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Based on a review of facility records, policies and procedures, Quality Improvement/Performance Improvement (QAPI) reports, governing body meeting minutes, and staff interview, it was determined that the governing body failed to take immediate actions for patient safety following a wrong site patient procedure.

Cross Reference to 0117 as it relates to informing each patient, or when appropriate, the patient's representative (as allowed under State law), of the patient's rights, in advance of furnishing or discontinuing patient care whenever possible.

Cross Reference to 0296 as it relates to the facility's Quality Assurance and Performance Improvement (QAPI) program lacking an ongoing program that shows measurable improvement in indicators for which there is evidence that it will identify and reduce medical errors and, measure, analyze, and track adverse patient events.

A review of QAPI meeting minutes dated 6/28/16 revealed that a discussion took place concerning a wrong site surgery and that an investigation was in progress. There was no evidence that training of personnel involved or other immediate actions had taken place to prevent further incidents.

An interview with the facility Quality Improvement Coordinator on 7/7/16 and an interview on 7/6/16 at 5:39 p.m. with the Vice President of surgical services confirmed the above finding.

Based on review of the facility's policies and procedures, review of randomly sampled medical records (#s 1-10), and interview with the Quality Improvement Coordinator, it was determined that the facility failed to have documented evidence that patients received notice of their rights in ten (10) of (10) sampled medical records (#s 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10).

Findings:

Review of undated policy entitled Patient Rights and Responsibilities revealed that all patients or parents/guardians would be informed of their patient rights and responsibilities.

Review of the patient care in ten (10) sampled medical records revealed that ten (10) of the ten (10) sampled medical records (#s 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) lacked documented evidence that patients or their representative received notice of their rights and responsibilities.

The Quality Improvement Coordinator acknowledged the above findings on 7/6/16 at 10:00 a.m.

Based on a review of facility records, Quality Improvement meeting minutes and staff interviews, it was determined that the governing body failed to ensure that patient safety was prioritized, and that following a wrong site patient procedure, immediate actions were put in place for patient safety.

Findings:

A review of QAPI meeting minutes dated 6/28/16 revealed that a discussion took place concerning a wrong site surgery and that an investigation was in progress. There was no evidence that actual training of personnel involved had taken place prior to the date of survey.

An interview with the facility Quaility Improvement Coordinator on 7/7/16 and an interview on 7/6/16 at 5:39 p.m. with the Vice President of surgical services confirmed the above findings.

Based on a review of facility records, policies and procedures, Quality
Improvement/Performance Improvement (QAPI) reports, governing body meeting minutes, and staff interview, it was determined that the governing body failed to ensure that patient safety was prioritized. Following a wrong site patient procedure, immediate actions were not taken to ensure patient safety.

Cross Reference 0296 as it relates to physicians ensuring that the correct patient, surgical site and correct procedure was being performed.

Based on record review, policy and procedure and interview, it was determined that the hospital failed to provide surgical services in a well organized safe manner and in accordance with acceptable standards of practice for three (3) of ten (10) patient (# 1, 2, and 3).

Findings:

Review of the following three (3) patient's (#1, 2, and 3) records revealed:

1. Patient #1 had a diagnosis of left hip avascular necrosis (loss of blood supply to tissue) and was scheduled for arthroplasty (the surgical reconstruction or removal of a joint) he/she signed a consent for right hip surgery. The procedure was done on the patient's left hip. The facility staff failed to obtain consent for surgery to the left hip.

2. Patient #2 had a diagnosis of compression fracture T10 (a location in the spine) and was scheduled for kyphoplasty (surgical filling of a collapsed area of the spine.) The patient signed consent for T10 portion of the spine. The procedure was performed on T9. The patient was returned for additional surgery.

3. Patient #3 had a diagnosis of cervical stenosis (a condition that causes pinches on the spinal cord in the neck) and neck pain. The patient consented for and was scheduled for surgery on C4-7. The procedure was performed on the C3-4 in addition to the C4-7 level of the spine.

During an interview at 12:34 p.m., on 7/6/16 in a facility office, the director of the operating room confirmed the above findings.

Based on review of records, policies and procedures and interview, it was determined that the facility failed to properly executed a informed consent form for the patient's operation before the start of the surgery of three (3) of ten (10) patient (#'s 1, 2 and 3)

Findings:

During an interview at 12:34 p.m., on 7/6/16 in a facility office, the director of the operating room confirmed the findings.


Review of the following three (3) patient's (#1, 2, and 3) records revealed:

1. Patient #1 had a diagnosis of left hip avascular necrosis (loss of blood supply to tissue) and was scheduled for arthroplasty (the surgical reconstruction or removal of a joint) he/she signed a consent for right hip surgery. The procedure was done on the patient's left hip. The facility staff failed to obtain consent for surgery to the left hip.

2. Patient #2 had a diagnosis of compression fracture T10 (a location in the spine) and was scheduled for kyphoplasty (surgical filling of a collapsed area of the spine.) The patient signed consent for T10 portion of the spine. The procedure was performed on T9. The patient was returned for additional surgery.

3. Patient #3 had a diagnosis of cervical stenosis (a condition that causes pinches on the spinal cord in the neck) and neck pain. The patient consented for and was scheduled for surgery on C4-7. The procedure was performed on the C3-4 in addition to the C4-7 level of the spine.

During an interview at 12:34 p.m., on 7/6/16 in a facility office, the director of the operating room confirmed the above findings.