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Based on review of documents, review of the medical record for patient #1 and staff interviews it was revealed the facility failed to ensure care was rendered in a safe setting (see tag 144).

Based on medical record review and staff interviews it was revealed the facility failed to ensure care was rendered in a safe setting. This failure was identified in one (1) of thirty (30) medical records reviewed (patient #1). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #1 revealed no documentation of a surgical procedure on 8/28/20 for patient #1. A request for documentation of the surgical procedure was made on entrance to the facility by the surveyor. An anesthesia report was obtained from the surgical department which was created by the Certified Registered Nurse Anesthetist (CRNA). The anesthesia report had a label for patient #2 located in the upper right corner of the report and a label for patient #1 located in the upper left corner of the same report. The surveyor was informed when the staff realized the wrong patient had been taken to the Endoscopy (Endo) suite, a label for patient #1 was put on the anesthesia report and the label for patient #2 was crossed out to signify it was the wrong patient label. No pre or post-anesthesia assessment was noted in the medical record for patient #1. The surgeon's report for the surgical procedure on patient #1 was completed on 9/1/20 after entrance was made at the facility. The Chief Executive Officer (CEO) stated the surgeon was unsure how to write the surgical report due to the wrong patient being taken to the Endo suite.

2. An interview was conducted with Registered Nurse (RN) #1 on 9/1/20 at 11:00 a.m. in the Administration conference room. She stated, "I was working in Endo suite 2 on 8/28/20. I was in Endo 2 when the nurse from Endo 1 came out and got me and told me they did the wrong procedure on the wrong patient." She stated she told the RN from Endo 1 to talk to the floor nurse. She stated the floor nurse and the Nurse Manager from the floor came to the Endo suite before anyone notified the second floor staff. She stated, "The Nurse Manager asked what patient was in that room. I told her not the right patient." She noted she called the Operating Room (OR) Manager. The OR manager notified the Community Chief Regulatory Affairs Officer and called the Department of Health and Human Services (DHHR). She stated the RN from Endo suite 1 was too upset to talk to DHHR so she talked to DHHR. She stated there was a room change with the patient that the OR did not know about. She stated the transporters were the scrub nurse and the circulating nurse from Endo 1. She stated the correct patient had been moved from room 206 bed 3 to room 207. She stated she was told the transporters asked patient #1 if she was patient #2 and the patient said yes.

3. An interview was conducted with RN #2 on 9/1/20 at 11:26 a.m. in the Administration conference room. She confirmed she was the primary nurse caring for patient #1 on 8/28/20. She stated she checked on patient #1 hourly because she was confused and falls when she gets up. She stated she went to her room around 3:30 p.m. to check on patient #1 but she was not there. She thought she may be down for a CT scan or something. She stated in part that a clerk contacted her on the walkie and told her that the Endo suite had called to give a report on Room 203, bed 3. She further stated that she went to talk to the clerk who was still talking to the Endo suite on the walkie, trying to tell them they had the wrong patient. She stated after she talked to the clerk she then went to room 206 bed 3 and then to room 207. She stated the patient was still in room 207 and she knew the patient was scheduled for an upper endoscopy (EGD). She confirmed patient #2 had been switched from bed 206 bed 3 to room 207. She stated once she figured out the wrong patient went to the OR, she spoke to her Nurse Manager. She was told to try and stop the procedure but she informed the Nurse Manager the OR was calling report to the floor. She stated they went to the Endo suite and talked to one (1) of the nurses and told them they had the wrong lady. The Nurse Manager asked them about the Time Out procedure. The managers from the floor and the OR went to an office and talked. She stated she was worried because the patient had eaten lunch and was taken down to the Endo room around 3:45 p.m. She stated when the patient arrived back in her room she went to check on her. She noted the patient was sitting up, alert but not oriented. Patient #1 told her she slept good. Her vital signs were stable. She stated when she was notified the OR staff was taking a patient to the OR she was unable to talk to them. She was doing a wound vac care. The Nurse Manager notified the OR the nurse was unavailable.

4. A telephone interview was conducted with the scrub nurse on 9/1/20 at 11:45 a.m. He stated he went to the floor to get the patient for a procedure in the Endo suite. He stated, "Went into room, asked if patient #2 and patient said yes." He confirmed no one looked at her arm band identification. He stated he can not remember if the anesthesiologist saw the patient in the Endo room or not. The procedure did not last long because the surgeon saw food in the patient's stomach. He stated after he took the scope to the sink he was told it was the wrong patient.

5. A telephone interview was conducted with RN #3 on 9/1/20 at 11:50 p.m. She concurred she was the circulating nurse for Endo suite #1 on 8/28/20. She stated, "I called ahead to the floor to see if patient had nothing by mouth (NPO) and signed a consent before procedure." She stated she spoke to the Nurse Manager and was told the nurse was busy. She stated she was put on hold while the Nurse Manager spoke to the nurse. She was told the patient was NPO but could not sign her consent. She stated they obtained a verbal consent from the next of kin listed on the medical record for patient #2 and they also called the second daughter because they were unsure who could give consent and verbal consent was given. She stated she did not check the arm band for proper identification of patient #1 when patient #1 said she was patient #2. She stated the scrub nurse had pulled the chart of patient #2 from slot 206 bed 3 at the nurse's station. She stated this was the correct chart for patient #2 but patient #1 was in 206 bed 3, not patient #2. Patient #2 had been moved to room 207 but her chart remained in slot 206 bed 3. She stated patient #1 was taken to Endo room 1. She stated she did her assessment, did the Time Out procedure and all agreed, but she did not identify patient #1 by her identification arm band. She stated after the procedure she went and called a report to the floor and she could hear the fright in their tone. She hung up and went and checked the patient. She stated she informed the other staff in Endo 1 this was the wrong patient.

6. A telephone interview was conducted with the scrub nurse on 9/1/20 at 12:02 p.m. When asked where the chart was located for patient #2 at the nurse's station, he stated it was in slot 206 bed 3.

7. A telephone interview was conducted with the CRNA on 9/1/20 at 12:29 p.m. She stated she did not do a pre-assessment on the wrong patient; the anesthesiologist did the pre-assessment on the right patient. She was told by the anesthesiologist the patient's potassium was low on the pre-op assessment. She had not seen the patient previously. She never saw the patient until she arrived in the endo suite. She stated the next of kin was notified and a verbal consent was given. She stated they got the surrogate's phone number from the electronic medical record. She stated her normal procedure, if she walks in a room with five (5) patients, she will verify the patient with their arm band to make sure it is the right patient. Endo patients are put in the room for her. She stated the patient was alert and talking when she arrived. They had the correct chart for patient #2 and drugs were pulled for patient #2. She stated when she spoke to patient #1 and said hi and asked her if she was patient #2, patient #1 said yes, she was patient #2. She stated she talked to patient #1, asked her if they would be looking into her belly and patient #1 said I guess so. She asked patient #1 what was going on and the patient said I haven't been feeling good. Patient #1 said she had nothing to eat or drink, said she was hungry. She stated she took it for granted it was the right person when she was handed the correct chart. She stated this will never happen again, never be brought a wrong patient. She concurred she did not check the arm band for identification of the patient before the surgical procedure.

8. A telephone interview was conducted with the Nurse Manager of the second floor on 9/1/20 at 1:05 p.m. She stated the primary care nurse and the Clinical Nurse Manager were in a patient's room doing a wound vac dressing when the OR called about the patient. She stated she spoke to the OR and told them, per the primary care nurse, the patient could not sign her consent for surgical procedure. She told them the number to the family was on the chart. She stated she was about to leave for the day when the nurse was talking to the Clinical Nurse Manager and then she went down the hall. The primary care nurse had a panicked look on her face and said seven (7) is still in her room. When she asked what was wrong she was told the wrong patient was taken to the OR. The Clinical Nurse Manager was calling the OR Manager. She stated it is her understanding there was an order for a scope on the patient in 206 bed 3. The OR staff pulled the chart for 206 bed 3. When informed the correct chart for patient #2 was still in slot 206 bed 3, she stated her expectations are when the patient moved to room 207 then her chart should have been moved to slot 207.

9. A review of the policy titled "OPERATING ROOM STANDARDS FOR PATIENTS UNDERGOING SURGERY, REVIEW DATE: 12/11/17 stated in part: "IV. Upon transportation the registered nurse will sign patient out to surgery, noting date, time, and mode of transportation verifying that chart is complete, and patient is ready for surgery. The nurse will give a verbal handoff to the person transporting. V. "TIME-OUT"- Team members will suspend activities, to the extent possible without compromising patient safety, to focus on the active confirmation of the correct patient, procedure, site and other critical elements of the procedure. 1. The O.R. Team, which consist of circulating nurse, anesthesia provider, physician performing the procedure and scrub nurse, will review the patient's medical record with the chart opened to the accurate procedure consent form, identification bracelet and will verbally confirm the correct patient ..."

10. A review of the policy titled "MEDICATIONS IN THE OPERATING ROOM, REVIEW DATE: 09/29/17 stated in part: "Any medication to be used on the operative field must be checked by a registered nurse to assure correct drug, dosage, patient, concentration, expiration date and allergies. The patient is identified using 2 patient identifiers (i.e. name and date of birth)."

11. A review of the policy titled "MEDICATION ADMINISTRATION, APPROVED: 7/29/2015 stated in part: "Basic safe practices for medication administration (in addition to scanning patient's wrist band bar code and medication bar code when applicable) require the following be confirmed prior to each administration of a medication: i. The patient's identity. Acceptable patient identifiers include: The patient's full name and date of birth. Identifiers should be confirmed by patient wrist band ..."

12. A review of the policy titled "COMPLETION OF PERI-ANESTHESIA RECORDS, REVIEW DATE: 12/29/13 stated in part: "A. All patients receiving anesthesia or sedation and analgesia care shall have a pre-anesthesia evaluation completed and documented by a practitioner ... lll. Completion of POST ANESTHESIA EVALUATION A. Inpatients receiving anesthesia or sedation and analgesia care shall have a post anesthesia evaluation completed and documented by a practitioner qualified to administer anesthesia, no later than 48 hours after surgery ..."

13. An interview was conducted with the CEO on 9/1/20 at 4:10 p.m. He concurred the staff failed to follow policies and procedures to ensure the correct patient was taken to the OR.

Based on review of documents, review of the medical record for patient #1 and staff interviews it was revealed the facility failed to ensure nursing care services was provided as per hospital policy (see Tag 392), failed to administer drugs and biologicals as per Federal and State law (see Tag 0405) and failed to ensure drugs were administered per physicians orders (see Tag 406).

Based on document review, review of the medical record and staff interviews it was revealed the nursing staff failed to provide care as per hospital policy. This failure was identified in one (1) of thirty (30) medical records reviewed (patient #1). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #1 revealed no documentation of a surgical procedure on 8/28/20. A request for documentation of the surgical procedure was made on entrance to the facility by the surveyor. An anesthesia report was obtained from the surgical department which was created by the Certified Registered Nurse Anesthetist (CRNA). The anesthesia report had a label for patient #2 located in the upper right corner of the report and a label for patient #1 located in the upper left corner of the same report. The surveyor was informed when the staff realized the wrong patient had been taken to the Endoscopy (Endo) suite, a label for patient #1 was put on the anesthesia report and the label for patient #2 was crossed out to signify it was the wrong patient label. The surgical procedure was ordered for patient #2, not patient #1.

2. An interview was conducted with Registered Nurse (RN) #1 on 9/1/20 at 11:00 a.m. in the Administration conference room. She stated, "I was working in Endo suite 2 on 8/28/20. I was in Endo 2 when the nurse from Endo 1 came out and got me and told me they did the wrong procedure on the wrong patient." She stated she told the RN from Endo 1 to talk to the floor nurse. She stated the floor nurse and the Nurse Manager from the floor came to the Endo suite before anyone notified the second floor staff. She stated, "The Nurse Manager asked what patient was in that room. I told her not the right patient."

3. An interview was conducted with RN #2 on 9/1/20 at 11:26 a.m. in the Administration conference room. She confirmed she was the primary nurse caring for patient #1 on 8/28/20. She stated she checked on patient #1 hourly because she was confused and falls when she gets up. She stated she went to her room around 3:30 p.m. to check on patient #1 but she was not there. She thought she may be down for a CT scan or something. She stated in part that a clerk contacted her on the walkie and told her that the Endo suite had called to give a report on Room 206, bed 3. She further stated that she went to talk to the clerk who was still talking to the Endo suite on the walkie, trying to tell them they had the wrong patient. She stated after she talked to the clerk she then went to room 206 bed 3 and then to room 207. She stated the patient was still in room 207 and she knew the patient was scheduled for an upper endoscopy (EGD). She confirmed patient #2 had been switched from bed 206 bed 3 to room 207. She stated once she figured out the wrong patient went to the OR, she spoke to her Nurse Manager. She was told to try and stop the procedure but she informed the Nurse Manager the OR was calling report to the floor. She stated they went to the Endo suite and talked to one (1) of the nurses and told them they had the wrong lady.

4. A telephone interview was conducted with the scrub nurse on 9/1/20 at 11:45 a.m. He stated he went to the floor to get the patient for a procedure in the Endo suite. He stated, "Went into room, asked if patient #2 and patient said yes." He confirmed no one looked at her arm band identification.

5. A telephone interview was conducted with RN #3 on 9/1/20 at 11:50 p.m. She concurred she was the circulating nurse for Endo suite #1 on 8/28/20. She stated, "I called ahead to the floor to see if patient had nothing by mouth (NPO) and signed a consent before procedure." She stated she spoke to the Nurse Manager and was told the nurse was busy. She stated she was put on hold while the Nurse Manager spoke to the nurse. She was told the patient was NPO but could not sign her consent. She stated they obtained a verbal consent from the next of kin listed on the medical record for patient #2 and they also called the second daughter because they were unsure who could give consent and verbal consent was given. She stated she did not check the arm band for proper identification of patient #1 when patient #1 said she was patient #2. She stated the scrub nurse had pulled the chart of patient #2 from slot 206 bed 3 at the nurse's station. She stated this was the correct chart for patient #2 but patient #1 was in 206 bed 3, not patient #2. Patient #2 had been moved to room 207 but her chart remained in slot 206 bed 3. She stated patient #1 was taken to Endo room 1. She stated she did her assessment, did the Time Out procedure and all agreed, but she did not identify patient #1 by her identification arm band. She stated after the procedure she went and called a report to the floor. She could hear the fright in their tone. She hung up and went and checked the patient. She stated she informed the other staff in Endo 1 this was the wrong patient.

6. A telephone interview was conducted with the CRNA on 9/1/20 at 12:29 p.m. She stated she never saw the patient until she arrived in the endo suite. Endo patients are put in the room for her. She stated the patient was alert and talking when she arrived. They had the correct chart for patient #2 and drugs were pulled for patient #2. She stated when she spoke to patient #1 and said hi and asked her if she was patient #2, patient #1 said yes, she was patient #2. She stated she talked to patient #1, asked her if they would be looking into her belly and patient #1 said I guess so. She asked patient #1 what was going on and the patient said I haven't been feeling good. Patient #1 said she had nothing to eat or drink, said she was hungry. She stated she took it for granted it was the right person when she was handed the correct chart. She concurred she did not check the arm band for identification of the patient before the procedure.

7. A telephone interview was conducted with the Nurse Manager of the second floor on 9/1/20 at 1:05 p.m. She stated the primary care nurse and the Clinical Nurse Manager were in a patient's room doing a wound vac dressing when the OR called about the patient. She stated she spoke to the OR and told them, per the primary care nurse, the patient could not sign her consent for surgical procedure. She told them the number to the family was on the chart. She stated she was about to leave for the day when the nurse was talking to the Clinical Nurse Manager and then she went down the hall. The primary care nurse had a panicked look on her face and said seven (7) is still in her room. When she asked what was wrong she was told the wrong patient was taken to the OR. The Clinical Nurse Manager was calling the OR Manager. She stated it is her understanding there was an order for a scope on the patient in 206 bed 3. The OR staff pulled the chart for 206 bed 3. When informed the correct chart for patient #2 was still in slot 206 bed 3, she stated her expectations are when the patient moved to room 207 then her chart should have been moved to slot 207.

8. A review of the policy titled "OPERATING ROOM STANDARDS FOR PATIENTS UNDERGOING SURGERY, REVIEW DATE: 12/11/17 stated in part: "IV. Upon transportation the registered nurse will sign patient out to surgery, noting date, time, and mode of transportation verifying that chart is complete, and patient is ready for surgery. The nurse will give a verbal handoff to the person transporting. V. "TIME-OUT"- Team members will suspend activities, to the extent possible without compromising patient safety, to focus on the active confirmation of the correct patient, procedure, site and other critical elements of the procedure. 1. The O.R. Team, which consist of circulating nurse, anesthesia provider, physician performing the procedure and scrub nurse, will review the patient's medical record with the chart opened to the accurate procedure consent form, identification bracelet and will verbally confirm the correct patient ..."

9. An interview was conducted with the CEO on 9/1/20 at 4:10 p.m. He concurred the staff failed to follow policies and procedures to ensure the correct patient was taken to the OR.

Based on document review, medical record review and staff interviews it was revealed the facility failed to ensure orders for drugs and biologicals were prepared and administered in accordance with Federal and State laws and per hospital policy. The facility failed to ensure orders for drugs and biologicals for the surgical procedure were ordered by the physician or other authorized provider and was a part of the patient's medical record. This failure was identified in one (1) of thirty (30) medical records reviewed (patient #1). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #1 revealed no documentation of a surgical procedure on 8/28/20. A request for documentation of the surgical procedure was made on entrance. An anesthesia report was obtained from the surgical department which was created by the Certified Registered Nurse Anesthetist (CRNA). The anesthesia report had a label for patient #2 located in the upper right corner of the report and a label for patient #1 located in the upper left corner of the same report. The surveyor was informed when the staff realized the wrong patient had been taken to the Endoscopy (Endo) suite, a label for patient #1 was put on the anesthesia report and the label for patient #2 was crossed out to signify it was the wrong patient label. The anesthesia report stated Propofol and Lidocaine were given during the surgical procedure to patient #1. No surgical procedure or medication for a surgical procedure was ordered for patient #1.

2. A review of the policy titled "MEDICATIONS IN THE OPERATING ROOM, REVIEW DATE: 09/29/17 stated in part: "Any medication to be used on the operative field must be checked by a registered nurse to assure correct drug, dosage, patient, concentration, expiration date and allergies. The patient is identified using 2 patient identifiers (i.e. name and date of birth)."

3. A review of the policy titled "Medication Administration, APPROVED: 7/29/2015 stated in part: "Basic safe practices for medication administration (in addition to scanning patient's wrist band bar code and medication bar code when applicable) require the following be confirmed prior to each administration of a medication: i. The patient's identity. Acceptable patient identifiers include: The patient's full name and date of birth. Identifiers should be confirmed by patient wrist band ..."

4. A telephone interview was conducted with the CRNA on 9/1/20 at 12:29 p.m. She stated drugs were pulled for patient #2. She concurred she did not check the arm band for identification of the patient before the surgical procedure.

Based on medical record review and staff interviews it was revealed the facility failed to ensure orders for drugs and biologicals for the surgical procedure were ordered by the physician or other authorized providers and was a part of the patient's medical record. This failure was identified in one (1) of thirty (30) medical records reviewed (patient #1). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #1 revealed no documentation of a surgical procedure on 8/28/20. A request for documentation of the surgical procedure was made on entrance to the facility by the surveyor. An anesthesia report was obtained from the surgical department which was created by the Certified Registered Nurse Anesthetist (CRNA). The anesthesia report had a label for patient #2 located in the upper right corner of the report and a label for patient #1 located in the upper left corner of the same report. The surveyor was informed when the staff realized the wrong patient had been taken to the Endoscopy (Endo) suite, a label for patient #1 was put on the anesthesia report and the label for patient #2 was crossed out to signify it was the wrong patient label. The anesthesia report stated Propofol and Lidocaine were given during the surgical procedure. No surgical procedure or medication for a surgical procedure was ordered for patient #1.

2. A telephone interview was conducted with the CRNA on 9/1/20 at 12:29 p.m. She stated drugs were pulled for patient #2. She concurred she did not check the arm band for identification of the patient before the surgical procedure.

Based on review of documents, review of the medical record for patient #1 and staff interviews it was revealed the facility failed to ensure surgical services were provided as per policy (see Tag 951); failed to have a proper informed consent for a surgical procedure (see Tag 955); and, failed to ensure the operating room register was complete and up to date (see Tag 958).

Based on medical record review and staff interviews it was revealed the facility failed to ensure surgical services were provided as per hospital policy. This failure was identified in one (1) of thirty (30) surgical records reviewed (patient #1). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #1 revealed no documentation of a surgical procedure order for patient #1 on 8/28/20. A request for documentation of the surgical procedure was made on entrance to the facility by the surveyor. An anesthesia report was obtained from the surgical department which was created by the Certified Registered Nurse Anesthetist (CRNA). The anesthesia report had a label for patient #2 located in the upper right corner of the report and a label for patient #1 located in the upper left corner of the same report. The surveyor was informed when the staff realized the wrong patient had been taken to the Endoscopy (Endo) suite, a label for patient #1 was put on the anesthesia report and the label for patient #2 was crossed out to signify it was the wrong patient label. The surgeon's report for the surgical procedure on patient #1 was completed on 9/1/20 after entrance was made at the facility by the surveyor. No order for a surgical procedure was ordered for patient #1. No pre and post-anesthesia assessment were noted in the medical record for patient #1. No intra-operative anesthesia report was noted in the medical record. No proper informed consent was noted in the medical record for the surgical procedure or anesthesia. No handoff documentation was noted in the medical record. No surgical procedure documentation was noted in the medical record. No pre-operative workup was noted in the medical record. Patient identification procedures were not followed as per policy.

2. An interview was conducted with Registered Nurse (RN) #1 on 9/1/20 at 11:00 a.m. in the Administration conference room. She stated, "I was working in Endo suite 2 on 8/28/20. I was in Endo 2 when the nurse from Endo 1 came out and got me and told me they did the wrong procedure on the wrong patient." She stated she told the RN from Endo 1 to talk to the floor nurse. She stated the floor nurse and the Nurse Manager from the floor came to the Endo suite before anyone notified the second floor staff. She stated, "The Nurse Manager asked what patient was in that room. I told her not the right patient." She noted she called the Operating Room (OR) Manager. The OR manager notified the Community Chief Regulatory Affairs Officer and called the Department of Health and Human Services (DHHR). She stated the RN from Endo suite 1 was too upset to talk to DHHR so she talked to DHHR. She stated there was a room change with the patient that the OR did not know about. She stated the transporters were the scrub nurse and the circulating nurse from Endo 1. She stated the correct patient had been moved from room 206 bed 3 to room 207. She stated she was told the transporters asked patient #1 if she was patient #2 and the patient said yes.

3. An interview was conducted with RN #2 on 9/1/20 at 11:26 a.m. in the Administration conference room. She confirmed she was the primary nurse caring for patient #1 on 8/28/20. She stated she checked on patient #1 hourly because she was confused and falls when she gets up. She stated she went to her room around 3:30 p.m. to check on patient #1 but she was not there. She thought she may be down for a CT scan or something. She stated in part that a clerk contacted her on the walkie and told her that the Endo suite had called to give a report on Room 206, bed 3. She further stated that she went to talk to the clerk who was still talking to the Endo suite on the walkie, trying to tell them they had the wrong patient. She stated after she talked to the clerk she then went to room 206 bed 3 and then to room 207. She stated the patient was still in room 207 and she knew the patient was scheduled for an upper endoscopy (EGD). She confirmed patient #2 had been switched from bed 206 bed 3 to room 207. She stated once she figured out the wrong patient went to the OR, she spoke to her Nurse Manager. She was told to try and stop the procedure but she informed the Nurse Manager the OR was calling report to the floor. She stated they went to the Endo suite and talked to one (1) of the nurses and told them they had the wrong lady. The Nurse Manager asked them about the Time Out procedure. The managers from the floor and the OR went to an office and talked. She stated when she was notified the OR staff was taking a patient to the OR she was unable to talk to them. She was doing a wound vac care. The Nurse Manager notified the OR the nurse was unavailable.

4. A telephone interview was conducted with the scrub nurse on 9/1/20 at 11:45 a.m. He stated he went to the floor to get the patient for a procedure in the Endo suite. He stated, "Went into room, asked if patient #2 and patient said yes." He confirmed no one looked at her arm band identification. He stated after he took the scope to the sink he was told it was the wrong patient.

5. A telephone interview was conducted with RN #3 on 9/1/20 at 11:50 p.m. She concurred she was the circulating nurse for Endo suite #1 on 8/28/20. She stated, "I called ahead to the floor to see if patient had nothing by mouth (NPO) and signed a consent before procedure." She stated she spoke to the Nurse Manager and was told the nurse was busy. She stated she was put on hold while the Nurse Manager spoke to the nurse. She was told the patient was NPO but could not sign her consent. She stated they obtained a verbal consent from the next of kin listed on the medical record for patient #2 and they also called the second daughter because they were unsure who could give consent and verbal consent was given. She stated she did not check the arm band for proper identification of patient #1 when patient #1 said she was patient #2. She stated the scrub nurse had pulled the chart of patient #2 from slot 206 bed 3 at the nurse's station. She stated this was the correct chart for patient #2 but patient #1 was in 206 bed 3 not patient #2. Patient #2 had been moved to room 207 but her chart remained in slot 206 bed 3. She stated patient #1 was taken to Endo room 1. She stated she did her assessment, did the Time Out procedure and all agreed but she did not identify patient #1 by her identification arm band. She stated after the procedure she went and called a report to the floor. She could hear the fright in their tone. She hung up and went and checked the patient. She stated she informed the other staff in Endo 1 this was the wrong patient.

6. A telephone interview was conducted with the CRNA on 9/1/20 at 12:29 p.m. She stated she did not do a pre-assessment on the wrong patient; the anesthesiologist did the pre-assessment on the right patient. She was told by the anesthesiologist the patient's potassium was low on the pre-op assessment. She had not seen the patient previously. She never saw the patient until she arrived in the endo suite. She stated the next of kin was notified and a verbal consent was given. She stated they got the surrogate's phone number from the electronic medical record. She stated her normal procedure, if she walks in a room with five (5) patients, she will verify the patient with their arm band to make sure it is the right patient. Endo patients are put in the room for her. She stated the patient was alert and talking when she arrived. They had the correct chart for patient #2 and drugs were pulled for patient #2. She stated when she spoke to patient #1 and said hi and asked her if she was patient #2, patient #1 said yes, she was patient #2. She stated she talked to patient #1, asked her if they would be looking into her belly and patient #1 said I guess so. She asked patient #1 what was going on and the patient said I haven't been feeling good. Patient #1 said she had nothing to eat or drink, said she was hungry. She stated she took it for granted it was the right person when she was handed the correct chart. She concurred she did not check the arm band for identification of the patient before the surgical procedure.

7. A telephone interview was conducted with the Nurse Manager of the second floor on 9/1/20 at 1:05 p.m. She stated the primary care nurse and the Clinical Nurse Manager were in a patient's room doing a wound vac dressing when the OR called about the patient. She stated she spoke to the OR and told them, per the primary care nurse, the patient could not sign her consent for surgical procedure. She told them the number to the family was on the chart. She stated she was about to leave for the day when the nurse was talking to the Clinical Nurse Manager and then she went down the hall. The primary care nurse had a panicked look on her face and said seven (7) is still in her room. When she asked what was wrong she was told the wrong patient was taken to the OR. The Clinical Nurse Manager was calling the OR Manager. She stated it is her understanding there was an order for a scope on the patient in 206 bed 3. The OR staff pulled the chart for 206 bed 3. When informed the correct chart for patient #2 was still in slot 206 bed 3, she stated her expectations are when the patient moved to room 207 then her chart should have been moved to slot 207.

8. A review of the policy titled "OPERATING ROOM STANDARDS FOR PATIENTS UNDERGOING SURGERY, REVIEW DATE: 12/11/17 stated in part: "IV. Upon transportation the registered nurse will sign patient out to surgery, noting date, time, and mode of transportation verifying that chart is complete, and patient is ready for surgery. The nurse will give a verbal handoff to the person transporting. V. "TIME-OUT"- Team members will suspend activities, to the extent possible without compromising patient safety, to focus on the active confirmation of the correct patient, procedure, site and other critical elements of the procedure. 1. The O.R. Team, which consist of circulating nurse, anesthesia provider, physician performing the procedure and scrub nurse, will review the patient's medical record with the chart opened to the accurate procedure consent form, identification bracelet and will verbally confirm the correct patient ..."

9. A review of the policy titled "COMPLETION OF PERI-ANESTHESIA RECORDS, REVIEW DATE: 12/29/13 stated in part: "A. All patients receiving anesthesia or sedation and analgesia care shall have a preanesthesia evaluation completed and documented by a practitioner ... lll. Completion of POST ANESTHESIA EVALUATION A. Inpatients receiving anesthesia or sedation and analgesia care shall have a post anesthesia evaluation completed and documented by a practitioner qualified to administer anesthesia, no later than 48 hours after surgery ..."

10. An interview was conducted with the CEO on 9/1/20 at 4:10 p.m. He concurred the staff failed to follow policies and procedures to ensure the correct patient was taken to the OR.

Based on medical record review and staff interviews it was revealed the facility failed to ensure a properly executed informed consent for the surgical procedure was obtained before the surgery. This failure was identified in one (1) of thirty (30) surgical records reviewed (patient #1). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #1 revealed no properly informed consent noted in the medical record for the surgical procedure on 8/28/20.

2. An interview was conducted with the CEO on 9/1/20 at 4:10 p.m. He concurred the staff failed to follow policies and procedures to ensure the correct patient was taken to the OR.

Based on review of a document and medical record review it was revealed the facility failed to ensure the operating room (OR) register was complete and up to date. This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the Anesthesia report for patient #1 revealed patient #1's surgical procedure started at 2:55 p.m. and stopped at 2:57 p.m.

2. A review of the OR register for 8/28/20 revealed patient #1 was not listed on the OR register.

3. An interview was conducted with the CEO on 9/1/20 at 4:10 p.m. He concurred the staff failed to follow policies and procedures.

Based on review of documents, review of the medical record for patient #1 and staff interviews it was revealed the facility failed to ensure anesthesia services provided a pre-anesthesia assessment as per policy (see Tag 1003) and failed to provide a post anesthesia assessment as per policy (see Tag 1005).

Based on document review, medical record review and staff interviews it was revealed anesthesia failed to complete a pre-anesthesia assessment evaluation within forty-eight (48) hours prior to the surgical procedure. This failure was identified in one (1) of thirty (30) medical records reviewed. This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #1 revealed no documentation of a surgical procedure order for patient #1 on 8/28/20. A request for documentation of the surgical procedure was made on entrance to the facility by the surveyor. An anesthesia report was obtained from the surgical department which was created by the Certified Registered Nurse Anesthetist (CRNA). The anesthesia report had a label for patient #2 located in the upper right corner of the report and a label for patient #1 located in the upper left corner of the same report. The surveyor was informed when the staff realized the wrong patient had been taken to the Endoscopy (Endo) suite, a label for patient #1 was put on the anesthesia report and the label for patient #2 was crossed out to signify it was the wrong patient label. The surgeon's report for the surgical procedure on patient #1 was completed on 9/1/20 after entrance was made at the facility by the surveyor. No pre and post-anesthesia assessment were noted in the medical record for patient #1.

2. A telephone interview was conducted with the CRNA on 9/1/20 at 12:29 p.m. She stated she did not do a pre-assessment on the wrong patient; the anesthesiologist did the pre-assessment on the right patient. She was told by the anesthesiologist the patient's potassium was low on the pre-op assessment. She had not seen the patient previously. She never saw the patient until she arrived in the endo suite. She stated the next of kin was notified and a verbal consent was given. She stated they got the surrogate's phone number from the electronic medical record. She stated her normal procedure, if she walks in a room with five (5) patients, she will verify the patient with their arm band to make sure it is the right patient. Endo patients are put in the room for her. She stated the patient was alert and talking when she arrived. They had the correct chart for patient #2 and drugs were pulled for patient #2. She stated when she spoke to patient #1 and said hi and asked her if she was patient #2, patient #1 said yes, she was patient #2. She stated she talked to patient #1, asked her if they would be looking into her belly and patient #1 said I guess so. She asked patient #1 what was going on and the patient said I haven't been feeling good. Patient #1 said she had nothing to eat or drink, said she was hungry. She stated she took it for granted it was the right person when she was handed the correct chart. She stated this will never happen again, never be brought a wrong patient. She concurred she did not check the arm band for identification of the patient before the surgical procedure.

3. A review of the policy titled "COMPLETION OF PERI-ANESTHESIA RECORDS, REVIEW DATE: 12/29/13 stated in part: "A. All patients receiving anesthesia or sedation and analgesia care shall have a preanesthesia evaluation completed and documented by a practitioner ... lll. Completion of POST ANESTHESIA EVALUATION A. Inpatients receiving anesthesia or sedation and analgesia care shall have a post anesthesia evaluation completed and documented by a practitioner qualified to administer anesthesia, no later than 48 hours after surgery ..."

4. An interview was conducted with the CEO on 9/1/20 at 4:10 p.m. He concurred the staff failed to follow policies and procedures to ensure the correct patient was taken to the OR.

Based on document review, medical record review and staff interviews it was revealed anesthesia failed to complete a post anesthesia assessment evaluation within forty-eight (48) hours after the surgical procedure. This failure was identified in one (1) of thirty (30) medical records reviewed. This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #1 revealed no documentation of a surgical procedure on 8/28/20 for patient #1. A request for documentation of the surgical procedure was made on entrance to the facility by the surveyor. An anesthesia report was obtained from the surgical department which was created by the Certified Registered Nurse Anesthetist (CRNA). The anesthesia report had a label for patient #2 located in the upper right corner of the report and a label for patient #1 located in the upper left corner of the same report. The surveyor was informed when the staff realized the wrong patient had been taken to the Endoscopy (Endo) suite, a label for patient #1 was put on the anesthesia report and the label for patient #2 was crossed out to signify it was the wrong patient label. No pre or post-anesthesia assessment was noted in the medical record for patient #1. The surgeon's report for the surgical procedure on patient #1 was completed on 9/1/20 after entrance was made at the facility. The Chief Executive Officer (CEO) stated the surgeon was unsure how to write the surgical report due to the wrong patient being taken to the Endo suite.

2. A telephone interview was conducted with the CRNA on 9/1/20 at 12:29 p.m. She stated she did not do a pre-assessment on the wrong patient; the anesthesiologist did the pre-assessment on the right patient. She was told by the anesthesiologist the patient's potassium was low on the pre-op assessment. She had not seen the patient previously. She never saw the patient until she arrived in the endo suite. She stated the next of kin was notified and a verbal consent was given. She stated they got the surrogate's phone number from the electronic medical record. She stated her normal procedure, if she walks in a room with five (5) patients, she will verify the patient with their arm band to make sure it is the right patient. Endo patients are put in the room for her. She stated the patient was alert and talking when she arrived. They had the correct chart for patient #2 and drugs were pulled for patient #2. She stated when she spoke to patient #1 and said hi and asked her if she was patient #2, patient #1 said yes, she was patient #2. She stated she talked to patient #1, asked her if they would be looking into her belly and patient #1 said I guess so. She asked patient #1 what was going on and the patient said I haven't been feeling good. Patient #1 said she had nothing to eat or drink, said she was hungry. She stated she took it for granted it was the right person when she was handed the correct chart. She stated this will never happen again, never be brought a wrong patient. She concurred she did not check the arm band for identification of the patient before the surgical procedure.

3. A review of the policy titled "COMPLETION OF PERI-ANESTHESIA RECORDS, REVIEW DATE: 12/29/13 stated in part: "A. All patients receiving anesthesia or sedation and analgesia care shall have a preanesthesia evaluation completed and documented by a practitioner ... lll. Completion of POST ANESTHESIA EVALUATION A. Inpatients receiving anesthesia or sedation and analgesia care shall have a post anesthesia evaluation completed and documented by a practitioner qualified to administer anesthesia, no later than 48 hours after surgery ..."

4. An interview was conducted with the CEO on 9/1/20 at 4:10 p.m. He concurred the staff failed to follow policies and procedures to ensure the correct patient was taken to the OR.