HospitalInspections.org

Based on staff interview, CAH policy and document review, it was determined that the CAH failed to follow polices and procedures related to unusual events, potentially affecting all patients, staff and visitors receiving services.

Findings include:

1. On 11/18/15 at 9:45 AM an interview was conducted with the Hospital Administrator (E #1). E #1 verbalized awareness of an incident which occured on 10/7/15 with surgical equipment and supplies being contaminated. E #1 verbalized the hospital surgical department had asbestos tile abated, new washer installed and flooring replaced in the "wrapping room". It was determined that the construction crew did not "tape off" cabinets and dust was noted in the cabinets where the supplies were located. E #1 stated, "We threw everything away and reprocessed all equipment. None of the contaminated supplies were used on any patients."

2. The CAH policy revision date 8/9/11, titled, "Event Reporting" was reviewed on 11/18/15. The policy indicated under, "V. PROCEDURE 1.0 Indications for completion of an Event Report include, but are not limited to the following....1.18 Safety concerns/issues/accidents". Under " 5.0 Events involving missing articles or damaged property...5.4 The Patient Relations Manager manages follow up as indicated."

3. A request was made on 11/18/15 at 10:30 AM for Adverse Events or Unusual Occurrences. There was no documentation regarding the surgical supplies being contaminated and no report of the incident occurring on 10/7/15.

4. On 11/18/15 at 2:45 PM, an interview was conducted with the Patient Relations Manager (E#9). E#9 when asked about documentation of the surgical supplies being contaminated replied, "I have not officially received any information about the incident. I have overheard other staff talking about what happened in surgery. I was told it was all taken care of". E#9 confirmed that the Event was not reported or managed per policy.