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Based on policy review and medical record review, staff did not ensure Patient #1's condition was monitored with timely notification of findings to the provider in accordance with facility protocol. This has potential to result in a delay in treatment.

Findings include:

Review of policy "Severe Sepsis/Septic Shock Protocol" last revised 8/16 revealed the Adult Severe Sepsis/Septic Shock Protocol is implemented when a patient presents with two or more Systemic Inflammatory Response Syndrome (SIRS) criteria:
Temp greater than 100.4 F or less than 96.8 F.
Pulse greater than 90 beats per minute
Respiratory rate greater than 20
White blood count (WBC) greater than 12,000/mm3 or less than 4,000/mm3 or great than 10% bands.
AND the presence of infection/suspected infection. If yes, the provider is alerted for suspected sepsis orders.

Review of Laboratory Services specimen results in medical record revealed the following:
12/17/16 at 10:31 AM: WBC 19.3 H (reference range 4.0-11.0)
12/18/16 at 05:50 AM: WBC 18.1 H
12/19/16 at 06:00 AM: WBC 4.8, Bands 34 H (0-3)

Review of Nursing documentation revealed the following:
On 12/17/16 at 12:00 AM temperature was 100.6 F and Pulse 106.
On 12/17/16 at 04:00 AM temperature was 101.3 F and Pulse 69.
On 12/17/16 at 08:00 AM temperature was 96.2 F and Pulse 112.
On 12/19/16 at 08:00 AM Vital Signs were: Blood pressure 87/54, Pulse 120.

No evidence of documentation was found in the medical record related to provider notification by nursing staff and/or that a sepsis screening was performed despite Patient #1 meeting the SIRS criteria on 12/17/16 and 12/19/16.

Based on policy review and medical record review, the provider did not ensure the timely documentation of patient evaluation following positive criteria for possible sepsis on Patient #1. This has the potential to negatively impact the continuity of patient care.

Findings include:

Review of the facility Sepsis Protocol indicates that if a potentially septic patient is identified by hospital staff, the provider will be notified and the protocol will be implemented if the provider feels the patient is septic.

Review of the medical record for Patient #1 revealed that a sepsis alert was activated on 12/17/16 at 08:00 PM with provider notification due to temperature of 101.4, Pulse 123 and elevated white blood cell count of 19.3 (reference range 4.0-11.0). No documentation was found in medical record of a physician assessment despite the sepsis alert activation.

Review of the medical record for Patient #1 on 12/19/16 at 07:30 AM revealed a physician assessment of Patient #1 meeting SIRS criteria for possible sepsis due to a pulse of 120 and Bands 34 (0-3). No documentation was found in medical record that the sepsis protocol was initiated at this time.

Based on policy review, observation and interview, surgical staff did not follow facility policy related to surgical attire, specifically coverage of all head hair when in the restricted areas of the surgical suite. This has the potential to increase the risk of infection.

Findings include:

Review of facility policy "Surgical Attire" last revised 05/16 indicates that all head and facial hair, including sideburns, beards and neckline, should be covered when in the semi-restricted and restricted areas of the Surgical Suite.

Observation on 01/26/17 at 10:00 AM of the Operating Room revealed Staff (W) and Staff (X) wearing skull type head coverings with exposed hair at nape of neck in Operating Rooms #1 and #6.

Staff interviews on 01/26/17 at 10:30 AM with Staff (M), (S) and (T) confirmed the observations indicating that the observed staff members were out of compliance with facility policy.