HospitalInspections.org

Based on document review and interview, it was determined for 2 of 3 (Pt. #12 and #15) patient expirations, the Hospital failed to ensure a physician pronounced the patient death.

Findings include:

1. The Medical Staff "Rules and Regulations (revised 1/15)" required, "In the event of a Hospital death, the deceased will be pronounced dead by the attending physician or his/her designee within a reasonable time."

2. The clinical record of Pt. #12 was reviewed on 7/29/15. Pt. #12 was an 81 year old male admitted on 6/11/15 with the diagnosis of shortness of breath. Per the organ and tissue referral form, Pt. #12 died on 6/11/15 at 3:45 PM. The discharge summary dated 6/13/15 at 12:49 PM included, "A discussion was held with with the patient's son and brother about the very dismal prognosis in this case, and they were amenable to comfort care. Within a few hours of removing aggressive support, the patient died comfortably." The clinical record lacked documentation of physician pronouncement of death.

3. The clinical record of Pt. #15 was reviewed on 7/29/15. Pt. #15 was an 83 year old male admitted on 4/12/15 with the diagnosis of generalized weakness. Per the organ and tissue referral form, Pt. #12 died on 4/14/15 at 7:12 AM. The nurses note dated the same included, "Called out of report to check patient. Patient in bed with no breathing, no pulse, asystole (no pulse) on cardiac monitor. Contacted doctor at this time." The clinical record lacked documentation of physician pronouncement of death.

4. During an interview on 7/30/15 at 9:10 AM, the Director of Nursing (E#2) stated there are inconsistencies with death documentation and would have expected to see a physician note regarding pronouncing death.

Based on document review and interview, it was determined, for 3 of 3 pain medications administered in the intensive care unit (ICU), the hospital failed to ensure the patient's pain level was assessed after the pain medication was administered.

Findings include:

1. On 7/28/15 at 9:00 AM, hospital policy titled, "Practice Guidelines for Pain", revised 8/11, was reviewed. The policy required, "3. The patient will be reassessed at least once per shift and after every pain control modality used."

2. On 7/27/15 at 10:50 AM, Pt. #2's clinical record was reviewed. Pt. #2 was a 98 year old female, admitted on 7/24/15, with diagnoses of dementia, urinary tract infection, and hypertension. Pt. #2's medication administration record included morphine was given for pain relief on 7/26/15 at 9:00 PM, 7/26/15 at 11:13 PM, and 7/27/15 at 1:04 AM. The clinical record lacked documentation of pain reassessments after medication was given.

3. On 7/27/15 at 11:00 AM, an interview was conducted with the ICU director (E #10). E #10 stated she could not find pain reassessment documentation for Pt. #2 for these 3 dates and times.

Based on document review and interview, it was determined for 2 of 2 (Pt. #3 and #4) patients on the 4th floor medical surgical unit, the Hospital failed to ensure nursing interventions to meet expected outcomes were included in the plan of care.

Findings include:

1. Hospital policy titled, "Plan for Provision of Nursing Care (revised 9/09)" required, "Evaluating response to nursing interventions and redirecting of the plan of care based on these findings."

2. The clinical record of Pt. #3 was reviewed on 7/27/15. Pt. #3 was a 60 year old female admitted on 7/19/15 with the diagnosis of aspiration pneumonia. The plan of care dated 7/19/15 included a list of problems and a list of expected outcomes; however, lacked any nursing interventions.

3. The clinical record of Pt. #4 was reviewed on 7/27/15. Pt. #4 was a 75 year old female admitted on 7/24/15 with the diagnoses of dehydration and depression. The plan of care dated 7/24/15 included a list of problems and a list of expected outcomes; however, lacked any nursing interventions.

4. During an interview on 7/27/15 at approximately 10:30 AM, the Director of Medical
Surgical Services (E#5) stated, "We had a computer upgrade a week ago. This must be a glitch in the system. There should be nursing interventions."

Based on document review and staff interview, it was determined for one of one Medical Records Department, the Hospital failed to ensure medical records were completed within 30 days after discharge.

Findings include:

1. The Hospital's "Medical Staff Bylaws and Rules and Regulations" (Revised 1/1/15) was reviewed and included, " ...a delinquent medical record is defined as: any medical record that does not contain all appropriate physician documentation within 30 days after discharge/date of service...or physican documentation that is not signed where indicated with 30 days after discharge/date of service..."

2. On 7/29/15 at approximately 11:55 AM, the Hospital's Director of Health Information Management Service (E#13) presented a letter of attestation dated 7/29/15 which included the Hospital had a total of 42 delinquent records past 30 days.

3. On 7/29/15 at approximately 9:30 AM during an interview, E #13 stated medical records are considered delinquent if not completed within 30 days following a patient's discharge.

Based on observation, document review and interview, it was determined for 1 of 2 (4 West) medication rooms on the 4th floor, the Hospital failed to ensure medications were securely locked, potentially affecting the safety of the 13 patients on census.

Findings include:

1. An observational tour of the 4th floor medical surgical unit was conducted on 7/27/15 at 10:00 AM. the nurses station on the west side of the unit was unattended. The door to the nurses station was open and there was no door to the medication room which contained a pyxis machine containing narcotics.

2. Hospital policy titled, "Inventory Control - Security of Medication Storage areas (revised 8/14)" required, All medication storage areas located throughout the facility shall be locked."

3. During an interview on 7/27/15 at approximately 10:30 AM, the Director of Medical Surgical Services (E#5) stated there was no door on the medication room, but was not sure why.

Based on direct observations during the survey walk-through, staff interviews and document reviews during a Non-Accredited Hospital Federal Re-Certification Survey conducted on July 27-28, 2015 the surveyor finds that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on direct observations during the survey walk-through, staff interviews and document reviews during a Non-Accredited Hospital Federal Re-Certification Survey conducted on July 27-28, 2015 the surveyor finds that the facility does not comply with the applicable provisions of the 2000 edition of NFPA 101 Life Safety Code.

See the life safety code deficiencies identified with K-tags on the CMS form 2567, dated July 28, 2015.

A. Based on document review, observation and interview, it was determined for 1 of 2 medication carts (4 west cart) on the 4th floor, the Hospital failed to ensure the cart was locked, potentially affecting the 13 patients on census.

Findings include:

1. Hospital policy titled, "Quality Control - Patient Medication Cart (revised 11/14)" required, "The distributed cart shall be placed in a secure area of the patient care unit, with contents locked and/or under direct supervision of nursing personnel at all times."

2. An observational tour of the 4th floor medical surgical unit was conducted on 7/27/15 at 10:00 AM. the nurses station on the west side of the unit was unattended. The door to the nurses station was open and there was no door to the medication room. A medication cart was located in the medication room. The top drawer containing syringes with needles attached was unlocked and accessible.

3. During an interview on 7/27/15 at approximately 10:30 AM, the Director of Medical Surgical Services (E#5) stated the drawer should have been locked.

B. Based on document review, observation and interview, it was determined for 2 of 3 nursing areas (4th floor and emergency room), the Hospital failed to ensure crash carts were checked per policy, potentially affecting all patients on census.

Findings include:

1. Hospital policy titled, "Cardiopulmonary Resuscitation (revised 6/11)" required, "Restocking and Maintenance of crash carts: The unit crash carts are to be opened each shift and checked for proper supplies,... The crash cart checklist is initialed that drugs/supplies are present or the safety control seal is intact. ... All crash carts are checked monthly for supply outdates."

2. An observational tour of the 4th floor medical surgical unit was conducted on 7/27/15 at 10:00 AM. The crash cart checklist was reviewed and the following shift checks were missing: July 2015: 7-11 shift: 25th and 26th; 3-11 shift: 1st, 2nd, 3rd, 5th,17th, 22nd and 23rd.

3. On 7/27/15 at 1:35 PM, an observational tour was conducted in the ED. There were 4 ED crash cart logs used for monthly checking of crash cart contents. All 4 logs had not been completed for the month of March 2015. In addition, one of the logs, for a pediatric crash cart, had it had not been completed for October or December 2014.

4. During an interview on 7/27/15 at approximately 10:30 AM, the Director of Medical Surgical Services (E#5) stated the checklist should have been completed every shift.

5. On 7/27/15 at 2:45 PM, an interview was conducted with the ED director (E #3). E #3 stated she did not know why the crash cart log had not been completed in March.

C. Based on document review, observation and interview it was determined for 2 of 2 glucomter control solutions, the hospital failed to ensure that outdated materials were not available for use.

Findings include:

1. On 7/27/15 at approximately 10:30 AM an obsevational tour was conducted on the behavioral health unit.

2. During the tour on 7/27/15 at approximately 10:30 AM, the glucometer and the solutions used to check glucometer accuracy were observed. The Accu-Chek Inform II high range/low range control solution was dated as follows: open date: 4/25/15; expired: 7/25/15.

3 . 7/28/15 the hospital's policy titled "Roche Accu-Chek Inform II(Gloucose Waive System)" (revised 5/7/15) was reviewed and required ...2.b. Controls are stable for 3 months from the date opened or until the "use by" date on the bottle label, whichever comes first..."

4. On 7/27/15 at approximately 10:30 PM, these finding were verified by the Director of Psychiatric Nursing (E #4). E #4 agreed the outdated solution had been used on 7/27/15 to check the glucometer.

A. Based on document review, observational tour, and interview, it was determined, for 2 of 2 staff (E #7 & 8) opening sterile instruments and supplies in operating room (OR) 1, the hospital failed to ensure staff adherence to OR policies and guidelines.

Findings include:

1. On 7/28/15 at 1:00 PM, the Association of Perioperative Registered Nurses (AORN) 2015 edition Guidelines for Perioperative Practice was reviewed. The Guidelines' chapter on Sterile Technique included, "Recommended VI. Items introduced to the sterile field should be opened, dispensed, and transferred by methods that maintain the sterility and integrity of the item and the sterile filed... VI.b. Items should be delivered to the sterile field in a manner that prevents unsterile objects or unscrubbed team members from leaning or reaching over the sterile field. Microorganisms are shed from the skin of perioperative personnel..."

2. On 7/28/15 at 9:30 AM, an observational tour was conducted in the OR. At 10:45 AM, in OR 1, a registered nurse (E #7) and a scrub assistant (E #8) were opening sterile instruments and supplies onto the sterile field of the back table. Both nurses placed their ungloved hands and arms over the sterile field while dropping sterile instruments and supplies on the sterile field.

3. On 7/28/15 at 10:50 AM, an interview was conducted with E #7. E #7 stated she flipped the supplies on the sterile field and was not aware her hands and arms were over the sterile field.

4. On 7/28/15 at approximately 11:30 AM, the Senior Director of Surgical and Cardiovascular Services (E #11) was informed of the findings and stated hands and arms should not be over the sterile field.


B. Based on document review, observational tour, and interview, it was determined, for 2 of 2 open and recapped sterile fluid bottles, the hospital failed to ensure sterile fluid bottles were emptied and not recapped, to reduce the potential for contamination of the fluid.

Findings include:

1. On 7/28/15 at 1:00 PM, the Association of Perioperative Registered Nurses (AORN) 2015 edition Guidelines for Perioperative Practice was reviewed. The Guidelines' chapter on Sterile Technique included, "Recommended VI. Items introduced to the sterile field should be opened, dispensed, and transferred by methods that maintain the sterility and integrity of the item and the sterile filed... VI.g.3. "When solutions are dispensed to the sterile field, the entire contents of the container should be poured... VI.g.5. The cap should not be replaced on opened medication or solution containers and any remaining fluids should be discarded."

2. On 7/28/15 at 9:30 AM, an observational tour was conducted in OR. At 10:00 AM, in OR 3, an opened, recapped 1000 ml bottle of normal saline with approximately 550 ml of fluid remaining had been placed on the back counter.

3. On 7/28/15 at 10:10 AM, in the area between suite 1 & 2, an opened, recapped 1000 ml bottle of sterile water with approximately 400 ml of fluid remaining had been returned to the fluid warmer.

4. On 7/28/15 at 10:15 AM, an interview was conducted with OR manager E #12. E #12 stated the OR follows AORN guidelines and the water bottles are emptied after the case ends.

5. On 7/28/15 at approximately 11:30 AM, the Senior Director of Surgical and Cardiovascular Services (E #11) stated the fluids should not be recapped.


C. Based on document review and interview, it was determined, for 1 of 1 flash sterilizer, the hospital failed to ensure biological indicator results were recorded.

Findings include:

1. On 7/29/16 at 9:00 AM, hospital policy titled, "Spore Testing / Use of Flash Sterilizer", revised on 2/08, was reviewed. The policy required, "7. Record [flash sterilizer biological indicator] results in daily Sterilization Record Form."

2. On 7/28/15 at 9:30 AM, an observational tour was conducted in OR. At 10:10 AM, the flash sterilizer log, between 11/4/14 and 7/27/15, was reviewed. The biological indicator test results were not documented on the log.

3. On 7/28/15 at 10:15 AM, an interview was conducted with OR manager E #12. E #12 stated the OR follows AORN guidelines and agreed that the biological indicator test results had not been completed.

4. On 7/28/15 at approximately 11:30 AM, the Senior Director of Surgical and Cardiovascular Services (E #11) was informed of the findings.

Based on document review and interview, it was determined for 2 of 3 (Pt. #12 and #15) patient expirations, the Hospital failed to ensure a physician pronounced the patient death.

Findings include:

1. The Medical Staff "Rules and Regulations (revised 1/15)" required, "In the event of a Hospital death, the deceased will be pronounced dead by the attending physician or his/her designee within a reasonable time."

2. The clinical record of Pt. #12 was reviewed on 7/29/15. Pt. #12 was an 81 year old male admitted on 6/11/15 with the diagnosis of shortness of breath. Per the organ and tissue referral form, Pt. #12 died on 6/11/15 at 3:45 PM. The discharge summary dated 6/13/15 at 12:49 PM included, "A discussion was held with with the patient's son and brother about the very dismal prognosis in this case, and they were amenable to comfort care. Within a few hours of removing aggressive support, the patient died comfortably." The clinical record lacked documentation of physician pronouncement of death.

3. The clinical record of Pt. #15 was reviewed on 7/29/15. Pt. #15 was an 83 year old male admitted on 4/12/15 with the diagnosis of generalized weakness. Per the organ and tissue referral form, Pt. #12 died on 4/14/15 at 7:12 AM. The nurses note dated the same included, "Called out of report to check patient. Patient in bed with no breathing, no pulse, asystole (no pulse) on cardiac monitor. Contacted doctor at this time." The clinical record lacked documentation of physician pronouncement of death.

4. During an interview on 7/30/15 at 9:10 AM, the Director of Nursing (E#2) stated there are inconsistencies with death documentation and would have expected to see a physician note regarding pronouncing death.

Based on document review and interview, it was determined, for 3 of 3 pain medications administered in the intensive care unit (ICU), the hospital failed to ensure the patient's pain level was assessed after the pain medication was administered.

Findings include:

1. On 7/28/15 at 9:00 AM, hospital policy titled, "Practice Guidelines for Pain", revised 8/11, was reviewed. The policy required, "3. The patient will be reassessed at least once per shift and after every pain control modality used."

2. On 7/27/15 at 10:50 AM, Pt. #2's clinical record was reviewed. Pt. #2 was a 98 year old female, admitted on 7/24/15, with diagnoses of dementia, urinary tract infection, and hypertension. Pt. #2's medication administration record included morphine was given for pain relief on 7/26/15 at 9:00 PM, 7/26/15 at 11:13 PM, and 7/27/15 at 1:04 AM. The clinical record lacked documentation of pain reassessments after medication was given.

3. On 7/27/15 at 11:00 AM, an interview was conducted with the ICU director (E #10). E #10 stated she could not find pain reassessment documentation for Pt. #2 for these 3 dates and times.

Based on document review and interview, it was determined for 2 of 2 (Pt. #3 and #4) patients on the 4th floor medical surgical unit, the Hospital failed to ensure nursing interventions to meet expected outcomes were included in the plan of care.

Findings include:

1. Hospital policy titled, "Plan for Provision of Nursing Care (revised 9/09)" required, "Evaluating response to nursing interventions and redirecting of the plan of care based on these findings."

2. The clinical record of Pt. #3 was reviewed on 7/27/15. Pt. #3 was a 60 year old female admitted on 7/19/15 with the diagnosis of aspiration pneumonia. The plan of care dated 7/19/15 included a list of problems and a list of expected outcomes; however, lacked any nursing interventions.

3. The clinical record of Pt. #4 was reviewed on 7/27/15. Pt. #4 was a 75 year old female admitted on 7/24/15 with the diagnoses of dehydration and depression. The plan of care dated 7/24/15 included a list of problems and a list of expected outcomes; however, lacked any nursing interventions.

4. During an interview on 7/27/15 at approximately 10:30 AM, the Director of Medical
Surgical Services (E#5) stated, "We had a computer upgrade a week ago. This must be a glitch in the system. There should be nursing interventions."

Based on document review and staff interview, it was determined for one of one Medical Records Department, the Hospital failed to ensure medical records were completed within 30 days after discharge.

Findings include:

1. The Hospital's "Medical Staff Bylaws and Rules and Regulations" (Revised 1/1/15) was reviewed and included, " ...a delinquent medical record is defined as: any medical record that does not contain all appropriate physician documentation within 30 days after discharge/date of service...or physican documentation that is not signed where indicated with 30 days after discharge/date of service..."

2. On 7/29/15 at approximately 11:55 AM, the Hospital's Director of Health Information Management Service (E#13) presented a letter of attestation dated 7/29/15 which included the Hospital had a total of 42 delinquent records past 30 days.

3. On 7/29/15 at approximately 9:30 AM during an interview, E #13 stated medical records are considered delinquent if not completed within 30 days following a patient's discharge.

Based on observation, document review and interview, it was determined for 1 of 2 (4 West) medication rooms on the 4th floor, the Hospital failed to ensure medications were securely locked, potentially affecting the safety of the 13 patients on census.

Findings include:

1. An observational tour of the 4th floor medical surgical unit was conducted on 7/27/15 at 10:00 AM. the nurses station on the west side of the unit was unattended. The door to the nurses station was open and there was no door to the medication room which contained a pyxis machine containing narcotics.

2. Hospital policy titled, "Inventory Control - Security of Medication Storage areas (revised 8/14)" required, All medication storage areas located throughout the facility shall be locked."

3. During an interview on 7/27/15 at approximately 10:30 AM, the Director of Medical Surgical Services (E#5) stated there was no door on the medication room, but was not sure why.

Based on direct observations during the survey walk-through, staff interviews and document reviews during a Non-Accredited Hospital Federal Re-Certification Survey conducted on July 27-28, 2015 the surveyor finds that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on direct observations during the survey walk-through, staff interviews and document reviews during a Non-Accredited Hospital Federal Re-Certification Survey conducted on July 27-28, 2015 the surveyor finds that the facility does not comply with the applicable provisions of the 2000 edition of NFPA 101 Life Safety Code.

See the life safety code deficiencies identified with K-tags on the CMS form 2567, dated July 28, 2015.

A. Based on document review, observation and interview, it was determined for 1 of 2 medication carts (4 west cart) on the 4th floor, the Hospital failed to ensure the cart was locked, potentially affecting the 13 patients on census.

Findings include:

1. Hospital policy titled, "Quality Control - Patient Medication Cart (revised 11/14)" required, "The distributed cart shall be placed in a secure area of the patient care unit, with contents locked and/or under direct supervision of nursing personnel at all times."

2. An observational tour of the 4th floor medical surgical unit was conducted on 7/27/15 at 10:00 AM. the nurses station on the west side of the unit was unattended. The door to the nurses station was open and there was no door to the medication room. A medication cart was located in the medication room. The top drawer containing syringes with needles attached was unlocked and accessible.

3. During an interview on 7/27/15 at approximately 10:30 AM, the Director of Medical Surgical Services (E#5) stated the drawer should have been locked.

B. Based on document review, observation and interview, it was determined for 2 of 3 nursing areas (4th floor and emergency room), the Hospital failed to ensure crash carts were checked per policy, potentially affecting all patients on census.

Findings include:

1. Hospital policy titled, "Cardiopulmonary Resuscitation (revised 6/11)" required, "Restocking and Maintenance of crash carts: The unit crash carts are to be opened each shift and checked for proper supplies,... The crash cart checklist is initialed that drugs/supplies are present or the safety control seal is intact. ... All crash carts are checked monthly for supply outdates."

2. An observational tour of the 4th floor medical surgical unit was conducted on 7/27/15 at 10:00 AM. The crash cart checklist was reviewed and the following shift checks were missing: July 2015: 7-11 shift: 25th and 26th; 3-11 shift: 1st, 2nd, 3rd, 5th,17th, 22nd and 23rd.

3. On 7/27/15 at 1:35 PM, an observational tour was conducted in the ED. There were 4 ED crash cart logs used for monthly checking of crash cart contents. All 4 logs had not been completed for the month of March 2015. In addition, one of the logs, for a pediatric crash cart, had it had not been completed for October or December 2014.

4. During an interview on 7/27/15 at approximately 10:30 AM, the Director of Medical Surgical Services (E#5) stated the checklist should have been completed every shift.

5. On 7/27/15 at 2:45 PM, an interview was conducted with the ED director (E #3). E #3 stated she did not know why the crash cart log had not been completed in March.

C. Based on document review, observation and interview it was determined for 2 of 2 glucomter control solutions, the hospital failed to ensure that outdated materials were not available for use.

Findings include:

1. On 7/27/15 at approximately 10:30 AM an obsevational tour was conducted on the behavioral health unit.

2. During the tour on 7/27/15 at approximately 10:30 AM, the glucometer and the solutions used to check glucometer accuracy were observed. The Accu-Chek Inform II high range/low range control solution was dated as follows: open date: 4/25/15; expired: 7/25/15.

3 . 7/28/15 the hospital's policy titled "Roche Accu-Chek Inform II(Gloucose Waive System)" (revised 5/7/15) was reviewed and required ...2.b. Controls are stable for 3 months from the date opened or until the "use by" date on the bottle label, whichever comes first..."

4. On 7/27/15 at approximately 10:30 PM, these finding were verified by the Director of Psychiatric Nursing (E #4). E #4 agreed the outdated solution had been used on 7/27/15 to check the glucometer.

A. Based on document review, observational tour, and interview, it was determined, for 2 of 2 staff (E #7 & 8) opening sterile instruments and supplies in operating room (OR) 1, the hospital failed to ensure staff adherence to OR policies and guidelines.

Findings include:

1. On 7/28/15 at 1:00 PM, the Association of Perioperative Registered Nurses (AORN) 2015 edition Guidelines for Perioperative Practice was reviewed. The Guidelines' chapter on Sterile Technique included, "Recommended VI. Items introduced to the sterile field should be opened, dispensed, and transferred by methods that maintain the sterility and integrity of the item and the sterile filed... VI.b. Items should be delivered to the sterile field in a manner that prevents unsterile objects or unscrubbed team members from leaning or reaching over the sterile field. Microorganisms are shed from the skin of perioperative personnel..."

2. On 7/28/15 at 9:30 AM, an observational tour was conducted in the OR. At 10:45 AM, in OR 1, a registered nurse (E #7) and a scrub assistant (E #8) were opening sterile instruments and supplies onto the sterile field of the back table. Both nurses placed their ungloved hands and arms over the sterile field while dropping sterile instruments and supplies on the sterile field.

3. On 7/28/15 at 10:50 AM, an interview was conducted with E #7. E #7 stated she flipped the supplies on the sterile field and was not aware her hands and arms were over the sterile field.

4. On 7/28/15 at approximately 11:30 AM, the Senior Director of Surgical and Cardiovascular Services (E #11) was informed of the findings and stated hands and arms should not be over the sterile field.


B. Based on document review, observational tour, and interview, it was determined, for 2 of 2 open and recapped sterile fluid bottles, the hospital failed to ensure sterile fluid bottles were emptied and not recapped, to reduce the potential for contamination of the fluid.

Findings include:

1. On 7/28/15 at 1:00 PM, the Association of Perioperative Registered Nurses (AORN) 2015 edition Guidelines for Perioperative Practice was reviewed. The Guidelines' chapter on Sterile Technique included, "Recommended VI. Items introduced to the sterile field should be opened, dispensed, and transferred by methods that maintain the sterility and integrity of the item and the sterile filed... VI.g.3. "When solutions are dispensed to the sterile field, the entire contents of the container should be poured... VI.g.5. The cap should not be replaced on opened medication or solution containers and any remaining fluids should be discarded."

2. On 7/28/15 at 9:30 AM, an observational tour was conducted in OR. At 10:00 AM, in OR 3, an opened, recapped 1000 ml bottle of normal saline with approximately 550 ml of fluid remaining had been placed on the back counter.

3. On 7/28/15 at 10:10 AM, in the area between suite 1 & 2, an opened, recapped 1000 ml bottle of sterile water with approximately 400 ml of fluid remaining had been returned to the fluid warmer.

4. On 7/28/15 at 10:15 AM, an interview was conducted with OR manager E #12. E #12 stated the OR follows AORN guidelines and the water bottles are emptied after the case ends.

5. On 7/28/15 at approximately 11:30 AM, the Senior Director of Surgical and Cardiovascular Services (E #11) stated the fluids should not be recapped.


C. Based on document review and interview, it was determined, for 1 of 1 flash sterilizer, the hospital failed to ensure biological indicator results were recorded.

Findings include:

1. On 7/29/16 at 9:00 AM, hospital policy titled, "Spore Testing / Use of Flash Sterilizer", revised on 2/08, was reviewed. The policy required, "7. Record [flash sterilizer biological indicator] results in daily Sterilization Record Form."

2. On 7/28/15 at 9:30 AM, an observational tour was conducted in OR. At 10:10 AM, the flash sterilizer log, between 11/4/14 and 7/27/15, was reviewed. The biological indicator test results were not documented on the log.

3. On 7/28/15 at 10:15 AM, an interview was conducted with OR manager E #12. E #12 stated the OR follows AORN guidelines and agreed that the biological indicator test results had not been completed.

4. On 7/28/15 at approximately 11:30 AM, the Senior Director of Surgical and Cardiovascular Services (E #11) was informed of the findings.