Brattleboro Memorial Hospital

“SURGICAL SERVICES CFR(s): 482.51 If the hospital provides surgical services, the services must be well organized and provided in accordance with acceptable standards of practice. If outpatient surgical services are offered the services must be consistent in quality with inpatient care in accordance with the complexity of services offered. This Condition is not met as evidenced by: 12112 Based on observation, interview and policy review, the Condition of Surgical Services was not met as evidenced by the Acute Care Hospital’s failure to ensure that there was appropriate cleaning in between surgical cases and end of the day terminal cleaning for 3 of 3 operating rooms. Findings include: During an observation of the cleaning of Operating Room (OR) #3 after a surgical case on 4/21/25 at approximately 12:46 PM, a large metal “Craftsman” tool cart with a butcher block wooden top was in the corner to the right of the double doors after you enter the OR. The top of the cart contained the following supplies: 9-1000 ml bottles of saline, 3 boxes of different types of sutures, a tissue box, a plastic binder with printed paper on the top cover, and an electric razor holder. The cart also contained approximately 8 drawers each with paper labels. This cart was not cleaned during the turnover of OR #3. Per interview with the Director at that time s/he was asked if wood was something that should be in the OR, and if the supplies and paper labels could be cleaned. S/He confirmed that the wood was not ideal for the OR and that the supplies and paper labels could not be cleaned. During a second tour on 4/22/25 at 8:45 AM of the perioperative suite, OR #1 & OR #2 also contained large metal “Craftsman” tool carts with butcher block wooden tops located in the corners to the right of the double doors after you enter the OR’s. The supplies on the top of each of these carts were like OR# 3. Per interview at that time with the OR Supervisor, s/he stated that each of these carts were set up similarly in all the OR’s and that Environmental Services staff were supposed to wipe them down when they did terminal cleaning each day, especially since in between cases “we don’t touch them”. Per interview on 4/22/25 at 12:30 PM with the Infection Preventionist, s/he stated that s/he was aware of the paper labels on the carts in the OR’s and had spoken to the staff about them. S/He confirmed it was not an appropriate infection control practice to have these types of labels and that the wood on the carts could not be adequately cleaned. Per interview on 4/23/25 at 8:15 AM with the Director of Plant Operations and Environmental Services (EVS) and the Infection Preventionist, they confirmed the carts in the OR’s had been at the hospital since 2022 when the new OR had opened. The Director of Plant Operations and EVS stated that the carts in the OR’s were wiped down during the terminal cleaning each day; however, the EVS staff did not touch the supplies on the carts, they cleaned around them. S/He further confirmed the presence of paper labels on the carts and that the paper cannot be cleaned. Per review of the policy “Cleaning and Disinfection of Operating Rooms”-effective 8/2024, it states, “The operating room will be cleaned thoroughly before cases, between and after each case to control infection and reduce the risk of cross-infection between the patients, staff and the environment ...C. After each surgical procedure: 1. All flat surfaces in each operating room cleaned with hospital germicide/disinfectant ...D. At the end of the day in all areas that have been used within a 24 hour time period ...5. Clean complete surfaces of all counters and cabinets.” Association of Perioperative Registered Nurses (AORN) (2024). Environmental cleaning. Guidelines for perioperative practice (pp.181-212). Denver. “Perform damp dusting on all horizontal surfaces (e.g., furniture, surgical lights, booms, equipment) before the first scheduled operative or other invasive procedure of the day ...5. Clean and disinfect all surfaces and equipment that are visibly soiled by blood, bodily fluids, or other potentially infectious materials ...Clean the OR ... in an organized manner, moving in a clockwise or counterclockwise direction in conjunction with a clean-to-dirty and top-to-bottom method, including: b. computer keyboards, computer mouse, and computer touch screens ...c. chairs, stools, and step stools ... h. horizontal surfaces of furniture ...Terminal Cleaning ...2. Terminally clean and disinfect exposed surfaces of all items in OR’s ...b. surfaces ...d. Storage cabinets, supply cabinets, and furniture.””

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 20101 Based on observation and confirmed by interview, the hospital failed to store medical records in a manner to protect them from water damage in one outpatient clinic. Findings include: During a tour of one outpatient clinic at 2 PM on 4-21-2025, accompanied by the Practice Manager, the Director of Speciality Services, and the Director of Quality and Patient Safety Team, paper-based medical records were observed to be stored on several floor to ceiling open faced bookshelves. The bookshelves sat directly under water pipes and the sprinkler system. Additionally, the records in the lowest shelf were approximately 2 inches from the floor. Per interview on 4-22-25 at 1:45 PM, the Practice Manager confirmed that the current storage system would not protect the paper-based files from potential water damage.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 12112 Based on observation, interview and policy review, the hospital failed to ensure the methods of preventing and controlling the transmission of infections were followed related to patient supplies in the Post Anesthesia Care Unit, and Personal Protective Equipment (PPE) use and hand hygiene in the Endoscopy Unit. Findings include: During a tour of the post-anesthesia care unit on 4/21/25 at approximately 1:41 PM, 2 of the 6 bays contained Yank-our (type) suction tips (removes secretions from one’s mouth) that were opened and stored in supply baskets near the suction and oxygen wall mounts. There was no indication when the Yank-ours were opened and/or how long they had been in the baskets. During an interview with the Director at that time s/he confirmed that s/he did not know how long they had been opened. S/He stated that they were there, “ready to go in an emergency”. Per observation on 4/22/25 at 8:39 AM of an endoscope cleaning, Staff #1 with eyeglasses on, donned a gown and gloves and then proceeded to begin the process of cleaning the endoscope. Once the endoscope was cleaned, Staff #1 put the scope into the sterilizer to finish the cleaning process. At 8:45 AM, Staff member #1 removed his/her gown and gloves, and without sanitizing his/her hands, donned new gloves and proceeded to wipe down the area. Staff #1 then removed one-glove obtained a red bag and new cleaning set for the next scope cleaning and then proceeded to remove the second glove without sanitizing and/or washing his/her hands. During an interview with Staff #1 on 4/22/25 at 8:48 AM, s/he was asked what type of protection was required for his/her eyes and face during the cleaning procedure. S/He stated that because s/he wore glasses, s/he did not need any further eye or face protection. Staff #1 was also asked when hand hygiene was expected to be done during the procedure and s/he stated that since s/he was doing a “dirty” procedure, s/he did need not perform hand hygiene in between glove use and that s/he washed his/her hands at the end of the procedure. Per interview on 4/22/25 at 12:44 PM with the Infection Preventionist, s/he confirmed that a face shield and/or goggles should be worn as eye protection during the cleaning the endoscope; and before and after glove use staff should use hand sanitizer and/or wash their hands. Per review of the policy “Hand Hygiene”-effective 10/2024, it states, “Health-care associated infections (HAI) cause an increase of morbidity and mortality among hospitalized patients. Transmission of organisms that cause HAI most often occurs by contaminated hands of health care workers (HCW) ...Hand hygiene is a critical component of patient and employee safety. Effective patient safety and infection prevention and control programs require that healthcare personnel be familiar with hand hygiene recommendations and consistently adhere to them. (apic.org) ...B. Indications for Handwashing and Hand Antisepsis ...b. 2. Before having direct contact with patients ...10. After removing gloves; hands may become contaminated in the process of removing gloves or as a result of small undetected holes in the gloves.””