HospitalInspections.org

Based on review of facility policy, facility documents, and interview with facility staff (EMP), it was determined the facility failed to respond to a complaint/grievance in a timely manner for one of one applicable medical record reviewed (MR1).

Findings include:

A review of the facility's employee handbook revealed: " ... Section 20. 20:1 Grievance process ... Any supervisor, manager or facility officer who receives a complaint about, hears of, or witnesses any inappropriate conduct is required to immediately notify the Human Resources Department. ... For serious complaints,we will immediately conduct a complete and impartial investigation."

An interview with EMP3 revealed that the employee received a complaint from EMP12 on October 16, 2013, and immediately reported the incident to EMP2.

An interview conducted on November 6, 2013, with EMP2 revealed that the employee was not aware of the complaint until October 21, 2013, and that an investigation had not been initiated. Further interview revealed that the employee was "too busy" to conduct employee interviews and initiate the investigation and that it was the expectation of the facility that the investigation be completed within 30 days. The employee did not provide a policy regarding this requirement.

An interview conducted on November 6, 2013, with EMP1 revealed that EMP1 met with EMP11 on October 31, 2013, as part of an exit interview. Further interview with EMP1 revealed that EMP1 had perviously met with EMP2 and felt the issue was not a clinical practice issue and chose not to investigate further.

Based on a review medical records (MR) and interview with staff (EMP), it was determined the facility failed to provide care in a safe setting for one of one medical record reviewed. (MR1)

Findings include:

A review on November 7, 2013, of MR1 revealed that medical record did not contain documentation that the surgeon left the operating suite prior to the end of the procedure, while the patient was still anesthetized, with surgical devices still in the body, and under the care of a surgical technician.

An interview conducted on November 7, 2013, with EMP7, who was present in the room during the procedure, confirmed that the surgeon left the operating suite prior to the end of the procedure, while the patient was still anesthetized, with surgical devices still in the body, and under the care of a surgical technician. Further interview with EMP7 revealed that the surgeon frequently left the operating room prior to the completion of ablation procedures.

An interview conducted on November 7, 2013, with EMP5, who was present in the room during the procedure, confirmed that the surgeon left the operating suite prior to the end of the procedure, while the patient was still anesthetized, with surgical devices still in the body, and under the care of a surgical technician. EMP5 also revealed that the surgeon was known to leave the operating room prior to the completion of ablation procedures.

An interview conducted on November 7, 2013, with EMP6, who was present in the room during the procedure, confirmed that the surgeon left the operating suite prior to the end of the procedure, while the patient was still anesthetized, with surgical devices still in the body, and under the care of a surgical technician.

An interview conducted on November 7, 2013, with EMP7, who was present in the room during the procedure, confirmed that the surgeon left the operating suite prior to the end of the procedure, while the patient was still anesthetized, with surgical devices still in the body, and under the care of a surgical technician.

Based on review of facility policy, medical records (MR), and interview with facility staff (EMP), it was determined the facility failed to ensure operative report, intra-operative nursing record and anesthesia record were accurately completed following a surgical procedure for one of one surgical record reviewed (MR1).

Findings include:

A review on November 6, 2013, of facility Surgical Services policy 701.4.02, "Documentation of Peri-operative Nursing Care", last reviewed December 2010 revealed: "POLICY: ... All care given to the patient from the time the patient arrives in the operating room to the time of transfer to the next unit must be accurately documented in a computerized record or black ink."

1) A review on November 6, 2013, of the operative report for MR1 revealed: "... A sterile pressure dressing was applied once sheath and catheters were removed. ...." Further review of the operative report revealed that there was no documentation that the surgeon left the operating room prior to the completion of the surgical procedure with the sheath and catheters still in place with over three minutes left in the ablation process and the patient still anesthetized.

An interview conducted on November 6, 2013, with EMP7 confirmed that the surgeon left the operating room prior to the completion of the procedure with the sheath and catheters still in place with over three minutes left in the ablation process and the patient still anesthetized. Further interview with EMP7 revealed that after the ablation was complete EMP7 removed the sheath and catheter and applied the sterile dressing.

An interview conducted on November 6, 2013, with EMP5 confirmed that the operative report did not include documentation that the surgeon left the operating room prior to the completion of the surgical procedure with the sheath and catheters still in place with over three minutes left in the ablation process and the patient still anesthetized or that the surgical tech removed the sheath and catheter and applied the sterile dressing.

2) A review on November 6, 2013, of the intra-operative nursing record failed to indicate that the surgeon left the operating room with the sheath and catheters still in place with over three minutes left in the ablation process and the patient still anesthetized.

An interview conducted on November 6, 2013, with EMP6 confirmed that the surgeon left the operating room with the sheath and catheters still in place with over three minutes left in the ablation process and the patient still anesthetized.

3) A review on November 6, 2013, of the anesthesia record failed to indicate that the surgeon left the operating room prior to the completion of the surgical procedure and while the patient was still anesthetized.

An interview conducted on November 6, 2013, with EMP6 confirmed that the surgeon left the operating room prior to the completion of the surgical procedure and while the patient was still anesthetized. Further interview with EMP6 revealed that the surgeon did not notify anesthesia prior to leaving the room.