HospitalInspections.org

Based on review of medical records, facility documents and staff interviews, the governing body failed to ensure that security services provided by contracted services furnished services that permitted the hospital to comply with all applicable conditions of participation and standards for the contracted services. Specifically, the facility failed to ensure that security services provided under contract to support nursing interventions with psychiatric/drug and alcohol patients with behavioral disturbances complied with the Condition of Participation for Patient Rights.

The facility failed to ensure that tasers were not used by contracted service security guards as a means of restraint for expediency, convenience and as a form of coercion for interventions with non-compliant or aggressive patients with psychiatric diagnoses/behavioral disturbances in the general hospital areas, including the Emergency Department (ED) and, in two instances, on the psychiatric unit, in sample patients #21, #22, #23, #24, #25, #26, #27, #28 and #29. Those sample patients represented all of the patients that were tased or threatened with taser use by contract security guard in the facility in 2009 and 2010. The failure created negative patient outcome for all of the patients that were tased (#21, #22, #25 and #26) and potentially for the patients that were threatened with taser use (#23, #24, #27, #28 and #29).

The findings were:

Reference findings in A 0115, the Condition of Participation for Patient Rights.

Based on review of medical records, facility documents and staff interviews, the governing body failed to ensure that security services provided by contracted staff were provided in a safe and effective manner. Specifically, the facility failed to ensure that tasers were not used by contracted service security guards as a means of restraint for expediency, convenience and as a form of coercion for interventions with non-compliant or aggressive patients with psychiatric diagnoses/behavioral disturbances in the general hospital areas, including the Emergency Department (ED) and, in two instances, on the psychiatric unit, in sample patients #21, #22, #23, #24, #25, #26, #27, #28 and #29. Those sample patients represented all of the patients that were tased or threatened with taser use by contract security guards in the facility in 2009 and 2010. The failure created negative patient outcome for all of the patients that were tased (#21, #22, #25 and #26) and potentially for the patients that were threatened with taser use (#23, #24, #27, #28 and #29).

The findings were:

Reference findings in Tags A 0083 and A 0154

Tag A 0083 provides evidence the facility failed to ensure that security services provided under contract to support nursing interventions with psychiatric/drug and alcohol patients with behavioral disturbances complied with the Condition of Participation of Patient Rights.

Tag A 0154 provides evidence the facility failed to ensure that security services, provided under contract to support nursing interventions with psychiatric/drug and alcohol patients with behavioral disturbances, did not include the use of tasers, as a means of restraint, for expediency, convenience and as a form of coercion for interventions with non-compliant or aggressive patients.

On 3/29/10 during a second on-site visit and on 3/30/10 by telephone, the director of patient safety/risk management was asked to provide evidence the facility had evaluated the services, provided by the outside security contractor, to ensure the services were provided in a safe and effective manner. S/he stated the facility had access to documentation the security contractor had evaluated itself. S/he was unable to provide evidence of evaluation conducted by the hospital to provide adequate oversight of the contractor, to ensure patient safety.

Based on the nature of deficiencies cited, the hospital failed to comply with the Condition of Patient Rights. The facility failed to protect and promote each patient's rights by ensuring that nursing staff had emergency access to medication rooms in the event of failure of the electronic lock system. In addition, the facility failed to prevent the utilization of tasers by contracted services security guards on psychiatric/drug and alcohol patients with behavioral disturbances.

The facility failed to meet the following standards under the condition of Patient Rights:

A 0144 Care in a Safe Setting
The facility failed to ensure that nursing staff were trained or had policies in place regarding the availability of a key for the medication room during a lightening strike, which could potentially disable the badge access to function.

A 0154 Use of Restraint or Seclusion
The facility failed to ensure that security services, provided under contract to support nursing interventions with psychiatric/drug and alcohol patients with behavioral disturbances, did not include the use of tasers, as a means of restraint, for expediency, convenience and as a form of coercion for interventions with non-compliant or aggressive patients. The failure created negative patient outcome for four patients that were tased (sample patients #21, #22, #25 and #26), and the potential for a negative patient outcome for the five other patients who were threatened with the use of a taser
(sample patients #23, #24, #27, #28 and #29).

Based on tour/observation and staff interview, it was determined that nursing staff were not trained or policies in place regarding the availability of a key for the medication room during a lightening strike, which could potentially disable the badge access to function. This failure could create a potential for patients in this area not to receive medications due to not being able to access the Pyxis.

The findings were:

On 3/1/10 at 3:00 p.m., a tour/observation of the Penrose Main Hospital ICU (Intensive Care Unit) medication rooms (2) were conducted. The medication rooms contained a Pyxis. The Crash Carts were not in the medication rooms but located in the hallway of the ICU. The Crash Carts contained all emergency drugs, IV's and intubation equipment. The Pyxis, however, does contain narcotics for patient pain relief and other patient medications. An interview with the ICU manager, was conducted during the tour. H/she stated that one medication room locked down preventing entry "once" that h/she knew of, sometime last year during an electrical storm. A facilities management person came to their aid and taped the lock on the door so it would remain open until the problem was fixed. H/she stated h/she was told there was a key to the medication room in the security office. There apparently had not been an issue since then. However, the ICU manager did not know there were keys to the medication rooms readily available to the nursing staff. According to the CNO (Chief Nursing Officer), s/he had a key as well as the supervisor and h/she would make keys available to the ICU charge nurses.

Based on review of medical records, facility documents and staff interviews, the facility failed to ensure that tasers were not used by contracted service security guards as a means of restraint for expediency, convenience and as a form of coercion for interventions with non-compliant or aggressive patients with psychiatric diagnoses/behavioral disturbances in the general hospital areas, including the Emergency Department (ED), and in two instances, on the psychiatric unit, in sample patients #21, #22, #23, #24, #25, #26, #27, #28 and #29. Those sample patients represented all of the patients that were tased or threatened with taser use by contract security guard in the facility in 2009 and 2010. The failure created negative patient outcome for all of the patients that were tased (#21, #22, #25 and #26) and potentially for the patients that were threatened with taser use (#23, #24, #27, #28 and #29).

The findings were:

1. Review of Policies/Procedures:

Review of the policy/procedure "Restraint and Seclusion - Behavioral (Danger to Self and/or Danger to Others)" revealed the following findings, in pertinent parts:
"...Purposes:
To support the patient's right to be free from restraint or seclusion of any form, imposed as a means of coercion, discipline, convenience or retaliation by staff.
To provide a systematic and safe approach to restraint and seclusion use for those patients demonstrating severely aggressive, violent, or destructive behavior that poses imminent danger to themselves or others while protecting the patient's health and safety and preserving their rights.
To use restraint and seclusion as a last resort, in the least restrictive manner possible and to end it at the earliest time possible...
Guidelines for Care:
19. Weapons shall not be used at any time for restraint procedure. Weapons include pepper spray, mace, nightsticks, tasers, stun guns, etc. Use of such weapons for other reasons can be found in the Weapons on (facility) Property guideline...
K. Training and Competence
...4. Staff will receive ongoing training and demonstrate understanding of restraint orders, techniques to identify staff and patient behaviors, events and environmental factors that may trigger circumstances including:
a. Underlying causes of threatening behaviors
i. Aggressive behavior exhibited may be related to underlying medical conditions
ii. How staff behaviors can affect patient behaviors
b. De-escalation, mediation, self-protection and other techniques (i.e. time-out)
c. Use of non-physical intervention skills
d. Choosing the least restrictive environment based on individualized assessment of the patient's medical and behavioral status or condition.
e. Safe application and use of all types of restraint including how to recognize and respond to signs of physical or psychological distress....
7. Individuals providing instruction must be evidenced by education, training and experience in techniques used to address patient behaviors..."

Review of the policy/procedure "Weapons on (facility) Property."
"...Guidelines for Care:
...NO unapproved weapons, of any kind, will be permitted on (facility) property, either by visitors, patients, associates, staff or anyone else with the following exception: Law enforcement officials who are in possession of a commission card are approved to carry weapons in (hospital) facilities. (On the locked psychiatric unit, law enforcement will be approved to carry their weapons only if they have been called for disturbances or patient control by the unit)...
Definitions: (Extracted from the Colorado Regulatory Statutes, Colorado Springs City Ordinances and local definitive sources): Dangerous or deadly weapons:
Includes any firearm whether loaded or unloaded, including, but not limited to, pistol, revolver, rifle, shotgun, air gun, gas-operated gun, spring gun, BB gun; any bow; any cross knuckles, brass knuckles, lead knuckles, bludgeon or blackjack, billy club, sandclub, sandbag, or other hand-operated striking weapon, knife, dirk, dagger, stiletto, gravity knife, switchblade knife, or any other weapon, device, instrument, materials, or substance, whether animate or inanimate, which, in the manner used or intended to be used, is calculated to produce serious bodily injury....
Practices:
A. No unapproved weapons of any kind, (see definition) will be permitted on any of the (hospital) property... "

Review of the "Taser Use" policy/procedure revealed the following findings, in pertinent parts:
"...Guidelines For Care:
To promote safety in the workplace, this guideline identifies uses of the (facility) approved TASER (referred to from here onin as TASER) as well as who will use it, and under what circumstances.
Response to Resistance Issues:
The TASER may be used when the individual is a threat and the officer/staff/patients/others are at imminent risk of injury. Other considerations for use may include: Individual is actively resisting arrest, or is in possession of a weapon. Potential contraindications/factors that will be considered before use:
1. Age
2. Pregnancy-visually evident or stated (NOT TO BE USED)
3. Distance between officer and subject greater than arm reach
4. Flammable liquids/fumes present or in use.
Practices:
The TASER is to be used as an additional officer tool and is not intended to replace self-defense and aggression management techniques and not to be used as a restraint. The TASER is to be used to control dangerous or violent individuals when a weapon is involved or that there is reasonable belief the individual is an imminent risk to officers/staff/patients or others.
TASER's are designed to assist with violent individuals, where alternative tactics have or are reasonably likely to fail, and/or where it would be unsafe for officers and associates to get closer to intervene.
Definitions:
Painting---When the security officer removes the TASER's safety device and a red dot appears on the target. This serves as a warning to the subject that if they do not become compliant, he/she could be subject to tasing.
Taser---Conductive Energy device.
Procedure:
A. Since the TASER will only be used in emergency situations where an imminent fear of harm is present, the Security Officer with the TASER will be the final decision maker....
F. The Security Shift Supervisor will contact the Facility Supervisor/Program Manager and the Nursing Supervisor or Director of Support Services anytime the TASER is deployed, or removed from its holster. This does include 'painting' of a person to obtain compliance..."

2. Staff Interviews:

Based on multiple interviews with the patient safety/risk management director during the first on-site survey (3/1/10 through 3/3/10) and in subsequent telephone conversations on 3/15/10 and 3/25/10, s/he stated the facility did not routinely do clinical debriefings after taser incidents. In addition,s/he stated that taser incidents were not reviewed by the facility's Restraint & Seclusion Committee, because the taser use was not considered a restraint, but a law enforcement technique. S/he stated the restraint policies/procedures and restraint oversight measures in place did not apply to taser use incidents.

3. Medical Record/"Taser Use Report" Reviews:

Review of the taser use documentation for 2009 and 2010 for the facility revealed the following findings, in pertinent parts:

1. Sample patient #21 was a young adult patient that was being transferred from a medical-surgical floor to the psychiatric unit on another campus by an ambulance service. The patient had been placed on a mental health hold and was verbally and physically resistant to being placed on a stretcher to be taken to the ambulance for transfer. Security was called and three security guards responded. The patient continued to refuse transfer and was forcibly placed on the stretcher. The patient continued to be verbally resistive and threatening and combative. The patient was tased once and then again when not compliant. The patient was then verbally stating that s/he would cooperate and was placed in soft restraints and taken by ambulance transport to the psychiatric hospital on a different campus.

2. Sample patient #22 was an adult that was seen in the ED (Emergency Department) and placed on a mental health hold. Security was called by the nurse when the patient was refusing to cooperate with medical procedures to complete the medical evaluation. Two students, two EMT's (Emergency Medical Technicians) and three security guards joined the nurse in the patient's room and the patient continued to refuse care. The group of staff/students "took down" the patient and had control of him/her on the floor, but the patient continued to struggle. The patient was warned that s/he would be tased if s/he "refused to comply with directives." The patient continued to be resistant and aggressive, so s/he was tased. The patient continued to be resistant, so was tased a second time and then was less resistive and was held down by staff for medical procedures. The physician then directed the patient be placed in restraints, which was done by the group of staff.

3. Sample patient #23 was an adult patient seen in the ED. The patient had been discharged but was refusing to leave. The report indicated that alcohol consumption may have been a factor in the patient's presentation. The nurse called for security and a security guard and the nurse took the patient by the arms and walked him/her out to the street and off facility property. The patient was attempting to be assaultive to the male nurse and was making verbal threats. At that point, the patient was out on the sidewalk, the patient was released from the nurse and the security guard and turned around and started spitting on both of them. The security guard threatened to tase the patient and s/he ran across the street. The patient continued to yell at them and threw a rock at them, which the security guard confiscated as "evidence." The security guard holstered his/her taser and pursued the patient down the street, but then stopped when the patient crossed a busier street.

4. Sample patient #24 was an adult patient that had been evaluated in the ED and was going to be admitted to the psychiatric unit on another campus. The patient was refusing to change into a hospital gown as a part of the security procedure to search the patient prior to transfer to the psychiatric unit. Security was called and the patient continued to refuse to cooperate, so the security guard took out the taser and threatened to use the taser on the patient. The patient stated s/he would cooperate at that point, so the taser was holstered. The patient was then cooperative with the nurse.

5. Sample patient #25 was an adult patient on the psychiatric unit. An emergency call for staff to respond to the unit had been called to "stand-by" for a patient that was going to be given "chemical restraint" (to de-escalate the patient's behaviors). Two security guards, medical staff and unit staff were on hand to intervene with the patient. The patient became verbally threatening and picked up a chair and appeared to be ready to throw it at someone. A security guard took out the taser and told the patient s/he would tase the patient if s/he did not put the chair down. The patient continued to "advance aggressively" and the patient was tased. The patient fell to the ground and after "the taser cycle (approx 5 seconds) ending" the medications were administered to the patient by nursing and medical staff.

6. Sample Patient #26 was an adult patient newly admitted to the psychiatric unit from another hospital ED after being treated for a self-inflicted head wound. The patient had a history of psychiatric symptoms and a head injury from birth. The patient was agitated, demanding to smoke, tearing at the staples in his/her head wound and attempting to leave the unit. Two security guards, in addition to medical staff and unit staff were present to respond to the patient. The patient did not respond to verbal commands or attempts to de-escalate him/her. The security guard told the patient to stop or taser would be used. The patient was tased once and then still not cooperative, so was tased a second time. At that point, the patient was cooperative and medication was administered to the patient and s/he was taken to an open seclusion room and remained cooperative.

The patient was found to have a broken left wrist secondary to one of the falls during tasing.

Review of the History & Physical stated the following, in pertinent parts: "...Basically positive for wrist pain on the left side and right finger pain. Apparently s/he had to be tased here last evening which resulted in a fall and s/he does have a significant swelling of his/her left wrist..."

Review of "Left Wrist Series" x-ray, dated the day after admission, stated the following, in pertinent parts: "...Findings: There is a comminuted intra-articular fracture of the distal radius. An ulnar styloid process fracture is also seen. No definite carpal fracture or dislocation is seen. Impression: 1. Comminuted intra-articular distal radial fracture. 2. Ulnar styloid process fracture..."

7. Sample patient #27 was and adult patient seen in the ED for alcohol intoxication. The patient was verbally and physically aggressive and resistant was told to leave the ED and facility property. Outside of the ED ambulance bays the patient was assaultive with one of the two security guard that were escorting the patient off of the property. One of the security guards withdrew the taser and told the patients/he would be tased if assaultive and threatening behavior was not stopped. The patient moved away from the security guard and did leave the area.

8. Sample patient #28 was an adult patient that was brought to the ED after being found unconscious on a bus. Patient was determined to be alcohol intoxicated validated by breathalyzer. Patient had history of drug seeking for pain at the other city hospital ED two days prior. The patient was determined to be medically stable and was told by the physician that s/he would be discharged and would need to leave. The patient became "verbally combative and physically aggressive (yelling and using quick hand gestures)." A security guard had been called to "stand by" in the psychiatric hall area, prior to the physician telling the patient s/he would be discharged. The security was joined by two additional security guards before prior to the physician contact with the patient. After the physician contact with the patient, a male nurse entered the patient room and told the patient to "get dressed and leave the property as patient continued to be verbal and confrontational." The patient apparently made several threats and "aggressive physical advances" against security. Security was unable to verbally deescalate the patient and the first security guard responded by taking out his/her taser and "ordering the patient to "back off" or s/he would be tased. The patient responded by getting dressed and then made and attempt to strike one of the security guards. The patient continued to be verbally aggressive and taking swings at security guard. Security guards controlled patient by hold arms and telling him/her s/he had to leave. Patient escorted out of ED by two security guards, with third carrying his/her belongings. Patient left at property edge at street and given belongings. Patient continued to make attempts to hit one security guard before all three guards left patient at the street and patient left. No injuries to security guards.

9. Sample patient #29 was an adult patient that was brought into the ED after an alcohol related argument with boyfriend at home. The patient was combative and resistive to with police and EMT's prior to being brought to the hospital. The patient was placed on an alcohol hold at the ED and was to be transported to the community detoxification facility. The patient tried to leave the ED and was told s/he had to stay and would be going to "detox" on an alcohol hold. The patient had to be physically escorted back to the psychiatric hall area in the ED where the patient was being held pending transfer. The medical record contained no documentation of an alcohol or mental health hold, although restraints were utilized on the patient. The medical record stated the patient went to "detox" on a voluntary basis. That information was inconsistent with the information in the taser documentation. The patient was attempting to strike the security guard who had responded to an ED call for security. The patient then punched the security guard twice on the right side of his/her face. At that point, the security guard removed his/her taser and placed it against patients upper torso and told patient to "comply with instructions and calm down or the taser would be deployed." The patient began to calm down and was placed in restraints with help of additional security guards and medical staff. The patient remained in restraints until discharge/transfer to "detox" facility.

Based on the nature of deficiencies cited, the hospital failed to comply with the Condition of Participation of Quality Assurance/Performance Improvement (QAPI). The facility failed to ensure the facility's performance improvement mechanism/activities adequately investigated an adverse patient event in which a sponge was retained in a surgical patient. In addition, the facility failed to adequately and consistently review all instances involving taser use, or threat of use, with patients from a clinical and quality improvement perspective, to insure appropriate restriction of taser use throughout the facility.

The facility failed to meet the following standards under the condition of Quality Assurance/Performance Improvement:

A 0288 QAPI Feedback and Learning
The facility failed to adequately investigate and address the underlying factor that contributed the utilization of tasers as an intervention with psychiatric/drug and alcohol patients with behavioral disturbances as a means of restraint, for expediency, convenience and as a form of coercion, by contracted security services.

A 0291 QAPI Sustained Improvement
The facility did not complete sufficient audits or take action as a result of the audit findings in the immediate time frame following an incident of a retained sponge in a patient. Failure to implement complete corrective action to ensure patient safety placed future patients at risk. Failure to follow up on data and demonstrate compliance for a "never event" fell below the standard of care and best practice for positive health outcomes for its patients.

Based on review of medical records, facility documents and staff interviews, the facility failed to ensure the performance improvement activities tracked all medical errors and adverse patient events, analyzed their causes and implemented preventive actions and mechanisms that include feedback and learning throughout the hospital. Specifically, the facility failed to adequately investigate and address the underlying factor that contributed the utilization of tasers as an intervention with psychiatric/drug and alcohol patients with behavioral disturbances as a means of restraint, for expediency, convenience and as a form of coercion, by contracted security services. The facility failed to adequately and consistently review all instances involving taser use or threat of use with patients from a clinical and quality improvement perspective, to insure appropriate restriction of taser use throughout the facility. The failure created the potential for negative patient outcomes.

The findings were:

1. Review of policy/procedure "Restrain and Seclusion - Behavioral (Danger to Self and/or Danger to Others)" revealed the following, in pertinent parts:
"...Definitions:
...15. Debriefing - a collaborative discussion between staff, the patient and family which occurs after discontinuation of restraint and seclusion episodes. The goal of the debrief is to identify what led to the event, what could have been handled differently, whether patient rights were maintained, whether there is need to counsel the patient for any resultant trauma and any need to modify the plan of care...
M. Behavioral Restraint and Seclusion Quality Assurance and Performance Improvement:
1. Behavioral restraint and seclusion data is collected and reviewed daily by each individual unit/department supervisor and formally analyzed monthly by the Restraint & Seclusion Committee with the goal to reduce use and duration, to introduce preventive strategies, to ensure alternatives to behavioral restraint/seclusion are used and to identify educational opportunities..."

2. Based on multiple interviews with the patient safety/risk management director during the first on-site survey (3/1/10 through 3/3/10) and in subsequent telephone conversations on 3/15/10 and 3/25/10, s/he stated the facility did not routinely do clinical debriefings after taser incidents. In addition s/he stated that taser incidents were not reviewed by the facility's Restraint & Seclusion Committee, because the taser use was not considered a restraint, but a law enforcement technique. S/he stated the restraint policies/procedures and restraint oversight measures in place did not apply to taser use incidents.

S/he stated that taser use was reviewed internally by a 3-person group ("Taser Committee") consisting of the patient safety/risk management director, the director of support services and the security program manager within three working days. The committee reviews the "Taser Use Report" that was required to be completed and submitted to the city police department for review within 24 hours after taser use. The committee determined that all 2009-2010 taser uses were appropriate. No other clinical reviews or quality reviews were conducted regarding these incidents. The patient safety/risk manager stated that no minutes were maintained of the Taser Committee meetings or findings, except for brief notes written at the top of the copy of the "Taser Use Report" kept on file. S/he stated the committee would be keeping formal minutes of the reviews going forward.

Based on staff interviews and a review of facility documentation, the facility failed to track a sufficient number of patients to measure the success of its corrective action and ensure patient safety.

On 3/02/2010, a review of occurrence reports for the facility for the past year revealed the following: a patient returned to the facility for removal of a foreign body in October 2009. The patient, a 51 year old female, had previous surgery at the facility in January 2009 for a total abdominal hysterectomy and bilateral salpingo-oophorectomy. The patient was seen by her primary physician in early October complaining of left side pain. A computerized tomography scan revealed a foreign body later identified as a sponge by pathology services.

The facility completed an investigation of the incident. It was determined that nursing staff did not document a completed sponge/instrument count for the January surgery. The facility was not able to determine if the count was truly incomplete as the surgeon documented a correct count x 2. The surgeon stated during an interview that s/he did not go near the area where the sponge was found. Pathology services could not determine how long the sponge was in the patient's abdomen. The patient had previous abdominal surgery in 2007 at a different facility and three cesarean sections prior to this.

As a result of the incident the facility made the following changes in practice:
1. The policy for "Guidelines for Surgical Sponge, Sharps, and Instrument Counts" was revised effective 12/2009. Emphasis was placed on suspension of procedure until a correct count was determined or negative X-ray confirmed there was no no foreign body retained.
2. New staff in the operating room will have an additional day of training dedicated for Meditech system documentation to include a quality check of documentation.
3. The clinical manager of the operating room audited the Meditech class for appropriateness of content to meet OR needs. The manager confirmed the training was complete and in depth. A booklet will also be provided to the learners emphasizing the information provided in class.
4. All staff were educated regarding the new policy.
5. Audits of Meditech documentation for counts for the months of November 2009 through February 2010 were completed.

Copies of the above corrective actions were received from the facility. It was noted that ten charts were audited each month at the campus location where the incident occurred. One chart for February did not have a completed count at all and several had no documentation of a final count at closing. The facility does approximately 300 surgeries per month. A phone interview with the clinical manager on 3/09/2010 at approximately 3:45 p.m. revealed that surgery staff complete counts at different times during the procedure, but it is a standard of practice to complete counts before skin closure of a patient. S/he was not aware one patient fell out. S/he stated s/he would follow up to determine if the count was not completed or just not documented. The nurse assigned to assist with the audits did not notify the manager that one patient fell out.

On 3/17/2010 at approximately 2:00 p.m., a telephone conference with the Medical Director and Director of Clinical Effectiveness revealed the following: both facilities were performing concurrent audits of sponge counts in their operating rooms as well as retrospective audits. The Medical Director stated retained foreign bodies are considered "never events" and s/he takes the matter seriously. It is unknown whether counts were not actually completed or whether there was a documentation issue within the electronic medical system. The facilities are addressing this with information technology (IT) and nursing staff. A follow up action plan post survey included re-education of staff, increased chart auditing to 100% of charts daily for the next month at the facility where the incident occurred, and counseling of staff who fall below the standard and expectations.

On 3/25/10, additional information was faxed (facsimile) to the Health Department. The documentation was an audit of 40 surgical records from 11/2/09 through 2/18/10. The reports were cross referenced to the occurrence reports, which would be completed if a count was determined to be incorrect, and x-rays which would have been performed on the patient if indeed the count was not correct. Twelve of 40 records revealed the surgeon had documented in their reports the count was correct. There were no occurrence reports or no x-rays completed with these counts which were not documented correctly. According to a telephone conversation with the Patient Safety/Risk Manager on 3/25/10 who had forwarded the reports, revealed the documentation problem had been fixed and training/education for the staff had been completed.

In summary, a retained foreign body was discovered in a patient who had previous surgery at one of the facilities several months before the finding. The surgeon had documented in the operative report a correct count x 2. However, a retrospective chart audit of nursing documentation revealed the sponge count was incomplete. Although it is unknown whether counts were actually not being completed or whether there was human error with documentation in the electronic medical record system, less than 10% of charts were audited for the facility where the incident occurred in the months following the incident. One chart fell out and was not immediately investigated to determine the cause. Four months have passed since the incident. Data received post survey demonstrates a continued problem with counts. It is therefore concluded the facility failed to adequately measure its success with the corrective actions to ensure improvements were sustained and patients remained unharmed.

Based on telephone interview on 3/8/10 with the facility's Director of Clinical Effectiveness, it was determined the facility failed to report a drug diversion occurring on 9/10/09 to the applicable State and Federal authorities. The facility did not report the drug diversion to the Board of Nursing and Drug Enforcement Agency until 3/1/10 and the State Health Department until 3/8/10. The nurse was, however, put on watch for suspicious activity in December 2009 and then was terminated in January 2010. A State deficiency for failure to report a drug diversion was cited.

An onsite complaint investigation was completed (see event ID #9H7U21), March 2 through March 18, 2010, was conducted by one (1) Life Safety Code Inspector and included an inspection for compliance with the fire safety requirements of Chapters 18, 19 and 39 of NFPA-101, Life Safety Code, (2000 edition) and the 1999 Edition of NFPA 99 Health Care Facilities, published by the National Fire Protection Association. The facility failed to comply with the regulations set forth and therefore the complaint is substantiated.

Deficiencies were cited.