/or patient recovery (employees #1, 2, 3, 4, 5, 6 and 9) revealed that each had undergone training in infection control within the previous 12 months. However, none of the files reviewed included documented evidence that each staff member had undergone training regarding infection control practices and prevention techniques specifically related to their job requirements, had been evaluated for understanding of the related concepts, and had been determined to be competent in their application. This was confirmed as follows: During interviews on 10/07/15 with the OR circulator (employee #6), the CNO (employee #15), the LPN/Scrub Tech (employee #2) and with the OR Director (employee #13) at 10:15 am, 10:15 am, 10:45 am and 10:57 am respectively, each stated that training in infection control techniques was provided on hire, then staff were required to read infection control information and answer a questionnare annually thereafter. Each staff member related that infection control training related to their specific job was not provided. The CNO added that the training on 10/06/15 was the first time that there had been a scope manufacturer to give them a class on the cleaning and reprocessing of the scopes. Each staff member interviewed related that he/she did not know of any projects conducted in the OR related to infection control. Failure to provide regular training to staff

During an interview in the OR hallway on 10/08/15 just prior to commencement of surgery, the contracted cleaning company's Supervisor ("employee" #16) stated that the person assigned to clean the OR had not been trained appropriately to perform this duty, and would either be re-assigned or re-trained. The Supervisor also stated that assessments of the staff's quality of work had not been performed.