HospitalInspections.org

Based on findings from document review and interview, the facility's policy and procedure (P&P) governing the use of alcohol based skin preparations for antisepsis in the operating room (OR) did not require documentation in the medical record (MR) of measures undertaken by staff at the time of use to reduce the risk of associated fire. Additionally, in 1 of 1 observations nursing staff did not verify the identity of a patient when his/her care was transferred between nurses.

Findings include:

-- Review of the facility's P&P titled "Skin Prep, Pre-Op," revised 8/2014, indicated fire risk reduction measures that should be undertaken to prevent surgery related fires when alcohol based skin preparations (i.e., Duraprep and Chloraprep) are used for skin antisepsis, e.g., prevent pooling or saturating linens, allowing drying before draping, etc. However, the P&P does not require staff to document in the patient's MR the measures taken to reduce the risk of fire associated with use.

-- Per interview of Staff A on 3/23/16 at 11:35 am, staff do not document measures undertaken to reduce the risk of associated fire in the patient's MR. He/she acknowledged the above findings.

This was previously cited in 12/2014 during a Validation Survey.

-- Review of the facility's P&P titled "Patient Identification," dated 12/2015, indicated that a health care professional should verify a patient's identity with their name and date of birth prior to treating or transporting the patient. However, per observation on 3/22/16 at 12:30 pm of a patient handoff between Staff B and Staff C, in the advanced recovery unit, the patient's identity was not verified.

-- During interview of Staff A on 3/23/16 at 4:30 pm, he/she acknowledged the above findings.

Based on findings from medical record (MR) review, document review and interview, surgical consents did not identify the specific provider conducting the surgical intervention. Additionally, the facility's policies and procedures (P&Ps) addressing consent for blood transfusions and consent form were not consistent in regard to the requirement for written patient consent for the administration of blood. Blood consent must be separate from surgical or other treatment consent.

Findings include:

-- Per review of Patient #2's Consent for Surgery or Other Procedure form dated 3/22/16, it listed individual provider names (i.e., 3 physicians from a group practice) authorized to perform surgery. However, it did not specifically indicate the provider performing surgery.

-- Review of the facility's P&P titled "Consent," revised 4/2010, indicated "Informed Consent" requires the patient to receive and understand the provider or providers who will perform the proposed procedure or treatment.

-- During interview of Staff A on 3/23/16 at 11:35 am, he/she acknowledged the above finding.

-- Review of the facility's P&P titled "Blood Packed Red Blood Cell (PRBC) Administration," revised 5/2015, indicated written consent should be obtained prior to transfusion except in emergency situations. If a patient chooses to refuse the administration of blood or blood products, the patient/guardian must sign the refusal for blood administration section of the consent form.

-- Review of the facility's P&P titled "Consent," revised 4/2010, indicated
"Specific Consent" is required for invasive procedures or treatments and should be obtained prior to the performance of any such procedure or treatment. Physicians may alternately document in their progress notes that they have obtained informed Specific Consent for the administration of blood and blood products.

-- Review of the facility's form titled "Consent for Surgery or Other Procedure," revised 7/2008, contained a section for patient's to consent or refuse the administration of blood or blood components.

-- During interview of Staff A on 3/23/16 at 11:35 am, he/she acknowledged the above findings.

This was previously cited in 12/2014 during a Validation Survey.

Based on findings from document review, observations and interview, in 1 of 3 observations, nursing staff did not follow the facility's policy and procedure (P&P) for verification of the patient identification prior to medication administration. The lack of patient identification could potentially lead to medication errors.

Findings include:

-- Review of the facility's P&P titled "Medication Administration," dated 5/2015, indicated staff should check patient's identification band for name and date of birth and ask the patient to state his name and date of birth, prior to medication administration. However, during observation of Staff B on 3/22/16 at 12:00 pm, he/she did not identify Patient #2 with her patient identification band and/or verbally confirm her identity by name and DOB prior to medication administration.

-- During interview of Staff A on 3/23/16 at 11:35 am he/she acknowledged the above findings.

Based on observation, document review and interview anesthesia staff did not follow generally accepted standards of aseptic technique for medication administration. Also, the facility's policy and procedure (P&P) lacked instruction to staff to cleanse intravenous (IV) ports prior to medication administration.

Findings include:

-- Per observation on 3/22/16 at 10:55 am, Staff D did not cleanse an IV port with an alcohol prep pad prior to IV medication administration.

-- Per observation on 3/22/16 at 11:15 am, Staff E did not cleanse the rubber septum of several medication vials with an alcohol prep pad after opening the vials and prior to needle insertion to withdraw medication. Also, Staff E did not cleanse an IV port with an alcohol prep pad prior to IV medication administration.

-- The facility's P&P titled "Medication Administration," dated 5/2015, lacked instruction to cleanse IV ports prior to IV medication administration with an alcohol prep pad.

-- During interview of Staff F on 3/22/16 at 11:30 am, he/she acknowledged the above findings.