HospitalInspections.org

Based on findings from observation and interview, medications available for use in an anesthesia cart in the Labor and Delivery (L&D) unit were left unsecured.

Findings include:

--Per observation on 5/11/15 at 1:50 pm in Operating Room (OR) #2 in the L&D unit, the top drawer of the anesthesia cart contained various medications but was unsecured.

--Per interview with the Labor and Delivery (L&D) Technician on 5/11/15 at 1:50 pm, the anesthesia carts automatically lock after 1 to 2 minutes.

--Per interview with Anesthesia Technician #1 on 5/11/15 at 2:00 pm, he/she had just stocked the anesthesia cart; it locks automatically in a few minutes.

--During interview with the OR Director, he/she indicated the anesthesia carts do not lock automatically and have to be locked manually.

Based on findings from observation and interview, the hospital did not have a formal infection control policy in place regarding which staff were responsible to monitor and ensure safe temperature and humidity levels in the operating rooms.

Findings include:

-- Per observations in the surgical suite operating room (OR) #5 at 9:30 am on 5/11/15, there were temperature and humidity units installed on the wall providing instant digital and continuous graph recordings of readings. The digital and graph recording units were also present in the other OR rooms in the surgical suite.

-- Per interview of the OR Director at 9:30 am on 5/11/15, the surgical nursing staff do look at the wall units in each OR for temperature and humidity readings, but the readings are not formally documented because there is no formal policy in place making the nursing staff responsible for tracking OR temperatures and humidity.

-- Per observation of a computer program in the Director of Plant Operations office at 2:00 pm on 5/11/15, temperatures were available for each individual OR, but the humidity level reading in the computer was based on an average of all ten ORs together. This reading alone in the computer system does not provide the required information for monitoring each room.

-- Per interview of the Director of Plant Operations and the Administrative Director of Facilities at 2:00 pm on 5/11/15, both confirmed that the Plant Operations and Facilities staff have the ability to monitor individual OR room temperatures on the computer but not individual OR room humidity levels; the computer only provides a humidity average for all ten ORs. Both individuals also confirmed lack of a formal policy outlining how temperature and humidity monitoring is done, and who is responsible.

Based on findings from interview, the hospital has not developed a written policy and procedure (P&P) describing measures staff should employ to minimize risk of surgical fires associated with the use of alcohol based skin preparations (ABSP) used for skin antisepsis in the operating room (OR).

Findings include:

--Per interview with the Perioperative Services Director on 5/11/15 at 3:30 pm, alcohol based skin preparations (i.e., alcohol, Duraprep and Chloroprep solutions) are used in the OR for patient skin antisepsis prior to surgery. Measures such as allowing to dry prior to draping, using towels to catch drips and not allowing solution to come in contact with hair are used by staff. However, the hospital does not have a written P&P addressing these measures.

Based on findings from medical record (MR) review, facility document review, and interview, the MRs of 2 out of 7 surgical patients (Patients A and B) lacked documentation of an updated examination of the patient prior to surgery when the medical history and physical examination (H&P) was completed within 30 days prior to admission.

Findings include:

--The hospital's "Rules and Regulations of the Medical Staff Bylaws," last revised 2/2015, indicated that when an H&P has been completed within 30 days before admission or registration, an updated medical record entry must be completed in the patient's medical record within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services - this must be done by the attending physician or appropriately credentialed practitioner. The updated note must document an examination for any changes in the patient's condition since the H&P was performed that might be significant for the planned course of treatment. If upon examination the licensed practitioner finds no change in the patient's condition since the H&P was completed, he/she may indicate in the patient's MR that the H&P was reviewed, the patient was examined and that no change has occurred in the patient's condition since the H&P was completed.

--Per review of Patient A's MR, he/she had an H&P completed on 5/5/15 during an office visit. Patient A underwent a surgical procedure on 5/11/15. There is no documentation in Patient A's MR indicating that the H&P was reviewed, Patient A was examined and whether any changes had occurred since the 5/5/15 H&P was completed.

--Per review of Patient B's MR, he/she had an H&P completed on 5/5/15 during an office visit. Patient B underwent a surgical procedure on 5/11/15. There is no documentation in Patient B's MR indicating that the H&P was reviewed, Patient B was examined and whether any changes had occurred since the 5/5/15 H&P was completed.

--During interview with the Perioperative Services Director on 5/11/15 at 3:30 pm, the above findings were acknowledged.

Based on findings from facility document review, medical record (MR) review and interview, in 2 of 7 MRs reviewed (Patients A and C), the surgical consent form lacked documentation of the time the consent was obtained and witnessed.

Findings include:

--Per review of the hospital forms titled "Consent for Diagnostic, Therapeutic, Invasive or Surgical Procedures," last reviewed 12/2014, they required documentation of the times the provider (attending physician or other staff explaining procedure), the patient and the witness sign the form.

--Review of the MRs for Patients A and C revealed each lacked the time the surgical consents were signed by the patient, surgeon and/or witness, as follows:

* On 5/11/15 Patient A was admitted to the hospital for laparoscopic vertical gastric sleeve resection. On 5/5/15, Patient A, a surgeon, and a nurse practitioner witness had signed a consent form for laparoscopic gastric sleeve possible open procedure. It lacked the times the surgeon and nurse practitioner had signed the form.

* On 5/4/15 Patient C was admitted to the hospital for treatment of benign prostatic hyperplasia (BPH). On 4/21/15, Patient C, a surgeon and a witness had signed a consent form for laser enucleation of prostate with morcellation. The consent lacked the times the patient, surgeon and witness had signed the form.

--During interview with the Director of Quality on 5/12/15 at 3:15pm, the above findings were acknowledged.