HospitalInspections.org

Based on document review, medical record review, observation and interview, the hospital failed to ensure the safety of all patients and ensure all staff operated within the scope of their responsibilities for 1 of 1 (Patient #1) patients reviewed in the emergency department (ED) who suffered a laceration during transport by a patient care technician (PCT) and contracted police officer.

The findings included:

1. The hospital failed to ensure the patients were transported out of the hospital in wheelchairs by qualified personnel within their specified job functions.
Refer to A0144.

Based on hospital contract agreements, observation of the hospital's security video and interview, the hospital failed to ensure the safety of all patients and ensure contracted staff operated within their scope of responsibilities and precautions were taken to ensure the safety of transporting patients for 1 of 1 (Patient #1) sample Emergency Department (ED) patients reviewed who sustained an injury during transport in a wheelchair.

The findings included:

1. A review of the Agreement for Extra-Duty dated 1/17/17 revealed, "...WHEREAS, District [JMCGH]...that wishes to enter into an agreement with the City of Jackson, to have additional police [JPD] presence in the interior/exterior areas and parking lots of its business...a need for additional security..."

A review of the Memorandum of Understanding executed and signed on 11/20/17 revealed, "...JPD Responsibilities...JPD law enforcement officers will perform law enforcement duties only, and will not participate in patient care activities..."

2. Medical record review revealed Patient #1 presented to Jackson Madison County General Hospital (JMCGH) Emergency Department (ED) on 9/25/19 with complaints of left arm pain and swelling. The patient was treated in the ED and discharged home to the care of family and to follow-up with the patient's physician for a Left Colles fracture, and left intra-articular distal radius fracture.

Review of the ED documentation on 9/25/19 at 3:30 PM revealed Patient #1 was brought back into the ED and the ED physician documented, "...Reexamination/Reevaluation... Patient sustained laceration while attempting to get back into her vehicle to go back home. 20 centimeter left lower extremity flap, associated bruising with friable skin [thin fragile skin that tears easily]".

Review of a ED nursing document dated 9/25/19 revealed, "pt discharged and assisted out of bed to w/c [wheelchair] x [times] 2 assist. Pt was being assisted out of w/c to car when pt suddenly felt pain to left lower leg. pt had laceration to left lower leg and bleeding profusely. The cause or source of laceration is unknown. Pt's leg was wrapped with pads to help stop the bleeding and was promptly escorted back in w/c to ER T2 [Trauma room 2]. pt's leg was then wrapped in gauze and Kerlex and bleeding controlled."

Review of the hospital's security video footage revealed Patient #1 was taken out of the ED in a wheelchair by Patient Care Tech (PCT) #1. The video footage revealed a Jackson Police officer who was contracted to work at the ED entrance assisted PCT #1 as he was transferring Patient #1 into the passenger seat of Patient #1's family car. It was during this time that Patient #1 sustained a laceration to the inside of her left lower leg. The door of the car obscured the view and it was unable to be determined what caused the laceration.
Review of the video footage revealed the JPD officer assisted by holding the patient's right upper arm and pulling her up from the wheelchair. The PCT was observed pushing the wheelchair away from the patient. Both the JPD officer and the PCT tried to assist Patient #1 into the car. The assistance lasted from 3:53:17 PM until 3:55:16 PM at which time the daughter was observed getting out of the car out and walking around the car to see what had happened. At 3:55:33 PM, the JPD officer was observed assisting Patient #1 back into the wheelchair. PCT #1 did not assist Patient #1 back in the wheelchair. The JPD officer held Patient #1's leg with the pad on it while PCT #1 pushed the patient back into the ED.

The patient was admitted to the hospital with diagnoses including Left Colles fracture, left intra-articular distal radius fracture, and a new diagnosis of a left lower extremity laceration.

3. A review of the hospital's investigation summary revealed the hospital was unable to determine what caused the patient's laceration during transport by the JPD officer and PCT to the patient's car.

4. In an interview on 10/1/19 at 3:15 PM in the ED conference room, the Executive Director of the ED confirmed the police officers should not be assisting patients with any care.

In an interview on 10/2/19 at 11:00 AM in the ED conference room PCT #1 was asked what happened when Patient #1 sustained a left leg laceration while he was transferring the patient to the vehicle and the PCT stated he was unaware of how the patient received the laceration. The PCT stated while he was helping the patient, Patient #1 stated, "Oh, that hurt."
PCT #1 stated that he looked down and saw the patient's shoe with blood in it and he sat the patient back in the wheelchair and rushed the patient back into the ED.
PCT #1 stated that he did not know how she cut her leg.

In an interview on 10/2/19 at 1:25 PM in the ED conference room, the ED Clinical Manager was asked if he inspected the wheelchair for any sharp, broken areas that could have contributed to the laceration and the ED Clinical Manager stated they were unable to find the wheelchair that was specifically used to transport the patient.

Based on policy review, medical record review, document review and interview, nursing services failed to provide necessary care and services to reduce the incidence of adverse healthcare-associated conditions and provide the necessary treatment for those conditions per physician's orders when those conditions were identified. Nursing services failed to administer medications per facility policy and physician orders; and nursing service failed to identify possible eating difficulties for stroke patients and provide interventions for those patients to prevent significant weight loss during the hospitalization, and failed to contact the dietician per hospital policy in order to meet nutritional needs of patients with unstageable pressure wounds.

The findings included:

1. Nursing services failed to perform ongoing accurate assessments of patients in order to prevent healthcare - associated unstageable wounds.
Refer to A 392

2. Nursing service failed to identify potential factors that would lead to a significant weight loss during hospitalization.
Refer to A 395.

3. Nursing services failed to administer all drugs and biologicals according to the physician's order.
Refer to A 405

Based on review of standards of practice, policy review, medical record review, document review, and interview, nursing service failed to provide accurate assessments and interventions to prevent the occurrence of healthcare associated adverse events for 2 of 2 (Patient #19 and 59) sampled patients with hospital-acquired unstageable pressure wounds.

The findings included:

1. Review of the National Quality Forum (NQF) Serious Reportable Events List (Never Events) describes the term "never events" as mistakes that should never happen in hospitals. Categories of "never events" include "Care Management Events". "Care management Events" include, "Any Stage 3, Stage 4 and unstageable pressure ulcers acquired after admission or presentation to a healthcare setting..."

2. Review of the Centers for Medicaid and State Operations transmittal #08-004 revealed, "The NQF defines Never Events as errors in medical care that are of concern to both the public and health care professionals and providers, clearly identifiable and measurable (and thus feasible to the reporting system), and of nature such that the risk of occurrence is significantly influenced by the polices and procedures of the healthcare organization..."

3. The National Pressure Ulcer Advisory Panel definition of pressure injuries during the 2016 Staging Consensus Conference dated 4/8/16-4/9/16 revealed, "...Unstageable Pressure Injury...Full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough (a mass of dead tissue separating from an ulcer) or eschar (thick leathery black or brown devitalized tissue). If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed..."

4. The facility policy "Skin/Risk Assessment & Pressure Injury Prevention Standing Orders" revealed, "...SKIN UNDER OR IN CONTACT WITH A REMOVABLE MEDICAL DEVICE SHOULD BE ASSESSED AT LEAST DAILY..."

The facility policy "Medical Device Related Pressure Injury Prevention" revealed, "Assigned nurses will assess the skin under and around a medical device on admission and every 8 hours for risk of potential and actual skin breakdown..."

The facility policy "Pressure Injury Treatment, Stage 3/4/Unstageable and Full Thickness Wounds (FTWs)" revealed, "...PURPOSE: Help prevent and treat Stage 3/4/Unstageable Pressure Injuries and Full Thickness Wounds (FTWs). Only pressure injuries are staged and are usually located over bony prominences but may be caused by a medical device or other object over soft tissue. The primary physician should be notified of the pressure injury when the injury is first discovered. Physician notification should be documented in the patient's record ...Unstageable Pressure Injury ...Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed ...Process ...Notify the Wound Ostomy Continence (WOC) nurse of all Stage 3, 4 and Unstageable pressure injuries ...the nurse is responsible for documenting assessment of wound and initiating the electronic standing orders in Powerchart. The order set is "MED [medical] Skin/Wound Care Standing Orders" ...Consult the dietician for WOUND CARE evaluation ...DOCUMENTATION ...Document wound location, appearance, size ...Initiate MED skin/wound care standing order set ...Document the physician notification of the pressure injury..."

5. Medical record review revealed Patient #19 presented to the Emergency Department on 7/29/19 after a fall at home and was unable to get up for approximately 2 days. He arrived with apparent urine, feces, and reported maggots present. The Patient reported a long-standing history of Lymphedema and Multiple Lower Extremity Wounds. He also presented with Confusion, Metabolic Acidosis, Hypernatremia, Renal Insufficiency and Leukocytosis. Patient #19 was admitted to the Surgery Intensive Care Unit and was placed on the ventilator.

The Admission Skin Assessment dated 7/30/19 revealed there was not a wound to the Patient's left upper posterior arm upon admission.

There was no documentation from 7/30/19 to 8/16/19 the nurses assessed the patient's skin under the blood pressure cuff every 8 hours per hospital policy to check for potential or actual skin breakdown.

The Activities of Daily Living Flow Record revealed Patient #19 received a bed bath on 8/15/19 at 10:00 AM. There was no documentation the patient had a pressure wound or if the blood pressure cuff had been removed during the patient's bath to assess the patient's arm.

On 8/16/19 at 3:19 PM a note documented by the Wound Ostomy Continence Nurse (WOCN) #2 revealed a new unstageable pressure injury had been identified on Patient #19's left upper posterior arm under the patient's blood pressure (BP) cuff. The wound measured 8 centimeters (cm) X (by) 3 cm X 0.3 cm (3.14 inches X 1.18 inches X 0.118 inches).

A physician's order dated 8/16/19 at 3:29 PM revealed to clean the wound with normal saline, apply Santyl and Vaseline Gauze daily, and secure with an abdominal pad and Kerlex. There was no documentation the nurses assessed the patient's wound per hospital policy or followed the physician's wound care orders.
Refer to A 405.

The "Risk Management Worksheet" dated 8/27/19 at 2:35 PM revealed Patient #19 developed a pressure injury to his left upper posterior arm from the blood pressure cuff.

In an interview in the Surgery Intensive Care Unit (SICU) on 10/1/19 at 3:03 PM, the Unit Director verified the blood pressure cuff was typically removed daily during a patient's bath.

The facility failed to ensure the SICU nurses removed the blood pressure cuff daily and/or every 8 hours as stated in the facilities policy and procedures resulting in an unstageable pressure injury constituted an SERIOUS AND IMMEDIATE THREAT to the health and safety of Patient #19 and all patients in the facility.

6. Medical record review for Patient #59 revealed an admission date of 7/11/19 with diagnoses which included Fall, Left Knee Pain, Anemia, Coronary Artery Disease, Dementia, Diabetes Mellitus and Idiopathic Normal Pressure Hydrocephalus (a disorder characterized by gait impairment, incontinence, and dementia that affects elderly patients) with Ventriculoperitoneal Shunt (medical device that relieves pressure on the brain caused by fluid accumulation).

Patient #59 presented to the emergency department on 7/10/19 at 7:23 PM and was admitted to the hospital on 7/11/19 at 4:38 AM.

On 7/11/19 at 4:38 AM, Nurse #6 documented the skin assessment for Patient #59 on admission was conducted, and the patient's skin integrity was intact with no wounds observed or assessed.

On 7/15/19 at 7:00 AM, 4 days after the patient's hospital admission, Nurse #1 documented Patient #59 had a pressure injury on the inner sacrum described as red and yellow skin color with necrotic tissue and slough in the wound bed. There was no documentation Nurse #1 measured the size of the pressure wound. Nurse #1 documented the pressure wound was a Stage 2. There was no documentation the physician was notified.

On 7/15/19 at 1:00 PM, Nurse #1 documented Patient #59's inner sacrum wound was present upon admission to the hospital, although Nurse #1 did not perform the skin assessment for Patient #59 on admission to the hospital.

On 7/15/19 at 1:00 PM, Nurse #1 documented a skin assessment for Patient #59 as the patient's skin integrity was intact and a Braden Score of 19 (a Braden score is a scale for predicting pressure ulcer risk. A score of 18 or greater was 'low risk' for development of a pressure injury.) which means no risk for developing a pressure ulcer.

On 7/15/19 at 7:00 PM Nurse #2 documented an assessment of Patient #59's inner sacrum pressure injury as Stage 2. There was no documentation of the wound type, wound appearance or measurement of the wound.

On 7/15/19 at 7:00 PM Nurse #2 documented a skin assessment that Patient #59's skin integrity was intact and a Braden Score of 19.

On 7/16/19 at 7:00 AM Nurse #1 assessed Patient #59's inner sacrum pressure injury as Stage 2. There was no documentation of the wound type, wound appearance or measurement of the wound.

On 7/16/19 at 1:00 PM Nurse #1 assessed Patient #59's inner sacrum pressure injury as Stage 2. There was no documentation of the wound type, wound appearance or measurement of the wound

On 7/16/19 at 7:00 PM, Nurse #1 documented a skin assessment that Patient #59's skin integrity was intact and a Braden Score of 19. There was no documentation of the inner sacrum wound.

On 7/16/19 at 7:00 PM Nurse #3 assessed Patient #59's inner sacrum wound as a "tear" but still documented the wound as Stage 2 (tears in the skin are not categorized by stages). There was no documentation of the wound appearance or measurement of the wound.

On 7/16/19 at 7:00 PM Nurse #3 documented a skin assessment for Patient #59 as the patient's skin integrity was intact and a Braden Score of 19.

On 7/17/19 at 7:00 AM Nurse #4 assessed Patient #59's inner sacrum wound as a "tear" but documented the wound as Stage 2 (tears in the skin are not categorized by stages). There was no documentation of the wound appearance or measurement of the wound.

On 7/17/18 at 7:00 AM Nurse #4 documented the skin assessment for Patient #59 as the patient's skin integrity was intact.

On 7/17/19 at 11:10 AM Nurse #4 assessed Patient #59's inner sacrum wound as a "tear" but documented the wound as Stage 2 (tears in the skin are not categorized by stages). There was no documentation of the wound appearance or measurement of the wound.

On 7/17/19 at 11:10 AM Nurse #4 documented a skin assessment for Patient #59 as the patient's skin integrity was intact.

On 7/17/19 at 1:00 PM Nurse #4 assessed Patient #59's inner sacrum wound as a "tear" but documented the wound as Stage 2 (tears in the skin are not categorized by stages). There was no documentation of the wound appearance or measurement of the wound.

On 7/17/19 at 1:00 PM Nurse #4 documented a skin assessment for Patient #59 as the patient's skin integrity was intact.

On 7/17/19 at 3:00 PM Nurse #4 assessed Patient #59's inner sacrum wound as a "tear" but documented the wound as Stage 2 (tears in the skin are not categorized by stages). There was no documentation of the wound appearance or measurement of the wound.

On 7/17/19 at 5:00 PM Nurse #4 assessed Patient #59's inner sacrum wound as a "tear" but documented the wound as Stage 2 (tears in the skin are not categorized by stages). There was no documentation of the wound appearance or measurement of the wound.

On 7/17/19 at 7:00 PM Nurse #2 assessed Patient #59's inner sacrum wound as a "tear" but documented the wound as Stage 2 (tears in the skin are not categorized by stages). There was no documentation of the wound appearance or measurement of the wound.

On 7/17/19 at 7:00 PM Nurse #2 documented a skin assessment for Patient #59 as the patient's skin integrity was intact.

On 7/18/19 at 7:00 AM Nurse #5 assessed Patient #59's inner sacrum wound as a "tear" but documented the wound as Stage 2. There was no documentation of the wound appearance or measurement of the wound.

On 7/18/19 at 7:00 AM Nurse #5 documented a skin assessment for Patient #59 as the patient's skin integrity was intact.

On 7/18/19 at 4:49 PM the Wound Ostomy Continence (WOC) Nurse #1 assessed Patient #59's inner sacrum wound as an Unstageable Pressure Injury with full thickness slough and necrotic tissue measuring 2 cms long and 1.5 cms wide (0.787 inches by 0.590 inches) This was the first and only measurement of Patient #59's pressure injury. Physician orders were received on 7/18/19 at 16:57 to clean the coccyx with bath wipes/soap and water, apply a generous amount of Venelex (a Balsam Peru/Castor Oil topical ointment) twice a day to the wound and only use white underpads.

On 7/18/19 at 7:00 PM Nurse #6 documented a skin assessment for Patient #59 that the patient's skin integrity was intact.

On 7/19/19 at 7:00 AM Nurse #7 documented a skin assessment for Patient #59 as the patient's skin integrity was intact.

On 7/19/19 at 1:00 PM Nurse #7 documented a skin assessment for Patient #59 as the patient's skin integrity was intact.

Patient #59's wound was unable to be observed during the survey, because Patient #59 was discharged to a skilled nursing facility on 7/19/19 and was not currently a patient at the facility.

In an interview in the hospital Conference Room on 10/1/19 at 3:54 PM, the WOC Nurse Manager stated Patient #59's inner sacrum pressure injury was unstageable and confirmed the nurses who assessed the wound as a Stage 2 did not stage the wound correctly.

In an interview in the hospital Conference Room on 10/2/19 at 9:53 AM, the WOC Nurse Manager confirmed there was a discrepancy in the documentation between the skin integrity (intact) and wound assessment.

In an interview in the hospital Conference Room on 10/2/19 at 10:35 AM, the Director of Nursing for the medical-surgical unit stated the nurses should measure and document a patient's pressure injury and notify the Director of the floor.

In an interview in the hospital Conference Room on 10/2/19 at 1:12 PM, Nurse #1 confirmed there was no documentation of a wound or skin breakdown for Patient #59 until she discovered the wound on 7/15/19 at 7:00 AM. Nurse #1 confirmed the wound had slough and necrotic tissue but stated she believed the wound was a Stage 2. Nurse #1 confirmed she did not measure the wound but stated she should have.

In an interview in the hospital Conference Room on 10/1/19 at 3:54 PM, the WOC Nurse Manager stated the floor nurses should have initiated the standing orders for wound care, consulted the Dietitian, consulted the Wound Ostomy Continence Nurse and notified the physician.

In an interview in the hospital Conference Room on 10/2/19 at 10:35 AM, the Director of Nursing for the medical-surgical unit stated the floor nurse should initiate the protocol of standing orders for wound care for any patient with a Braden Score of 18 or less. The Director of Nursing for medical surgical unit confirmed the floor nurses should have initiated the standing orders for wound care for Patient #59, consulted the Dietitian, consulted the Wound Ostomy Continence Nurse and notified the physician.

In an interview in the hospital Conference Room on 10/2/19 at 1:12 PM, Nurse #1 confirmed she should have initiated the standing orders for wound care, consulted the Dietitian, consulted the Wound Ostomy Continence Nurse and notified the physician.

In an interview in the hospital Conference Room on 10/3/19 at 11:19 AM, the Director of System Accreditation stated the hospital staff could not find any documentation a physician had been notified of Patient #59's inner sacrum pressure injury during his hospital stay.

The nursing staff failed to implement interventions to treat Patient #59's unstageable pressure injury.
The nursing service failed to initiate medical skin/wound care standing order per hospital policy for treatment of an unstageable pressure injury.
The nursing service failed to consult the Dietitian when the pressure injury was discovered on 7/15/19 at 7:00 AM. The consult for the Dietitian was entered on 7/16/19 at 11:49 PM (1 day 16 hours 49 minutes after the wound was discovered on 7/15/19).
The nursing service failed to initiate "Skin/Wound Care Standing Orders" for pressure injury treatment when the pressure injury was discovered on 7/15/19 at 7:00 AM. The standing orders were entered on 7/17/18 at 8:28 AM (2 days 1 hour 28 minutes after the wound was discovered).
The nursing service failed to consult WOC nurse when the pressure injury was initially discovered on 7/15/19 at 7:00 AM. There was no physician's order for a WOC nurse consult, but the WOC nurse did assess Patient #59's wound on 7/18/19 at 4:57 PM (3 days 9 hours 57 minutes after the wound was discovered).
There was no documentation the physician was notified Patient #59 had an unstageable pressure injury.

Based on The American Nurses Association Scope and Standards of Practice, medical record review, observation and interview, the facility failed to monitor and prevent weight loss in 1 of 3 (Patient #32) sampled patients reviewed for weight loss.

The findings included:

1. A review of The American Nurses Association Scope and Standards of Practice revealed the Standards of Practice describe a competent level of nursing care as demonstrated by the critical thinking model known as the nursing process. Standard 1 is assessment. The Registered Nurse (RN) collects pertinent data and information relative to the patient's health. The RN uses evidence-based assessment techniques, available data, information and knowledge relevant to the situation to identify patterns and variances.

2. Medical record review for Patient #32 revealed an admission date of 5/12/19 with diagnoses which included Cerebrovascular Accident (CVA - a stroke), Right Sided Weakness, Aphasia (Loss of ability to understand or express speech) and Dysphagia (Difficulty in swallowing).

Patient #32's admission weight on 5/12/19 was 73.5 Kilograms (kg) which equals 161.7 pounds (lbs).

A review of Patient #32's weight flowsheet from 5/15/19 to 9/26/19 revealed 21 documented weekly weights of exactly 73.5 kg (161.7 lbs). During this time there was no fluctuation of the patients weight.

There was no documentation the available data of 21 weekly weights of exactly 73.5 kg was identified as a questionable pattern by any nurse or dietitian.

3. Observations on 10/2/19 at 2:55 PM revealed Patient #32 was lying in a hospital bed that weighed patients by pushing the "weigh" button. The button was pushed by a staff nurse and Patient #32's weight was 62 kg which equaled 136 lbs. Patient #32 experienced a 25.7 lb weight loss from his initial documented admission weight of 73.5 kg (162.04 pounds).

Observations on 10/3/19 at 1:46 PM revealed Patient #32 was placed back in the bed and was weighed again on the bed. Nursing stated the bed had been recalculated. Patient #32's weight this time was 65 kg which equaled 143 lbs. This weight was an 18.7 lb weight loss.

There was no documentation nursing or dietary had identified Patient #32 as having a significant weight loss, an assessment to determine if the patient had any special needs following a CVA requiring assistance with meals or interventions for the patient's weight loss.

4. In an interview on 10/2/19 at 3:00 PM the Chief Nursing Officer (CNO) stated Patient #32 did not have orders for weights. She stated that the nurses weigh the patients. She stated that someone has to actually put in the weights in the computer.

In an interview at the nurses' station on 10/3/19 at 9:55 AM, the Clinical Informatics RN stated that the initial weight is entered in the assessment screen. When the dietitian opens the first dietary assessment note, the last entered weight is automatically pulled to the dietary note. Once the dietitian completes the dietary note and electronically signs the note, that weight then defaults back to the weight measurement screen. If no new weight is entered, that process repeats and the weight appears unchanged in the chart.

In an interview at the nurses' station on 10/3/19 at 10:10 AM, Nurse #13 was asked when she would use nursing judgment to weigh a patient if there were no orders. She stated, "I would weigh a patient if labs [values] looked off, if the patient showed signs or symptoms of fluid overload. A total change if I had him [patient] consistently and noticed something."

In an interview at the nurses' station on 10/3/19 at 10:15 AM, the CNO was asked if she expected the nurses to weigh a patient if there was no order. She confirmed that when a patient has a long length of stay there needed to be a process so they were weighed regularly.

The patient was admitted on 5/12/19 weighing 73.5 kg or 161.7 lbs. There was no documentation the patient was weighed from 5/12/19 until 10/2/19 when the surveyor requested a current weight. The facility failed to have an effective system in place to identify significant weight loss and implement interventions to prevent further weight loss.

Based on Medications via Feeding Tube Administration and Medication Administration policy review, medical record review, observation, and interview, the facility failed to ensure nursing service performed wound care for an unstageable wound per physician's order for 1 of 2 (Patient #19) sampled patients with a hospital-acquired unstageable pressure wound and failed to ensure nursing service administered medications per policy for 2 of 7 (Patient #2 and #28) medication administration observations.


The findings included:

1. Medical record review for Patient #19 revealed an admission date of 7/29/19 with diagnoses which included Lymphedema and Multiple Skin and Lower Extremity Wounds. There was no documentation provided by the hospital Patient #19 had a wound on the left upper posterior arm upon admission.

On 8/16/19 at 3:19 PM Wound Ostomy Continence (WOC) Nurse #2 documented Patient #19 had a new unstageable pressure wound to the left upper posterior arm. The wound was identified under the blood pressure cuff on the patient's arm. The wound measured 8 centimeters (cm) X (by) 3 cm X 0.3 cm.

On 8/16/19 at 3:29 PM the patient's physician ordered for nursing to clean the patient's unstageable wound with normal saline, apply Santyl and Vaseline Gauze daily, and secure with abdominal pad and Kerlex.

Review of the wound care flowsheets revealed Surgery Intensive Care Unit (SICU) nursing staff failed to provide daily wound assessments and wound care treatment as ordered by the physician to Patient #19's left upper posterior arm on 8/19/19, 8/21/19, 8/22/19, 8/23/19, 8/24/19, and 8/25/19.

On 8/30/19 Patient #19 was transferred from SICU to a cardiac nursing unit with continued daily wound care orders.

Review of the wound care flowsheets on the cardiac nursing unit revealed nursing service continue to fail to provide daily wound assessments and wound care treatment as ordered by the physician to Patient #19's left upper posterior arm on 9/1/19, 9/9/19, and 9/12/19.

On 9/14/19 Physical Therapy (PT) performed a sharps debridement of Patient #19's unstageable wound. After the debridement the wound measured 4.8 cm X 1.4 cm x 0.3 cm with 95% slough.

Review of the wound care flowsheets revealed nursing staff on the cardiac nursing unit failed to provide daily wound care as ordered by the physician to Patient #19's left upper posterior arm on 9/21/19 and 9/28/19.

Observations on 10/2/19 at 10:53 AM, revealed a debrided wound to Patient #19's left posterior upper arm. The WOC Nurse #2 documented the wound appeared moist with areas of maceration (occurs when skin is in contact with moisture for too long). The surveyor asked the WOCN what stage was the pressure wound to Patient #19's pressure wound following the debridement and the WOCN stated the wound was a Stage 3 and she would recommend changing the wound treatment to Aquacell (Specialized wound dressing).

In an interview in the hospital conference room on 10/3/19 at 9:00 AM, the Chief Nursing Officer (CNO)verified she expected nursing service to follow physician orders for wound care.

In an interview in the hospital conference room on 10/3/19 at 10:00 AM, the System Accreditation Director verified wound care was not performed as ordered by the physician.

The failure to administer wound care treatment as ordered to aid in the healing of the hospital-acquired unstageable wound constituted a SERIOUS AND IMMEDIATE THREAT to the health and safety of Patient #19.

2. The facility policy, "Medications via Feeding Tube, Administration..."revealed, "...Policy...Ensure proper tube placement by instilling 30 ml (milliliters) of air via the tube, while auscultating (listening with a stethoscope) over the left upper quadrant of the abdomen...Carefully aspirated the gastric content. If the aspirated amount is less than 250 ml, return it to the stomach and proceed with medication administration...Crush or dissolve any pills in warm water with exceptions: capsules, enteric coated or time released pills...Draw each medication separately into the syringe and eliminate air. Do not mix medications...Insert syringe into tube and slowly instill the medication..."

The facility policy, "Medication Administration" revealed, "...Policy...Prior to administering any medication, the nurse is expected to be familiar with the medication...and the appropriate routes of administration...Crushing Medications: Enteric coated or sustained-released medication should not be crushed..."

3. Observations on 9/30/19 at 9:25 AM revealed Nurse #8 removed medication from the medication cart and prepared it for administration in the Surgical Intensive Care Unit (SICU) for Patient #2. Nurse #8 opened the following medications: Baclofen 10 milligrams (mg), Ferrous Sulfate 325 mg, Loratadine 10 mg, Metoprolol 50 mg and Lamictal 200 mg. Nurse #8 opened each medication, placed all tablets in a single plastic sleeve and crushed the medication together. In Patient #2's room, after verifying placement and flushing the patient's oro-gastric (OG) tube, Nurse #8 poured the crushed medication into a cup, added 40-50 ml of water, stirred the mixture, administered it via the OG tube, and flushed the tube with 30 ml water.

In an interview at the SICU Nursing Station on 10/2/19 at 8:40 AM, when asked how medication should be given through an OG tube, the SICU Clinical Manager stated, "...Crush, mix, give. Repeat with each medication."

In an interview in the hospital conference room on 10/2/19 at 9:20 AM, when asked if medications given via an oro-gastric tube should be given individually, the Chief Nursing Officer (CNO) stated, "...our policy says to give them one at a time..."

4. Observations on 9/30/19 beginning at 9:17 AM in the Neuro ICU medication room, Nurse #11 was observed crushing an enteric coated aspirin and mixing it in 30 ml of water. At 9:40 AM, Nurse #11 did not auscultate the naso-gastric tube prior to aspirating 90 ml of formula. Nurse #11 was observed to administer the enteric coated aspirin via naso-gastric tube to Patient # 28. After administering medications, the nurse was observed to inject the 90 ml of aspirate back into the naso-gastric tube.

In an interview in the Neuro ICU nurses station, on 10/30/19 at 9:17 AM, Nurse #11 stated, "I did crush enteric coated aspirin."

The facility failed to ensure their policy and procedure for medication administration was followed as evidenced by failing to ensure Patient #2 and Patient #28's medications were administered according to the facility's policy and procedure.

Based on Medication Administration policy review, observation and interview, the facility failed perform hand hygiene before or after glove changes, assess and administer medications per tube, utilize aseptic technique when drawing up medication and following the policy for Lifeport aseptic techniques.

The findings included

The facility failed to implement an effective infection control program to avoid the transmission of infections.
Refer to A-749

Based on policy review, observation and interview, the facility failed to ensure staff implemented measures to prevent the spread of infection and communicable diseases during 1 of 7 (Nurse #11) nurses observed during medication administration, 1 of 4 (Nurse #12) nurses observed during wound care, 2 of 5 (Nurse #2 and #9) nurses observed administering injectable medications, and 1 of 2 (Nurse #10) nurses observed accessing a Lifeport (implanted device to access blood).

The findings included:

1. The facilty policy, "Isolation Precautions with CDC [Center for Disease Control] disease specific precautions attached revealed, "...Handwashing:...Wash hands immediately after gloves are removed..."

2. The facility policy "Subcutaneous Vascular Access Devices Lifeport, Portacath" revealed, "...ACCESSING A VASCULAR ACCESS DEVICE...Cleanse VAD (Vascular Access Device) site using hospital approved antiseptic swab. If using Chlorohexadine Gluconate [CHG - an antiseptic solution], scrub back and forth with a vigorous motion from top to bottom of area for one full minute..."

3. Observations in Patient #28's room on 9/30/19 beginning at 9:17 AM revealed Nurse #11 donned gloves prior to entering the patient's room. Patient #28 was in contact isolation. The nurse did not perform hand hygiene prior to donning gloves.

Observations in the medication room at 9:28 AM revealed Nurse #11 drew up Heparin from a vial, changed the needle on the syringes and donned gloves. The nurse did not perform hand hygiene prior to donning the gloves.

Observations at 9:40 AM revealed Nurse #11 dropped a pill on the floor. The nurse picked the pill up off the floor, took off their gloves and re-gloved. The nurse did not perform hand hygiene prior to donning gloves.

4. Observations on 10/2/19 beginning at 9:26 AM revealed Nurse #12 was performing wound care to Patient #28. The nurse removed the gloves and applied new gloves without performing hand hygiene.

The nurse wiped the patients hip wound with normal saline soaked in a 4 by 4 gauze. The nurse changed gloves and re-gloved without performing hand hygiene. The nurse then applied normal saline to the wound, applied normal saline soaked 4 by 4s and covered the wound with a dry 4 by 4 and abdominal pad.

In an interview at the nurses station on 10/2/19 at 10:20 AM, Nurse Manager #1 stated "They [nurses] have been instructed to do hand hygiene every time gloves are changed."

5. Observations in the Surgical Intensive Care Unit (SICU) on 9/30/19 at 9:25 AM revealed Nurse #8 opened a vial of Pantoprazole 40 milligrams (mg) and reconstituted the medication for Intravenous administration by adding 10 milliliters (ml) of Normal Saline (NS). Nurse #1 failed to clean the top of the medication vial after removing the cap off the vial and prior to the insertion of the needle with NS..

6. Observations on the 8th floor on 9/30/19 at 1:30 PM revealed Nurse #9 opened a new vial of Piperacillin and without cleaning the top of the medication vial, entered the vial with a needless system. Nurse #9 failed to utilize aseptic technique when preparing medications.

In an interview in the Hospital Conference Room on 10/3/19 at 9:20 AM, the Chief Nursing Officer (CNO) verified the top of medication vials should be cleaned before use, even when a new vial is used.

7. Observations in the Medical Intensive Care Unit (MICU) on 10/1/19 at 10:00 AM revealed Nurse #10 cleaning Random Patient (RP) #2's Lifeport site with CHG. Nurse #10 cleaned the site for approximately 30 seconds. Nurse #10 failed to clean the Lifeport site for one full minute per hospital policy.

In an interview in the Hospital Conference Room on 10/3/19 at 9:20 AM, the CNO verified Lifeport sites should be cleaned for one full minute.

Based on review of AORN (Association of peri-Operative Registered Nurses) Journal, policy review, hospital document review, medical record review, observation and interview, the hospital failed to provide surgical services in accordance with acceptable standards of practice by failing to ensure a qualified registered nurse performed circulating duties in the operating room who accurately and efficiently counted the surgical sponges used pre-operative and post-operative, and provided supervision for an Orientee (employee in training) during a surgical procedure for 1 of 3 (Patient #1) sampled surgical patients.

The failure of the hospital to provide surgical services in accordance with acceptable standards of practice, ensure a qualified registered nurse performed circulating duties in the operating room and adequate supervision was provided to an Orientee during a surgical procedure placed all surgical patients in a SERIOUS and IMMEDIATE threat of their health and safety and for the potential of serious adverse occurrences including death.

The findings included:

1. The hospital failed to ensure a qualified registered nurse performed circulating duties in the operating room and adequate supervision was provided to an Orientee during a surgical procedure. This failure led to a patient who initially underwent abdominal surgery, required a second abdominal surgery to remove a surgical sponge that had been left in the patient following the first abdominal surgery.
Refer to A 0944.

Based on review of the AORN [Association of peri-Operative Registered Nurses] Journal, policy review, review of the hospital's job descriptions, personnel file review, medical record review, observation and interview, the hospital failed to ensure a qualified registered nurse performed circulating duties in the operating room and provided adequate supervision to an surgical registered nurse (RN) Orientee (employee in training) during a surgical procedure for 1 of 3 (Patient #1) sampled surgical patients.

The failure of the hospital to implement and follow acceptable standards of practice, and ensure the circulating nurse was qualified to perform duties as a Preceptor and monitor an Orientee resulted in a surgical sponge being left in Patient #1 following abdominal surgery and led to Patient #1 requiring a second abdominal surgery to remove the surgical sponge which resulted in the hospitalization for Patient #1 due to sepsis. This failure placed all surgical patients in the hospital at risk for SERIOUS AND IMMEDIATE THREAT for their health, safety and well-being.

The findings included:

1. Review of AORN Journal February 2012 section titled, Implementing AORN Recommended Practices for Prevention of Retained Surgical Items revealed, "...The National Quality Forum includes RSIs [retained surgical items] on its list of serious reportable events, the Centers for Medicare & [and] Medicaid Services has referred to an RSI as a 'never event,' and RSI is on the list of hospital-acquired conditions that could reasonably have been prevented...Counts are performed to decrease the potential for harm to the patient and to account for all items on the surgical field. Developing 'standardized, transparent, verifiable, reliable practices' is the responsibility of the health care organization...A key element to successful implementation of the recommended practices for prevention of RSIs in an organization is a 'consistent multidisciplinary approach during all surgical and invasive procedures.' Perioperative team members, including the RN [registered nurse] circulator, scrub person, surgeon, anesthesia professionals, and others assisting in the procedure, share responsibility for preventing RSIs...Unnecessary activity and distractions should be avoided during the counting process, and counts or events that would require a count (eg [for example], relief of the RN circulator or scrub person) should not be performed during critical portions of the surgery...The RN circulator and scrub person should follow a standardized procedure for counting, as indicated by the health care's policy, because errors typically result from a deviation in routine practice...The RN circulator should be an active participant in the counting process and should be observant of activities at the sterile field throughout the procedure...Any soft goods opened onto the sterile field, such as towels and sponges, should be counted and added to the count documentation. Initial counts should be performed and recorded to establish a baseline..."

2. Review of the hospital's Counts: Instruments, Sharpes, and Sponges policy revealed, "...Counts will be done on all procedures that meet the criteria contained within this policy. While it is the responsibility of the primary scrub nurse and primary circulator to perform the actual count, all surgical team members should maintain an awareness of the counts being performed and communicate as necessary...Sponge and sharp counts will be taken on all procedures except ophthalmology cases, cystoscopy, superficial skin lesions, non-open arthroscopy and non-open endovascular cases...All sponges (raytex, laps, etc.) will be separated, with band removed, and counted audibly by the primary scrub nurse while one by one being placed in a separate pile. The primary circulating nurse will audible [sic] and visually observe and verify the count with the scrub nurse...All counts will be taken verbally as both circulator and scrub visualize the counted items. Counts will be immediately recorded...All items are to be counted in specific units (e.g. raytex - 10; lap sponges - 5), accounting for total number of raytex/laps used...If an incorrect count is found on initial count (pre-incision), the entire incorrect unit must be removed from the room...Any discrepancies in counts must be corrected immediately. Immediate search for item should be initiated, at the field and the non-sterile area surrounding the OR [operating room] table...All counts (correct and incorrect) must be documented on the intra-operative record..."

Review of the hospital's Orientation of staff to the Operating Room (OR) policy revealed, "...Purpose: To determine the level of competency and individual needs...Policy: A comprehensive three to six month orientation period is provided to the new RN, LPN [licensed practical nurse] or Surgical Technologist employed in the operating room...Procedure: The time frame of orientation will be determined on an individual basis according to skills assessment. Orientation will include but not limited to...Patient Safety...Policies and Procedures...Surgical Instrumentation...Surgical Procedures...Scrubbing and/or Circulating...Skills Assessment and Orientation Checklist will be completed during the orientation period and/or when specific procedures are performed..."

3. Review of the hospital's Job Description for the Operating Room Staff Registered Nurse revealed, "...Responsible for providing optimal patient care, addressing age specific needs, in the assigned single operating room in scrub and/or circulating capacity...Essential Job functions...Insures correct sponge, needle, and instrument counts..."

Review of the hospital's Job Description for the Licensed Practical Nurse OR revealed, "...Responsible for aiding the professional nurse or physician in providing optimal patient care, addressing age specific needs, in the assigned single operating room in a scrub capacity... Essential Job Functions...Insures correct sponge, needle, and instrument counts..."

4. Review of the hospital's Preceptor Expectations included general guidelines for the preceptor such as maintaining constant supervision, serve as an appropriate role model and follow hospital and unit polices and procedures. There were no specific instructions or delineation of responsibilities for the preceptor-Orientee relationship.

5. Review of the hospital's personnel file for RN #1 (surgical Preceptor) revealed the RN had a date of hire at the hospital on 1/18/18 as a graduate nurse.
RN #1 received initial RN license on 2/15/18.
On 2/16/18 RN #1 was performing as a nurse resident (licensed nurse in orientation).
On 4/29/18 RN #1 obtained a Bachelor of Science in Nursing (BSN) degree.

Review of the Learning Transcript for RN #1 revealed the RN had completed the training for prevention of retained surgical items on 12/31/18.

Review of the Preceptor Expectations form revealed RN #1 had signed the form on 3/5/18 as a nurse resident. There was no documentation RN #1 received any instruction or training on the specific responsibilities and requirements for being a preceptor.

Review of the hospital's personnel file for RN #2 (surgical Orientee) revealed a date of hire on 7/9/18 as a Patient Care Technician.
On 6/11/19 RN #2 was now a graduate nurse employee of Hospital #1.
On 7/14/19 RN #2 received the initial RN license.
On 7/16/19 RN #2 as a nurse resident employee of Hospital #1.
On 9/29/19 RN #2 was a RN/BSN.

Review of the cumulative Learning Transcript for RN #2 (surgical Orientee) revealed the RN had not completed the training for prevention of retained surgical items. RN #2 initialed she had received the policy for counting instruments, sharps and sponges and completed a 6 question test for surgical counts on 8/13/19. There was no documentation RN #2 received training or demonstrated skills competency in surgical counts of surgical sponges.

Review of the hospital's personnel file for LPN #1 revealed a date of hire of 9/22/14 as a Surgery Support Technician.
On 3/3/19 LPN #1 was listed as a LPN/Operating Room (OR).

Review of the Learning Transcript for LPN #1 revealed the LPN had not completed the training for prevention of retained surgical items but on 6/17/19 on the Age Specific Competency Checklist LPN #1 it was documented the LPN had demonstrated competency in surgical counts.

6. Medical record review for Patient #1 revealed the patient presented to the hospital's emergency department (ED) on 10/7/19 with the chief complaint of abdominal pain, nausea and vomiting and loose stools. The patient was alert, oriented, and coherent with clear speech. The patient was cooperative and had appropriate mood, affect and normal judgement.

The patient's history included small bowel obstruction, coronary artery disease, status post coronary bypass graft, diastolic congestive heart failure, chronic obstructive pulmonary disease, Stage 3 chronic kidney disease, rheumatoid arthritis and chronic pain. The patient was diagnosed with a small bowel obstruction likely secondary to adhesions and admitted to the hospital for surgery.

Review of the Patient #1's laboratory results revealed the patient's creatinine level on 10/7/19 was 2.36 (normal creatinine level 0.6-1.2 - measures kidney function). The patient's blood urea nitrogen (BUN) on 10/7/19 was 31 (normal being 7 - 12, measures kidney function).

Review of the electronic Surgical Summary document dated 10/8/19 revealed Patient #1 entered the operating room at 1:05 PM. Patient #1 underwent a small bowel resection with lysis of adhesions by Physician/Surgeon #1. (a Small bowel resection is surgery to remove part or all of your small bowel. It is done when part of your small bowel is blocked or diseased. The small bowel is also called the small intestine. Adhesions are bands of scar tissue that can grow anywhere inside your body. Common places for adhesions to grow are in your abdomen and pelvis. Lysis of adhesions is a surgical procedure that removes this soft scar tissue).
RN #1 (surgical Preceptor), RN #2 (surgical Orientee) and RN #3 (who was not listed on the Surgical Summary as staying for the surgical procedure) were each listed as "Circulator" for the patient's surgery. There was no documentation on the surgical report identifying RN #1 as the Preceptor and RN #2 as the Orientee.

Review of the handwritten document titled General Surgery Count Sheet dated 10/8/19 which is used in surgery but is not a part of the patient's medical record revealed the initial surgical sponge count was documented as 25 and the closing and final post operative surgical sponge counts were documented as correct.
Under the title of the sheet were the instructions that stated to "Place Initials of Persons Performing Counts". There were no initials on the sheet indicating who performed the initial or final surgical sponge counts, no documentation who counted the surgical sponges or the time when the surgical sponges were counted. The names on the bottom of the sheet were listed as RN #1 (Preceptor) and RN #2 (Orientee) were the circulating nurse, LPN #1 was the scrub nurse and Physician #1 was the surgeon.

Review of the electronic Surgical Summary sheet revealed the initial surgical sponge count was performed by RN #2 (Orientee) and LPN #1 (scrub nurse) and documented as "correct". The closing/final post operative surgical sponge count was performed by RN #2 (Orientee) and LPN #1 (Scrub nurse) and verified as correct. There was no documentation RN #1 (Preceptor) had been involved with the initial and final surgical sponge count for Patient #1 and provided oversight of RN #2 (Orientee).

Patient #1's surgery was completed surgery on 10/8/19 at 2:47 PM. The patient was transferred to the Post Anesthesia Care Unit (PACU) for recovery and then was transferred from PACU back to his room.

Review of a post operative Physician Progress Note dated 10/9/19 by Physician/Surgeon #1 revealed Patient #1 complained, "he is in a lot of pain today". Physician/Surgeon #1 noted the patient's creatinine level had increased to 3.29.

Review of the post-operative Physician Progress Note dated 10/9/19 by Physician/Hospitalist #2 (a hospitalist is a physician who works for Hospital #1) revealed Patient #1 complained of abdominal pain the morning of 10/9/19.

Review of the post-operative Physician Progress Note dated 10/10/19 by Physician/Surgeon #1 revealed Patient #1 was experiencing increased confusion and the patient's kidney function had worsened with a BUN level increased to 52 and the patient's creatinine level increased to 4.27. The Physician/Surgeon order for the patient to be transferred to the Intensive Care Unit (ICU) and to initiate the sepsis protocol. (Sepsis a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death).

On 10/10/19 Patient #1 was transferred to the hospital's Medical Intensive Care Unit (NICU) due to encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition, such as viral infection or toxins in the blood).) and anemia (excess of immature white blood cells also called band cells which signifies infection or inflammation).

Review of the post-operative Physician Progress Note dated 10/10/19 by Physician/Hospitalist #2 revealed Patient #1 was "very confused today, actually called 911 for help". A renal ultrasound was ordered and a nephrologist (kidney physician) consultation was ordered.

Review of the post-operative Physician Progress Note dated 10/10/19 by Physician/Nephrologists #5 revealed the patient had "acute kidney injury...worsening renal function, not improving...".

Review of the post-operative Physician Progress Notes dated 10/11/19 by Physician/Infectious Disease Specialist #3 revealed the patient had agitation, and hallucinations due to possible sepsis. Physician/Infectious Disease Specialists #3 documented the ultrasound results "suggests" a foreign body had been retained in the patient possibly post-operatively.

Review of the ultrasound results date 10/11/19 revealed, "...foreign body projects over the abdomen, which could represent a retained [surgical] sponge...".

Review of the Physician Progress Notes dated 10/11/19 revealed Physician/Surgeon #1 discussed the retained surgical sponge with the patient's family, and the family gave permission to proceed with surgery to remove the surgical sponge from the patient's abdomen with a second surgery.

Review of the electronic Surgical Summary report dated 10/11/19 at 3:39 PM, Patient #1 underwent a second surgical procedure to remove the surgical sponge in the abdomen. An x-ray was performed at the completion of the surgery and verified the surgical sponge had been removed and there were no other surgical sponges retained in the abdomen of Patient #1.

Review of the post-operative Physician Progress note following the second surgery dated 10/12/19 at 10:07 AM revealed Physician/Hospitalist #2 documented the patient remained intubated (intubated is to insert a tube into the patient's airway to help them breathe) and sedated post-operatively. The Physician/Hospitalist documented the patient's renal function had worsened overnight.

Review of the post-operative Physician Progress note following the second surgery dated 10/12/19 at 4:22 PM revealed Physician/Hospitalist #2 documented the patient's creatinine "was worse...not improving...".

Review of the post-operative Physician Progress note following the second surgery dated 10/13/19 at 10:45 AM revealed Physician/Hospitalist #2 documented Patient #1 remained intubated and was, ".following some commands...not cooperative...not appropriate mood & [and] affect...". The Physician/Hospitalist #2 documented the patient now required hemodialysis (hemodialysis is a process using a machine to remove excess fluids and poisons from the body) and also a wound vac (a device used on open wounds to remove fluid secretion and enhance and wound healing).

7. Observations during the survey in Patient #1's room on 10/21/19 at 2:00 PM revealed Patient #1 was lying in the bed with a nasogastric tube in place (a nasogastric tube (NG tube) is a special tube that carries food and medicine to the stomach through the nose).
Patient #1 had been extubated (extubated means the tube had been taken out of the patient's airway) and the patient now had an oxygen mask on to assist with breathing.
Observed also was a urinary catheter to bedside drainage bag and soft restraints attached to his bilateral wrists. Patient #1 was arousal to voice but had a decreased level of consciousness and only able to respond to yes-no or simple questions.

8. In an interview in the conference room on 10/21/19 at 12:00 PM, RN #2(surgical Orientee) confirmed she had performed the initial count of surgical sponges with LPN #1 (scrub nurse) during the surgical procedure for Patient #1 on 10/8/19. RN #2 (surgical Orientee) verified the initial count of surgical sponges was 25.
RN #2 (surgical Orientee) stated when she and LPN #1 (scrub nurse) performed the final count at the end of the surgical procedure, the surgical sponge count was 24.
RN #2 (surgical Orientee) stated she and LPN #1 (scrub nurse) found a dirty surgical sponge under a towel on the table which made the surgical sponge count 25.
RN #2 (surgical Orientee) stated she, RN #1 (Preceptor) and LPN #1 (scrub nurse) all believed the surgical sponge count was correct. Rn #2 (surgical Orientee) stated that RN #1 (Preceptor) documented the surgical sponge count was correct on the Surgical Summary form.
RN #2 (surgical Orientee) stated the procedure for counting surgical sponges was for the scrub nurse to physically hold and count the sponges, and the circulating nurse would observe and count at the same time.
RN #2 (surgical Orientee) stated she had worked with RN #1 (Preceptor) one other time previously and confirmed RN #1 was her preceptor for this surgical case.

In an interview in the conference room on 10/21/19 at 2:14 PM, the Chief Executive Officer (CEO) stated Physician/Surgeon #1 discovered the retained sponge, and he notified the Administrator on call who then, notified her about the incident. The CEO stated the hospital would do a root cause analysis to determine how the incident could have happened, and the hospital would be looking into the Preceptor program for possible concerns.
The CEO stated RN#1 was precepting RN #2 during this surgical procedure.
The CEO stated RN #2 was terminated from employment, because this was the second patient safety event by her.

In an interview in the conference room on 10/22/19 at 8:08 AM, the Executive Director of Perioperative and Respiratory Services stated the surgery department hired RN #1 (Preceptor) a little over a year ago.
The Executive Director of Perioperative and Respiratory Services stated the typical orientation for a nurse in the surgery department was approximately 6 months, but the surgery department extended RN #1's orientation until she was ready to be on her own.
The Executive Director of Perioperative and Respiratory Services stated RN #1 (Preceptor) had received disciplinary action approximately 1 ½ months prior to this incident because she transported a surgical patient to the wrong operating room.
The Executive Director of Perioperative and Respiratory Services stated the initial surgical sponge count was wrong for Patient #1's surgical procedure on 10/8/19 and confirmed RN #1 (Preceptor) failed to appropriately count the surgical sponges and supervise RN #2 (surgical Orientee).

In an interview in the conference room on 10/22/19 at 10:47 AM, LPN #1 (scrub nurse) confirmed he was the scrub nurse during the surgical procedure for Patient #1 on 10/8/19.
LPN #1 (scrub nurse) stated he counted 25 sponges during the initial count with RN #2 (surgical Orientee).
LPN #1 stated he counted 24 surgical sponges during the final surgical sponge count but found a dirty surgical sponge wrapped up in a dirty towel which made the count correct with 25.

In an interview in the conference room on 10/22/19 at 10:47 AM, the Clinical Coordinator of General and Plastics Surgery stated she was notified by Physician/Surgeon #1 that Patient #1 had a retained surgical sponge post operatively.
The Clinical Coordinator of General and Plastics Surgery stated she reviewed the documentation to see who was in the operating room during the case and interviewed the staff.
The Clinical Coordinator of General and Plastics Surgery stated RN #1 (Preceptor) was very nonchalant and shrugged her shoulders when she was informed about the retained surgical sponge in Patient #1.
The Clinical Coordinator of General and Plastics Surgery stated the surgical sponges used in this surgery were packaged in a container with 25 sponges.
The Clinical Coordinator of General and Plastics Surgery stated there had been instances when the count of surgical sponges in the containers were incorrect.
The Clinical Coordinator of General and Plastics Surgery stated there was a surgical case on 10/21/19 where the count of surgical sponges in the container was 26.

In an interview in the conference room on 10/22/19 at 12:52 PM, Physician/Surgeon #1 stated he learned of the retained surgical sponge from the results of the ultrasound that was performed on Patient #1 on 10/11/19.
Physician/Surgeon #1 stated he was told by the surgical staff the surgical sponge counts were correct during and after the procedure and was surprised to see the surgical sponge on the patient's x-ray.
Physician/Surgeon #1 stated since the incident had occurred with Patient #1, he learned the surgical sponges come packed in a container of consisting of 25 surgical sponges.
Physician/Surgeon #1 denied ever hearing before this incident of any cases where the containers of surgical sponges had been incorrect.

In a phone interview on 10/22/19 at 12:52 PM, RN #1 (Preceptor) confirmed she was the circulating nurse during the surgical procedure for Patient #1 on 10/8/19.
RN #1 (Preceptor) stated she had gone to lunch before the surgery case had started, and when she returned RN #2 (surgical Orientee) and LPN #1 (scrub nurse) had already performed the initial count of surgical sponges.
RN #1 confirmed she was assigned as the preceptor for RN #2 (surgical Orientee) but stated she had never been given any instructions on what her responsibilities were as a preceptor.
RN #1 (Preceptor) stated she was told by LPN #1 (scrub nurse) and RN #2 (surgical Orientee) the initial surgical sponge count was correct.
RN #1 (Preceptor) verified she documented the surgical sponge count as correct in the Patient #1's medical record. RN #1 stated she could not recall the sequence of events concerning the final counts of the surgical sponges but stated RN #2 (surgical Orientee) and LPN #1 (scrub nurse) performed the surgical sponge counts.
RN #1 stated she was never asked to be a preceptor or if she was comfortable serving as a preceptor.

In a phone interview on 10/22/19 at 2:50 PM, the RN Educator for Perioperative Services stated she would typically make preceptor assignments for the following day.
The RN Educator for Perioperative Services stated preceptors were responsible for supervising Orientee and should never leave them alone.
The RN Educator for Perioperative Services stated the hospital did not have an official training program to train preceptors and confirmed there was no documentation to delineate the preceptor's specific responsibilities.

In a phone interview on 10/22/19 at 2:58 PM, RN #2 (surgical Orientee) stated she remembered RN #1 (Preceptor)was in the operating room during the initial surgical sponge count for the surgical procedure for Patient #1 on 10/8/19.
RN #2 (surgical Orientee) stated RN #1 (Preceptor) did not count the surgical sponges or observe the counting of the surgical sponges with her and LPN #1 (scrub nurse) during the initial count of the surgical sponges.

In a phone interview on 10/22/19 at 3:06 PM the RN Educator for Perioperative Services stated she had asked LPN #1 (scrub nurse) if RN #1 (Preceptor) was in the operating room during the initial count of the surgical sponges for the surgical procedure for Patient #1 on 10/8/19.
The RN Educator for Perioperative Services stated LPN #1 (scrub nurse) responded that he could not remember if RN #1 (Preceptor) was in the operating room during the initial count of the surgical sponges but did remember RN #1 (Preceptor) had left the operating room during one of the surgical sponge counts to obtain further supplies.

The hospital failed to ensure that the Standards of Peiopertive Nursing were met for Patient #1 on 10/8/2019 as evidenced by the hospital failing to ensure the following standards for the surgical staff were implemented, "...Coordination of care...Delegates tasks and functions according to applicable laws, regulations, and standards taking into consideration the competency of the assignee...Education...Completes an individualized orientation based on identified needs...Demonstrates skill proficiency relevant to peri operative nursing practice...Seeks experience to maintain skills and competency necessary to practice periopertive nursing...Maintains records and documentation to support competencies in Peri operative nursing..."