567.1 Principle
The ASF shall have a sanitary environment, properly constructed,
equipped and maintained to protect surgical patients and ASF personnel from
cross-infection and to protect the health and safety of patients.
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Observations:
Based on observation, review of facility document, and interview with staff (EMP), it was determined the facility failed to ensure staff adhered to professionally acceptable standards and facility standards as outlined in the Infection Control Plan for hand hygiene precautions and the use of personal protective equipment (PPE) for the delivery of perioperative services for one of one medical record (MR9).
Findings include:
Review of facility document "Infection Control Plan", last revised May 2022, revealed, " PURPOSE: The purpose of the Infection Control Plan is to improve the health and safety of all patients and healthcare workers at the Center ...Standard Precautions: Practice: All Persons who present to Nazareth Health Endoscopy Center are considered to be infected or colonized with an organism that could be transmitted at the Center. Standard Precautions will be applied to all persons during the delivery of healthcare and personal protective equipment will be selected according to the anticipated care to be provided. Handwashing is the single most important means of preventing the spread of infection and there is no substitute for it. Moreover, handwashing is a procedure that must be practiced faithfully by all personnel. Personnel will wash their hands ...before gloves are worn ... and immediately after gloves are removed .... ...Barrier Garments: Fluid resistant gowns must be worn during all endoscopic procedures."
Observation of a surgical procedure for MR9, admitted on August 22, 2024, for an endoscopy and colonoscopy surgical procedure in Procedure Room One, with EMP1 and the surgical team beginning at 10:27 AM and concluding at 11:07 AM revealed:
1) Observations conducted at approximately 10:37 AM through 10:45AM during the surgical procedure for MR9 revealed OTH2, an anesthesiologist, removed gloves and failed to sanitize hands after the removal of the gloves. In addition, OTH2 was observed performing various tasks throughout the surgical procedure. Further observation revealed OTH2 failed to sanitize ungloved hands prior to donning gloves in preparation of medication administration for MR9, during the surgical procedure.
Observation conducted at approximately 10:45AM through 10:52 AM during the surgical procedure for MR9 revealed OTH1, a surgeon, failed to sanitize ungloved hands prior to donning gloves. In addition, OTH1, was observed performing various tasks throughout the surgical procedure specific to operating the computer and the computer keyboard located in Procedure Room One. Further observation revealed OTH1 failed to sanitize hands prior to donning gloves upon exiting from the computer station.
An interview conducted on August 22, 2024, at approximately 1:45 PM with EMP1, confirmed the anesthesiologist and surgeon failed to follow the facility's policy based on the findings.
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Based on observation, review of facility document, and interview with staff (EMP), it was determined that the facility failed to ensure a medical staff provider (anesthesiologist) was compliant with the facility's policy for wearing fluid resistant barrier garments during endoscopic surgical procedures and adhering to professionally acceptable standards.
Findings include:
Review of facility document "Infection Control Plan", last revised May 2022, revealed, " PURPOSE: The purpose of the Infection Control Plan is to improve the health and safety of all patients and healthcare workers at the Center ... ...Barrier Garments: Fluid resistant gowns must be worn during all endoscopic procedures."
2) Observation of OTH2, an anesthesiologist on August 22, 2024, during the endoscopic surgical procedure for MR9 in Procedure Room One, at approximately 10:27 AM to 11:07 AM revealed OTH2 failed to select a barrier gown according to the facility ' s Infection Control Plan.
Observation of OTH2 at approximately 11:10 AM, revealed OTH2 exiting Procedure Room One to the Pre-Operative and Post-Operative patient care area without covering and or changing the surgical attire worn during the surgical procedure for MR9. Further observation revealed OTH2 proceeded to provide direct patient care without covering and or changing the surgical attire worn during the surgical procedure for MR9.
An interview conducted on August 22, 2024, at approximately 1:47 PM with EMP1, confirmed the anesthesiologist was not wearing a barrier gown during the surgical procedure for MR9 and had failed to follow the requirements of the facility's Infection Control Plan.
| | Plan of Correction - To be completed: 09/20/2024
In order to provide a functional and sanitary environment for the provision of perioperative services, by adhering to professionally acceptable standards of practice, the Nurse Administrator will re-educate all healthcare providers at the Center on the Infection Control Plan. Review of policies, specifically, "Hand Hygiene", "Standard Precautions", "Personal Protective Equipment", "Safe Environment" and "Safe Injection Practices" will be mandated for all staff members. An In-Service sign-in sheet will be maintained to assure all staff have reviewed the policies. Hooks will be installed on the Procedure Room door to allow placement of the GI/Anesthesia provider barrier gowns before exiting the Procedure Room. CDC signage referencing "clean hands" has been placed at the workstations of both GI and Anesthesia providers. "Fluid-resistant, barrier gowns are worn by GI/Anesthesia providers in Procedure Room" and "Scrub gown not worn outside of Procedure Rooms" has been added to the Safe Environment/Infection Control "Protection from Blood Born Pathogens" monthly audit. On October 1, 2024, this audit will be conducted weekly for a two month period, to ensure compliance with the standards of Infection Control. The Nurse Administrator will be responsible for conducting the audits and maintaining results of the audit in the Quality Assurance Log. Failure to adhere to the standards of practice will result in a second re-education, and reporting to the Governing Body and Director of Anesthesia for further management of the non-compliance.
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