HospitalInspections.org

Based on findings from document review and interview, the hospital's Governing Body (GB) has not approved the frequency and method of data collection for the Quality Assessment Performance Improvement (QAPI) program indicators.

Findings include:

-- Review of the Professional Practice Committee (a subcommittee of the hospital's GB) Meeting minutes dated 9/19/2019, 11/21/2019 and 1/23/2020, at which the 2020 QAPI plan was approved, revealed the meeting minutes lacked discussion and/or approval of the method and frequency of data collection for quality indicators planned for review and report to the QAPI program, prior to initiation.

-- During interview of Staff A, Director Quality Management on 10/14/2020 at 10:00 am, he/she acknowledged the above findings.

Based on observation, document review and interview, the hospital did not ensure that all generally accepted infection control measures relative to proper operating room (OR) attire and hand hygiene were implemented and followed. Also, the hospital's policy and procedure (P&P) did not instruct staff on acceptable jewelry in the OR. These lapses in infection control may increase the risk of infection transmission.

Findings include:

-- Per observation, in the OR, on 10/13/2020 at 12:20 pm, an anesthesiologist was wearing hoop earrings exposed below his/her bouffant hair covering.

-- Review of the hospital's P&P titled "Surgical and Procedural Attire," dated 1/14/2020, indicated guidelines on reducing the risk of infections for both patients and personnel, however, the P&P did not specifically address the wearing of jewelry in the OR.

-- During interview of Staff B, OR Coordinator, on 10/13/2020 at 3:35 pm, only stud earrings may be worn in the OR, no hoop earrings are allowed. He/she acknowledged the above finding.

-- Per observation on 10/13/2020 at 12:30 pm, a certified registered nurse anesthetist (CRNA) did not perform hand hygiene prior to donning gloves to initiate an intravenous (IV) line.

-- Per observation on 10/13/2020 at 1:40 pm, an anesthesiologist did not perform hand hygiene after initiating an IV line and doffing gloves.

-- Review of the hospital's document titled "Surgical Hand Antisepsis - CE," dated 2018, indicated all health care team members must practice general hand hygiene.

-- During interview of Staff B, OR Coordinator on 10/13/2020 at 1:10 pm, he/she acknowledged the above findings.

Based on medical record (MR) review, document review and interview, in 1 (Patient #1) of 9 MRs reviewed of patients who had a surgical procedure performed, documentation in the "time-out" (an immediate pause by the entire surgical team to confirm the correct patient, procedure and site) was incomplete. Additionally, the hospital's policy and procedure (P&P) did not instruct staff to document the names of all staff in the operating room (OR) at the time the time-out was performed. This lack could lead to a potential error in procedure and/or cause patient harm.

Findings include:

-- Review of Patient #1's MR revealed on 10/13/2020 at 10:09 am, the circulating Registered Nurse (RN) and certified registered nurse anesthetist (CRNA) names were documented in the time-out section titled "pre-incision," however, the names of the surgeon, scrub technician, second RN and the neurodiagnostic technician were not identified as being present and acknowledging the time-out pause.

-- Review of the hospital's policy and procedure (P&P) titled "Verification of Procedure to be Performed," last revised 12/2018, indicated the entire operative/procedure team including procedure practitioner(s), assistant(s), anesthesia provider(s), accountable (circulating nurse) RN, scrub technician, any additional ancillary/support staff and anyone assisting in any way, will participate in the time-out. Each individual team member will verbally acknowledge agreement with all information provided during the time-out. However, the P&P lacked instruction to staff to document the names of all staff that were present at the time-out.

-- During interview of Staff B, OR Coordinator, on 10/14/2020 at 1:00 pm, he/she indicated the expectation is that all staff involved in the procedure participate in the time-out pause and the names of the participants should be documented in the MR. He/she acknowledged the above findings.

Based on medical record (MR) review, document review, and interview, 1) in 10 of 10 MRs (Patient's #1-#10), the informed consent forms and the anesthesia consent forms did not identify the specific facility where the procedure was performed. Distally, in 6 of 9 MRs (Patient's #1, #3, #4, #5, #6, #8), the "Consent for Blood and Blood Derivatives Transfusion"consent form did not identify the specific facility where the procedure may be performed. Also, 2) in 9 of 10 MRs (Patient's #1- #9), the anesthesia consent forms lacked the name of the anesthesiologist and/or the certified registered nurse anesthetist (CRNA) performing the anesthesia service and the electronic signature of the anesthesiologist was not legible. Additionally, the hospital's policies and procedures (P&Ps) addressing informed consent does not include all the required elements for informed consent and does not specifically address an anesthesia consent. This lack of documentation does not portray the actual care provided to the patient.

Findings regarding (1) include:

-- Review of Patient #2's MR revealed the informed and anesthesia consent forms dated 9/29/2020 at 8:53 am, began with the following statement: "I am receiving medical care from one or more of the following United Health Services (UHS) entities: United Health Services Hospitals, INC., United Medical Associates, P.C., Chenango Memorial Hospital, Inc., and its authorized employees and agents (hereinafter defined as "UHS Entities)." The consent does not identify the specific facility where the procedure was performed.

-- The same lack of documentation identifying the specific facility where treament was noted in Patient's #1, #3 - #10's MRs.

-- During interview of Staff B, Operating Room (OR) Coordinator on 10/14/2020 at 1:00 pm, he/she acknowledged the above findings.

-- Review of the Patient #4's MR, revealed the "Consent for Blood and Blood Derivatives Transfusion"consent form dated 10/13/2020 at 8:16 am, began with the following statement: "I am receiving medical care from one or more of the following United Health Services (UHS) entities: United Health Services Hospitals, INC., United Medical Associates, P.C., Chenango Memorial Hospital, Inc., and its authorized employees and agents (hereinafter defined as "UHS Entities)." The consent does not identify the specific facility where the procedure may be performed.

-- The same lack of documentation of the entity that may be providing blood/blood derivatives was noted in Patient's #1, #3, #5, #6, #8 MRs.

-- During interview of Staff C, Nurse Manager on 10/14/2020 at 11:00 am, he/she acknowledged the above findings.

Findings regarding (2) include:

-- Review of Patient #2's MR dated 9/29/2020 at 8:53 am, revealed an anesthesia consent signed by the patient. There was no documentation of the name of the anesthesiologist and/or CRNA that provided anesthesia services to the patient. Additionally, the anesthesia provider's signature on the consent was not legible.

-- The same lack of documentation of anesthesiologist/CRNA was noted in Patient's #1, #3-#9 MRs. Additionally, all the anesthesia providers signatures on the consents were not legible.

-- During interview of Staff C, Nurse Manager on 10/14/2020 at 11:00 am, he/she acknowledged the above findings.