HospitalInspections.org

Based on observations and staff interview the facility failed to follow current standards of practice for patient environmental safety. Findings include:

During tour of the inpatient psychiatric unit, on the afternoon of 3/14/13, seven bathrooms, utilized by patients, included sinks that contained faucets that could be used as potential ligature points. The RN Unit Manager confirmed the observations at the time of tour and stated that staff would attempt to place any patient assessed at high risk of suicide in one of the two rooms that had been renovated to include sinks with faucets that did not provide potential ligature points.

Staff interview and review of Ambulatory Care Unit outpatient surgical records identified a failure of an anesthesiologist to document if a medication was administered during the course of a surgical procedure for 1 of 3 applicable patients. (Patient #35) Findings include:

1. On 3/11/13 a Tonsillectomy was performed on Patient #35. The surgeon had ordered Kefzol I Gram intravenously to be infused at the time of surgery. Review of the Pre-Operative check list noted a nurse had documented prior to surgery, Kefzol I Gram had been hung but not administered. Per review of the Anesthesia Intraoperative documentation, there is no evidence the anesthesiologist administered the antibiotic to Patient #35. Per interview on 3/11/13 at 3:35 PM both the Director of Ambulatory Care Services and the Vice President of Medical Staff Affairs confirmed it is the responsibility of the anesthesiologist to infuse the prescribed antibiotic usually occurring at the beginning of a surgical procedure. In regard to Patient #35, it was further confirmed there was no evidence the patient ever received the antibiotic. On the morning of 3/13/13, the Vice President of Medical Staff Affairs stated s/he was unable to confirm with the anesthesiologist if the medication had been infused but not documented.