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Based on interview, policy review and medical record review, the Critical Access Hospital (CAH) failed to ensure services were provided in accordance with written policies for documentation of dry time for use of alcohol based skin preparations for 3 of 9 medical records reviewed; and documentation the Flash Sterilization was utilized for emergency situations only. Findings included:

Proper procedures were not documented in regard to the use of alcohol based skin preparation products in anesthetizing locations to reduce the risk of surgical fires. This process was not documented for 3 of 9 patients (P1, P2, P3) for whom surgeons used ChloroPrep, DuraPrep or Chlorhexidine Gluconate as skin preparation prior to procedures.

Patient (P1), scheduled for a right shoulder rotator cuff repair on 8/26/2010, had a pre-operative skin preparation with ChloroPrep. The surgical record, reviewed with the Director of Health Information Services at approximately 11:00 am on 9/2/2010, lacked documentation that the ChloroPrep was dry and not pooled under the patient prior to draping.

The Surgical Services policy/procedure for Preparing the Patient's Skin for Surgical Procedures revised 8/2010, indicated "The surgical team will conduct a "time out" before the start of the surgery to ensure that: 1) The surgical site is dry before draping and before the use of the electrosurgical unit, cautery and/or laser. 2) There is not pooling of the prep solution around the patient." The documentation requirements included "Date and Time" and "Safety measures taken to reduce the risk of fire. Verify and document "no pooling of skin prep" and "skin prep dry before draping."

Patient (P2), scheduled for open reduction/internal fixation of a left clavicle fracture on 8/17/2010, had a pre-operative skin preparation with Chlorhexidine Gluconate. The surgical record, reviewed with the Director of Health Information Services at approximately 11:00 am on 9/2/2010, lacked documentation that the Chlorhexidine Gluconate was dry and not pooled under the patient prior to draping.

Patient (P3), scheduled for a right knee arthroscopy on 8/19/2010, had a pre-operative skin preparation with DuraPrep. The surgical record, reviewed with the Director of Health Information Services at approximately 11:00 am on 9/2/2010, lacked documentation that the DuraPrep was dry and not pooled under the patient prior to draping.

The Director of Surgical Services, interviewed at 1:15 pm on 9/2/2010, stated that surgical staff were educated in regard to revised policies and procedures and verified the lack of documentation in regard to ensuring alcohol based skin preparations were dry prior to draping. She stated that Aplicare Antiseptic Chlorhexidine Gluconate was the usual skin preparation solution and she did not think it contained alcohol. The CAH provided a copy of the Drug Facts list of ingredients for Aplicare that included isopropyl alcohol.

Education records were reviewed and indicated that surgical staff were provided education in regard to updated policies and procedures for documentation of alcohol based skin preparations being completely dry and not pooled under the patient before drapes were applied.

Daily logs of Flash Sterilization were reviewed with the Director of Surgical Services and the Central Supply Room Agent (CSR) at approximately 10:55 am on 9/2/2010. The logs indicated that various instruments were flashed each day; however, there was no documentation to indicate the nature of the emergency that required flashing of instruments. The CSR stated the logs were supposed to have spaces labeled for staff to document why Flash Sterilization was required and if the instrument was utilized after it was flashed.

A review of the "Surgical Services/Flash Sterilization" policy, last reviewed 8/2010, indicated "Flash sterilization should be avoided whenever possible and will be utilized only in emergencies" and "An emergency situation is defined as the inability to locate replacement instruments when one or more have been contaminated." Education records indicated that the revised policies and procedures were reviewed with surgical staff.

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Based on staff interview and medical record review the Community Access Hospital (CAH) failed to ensure dates and times were included with physician/certified registered nurse anesthetist signatures on 3 of 11 medical records reviewed. Findings included:

Patient (P3) had pre-operative orders signed by the certified registered nurse anesthetist on 8/17/2010, that did not include the time the orders were written.

P4 had outpatient surgery orders signed by the physician on 8/17/2010 that did not include the time of day.

P5 had post operative orders on 8/19/2010 that were signed by the physician but did not include the time of day. In addition there were physician progress notes dated 8/19/2010 and 8/20/2010 that did not include the time of day.

These findings were verified by the Director of Health Information Services at approximately 11:00 am on 9/2/2010.




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