HospitalInspections.org

Based on review of medical records, hospital policy and interview, it was determined the hospital intraoperative records lacked documentation of the time of occurrence for the surgical pre-procedural pause, or "time out."

The findings include:

1. The hospital policy Universal Protocol, and procedure Operating Room/Procedure Area Team Time Out, (UP.01.03.01) reads, "1. Conduct the Time Out prior to starting any procedure, 2. Repeat if the patient is re-positioned, the original approach or the procedure is changed during the case, e.g. closed to open. 3. Document all components of the Universal Protocol and Time Out."

2. Review of two surgical medical records revealed that in two of two records the "time out" documentation did not include the time the pre-procedure verification or "time out" occurred.

3. In a morning interview on December 8, 2010, with the Director of Surgical/Cardiopulmonary Services, he said the actual time of the "time out" was not included in their electronic record software program, so if we looked at any more surgical charts, the "time out" results would be the same.

Based on observations and staff interviews the facility staff failed to ensure the computer keyboards were covered in such a manner that they could be cleaned. Computer keyboards were observed on the the Emergency Department, Intensive Care Unit and the Isolation room of the Intermediate Nursery with no covers on the keyboards.

The Findings Include:

On 12/07/10 during the initial tour of the facility with the Director of Surgical Services and the Director of Emergency Services at approximately 1:20 P.M. in the Emergency Department the movable computer set-ups (WOWs) were observed with no covers on the keyboards. The Director of Emergency Services stated, "the WOWs could be taken into a patient room where a patient could have some sort of communicable disease". She stated, "We are in a discussion with our IT (Information Technology) Staff to get the covers that work the best or get the rubberized keyboards". "I have told them the keyboards must be covered with a cleanable cover until they figure out what they want."

On 12/8/10 during a tour of the Nursery and Intermediate Nursery with the Vice President of Patient Services (VPPS) the isolation room was observed. The room contained a computer and keyboard that was a permanent part of the room. The keyboard had no cover. The VPPS stated, "I know that keyboard needs to be covered and it will be."

Also on 12/8/10 with the VPPS and the Nurse Manager of the Intensive Care Unit (NMICU) the computers and keyboards were observed in 16 of 16 patient rooms. All of the room contained permanent computers with keyboards that were not covered. The NMICU stated, "All of the rooms could be used by a patient with a communicable disease."

One keyboard had a substance around the keys that was white and could be scratched off. Both the VPPS and NMICU stated, "The keyboards need to be covered on changed to a keyboard that can be cleaned."