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Based upon observation, interview and record review, the critical access hospital (CAH) did not ensure the surgical cautery was utilized in accordance with hospital policy and manufacturer's recommendation for 1 of 3 patients (P3) whose surgical procedures were observed.

Findings include:

The electrocautery device was not used in accordance with hospital policy and manufacturer's recommendations. MD-A was observed performing a right knee arthroplasty on P3 on 1/14/2014 at 8:45 a.m. The physician used a surgical cautery at 8:46 a.m., 8:48 a.m., 8:50 a.m. and 8:55 a.m. The physician placed the cautery tip on the surgical drape, not in the cautery holster, after each use. Registered nurse (RN)-A was interviewed on 1/14/14 at 9:05 a.m. and stated the cautery holster was available and was visible on the drape covering the patient's lower abdominal area. RN-A stated the cautery tip was to be placed in the holster when the device was not in use.

The CAH policies related to electrical safety were reviewed with the director of surgical services on 1/15/14 at 12:45 a.m. The policy related to the use of the electrocautery referred staff to the manufacturer's recommendations. A review of the hospital's current Valleylab users manual related to the Force Triad electrocautery device indicated electrosurgical instruments which were activated or hot from use could cause a fire. The manual also indicated when electrosurgical instruments were not in use they were to be placed in a safety holster or safely away from patients, the surgical team and flammable materials.

The director of surgical services was interviewed on 1/15/14 at 12:45 p.m. and stated the cautery tip should be placed in the holster when the device was not in use.

Based upon interview and document review, the critical access hospital (CAH) did not ensure patient names or other identifiers were included on the Immediate Use Sterilization Log so that potential infections could be identified, reported and/or tracked for 10 of 12 unidentified patients (P1, P2, P3, P4, P5, P6, P7, P8, P9 and P10) listed on the log who underwent surgical procedures and had instruments sterilized per this hospital procedure.

Findings include:

A log had not been maintained which identified the names of patients who had surgical procedures which utilized instruments that had been identified as "immediate use"sterilization.

P1 had a surgical procedure on 10/10/13 and a cystoscopy tray was sterilized using the immediate use sterilization method. There was no name or medical record number on the Immediate Use Sterilization Log to provide tracking of items to the individual patient.

P2 had a surgical procedure on 10/10/13 which required the sterilization of a cystoscopy tray using the immediate use sterilization method. There was no name or medical record number on the Immediate Use Sterilization Log to provide tracking of items to the individual patient.

P3 had a surgical procedure on 11/6/13 which required sterilization of instruments to perform a dilation and curettage (D and C). There was no name or medical record number on the Immediate Use Sterilization Log to provide tracking of items to the individual patient.

P4 had a surgical procedure on 11/6/13 which required sterilization of a hysteroscope using the immediate use sterilization method. There was no name or medical record number on the Immediate Use Sterilization Log to provide tracking of items to the individual patient.

P5 had a surgical procedure on 11/6/13 which required sterilization of a hysteroscope and D and C instruments using the immediate use sterilization method. There was no name or medical record number on the Immediate Use Sterilization Log to provide tracking of items to the individual patient.

P6 had a surgical procedure which required sterilization of a podiatry tray using the immediate use sterilization method. There was no date of the procedure nor name or medical record number on the Immediate Use Sterilization Log to provide tracking of items to the individual patient.

P7 had a surgical procedure on 12/17/13 which required sterilization of a nasal tray using the immediate use sterilization method. There was no patient name or medical record number on the Immediate Use Sterilization Log to provide tracking of items to the individual patient.

P8 had a surgical procedure on 12/18/13 which required sterilization of a hysteroscope and D and C instruments using the immediate use sterilization method. There was no patient name or medical record number on the Immediate Use Sterilization Log to provide tracking of items to the individual patient.

P9 had a surgical procedure on 1/7/14 which required sterilization of cystoscopy instruments using the immediate use sterilization method. There was no patient name or medical record number on the Immediate Use Sterilization Log to provide tracking of items to the individual patient.

P10 had a surgical procedure on 1/7/14 which required sterilization of ureteroscopy instruments using the immediate use sterilization method. There was no patient name or medical record number on the Immediate Use Sterilization Log to provide tracking of items to the individual patient.

The director of surgical services was interviewed on 1/15/14 at approximately 12:30 p.m. and verified the sterilization log was to include the date the instruments were processed as well as the name of the patient.

A review of the Immediate Use Sterilization policy, last reviewed/revised 12/12, indicated documentation of cycle information and monitoring results would be maintained in a log to provide tracking of items to the individual patient. The policy also indicated the sterilization log would include the name of the patient receiving the items and the date and time the cycle was run. The Immediate Use Sterilization log did not include patient names thus there was no way to identify the patients and therefore track potential infections for patients who had procedures which utilized instruments identified on the log.

Based upon interview and record review, the critical access hospital (CAH) did not ensure the organ procurement organization (OPO) was notified in a timely manner following the deaths of 2 of 3 patients (P-1 and P-2).

Findings include:

P1 was admitted to the emergency room on 12/3/13 and declared deceased at 10:59 a.m. Although the medical record indicated the OPO had been notified, there was no documentation of the time the notification had been made.

P2 was admitted to the emergency room on 12/23/13 and was declared deceased at 9:25 a.m. The OPO was not notified of the death until 11:11 a.m. (1 hour 46 minutes later).

The CAH's policy Organ/Tissue Procurement, last reviewed/ revised 2/08, indicated the OPO should be notified within one hour of all deaths which occurred in the CAH.

A review of an amendment to the Organ Recovery Agreement with the OPO, dated 8/25/05, defined "timely notification of imminent death" as within one hour of the patient meeting clinical trigger criteria for imminent death. The amendment also defined timely notification to the OPO as within one hour of cardiac death.

The assistant director of nursing was interviewed on 1/14/14 at 2:30 p.m. and stated the hospital policy directed staff to report all deaths to the OPO within one hour.