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Based on observation, interview, and record review, the facility failed to ensure patients received care in a safe environment, as evidenced by:

1. One of two crash carts (a cart stocked with emergency equipment, supplies and medications to be used in a medical emergency) in the Main Operating Room (OR) was not checked to ensure emergency supplies, equipment, and medications were readily available in the event of an emergency.

2. One of two crash carts in the Main OR was not equipped with a backboard (used to provide support when performing cardiopulmonary resuscitation [CPR] on a patient that is in a bed).

These deficient practices had the potential for emergency supplies to not be readily available in case of an emergency and had the potential to result in a delayed provision of emergency care needed by patients, which may lead to patient harm and/or death.

Findings:

1. During an observation on 10/2/2023 beginning at 2:21 P.M., in the Main Operating Room (OR) area, one of two Crash Carts Log was reviewed. There was no documentation to indicate that the crash cart was checked for emergency medications, supplies, and equipment on 9/22/2023.

Concurrently, at 2:21 P.M., the director of the Main OR (DMOR) stated the crash carts should be checked every day, when the Main OR is open. The DMOR verified the Main OR was open on 9/22/2023 and stated, we "missed 9/22/2023 (referring to the crash cart check)."

During a review of "Crash Cart Log," dated 9/2023, the Crash Cart log indicated there was no documented check of the crash cart for expiration of medications, and emergency supplies such as, oxygen tanks, back board ... on 9/22/2023.

During a review of the facility ' s policy and procedure (P&P) titled, "Crash Cart & Transport Defibrillator, Testing, and Maintenance," revised date 2/14/2023, the P&P indicated "emergency medications and supplies for use in medical emergencies shall be immediately available at each patient care area ... Crash Carts are checked each shift, when the department is open and documented on the Crash Cart Log. The user department is responsible for checking the integrity of all the equipment on top and outside of the Crash Cart, including the integrity of the locks ...Back board is present."

2. During an observation on 10/2/2023 at 2:45 P.M., the second crash cart, in the Main OR did not have a backboard.

Concurrently, at 2:45 P.M., the Assistant Manager for the Main OR (AMMOR) stated the crash cart was missing the back board and must have been used earlier and not replaced. The AMMOR stated the crash carts should be equipped with all supplies and equipment at all times, in case of an emergency.

During a review of the facility ' s policy and procedure (P&P) titled, "Crash Cart & Transport Defibrillator, Testing, and Maintenance," revised date 2/14/2023, the P&P indicated "emergency medications and supplies for use in medical emergencies shall be immediately available at each patient care area ... Crash Carts are checked each shift, when the department is open and documented on the Crash Cart Log. The user department is responsible for checking the integrity of all the equipment on top and outside of the Crash Cart, including the integrity of the locks ...Back board is present."

Based on interview and record review, the facility failed to ensure that a comprehensive care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) addressing respiratory issues was developed upon admission for one of thirty (30) sampled patients (Patient 12).

This deficient practice had the potential to result in the delayed provision of care to the Patient 12 by not identifying patient ' s needs and risk.

Findings:

During a review of Patient 12 ' s History and Physical (H&P) dated 9/29/2023, the H&P indicated the following. Patient 12 presented to an outside hospital for acute respiratory failure (a serious condition that make it difficult to breathe on your own) and hypotension (low blood pressure). Patient 12 arrived on a ventilator (a machine that helps you breathe) and intubated (a tube inserted through a person ' s nose or mouth, then down to the airway, so air can get through). Patient 12 now transferred to the facility for evaluation of advance heart therapy. There is a concern for pneumonia (lung infection/inflammation) or inflammatory changes.

During a review of Patient 12 ' s Care plans (provides a framework for evaluating and providing patient care needs related to the nursing process), dated 10/01/2023, the care plan indicated that the following care plans were initiated: Pain Management, Infection surveillance, Knowledge Deficit, Skin Integrity Management, and Discharge Planning.

During a concurrent interview and record review of Patient 12 ' s medical record on 10/4/2023 at 1:37 P.M., with the Operating Room Supervisor (ORS) and Clinical Nurse Specialist (CNS) 1, the ORS and CNS 1 stated the following. The ORS and CNS 1 verified that the nursing care plans initiated upon admission did not include any care plans addressing respiratory issues. CNS 1 stated the care plan was necessary to guide the care of the patient.

During a review of the facility ' s policy and procedure (P&P) titled "Interprofessional Plan of Care (IPOC) Guidelines for Completion and Use," revised date 7/12/2022, the "P&P" indicated the following. "The IPOC is developed by the healthcare team to plan and provide care in a collaborative manner. Assessment, planning and evaluation are interprofessional and based upon actual or potential problems...assessed needs...The IPOC is individual and based upon actual or potential problems...assessed needs...policies...patient care standards."

Based on observation, interview, and record review, the facility failed to ensure the surgical site was marked with the surgeon ' s initials during the observation of one of two surgical tracers (a methodology to analyze the organization ' s system of providing care, treatment or services using actual patients as the framework for assessing standards compliance), for Patient 11, in accordance with the facility ' s policy and procedure.

This deficient practice had the potential to reduce the reliability of the site marked and had the potential to result in patient harm.

Findings:

During a review of Patient 11 ' s "Operative Report," dated 10/03/2023, the Operative report indicated Patient 11 was admitted to the Outpatient Surgery Center for the removal of a cataract (cloudy area in the lens of the eye) to the right eye.

During an observation on 10/3/2023 beginning at 9:47 A.M., in the Outpatient Surgery Department, the following was observed in the presence of the Associate Administrator for Perioperative Services (AAPS). Patient 11 was in the pre-operative area. At 10:03 A.M., the Surgeon (Surgeon 1) marked the top of Patient 11 ' s right eye with the word "Yes." Concurrently, Surgeon 1 stated he (Surgeon 1) marked the area with the word "Yes."

During a review of Patient 11 ' s medical record on 10/4/2023 at 1:37 P.M., with Operating Room Supervisor (ORS) and Clinical Nurse Specialist (CNS) 1, the ORS and CNS 1 stated the following. The surgical site should be marked with "Yes" and the initials of the physician or physician designee who marked the site. It was important to also write the initials so staff would know who marked the surgical site.

During a review of the facility ' s policy and procedure (P&P) titled, "Universal Protocol for Operative/Invasive Procedures," dated 7/23/2023, the P&P indicated the following. "The physician or physician designee performing the procedure in conjunction with the patient shall clearly mark Yes at the procedure side/site with their initials to enhance the reliability of the process..."