Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 01C0001011 (X3) Date Survey Completed 12/07/2023
Name of Provider or Supplier Gadsden Surgery Center, Ltd Street Address, City, State 418 South 5th Street, Gadsden, AL
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
Q0241 SANITARY ENVIRONMENT
CFR(s): 416.51(a)

The ASC must provide a functional and sanitary environment for the provision of surgical services by adhering to professionally acceptable standards of practice.


This STANDARD is not met as evidenced by:
Based on observations, review of facility policies and procedures and staff interviews, it was determined the facility failed to ensure the staff:


1. Performed hand hygiene prior to donning gloves and after removing gloves.


2. Wore gloves per facility policy and procedure.


Findings Include:


Facility Policy: Hand Hygiene


Policy Number: 11011


Reviewed: 1/2023


...All personnel will wash hands:


When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or body fluids.


Before having direct contact with patients.


...After coming in contact with the patient's intact skin...


After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.


After removing gloves...





2. An observation of patient care was conducted on 12/6/23 at 12:04 PM to follow PI # 20 through the Pre-Op, Surgery, Recovery and Discharge process for a Right Carpal Tunnel Release and Right Ulnar Nerve Decompression.


In the Pre-Op area, EI # 6, RN (Registered Nurse), removed gloves prior to starting an IV (Intravenous) line and without performing hand hygiene (HH), donned a pair of gloves and started the patient's IV.


In the PACU (Post Anesthesia Care Unit), EI # 8, RN, without performing HH, donned gloves to inject Demerol.


Without performing HH, EI # 8 donned gloves prior to injecting Labetalol.


With gloved hand, EI # 8 threw the patients coffee cup away, removed gloves and did not perform HH.


Without performing HH, EI # 8, donned gloves to remove the pulse oximeter from the patient's finger, removed gloves and did not perform HH.


After discontinuing the patient's IV, EI # 8, removed gloves and without performing HH, donned gloves to transport the patient to the Discharge area.


An interview was conducted on 12/07/23 at 12:05 PM with EI # 1, Practice Administrator, who confirmed staff failed to perform HH prior to donning gloves and after removing gloves per facility policy.













1. On 12/6/23 at 11:55 AM an observation of the staff cleaning an endoscope was conducted in procedure room # 1. Employee Identifier (EI) # 10, Endoscopy Technician, flushed the ports with solution, removed gloves then donned new gloves. EI # 10 failed to perform hand hygiene after removing gloves.


EI # 10 then cleaned the Neptune suction machine with disinfecting wipes, disposed of the suction tubing, removed gloves then donned new gloves. EI # 10 failed to perform hand hygiene after removing gloves. EI # 10 then transported the endoscope to the endoscope cleaning room.


EI # 11, Surgical Technician, cleaned the outer surface of the scope, cleaned the ports, flushed the lines, and placed the endoscope in the Steri-Cycle machine. EI # 11 then removed gloves and donned new gloves. EI # 11 failed to perform hand hygiene after removing gloves.


EI # 11 then wiped the endoscope transport bin with disinfecting wipes, removed gloves and donned new gloves. EI # 11 failed to perform hand hygiene after removing gloves.


An interview was conducted on 12/7/23 at 12:00 PM with EI # 1, Practice Administrator, who confirmed the staff failed to perform hand hygiene after glove removal per facility policy.