HospitalInspections.org

Based on observation and interview, the CAH (Critical Access Hospital) failed to ensure the ManoScan 360 (motility visualization system) was on a preventive maintenance program. This practice had the potential to effect all patients who required such test.

Findings include:

During tour of the surgical department with the director of surgical services (DSS) on 2/5/13, at 1:10 p.m. the ManoScan machine was observed to lack identification of an equipment function check by the maintenance/biomed department. At this time the DSS verified the lack of a preventative maintenance check sticker.

On 2/6/13, at approximately 1:00 p.m. the DSS verified the ManoScan machine had not been checked for function or safety, nor added to the facility's routine preventative maintenance check list.

Based on staff interview and document review, the Critical Access Hospital (CAH) failed to follow facility policy in regard to documenting dry status of alcohol based skin preparations prior to drape for 2 of 2 surgical patient procedures (P1, P2) observed.

Findings include:

The facility policy for Surgical Skin Preps identified the following procedure: "Do not allow the prep solution to pool around or underneath the patient or under any equipment on the patient , i.e., electrodes, electrosurgical unit grounding pad. Allow prep solutions ample contact time before applying the sterile drapes. This helps achieves optimal effect of prep solution. If using flammable antiseptic prep solutions, allow time for complete evaporation of solution before beginning surgery, to decrease the risk of fire. Document the preoperative skin preparation on the operative nursing note, noting the area prepped and the antimicrobial agents used."

During observation of surgery for P1 and P2 on 2/7/13, alcohol based skin preparation (Chloraprep" which is 70% alcohol) was utilized.

P1 surgery was observed on 2/7/13, at 9:20 a.m., and Chloraprep was used for cleaning the skin. Two minutes passed before the sterile drapes were applied by the surgical staff. There was no indication or documentation the surgical staff ensured the prep was dry before the surgical drape was applied.

P2 was observed on 2/7/13, at 11:57 a.m., and Chloraprep was utilized for the skin prep prior to the procedure. A cloth sleeve was placed around P2's upper thigh followed by a plastic barrier that adhered to part of the sleeve and to the skin. At 12:00 p.m., the Chloraprep prep was finished. When the prep was complete, three other staff started to apply the sterile drapes. There was no indication that staff checked to ensure the prep was dry before applying the drape and dry status was not documented


The registered nurse (RN)-T, interviewed on 2/7/13, at 10:40 a.m., stated the CAH did not follow a procedure to ensure alcohol based preps are dry and do not record anything about the dry time. She stated that they just know that they have to wait to ensure that it is dry.

During interview on 2/7/13, at 3:00 p.m., the surgical manager stated he didn't think procedures related to the use of alcohol based skin preps were required by regulation.

Based on interview and document review the Critical Access Hospital (CAH) failed to provide nursing care in accordance with patient needs for 1 of 20 patients (P1) whose medical record was reviewed.

Findings include:

Review of P1's record indicated she did not receive oxygen as ordered by the physician.

P1's physician's order dated 1/31/13, directed oxygen 2-4 liters per nasal cannula, as needed, to keep the pulse oximetry level above 94. Pulse oximetry measures percentage of oxygen saturation (O2 sat) of the blood.

Vital sign records for 2/3/13, indicated P1's O2 sats were 93% at 3:00 p.m.; 93% at 3:42 p.m.; 93% at 3:54 p.m.; and 92% at 4:00 p.m.; all on room air. Although the O2 sats were below 94%, oxygen was not administered. The vital sign record on 2/3/13, at 11:00 p.m. indicated O2 sats of 97% with oxygen per nasal cannula.

The director of nursing (DON) was interviewed on 2/7/13, at 2:00 p.m. and verified that oxygen should have been provided for P1 when the O2 sats were below 94%.

Based on interview and document review, the CAH failed to develop a timely and appropriate care plan for 1 of 10 surgical patients (P11) whose records were reviewed.

Findings include:

P11 was admitted 10/25/12, for a right total knee arthroplasty (TKA). The care plan dated 10/28/12, directed care for a newborn baby with potential problems including hypothermia and altered sleep patterns.

On 2/7/13, at 12:25 p.m., the director of nursing (DON) was interviewed, and stated registered nurses (RNs) input care plans into the computer. The DON verified a newborn care plan is not appropriate for a surgical patient, and was unable to state how often nursing staff reviewed care plans. The DON further stated the facility has no monitoring system in place to ensure appropriate care plans are developed on patients.

The facility policy and procedure on Care Planning, dated 10/1/03, indicated the care plan should be individualized, based on the diagnosis and patient assessment, and should be started within eight hours of admission.

Based on interview and document review, the CAH failed to provided a comprehensive post-anesthesia evaluation for 3 of 10 surgical patients (P11, P12, P1) reviewed.

Findings include:

P11 was admitted on 10/25/12, for a right total knee arthroplasty (TKA). The post-anesthesia evaluation was blank with no documentation and no signature.

P12 was admitted on 11/16/12, for surgical repair of a left patella (knee) fracture. The post-anesthesia note did not address level of consciousness, pain, hydration, follow-up care and/or observations, or any potential complications occurring during post-anesthesia recovery.


12831


P1 was admitted on 1/30/13, for surgical repair of a left hip fracture. P1 received general anesthesia and the hip surgery was completed on 2/1/13. The post-anesthesia note dated 2/1/13, did not address level of consciousness, pain, hydration, follow-up care and/or observations, or any potential complications occurring during post-anesthesia recovery.

The surgical manager was interviewed on 2/5/13, at 3:30 p.m., and verified P1's post- anesthesia evaluation was not complete. A policy for what they expected in a post-anesthesia evaluation was requested but not provided.