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Based on observation and interview, the facility failed to ensure expired medication-Promethazine 25 milligrams (mg)/milliliter (ml)-was not available for patient use on one of one Anesthesia Cart located in Surgery. The efficacy of expired medications could not be ensured and had the potential to affect all surgical patients to which they were administered. Findings follow:

A. On 03/01/17 at 0940, two ampules of Promethazine 25 mg/ml, expired 11/16, were observed on one of one Anesthesia Cart located in Surgery.
B. It was verified through interview with the Operating Room Manager on 03/01/17 at 0950 the two ampules of Promethazine 25 mg/ml were expired and available for patient use.


Based on observation, manufacturer medication label review, manufacturer medication package insert review, and interview, the facility failed to have a process in place to ensure Anectine, Succinylcholine and Rocuronium Bromide on one of one Anesthesia Cart in Surgery was stored according to manufacturer guidelines when stored at room temperature. The three medications were unusable since it could not be determined the length of time of storage at room temperature which could affect the efficacy of the medications. The potential existed to affect all surgical patients in which the medications were administered. Findings follow:

A. A tour of Surgery was conducted on 03/01/17 between 0920 and 0950. At 0940, the following medications were observed stored at room temperature on one of one Anesthesia Cart with no evidence as to length of time stored at room temperature:
1) One multiple dose vial (MDV) of Anectine 200 milligrams (mg)/10 milliliters (ml);
2) One MDV of Succinylcholine 200 mg/10 ml; and
3) Four MDV of Rocuronium Bromide 50 mg/5 ml.
B. The manufacturer medication label for Rocuronium Bromide was reviewed at 0945 on 03/01/17. It revealed once the medication was removed from refrigeration the unopened MDV could be stored for 60 days at room temperature and an opened vial for 30 days.
C. The manufacturer medication package insert for Anectine and Succinylcholine was reviewed on 03/01/17 at 1000. It revealed once Anectine and Succinylcholine were removed from refrigeration the medications could only be stored at room temperature for 14 days.
D. The Operating Room Manager was interviewed on 03/01/17 at 0950. It was verified the three medications had been removed from refrigeration and placed on the Anesthesia Cart in Surgery at room temperature. Through the same interview, it was verified there was no process to determine how long the medications had been stored at room temperature rendering the medications unusable.

Based on observations and interview, it was determined the facility failed to ensure only currently dated supplies were available for patient use in two (Medical Surgical Unit Clean Supply Room and Surgical Work Room) of three patient care areas (Medical Surgical Unit, Emergency Room and Surgical Services). Failure to ensure only currently dated supplies were available for use had the potential to affect the efficacy of patient care and treatment. The failed practice was likely to affect any patient whose care and treatment was rendered in the Medical Surgical Unit and Surgical Suite. Findings follow:

A. During the tour of the facility at 1000 on 02/28/17 the following expired items were observed: 1 of 2 Bard 350 ml (milliliter) Urine Meter drainage bag expired 01/2017; 10 of 10 12 Fr (French) Trocar Catheters expired 07/16; and 10 of 10 16 Fr Trocar Catheters expired 04/16. The above findings were verified in an interview with Registered Nurse at 1030 on 02/28/17.
B. During the tour of the Surgical Suite at 0915 on 03/01/17 the following expired items were observed: 7 of 7 boxes of Attest Rapid Readout BI (Biological Indicators) with 50 BI's per box, expired 10/2016; one of one Tracheotomy Tube inducer expired 04/2016. The above findings were verified in an interview with the Surgical Services Manager at 0950 on 03/31/17.

Based on policies and procedures review, clinical record review and interview, it was determined a Registered Nurse (RN) failed to supervise and evaluate the nursing care for eight of eight (#3-10) patients who underwent surgical procedures in that Admission RN Assessments, PACU (Post Anesthesia Care Unit) RN Assessments, Aldrete Scores and PACU Discharge Assessments were not performed. Failure to perform and document the above assessments did not ensure the patients were assessed as they moved through each stage of the operative process. The failed practice affected Patients #3-10. Findings follow:

A. Review of the policy and procedure titled "Patient Assessment" received from the Surgical Services Manager on 03/01/17 revealed the following:
"Purpose:
Every patient must have his/her needs assessed by an RN, and must be assessed for any/all changes in his/her care.
Policy:
As admission assessment will be completed on all patients that receive services in the department. A Pre-operative assessment will be performed by a RN for all patients. An Intra- Op site/side assessment will be performed and documented by the RN Circulating Nurse before entering the operating room. Upon completion of the operative process, an assessment is done during the nursing hand off to the PACU. Assessment during the patient's recovery is an on-going process. Documentation will occur according to interventions and/or a change in patient's condition. An assessment will be recorded immediately prior to discharge.
Procedure:
An admission assessment shall be completed by an RN within one hour of arrival time to the unit following the policy outlined in the Department of Nursing Assessment Policy. If the patient assessment was completed during a pre-surgical admission process, the information shall be verified, vital signs taken and documented.
The following documentation shall be completed and/or reviewed:
" Surgical Consent
" Preoperative Physician
" Preoperative Testing with results including Anesthesia Pre-operative orders, if applicable)
" A History and Physical (within one month of the scheduled procedure, 45 days for Cataract surgery) including an update if the patient is an outpatient.
" Current Medications

1. Assessment and documentation will be completed according to Pre-operative Pre Procedure Checklist Protocol (Peri-op Navigator).
2. The RN Circulating Nurse will review the information available, interview the patient, and assess for special needs in the operating room he/she will compete the Intra-op side/site portion electronically and/or on the down time forms if indicated.
3. The RN Circulating Nurse will document care provided in the operating room throughout the surgical procedure. An assessment of the patient condition will be ongoing and documented as indicated.
4. A complete assessment shall be performed on all patient entering recover areas.
5. Assessment of patients in the PACU setting is an on-going process. Documentation will occur as the patient's condition changes.
6. An assessment will occur immediately prior to discharge.
7. All patient assessment and documentation will be performed according to the Post Anesthesia Patient Management Protocol."
B. Review of the policy and procedure titled "Documentation in PACU) revealed under PROCEDURE, ...#5 the following; "The Aldrete Post Anesthesia Scoring System will be used to document patient assessment concerning respiratory response, neuromuscular movement and level of consciousness every 10 (10) minutes ..."
C. Review of Patient #3's clinical record revealed no Admission RN assessment, no RN assessment at PACU admission, no Aldrete scores every 10 minutes and no discharge assessment. The findings were verified in an interview with the Surgical Services Manager at 1019 on 03/02/17.
D. Review of Patient #4's clinical record revealed no Admission RN assessment, no RN assessment at PACU admission, no Aldrete scores every 10 minutes and no discharge assessment. The findings were verified in an interview with the Surgical Services Manager at 1022 on 03/02/17.
E. Review of Patient #5's clinical record revealed no Admission RN assessment, no RN assessment at PACU admission, no Aldrete scores every 10 minutes and no discharge assessment. The findings were verified in an interview with the Surgical Services Manager at 1016 on 03/02/17.
F. Review of Patient #6's clinical record revealed the RN assessment at PACU admission was not performed by a RN, no Aldrete scores every 10 minutes and the discharge assessment was not performed by a RN. The findings were verified in an interview with the Surgical Services Manager at 0945 on 03/02/17.
G. Review of Patient #7's clinical record revealed no RN assessment at PACU admission, no Aldrete scores every 10 minutes and no discharge assessment. The findings were verified in an interview with the Surgical Services Manager at 1010 on 03/02/17.
H. Review of Patient #8's clinical record revealed no RN assessment at PACU admission, no Aldrete scores every 10 minutes and the discharge assessment was not performed by a RN. The findings were verified in an interview with the Surgical Services Manager at 1034 on 03/02/2017.
I. Review of Patient #9's clinical record revealed no Admission RN assessment, no RN assessment at PACU admission and no Aldrete scores every 10 minutes. The findings were verified in an interview with the Surgical Services Manager at 1030 on 03/02/17.
J. Review of Patient #10's clinical record revealed no Aldrete scores every 10 minutes. The findings were verified in an interview with the Surgical Services Manager at 1025 on 03/02/17.

Based on clinical record review, Medical Staff Bylaws review, and interview, it was determined the facility failed to ensure a general consent for treatment was signed at the time of admission for 14 (#3-#7, #9-#11, #13, #15, #16, and #18-#20) of 21 (#1-#21) patients as stated in the Medical Staff Bylaws. The failed practice did not ensure patients had given consent before treatments were administered. Findings follow.

A. Review of Medical Staff Bylaws stated "A general consent form will be obtained at the time of admission."
B. Review of clinical records revealed the following:
1) Patient #3-admitted on 02/08/17. The consent was signed on 09/21/16.
2) Patient #4-admitted on 01/18/17. The consent was signed on 06/07/16.
3) Patient #5-admitted on 01/24/17. The consent was signed on 12/27/16.
4) Patient #6-admitted on 02/28/17. The consent was signed on 12/13/16.
5) Patient #7-admitted on 02/28/17. The consent was signed on 01/08/17.
6) Patient #9-admitted on 02/28/17. The consent was signed on 06/30/16.
7) Patient #10-admitted on 02/28/17. The consent was signed on 02/08/17.
8) Patient #11-admitted on 09/01/16. The consent was signed on 07/11/16.
9) Patient #13-admitted on 11/06/16. The consent was signed on 03/08/16.
10) Patient #15-admitted on 12/29/16. The consent was signed on 10/22/16.
11) Patient #16-admitted on 12/31/16. The consent was signed on 08/23/16.
12) Patient #18-admitted on 01/23/17. The consent was signed on 05/25/16.
13) Patient #19-admitted on 02/02/17. The consent was signed on 12/02/16.
14) Patient #20-admitted on 02/23/17. The consent was signed on 07/28/16.
C. During an interview on 03/02/17 at 1109, the Health Information Management Manager confirmed the consents were not signed on admission.

Based on review of policies and procedures, clinical record review and interview, it was determined the facility did not provide care in a safe manner in that a Registered Nurse (RN) was not immediately available to all PACU (Post Anesthesia Care Unit) patients in the event of an emergency to physically intervene and provide care for seven (#3-9) of eight (#3-10) surgical patients. Failure to ensure a RN was available to all PACU patients did not ensure a RN was immediately available for emergent situations and did not ensure patient assessments were performed by an RN per policy. Findings follow:

A. Review of the policy and procedure titled "Nursing Documentation Guidelines" received from the Clinical Nurse Manager at 1430 on 02/27/17 revealed the following under "Policy: ...Responsibilities of the RN include patient assessment, planning, delivery, teaching, and supervising care and reporting and recording the patient's responses to that care.
Responsibilities of the LPN (Licensed Practical Nurse) include making observations, reporting, teaching, recording nursing care, and the patient's responses to that care ...."
B. Review of the policy and procedure titled "Patient Assessment" received from the Surgical Services Manager on 03/01/17 revealed the following:
"Purpose:
Every patient must have his/her needs assessed by an RN, and must be assessed for any/all changes in his/her care.
Policy:
...Upon completion of the operative process, an assessment is done during the nursing hand off to the PACU. Assessment during the patient's recovery is an on-going process. Documentation will occur according to interventions and/or a change in patient's condition. An assessment will be recorded immediately prior to discharge ....
4. A complete assessment shall be performed on all patient entering recover areas.
5. Assessment of patients in the PACU setting is an on-going process. Documentation will occur as the patient's condition changes.
6. An assessment will occur immediately prior to discharge ..."
C. Review of the policy and procedure titled "Admission procedure to PACU" received from the Clinical Nurse Manager at 1430 on 02/27/17 revealed the following under "PROCEDURE: ...#5. Assess patient's condition, using the PACU unit scoring system, and record on the PACU record.
...Under Responsibility: ...All nurses assigned to the PACU must be able to correctly admit and assess post-operative patients."
D. Review of the policy and procedure titled "Moderate Sedation" received from the Clinical Nurse Manager at 1300 on 02/27/17 revealed the following under "REGISTERED NURSE: ... The RN will continually monitor the patient receiving moderate sedation and be free of any other responsibilities that would leave the patient unattended or compromise continuous monitoring ..."
E. Review of the clinical records of Patients #3, #4, #5, #7, #8 and #9 revealed no RN assessment at PACU admission. Review of Patient #6's clinical record revealed the PACU admission assessment was performed by LPN.
F. Review of the clinical records of Patients #3, #4, #5, and #7 revealed no RN assessment at PACU discharge. Review of Patient #6 and #8's clinical record revealed the assessment at PACU discharge was performed by LPN.
G. During an interview with the Surgical Services Manager at 1055 on 03/01/17, she stated all eyes (cataracts) and scopes (endoscopies and colonoscopies) was recovered by a LPN and any patient who received general anesthesia was recovered by a RN.
H. During an interview with the Director of Nursing at 1240 on 03/01/17, she stated "one RN, one LPN and one ST (scrub technician) were assigned to the OR (operating room) and some days a second RN from another facility was here."
I. During an interview with the Director of Nursing at 0900 on 03/02/17, she stated patients who received general anesthesia were recovered by a RN and LPNs will recover patients who didn't receive general anesthesia. The Director of Nursing stated if the RN was administering MAC (moderate anesthesia care) there was no RN available to the PACU patients.


Based on clinical record review and interview, it was determined the facility failed to provide surgical services in a safe manner in that the operatitive report did not include the pre-operative and post-operative diagnoses for six (#5-10) of eight (#3-10) surgical patients. Failure to include the pre-operative diagnosis and the post-operative diagnosis on the operative report did not ensure the final diagnosis based on surgical findings was recorded on the operative report. The failed practice affected Patients #5-10. Findings follow:

A. Review of the clinical records of Patients #5-10 revealed no pre-operative and post-operative diagnosis listed on the operative report.
B. During an interview with the Health Information Manager at 1133 on 03/02/17, she verified the findings in "A."

Based on clinical record review, Medical Staff Bylaws review, and interview, it was determined the facility failed to ensure a general consent for treatment was signed at the time of admission for one of one (Patient #1) Swing-Bed Patient as stated in the Medical Staff Bylaws. The failed practice did not ensure the patient had given consent before treatments were administered. Findings follow.

A. Review of Medical Staff Bylaws stated "A general consent form will be obtained at the time of admission."
B. Review of the clinical record of Swing-Bed Patient #1 revealed she was admitted to the facility on 02/13/17. A consent to treat was last signed on 10/25/16.
C. During an interview on 03/02/17 at 1109, the Health Information Management Manager confirmed the consent was not singed on admission.