HospitalInspections.org

The hospital reported a census of 25 current patients, with 10 closed emergency department patient records chosen for review. Based on observation, policy review, document review and staff interview the governing body failed to ensure their medical staff completed credentialing for 4 of 4 Certified Registered Nurse Anesthetist (CRNA) (Staff members J, K, L and M).

Findings include:

- Medical Staff By-laws reviewed on 11/14/13 at 10:45am entitled "Article V. Allied Health Professionals" dated 04/11/10 stated "1. Nature of Allied Health Professionals. An Allied Health Professional (AHP) is an individual other than a licensed non-physician practitioner who functions in a medical support role to a Physician or exercises independent judgement within the area of his or her professional competence and who is qualified by licensure, certification or other approval to render medical or surgical care....This category of Practitioners shall consist of social workers, advanced nurse practitioners, physician's assistants, certified registered anesthetists... Medical Staff By-laws stated the hospital required the CRNA to provide their qualifications and become eligible for Clinical Privileges within the hospital. Medical Staff By-laws directed the CRNA required approval for Clinical Privileges by the Board of Managers (Governing Body) at the hospital.

- CRNA J's employment record reviewed on 11/15/13 lacked evidence any clinical privileging documentation.

Physician N interviewed on 11/15/13 at 9:30am reported the hospital did not require their hospital employed CRNAs to go through their Clinical Privileges process. Physician N acknowledged their Medical Staff By-laws stated the CRNAs would be part of the clinical Privileges process. Physician N reported the hospital lacked clinical privileging documentation for CRNA J and reported CRNA Staff K, L and M also lacked clinical privileging documentation.

The Hospital reported a census of 25 acute patients. Based on observation, policy review and staff interview, the hospital failed to follow their policy to remove unusable (expired) medications and disposable equipment in 2 of 2 emergency department carts.

Findings include:

- The hospital's policy "Expired Drugs" reviewed on 11/15/13 at 3:00pm revealed "...all expired drugs that are not controlled substances are immediately returned to the designated area in the pharmacy on a daily basis ..."

- The hospital's policy "Crash Cart Restock and Maintenance" reviewed on 11/15/13 at 3:15pm revealed, "...the expiration dates on all drugs, I.V. solutions, and any disposable equipment will be checked and replaced one month prior to their expiration date..."

Observation of emergency department on 11/12/13 at 11:40pm revealed the following unusable (expired) items:

Ears, nose and throat cart-
1. Two- Oto Rhino Foreign Body Removers (Instruments that remove foreign bodies from ears and noses) with expiration dates of 09/2012.
2. Three- Oto Rhino Foreign Body Removers with expiration dates of 04/2012.
3. Four- Oto Rhino Foreign Body Removers with expiration dates of 09/2011.
4. One- Oto Rhino Foreign Body Removers with expiration date of 07/2012.
5. One- topical antibacterial agent for oral mucosa with expiration date of 02/2009.
6. One- container of Temporary Cement for oral use with expiration date of 04/2010.
7. One- container of EMT Tooth saver Solution (a solution to insert tooth into to preserve it) with an expiration date of 03/06/2009.
8. 40- single use vials of Marcaine 0.5% (a numbing agent) with expiration dates of 11/2008.
Pediatric Cart (emergency cart used for children)-
1. 7-24 gauge Protect IV Plus IV catheters with expiration dates of 08/2012.
2. Two-24 gauge Protect IV Plus IV catheters with expiration dates of 12/2012.
Broselow Emergency Pediatric Kit (kit used for infants and small children)-
1. Four- size 5/6 French Air Life Tri Flow Suction Cath-N-Glove Kits (for oral suctioning) with expiration dates of 10/2013.
2. Two- 15 gauge sternal/iliac aspiration needles with extension (used for delivering intravenous fluids through the bone marrow) with expiration dates of 09/2013.
3. One- 15-gauge sternal/iliac aspiration needle with extension with expiration date of 06/2013.
4. One- Green Intubation Module (kit used for airway intubation) with expiration date of 12/2012.
5. One- White Intubation Module with expiration date of 12/2012.
6. One- Orange Intubation Module with expiration date of 12/2012.
7. One- Blue Intubation Module with expiration date of 12/2012.
8. One- size 36 French ET (endotracheal) tube (used for intubation of airway) with expiration date of 5/2013.
9. One- size 40 French ET tube with expiration date of 7/2013.
10. One- size 28 French ET tube with expiration date of 10/2013.
11. One- size 26 French ET tube with expiration date of 3/2013.
12. One- size 16 French ET tube with expiration date of 10/2013.
Staff A, Director of Nursing services, interviewed on 11/12/13 at 11:43 acknowledged the expired disposable equipment and medications in the pediatric crash cart and Ear Nose and Throat cart.

Staff A, Director of Nursing services, interviewed on 11/12/13 at 11:50 acknowledged the expired disposable equipment in the Broselow bag.

The hospital reported an average of 300 surgeries per month. Based on observations, policy review, document review and staff interview the hospital failed to ensure nursing staff and practitioners wore hair covers that covered the hair around their ears, their sideburns and the hair at the nape of their neck during 2 of 2 surgical procedures observed (patient # 12 and random patient #28.

Findings include:

- Hospital policy reviewed on 11/14/13 at 10:45am titled "Dress code for Operating Room Personnel" dated 06/03/2013 "directed" ...Operating room personnel will be required to wear appropriate apparel to maintain a healthy surgical environment and help prevent nosocomial infections ...Proper attire in in the OR shall include hospital supplied ...Bouffant cap or surgeon's cap ..."

Review of the AORN 2012 Perioperative Standards & Recommended Practices on 11/13/13 at 3:15pm the following:

AORN 2012 Recommendation IV reads: "All personnel should cover their head and facial hair when in the semi-restricted and restricted areas. Hair coverings should cover facial hair, sideburns and the nape of the neck ...Skulls caps are not recommended because they do not completely cover the wearer's hair and skin: they fail to cover the side hair above and in front of the ears and the hair at the nape of the neck ..."

Patient #12 on 11/13/13 underwent a surgical procedure to replace their aortic value and also had a CABG (Coronary Artery Bypass Graft). Observations on 11/13/13 from 6:30am to 7:30am revealed the following:

Operating room nursing staff member D entered the OR (operating room) at 6:30am wearing a "skull cap" hair cover. The "skull cap" hair cover failed to cover the hair around their ears, their sideburns and the hair at the nape of their neck.

Anesthesiologist E entered the OR at 6:35am wearing a "skull cap" and inserted blood infusion lines in the patient ' s left forearm and their right jugular vein. The "skull cap" hair cover failed to cover the hair around their ears, their sideburns and the hair at the nape of their neck.

Physician F entered the OR at 7:30am wearing a "skull cap" and began the patient's surgery. The "skull cap" hair cover failed to cover the hair around their ears, their sideburns and the hair at the nape of their neck.

Random observation of patient #28 on 11/13/13 at 7:55am revealed patient #28 in OR #3. Physician G wore a "skull cap" hair cover as they performed prostate surgery using the DaVinci robot. The "skull cap" hair failed to cover the hair around their ears, their sideburns and the hair at the nape of their neck. Physician Assistant H wore a "skull cap" hair cover as they assisted Physician G with patient Z surgery. The "skull cap" hair cover failed to cover the hair around their ears, their sideburns and the hair at the nape of their neck. Physician Assistant student I entered OR #3 at 8:00am wearing a "skull cap". The "skull cap" hair cover failed to cover the hair around their ears, their sideburns and the hair at the nape of their neck.

Administrative registered nurse C interviewed on 11/13/13 at 11:00am acknowledged the Hospital follows AORN recommendations and guidelines. They verified the "skull cap" hair covering failed to cover a person's sideburn hair, hair above the ear and hair at the nape of the neck.

The hospital reported a census of 25 current patients, with 10 closed emergency department patient records chosen for review. Based on policy review, document review and staff interview the emergency department staff failed to follow their policy for treatment of a patient with psychological health concerns, including suicidal idealizations for 1 of 10 closed emergency department records reviewed (patient #1).

Findings include:

- Hospital policy reviewed on 11/14/13 at 10:45am titled "Suicide Precautions" dated 05/06/2013 directed staff to initiate suicide precautions to provide and maintain a safe environment for those patients who are a suicidal risk and have a suicide plan. The policy stated " It is the responsibility of the attending physician and/or emergency department (ED) physician to order suicide precautions." The policy directed staff to obtain a physician order for Suicide Precautions.

The Suicide Precautions policy directed staff to initiate the following interventions to ensure patient safety:
2. Precautionary measures can be put in place by the nurse for patients who may present suicidal risk, until such as an order can be obtained from the ED/attending physician for suicide precautions or it is determined by the physician that is not at risk for suicide. Which include: provide constant direct observation of the patient, provide a safe environment, restrict personal property.

5. Notify Kansas Health Solutions (area mental health screening provider) and ask for a suicide screen.

- Patient #1's medical record reviewed on 11/14/13 revealed they presented to the Emergency department on 8/27/13 with a reported drug overdose. Nursing notes dated 8/27/13 revealed emergency department nurse O documented they placed patient #1 in suicide precautions and emergency department physician P noted patient #1 had a plan and executed they plan by an overdose of medications and alcohol.

Patient #1's medical record lacked evidence of a mental health screening by the designated provider, lacked evidence of a physician order for suicide precautions and lacked evidence of constant direct observation of patient #1.

- Administrative nurse interviewed on 11/13/13 at 4:30pm verified patient #1 had a plan for suicide and acknowledged the emergency department staff failed to follow the hospital's policy for suicide precautions. Administrative staff A reported the Patient #1's medical record lacked evidence of a physician order for suicide precautions, lacked evidence of a mental health provider screened patient #1 and stated the medical record lacked evidence to demonstrate patient #1 had constant direct observation in the emergency department.