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Based on documentation and interview, the Hospital's investigation related to one of one sampled (Patient #1), the Hospital had not yet completed its analysis of the SRE and therefor failed identify all opportunities for improvement, identified by the Surveyor at the time of the Survey.


Findings include:

1) The Director of Risk Management and Patient Safety was interviewed in person intermittently throughout the survey. The Director said at the time of the Surveyor's onsite investigation she/he was in the process of interviewing Hospital staff involved in the incident regarding Patient #1. The Director of Quality Improvement and Patient Safety said the following; she/he had not completed her/his interviews; the Hospital had not yet conducted a root cause analysis (RCA) but was planning to do so.

2) There was no evidence that Surgeon #1 received any education regarding defective equipment in the Operating Room. Surgeon #1 said he was not aware of any practice in the OR to sequester equipment that did not function as intended.

3) Review of Hospital policies and procedures related to defective equipment in the Operating Room indicated any instrument or equipment that has been or is being used on a patient in the operating room and subsequently found to be defective or broken, must be retained in the operating room and the incident reported to the Director of the Operating Room or her designate. An incident report must be made out by the circulator and given to the Director.

4) Review of the Hospital's incident log indicated an incident report was not completed by either Nurse #2 or Nurse #3, who were assigned circulator nurse during Patient #1's surgery.

5) At the time of the onsite investigation the Hospital did not have the Manufacture's best practice guidelines for the use of the Ethicon Endo-Surgery Articulating Endoscopic Linear Cutter with a 45 mm staple line in the Hospital.

6) At the time of the Survey the Hospital failed to ensure the typed transfer of care report for Patient #1 and all components the medical record were promptly integrated into Patient #1's medical record.

7) The Hospital failed to ensure that all handwritten entries on Critical Care Nursing Flow Sheets dated 9/20/10 and 9/21/10 were authenticated by the nurse providing care to Patient #1.