HospitalInspections.org

Based on interview, observation, and record review the hospital failed to assure the hospital surgical patients' right to a safe setting in that

1) three of three hospital personnel (Hospital Personnel #6, #14, and #15) assigned to terminally clean the hospital's surgery suites did not receive training prior to assuming the task, and
2) one of two hospital personnel (Personnel #17) assigned to provide vacation coverage in the hospital's sterile processing department performed sterilization of instruments on five consecutive days from 07/07/14 through 07/11/14 and did not have sterile processing department competencies.


Findings included:

On 07/31/14 between 07:30 and 10:45 observational rounds were conducted with Hospital Personnel #4 in the hospital three operating suites (OR #1, #2, and #3) and hallways.

One cabinet in OR #3 had three blue bins with dust particles. Equipment without protective cover included a black and gray extension cord and an air pump. An orange extension cord reel was on the floor.

Hospital Personnel #4 agreed that the supply bins were dusty and stated he did not know whether the bins were on a cleaning schedule.

Uncovered equipment in OR #2 included at least one Sequential Compression Device (SCD).

One of the cabinets in OR #1 contained uncovered items including an MP3 Player (digital media player), three extension cords, a CD player (compact disc player), and an SCD. The protective cover of three pillows was ripped in three places, leaving the surface open to the environment. Hospital Personnel #4 stated that uncovered, "not clean" equipment could "potentially be used during surgery."

Two extension cords were observed on the floor of OR #1. Hospital Personnel #4 was asked about the policy regarding extension cords in OR suites and stated he was not sure whether there was a policy.

The Utility Room close to the post-anesthesia care unit (PACU) had a dirty linen bag with used mop heads stored in close proximity to the clean mop storage area. Hospital Employee #2 was interviewed on 07/31/14 at 09:15 regarding the storage of used mop heads close to clean ones and stated, "That's not good."

In the hallway, the floor of a small storage area ("cove") with suture supplies was dusty and grimy. Hospital Personnel #15 agreed that the floor was not clean. Hospital Personnel #15 was asked about OR cleaning assignments and stated "Nobody is really assigned to it. We all do it and were thrown in this role when environmental services were told not to clean the OR anymore." Hospital Employee #4 witnessed the statement and agreed.

Review of the OR/Procedure Room Terminal Cleaning Checklist Audit Tools dated 07/29/14, 07/30/14, and 07/31/14 reflected cleaning tasks included "...cabinets and all surfaces are cleaned, dusted, and spot free...and the floor in the operating/procedure room and hallway is thoroughly swept and mopped." The documents were signed off as completed by Hospital Personnel #6, #14, and #15. Hospital Personnel #4's initials reflected that the cleaning had passed inspection.

Review of Hospital Employee #6's employee file reflected a job description of an Operating Room Technician. His hospital training did not reflect demonstrated competency for terminal cleaning of the OR.

Review of Hospital Personnel #14's employee file reflected he was hired as an Operating Room Attendant and Transporter. There was no documented training of terminal OR cleaning.

Review of Hospital Personnel #15's employee file reflected a job title of OR Supply Chain Technician. His 01/10/14 hospital training did not reflect training in terminal cleaning of surgery suites.

Hospital Personnel #5 stated on 7/31/14 at 16:31 she did not see any demonstrated competency for terminal cleaning in Hospital Personnel #6's, #14's, nor #15's employee files.

Hospital Personnel #1 denied awareness of the above findings on 07/31/14 at approximately 17:00.

The Hospital Policy Infection Control for Surgery dated 06/2013 noted that "...the employee assigned to environmental cleaning will be trained annually on special cleaning required in the Surgery Department."


2) Hospital Personnel #13 was interviewed on 07/31/14 at 10:45. He stated he performed the hospital's sterilization procedures. In his absence, Hospital Personnel #16 worked in the sterile processing department. A faxed document dated 08/06/14 at 21:59 reflected Hospital Personnel #13's statement that Hospital Personnel #17 was his "primary back up" during his recent vacation.

Review of a faxed statement dated 08/07/14 at 13:29 by Hospital Personnel #1 reflected Hospital Personnel #17 performed the sterilization of instruments on 07/07/14, on 07/08/14, on 07/09/14, 07/10/14, and 07/11/14. The document noted that Hospital Personnel #17 did not have sterile processing department competencies.

The Hospital Policy titled Decontamination, Sorting, and Sterilization of Contaminated Instruments and Equipment dated 06/2013 noted that "...Relief Personnel need to follow the same procedure as regular personnel...employees providing relief in Sterile Processing Department will have documented training..."

Based on observation, record review, and interview, the hospital failed to maintain the condition of the hospital OR (Operating Room) area in such a manner that the safety and well-being of patients were assured in that unclean and/or uncovered equipment and an unclean floor were observed in 3 of 3 OR suites (OR #3, #2, #1) and a hallway on 07/31/14.


Findings included:

On 07/31/14 between 07:30 and 10:45 observational rounds were conducted with Hospital Personnel #4 in the hospital three operating suites (OR #3, #2, #1) and hallways.

One cabinet in OR #3 had three blue bins with dust particles. Equipment without protective cover included a black and gray extension cord and an air pump. An orange extension cord reel was on the floor.

Hospital Personnel #4 agreed that the supply bins were dusty and stated he did not know whether the bins were on a cleaning schedule.

Uncovered equipment in OR #2 included at least one Sequential Compression Device (SCD).

One of the cabinets in OR #1 contained uncovered items including an MP3 Player (digital media player), three extension cords, a CD player (compact disc player), and an SCD. The protective cover of three pillows was ripped in three places. leaving the surface open to the environment. Hospital Personnel #4 stated that uncovered, "not clean" equipment could "potentially be used during surgery."

Two extension cords were observed on the floor of OR #1. Hospital Personnel #4 was asked about the policy regarding extension cords in OR suites and stated he was not sure whether there was a policy.

In the hallway, the floor of a small storage area ("cove") with suture supplies was dusty and grimy. Hospital Personnel #15 agreed that the floor was "not clean."

The Hospital Policy titled Environmental Cleaning of the Surgical Practice Setting dated 06/2013 noted the purpose "to provide a clean environment for surgical patients [and] to minimize healthcare worker's and patients' exposure to potentially infectious microorganisms."