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Based document review and interviews, the facility failed to follow emergency procedures in accordance with the requirements of 2012 Edition NFPA 99 The Health Care Facilities Code Chapter 15 Section 15.13.3.9.1

Findings:
On 10/29 through 11/03/2020, during interviews with Surgical Technician, OR Staff Nurse Circulator, Trauma Surgeon, CRNA and AVP Perioperative Services, the Patient Care Directive - PCD Dated 01/19/2017 was not followed. As result of interviews and documentation review the following was found:

1) There was no coating of the head and facial hair near the surgical site with water-soluble surgical lubricant to decease flammability of the surgery being performed above the xiphoid. This was confirmed with Surgical Technician, OR Staff Nurse Circulator and Trauma Surgeon

2) Titration of oxygen to the lowest percentage necessary to support the patents physiological need was not done. This was confirmed with the CRNA.

3) There was no stopping of supplemental oxygen or nitrous oxide for one minute before using electrosurgery. This was confirmed with CRNA
.
4) The surgery procedure took place on the neck. A 26 ML Applicator of ChloraPrep (2% chlorhexidine gluconate (CHG) and 70% isopropyl alcohol) was used to prep surgery site. The manufactures instruction state "Do not use 26-ml applicator for head and neck surgery".The use of the 26 ML was confirmed by the OR Staff Nurse Circulator and the AVP Perioperative Services.

5) The facilities fire plan for entire campus advises to pull fire alarm pull station or dial 4444 in the event of a fire. No one pulled the alarm or called 4444 to report the fire. This was confirmed by Fire and Life Safety Director, CRNA, Trauma Surgeon, OR staff Nurse Circulator and the Surgical Technician.