HospitalInspections.org

Based on observation, record review and interview, the facility failed to maintain an acceptable level of safety and quality for the equipment, in that, 2 of 4 anesthesia carts (OR #1 and #5 anesthesia carts) had rust on the front of their drawers, 1 of 1 "Fibergalss cart" in the clean storage room had rust on the front/side of the cart, and 4 of 4 carts for the electrosurgical machines in OR #1, #2, #3 and #5 had rust on the base and wheels of the carts.

Findings Included:

During the tour of the Surgical Department on 7/09/14 at 9:25AM, the surveyor observed the following:

Rust was observed on a drawer front on the anesthesia cart in Operating Room (OR) #1 and #5, on both front/sides of a blue "Fiberglass cart" in the clean Storage Room, and on the base and wheels of the carts for four Aspen Excalibur Plus electrosurgical machines.

Personnel #3 was present and confirmed all findings listed for the Surgical Department. Personnel #3 was asked about the rust on this equipment. Personnel #3 said there shouldn't be but the equipment is old and there is no money to replace the carts.

Personnel #8 was asked if the rusted equipment was reported to the Maintenance Department. Personnel #8 stated no.

The 6/10/13 "Inspecting, Testing, and Maintaining Medical Equipment" policy required, "the hospital inspects, tests, and maintains...Equipment these activities are documented."

Based on observation, records review, and interview, the infection control officer failed to develop a system to identify, report, investigate, and control sources and transmission of infections and communicable diseases, in that, 4 of 4 anesthesia carts in Operating Rooms (OR) #1, #2, #3, and #5 were observed with dried white fluid drips on drawers; 1 of 4 anesthesia cart (OR #1 anesthesia cart) was observed with dried brownish fluid on the drawer; and 1 of 2 laparoscopy carts (Laparoscopy Cart II) was observed with dried brownish fluid on the face of the carts.

Findings Included:


During the tour of the Surgical Department on 7/09/14 at 9:25 AM, the surveyor observed the following:

Four anesthesia carts in OR #1, #2, #3 and #5 were observed with dried, white fluid drips on the face of the drawers.

One anesthesia cart in OR #1was observed with dried, brownish fluid drip on the face of the cart beside the drawer.

One "Laparoscopy Cart II" was in the hallway outside of OR #4. It was observed to have 2 dried, brownish drops/splatters and 1 smudge of similar color on the face of the cabinet.

Personnel #3 was present and confirmed all findings listed for the Surgical Department. Personnel #3 was asked when and who should have cleaned the carts/cabinets. Personnel #3 stated the anesthesia technicians clean the carts after each case when they are restocking.

Personnel #3 called in Personnel #4. Personnel #4 was asked about the process of clean up after a procedure. Personnel #4 stated, "I restock and clean the anesthesia cart." Personnel #4 stated, "I must have missed cleaning this cart."

Personnel #3 said they did not have a policy or checkoff list for the anesthesia cart/cabinet cleaning.

The 4/29/05 "Environmental Cleaning of the Surgical Practice Setting" policy required, "equipment and furniture that are visibly soiled will be cleaned with hospital approved disinfectant. Walls, doors, surgical lights, and ceiling will be spot cleaned if soiled with blood, tissue or body fluids...End of the gate terminal cleaning...All horizontal surfaces, equipment, and furniture will be damp dusted...Including wheels...Handles of cabinets and push plates...Cleaning responsibilities of the OR personnel...daily inspection of all equipment...will be performed."