HospitalInspections.org

Based on document review and interview the facility's staff failed to follow "time out" policies for two of fourteen cesarean section patients (Patient #23 and Patient #27).

The findings included:

Thirty five electronic medical records (Patient Records #1-#35) were reviewed from January 20, 2015 through January 21, 2015. Two of fourteen (Patient #23 and Patient #27) cesarean section patient's electronic medical records reviewed revealed the following information:

1. Patient #23's electronic medical record was reviewed on January 21, 2015 at approximately 10:00 am. Patient #23 is a 33 year old gravida (the number of times a woman has been pregnant) 1 (one) para (number of deliveries greater than twenty weeks gestation) 0 (zero) at 41 weeks gestation admitted to the above named facility on January 20, 2015. Chart review revealed Patient #23's "time out" documentation prior to a cesarean section was not completely filled out per the facility's policy. The staff failed to complete Phase 2 of the "time out" which included prior to skin incision verification of the correct patient, correct procedure, and correct site. Documentation was found in the physician's operative report which stated "a time out was taken and the patient's identity and planned surgical procedure was confirmed."

2. Patient #27's electronic medical record was reviewed on January 20, 2015 at approximately 11:30 am. Patient #27 is a 37 year old gravida 4 (four) para 1 (one) at 39 weeks gestation admitted to the above named facility on January 19, 2015. Chart review revealed Patient #27's Phase 2 documentation pertaining to "time out" was not filled out. No documentation was found of the verification of the correct patient, correct procedure, and correct site in the nursing documentation. No documentation found in the physician's operative procedure report of a "time out" being performed prior to skin incision.

Staff #2 was present during the electronic medical record reviews on January 20, 2015 and January 21, 2015. Staff #2 was aware of the findings and confirmed the entire Universal Protocol Documentation is required to be filled out.

The Universal Protocol/Invasive Procedure Verification and Time Out Process was requested and received on January 21, 2015. The policy states under Section C "there will be a Procedure Time Out immediately prior to the beginning of all procedures to verify correct patient, correct procedure, and correct site/side with all members of the surgical procedure team. The Procedure Time Out will be documented in the patient medical record." The policy further states under Section D "a member of the surgical or procedure team is responsible for ensuring all required elements are complete. No personnel shall begin a surgical or invasive procedure without completing Universal Protocol Documentation."

Staff #6 stated on January 21, 2015 at 3:09 pm all the Universal Protocol documentation "must be completed." Staff #6 and Staff #2 stated on January 22, 2015 the Universal Protocol Documentation Policy is based on the Association of Perioperative Registered Nurses (AORN) standards and the World Health Organization's surgical safety checklist. Copies of the standards were requested and received on January 22, 2015 at approximately 11:20 am.