HospitalInspections.org

27457

Based on observation, interview, record review, and manufacturer's manual review, the provider failed to test one of one cardiac defibrillator located in the cardiac stress testing/rehabilitation area according to the manufacturer's testing instruction. Findings include:

1. Interview, record review, and manufacturer's manual review on 7/23/13 at 1:00 p.m. in the cardiac stress testing laboratory with the cardiac rehabilitation coordinator revealed:
*The cardiac defibrillator was only tested on a monthly basis.
*The cardiac rehabilitation department was in-use up to three days a week.
*The cardiac rehabilitation coordinator confirmed after reviewing the manufacturer's manual the instructions called for daily testing of the defibrillator.
*She was unable to explain why daily checks were done on the cardiac defibrillators in the other areas of the hospital and not in the cardiac rehabilitation area.
*She was not aware of any policy that guided the testing of the cardiac defibrillators.

26180

Based on observation, interview, and policy review, the provider failed to ensure:
*Proper labeling of multi-dose vials of an anesthetic in one of three examination rooms (large examination room) of the emergency department.
*There was appropriate documentation of the shift-to-shift counts of schedule II narcotic medication.
*There was appropriate ongoing auditing of anesthesias narcotics usage and disposition.
Findings include:

1. Observation on 7/22/13 at 4:05 p.m. in the emergency room (ER) large examination room revealed two multi-dose vials of Lidocaine HCL (anesthetic) 10 milligrams/milliliter. The vial had not been appropriately labeled with the date for when it should have been discarded.

2. Review of the provider's nursing narcotic count documents revealed for the months of:
*May 2013 - There were thirteen shifts that had not recorded a narcotic count from one shift to the next.
*June 2013 - There were six shifts that had not recorded a narcotic count from one shift to the next.
*July 2013 - There were twelve shifts that had not recorded a narcotic count from one shift to the next .

3. Interview on 7/23/13 at 8:00 a.m. with the pharmacist revealed:
*The Lidocaine should have been discarded after twenty-eight days. The date should have been written on the vial on the designated label.
*The nurses were to complete a narcotic count at the beginning and the end of their shift and record it. She verified that had not been done after review of the documentation noted above.
*She had not done any narcotic usage audits for the anesthesia providers to detect theft or mis-use.

Review of the provider's 11/19/12 Controlled Drug Management on Patient Care Units policy revealed "Licensed substances must be counted at the change of each shift by a licensed nurse. The nurse must sign the controlled substance count sheet thereby verifying that the count is correct."

Review of the provider's 12/31/12 use of Multiple Dose Vials policy revealed:
*"The beyond-use date for an opened or entered (i.e. needle-punctured) multiple dose container with antimicrobial preservatives shall be 28 days unless otherwise specified by the manufacturer.
*The healthcare provider shall write the expiration date on the vial, when it is opened."

Based on interview, policy review, and record review, the provider failed to ensure:
*Education in infection control (IC) practices had been provided to one of one staff member (registered nurse [RN] A) assigned as the IC preventionist.
*Sufficient time had been allotted to one of one staff member (RN A) that was responsible for oversight of the IC program within the facility.
*Surgical services and anesthesia services had been fully incorporated into the quality assurance improvement program.
Findings include:

1. Interview on 7/23/13 at 10:15 a.m. with RN A regarding the IC program revealed:
*She had assumed responsibility for the provider's IC program in August 2012.
*She was also responsible for surgical services and participated as the RN circulator nurse on surgical cases.
*On days surgery was performed she did not have time to review IC practices or information. Perhaps 1 to 2 hours per week had been allotted to the IC program.
*She did not have a preceptor to assist her with understanding her role and responsibilities as the IC preventionist.
*The position of IC had been vacant for at least one year prior to her assuming responsibility for the program.
*She had not received formal IC training. Her IC training was on-the-job training of information she had gathered herself.
*She did not have a resource individual to ask questions of or have them review current practices and policies she had established.
*The hospital department heads did not have specific IC monitoring requirements. If a staff member from other departments was observed using inappropriate IC practices it would have been brought to her attention for follow-up.
*A review of the concerns and issues the survey team were finding in regards to surgical services and IC had not been actively monitored.

Review of the provider's 2013 Infection Control Plan and the Infection Prevention and Control Committee policy revealed:
*The IC committee should have met no less than quarterly.
*The committee members consisted of staff from administration, nursing, laboratory, quality services, surgery, and medical staff.
*The IC committee should have met quarterly to review surveillance activities that had been conducted.
*The last IC meeting had been conducted on 5/6/13 for the first quarter in 2013 (January, February, and March). She did not have any additional meeting minutes prior to that date.

Review of the undated Coordinator OR (operating room) and Infection Control job description revealed responsibilities included but were not limited to:
*Coordination of nursing care given to pediatric, adolescent, adult, and geriatric patients within the surgical suite in accordance with nursing principles.
*Oversight of safety measures to prevent accidents, harm or injury to the patient, staff, or equipment.
*Initiating the collection of cultures and isolation precautions and staff education on infection prevention and control.
*Assisted the surgeons in operation through provision of qualified staff, prepared and maintained schedules that ensured staff availability for all procedures, and call schedule to ensure 24 hour operating room coverage.
*"Develops and implements a system for identifying, investigating, reporting, maintaining records, and preventing, the spread of nosocomial infections among patients of all ages and healthcare personnel. Confers with medical and nursing staff to determine occurrence of nosocomial infections and appropriate implementation of isolation precautions."
*"Investigates infections, especially those occurring above established thresholds, and/or in clusters by patient units."
*Developing and maintaining applicable policies and procedures for the OR and IC areas in accordance with the South Dakota Department of Health.
*Monitor use of germicides, cleaning products, antiseptics, and disinfectants in-use throughout the facility.
*Monitors methods of asepsis, sterilization, and disinfection employed throughout the hospital.
*Chair the IC committee, prepared statistics and other pertinent data, and conducted quarterly meetings.
*Stayed informed on changing IC practices and presented plans for compliance
*Developed and implemented departmental quality assessment plan and process improvement.

A. Based on observation, interview, and record review, the provider failed to ensure critical instruments were sterilized prior to use for one of one observed patient's (17) surgical procedure. Findings include:

1. Observation on 7/23/13 at 12:13 p.m. of patient 17's carpal tunnel procedure revealed:
*Licensed practical nurse (LPN) B handed registered nurse (RN) A a small round package that had been opened and the edges refolded to close the package.
*RN A unwrapped the small package, presented the package to surgical technician C, who then placed the basin on the sterile backtable.
*Inside that basin was a small pair of scissors on top of a pile of gauze.
*Technician C placed the scissors on the Mayo stand for the surgeon to use during the procedure.

Interview with LPN B during the surgical procedure revealed:
*The scissors had been opened for a previous case that had been rescheduled to follow patient 17's procedure.
*There was not another pair available, and the surgeon wanted to use them on patient 17's procedure.
*In the scope room she had soaked the scissors in Cidex OPA for 12 minutes, the scissors were sterile, and could be used on patient 17's case.
*LPN B was informed by the surveyor the scissors were not sterile. She had only performed high-level disinfection for the scissors. The scissors should have been steam sterilized in the autoclave.
*LPN B stated the scissors were sterile, they had been informed by the Cidex representative instruments could be sterilized with Cidex.

Review of the Cidex OPA written manufacturer's instructions revealed high-level disinfection was achieved with a 12 minute soak in the disinfectant solution.

Review of the provider's 1/31/13 Infection Control policy revealed:
*"Reusable patient care equipment will be classified and processed according to Centers for Disease Control (CDC) guidelines. Disinfectant agents used for the reprocessing of medical instruments/devices must be approved by the Infection Prevention and Control Committee."
*"Instruments/devices that were classified as Class I - Critical were instruments introduced into the bloodstream, through the patient's skin, or other normally sterile areas."
*Class I instruments/devices level of disinfection were sterile and those items should have been steam sterilized in central services.

B. Based on observation, interview, and record review, the provider failed to ensure:
*The manufacturer's instructions for use of Cidex OPA high-level disinfectant was followed for processing three of three endoscopic scopes used for gastrointestinal procedures in one of one scope room.
*Endoscopes and accessories were stored in a sanitary manner to prevent potential contamination and bacterial growth in one of one scope room.
*A protocol was in place to identify which scopes required reprocessing between extended periods of non-use for one of one scope room.
Findings include:

1. Observation on 7/23/13 at 9:35 a.m. in the scope room revealed:
*A storage cabinet with three endoscopes hanging in it. The cabinet did not have vents to allow air flow around the hanging endoscopes.
*Underneath the endoscopes was a white towel to catch any moisture from the scopes. The towel edges had brownish discoloration on them.
*On top of the white towels were three small paper boxes with brownish discoloration on them. The exterior of the three small boxes had a crinkled appearance.
*The interior of the cabinet had a thin layer of dust on it.
*Several endoscopic snares (catchers) hung exposed and unprotected in a wall mounted hanging device.
*A large sterilized package was on a table in the scope processing area.

Interview at the time of the above observations with RN A, LPN B, and surgical technician C revealed:
*The large sterilized package contained a pan used to rinse the endoscopes after they had been high-level disinfected.
*If more than one colonoscopy or esophagogastroduodenoscopy (EGD) procedure was scheduled for the day, the scopes were high-level disinfected, and rinsed with sterile water in the pan. The scopes received two sterile water rinses prior to use on a patient.
*The provider only had one sterile pan to perform rinsing procedures.
*The endoscope representative had informed the staff they only needed to rinse the scopes once.
*They were not aware of the rinsing requirement for the Cidex OPA high-level chemical disinfectant.
*When informed the Cidex OPA manufacturer required three water rinses after high-level disinfection they stated additional equipment would have to be purchased to meet the requirement.
*They were not aware the endoscope cabinet should have been vented to allow proper air ventilation.
*The scopes were terminally disinfected at the end of each surgical day. There might have been several days to a week that cases were not performed. The provider did not have a system in place to ensure if scopes were not used within seven to fourteen days they would be reprocessed.
*To prevent potential cross-contamination they were not aware surgical snares (catchers) exposed during one patient's procedure should not have been used for another patient without being high-level disinfected.
*The towel on the bottom of the scope cabinet was discolored brown. They thought the towel was changed weekly. The small boxes were discarded.
*There was no cleaning schedule for the interior of the cabinet identified at the time of the interview.

Review of the Cidex OPA manufacturer's rinsing instructions revealed:
*"Following removal from CIDEX OPA Solution, thoroughly rinse the medical device by immersing it completely in a large volume (e.g. 2 gallons) of water. Use sterile water unless potable water is acceptable.
*Keep the device totally immersed for a minimum of 1 minute in duration, unless a longer time is specified by the reusable device manufacturer.
*Remove the device and discard the rinse water. Always use fresh volumes of water for each rinse. Do not reuse the water for rinsing or any other purposes.
*Repeat the procedure TWO (2) additional times, for a total of THREE (3) RINSES, with large volumes of fresh water to remove CIDEX OPA Solution residues. Residues may cause serious side effects."

Review of the Association of periOperative Registered Nursing Perioperative Standards and Recommended Practices, 2012 Edition, Denver, CO, p. 489, revealed:
*After being exposed to the disinfectant solution the instruments should have been thoroughly rinsed with water according to the manufacturer's written instructions.
*"Rinsing removed toxic and irritating residues that can result in tissue damage or staining."
*"Rinsing critical and semicritical items with sterile water prevents potential recontamination that could result from tap water."

C. Based on observation, interview, and manufacturers' direction for use review, the provider failed to ensure staff followed manufacturers' recommendations for mixing of the environmental disinfectant and the instrument cleaning detergent for one of one OR. Findings include:

1. Observation and interview on 7/23/13 at 12:45 p.m. in the OR revealed:
*Surgical technician C filled a blue basin with an unknown amount of water and added one squirt of Virex II disinfectant to clean after a surgical procedure.*She had not measured the amount of water added to the basin.
*She stated the basin had two gallons of water and then added an additional squirt of the Virex II disinfectant.
*Housekeeper G entered the OR, filled the mop bucket with an unknown amount of water, and added two squirts of Virex II disinfectant.
*Housekeeper G stated she was not sure what the correct concentration of water to disinfectant should have been and added an additional squirt of Virex II to the water in the mop bucket.

Interview on 7/24/13 at 8:00 a.m. with the DON and IC preventionist revealed:
*Staff should have followed the manufactures' directions for use of the EmPower cleaning detergent and the Virex II disinfectant.
*Both manufacturers' directions stated to use one ounce per one gallon of water.
*There was no policy for mixing the cleaning detergent or the Virex II disinfectant to ensure the correct concentration was achieved.

Review of the manufacturers' instructions for use of the EmPower cleaning detergent and the Virex II disinfectant revealed both products should have been mixed by using one ounce of solution added to one gallon of water.

Review of the Association of periOperative Nursing Standards and Recommenced Practices, 2012 Edition, Denver, CO, p. 519, revealed:
*The manufacturers' instructions for use should have been followed for cleaning agents dilution.
*The chemicals could have been measured to ensure the correct concentration of the solution was obtained.

D. Based on observation and interview, the provider failed to ensure:
*LPN B and certified registered nurse anesthetist (CRNA) F performed appropriate hand hygiene to prevent cross-contamination of the OR environment for two of two sampled patient's (17 and 18) surgical procedures.
*Surgical masks were worn appropriately by two of two observed staff members (B and F) working in the OR.
*Staff wore appropriate personal protective equipment for one of two observations of staff members (C) cleaning contaminated surgical instruments.
Findings include:

1.a. Observation on 7/23/13 at 11:30 a.m. of the surgical team preparing for patient 18's surgical procedure revealed:
*LPN B wore her mask under her chin, washed her hands, and then pulled her mask up over her mouth and nose.
*CRNA F entered the OR, pulled his mask up from under his nose, and put on clean gloves.
*LPN B wore her contaminated gloves and removed a sterile gown from the sterile backtable.

Observation of surgical technician C at the end of patient 18's surgical procedure revealed:
*She entered the soiled utility room adjacent to the OR and prewashed the contaminated instruments used during the procedure.
*She had not put on protective personal equipment to clean the contaminated instruments. She had not put on a face shield or a water proof gown over her scrub attire to protect against contaminated splatter.
*Removed one of her contaminated gloves, opened the outer door to the OR suite, entered the decontamination room in the central sterilization room, removed her contaminated glove, put on clean gloves, placed the contaminated instruments in the SoniCare machine, exited the decontamination room wearing the contaminated gloves, reentered the OR soiled utility room, removed her contaminated gloves, and washed her hands.

b. Observation on 7/23/13 at 11:55 a.m. of the surgical team preparing for patient 17's surgical procedure revealed:
*LPN B was observed numerous times wearing her mask on her chin, readjusting the mask with her gloved hands, and assisted with opening sterile packaging for the patient's surgical procedure.
*Prior to the start of patient 17's surgical procedure CRNA F was observed with his mask dangling around his neck and positioned just under his nose, pulling the mask down and leaving the OR suite, returning to the OR suite and pulling that same mask over his nose and mouth. During the surgical procedure his surgical mask was not always covering his nose but was positioned under it covering only his mouth.

Interview on 7/24/13 at 8:00 a.m. with the DON and RN A revealed:
*Staff should have performed hand hygiene after contact with contaminated items.
*Hand hygiene was required when gloves were removed.
*The correct placement of the surgical mask was over the nose and mouth. Touching the mask after application would have contaminated the staffs hands/gloves.
*CRNA F had been verbally informed several times about the proper method of wearing his surgical mask.

E. Based on observation and interview, the provider failed to ensure:
*Anesthesia services had not used an expired SodaLime cannister (anesthesia scavenger gas device) for one of one observed patient's (18) induction procedure.
*Anesthesia services had not mixed unsterile endotracheal tubes (ET) with sterile ET tubes for one of one anesthesia cart.
*Medications and medical supplies beyond the manufacturer's use date were not available for patient use in one of one OR and one of one endoscopic scope room.
Findings include:

1. Observation on 7/23/13 at 8:55 a.m. in the OR revealed:
*Two bottles of Forane had expired June 2013.
*Three opened packages of ET tubes mixed in with sterile ET tube packages. One of the opened ET tubes had the syringe attached for balloon inflation. It was not clear if the ET tube had been used.
*The SodaLime cannister on the anesthesia machine expiration date read June 2013.

Observation on 7/23/13 at 9:35 a.m. in the scope room revealed:
-Atropine one vial had expired on 6/1/13.
-Biopsy forceps one had expired in May 2006 and two in June 2013.

Interview with the above listed staff members at the time of the observations revealed:
*They were not aware the Forane had expired or there were three ET tubes mixed with sterile ET tubes.
*They were aware the SodaLime cannister had expired, there were no other cannisters in the facility, it had been ordered, but they did not know of an arrival date.
*The anesthesia provider was aware the SodaLime cannister had expired.
*Staff checked for outdated medications and supplies monthly in the OR and scope room, but some items had been missed.

Interview on 7/24/13 in the afternoon with LPN B revealed:
*Several weeks ago she had ordered the SodaLime cannisters, she did not remember the exact date, and had not documented the phone order.
*A customer rush order dated 7/23/13 for one box of multi-absorber cannisters.

F. Based on interview and manufacturer's written instructions review, the provider failed to ensure staff performed recommended cleaning procedures for one of one steam sterilizer in the OR suite. Findings include:

1. Observation and interview with RN A, LPN B, and surgical technician C on 7/24/13 at 3:05 p.m. revealed:
*There was one steam sterilizer located in the central sterilization room.
*They had not performed any cleaning activities for the steam sterilizer.
*They were not aware the sterilizer required cleaning.

Review of the manufacturer's operator manual for the steam sterilizer with the above listed staff revealed:
*Cleaning should have been done daily, weekly, every three months, and every six months.
*Daily the staff should have:
-Cleaned the door gasket(s) with a damp cloth.
-Removed the sediment screen from the chamber drain and cleaned it thoroughly.
-Routinely cleaned the exterior surfaces with a mild cleaning agent.
*Weekly the staff should have:
-Cleaned the interior surfaces of the sterilizer chamber, shelves, and trays with a suitable detergent.
*Every three months the staff should have:
-Checked the safety valve. That procedure required access to the sterilizer piping and should have been performed by the maintenance department.
*Every six months the staff should have:
-Cleaned the steam strainer, that procedure should have been completed by the maintenance department.
*Maintenance staff performed the three month and six month service requirements.

G. Based on observation, interview, and record review, the provider failed to ensure:
*A safety belt was applied on the patient prior to the start of one of two patient's (17) surgical procedure.
*An appropriate surgical time-out prior to starting the surgical procedure was performed for one of one observed surgical patient's (17) procedure.
Findings include:

1. Observation on 7/23/13 at 11:55 a.m. of patient 17's surgical procedure revealed:
*The consent form indicated the surgical procedure was a left carpal tunnel repair.
*The patient was positioned on her back on the OR table and provided warm blankets.
*RN A and LPN B did not apply the safety belt across the patient's upper thighs to prevent potential falls from the OR table.
*Prior to draping and anesthesia agents being administered RN A and physician H spoke with the patient separately regarding her procedure.
*Prior to the surgical incision the surgical team RN A, LPN B, and physician H had not conducted a time out procedure verifying the patient's identity, type of surgical procedure, and the surgical site.

Review of patient 17's intraoperative documentation revealed the section to check if the safety belt had been applied had been left unchecked.

Interview on 7/24/13 at 8:00 a.m. with the director of nursing and RN A revealed:
*The safety belt should have been put on patient 17 after she had been positioned on the OR table to prevent falls.
*The staff as a team had not performed an appropriate time-out procedure.

Review of the provider's 12/27/12 Positioning policy revealed:
*The circulating RN was responsible for placing the patient on the table and assisted the nurse anesthetist and surgeon with the final positioning.
*"All patients will have safety belts when positioned on the OR table; other securing devices will be used as necessary."
*For patients positioned on their backs the safety belt should have been placed across the legs at mid-thigh level.

Review of www.ortoday.com website, publication August 2012, p. 42-43, revealed:
*The surgery time out confirmed the surgical site, patient, and procedure.
*"It is the time when the entire surgical team pauses to confirm and agree that the appropriate surgery is about to be performed."

H. Based on observation and interview, the provider failed to ensure:
*Dehumidifiers were not used by the staff in one of one OR.
*The interior door to the OR remained closed during two of two observed patients' (17 and 18) surgical procedure.
Findings include:

1. Observation on 7/23/13 at 8:55 a.m. in the OR revealed:
*Two large dehumidifiers were on and blowing air into the OR environment.
*There were no cases being conducted at the time of the observation.
*The interior door for the OR was standing open.

Observations on 7/23/13 at 11:55 a.m. and at 1:30 p.m. revealed:
*Patient 17's procedure was in progress at 11:55 a.m. and patient 18's surgical procedure was in progress at 1:30 p.m.
*The dehumidifiers had been removed from the OR during the patient cases, but the OR door remained opened.
*Throughout patient 17's surgical procedure several staff entered and exited the OR by the anteroom. The anteroom door opened directly into the hospital corridor.

Interview on 7/24/13 at 8:00 a.m. with the DON and RN A revealed:
*The provider used dehumidifiers in the OR, because the humidity was too high.
*The humidity was documented on the patient's intraoperative record.
*The humidity was not documented on a central log.
*To find trends in humidity levels you had to pull numerous OR patients' charts for review.
*Maintenance was aware of the high humidity levels in the OR. Not too long ago they had worked on the ventilation system which had improved humidity levels.
*The doors to the OR always remained opened.
*They were not aware the OR doors should have been closed during surgical procedures.

Review of www.cdc.gov website, Morbidity and Mortality Weekly Report, June 6, 2003/52(RR10); 1-42, Guidelines for Environmental Infection Control in Health-Care Facilities recommendations for infection control and environmental ventilation requirements for the operating room measures included keeping the operating room door closed except for the passage of equipment, personnel, patients, and to limit the entry to essential personnel.

I. Based on interview and record review, the provider failed to ensure pre-operative history and physical reports and pre-nursing assessments were completed for two of two reviewed closed patients' (15 and 16) medical records. Findings include:

1. Review of the closed medical records for patients 15 and 16 revealed:
*Both patients had outpatient colonoscopy procedures performed; patient 15 on 6/17/13 and patient 16 on 6/6/13.
*There were no history and physical reports documented in those patients' medical records.
*There were no admitting nursing assessments documented in those patients' medical records.

Interview on 7/24/13 at 1:35 p.m. with the DON regarding patients 15 and 16 revealed:
*There should have been a history and physical documented in the patients' medical records prior to the start of their surgical procedures. That was required by the provider's policy and procedures.
*The admitting nursing assessment should have been completed at the time of the patient's admission.
*The admitting nursing assessment had not been documented by the nursing staff for either patients.
*The nursing staff should have completed the "outpatient surgery admit form" for both patients.
*The outpatient surgery admit form required documentation on the patient's, allergies, general admission information, personal belongings, past medical history, personal habits, home medications, and advance directive/power of attorney.
*There was no policy and procedure for completing the outpatient surgery unit form.
*Completing the outpatient surgery unit form was "good nursing practice."

26180

Based on interview, record review, and policy review, the provider failed to maintain an effective quality assurance (QA) program to ensure:
*The QA coordinator was fully trained and knowledgeable regarding QA.
*All newly identified areas of concern became part of the QA process.
*Contracted services were monitored and evaluated for delivery of service.
Findings include:

1. Review of the provider's 2013 QA/safety summary revealed:
*Quality measures were identified by each department.
*An asterisk (*) meant the area identified was a critical indicator for quality and safe patient care.
*Each department had:
-A measure description (focus area).
-The baseline/benchmark (starting point) that was NA (not applicable).
-A goal and data findings all defined in percentages of achieving their goal.
*There were no contracted services identified on the plan.
*Review of the Anesthesia department quality improvement plan had no critical indicators of quality and the only area they were monitoring was "All anesthesia personnel will visit the patient prior to procedure as able."

Review of the provider's Quality Improvement and Patient Safety Plan for 2013 revealed:
*"Quality improvement is the process of identifying, evaluating, and implementing procedures, actions, and behavior that will continually improve services, costs, time, and satisfaction for all internal and external customers.
*The departmental/service quality improvement process included:
-Aspects of patient care or services provided to internal/external customers are identified by the director/manager/supervisor of each respective department or service based on aspects important to health, safety, services, customer satisfaction, time, or costs.
-Aspects of patient care or services provided may be prioritized in order of importance, impact on patient care and/or patient safety, frequency of occurrence, effect on large numbers of internal, external customers, potential risk of serious consequence, and/or that will improve customer satisfaction, time, or costs, Evaluation of these aspects will be prioritized by the individual department/service/committee responsible for evaluation. The QI [quality improvement] committee may alter or provide additional determinations based on their review of reports submitted.
-Follow-up methods to determine effectiveness of the implemented action plan are established."

Interview on 7/23/13 at 1:35 p.m. with the QA coordinator revealed:
*She had started the position in April 2013.
*The previous QA coordinator was no longer at the facility when she had started but had been responsible for the current QA plan.
*She had no prior experience with QA.
*She had been a floor nurse prior to becoming the QA coordinator.
*She had not received any QA training from the provider.
*Her other responsibilities were as safety coordinator and risk management.
*She was not sure how the current QA plan had been derived, and no one had given her information on it.
*The anesthesia measure of seeing the patient before a procedure had probably been put in place, because the anesthetist had not always done that.
*She was unaware if they were monitoring surgical-site infections in the operating room (OR).
*She was unaware the QA plan could have been changed as new concerns were identified.
*She thought the QA plan had to remain unchanged for the entire year.
*The provider had multiple patient care contracted services that were not part of the QA process.

Review of the provider's contracted services revealed there were seven services that were involved in patient care and included:
*Radiology.
*Biomedical.
*Organ procurement.
*Nuclear medicine.
*Vascular.
*Medical rental equipment.
*Sleep studies.

Interview on 7/24/13 at 9:10 a.m. with the OR/ infection control (IC) coordinator, QA coordinator. director of nursing, and assistant director of nursing revealed:
*The OR/IC coordinator stated:
-She had been employed in that position since August 2012.
-There were other infection control issues that should have been part of the QA process but were not.
-The current measures for infection control had been in place for three years. She had not changed them because when she took over she thought there was not enough documentation to support the measures being changed. Their measures were not accurate.
-The data she had was they were in 100 percent (%) compliance when they were really only 7% in compliance.
-She monitored other areas, but the data was not submitted for the QA process.
-They were not looking at high risk error-prone areas in anesthesia or surgery.
-There were multiple areas in anesthesiology that should have been part of the QA process but were not.
-She had not thought the current QA process in the OR was effective.
*The QA coordinator revealed:
-Their QA program had not focused on high-risk error-prone areas in anesthesia or surgery.
-The anesthetist refused to participate in the QA process and had not tracked any data.
-She confirmed there was not sufficient data in anesthesia and surgery.
-The only contracted services that had been reviewed were laboratory, dietary, and physical therapy.

Review of the provider's QA coordinator job descriptions revealed:
*The essential duties and responsibilities included:
-"Provides leadership for system-wide development and implementation of the QI (quality improvement) plan in all domains of quality including patient safety and care processes in accordance with the mission and vision of CDP [provider's initials].
-Develops a system for defining, identifying, monitoring and analyzing departmental quality indicators.
-Reviews departmental indicators on a regular basis and makes recommendations as needed to ensure quality improvement efforts are effective."
*The education and experience revealed a minimum of three years experience in health information, quality, or risk management helpful.