HospitalInspections.org

Based on observations, interviews and record reviews, the hospital failed to ensure the system for preventing and controlling infections and infectious diseases was followed, maintained and monitored as evidenced by: 1) failing to ensure that Surgical Services and Environmental Services followed the hospital ' s infection control policy/practices in the terminal cleaning of the surgical suites and, 2) failing to ensure that Environmental Services followed the hospital ' s infection control policy/practices when cleaning patient rooms.

Findings:

1) failing to ensure that Surgical Services and Environmental Services followed the hospital ' s infection control policy/practices in the terminal cleaning of the surgical suites.

A review of the AORN (Association of periOperative Registered Nurses) Guidelines for Perioperative Practice, revised Environmental Cleaning practice for 2015, revealed in part: Terminal cleaning of the perioperative areas should be performed daily when the areas are used. The perioperative Surgical Services Department should determine the frequency and extent of cleaning required in semi-restricted and restricted areas when areas are not occupied (eg. unused rooms and weekends). Terminal cleaning in semi-restricted and restricted areas for unused rooms and weekends should be determined by hospital policy.

A review of the hospital policy titled, " OR Environmental Cleaning of the Operating Room " , as provided by S7QA as the most current, revealed in part: Operating Rooms are terminal cleaned once every 24 hours by EVS (Environmental Services) housekeeping personnel

In an interview on 09/01/15 at 7:00 a.m. with S36EVS/OR she indicated that she was the EVS staff assigned to do the terminal cleaning of the OR (operating room) on 08/31/15 on the 11:00 p.m. to 7:00 a.m. shift. S36EVS/OR indicated that she only had 1 (one) OR to terminally clean that shift after 11:00 p.m. She indicated that OR #12 was in progress when she arrived on her shift and she terminally cleaned it when the surgical procedure was finished. S36EVS/OR was asked if she had to do terminal cleaning of any unused rooms that were not terminally cleaned in the last 24 hours. S36EVS/OR indicated that she did not know anything about the terminal cleaning of any of the unused rooms that were not terminally cleaned in the last 24 hours. S36EVS/OR further indicated that she did not have any way of knowing which OR rooms were not terminally cleaned in the last 24 hours. S36EVS/OR indicated that she just performs terminal cleaning on the rooms that were still in progress on the 11-7 am shift after the surgical procedure was completed.

On 09/01/15 from 8:30 p.m.to 10:30 p.m., in the presence of S38EVSMgr, an observation was made of the EVS/OR staff, S39EVS/OR and S40EVS/OR terminally cleaning rooms.

In an interview on 09/01/15 at 9:40 p.m. with S40EVS/OR she indicated that she was 1 of 2 EVS/OR staff assigned to the OR on the 3-11 p.m. shift that night (09/01/15). S40EVS/OR indicated that her assignment was OR rooms #11- #15, #17- #19 and she was to terminal clean any used room that was not terminal cleaned by the 7-3 p.m. EVS/OR shift and to terminal clean any room that was still in progress after the surgical procedure was completed in that OR room.
S40EVS/OR indicated that she terminal cleaned OR #11 and OR #18 and was presently terminally cleaning OR #15 and that she still had to terminal clean OR #12. S40EVS/OR was asked about OR #13, OR#14, OR# 17, OR#19 and if they had been unused in the last 24 hours and needed to be terminal cleaned. S40EVS/OR indicated that she did not have any way of knowing which unused OR rooms were not terminal cleaned in the last 24 hours S40EVS/OR further indicated that terminal cleaning takes about 45 minutes a room and she would not have time on her shift to terminal clean OR #13, OR#14, OR# 17, OR#19. S40EVS/OR indicated that she would only report to the 11- 7 am EVS/OR shift which used rooms needed to be terminal cleaned. S40EVS/OR indicated that she did not know if OR #13, OR#14, OR# 17, OR#19 were scheduled to be used in the morning.

In an interview on 09/01/15 at 10:15 p.m. with S39EVS/OR he indicated that he was 1 of 2 EVS/OR staff assigned to the OR on the 3-11 p.m. shift that night (09/01/15). S39EVS/OR indicated that his assignment was OR rooms #1- #10, and he was to terminal clean those rooms that were used today and were not terminally cleaned by the 7-3 p.m. EVS/OR staff, and to terminal clean any room that was still in progress after the surgical procedure was completed in that OR room. S39EVS/OR indicated that he terminal cleaned OR #2, OR #3, and OR #10 and was presently terminal cleaning OR #1. S39EVS/OR indicated that he had to terminally clean OR #2 again because another surgical case was placed in there after he had terminal cleaned it. S39EVS/OR was asked about OR #4 - OR #9 and if they had been unused in the last 24 hours and needed to be terminal cleaned. S39EVS/OR indicated that he did not have any way of knowing which unused OR rooms were not terminal cleaned in the last 24 hours. S39EVS/OR further indicated that terminal cleaning takes about 45 minutes a room and he would not have time on his shift to terminal clean OR #4 - OR #9. S39EVS/OR indicated that he would only report to the 11- 7 am EVS/OR shift which used rooms needed to be terminal cleaned. S39EVS/OR indicated that he did not know if OR #4 - OR #9 were scheduled to be used in the morning.

In an interview on 09/01/15 at 10:30 p.m., the following hospital staff were present: S5SVP, S6VP, S8DirPeriop, S41RN/OR, S38EVSMgr, S39EVS/OR and S40EVS/OR, and the process of identifying unused rooms that required terminal cleaning by EVS/OR staff after 24 hours of being unused was discussed. S39EVS/OR indicated that when they (EVS/OR staff ) arrived on the unit (OR) they asked the OR charge nurse which rooms were used that day and were not able to be terminal cleaned by the 7-3 p.m. EVS/OR staff and which OR rooms were still in progress. S39EVS/OR indicated that the EVS/OR staff made their own assignments based on the information given to them by the OR charge nurse. S39EVS/OR further indicated that the EVS/OR 3-11 p.m. staff did not know which rooms had been unused in the last 24 hours and needed to be terminal cleaned. S39EVS/OR indicated that he thought that the OR charge nurse kept a record of which rooms had been unused in the last 24 hours and needed to be terminal cleaned. S41RN/OR (3-11pm charge nurse) indicated that the OR charge nurses did not keep a record of which rooms had not been used in the last 24 hours and needed to be terminal cleaned. S38EVSMgr indicated that she would have to check assignments sheets for the last couple of days in order to determine which OR rooms had not been used in the last 24 hours and needed to be terminal cleaned. S38EVSMgr further indicated that this information was not passed on to the EVS/OR staff on each shift. S38EVSMgr indicated that the present process used by the EVS/OR staff and the EVS managers did not communicate effectively which OR rooms had not been used in the last 24 hours and needed to be terminal cleaned as per hospital policy.


2) failing to ensure that Environmental Services followed the hospital ' s infection control policy/practices when cleaning patient rooms.

A review of the hospital policy titled, " Environmental Services- Patient Room Cleaning -Daily " , as provided by S7QA as the most current, revealed in part: EVS staff, when cleaning patient room, should work in a counter-clockwise direction around the room starting at the door and not in the bathroom and should work from clean surfaces to dirty surfaces.

On 09/01/15 at 11:30 a.m. an observation was made of S37EVS cleaning a patient room, in the presence of S1CNO. S37EVS was observed cleaning the patient bathroom toilet first upon entering the patient room and then was observed cleaning the rest of the patient bathroom with the same gloves and the same cleaning rag. After cleaning the patient bathroom, S37EVS was observed picking up the dirty laundry from the patient ' s bathroom floor and leaving the patient ' s room with the dirty laundry in her hands. S37EVS went down the hallway with the dirty laundry in her hands and returned with a rolling laundry container which she placed in the patient ' s room. S37EVS was then observed proceeding to clean the rest of the patient ' s room with the same gloves and was not observed changing her gloves when going from dirty tasks to clean tasks or performing any hand hygiene during the observations by the surveyor.
In an interview on 09/01/15 at 3:20 p.m. with S22DirEVS he was made aware of the infection control breaches, by S37EVS, during the cleaning of a patient's room. S22DirEVS indicated that the cleaning of the patient room by S37EVS did not follow acceptable infection control practices or hospital policy.

Based on observations, interviews, and record reviews the hospital failed to ensure the Surgical Services Department followed acceptable professional standards of practice and/or hospital policy as evidenced by:

1) failing to ensure that staff in the surgical suite ' s restricted and semi-restricted areas followed acceptable professional standards of practice and/or hospital policy for surgical attire by: a) observations of non-scrubbed surgical staff not wearing a long sleeved warm up jacket during surgical procedures and wearing long disposable surgical gowns as warm up jackets during surgical procedures, b) observations of surgical staff wearing undergarments that were not completely covered by their surgical attire and surgical staff wearing two-piece surgical attire with their scrub tops not secured at the waist, c) observations of surgical personnel wearing skull caps (surgeon caps) that did not completely cover all their hair (head and facial hair), d) observations of surgical personnel wearing cloth hats (reusable head coverings) that were not completely covered by a surgical bouffant hat, e) observations of surgical staff wearing surgical masks around their necks or having surgical masks in their pockets, f) observation of a sterile surgical field that was created and not being continuous monitored by OR personnel, g) observations of sterile supplies being left on top of OR furniture during EVS cleaning in the ORs and not returned to secured sterile supply areas after cases were completed and of a perfusion pump machine, in a sub-sterile OR room, being pre-set up in advance with opened sterile tubings and covered with a cloth bed sheet, h) observations of staff wearing stethoscopes around the neck, i) observations of EVS/OR staff not adhering to the surgical dress requirements while performing EVS cleaning in the OR and

2) failing to ensure that Surgical Services and Environmental Services Departments followed the hospital ' s infection control policy/practices in the terminal cleaning of the surgical suites

Findings:

1) failing to ensure that staff in the surgical suite ' s restricted and semi-restricted areas followed acceptable professional standards of practice and/or hospital policy for surgical attire by: a) observations of non-scrubbed surgical staff not wearing a long sleeved warm up jacket during surgical procedures and wearing long disposable surgical gowns as warm up jackets during surgical procedures, b) observations of surgical staff wearing undergarments that were not completely covered by their surgical attire and surgical staff wearing two-piece surgical attire with their scrub tops not secured at the waist, c) observations of surgical personnel wearing skull caps (surgeon caps) that did not completely cover all their hair (head and facial hair), d) observations of surgical personnel wearing cloth hats (reusable head coverings) that were not completely covered by a surgical bouffant hat, e) observations of surgical staff wearing surgical masks around their necks or having surgical masks in their pockets, f) observation of a sterile surgical field that was created and not being continuous monitored by OR personnel, g) observations of sterile supplies being left on top of OR furniture during EVS cleaning in the ORs and not returned to secured sterile supply areas after cases were completed and of a perfusion pump machine, in a sub-sterile OR room, being pre-set up in advance with opened sterile tubings and covered with a cloth bed sheet, h) observations of staff wearing stethoscopes around the neck, i) observations of EVS/OR staff not adhering to the surgical dress requirements while performing EVS cleaning in the OR.

A review of AORN (Association of periOperative Registered Nurses) Perioperative Standards and Recommended Practices, 2013 edition - Surgical Attire: Recommendation IX revealed in part: Restricted areas in a surgical suite includes the OR (operating room) and procedure rooms, the clean core and the scrub sink areas. People in the restricted areas are required to wear full surgical attire (scrub attire, head coverings, masks, and shoe covers). The Semi-Restricted areas include the peripheral support areas of the surgical suite, the storage areas, the work areas, and corridors leading to the restricted areas of the surgical suite.

A review of the AORN Perioperative Standards and Recommended Practices, 2013 edition,- Recommended Practice for Surgical Attire - Recommendation III revealed in part: When in the semi-restricted or restricted surgical areas, all non-scrubbed personnel should wear a freshly laundered or single use long sleeved warm up jacket snapped closed with the cuffs down to the wrists. Wearing the warm up jacket snapped closed prevents the edges of the front of the jacket from contaminating a skin prep area or the surgical sterile field. Long sleeved attire helps contain skin squames shed from bare arms. All personal clothing should be completely covered by the surgical attire. Undergarments such as T-shirts with a V-neck, and shirts with sleeves which can be contained underneath the scrub top, may be worn; personal clothing that extends above the scrub top neckline or below the sleeve of the surgical attire should not be worn. Personnel clothing is not laundered by a health care-accredited laundry facility.
A review of the AORN Perioperative Standards and Recommended Practices, 2013 edition, - Recommended Practice for Surgical Attire - Recommendation II revealed in part: When wearing a two-piece scrub suit, the top of the scrub suit should be secured at the waist, tucked into the pants, or fit close to the body to prevent skin squames from being dispersed into the environment from the axilla and chest. The major source of bacteria dispersed into the air comes from health care provider ' s skin.
A review of the AORN Perioperative Standards and Recommended Practices, 2013 edition, - Recommended Practice for Surgical Attire - Recommendation IV revealed in part: All personnel should cover head and facial hair, including the sideburns, the ears and the nape of the neck, when in semi-restricted and restricted areas. Human hair can be a site of pathogenic bacteria such as MRSA. Hair acts as a filter when it is uncovered and collects bacteria. A clean, low-lint surgical head covering or hood that confines all hair and covers scalp skin and ears should be worn. The head covering or hood should be designed to minimize microbial dispersal. Skull caps (surgeon caps) fail to contain the side hair above and in front of the ears and hair at the nape of the neck and the ears and should not be worn.
A review of the AORN Perioperative Standards and Recommended Practices, 2013 edition, - Recommended Practices for Surgical Attire - Recommendation III revealed in part: Only facility-approved, clean and freshly laundered surgical attire should be donned daily by all personnel entering or reentering the semi-restricted and restricted surgical areas to decrease the possibility of cross-contamination. Recommendation IV revealed in part: Reusable head coverings (cloth hats) that are not laundered in a health care- accredited laundry facility should be covered by a disposable bouffant surgical hat that completely covers the cloth hat.

A review of the AORN Perioperative Standards and Recommended Practices, 2013 edition - Recommended Practices for Surgical Attire, Recommendation VI revealed in part: All individuals entering the restricted surgical area and the OR suites should wear a surgical mask when scrubbed personnel, sterile supplies and/or sterile equipment are present. A surgical mask protects the patient from transfer of microorganisms. Surgical masks should not be worn hanging down from the neck. Surgical masks are intended to contain and filter droplets from the nasopharynx. The filter portion of the surgical mask harbors bacteria collected from the nasopharyngeal airway and should not be worn hanging from the neck.

A review of the AORN Perioperative Standards and Recommended Practices, 2013 edition, Recommended Practices for Selection and Use of Packaging Systems for Sterilization: Recommendation VIII revealed in part: Sterilized items should be considered sterile until an event occurs to compromise the sterility of the sterile item such as, moisture penetration or unacceptable storage conditions, exposure to airborne and other environmental contaminants. The sterility of sterile items is event related and not time related. Events that affected the sterility of sterile packages included in part: multiple handing of the sterile package, compression, moisture penetration to include disinfectant solutions, exposure to airborne and environmental contaminants and storage conditions (improper shelving, temperature, humidity, cleanliness, and traffic), type of packaging materials used, use of sterility maintenance covers and method of sealing. Sterile items should be stored under environmentally controlled conditions.
A review of AORN Perioperative Standards and Recommended Practices, 2013 edition - Sterilization: Recommendation XV revealed in part: Sterilized items should have limited exposure to moisture and humidity to decrease the potential contamination of the sterilized items. Factors that contribute to contamination include air movement, humidity, temperature, location of storage, presence of vermin, whether shelving is open or closed, and properties of the packaging material. Sterile packages should be stored under environmental controlled conditions. Sterile items should not be stored under sinks or in other locations where they can become wet. Open shelving may be used if they are located in a secure, environmental controlled clean area.
A review of the AORN Perioperative Standards and Recommended Practices, 2013 edition, - Recommended Practices for Sterile Technique - Recommendation V revealed in part: The sterile field should be prepared in the location where it will be used and should not be moved. Moving the sterile field from one location to another increases the potential for contamination. The sterile field should be prepared as close as possible to the time of use. The potential for bacterial growth and contamination increases with time because dust and other particles present in the ambient environment settle on horizontal surfaces. Particulate matter can be stirred up by personnel movement and can settle on open sterile supplies. The sterility of an open sterile item is event related. Recommendation VII revealed in part: The sterile field is subject to unrecognized contamination by personnel, vectors, or breaks in sterile technique if left unobserved/unmonitored. Once created, a sterile field should not be left unattended until the operative or invasive procedure is completed. Scrubbed personnel should not leave the sterile field to retrieve items once the sterile field has been created.
A review of the AORN Perioperative Standards and Recommended Practices, 2013 edition, - Recommended Practices for Surgical Attire, Recommendation II revealed in part: Stethoscopes should be clean and not worn around the neck. Stethoscopes may transmit pathogens such as MRSA by indirect contact, by wearing the stethoscope around the neck and contaminating the skin and surgical attire. Stethoscopes come in direct contact with the skin and could provide an opportunity for transmission of microbes from patient to patient and/or from health care personnel to patients.

A review of the hospital ' s Surgical Services policy titled, " Dress Code in the OR " , as provided by S7QA as the most current, revealed in part: All personnel authorized to enter the surgical suites will adhere to the appropriate dress code. Restricted area includes the OR, sterile stores, and scrub areas. People in this area are required to wear full surgical attire and cover all head and facial hair, including sideburns, beards, and necklines. Semi-restricted area includes the peripheral support areas of the surgical suite. Surgical attire includes a two-piece surgical pantsuit, long-sleeved surgical scrub jacket, head coverings, shoes, masks, protective eyewear, and other protective barriers. In the Restricted area, surgical attire, including hair covering, is required. Masks are required where open sterile supplies or scrubbed persons may be located. It is recommended that scrub tops be tucked into scrub pants or fit close to the body. If wearing a long sleeved warm-up jacket, it should be snapped closed with the cuffs extending to the wrist. Masks must not be dangled around the neck or placed in pockets after use. Hair must be covered at all times while in the restricted and semi-restricted areas. Cloth hair coverings may be worn only if they are covered with a disposable cap. Caps are to be worn to cover all hair. Any style of surgical cap that fails to contain all hair, including hair at the nape of the neck, should not be worn. Facial hair must be covered at all times while in the restricted and semi-restricted areas. Unscrubbed personnel are allowed to wear one watch and one ring on each hand.

A review the hospital policy titled, " Cleaning the Surgery Department " , provided by S7QA as the most current, revealed in part: EVS/OR personnel will observe surgical suite dress requirements at all times.
A review of the hospital ' s Surgical Services policy titled, " Aseptic Practice in the OR " , as provided by S7QA as the most current, revealed in part: The sterile field should be prepared as close as possible to the time of use. Unguarded sterile fields should be considered contaminated.

Observations on 08/31/15 from 12:15 p.m. to 2:15 p.m. of the restricted and semi-restricted areas of surgical suites, in the presence of S6VP and S8DirPeriop, revealed the following observations:
-S43Tech wearing a personal reusable cloth head covering that was not covered with a disposable bouffant hat,
-S44RN/OR wearing a personal reusable cloth head covering that was not covered with a disposable bouffant hat,
-S9CRNA with a surgical mask in his pocket,
-S10RN/OR circulating in an OR room wearing a disposable long blue surgical gown as a warm up jacket that was unsecured and flapping,
-S11RN/OR wearing a surgical mask around her neck in a restricted hallway and wearing a warm up jacket while circulating in an OR room that was not snapped closed and was flapping.
-S45CRNA wearing a disposable long blue surgical gown as a warm up jacket that was unsecured and flapping,
-S12CRNA wearing a T-shirt under his scrub attire that was not completed covered by his scrub attire,
-S13ST in a surgical room with her scrub top not secured at the waist while she was opening sterile supplies onto the sterile field,
-S14ST wearing a personal reusable cloth head covering that was not completely covered by the disposable bouffant hat,
-S15RN/OR wearing a skull cap (surgeon ' s hat) that did not cover all of his hair at the nape of the neck,
-A Resident in an OR room wearing a skull cap (surgeon ' s hat) that did not cover all of his hair at the nape of the neck or the hair around his ears and wearing a T-shirt under his scrub attire that was not completed covered by his scrub attire,
-S29CRNA with a stethoscope around her neck,
-S17CRNA with a stethoscope around his neck,
-S18MD in an OR room wearing a skull cap (surgeon ' s hat) that did not cover all of his hair at the nape of the neck or the hair around his ears,
-S19RN/OR wearing a warm up jacket while circulating in an OR room that was not snapped closed and was flapping,
-S20RN/OR circulating in an OR room wearing a disposable long blue surgical gown as a warm up jacket that was unsecured and flapping,
-S21RN/OR wearing a skull cap (surgeon ' s hat) that did not cover all of his hair at the nape of the neck or the hair around his ears and wearing a T-shirt under his scrub attire that was not completed covered by his scrub attire,
-S23EVS/OR cleaning an OR room with his scrub top not secured at the waist and wearing a T-shirt under his scrub attire that was not completed covered by his scrub attire,
-S24EVS/OR cleaning an OR room with his scrub top not secured at the waist and wearing a T-shirt under his scrub attire that was not completed covered by his scrub attire,
-S28EVS/OR cleaning an OR room with her scrub top not secured at the waist and wearing a shirt under her scrub attire that was not completed covered by her scrub attire,
-EVS/OR staff x2 with surgical masks in their pockets, masks with the bottom tie not tied and dangling around their necks and with their scrub tops not secured at the waist and wearing T-shirts under their scrub attire that was not completed covered by their scrub attire,
-S25Anes wearing a disposable bouffant hat only on the top portion of his head that did not cover all of his hair at the nape of the neck or the hair around his ears,
-S27RN/OR wearing a warm up jacket while circulating in an OR room that was not snapped closed and was flapping,
-S26RN/OR wearing a warm up jacket while circulating in an OR room that was not snapped closed and was flapping,
-S30CRNA wearing a T-shirt under his scrub attire that was not completed covered by his scrub attire,
-Sterile packages left in OR #8 and OR #9 on back tables and ring stands when no surgery cases were presently scheduled in those rooms,

Observations on 09/01/15 from 6:00 a.m. to 8:00 a.m. of the restricted and semi-restricted areas of surgical area, in the presence of S6VP and S8DirPeriop, revealed the following observations:

-S31CRNA with no mask and no warm up jacket in an OR suite while he was setting up an anesthesia cart prior to a surgical procedure and with facial hair (beard) that was not covered,
-S32CRNA with no mask and no warm up jacket in an OR suite while she was setting up an anesthesia cart prior to a surgical procedure,
-S34RN/OR in a OR room charting prior to a surgical procedure with bangle bracelets on her arm,
-S33MgrSC wearing a personal reusable cloth head covering that was not completely covered by the disposable bouffant hat,
-OR #15 with the sterile field created prior to a patient entering the OR room was left unmonitored for over 5 (five) minutes while S35ST left the room to obtain other supplies,
-Sterile basin sets were left in several rooms on the warming machines during EVS/OR cleaning of the rooms,
-S36EVS/OR with her scrub top not secured at the waist and wearing a shirt under her scrub attire that was not completed covered by her scrub attire,
-Sub sterile room by the open heart OR room had a perfusion machine pre-set up in advance with the sterile tubing packages opened and set up in the perfusion machine and the perfusion machine was covered with a cloth blue bed sheet when no surgery cases were presently scheduled in the heart room that day or for over the last 24 hours as indicated by S8DirPeriop.

In an interview on 08/31/15 with S6VP and S8DirPeriop at 2:15 p.m. they indicated that the hospital ' s perioperative Surgical Services Department followed the AORN Perioperative Standards and Recommended Practices (AORN Guidelines for Perioperative Practice).



2) failing to ensure that Surgical Services and Environmental Services Departments followed the hospital ' s infection control policy/practices in the terminal cleaning of the surgical suites

A review of the AORN (Association of periOperative Registered Nurses) Guidelines for Perioperative Practice, revised Environmental Cleaning practice for 2015, revealed in part: Terminal cleaning of the perioperative areas should be performed daily when the areas are used. The perioperative Surgical Services Department should determine the frequency and extent of cleaning required in semi-restricted and restricted areas when areas are not occupied (eg. unused rooms and weekends). Terminal cleaning in semi-restricted and restricted areas for unused rooms and weekends should be determined by hospital policy.

A review of the hospital policy titled, " OR Environmental Cleaning of the Operating Room " , as provided by S7QA as the most current, revealed in part: Operating Rooms are terminal cleaned once every 24 hours by EVS (Environmental Services) housekeeping personnel

In an interview on 09/01/15 at 7:00 a.m. with S36EVS/OR she indicated that she was the EVS staff assigned to do the terminal cleaning of the OR (operating room) on 08/31/15 on the 11:00 p.m. to 7:00 a.m. shift. S36EVS/OR indicated that she only had 1 (one) OR to terminally clean that shift after 11:00 p.m. She indicated that OR #12 was in progress when she arrived on her shift and she terminally cleaned it when the surgical procedure was finished. S36EVS/OR was asked if she had to do terminal cleaning of any unused rooms that were not terminally cleaned in the last 24 hours. S36EVS/OR indicated that she did not know anything about the terminal cleaning of any of the unused rooms that were not terminally cleaned in the last 24 hours. S36EVS/OR further indicated that she did not have any way of knowing which OR rooms were not terminally cleaned in the last 24 hours. S36EVS/OR indicated that she just performs terminal cleaning on the rooms that were still in progress on the 11-7 am shift after the surgical procedure was completed.

On 09/01/15 from 8:30 p.m.to 10:30 p.m., in the presence of S38EVSMgr, an observation was made of the EVS/OR staff, S39EVS/OR and S40EVS/OR terminally cleaning rooms.

In an interview on 09/01/15 at 9:40 p.m. with S40EVS/OR she indicated that she was 1 of 2 EVS/OR staff assigned to the OR on the 3-11 p.m. shift that night (09/01/15). S40EVS/OR indicated that her assignment was OR rooms #11- #15, #17- #19 and she was to terminal clean any used room that was not terminal cleaned by the 7-3 p.m. EVS/OR shift and to terminal clean any room that was still in progress after the surgical procedure was completed in that OR room.
S40EVS/OR indicated that she terminal cleaned OR #11 and OR #18 and was presently terminally cleaning OR #15 and that she still had to terminal clean OR #12. S40EVS/OR was asked about OR #13, OR#14, OR# 17, OR#19 and if they had been unused in the last 24 hours and needed to be terminal cleaned. S40EVS/OR indicated that she did not have any way of knowing which unused OR rooms were not terminal cleaned in the last 24 hours S40EVS/OR further indicated that terminal cleaning takes about 45 minutes a room and she would not have time on her shift to terminal clean OR #13, OR#14, OR# 17, OR#19. S40EVS/OR indicated that she would only report to the 11- 7 am EVS/OR shift which used rooms needed to be terminal cleaned. S40EVS/OR indicated that she did not know if OR #13, OR#14, OR# 17, OR#19 were scheduled to be used in the morning.

In an interview on 09/01/15 at 10:15 p.m. with S39EVS/OR he indicated that he was 1 of 2 EVS/OR staff assigned to the OR on the 3-11 p.m. shift that night (09/01/15). S39EVS/OR indicated that his assignment was OR rooms #1- #10, and he was to terminal clean those rooms that were used today and were not terminally cleaned by the 7-3 p.m. EVS/OR staff, and to terminal clean any room that was still in progress after the surgical procedure was completed in that OR room. S39EVS/OR indicated that he terminal cleaned OR #2, OR #3, and OR #10 and was presently terminal cleaning OR #1. S39EVS/OR indicated that he had to terminally clean OR #2 again because another surgical case was placed in there after he had terminal cleaned it. S39EVS/OR was asked about OR #4 - OR #9 and if they had been unused in the last 24 hours and needed to be terminal cleaned. S39EVS/OR indicated that he did not have any way of knowing which unused OR rooms were not terminal cleaned in the last 24 hours. S39EVS/OR further indicated that terminal cleaning takes about 45 minutes a room and he would not have time on his shift to terminal clean OR #4 - OR #9. S39EVS/OR indicated that he would only report to the 11- 7 am EVS/OR shift which used rooms needed to be terminal cleaned. S39EVS/OR indicated that he did not know if OR #4 - OR #9 were scheduled to be used in the morning.

In an interview on 09/01/15 at 10:30 p.m., the following hospital staff were present: S5SVP, S6VP, S8DirPeriop, S41RN/OR, S38EVSMgr, S39EVS/OR and S40EVS/OR, and the process of identifying unused rooms that required terminal cleaning by EVS/OR staff after 24 hours of being unused was discussed. S39EVS/OR indicated that when they (EVS/OR staff ) arrived on the unit (OR) they asked the OR charge nurse which rooms were used that day and were not able to be terminal cleaned by the 7-3 p.m. EVS/OR staff and which OR rooms were still in progress. S39EVS/OR indicated that the EVS/OR staff made their own assignments based on the information given to them by the OR charge nurse. S39EVS/OR further indicated that the EVS/OR 3-11 p.m. staff did not know which rooms had been unused in the last 24 hours and needed to be terminal cleaned. S39EVS/OR indicated that he thought that the OR charge nurse kept a record of which rooms had been unused in the last 24 hours and needed to be terminal cleaned. S41RN/OR (3-11pm charge nurse) indicated that the OR charge nurses did not keep a record of which rooms had not been used in the last 24 hours and needed to be terminal cleaned. S38EVSMgr indicated that she would have to check assignments sheets for the last couple of days in order to determine which OR rooms had not been used in the last 24 hours and needed to be terminal cleaned. S38EVSMgr further indicated that this information was not passed on to the EVS/OR staff on each shift. S38EVSMgr indicated that the present process used by the EVS/OR staff and the EVS managers did not communicate effectively which OR rooms had not been used in the last 24 hours and needed to be terminal cleaned as per hospital policy.

Based on observations, interviews and record reviews, the hospital failed to ensure the system for preventing and controlling infections and infectious diseases was followed, maintained and monitored as evidenced by: 1) failing to ensure that Surgical Services and Environmental Services followed the hospital ' s infection control policy/practices in the terminal cleaning of the surgical suites and, 2) failing to ensure that Environmental Services followed the hospital ' s infection control policy/practices when cleaning patient rooms.

Findings:

1) failing to ensure that Surgical Services and Environmental Services followed the hospital ' s infection control policy/practices in the terminal cleaning of the surgical suites.

A review of the AORN (Association of periOperative Registered Nurses) Guidelines for Perioperative Practice, revised Environmental Cleaning practice for 2015, revealed in part: Terminal cleaning of the perioperative areas should be performed daily when the areas are used. The perioperative Surgical Services Department should determine the frequency and extent of cleaning required in semi-restricted and restricted areas when areas are not occupied (eg. unused rooms and weekends). Terminal cleaning in semi-restricted and restricted areas for unused rooms and weekends should be determined by hospital policy.

A review of the hospital policy titled, " OR Environmental Cleaning of the Operating Room " , as provided by S7QA as the most current, revealed in part: Operating Rooms are terminal cleaned once every 24 hours by EVS (Environmental Services) housekeeping personnel

In an interview on 09/01/15 at 7:00 a.m. with S36EVS/OR she indicated that she was the EVS staff assigned to do the terminal cleaning of the OR (operating room) on 08/31/15 on the 11:00 p.m. to 7:00 a.m. shift. S36EVS/OR indicated that she only had 1 (one) OR to terminally clean that shift after 11:00 p.m. She indicated that OR #12 was in progress when she arrived on her shift and she terminally cleaned it when the surgical procedure was finished. S36EVS/OR was asked if she had to do terminal cleaning of any unused rooms that were not terminally cleaned in the last 24 hours. S36EVS/OR indicated that she did not know anything about the terminal cleaning of any of the unused rooms that were not terminally cleaned in the last 24 hours. S36EVS/OR further indicated that she did not have any way of knowing which OR rooms were not terminally cleaned in the last 24 hours. S36EVS/OR indicated that she just performs terminal cleaning on the rooms that were still in progress on the 11-7 am shift after the surgical procedure was completed.

On 09/01/15 from 8:30 p.m.to 10:30 p.m., in the presence of S38EVSMgr, an observation was made of the EVS/OR staff, S39EVS/OR and S40EVS/OR terminally cleaning rooms.

In an interview on 09/01/15 at 9:40 p.m. with S40EVS/OR she indicated that she was 1 of 2 EVS/OR staff assigned to the OR on the 3-11 p.m. shift that night (09/01/15). S40EVS/OR indicated that her assignment was OR rooms #11- #15, #17- #19 and she was to terminal clean any used room that was not terminal cleaned by the 7-3 p.m. EVS/OR shift and to terminal clean any room that was still in progress after the surgical procedure was completed in that OR room.
S40EVS/OR indicated that she terminal cleaned OR #11 and OR #18 and was presently terminally cleaning OR #15 and that she still had to terminal clean OR #12. S40EVS/OR was asked about OR #13, OR#14, OR# 17, OR#19 and if they had been unused in the last 24 hours and needed to be terminal cleaned. S40EVS/OR indicated that she did not have any way of knowing which unused OR rooms were not terminal cleaned in the last 24 hours S40EVS/OR further indicated that terminal cleaning takes about 45 minutes a room and she would not have time on her shift to terminal clean OR #13, OR#14, OR# 17, OR#19. S40EVS/OR indicated that she would only report to the 11- 7 am EVS/OR shift which used rooms needed to be terminal cleaned. S40EVS/OR indicated that she did not know if OR #13, OR#14, OR# 17, OR#19 were scheduled to be used in the morning.

In an interview on 09/01/15 at 10:15 p.m. with S39EVS/OR he indicated that he was 1 of 2 EVS/OR staff assigned to the OR on the 3-11 p.m. shift that night (09/01/15). S39EVS/OR indicated that his assignment was OR rooms #1- #10, and he was to terminal clean those rooms that were used today and were not terminally cleaned by the 7-3 p.m. EVS/OR staff, and to terminal clean any room that was still in progress after the surgical procedure was completed in that OR room. S39EVS/OR indicated that he terminal cleaned OR #2, OR #3, and OR #10 and was presently terminal cleaning OR #1. S39EVS/OR indicated that he had to terminally clean OR #2 again because another surgical case was placed in there after he had terminal cleaned it. S39EVS/OR was asked about OR #4 - OR #9 and if they had been unused in the last 24 hours and needed to be terminal cleaned. S39EVS/OR indicated that he did not have any way of knowing which unused OR rooms were not terminal cleaned in the last 24 hours. S39EVS/OR further indicated that terminal cleaning takes about 45 minutes a room and he would not have time on his shift to terminal clean OR #4 - OR #9. S39EVS/OR indicated that he would only report to the 11- 7 am EVS/OR shift which used rooms needed to be terminal cleaned. S39EVS/OR indicated that he did not know if OR #4 - OR #9 were scheduled to be used in the morning.

In an interview on 09/01/15 at 10:30 p.m., the following hospital staff were present: S5SVP, S6VP, S8DirPeriop, S41RN/OR, S38EVSMgr, S39EVS/OR and S40EVS/OR, and the process of identifying unused rooms that required terminal cleaning by EVS/OR staff after 24 hours of being unused was discussed. S39EVS/OR indicated that when they (EVS/OR staff ) arrived on the unit (OR) they asked the OR charge nurse which rooms were used that day and were not able to be terminal cleaned by the 7-3 p.m. EVS/OR staff and which OR rooms were still in progress. S39EVS/OR indicated that the EVS/OR staff made their own assignments based on the information given to them by the OR charge nurse. S39EVS/OR further indicated that the EVS/OR 3-11 p.m. staff did not know which rooms had been unused in the last 24 hours and needed to be terminal cleaned. S39EVS/OR indicated that he thought that the OR charge nurse kept a record of which rooms had been unused in the last 24 hours and needed to be terminal cleaned. S41RN/OR (3-11pm charge nurse) indicated that the OR charge nurses did not keep a record of which rooms had not been used in the last 24 hours and needed to be terminal cleaned. S38EVSMgr indicated that she would have to check assignments sheets for the last couple of days in order to determine which OR rooms had not been used in the last 24 hours and needed to be terminal cleaned. S38EVSMgr further indicated that this information was not passed on to the EVS/OR staff on each shift. S38EVSMgr indicated that the present process used by the EVS/OR staff and the EVS managers did not communicate effectively which OR rooms had not been used in the last 24 hours and needed to be terminal cleaned as per hospital policy.


2) failing to ensure that Environmental Services followed the hospital ' s infection control policy/practices when cleaning patient rooms.

A review of the hospital policy titled, " Environmental Services- Patient Room Cleaning -Daily " , as provided by S7QA as the most current, revealed in part: EVS staff, when cleaning patient room, should work in a counter-clockwise direction around the room starting at the door and not in the bathroom and should work from clean surfaces to dirty surfaces.

On 09/01/15 at 11:30 a.m. an observation was made of S37EVS cleaning a patient room, in the presence of S1CNO. S37EVS was observed cleaning the patient bathroom toilet first upon entering the patient room and then was observed cleaning the rest of the patient bathroom with the same gloves and the same cleaning rag. After cleaning the patient bathroom, S37EVS was observed picking up the dirty laundry from the patient ' s bathroom floor and leaving

Based on observations, interviews, and record reviews the hospital failed to ensure the Surgical Services Department followed acceptable professional standards of practice and/or hospital policy as evidenced by:

1) failing to ensure that staff in the surgical suite ' s restricted and semi-restricted areas followed acceptable professional standards of practice and/or hospital policy for surgical attire by: a) observations of non-scrubbed surgical staff not wearing a long sleeved warm up jacket during surgical procedures and wearing long disposable surgical gowns as warm up jackets during surgical procedures, b) observations of surgical staff wearing undergarments that were not completely covered by their surgical attire and surgical staff wearing two-piece surgical attire with their scrub tops not secured at the waist, c) observations of surgical personnel wearing skull caps (surgeon caps) that did not completely cover all their hair (head and facial hair), d) observations of surgical personnel wearing cloth hats (reusable head coverings) that were not completely covered by a surgical bouffant hat, e) observations of surgical staff wearing surgical masks around their necks or having surgical masks in their pockets, f) observation of a sterile surgical field that was created and not being continuous monitored by OR personnel, g) observations of sterile supplies being left on top of OR furniture during EVS cleaning in the ORs and not returned to secured sterile supply areas after cases were completed and of a perfusion pump machine, in a sub-sterile OR room, being pre-set up in advance with opened sterile tubings and covered with a cloth bed sheet, h) observations of staff wearing stethoscopes around the neck, i) observations of EVS/OR staff not adhering to the surgical dress requirements while performing EVS cleaning in the OR and

2) failing to ensure that Surgical Services and Environmental Services Departments followed the hospital ' s infection control policy/practices in the terminal cleaning of the surgical suites

Findings:

1) failing to ensure that staff in the surgical suite ' s restricted and semi-restricted areas followed acceptable professional standards of practice and/or hospital policy for surgical attire by: a) observations of non-scrubbed surgical staff not wearing a long sleeved warm up jacket during surgical procedures and wearing long disposable surgical gowns as warm up jackets during surgical procedures, b) observations of surgical staff wearing undergarments that were not completely covered by their surgical attire and surgical staff wearing two-piece surgical attire with their scrub tops not secured at the waist, c) observations of surgical personnel wearing skull caps (surgeon caps) that did not completely cover all their hair (head and facial hair), d) observations of surgical personnel wearing cloth hats (reusable head coverings) that were not completely covered by a surgical bouffant hat, e) observations of surgical staff wearing surgical masks around their necks or having surgical masks in their pockets, f) observation of a sterile surgical field that was created and not being continuous monitored by OR personnel, g) observations of sterile supplies being left on top of OR furniture during EVS cleaning in the ORs and not returned to secured sterile supply areas after cases were completed and of a perfusion pump machine, in a sub-sterile OR room, being pre-set up in advance with opened sterile tubings and covered with a cloth bed sheet, h) observations of staff wearing stethoscopes around the neck, i) observations of EVS/OR staff not adhering to the surgical dress requirements while performing EVS cleaning in the OR.

A review of AORN (Association of periOperative Registered Nurses) Perioperative Standards and Recommended Practices, 2013 edition - Surgical Attire: Recommendation IX revealed in part: Restricted areas in a surgical suite includes the OR (operating room) and procedure rooms, the clean core and the scrub sink areas. People in the restricted areas are required to wear full surgical attire (scrub attire, head coverings, masks, and shoe covers). The Semi-Restricted areas include the peripheral support areas of the surgical suite, the storage areas, the work areas, and corridors leading to the restricted areas of the surgical suite.

A review of the AORN Perioperative Standards and Recommended Practices, 2013 edition,- Recommended Practice for Surgical Attire - Recommendation III revealed in part: When in the semi-restricted or restricted surgical areas, all non-scrubbed personnel should wear a freshly laundered or single use long sleeved warm up jacket snapped closed with the cuffs down to the wrists. Wearing the warm up jacket snapped closed prevents the edges of the front of the jacket from contaminating a skin prep area or the surgical sterile field. Long sleeved attire helps contain skin squames shed from bare arms. All personal clothing should be completely covered by the surgical attire. Undergarments such as T-shirts with a V-neck, and shirts with sleeves which can be contained underneath the scrub top, may be worn; personal clothing that extends above the scrub top neckline or below the sleeve of the surgical attire should not be worn. Personnel clothing is not laundered by a health care-accredited laundry facility.
A review of the AORN Perioperative Standards and Recommended Practices, 2013 edition, - Recommended Practice for Surgical Attire - Recommendation II revealed in part: When wearing a two-piece scrub suit, the top of the scrub suit should be secured at the waist, tucked into the pants, or fit close to the body to prevent skin squames from being dispersed into the environment from the axilla and chest. The major source of bacteria dispersed into the air comes from health care provider ' s skin.
A review of the AORN Perioperative Standards and Recommended Practices, 2013 edition, - Recommended Practice for Surgical Attire - Recommendation IV revealed in part: All personnel should cover head and facial hair, including the sideburns, the ears and the nape of the neck, when in semi-restricted and restricted areas. Human hair can be a site of pathogenic bacteria such as MRSA. Hair acts as a filter when it is uncovered and collects bacteria. A clean, low-lint surgical head covering or hood that confines all hair and covers scalp skin and ears should be worn. The head covering or hood should be designed to minimize microbial dispersal. Skull caps (surgeon caps) fail to contain the side hair above and in front of the ears and hair at the nape of the neck and the ears and should not be worn.
A review of the AORN Perioperative Standards and Recommended Practices, 2013 edition, - Recommended Practices for Surgical Attire - Recommendation III revealed in part: Only facility-approved, clean and freshly laundered surgical attire should be donned daily by all personnel entering or reentering the semi-restricted and restricted surgical areas to decrease the possibility of cross-contamination. Recommendation IV revealed in part: Reusable head coverings (cloth hats) that are not laundered in a health care- accredited laundry facility should be covered by a disposable bouffant surgical hat that completely covers the cloth hat.

A review of the AORN Perioperative Standards and Recommended Practices, 2013 edition - Recommended Practices for Surgical Attire, Recommendation VI revealed in part: All individuals entering the restricted surgical area and the OR suites should wear a surgical mask when scrubbed personnel, sterile supplies and/or sterile equipment are present. A surgical mask protects the patient from transfer of microorganisms. Surgical masks should not be worn hanging down from the neck. Surgical masks are intended to contain and filter droplets from the nasopharynx. The filter portion of the surgical mask harbors bacteria collected from the nasopharyngeal airway and should not be worn hanging from the neck.

A review of the AORN Perioperative Standards and Recommended Practices, 2013 edition, Recommended Practices for Selection and Use of Packaging Systems for Sterilizati