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Based on record review, interview, and document review, the facility failed to have a complete and accurate medical record for 3 (#29, 32, 38) of 7 expired patients resulting in the potential for the inability to recovering tissue and/or organs for use in transplant. Findings include:

Patient #29's medical record was reviewed on 12/11/2018 at 1520 and revealed that the patient expired on 11/7/2018 at 0200. The "Patient Expiration Form" revealed, in the top section, an area for "Date/Time Called ____/____" that the organ procurement organization (OPO) was notified. In the provided blanks was "11/7" and no time was indicated when the call was made.

Patient #32's medical record was reviewed on 12/11/2018 at 1550 and revealed that the patient had expired on 12/9/2018 at 1521. Review of the "Patient Expiration Form" revealed in the blanks for the date/time called that the person filling out the form added a slash and wrote "12/9/2018." No time was present that indicated when the OPO was notified following the patient expiration.

Patient #38's medical record was reviewed on 12/12/2018 at 0930 and revealed that the patient had expired on 11/17/2018 at 1530. Review of the "Patient Expiration Form" revealed a date of "11/17/18"; however, the blank for the time was left blank.

Clinical Coordinator staff K, who was the facility's OPO representative, was interviewed on 12/12/2018 at 1530, was shown the missing times on the "Patient Expiration Forms," and was queried as to if it were okay for the times to be missing. Staff K stated that the times should be there, that this had been discovered and presented before the nursing counsel committee, and that the nurses had been educated on how to properly fill out the "Patient Expiration Form." Staff K was then asked when this had taken place to which she replied, "I think it was sometime last year."

Facility policy #1 CLN 016 titled "Anatomical Gift Donation-Cardiac Death" effective 5/30/2014 states, "The (OPO) is notified by phone within one hour after a patient has died...Staff will document notification of (the OPO) on the Patient Expiration Form...Documentation will include: Date/time (OPO) called..."

Based upon observation, interview, and record review the facility failed to provide and maintain adequate physical facilities for the safety and needs of the patients and was found not in substantial compliance with the requirements for participation in Medicare and/or Medicaid 42 CFR Subpart 482.41(b), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care. Findings include

A-0710 - Failure to comply with applicable provisions of the 2012 edition of the Life Safety Code

Based upon observation, interview, and record review the facility failed to provide and maintain adequate physical facilities for the safety and needs of the patients and was found not in substantial compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 482.41(b), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care. Findings include

See the individually and below cited K-tags dated December 13, 2018.
K-0211
K-0222
K-0223
K-0225
K-0321
K-0324
K-0325
K-0343
K-0345
K-0351
K-0353
K-0355
K-0363
K-0918
K-0920
K-0923

Based on observation, interview and policy review the facility failed to ensure staff compliance with nationally accepted standards of practice and enforce facility policies to assure achievement and maintenance of aseptic and sterile practice while donning acceptable operating room attire in the semi-restricted and restricted areas of the surgical suites, in two of two observations involving staff MMM, resulting in the potential for contamination of sterile equipment, cross contamination for patients and poor surgical outcomes. Findings include:

On 12/12/18 at 1025 during a tour of the surgical Operating room sterile corridors, with staff X (administrative director of surgical services) and staff W (director of surgical services), while looking through the door/window of operating room #1, staff MMM (Anesthesiologist) was observed leaning over a patient's arm, performing a surgical block (anesthetizing or injecting a nerve numbing agent to manage pain of a specific area of the body). Staff MMM was observed to have a surgical mask pinched over his nose with the upper and lower ties of the mask untied and dangling. The ties of the surgical mask were touching and draping over the patient's arm, as staff MMM moved about to perform the procedure. At the same time (1025) staff MMM was observed to be wearing a disposable blue warm up jacket, the bilateral sleeves were pushed up to the elbow area. Staff X was asked to observe staff MMM, and was then queried regarding the facilities policy for acceptable operating room attire. Staff X stated, "masks should be tied and sleeves down, arms covered." At 1029 staff X was observed entering Operating room #1. Staff X was observed speaking with staff MMM.

On 12/12/18 at 1135 during an interview with staff UU (Anesthesiologist/Chief of Staff) the above findings were confirmed to not be in accordance with national standards of care and/or the facility policy regarding acceptable surgical attire.

On 12/12/18 at 1108 staff MMM was observed entering Operating room #11. Staff MMM had a surgical mask pinched over his nose with ties undone and dangling down over his neck, chest and shoulder area, staff MMM had a blue disposable warm up jacket on with sleeves pushed up to the bilateral elbow area. On 12/12/18 at 1109 upon entering Operating room #11 with staff W and staff X, Staff X stated, "will one of you please tie Dr. (staff MMM's) mask please."

On 12/12/18 review of Policy No: 2 POS 012 Title: Surgical Attire, Effective date 06/01/2018 "Provisions 1. Surgical attire intended for wear within the surgical suite must be worn in the semi-restricted and restricted areas. a ...b ...c ...d ...e ...f ...g. Hospital issued disposable warm up jackets are to be worn in the semi-restricted and restricted areas by non-scrubbed personnel. The warm up jacket must be worn with the front snapped closed and the cuffs down to the wrists to prevent the front of the jacket from contaminating a skin prep area or the sterile surgical field and prevent skin squames shed from bear arms."

Page 2 of 3, #3. "A properly applied (2IC 005 appendix A) mask must be worn in the restricted areas where open sterile supplies and equipment are present. A fresh, clean surgical mask should be worn for every procedure."

Based on observation, interview and record review the facility failed to follow nationally accepted guidelines and regulations, additionally the facility failed to follow their own "rules and regulations" to ensure compliance and implementation of the immediate postoperative report in 2 (#20 & #21) of 4 post-operative patient records reviewed, resulting in potential harm to patients due to the lack of available pertinent patient information. Findings include:

On 12/11/18 at 1120 a tour of the post anesthesia care unit (PACU) was conducted with the Administrative Director of Surgical Services, staff X, and the Registered Nurse (RN) Clinical Coordinator of Surgical Services (pre/post/PACU), staff U. On 12/11/18 at 1125 PACU RN staff V was queried regarding patient #20's arrival time to PACU, and if she could locate patient #20's immediate post-operative report for review. Staff V scrolled through patient #20's EMR (electronic medical record) for several minutes then stated, "according to the record, she arrived in this unit at 0931, but I cannot locate the post op note." staff V, staff X and staff U attempted to find the immediate postoperative report in the EMR. At 1140 staff X and staff U confirmed the inability to find an immediate post-operative note for patient #20.

On 12/11/18 at 1145 Review of records revealed patient #21 arrived in the PACU unit at 0923. Multiple attempts by staff V, staff X and staff U were made to locate an immediate postoperative report for patient #21. At 1150 staff X stated, "our doctors are good about getting the report in the EMR, especially doctor (DDD), he is meticulous. I know we can't find it, but I think we must not be looking in the right spot."

On 12/11/18 at 1330 staff X stopped staff DDD (the surgeon for patient #20) in a semi restricted hallway area and requested he find the immediate postoperative report. Staff DDD sat down at a computer and stated, "I know it's done, I saw the resident doing it." Staff DDD was unable to find the report and was observed placing a phone call. At 1336 staff DDD stated, "I just called the resident and when I saw her earlier, she was not doing the postoperative report, she was doing something else, she is on a PIP for organizational issues. The immediate post-operative report was not completed."

On 12/12/18 review of records titled "Rules and Regulation DMC Staff," on page 11 of 17 G. Operative Reports, Complete reports shall include detailed accounts of procedures. The report includes at minimum ...The report shall be fully entered or dictated immediately following the procedure. When the report is dictated, a progress note shall be entered in the medical record immediately after the procedure, BEFORE the patient is transferred to the next level of care, to provide pertinent information for individuals required to attend the patient."