HospitalInspections.org

Based on policy and procedure review, clinical record review and staff interview, it was determined the hospital failed to comply with a patient's request for a Do Not Resuscitate (DNR) status.

Findings:

A hospital interdisciplinary policy, titled, "Do Not Resuscitate Orders" documented, "... A physician may sign the Certification of Physician based on evidence of the patient's wishes gathered from the following: 1). Previous conversations with the patient. 2). Patient's family 3). Health care providers 4). Others close to the patient with knowledge of patient's personal desires...

All discussions with patients, legal representatives, and others with evidence of the patient's wishes regarding DNR orders must be noted on the patient's medical record...

Revocation of DNR During Surgery: If a physician has completed a Physician's Do Not Resuscitate Order form, the patient or Patient Legal Representative will be asked their wishes regarding continuation of the Physician DNR orders during surgery.

1. Should the patient wish to revoke the DNR because of surgery, the physician will write an order to cancel the DNR order prior to the start of surgery...

3. If the patient wishes to remain DNR during surgery, in the event of cardiopulmonary arrest, the patient would not be resuscitated..."

A hospital anesthesia policy, titled, "Do Not Resuscitate" documented, "... A patient's right to accept or refuse medical treatments is fundamental... The aim of this policy statement is to preserve and make known this right as it pertains to the patient in the operating room...

It is the responsibility of all involved practitioners (i.e., internist, surgeon and anesthetist) to clearly communicate with each other the proposed treatment plan, as (it) concerns DNR status in the operative setting, and to document in the progress note that this multidisciplinary discussion has transpired....

Individualized Patient Plan: In the case of any patient, who has been designated DNR at anytime preoperatively, it must be clearly stated at the end of the anesthetist's preoperative note that the patient falls into one of two categories:

~ Patient has agreed to suspension of DNR status (all resuscitative measures will be employed in the operating room and PACU).

~ Patient wishes DNR status continued into the peri-operative setting and into the operating room. In this case, there must be a clear discussion of the intervention to be withheld in the operating room and under what circumstances specifically they are to be withheld.

A member of the multidisciplinary team (i.e., anesthetist, surgeon and internist) must designate in the physician's orders, preoperatively, that the patient is either "Suspend DNR for Anesthesia" or "Continue DNR for Anesthesia."

The OR nurse's preoperative checklist should note the presence or absence of "OR - DNR Discussion in Progress Notes" and "OR -DNR Orders Written."

Patient #1 was admitted to the hospital emergency room with a left hip fracture.

A review of the patient's clinical record documented the patient signed a request for DNR status originally on 04/11/06 and again on 06/08/10. Copies of these documents were attached to the clinical record.

A hospital form, titled, "Physician's Do Not Resuscitate Order", dated 11/17/12, and signed by the admitting physician, documented the patient was to be placed on a DNR status. The nursing staff entered a DNR order into the electronic medical record system on 11/17/12 at 6:00 a.m..

A physician's history and physical examination report, dated 11/17/12, documented, "... The patient is a DO NOT RESUSCITATE status according to the records..."

A surgeon's order, dated 11/17/12 at 10:34 a.m., documented, "... Please get consent from patient's daughter (POA) [power of attorney] for left hip hemiarthroplasty..."

A nurse's note, dated 11/17/12, documented informed consent for surgery was given by the patient's POA. There were no additional comments written by the nurse regarding the informed consent.

There was no documentation of discussion with the POA regarding the patient's DNR status and whether the DNR should remain in place or be cancelled for the surgical procedure.

A physician's evaluation for cardiac clearance, dated 11/17/12 at 1:00 p.m., documented, "... Patient has intermediate clinical predictors of cardiac risk... Patient has poor functional status... Based on these, she will be a poor surgical candidate... I've discussed the situation with the POA... Considering the possibility that the patient may not have a favorable outcome, she requested that surgery be postponed until Tuesday when the grand-kids of the patient will have time to travel and visit the patient before surgery..."

An untimed surgeon's progress note, dated 11/18/12, had no documentation why the surgery was scheduled to proceed on this date, rather than waiting until 11/20/12 as the family requested.

The surgeon's progress note had no documentation the family was consulted about the special circumstances surrounding the patient's DNR status and peri-operative care.

There were no physician's orders that indicated the DNR status was to be suspended during the peri-operative care.

A pre-operative checklist, dated 11/18/12, had no documentation of the patient's DNR status. There were no pre-operative nurse's notes found in the clinical record.

A pre-anesthesia evaluation, dated 11/18/12, had no documentation of the patient's DNR status. There was no documentation of discussion with the family about continuing or suspending the patient's DNR status during the peri-operative period.

An intra-operative record, dated 11/18/12, had no documentation of the patient's DNR status.

An anesthesia report, dated 11/18/12, documented, "... pt's [oxygen saturation] dropped suddenly and pt. stopped breathing spontaneously... and it was noted that her heart rate had become bradycardic into the 50's, then 40's. Carotid and femoral pulses were checked and were not palpable. Chest compressions were begun and the crash cart was called for... She was taken to the ICU... After 5-7 minutes pt's [heart rate] began to drop... and pulse was barely palpable... [blood pressure] could not be obtained... Crash cart was called for... Epinephrine infusion started..."

A surgeon's operative report, dated 11/18/13, documented, "... Complications: The patient appeared to have a cardiovascular event after the case was finished, but before transfer to recovery room... Description of the operation/procedure:... When the patient was placed supine she had been breathing on her own, but she stopped. The endotracheal tube was still in place and the anesthesiologist put her back on the ventilator. She was given epinephrine and the remainder of her medication list is on the anesthesia chart. I did perform chest compressions for approximately one minute following administration of the epinephrine... The patient regained her pulses and her pressure rebounded. Because of the event, the patient was left intubated and was transferred to the Intensive Care Unit..."

On 11/18/12, the critical care nursing record documented the patient remained intubated and on a ventilator. Additional invasive measures were performed on the patient including the placement of a subclavian intravenous line and a femoral arterial line.

On 11/19/12, a physician's note documented, "... Pt. sleeping. Did awaken and nod, try to pull [endotracheal tube] per [doctor name deleted]..."

Critical care nurse's notes documented the patient responded to painful stimuli on occasion.

A critical care nurse's note, dated 11/20/12, documented, "... DNR status in place..."

After the patient was taken off the ventilator, medications were discontinued, and IV fluids were withdrawn, the patient expired on 11/20/12 at 11:20 p.m.

On 02/20/13, administrative staff were asked if the hospital's policies on DNR status were followed. No comment to this question was made, but they stated the surgeon and the anesthesiologist were given a copy of the hospital's DNR policy.

No documentation of this was found in the physicians' files.

Based on record review, observation and interviews with hospital staff, the hospital failed to ensure that anesthetizing locations are protected and are in compliance with NFPA (National Fire Protection Association) 99, Health Care Codes.
Findings:
NFPA 99 establishes criteria for levels of health care services or systems based on risk to the patients, staff, or visitors in health care facilities to minimize the hazards of fire, explosion, and electricity and the requirements address installation, inspection, testing, maintenance, performance, and safe practices for facilities, material, equipment, and appliances, including medical gas and vacuum systems.
1. All anesthetizing locations in the hospital are not identified and recognized by all hospital personnel including administration so that maintenance and criteria can be established in these areas to assure that it is safe for patients and hospital staff.
A. Humidifying equipment in operating rooms 5, 6, 7 and 8 were unhooked from the air handling system several years ago according to hospital staff H on 02/05/13. The requirement for humidifying equipment for anesthetizing locations according to NFPA 99 - 1999 Chapter 5 - 6.1.1 requires that humidifying equipment for anesthetizing location be kept in operable condition during surgery.
B. Anesthesia is provided occasionally in the Cath Lab according to hospital staff. This area does not meet the requirements of NFPA 99 - 1999 Chapters 5-4 through 5-4.1.6 for anesthetizing locations pertaining to humidity, emergency power, medical gas and vacuum systems and smoke evacuation.
C. Fire loss prevention training in anesthetizing locations was not conducted in all locations to include all personnel. NFPA 99 Chapter 12-4.1.2.10 requires there is a fire loss prevention program that is reviewed monthly and procedures reviewed annually. There was no evidence of any fire loss prevention training for Cath Lab personnel and physicians. Only operating room staff were trained in fire loss prevention.
D. The hospital could not provide evidence the smoke evacuation system in the operating suites are operational. Four of the twelve operating rooms did not have a smoke evacuation system and eight of the twelve did not have evidence of testing of the smoke evacuation system.
E. The hospital did not have evidence of periodic training and review of manufacturing safety guidelines and usage requirements by personnel using energy-delivering devices, including, but not limited to electrosurgical units, surgical lasers, electrocautery devices and fiber optics in accordance with NFPA 99 Chapter 7-6.5 , concerning fire suppression while using this equipment.
F. Policies and procedures concerning the parameters for humidity in anesthetizing locations were incorrect and had not been reviewed by the hospital. The parameters used were not in compliance with Hospital Standards Chapter 667. The hospital was using the parameters of 20% to 60%. Hospital Standards Appendix A. Ventilation Requirements for Areas Affecting Patient Care in Hospitals and Outpatient Facilities' are 30% to 60% humidity.

Based on policy and procedure review, clinical record review and staff interview, it was determined the hospital failed to ensure:

a. surgery flash sterilization practices were monitored, analyzed and reported to the infection control officer and the infection control committee;

b. all hospital staff were screened for required immunizations and communicable disease; and

c. particulate respirator fit-testing was performed annually as required by OSHA regulation.

Findings:

1. The flash sterilization policy did not document a requirement to monitor, analyze and report flash sterilization events to the infection control committee.

There was no policy that stated flash sterilization practices would be included in the surveillance of surgical site infections.

On 02/04/13, the director of surgery was asked for documentation of flash sterilization monitoring, analysis and reporting. No documentation was provided.

On 02/20/13, the infection control officer stated he had limited information on the hospital's flash sterilization practices. He stated he had no documentation of surgery reports to the infection control committee regarding flash sterilization.

He was asked if flash sterilization was included in the surveillance of surgical site infections. He stated it was not.

2. Immunization and TB skin testing records were reviewed for seven selected employees. The following deficiencies were identified:

~ Employee #A had no evidence of immunity to varicella
~ Employee #B had no evidence of hepatitis B immunization or declination of the vaccine
~ Employee #D had no evidence of hepatitis B immunization or declination of the vaccine
~ Employee #E had no documentation of TB skin testing within the past year, no evidence of hepatitis B immunization or declination of the vaccine, and no documentation of immunity to varicella
~ Employee #F had no documentation of influenza or hepatitis B vaccination or declination
~ Employee #G had no evidence of hepatitis B immunization or declination of the vaccine and no evidence of immunity to varicella.

3. The hospital had several negative airflow pressure rooms for patients who required airborne isolation precautions. The hospital had no documentation of a comprehensive respiratory protection program. None of the employee files reviewed had evidence of annual respirator fit-testing.

4. On 02/20/13, the infection control officer stated the employee health services department was responsible for review of immunization status at the time of employment. He stated he did not monitor immunization deficiencies among staff and was not aware of deficiencies in TB skin testing.

He stated the hospital had done a departmental TB risk assessment and had determined some employees did not need annual TB skin testing because the departments were "low risk."

He was asked if the hospital had done a risk assessment for the facility as a whole, using data from staff and patient TB test conversions and data from the local county health department. He stated he had done the assessment. He was asked to provide documentation of the risk assessment algorithm with the numbers he used for the previous year.

No documentation was provided.

He was asked for documentation of employee respirator fit-testing. He stated employee health had that documentation. He stated employees were fit-tested once upon hire. He stated there was not an annual fit-testing program.

No documentation of employee respirator fit-testing was provided to the surveyors.

Based on policy and procedure review, clinical record review and staff interview, it was determined the facility failed to develop and implement an immediate use (flash) sterilization policy that reflected accepted AORN and AAMI national standards. Findings:

A hospital policy, titled, "Autoclave Procedures," did not define flash sterilization and did not designate acceptable circumstances for it's use. The policy did not prohibit flash sterilization for reasons of staff convenience and for lack of adequate surgical instrument inventory.

The policy did not document a quality assurance and performance improvement protocol for monitoring and reporting flash sterilization events. There was no documentation the surgery department would report flash sterilization to the infection control committee.

The policy did not document flash sterilization was to be included in the hospital's monitoring of surgical site infections.

The policy documented, "... All implants and instruments outside [Comanche County Memorial Hospital] need to be sterilized through the Sterile Processing Department prior to usage. Please allocate 1.5 - 2 hours for this process. There are NO EXCEPTIONS made for emergency cases..."

The policy instructed staff to "... Document all sections of the Flash Sterilization Log... Record operator initials on autoclave tape... Record reason for flash sterilization usage..."

The surgery department's flash sterilization logs for November 2012 through January 2013 documented the following:

~ inconsistent documentation of operators' initials
~ inconsistent documentation of results of the sterilization cycle
i.e., pass/fail/accept/decline
~ inconsistent documentation of a patient identification
~ inconsistent documentation of why instruments were flashed
~ multiple episodes of flash sterilization due to "hole in drape" or "hole in blue wrapper"
~ multiple episodes of flash sterilization due to "no indicator tape"
~ episodes when vendor representatives brought items late to the hospital and they were flash sterilized.

At times, staff documented reasons for flash sterilization that included "unsterile" and "not enough sets."

In November 2012, the flash sterilization log documented multiple eye instrument sets were flash sterilized on 11/13/12. There were no eye cases scheduled on this date. Ten eye cases were performed on 11/14/12. Again on 11/15/12, multiple eye instrument sets were flash sterilized. No eye cases were scheduled on this date.

The flash sterilization log for December 2012 again documented the regular flashing of eye instruments. On 12/18/12, the log documented a minor instrument set was flash sterilized because there were "not enough sets" in the surgery department.

The log for January 2013 documented flash sterilizing of eye instruments occurred on 01/24/13 and 01/30/13. There was no documentation of the patients who received a procedure where flash sterilized instruments were used.

On 02/04/13, the director of surgery was asked why eye instruments were flash sterilized on the day before eye cases were scheduled. She stated she was not aware of this practice and did not know why it was being done. She was asked if it was done for staff convenience. No comment was made.

She was asked why there were so many instances of flash sterilization for holes in drapes and holes in wrappers. She stated she had not determined the reason for this.

She was asked if she routinely monitored flash sterilization practices. She stated she did. She was asked to provide documentation of flash sterilization monitoring, analysis and reporting. She stated she did not have any documentation.

Based on policy and procedure review, record review and staff interview, it was determined the hospital failed to maintain an operating room register that contained all information required by regulations.

Findings:

A hospital policy provided by administration to the surveyors, titled, "Surgical Log Information", documented, "... A peri-operative log will be maintained that reflects the following information:

1. Patient
2. Date of Surgery
3. Procedure
4. Pre-operative and post-operative diagnosis
5. Hospital medical record number
6. Operating room number
7. Surgeon
8. Surgical Assistant
9. Anesthetist or Anesthesiologist
10. Type of Anesthesia
11. Operating room crew
12. Sponge count correctness
13. Complications
14. Wound classification..."

On 02/04/13, the hospital was asked to provide the operating room register/log for the previous three months.

The information was provided not as a log, but in individual case records titled, "Case Turnover". The records did not include all the information required.

On 02/19/13, another set of individual case records, for one date in February 2013 only, was provided to the surveyors. These records, titled, "CMS Operating Room Register", did not document the type of anesthesia provided and the actual procedures performed. The records did not consistently document pre- and post-operative diagnosis.

On 02/20/13, the findings were discussed with administrative personnel. No comment was made.