GOTCHA! You might be surprised at the things that accreditation surveyors can cite you for.

A cigarette butt on a rooftop. (Really?) Expired hand sanitizer. (Who knew?) Waste receptacles 1 inch too close to each other. (Yes, they pulled out a tape measure.) Not having a policy on warming up Danish in the microwave. (Wait, what?) These infractions top of the list of the zany things accreditation surveyors cited facilities for in Outpatient Surgery’s annual look at odd and unusual dings. These kinds of hard-to-fathom dings may not be typical — about 65% of your colleagues say their surveyors were just about the right amount of picky during their last accreditation surveys — but a hefty minority (about 31%) say their surveyors were more persnickety than warranted, and they have the stories to prove it.

FALSE ALARM Surveyors might want you to actually pull the fire alarm — even if you share your building with other practices.

1. The fire alarm. Stephanie Reed, MSN, RN, CNOR, nurse manager at Ophthalmology Associates in Lutherville, Md., and her staff assumed it wouldn’t be necessary to disrupt and frighten the numerous other medical practices that share her building. They assumed wrong.

“We were cited for a tabletop drill because we didn’t physically pull the fire alarm, even though the staff had correctly identified the need to pull the alarm in a real emergency,” she says. “When I explained to the surveyor that we’re in a multi-use building and that it wasn’t feasible, he said it didn’t matter. He cited the EP (Elements of Performance), which was in the hospital book. I showed him the ambulatory book, which didn’t have that and he said he’d have to check with headquarters. I knew it was sticking when we got the final report back.”

2. 7 feet, 11 inches apart. Technically, of course, surveyors aren’t supposed to be in the business of cutting people slack, but does that mean there can be no gray areas at all? “Would you believe we got cited for having our waste receptacles off by 1 inch?” asks one facility administrator. “According to the fire code, garbage receptacles and dirty laundry receptacles have to be 8 feet away from each other. They literally pulled out a tape measure, and we got cited!”

If that kind of attention to detail surprises you, imagine the eagle eye (and consummate nerve?) it took to cite this facility: “As we walked across a facility bridge on the 4th floor of the hospital,” reports another administrator, “the surveyor looked out of the window and saw a cigarette butt on the roof. She made security walk her out onto the roof to verify, and cited the hospital, which was a non-smoking facility, for letting employees or contractors smoke in a restricted area.”

3. Expired hand sanitizer. Here’s an add-on for your to-do list: Check your soap dispensers. “We had no idea that the hand sanitizer and hand soaps in the dispensers had expiration dates,” says Debby Augst, RNFA, CNOR, nurse manager of the Limestone Surgery Center in Gainesville, Ga. “Our accreditation surveyor obviously knew this and went straight to the dispenser, opened it and several were expired. Who knew?” Other than the surveyor, our guess is not a lot of people.

4. Is that a T-shirt under your scrub top? You might want to take a glance at what your people are wearing under their scrubs. “We were cited because a staff member was wearing a T-shirt under a scrub shirt,” says Patrick Linton, MD, director of endoscopy at NYU Langone Medical Center in New York. “They said it was an infection risk. If any part of it was visible, it was not acceptable. We were not aware of this, but we are now.”

5. Which way is out? Some reported (and questionable) dings seem to spring from a by-the-book mentality that doesn’t seem to care whether the “book” has anything to do with the reality of a given situation. “We were told we didn’t have enough exit signs,” says one facility leader. “The whole center is less than 10,000 square feet and has an excellent floor plan. But [the surveyor] wanted to be able to see an exit sign from any point in the building, so we had to add 6 more. We now have 25 exit signs!”

6. X-rays in use. “Our surveyor requested that we post a warning sign in our waiting room saying X-rays are in use,” says Carol Cappella, RN, MSN, CNOR, clinical director of the Delray Beach (Fla.) Surgery Center. “The only X-ray the center performed was C-arms for spine procedures and mini C-arms for podiatry and orthopedic hand procedures. And the waiting room is nowhere near the operating room.”

7. When is a procedure room not a procedure room? When it’s never used for procedures. But “we have a procedure room that wasn’t being used except as an office space for our pre-surgical phone calls,” says a facility chief. “We got hit because a nurse was having coffee in an unused procedure room. It was an easy fix, but it was crazy.”

A LITTLE RUSTY? One surveyor thought she saw something else dripping from a metal cabinet.

8. Bad blood? Is crazy too strong a word for what this facility manager witnessed from a surveyor? “The supply cabinets in our OR are metal,” she says. “The surveyor took an alcohol swab, wiped it on a tiny rust spot and said, ‘This room was not cleaned properly. The cabinets have blood dripping from them!’”

COLOR BLIND These Velcro straps raised concerns, but there was an easy solution.

9. Discolored Velcro? OK, so surveyors aren’t infallible. Sometimes what they think they see isn’t really what they see at all. “The Velcro we used to secure our GI endoscopes was white but had discolored over the years,” recalls another administrator. “The surveyor thought the Velcro was contaminated. It wasn’t, but we solved the ‘problem’ by changing the Velcro color to black.” It’d be nice if all fixes were that easy — and that cheap.

10. Battery backup? “One fire marshal said we were great. The next one gave us several dings that ended up costing us $9,000 in parts and labor and didn’t improve safety,” bemoans another facility boss. “All of our exit signs had battery backup capability, but they were attached to a generator, so I disabled the batteries. That meant we couldn’t test them (and, admittedly, it probably destroyed the warranty). We were told we had to order all new signs that didn’t have battery capability. When the new signs arrived, they were exactly the same, but with a blank where the battery test button had been in the old units. The only difference was that these were manufactured to work without batteries, so the warranty and UL approval were still technically in effect.”

BIG TROUBLE Sure, this Danish looks innocent enough ...

11. Hot pastry. One facility got dinged for not having a policy on warming up Danish in the microwave. “For 10 years we’d offered our patients coffee, juice, water or soda in PACU along with cookies, crackers or Danish, which we kept refrigerated,” says the administrator. “The staff would warm the Danish for a few seconds in the microwave to take the chill off before serving it. But we didn’t have a policy stating how long to heat them in the microwave, nor did we test them to make sure there were no hot spots that might scald the mouth. Instead of trying to write a policy, we decided to just get rid of the Danish. Our food bill got a lot smaller.”

Mostly fair
To be fair, most surveyors are seen as very fair and very helpful, a fact that’s reflected in the comments of many readers. “I felt our last survey was all fair,” says one. “What we got cited for were things that did need to be either updated or changed. It wasn’t the horror story that I was expecting. It was still nerve-wracking, but I learned a lot.”

“We got dinged for not having an anesthesia cart locked when it wasn’t attended,” recalls another. “We deserved it.”

If you’d like to share a zany ding for next year’s story, e-mail Associate Editor Jim Burger at [email protected].