HospitalInspections.org

Based on interviews and documentation review the Hospital failed to ensure that the corrective action plan was fully implemented in a timely manner.

Findings included:

Review of medical record documentation indicated that in 2008 Patient #1 had gastric bypass surgery. On 10/29/10 Patient #1 had exploratory abdominal surgery and at that time an ovarian cyst was identified and measured as approximately 2 centimeters. There were no other findings. On 11/1/10 Patient #1 had a computerized tomography (CT) scan of the abdomen due to abdominal distention and there were no acute findings. On June, 2011 Patient #1 developed abdominal pain. A CT scan was done and identified an intussusception (telescoping of the bowel over itself, mostly occurs in pediatric patients). On 6/25/11 Patient #1 was brought to surgery to correct the intussusception. During the surgery a retained foreign object was found (a ruler).

The Surgeon who performed Patient #1 ' s surgeries was interviewed on 7/12/11 at 12:50 P.M. The Surgeon said a ruler was used during the 10/29/10 surgery to measure an ovarian cyst and to take pictures (provided by the Hospital) for a gynecological consult and he inadvertently left the ruler.

Observation of the type of ruler used in the OR indicated it was thin and flexible coated plastic approximately ? inch wide and 6 inches in length, came in a kit, and was not radio opaque.

The Surgeon said the ruler was seated on top of the liver, was not adhered to anything, was not near the intussusception, and was easily removed. The Surgeon said he disclosed the finding to Patient #1 and a family member and asked management in the OR if they could start including the ruler in counts.

Review documentation provided by the Hospital indicated on 6/27/11 an electronic mailing was sent requesting that rulers be included in counts. On 6/29/11 a staff meeting was held and indicated that counting rulers was discussed as well as asking surgeons to announce when an item was removed from the field and placed in the abdomen. Review of the Staff Meeting Minutes indicated there was no attendance taken. After the meeting an electronic mailing regarding counting rulers was sent out to a group of OR staff identified as assigned to the general surgery pod.

The Nursing Directors of the OR (Nursing Director #1 and Nursing Director #2) were interviewed in person throughout the survey as needed. Nursing Director #2 said rulers were counted by several of the surgery pods such as Neurology but not by everyone. Nursing Director #1 said since the meeting and electronic mail she has been checking with staff to ensure they were aware rulers were being counted. They said they were still trying to determine the best way to handle counting rulers.

There was no indication that surgeons had been informed of changes or that all OR staff was aware of the current requirement to count rulers.

Based on documentation review the Hospital failed to ensure that all documents scanned into the electronic medical record were appropriately scanned for 1 of 10 applicable patients (Patient #1).

Findings included:

During the survey of 7/12/11 if was determined the Hospital had not yet fully converted to an electronic medical record. Paper documentation was scanned into the electronic medical record system and then the paper documentation was destroyed.

During observation and review of Patient #4 ' s electronic medical record it was noted that the Nursing Operative Record dated 6/25/11 was not completely scanned into the system. The Nursing Operative Record was a 3 page document and page 2 contained documentation regarding counts, devices and specimens. Observation determined Page 2 was a blank sheet of paper.

Based on documentation review the Hospital failed to ensure that an operative report was completed by the surgeon immediately following surgery for 2 of 10 applicable patients (Patient #1 and Patient #4).

Findings included:

Review of Administrative policies regarding physician documentation indicated that the surgeon was required to complete a brief operative note immediately following surgery and before the patient was transferred to the next level of care. A dictated Operative Report was to be dictated and signed within 7 days of the procedure.

Review of medical records for Patients #1-10 indicated although a dictated Operative Report was completed within 7 days of the surgical procedure for 10 of 10 patients; a Brief Operative Note was not completed for Patient #1 following both the 10/29/10 and 6/25/11 surgical procedures and was not completed for Patient #4 following the surgical procedure on 6/22/11.