HospitalInspections.org

Based on observation and staff (EMP) interview, it was determined the facility failed to ensure staff followed established policy and procedure to maintain a fire safe environment in the surgical department for patients and staff in one of one observation.

Findings include:

Review on November 22, 2019, of facility policy "Fire Safety in the Operating Room," last approved May 22, 2019, revealed "Purpose The purpose of this policy is to provide and maintain a safe environment for staff and patients undergoing operative procedures by reducing the risk of fires in the OR...VI. Procedure A. General Precautions ... 4. Keep exit routes, manual fire alarm pull stations, fire extinguishers, medical gas control valves, and electrical panels clear and free from obstructions ..."

Observed November 21, 2019, at approximately 11:00 AM, during a tour of the surgical department, a hallway with approximately eight pallets of supplies/equipment obstructing egress in a corridor signed as an exit route. Observed November 21, 2019, at approximately 3:00 PM, during a tour of the same hallway in the surgical department with EMP6, approximately eight pallets of supplies/equipment obstructing egress in a corridor signed as an exit route.

Interview with EMP6 on November 21, 2019, at approximately 3:00 PM, confirmed the presence of supplies in the corridor obstructing egress. EMP6 further confirmed that no equipment or supplies were permitted to be stored in this exit corridor.

Based on review of facility guidelines, observation and staff (EMP) interview, it was determined the facility failed to ensure staff followed infection control guidelines, accepted by the facility, for administration of intravenous fluids in twelve of twelve instances.

Findings include:

Review on November 22, 2019, of documentation from The Joint Commission (TJC), printed from the TJC website by the facility on November 22, 2019, and provided as the source of guidance for how soon an infusion must be initiated following spiking an intravenous (IV) fluid bag with IV tubing, revealed "...The infusion must be started within 1 hour of spiking the bag unless the bag was spiked in an ISO 5 environment [a special atmospheric environment found in a pharmacy]..."

Observed during a November 21, 2019, tour of the surgical department preoperative patient unit, at approximately 9:00 AM, an IV pole with four bags of IV fluids spiked with IV tubing, an IV pole with five bags of IV fluids spiked with IV tubing and an IV pole with three bags of IV fluids spiked with IV tubing. None of the IV bags were labeled with the date and time the bags were spiked.

Interview with EMP5 on November 21, 2019, at approximately 9:00 AM, confirmed the IV bags spiked with IV tubing should begin infusion within one hour of spiking. EMP5 further confirmed the spiked IV bags were not labeled with the date and time the bags were spiked.

Based on review of facility policy and staff (EMP) interview, it was determined the facility failed to follow established operating room policy regarding fire safety education and training for surgical team members.

Findings include:

Review on November 21, 2019, of facility policy "Use of Alcohol-based Surgical Prep Solutions," last approved December 31, 2018, revealed "Policy It is the policy of UPMC that all healthcare personnel provide a safe environment when alcohol based skin prep is used ... IV. Procedure ... 13. Annual mandatory education will be provided to all surgical team members involved in the use of skin preparation that contains combustible agents..."

Review on November 21, 2019, of facility policy "Fire Safety in the Operating Room," last approved May 22, 2019, revealed "... III. Purpose The purpose of this policy is to provide and maintain a safe environment for staff and patients undergoing operative procedures by reducing the risk of fires in the OR ... VI. Procedure A. General Precautions 1. The OR staff must participate in annual fire safety training. A minimum of one fire drill will be conducted annually in the OR ..."

Following multiple requests by the surveyor on November 21 and 22, 2019, the facility did not provide documentation that members of the medical staff operating in the surgical department had received annual fire safety training.
Interview on November 22, 2019, at approximately 2:00 PM, with EMP1 revealed the facility considered members of the medical staff operating in the surgical department as OR staff. EMP1 further confirmed the facility had not provided annual education specific to the use of alcohol-based skin preps to the medical staff operating in the surgical department.

Based on review of facility documents, medical record (MR) review and staff (EMP) interview, it was determined the facility failed to ensure a physical examination update was completed prior to surgery requiring anesthesia services in four of four medical records (MR1, MR4, MR5 and MR29).

Findings include:
Review on November 21, 2019, of the facility's "UPMCS-Williamsport (City) Medical Staff Rules and Regulations," last approved May 30, 2019, revealed "...5. Health Records ... b) History and Physical - A complete admission history and physical examination shall be recorded with twenty-four (24) hours of admission by the attending physician...If a complete history has been recorded and a physical examination performed or thoroughly updated within thirty (30) days prior to the patient's admission to the Hospital, a copy of these may be used in lieu of the admission history and physical examination if accompanied by an admission interval note documenting an evaluation for any change in the patient's condition, including a reference to [sic] physical examination ... The health record must contain the pertinent history and physical exam information including the current condition of the heart and lungs, general physical condition, indication for admission or procedure, and allergies prior to performance of any scheduled procedure..."

Review of MR1 on November 21, 2019, revealed a history and physical (H&P) was performed by OTH3 on November 19, 2019, for a procedure scheduled for November 21, 2019. OTH4 did not document an admission interval note or an updated physical examination prior to MR1's procedure on November 21, 2019.

Interview with EMP1 on November 21, 2019, at approximately 11:40 AM confirmed there was no admission interval note in MR5 prior to the procedure.

Review of MR4 on November 21, 2019, revealed a H&P was performed by CF1 on October 9, 2019. Following admission to the facility on October 30, 2019, for a scheduled procedure, there was no documentation in MR4 of an admission interval note documenting an evaluation for any change in the patient's condition or a reference to a physical examination.

Interview with EMP2 on November 21, 2019, at approximately 2:00 PM, confirmed there was no admission interval note in MR4 prior to the procedure.

Review of MR5 on November 21, 2019, revealed a H&P for cardiac clearance was performed by OTH1 on September 9, 2019, for a procedure scheduled for October 1, 2019. Following admission to the facility on October 1, 2019, for a scheduled procedure, there was no documentation in MR5 of an admission interval note documenting an evaluation for any change in the patient's condition or a reference to an updated physical examination.

Interview with EMP2 on November 21, 2019, at approximately 2:15 PM, confirmed there was no documentation in MR5 of an admission interval note documenting an evaluation for any change in the patient's condition or an updated physical examination.

Review of MR29 on November 22, 2019, revealed an H&P was performed by OTH5 on August 21, 2019. Prior to MR29's procedure on September 4, 2019, there was no admission interval note documenting an updated physical examination.

Interview with EMP8 on November 22, 2019, at approximately 11:00 AM, confirmed there was no documentation in MR29 of an admission interval note documenting an updated physical examination.