HospitalInspections.org

Based on policy review, it was determined the facility failed to ensure there was a written policy regarding abuse of a patient by a staff member. The failed practice did not allow the facility to be knowledgeable, proactive, and timely in responding to allegations of patient abuse by staff and could affect any patient alleging abuse. Findings follow.

A. An abuse policy was requested upon entrance to the facility on 10/26/15 at 1230, again on 10/28/15 at 0900 and 1400, and on 10/29/15 at 1300.
B. A policy was requested from the Chief Nursing Officer, the Administrative Assistant, and the Director of Quality.
C. No abuse policy was ever provided for review.

Based on review of clinical records, review of Arkansas State Board of Nursing Scope of Practice and interview, it was determined the facility failed to assure patient assessments were conducted by a Registered Nurse (RN) for one (#9) of three (#7, #9, #10) patients admitted to the Women's Center. Failure to assure patient assessments were performed by RNs did not assure interventions were planned based on assessment findings. The failed practice was likely to affect all patients admitted to the Women's Center. Findings follow:

A. Review of Arkansas State Board of Nursing Scope of Practice ACA 17-87-102(6)(A-E) revealed the Practice of Professional (Registered) Nursing: the delivery of health care services which require assessment, diagnosis, planning, intervention and evaluation fall within the professional nurse scope of practice.
B. Review of Arkansas State Board of Nursing Scope of Practice ACA 17-87-102(5) revealed the Practice of Practical Nursing: the delivery of health care services which are performed under the direction of the professional nurse, licensed physician, or licensed dentist, including observation, intervention and evaluation, fall within the LPN/LPTN (Licensed Practical Nurse/Licensed Practical Technical Nurse) scope of practice.
C. Review of the Patient Flowsheet Report dated 10/26/15 at 0740 revealed an LPN conducted the patient's assessment. There was no evidence an assessment was conducted by an RN.
D. Review of the Patient Flowsheet Report dated 10/27/15 at 0800 revealed an LPN conducted the patient's assessment. There was no evidence an assessment was conducted by an RN.
E. During interview with the Director of the Women's Center on 10/29/15 at 1500 when asked about LPN's conducting assessments, she stated LPN's conducted assessments but the RN co-signed their findings. When asked if the RN conducted her own assessment, she answered, "no".
F. Findings listed as A-D were confirmed on interview with the Director of the Women's Center on 10/29/15 at 1400.

Based on clinical record review and interview, it was determined Mefoxin (antibiotic medication) was not administered as ordered for one of one (#9) patients undergoing Cesarean section. Failure to administer medications as ordered prevented the patient from receiving the medication as prescribed, did not assure the physician agreed with the change in the medication administered, and did not assure the individual needs of the patient would be met to prevent infection. The failed practice was likely to affect all patients admitted to the Women's Center. Findings follow:

A. Review of OB (Obstetric) C (Cesarean)-Section Post-partum Orders for Patient #7 dated 10/25/15 revealed Mefoxin 2 gm (gram) IVPB (intravenous piggy back) q (every) 8 hours x (times) 3 doses starting @ (at) 1700.
B. Review of Medication Administration record dated 10-25-15 through 10-27-15 for Patient #7 revealed no evidence Mefoxin 2 gm was administered.
C. Findings were confirmed on interview with the Director of the Women's Center on 10/29/15.

Based on observation and interview it was determined the facility failed to have a policy about medical records storage and failed to store medical records properly in that 20 cases of medical records were stored on the ground and could not be protected from water/flood. By not storing medical records properly, the facility could not assure the integrity of the records. The failed practice had the likelihood to affect all patients' records stored in medical records. The findings follow:
A. On a tour of the Health Information Management Department on 10/26/15 at 1500 with the Director of Health Information Management Department, observation revealed 20 boxes of Medical Records stored on the floor.
B. Review of Health Information Management Department policies on 10/26/15 and 10/27/15 revealed they did not have a policy addressing the storage of medical records and protecting them from water/flood.
C. During an interview on 10/26/15 at 1555, the Director of Health Information Management Department verified the findings in A-B.

Based on observation and interview, it was determined the facility failed to assure propofol (a medication used to render patients unconscious during anesthesia) was not accessible to housekeeping (unlicensed) personnel in one of one (Same Day Procedure) procedure room. Failure to assure propofol was not accessible to unlicensed personnel did not assure unauthorized use of the drug did not occur. The failed practice was likely to affect all persons working in the Same Day Procedure Room. Findings follow:

A. On observation 10/27/15 at 1420 in the Same Day Procedure Room, a large red sharps container was upright on the floor next to the Anesthesia machine. The lid to the container was hinged in the middle and folded back exposing half the opening (measuring approximately six inches by six inches in diameter) into the container. The container was over half filled with used syringes containing verious liquids. On observation, the container contained in excess of 15 manufacturer's pre-filled syringes containing white liquid labeled "propofol".
B. During interview with the Chief Nursing Officer at the time of observation, when asked if housekeeping staff cleaned the room, he answered, "yes". Findings listed as A were verified on interview with the Chief Nursing Officer at the time of observation.



31039

Based on observation, review of policy and interview, it was determined the facility failed to control Lorazepam in two (Intensive Care Unit (ICU) and Emergency Department (ED)) of three (ICU, ED and Labor and Delivery (L&D)) medication refrigerators containing controlled substances in that Lorazepam was accessible to everyone who entered the refrigerator. By not locking the Lorazepam within the refrigerator, any discrepancy of Lorazepam potentially could go unnoticed until the next time it was dispensed, when a blind count was required. The failed practice had the likelihood to affect the accountability of the controlled substance. Findings follow:

A. During a tour of the facility on 10/27/15 from 1300 to 1421, observation revealed the following:
1) ICU medication refrigerator contained seven Lorazepam 2 milligram/milliliter (mg/ml) 1 ml vials not locked within the refrigerator; and
2) ED medication refrigerator contained five Lorazepam 2 mg/ml 1 ml vials not locked within the refrigerator.
B. Review of Pharmacy policy titled Storage: General stated "Drugs shall be stored under the proper conditions of sanitation, temperature, light, moisture, ventilation, segregation, and security".
C. Findings were verified at the time of observation with the Operating Room Charge Nurse.
D. During an interview on 10/27/15 at 1530, the Director of Pharmacy verified the Lorazepam was to be locked within the refrigerator.

Based on review of IV (intravenous) Admixture competencies, policy and interview, it was determined the facility failed to ensure annual re-certification of IV Admixture technique for all personnel trained to compound medications in the Laminar Flow Hood per policy. The failed practice did not assure the sterility or accuracy of the medications compounded. The failed practice had the likelihood to affect all patients who received medications compounded in the Laminar Flow Hood. Findings follow:

A. Review of IV Admixture competencies revealed the required (per policy) media-fill portion of the annual testing had not been completed since 2013.
B. Review of policy titled Sterile Products: Education and Qualifications stated "Compounding personnel shall pass media-fill testing of aseptic manipulative skills initially and on an annual basis ...Documentation shall be maintained in the pharmacy department."
C. During an interview with the Director of Pharmacy on 10/28/151530 at 0930, the Director stated the last evidence of media-fill portion of the annual testing for competencies was from 2013.

Based on observation, review of manufacturer recommendations and interview, it was determined the facility failed to follow manufacturer recommendations in that medication was observed improperly labeled in two of two (Anesthesia Cart #1 and 2) Anesthesia Carts. The facility could not assure the safety or efficacy of the medication. The failed practice had the likelihood to affect all patients that have had procedures using the medication. Findings follow:

A. During a tour of the facility on 10/27/15 from 1300 to 1421, observation revealed Anesthesia Cart #1 had a vial of Succinylcholine and was dated 11-20-15. The label had a 30 day expiration date on it. Anesthesia Cart #2 had two vials of Succinylcholine that were dated 11-10-15. These labels were dated with a 30 day expiration date.
B. Review of manufacturer's recommendation for storage of Succinylcholine Chloride revealed the "multi-dose vials are stable for up to 14 days at room temperature without significant loss of potency." The facility did not have a process to assure the Succinylcholine Chloride was not in use beyond the 14 days, once removed from refrigerated storage.
C. During an interview on 10/27/15 at 1325, Certified Registered Nurse Anesthetist #1 verified the date on the vials were a 30 day expiration date.

Based on observation, temperature log review, policy review, and interview, it was determined the facility failed to ensure temperatures of refrigerators and freezers in the kitchen were documented three times daily as required per policy from 07/01/15 through 10/29/15. The failed practice created the potential for a refrigerator or freezer malfunction to go unnoticed and could affect any patient receiving food from those areas. Findings follow.

A. Review of policy titled "Purchasing, Receiving and Storage" stated, "Each freezer is provided with a thermometer and is checked three times a day so that proper temperature is maintained" and "Each refrigerator is provided with a thermometer and is checked at least three times daily so that proper temperatures are maintained."
B. Review of temperature logs from 07/01/15 through 10/29/15 revealed temperatures were not documented three times per day.
C. During an interview on 10/29/15 at 0940 the Foodservice Director confirmed the temperatures were not documented three times per day.

Based on clinical record review and interview, it was determined the facility failed to ensure meal consumption was documented for two of two (#3 and #5) inpatients requiring therapeutic diets. The failed practice did not allow medical personnel to assess the patient ' s diet tolerance and had the potential to affect any patient on a therapeutic diet. Findings follow.

A. Review of clinical records revealed the following:
1) Patient #3 had a diabetic diet ordered on 10/25/15 at 1100 and a pureed diet at 1515 - five of five possible meals were not documented
2) Patient #5 had a cardiac diet ordered on 10/25/15 at 0300 - four of ten possible means were not documented.
B. During an interview on 10/29/15 at 1510, the Director of Health Information Management confirmed the missing meal documentation

Based on observation, it was determined the facility failed to maintain the building physical structure, environment and equipment in a state of good repair. In two of eight areas (PACU, ICU, surgical area, procedure rooms, 2nd-floor sleeping areas, 1st-floor sleeping areas, dining area, and Women ' s Center ) observed had damaged surfaces and rust on metal surfaces. The failed practice had the potential to affect all patients, staff, and visitors due to potential injury. Findings follow:

A. On a tour of the Facility on 10/27/2015 at 1300 with the OR Charge Nurse, the following observations were made and verified:
1) Rust on the door-closer of the door located in front of the Flash Autoclave unit in the surgical area.
2) Cracks in the lamination around the Nurses' station in PACU.

Based on observation, review of manufacturer's directions for use and interview, it was determined the Infection Control Officer failed to control infection in that one of one (#2) Registered Nurse observed failed to disinfect the glucometer device and case after performing glucose testing and prior to returning them to the nursing station for one of one glucose testing observed. The failed practice promoted the spread of infection and had the potential to affect all patients on which the glucometer was used. The findings follow:

A. Observation on 10/26/15 at 1530 revealed Registered Nurse #2 took the glucometer and the glucometer case to the patient's room to perform glucometer testing. Registered Nurse #2 placed the glucometer case and device on the patient's bedside table next to a urinal with urine. Registered Nurse #2 performed the glucose testing on the patient then returned the glucometer device and case to the docking station at the nurses' station. Registered Nurse #2 did not disinfect the glucometer device or the glucometer case prior to returning them to the nurses' station.
B. The findings of A were confirmed in an interview with the Director of Clinical Support Services on 10/26/15 at 1535.
C. Review of the Accu-Chek Inform II directions for use on 10/28/15 revealed, "All parts of the glucose monitoring system should be considered potentially infectious and are capable of transmitting blood-borne pathogens between patients and healthcare professionals. Disinfect the meter after use on each patient. The Accu-Check Inform II system may only be used for testing multiple patients when Standard Precautions and the Accu-Chek Inform II system disinfecting procedures are followed."
D. The findings of C were confirmed in an interview with the Chief Nursing Officer on 10/28/15 at 0850.


Based on observation and interview, it was determined the Infection Control Officer failed to control infection in that one (Operating Room Registered Nurse #1) of two (Operating Room Registered Nurse #1 and Certified Registered Nurse Anesthetist #1) staff failed to disinfect the rubber septum of a medication vial prior to instilling Normal Saline into the vial. The failed practice did not ensure the rubber septum was clean of contaminants prior to the instilling of the Normal Saline. The failed practice had the potential to affect all patients in the Operating Room. The findings follow:

A. Observation on 10/27/15 at 0755 revealed Operating Room Registered Nurse #1 removed the plastic top off of a medication vial then instilled Normal Saline into the vial of medication. Operating Room Registered Nurse #1 did not disinfect the rubber septum with alcohol prior to instilling the Normal Saline into the vial.
B. The findings of A were confirmed in an interview with the Operating Room Director on 10/27/15 at 0945.


Based on observation, policy and procedure review and interview, it was determined the Infection Control Officer failed to control infection in that one (Operating Room Registered Nurse #1) of four (Operating Room Registered Nurse #1, Certified Registered Nurse Anesthetist #1 and Operating Room Technician #1 and #2) staff failed to wear a mask over her nose in Operating Room Suite #1. The failed practice had the potential to spread infection and had the potential to affect Patient #31. The findings follow:

A. Observation on 10/27/15 from 0800 to 0815 revealed Operating Room Registered Nurse #1 wore her mask below her nose in Operating Room Suite #1.
B. Review of the Policy "Infection Control Practices" on 10/28/15 revealed, "Wear the Operating Room cap to ensure complete hair coverage, and a clean mask is placed over the nose and mouth and tied securely to prevent venting at the sides."
C. The findings of B were confirmed in an interview with the Chief Nursing Officer on 10/28/15 at 0825.


Based on observation and interview, it was determined the Infection Control Officer failed to control infection in that Environment Services Employee #1 failed to dispose of and change cleaning cloths after cleaning each surface of Operating Room Suite #3. The failed practice had the potential to cause cross contamination and had the potential to affect all patients in the Operating Room. The findings follow:

A. Observation on 10/27/15 from 0915 to 0930 revealed Environmental Services Employee #1 disinfected the patient operating room bed, the IV (intravenous) pole and the legs of the pole, the over-head lights, four tables and the legs of the table, two stands and the legs of the stands, the SCD (sequential compression device) machine then the patient operating room bed again. Environmental Services Employee #1 used the same rag to disinfect all the surfaces of the operating room suite.
B. In an interview with the Operating Room Director on 10/27/15 at 0945, she confirmed the Operating Room used AORN (Association of Perioperative Registered Nurses) standards of practice. She confirmed Environmental Services Employee #1 should have changed her disinfecting rag after each surface.


30580

Based on review of sterile package labeling, observation and interview, it was determined the Infection Control Officer failed to control infections by not assuring sterile supplies (i.e. oxygen tubing, oxygen masks, suction tubing, suction catheters, nasal cannulas) were not open and available for patient care in five (Operating Rooms #1 and #4, Minor Room, Intensive Care Unit Rooms #7 and #8) of seven (Operating Rooms #1, #2, #4, Minor Room, Pain Room, Intensive Care Unit Rooms #7 and #8) areas. Failure to assure sterile supplies were not opened did not assure patients were not exposed to contaminants. The failed practice was likely to affect all patients admitted to the hospital. Findings follow:
A. During tour of the facility on 10/27/15 from 1300-1430 with the Chief Nursing Officer the following were observed:
1) In Operating Room (OR) #1 which was clean and ready to receive a patient, an opened package of sterile suction tubing and an opened package of oxygen connection tubing were observed hanging on the Anesthesia machine and available for patient use. Review of both packages revealed, "Do not use if package is opened";
2) In OR #4 which was clean and ready to receive a patient, an opened package of sterile suction tubing was hanging on the Anesthesia machine and available for patient use. Review of the package label revealed, "Do not use if package is opened";
3) In the Minor Room which was clean and ready to receive a patient, a nasal cannula was connected to oxygen tubing and hanging on the side of the endoscope cart as well as an oxygen mask with tubing hanging on an IV (intravenous) pole and was available for patient use;
4) In Intensive Care Unit (ICU) Rooms #7 and #8 which were clean and ready to receive patients, opened packages of sterile suction tubing with Yankauer suction catheters attached were located in built-in racks at the heads of each bed and were available for patient use.
B. Findings listed as A were verified on interview with the Chief Nursing Officer at the time of observation.


Based on observation and interview, it was determined the Infection Control Officer failed to control the spread of contamination by not assuring endoscopic biopsy forceps were not stored touching the floor; gas cords were not secured with tape; chair upholstery was not cloth; arm boards were free of tape and tape residue; linen was stored covered; rust and dust was not on gas delivery columns; microwaves used for patient nutrition were free of residue; and supplies were not stored in cardboard boxes in five (Operating Room #1, Minor Room, Medical Surgical Unit, Same Day Procedure Room, Respiratory Therapy Storage Room) of nine (Operating Room #1, #2, #4, Minor Room, Intensive Care Unit Nutrition Area, Rooms #7 and #8, Same Day Procedure Room and Respiratory Therapy Storage Room) areas. The failed practices did not assure the ability to clean/disinfect surfaces of equipment or that equipment was free of contaminants. These failed practices were likely to affect all patients admitted to the facility. Findings follow:

A. During tour of the facility on 10/27/15 from 1300-1430 with the Chief Nursing Officer the following was observed:
1) In Operating Room #1 on the back of the Anesthesia machine, a purple cord was coiled and held together with clear tape. Tape has a sticky residue and can harbor contaminants. Rust, which has a porous nature and cannot be disinfected, and dust was on the gas delivery column which did not assure it was clean.
2) In the Minor Room, biopsy forceps, hanging on a wall were touching the floor which did not assure they remained clean.
3) In the Intensive Care Unit Nutrition Area, a microwave used for patient nutrition had a brown residue inside which did not assure it was clean.
4) In the Same Day Procedure Room, the Anesthesia chair was covered in cloth upholstery. Cloth is absorbent and cannot be disinfected. Tape was on the bed's arm board. Tape has a sticky residue and can harbor contaminants. Linen, stored in a closet was uncovered which did not protect it from contamination.
B. During tour of the Respiratory Therapy Storage Room with the Director of Respiratory Therapy on 10/28/15 at 1440, sterile and clean supplies were stored in cardboard boxes. Cardboard has an absorbent nature and cannot be disinfected.
C. Findings listed as A were verified during interview with the Chief Nursing Officer at the time of observation. Findings listed as B were verified on interview with the Director of Respiratory Therapy at the time of observation.


Based on review of KimGuard Sterilization Wrap manufacturer's directions for use, observation and interview, it was determined the Infection Control Officer failed to control the spread of contamination by not assuring sterile wrapped instrument sets were not stacked on top of one another in one of one (Sterile Instrument Room) area. Failure to assure sterile instrument sets were not stacked did not assure their sterility was not compromised from crushing which could allow contamination to enter the packages. The failed practice was likely to affect all surgical patients admitted to the facility. Findings follow:

A. On observation 10/27/15 at 1335 in the Sterile Instrument Room, greater than 11 sets of wrapped sterile instruments were on shelves and available for patient use.
B. Review of KimGuard Sterilization Wrap manufacturer's directions for use provided by the Operating Room Director revealed, "Caution, do not stack trays. Stacking trays can result in damage to the wrap caused by undue pressure from the weight".
C. Findings listed as A was verified on interview with the Operating Room Charge Nurse at the time of observation.


Based on observation and interview, it was determined the Infection Control Officer failed to control the spread of contamination by not assuring sharps containers containing medication syringes with affixed needles were not secured and had accessible lids in one of one (Same Day Procedure) procedure room. Failure to assure sharps containers were secured with inaccessible lids did not prevent the contents from spilling out in the event they were knocked over creating a potential for cross contamination to staff from sharps injury. This failed practice was likely to affect all persons working in the Same Day Procedure Room. Findings follow:

A. On observation 10/27/15 at 1420 in the Same Day Procedure Room, a large red sharps container was upright on the floor next to the Anesthesia machine. The lid to the container was hinged in the middle and folded back exposing the contents through the opening (measuring approximately six inches by six inches in diameter) into the container. The container was over half filled with labeled medication syringes with needles affixed.
B. Findings were verified on interview with the Chief Nursing Officer at the time of observation.


30634

Based on observation and interview, it was determined the Infection Control Officer controlled infections in that one of one bone density exam table did not have a cleanable surface. The failed practice did not allow for control of the spread of infections and created the potential for germs to be spread between patients, and could affect any patient needing a bone density exam.

A. During a tour of the bone density exam room on 10/27/15 at 1325 a fabric covered cushion was observed to be on top of the exam table. When asked how the cushion was cleaned the Director of Radiology stated "I don't know, I mean, the patients lay on it with their clothes on so ..."
B. During an interview at the time of the tour, the Director of Radiology confirmed the cushion could not be cleaned between patients.

Based on review of policy, review of employee records and interview, it was determined the facility failed to assure tuberculosis (TB) skin testing was conducted for 9 (Registered Nurse (RN) #3, #7, Paramedic #1, #2, Respiratory Therapist (RT) #1, #2, #4, #6 and #7) of 26 (Operating Room (OR) Director, OR Charge Nurse, OR Technician #1, RN #3, #4, #5, #6, #7, #8, Licensed Practical Nurse (LPN) #1, #2, Paramedic #1, #2, RT #1-#13) staff; four (#1, #3, #5, and #6) of 9 (#1-#9) physicians and one of one CRNA did not have TB skin testing; and failed to follow facility policy to record employee hepatitis B vaccination status for 7 (OR Charge Nurse, RN #5, LPN #2, Paramedic #2, RT #1, #2, #3) of 26 (OR Director, OR Charge Nurse, OR Technician #1, RN #3, #4, #5, #6, #7, #8, LPN #1, #2, Paramedic #1, #2, RT #1-#13) staff. Failure to assure TB skin testing was conducted did not assure the facility knew staff's immunity status to tuberculosis. Failure to record hepatitis B vaccination status prevented the facility from formulating an effective (vaccine booster, immune globulin, complete hepatitis B vaccine series) plan in the event of potential blood bourn pathogen exposure to the staff. These failed practices were likely to affect all persons in the facility. Findings follow:

A. Review of the employee records for RN #3, #7, Paramedic #1, #2, RT #1, #2, #4, #6 and #7 revealed no evidence of a current TB skin test, questionnaire or chest x-ray.
B. Review of the employee records for OR Charge Nurse, RN #5, LPN #2, Paramedic #2, RT #1, #2, #3 revealed no evidence of hepatitis B vaccination status.
C. A current TB skin test was requested for Physicians #1-#9 and CRNA #1 on 10/27/15 at 1300, 10/28/15 at 1300 and 0900 and 10/29/15 at 1020.
D. Current TB skin tests were never received from Physicians #1, #3, #5, #6 and CRNA #1.
E. Review of policy, "Employee Health Infection Control Recommendations: Medical Management of Parental & Mucous Membrane Exposure of Health Care Workers" revealed "the employee health nurse will maintain medical records for employees with occupational exposures. This record shall include copy of employee's hepatitis B vaccination status".
F. Findings listed as A and B were verified on interview with the Chief Nursing Officer on 10/29/15 at 1545.


31039

Based on observation, review of policy and interview, it was determined the Infection Control Officer failed to control infections in that three (#1-3) of three in-patient walkers located in the Rehabilitation Gym was not maintained to allow a thoroughly clean as there were paper stickers/or worn stickers on them leaving a sticky residue which cannot be cleaned or disinfected. The facility could not assure a sanitary environment when patients used these items. The failed practice had the likelihood to affect all patients that receive therapy services using the walkers. Findings follow:

A. During a tour of Rehabilitation Services on 10/26/15 at 1255, observation revealed three in-patient walkers were stored in the Rehabilitation Gym. The walkers had paper stickers/or worn stickers on them.
B. Review of policy titled Treatment Area and Equipment Cleaning stated their objective was "To decrease the possibilities of cross-contamination in the Rehabilitative Services Department by performing routing cleaning of the treatment areas and therapy equipment."
C. During an interview on 10/26/15 at 1300, the Director of Rehabilitation verified the three walkers had paper stickers/ or worn stickers on them.

Based on review of policies and procedures, review of Duraprep Surgical Solution and Chloraprep One-Step manufacturer's instructions for use and interview, it was determined the facility failed to have a policy for the use of Duraprep Surgical Solution and Chloraprep One-Step (both alcohol based) skin prep (preparation) solutions. Failure to have a policy for alcohol based skin prep solutions did not assure staff were made aware of the risks associated with the products or that the manufacturer's application process would be followed. The failed practice was likely to affect all surgical patients admitted to the facility. Findings follow:

A. Review of policy, "Skin Preparation for Surgery" revealed no evidence Duraprep or Chloraprep skin preparations or their warnings and precautions were included.
B. Review of the manufacturer's instructions for Duraprep Surgical Solution revealed: "Warning: To Prevent Fire, do not drape or use ignition source (e.g. electrocautery) until dry (2-3 minutes on skin), do not allow to pool, remove solution-soaked materials, if prep accidentally drips into hair allow to dry completely.
C. Review of the manufacturer's instructions for ChloraPrep One-Step revealed, "Warning, Flammable, keep away from fire or flame. To reduce risk of fire, prep carefully, solution contains alcohol and gives off flammable vapors, avoid getting solution into hairy areas, hair may take up to 1 hour to dry. Wet hair is flammable. Do not drape or use ignition source (e.g. cautery, laser) until solution is completely dry (minimum of 3 minutes on hairless skin; up to 1 hour in hair), do not allow solution to pool, remove wet materials from prep area".
D. During interview with the Director of Surgical Services on 10/27/15 at 1535, she confirmed there was no policy for the use of Duraprep or Chloraprep skin prep solutions.

Based on clinical record review and interview, it was determined the facility failed to assure Operative Reports included the time of surgery in 7 (#9, #21-26) of 11 (#9, #21-30) surgical records. Failure to assure the time a surgical procedure took place did not establish a time-line of surgical events in the course of a patient's admission to the facility. The failed practice was likely to affect all surgical patients admitted to the facility. Findings follow:

A. Review of the Operative Report for Patient #9 revealed she underwent surgery on 10/25/15. There was no evidence the time the surgery was performed was included.
B. Review of the Operative Report for Patient #21 revealed she underwent surgery on 10/06/15. There was no evidence the time the surgery was performed was included.
C. Review of the Operative Report for Patient #22 revealed she underwent surgery on 10/09/15. There was no evidence the time the surgery was performed was included.
D. Review of the Operative Report for Patient #23 revealed he underwent surgery on 10/13/15. There was no evidence the time the surgery was performed was included.
E. Review of the Operative Report for Patient #24 revealed he underwent surgery on 10/06/15. There was no evidence the time the surgery was performed was included.
F. Review of the Operative Report for Patient #25 revealed she underwent surgery on 10/05/15. There was no evidence the time the surgery was performed was included.
G. Review of the Operative Report for Patient #26 revealed she underwent surgery on 10/08/15. There was no evidence the time the surgery was performed was included.
H. Review of the Operative Report for Patient #27 revealed she underwent surgery on 10/20/15. There was no evidence the time the surgery was performed was included.
I. Findings listed as A-H were verified on interview with the Director of Surgical Services on 10/29/15 during record review.

Based on review of Anesthesia Policies and Procedures Manual, review of Medical Staff Bylaws and interview, it was determined the facility failed to meet the educational needs of patients by not developing policies for patient consent and failed to establish policies for reporting requirements for Anesthesia Services. Failure to develop policies for patient consent prevented staff from having guidelines to follow to provide patients with information needed to obtain consent for anesthesia which did not assure the educational needs of patients were met. Failure to develop policies for reporting requirements for Anesthesia Services prevented staff from knowing what events (i.e. difficult airway, broken tooth, adverse drug reaction, use of reversal agents) were required to be reported to hospital leadership. These failed practices were likely to affect all patients undergoing anesthesia. Findings follow:

A. Review of Anesthesia Policies and Procedures Manual revealed no evidence policies for consent for anesthesia or reporting requirements were included. There was no evidence the Chief of Anesthesia reviewed the policies.
B. Review of Medical Staff Bylaws revealed Functions of Department Chiefs included, "develop and implement policies and procedures that guide and support the provision of services in the hospital".
C. Findings listed as A and B were verified during interview with the Chief Nursing Officer on 10/29/15 at 0845.