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Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to ensure outside emergency medical personnel could be contacted immediately in the event of medical emergency. Findings:

A hospital policy titled, " Rapid Response Medical Emergency at St. Anthony South" documented, "... EMSA is notified by staff calling 911 to obtain additional assistance as indicated..."

Patient #7 experienced a medical emergency requiring CPR. The clinical record documented three separate staff members attempted to call 911 with no response. A fourth staff person dialed 911 and reached the emergency operator. The operator stated no other 911 calls were received from the south campus location.

The clinical record indicated due to the delay in the arrival of emergency assistance, the hospital staff performed CPR for 15-20 minutes before they were assisted on-site by EMSA personnel. The patient expired after attempts by EMSA staff to resuscitate.

An adverse occurrence report for the CPR event and patient death had no documentation of the staff's failed attempts to reach the 911 operator. Staff A stated hospital leadership was not aware of any problems at the south campus related to contacting 911 in the event of an emergency.

Based on review of infection control data, meeting minutes, and hospital documents, and interviews with hospital staff, the hospital failed to ensure the infection control practitioner (ICP) and committee developed and maintained a comprehensive system for ensuring a safe and sanitary environment by reporting, analyzing and implement changes surgical and sterilization practices to help prevent and reduce infections.

Findings:

1. Meeting minutes only contained percentages for "immediate use"/"flash" sterilization. They did not reflect the infection control committee reviewed and analyzed the "immediate use"/"flash" sterilization practices to identify if surgical case scheduling changes needed to occur; or if purchase of additional instruments needed to occur to limit and reduce the use of shortened/"flash" cycles, unless the "immediate use"/"flash" sterilization process was the manufacturer's recommended guideline for routine processing of said instrument(s).
a. This finding was reviewed and verified with Staff E on 11/08/2012 at 1115. She stated she did not get a report detailing why instruments were processed by "immediate use" sterilization.
b. Review of sterilization logs did not contain the reason instruments were processed by "immediate use" sterilization cycles.
c. On 11/08/2012 at 1400, Staff F and G told the surveyors that they did not identify reasons for cycles or review "immediate use" cycles.

2. Meeting minutes documented three orthopedic surgical site infections (SSI) for the third quarter of 2012. "Immediate use" sterilization was used to sterilize consignment instruments on 08/28/2012 for Patient #15, one of the reported SSI. The patient was admitted on 08/26/2012 with a documented left hip fracture through the prothesis.
a. Investigation data did not demonstrate, other than noting the instruments were flashed, any investigation of the sterilization process had been performed. This was reviewed with Staff E on 11/08/2012.
b. On the afternoon of 11/08/2012, Staff E (at 1300), F and G (at 1400) told the surveyors that all instrument sets at Bone and Joint were consignment instruments.
c. Staff G told the surveyors that Patient #15 was an "add-on". She stated that they did not have the consignment instrument set needed and because the set did not arrive the day prior, it was processed through an "immediate use" cycle and not a complete sterilization cycle.
d. The hospital does not have a policy regarding sterilization and handling of consignment instruments with documentation of manufacturer recommended sterilization practices.

Based on review of medical records and hospital documents and interviews with hospital staff, the hospital failed to ensure physical therapy (PT) services were provided according to physician orders. For two of two medical records reviewed (Record #15 and 23) that had PT orders and PT services were provided past the initial evaluation, the orders for physical therapy did not contain the type, frequency and duration of services as required by Oklahoma Licensure Hospital Standards Chapter 667, Subchapter 23-5(f). These findings were reviewed and verified with Staff F and H at the time time of review on 11/07 and 08/2012.