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Based on observations as referenced in the Life Safety Report of survey completed 12/01/2011, the hospital failed to develop and maintain the facilities in a manner to ensure the safety of patients.

The findings include:

1. The hospital failed to ensure all essential mechanical and electical equipment was maintained in safe operating condition to assure the safety and well being of patients.

~Cross refer to 485.623(b)(1) - Maintenance - Standard Tag C0222.

2. The hospital failed to ensure the safety and well-being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association (NFPA).

~Cross refer to 485.623(d)(1)&(3) - Life Safety From Fire - Standard Tag C0231.

Based on observations as referenced in the Life Safety Report of survey completed 12/01/2011, the hospital failed to ensure all essential mechanical and electical equipment was maintained in safe operating condition to assure the safety and well being of patients.

The findings include:

A. Observations of Building 1 on 11/29/2011 - 12/01/2011 revealed the following:

1. Based on observation and staff interview, the exit discharge from the South stair well did not have the required emergency lighting to a safe public way.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0045

2. Based on observation on 12/01/2011, there were no guardrails as required on loading dock to prevent someone from falling from loading dock.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0130

3a. Based on observation on 12/01 2011 there were 02 cylinders stored in front of the electrical panel at SNF nurses station.

3b. Based on observation and staff interview on 12/01/2011 there were surge protectors and multi-plug outlets being used in the SNF day room.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0147

B. Observations of Building 2 on 11/29/2011 - 12/01/2011 revealed the following:

1. Based on observation on 11/30/2011 the electrical panel in the med. room had storage in front of it.

2. There were exposed light bulbs in the toilet near the fire alarm panel.
42 CFR 483.70 (a)

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0147

C. Observations of Building 3 on 11/29/2011 - 12/01/2011 revealed the following:

Based on observation on 11/30/2011 there was no emergency lighting in the medical records storage area.
42 CFR 483.70 (a)

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0046

Based on observations as referenced in the Life Safety Report of survey completed 12/01/2011, the hospital failed to ensure the safety and well-being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association (NFPA).

The findings include:

A. Observations of Building 1 on 11/29/2011 - 12/01/2011 revealed the following:

1. Based on observation and staff interview on 12/01/2011, the doors from OR , the lab, and the conference room required more than one (1) motion of the hand in order to exit.
42 CFR 483.70 (a)

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0038

2. Based on observation and staff interview on 12/01/2011 there were sprinkler valves that were not supervised . (one near the OR and one in the soiled linen room on the SNF floor)
42 CFR 483.70 (a).

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0062

3. Based on observation and staff interview on 12/01/2011 there were no ashtrays of approved design nor a metal self-closing container in the smoking area.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0066

4. Based on observation and staff interview on 12/01/2011 the OR staff had no way to monitor the temperature nor the humidity in the OR. ( the equipment was being repaired at the time of the survey).
42 CFR 483.70 (a)

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0067

5a. Based on observation and staff interview on 12/01/2011 the medical gas cylinders in the 02 farm outside are not protected from the weather ( snow, sleet, rain, etc). There must be a cover to protect them.

5b. There were 02 cylinders at the SNF nurses station that were not secured and fulls and empty cylinders were mixed.
42 CFR 483.70 (a)

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0076

B. Observations of Building 2 on 11/29/2011 - 12/01/2011 revealed the following:

1. Based on observation on11/30/2011 there were unsealed penetrations in the smoke wall over the smoke door in the lobby. (The one that did not close on the fire alarm)
42 CFR 483.70 (a)

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0025

2. Based on observation on 11/30/2011 the smoke door off the lobby failed to close upon activation of the fire alarm.
42 CFR 483.70 (a)

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0027

3. Based on observation on 11/30/2011 the door from the exam room requires more than one (1) motion of the hand to exit the room.
42 CFR 483.70 (a)

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0038

4. Based on observation on11/30/2011 there was an exit door from the main lobby that was lacking an EXIT sign.
42 CFR 483.70 (a)

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0047

5. Based on observation on 11/30/2011 the fire alarm panel failed to give an visual trouble signal when the phone line was disconnected.
42 CFR 483.70 (a)

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0051

6. Based on observation on 11/30/2011 the air handlers failed to shut down upon activation of the fire alarm.
42 CFR 483.70 (a)

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0067

7. Based on observation on 11/30/2011 there were unsecured and mixed full and empty 02 cylinders in the out side storage room on the dock.
42 CFR 483.70

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0076

C. Observations of Building 2 on 11/29/2011 - 12/01/2011 revealed the following:

Based on observation on 11/30/2011 there was not proper exit signage to direct you out of the gym area.
42 CFR 483.70 (a)

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0047

Based on policy review, observation, medical record review, and staff interview, the hospital's Pharmacy failed to maintain oversight over all drugs and biologicals in the hospital by failing to ensure contrast solutions were stored per manufacturer's recommendations in the Radiology Department and ensure patients' home medications stored on the inpatient nursing unit were accounted for and returned to patients or sent to pharmacy for disposal at time of discharge.

The findings include:

Review of current hospital policy entitled "Medication Use Processes" dated 09/2011 revealed, "...III. Procedures/Policy Statements:....C. Storage and Control....1. Medications are properly and safely stored throughout the hospital....The Department of Pharmacy with cooperation from individual departments is responsible for the safe storage and control of medications....b. Medications are stored under necessary conditions to ensure stability (according to the manufacturers' recommendations....)....2. Controlled substances are stored to prevent diversion....b. The Pharmacy Department will manage a controlled substance distribution system to exercise tight control on all controlled substances. c....Nursing units will be approved to stock a supply of needed controlled substances. A perpetual inventory will be maintained for all controlled substances in each storage area....9. Policy - All medication storage areas are periodically inspected according to the hospital's policy to make sure medications are stored properly....c. The Department of Pharmacy is responsible for communicating areas of concern related to medication storage and control in the patient care areas to departmental administration....11. Policy - Processes have been established to safely manage medications brought into the hospital by patients or their families....(8). If the patient's own medication(s) have been brought into the hospital but will not be used, the following should occur: (a). The patient's medication(s) will be sent home, if possible. (b). If the patient is unable to send the medication(s) home, the medications will be placed in a paper bag and securely sealed. A stamped label will be applied to the bag. The patient's name should be legibly placed on the bag. (c). Medication(s) will be placed in the unit's designated locked storage area....(9). Transfer or discharge of patient. (a). Patient's own medication(s) should be transferred with the patient. (b). At time of discharge, medication(s) brought from home should be collected and returned to the patient. Nursing staff should check that the patient received the medications....(c). Medications left after discharge should be given to the pharmacy for disposal. if controlled substances, records of receipt shall be kept...."

1. Observation during tour of the radiology department at Satellite Campus #1 on 11/30/2011 at 1600, in the CT (computed tomography) room, revealed four (4) boxes of contrast solution (Optiray 350 Ioversol Injection) stored in a warmer. Review of the warmer temperature log revealed documentation of temperature monitoring by staff from January 1, 2011 through October 4, 2011. Further review revealed the temperature was documented as 102 degrees Fahrenheit. Further review of the temperature log revealed no documentation of temperature monitoring by staff from October 5th, 2011 to November 30, 2011. Review of labelling printed on the manufacture's box that contained the contrast solution and of the product insert revealed under storage "Store OPTIRAY and OPTIRAY RFID-tagged syringes at 25 C (77F) [25 degrees Celsius equals 77 degrees Fahrenheit]: excursions permitted to 15 to 30 C (59 to 86 F) [15 to 30 degrees Celsius equals 59 to 86 degrees Fahrenheit]."

Interview during tour on 11/30/2011 at 1630 with the staff radiology technician onsite at Satellite Campus #1 revealed there was not a departmental policy that referenced storage of contrast solutions. Interview revealed the previous Department Director had instructed staff to store contrast solutions at 102 degrees Fahrenheit. Interview revealed the previous Department Director no longer worked for the hospital and a new Department Director started approximately two weeks ago.

Interview during tour with the current Radiology Department Director on 11/30/2011 at 1630 revealed she was unaware of how the contrast solutions were being stored. Further interview revealed this was inappropriate storage of the contrast solutions. Interview revealed she will discard the four (4) boxes of contrast solutions being stored in the warmer.


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2. Observation during tour of the acute inpatient unit with the Charge Nurse on 11/30/2011 at 1500 revealed a locked medication storage/preparation room (med room). Observation revealed a locked drawer in the med room labeled "Patient Medication". Observation revealed the Charge Nurse opened the drawer for surveyor's inspection. Observation revealed 3 clear plastic bags labeled with 3 different patients' names, containing medications in non-hospital dispensed prescription bottles, being stored in the drawer. Observation revealed the following patients' medications were in the drawer:
· Patient #27 - Xanax (controlled substance; antianxiety medication) 0.5 milligram (mg) tablets - 10.5 tablets in bottle - date dispensed (on label) 03/02/2011,Metformin (hypoglycemic medication) 500 mg tablets - several tablets in bottle - date dispensed 04/04/2011,and Requip (antiparkinsonian medication) 2 mg tablets - several tablets in bottle - date dispensed 03/02/2011;
· Patient #28 - Crestor (antilipemic medication) 10 mg tablets - several tablets in bottle - date dispensed 02/17/2010; and
· Patient #29 - Lantus Solo Star insulin Pen 100 units per milliliter (u/ml) (3 ml in pen) - no date dispensed on label, Simvastin (antilipemic medication) 80 mg tablets - several tablets in bottle - no date dispensed on label; (2) Cyanocobalamin (vitamin B12) injection 1000 micrograms per ml (30 ml in bottle) - date dispensed on bottles 12/23/2010, Novolog Insulin 10 ml bottle (100 u/ml) - date dispensed 12/28/2010, and Metformin 1000 mg tablets - several tablets in bottle - date dispensed 06/17/2011.

Closed medical record review for Patient #27 revealed the patient's most recent admission was from 04/29/2011 to 05/03/2011 (discharged 6 months and 27 days before observation).

Closed medical record review for Patient #28 revealed the patient's most recent admission was from 05/06/2010 to 06/10/2010 (discharged 1 year, 5 months and 20 days before observation).

Closed medical record review for Patient #29 revealed the patient's most recent admission was from 06/24/2011 to 06/29/2011 (discharged 5 months and 1 day before observation).

Interview on 11/30/2011 at 1500 with the Charge Nurse during observation revealed, "We try to send (patient's home medications) home with the family. If we can't, we lock them in the drawer....I don't know if pharmacy looks in that drawer." Further interview revealed controlled substance medications were counted by 2 licensed nurses at each shift change, to ensure all controlled substances were accounted for and no discrepancies were present. Interview revealed Xanax is a controlled substance. Interview revealed, "I have not counted the Xanax (found in the 'Patient Medication' drawer). I didn't know it was in there." Interview revealed there was no available documentation the Xanax had been counted since it was placed in the "Patient Medication" drawer (7 months and 1 day, when Patient #27 was admitted).

Interview on 12/01/2011 at 1130 with the Director of Pharmacy revealed whenever possible, patients' home medications should be sent home as soon as possible after admission. Interview revealed when medications can't be sent home, they should be placed in a plastic bag, labeled with the patient's name, and locked in the cabinet in the medication room. Further interview revealed pharmacy staff makes rounds and checks and inventories all medications on all units in the hospital every 2 months. Interview revealed pharmacy staff have not been routinely checking the "Patient Medication" drawer in the medication room. Interview revealed, "It has not been the practice here to check the home meds drawer....I spoke to my (pharmacy) techs yesterday and they had never been given any duties regarding patients' home meds." Interview revealed prior to the surveyor finding the medications in the drawer on 11/30/2011 the Director was not aware the medications were there. Further interview revealed all controlled substance medications must be counted by nursing staff each shift to ensure no discrepancies in expected amounts of controlled substances are present. Interview revealed Xanax is a controlled substance and should be counted each shift. Interview confirmed there was no documented evidence the Xanax observed in the "Patient Medication" drawer had been counted during the 7 months and 1 day it was in the drawer.

Based on policy review, Medication Variance Report review, and staff interview, the hospital failed to ensure medication variances were reduced by failing to implement corrective actions for 1 of 2 medication variances reviewed (Patient #9).

The findings include:

Review of current hospital policy entitled "Medication Use Processes" dated 09/2011 revealed, "...III. Procedures/Policy Statements:....G. Monitoring Effects of Medication...2. Policy - The hospital responds appropriately to actual or potential adverse drug events and medication errors....b. Medication Variances: A medication variance includes...variances that reach the patient which may or may not have an effect on patient outcomes....(1). Medication variances should be reported using the Medication Variance Report form....(6). Under Action Plan on the report, the clinician identifies actual or potential causes of the variance and where there was a breakdown in the process. (7). When it is clear which staff member(s) were involved in a variance, the staff member should be consulted to assist in the identification of contributing factors....(8). The Medication Variance Report is sent to Nursing administration. (9). The Medication Variance Report is used for performance improvement...."

Review of a Medication Variance Report 09/12/2011 at 0900 for Patient #9 revealed documentation of a medication variance that occurred on 09/10/2011 during first shift. Report review revealed, "...Variance Indicator:...(checked) Dose or Rate Incorrect....Exact Written Order: Ferrous Sulfate (iron supplement medication) 325 mg (milligrams) 1 daily. Description of Variance/Reason for Error (Include Contributing Factors): New patient on weekend, med(ication) pulled incorrectly from documed (non-automated, non-electronic medication dispensing system) Slo-Fe (extended release iron supplement medication) 160 mg x 2 tabs (tablets) pulled + given. Reason for Variance: (none of the listed choices checked)....Name of Person Completing Form (Optional): (name of a pharmacy technician)....(checked) Category C: An error occurred that reached the pt. (patient) but no harm done....Action Plan: (blank)....Pharmacist Review by: (name of pharmacist no longer employed at hospital) Date: 9-12-11. Reviewed MedWise (committee that reviews all medication variances) 9-12-11."

Review of MedWise meeting minutes dated 09/12/2011 revealed the Director of Nursing was present at the meeting. Review revealed the Medication Variance Report for Patient #9 was one of six Medication Variance Reports reviewed during the meeting. Review of "Recommendation/Action" section listed beside the Medication Variances review section of the minutes revealed, "The MedWise Committee will continue to review and report all mediation variance reports." Review of the minutes revealed no corrective actions for the medication variance that involved Patient #9.

Interview on 11/30/2011 at 1340 with the Director of Pharmacy revealed ferrous sulfate and Slo-Fe were both iron supplements, but were different in the way they acted and should not be used interchangeably. Interview revealed Slo-Fe was an extended release form of iron supplement, and ferrous sulfate was not. Further interview revealed the MedWise team was a formal group that included pharmacy staff and nursing managers that meets monthly and reviews medication issues, including medication variances. Interview revealed Medication Variance Reports that show nursing errors were given to the Director of Nursing (DON) for follow up with nursing staff. Interview revealed the DON then documents corrective actions, including re-education of staff, etc., on the Report and then returns it to the pharmacist, who maintains the reports. Interview revealed, "I can't tell from the documentation (on Patient #9's Medication Variance Report) whether or not nursing addressed the issue with the nurse. Ideally, there would have been an action plan here (on the report)."

Interview on 11/30/2011 at 1535 with the registered nurse (RN) that administered Slo-Fe to Patient #9 on 09/10/2011 revealed the nurse was not aware she had made an error by administering Slo-Fe to the patient, rather than ferrous sulfate. Interview revealed, "No one has talked to me about this....Clearly I put Ferrous Sulfate 160 mg times two on the (documed) sign out sheet. I thought they (ferrous sulfate and Slow-Fe) were the same, just different doses."

Interview on 11/30/2011 at 1620 with the Director of Nursing revealed, "I got a copy of the med variance, but not the attached documed sign out sheet or order. I don't recall when (I got it), usually get it during the MedWise meeting." Interview revealed the DON had just followed up with the RN regarding the medication variance after the surveyor interviewed her on 11/30/2011 at 1535 (2 months and 18 days after the medication variance was reported). Interview revealed, "I had not followed up with her at all because of the type of medication, it was just ferrous sulfate. It was not a life threatening error.... It (Medication Variance Report) was in my stack of papers....It got lost on my desk, got buried in all the other paperwork."

Based on review of hospital policy for disinfection of equipment, manufacturer's recommendation for the use of a cleaning solution, observation and staff interviews, the hospital failed to ensure a sanitary environment by failing to ensure cystoscopy equipment (instrument inserted into the body to examine the bladder) was disinfected according to manufacturer's recommendations prior to use.

The findings include:

Review of the "Reprocessing of Medical Devices" policy effective September 1, 2008 revealed "... Departments that reprocess reusable medical devices/equipment within their department must develop written procedures for the components of reprocessing performed in their department....This includes but is not limited to: the method of sterilization or high-level disinfection.... The Manager of Infection Control will have oversight authority for the reprocessing of medical devices/equipment performed throughout the hospital...."

Review of the "Cleaning and Processing Flexible Endoscopes and Endoscopic Accessories" policy effective January 2011 revealed "... Procedure: 1. Flexible endoscopes should be cleaned and stored in accordance with the manufacturer's written instructions. Failure to follow the manufacturer's written instructions could result in ineffective cleaning that interferes with high-level disinfection or sterilization creating a risk of infection for the patient...."

Observation during tour of a cystoscopy clinic located at Satellite Campus #2 on 12/01/2011 at 1110 revealed two containers of yellow liquid sitting on a counter. Observation of the containers revealed no label or date identifying the liquid. Interview with the registered nurse (RN) in the clinic revealed the liquid was "Wavicide" that was used as a high level disinfectant for cleaning the cystoscopes. Interview revealed the Wavicide was used full strength (not diluted) and did not require strength testing. Interview further revealed that the liquid was not dated because it was only used one day a week (on Thursdays when the clinic performed cystoscopys) and discarded at the end of the day. Interview revealed the scopes were cleaned and placed into the Wavicide solution to soak for 30 minutes, rinsed, then hung to dry before re-use.

Review of the "Wavicide (gluteraldehyde solution )" manufacturer's recommendations revealed "HIGH LEVEL DISINFECTANT: Wavicide-01 Solution is a high level disinfectant when used according to directions at full strength and 22 degrees Celsius with an immersion time of at least 45 minutes."

Interview on 12/1/2011 at 1640 with the hospital's Infection Control Nurse revealed she did not review the practice of manually reprocessing (high-level disinfecting) scopes. The staff member stated she was not aware that staff were soaking the scopes for 30 minutes rather than the recommended 45 minutes. Interview confirmed that the staff should be following the manufacturer's recommendations and soaking a minimum of 45 minutes as recommended to prevent the spread of infection.

Based on policy review, closed record review, observation, radiation monitoring reports and staff interview, the hospital staff failed to monitor radiation exposure to staff and physicians during surgical procedures requiring the use of a portable ionizing radiology (C-Arm) machine.

The findings include:

Review of the Radiology "Personnel Monitoring" policy revised May 2008 revealed "Personnel monitoring is the use of a device that is sensitive to radiation and produces a quantifiable response to determine an approximate dose received by the individual wearing or carrying the device. Common examples are film badges, thermoluminescent dosimeters, and pocket ion chambers. Personnel monitoring is necessary for estimating the dose received by an individual. An estimation of dose provides a means of complying with the North Carolina Regulations For Protection Against Radiation (NCRFPAR) Section .1600, and a means of following the principle of keeping radiation exposure as low as reasonable achievable (ALARA). Occupational exposure to radiation shall be monitored and the facility shall supply and require the use of individual monitoring devices by adults likely to receive, in one year from sources external to the body, a dose in excess of 10 percent of the limits in Rule .1604...."

Review of the "Operating Room radiation Policy" revised June 23, 2011 revealed "The same policies that apply to portable radiography must be observed in operating room radiography....Film badges will be provided if it is likely that the radiation exposure will exceed 10% of the dose limit.... Employees that have been issued film badges must follow the same procedure for the technologist in wearing the film badge...."

Open record review for Patient #31 revealed a 58 year-old female that had a surgical procedure as an outpatient on 11/30/2011. Review of the record revealed the use of a portable ionizing radiology (C-Arm) machine during surgery.

Open record review for Patient #32 revealed a 68 year-old female that had a surgical procedure as an outpatient on 11/30/2011. Review of the record revealed the use of a a portable ionizing radiology (C-Arm) machine during surgery.

Observation during tour of the hospital's operating room (OR) suite at Satellite Campus #1 on 11/30/2011 at 1610 revealed a portable ionizing radiology (C-Arm) machine located in OR #1. Interview during tour with the surgical nursing director revealed the machine, when in use is operated by the surgeon. Interview revealed there were four surgeons that utilize the C-Arm during surgery. Interview revealed the surgical staff and CRNA (Certified Nurse Anesthetist) remain in the room when the C-Arm is used. Interview further revealed that the physicians and surgical staff do not wear personal radiation monitoring devices. The staff member stated that a radiation monitoring device (badge) is secured to the C-Arm for monitoring exposure to radiation.

Review of "Radiation Dosimetry (personal radiation monitoring device) Report" dated July, August, September and October 2011 revealed results reported for CRNA #1 for each of the months. Interview with the Radiology and Surgical Directors on 12/01/2011 at 1430 revealed the reports were submitted using CRNA #1's name. Interview confirmed CRNA #1 did not wear a Dosimetry badge and the reports were from the Dosimetry badge secured to the C-Arm.

Interview with the Radiology Department Director on 12/01/2011 at 1430 confirmed the use of a portable ionizing radiology (C-Arm) machine during surgery. The Director stated no personal radiation monitoring devices were worn by the physicians or surgical staff during the use of the C-Arm, but should be worn by each staff member to monitor individual radiation exposure. Interview confirmed the use of the badge was based on individual exposure and to be worn by a single person. The Director stated it was not appropriate to secure the badge to the C-Arm for measuring exposure to radiation. The Director stated "We are not leaving that badge on that C-Arm. It is not appropriate." Interview confirmed no personal radiation monitoring devices had been issued to surgeons or surgical staff for individualized radiation monitoring.

Based on policy review, medical record review, and staff interview the hospital failed to assure medical records were accurately written to reflect the care and treatment provided to patient's undergoing surgical procedures by failing to ensure operative notes were completed immediately after the surgical procedure by the surgeon and not before the procedure for 1 of 6 surgical records reviewed (#16).

The findings include:

Review of current hospital policy revealed "The medical record of patients undergoing operative or other invasive procedures and/or anesthesia includes additional information of the preoperative diagnosis prior to surgery, the operative reports are dictated or written immediately after surgery describing the findings, technical procedure used, specimen removed, postoperative diagnoses, and the name of the primary surgeon and any assistants..." and "Reports of operation shall be written or dictated by the operating surgeon immediately after the operation. ..."

Closed medical record review on 11/30/2011 for Patient #16 revealed a 67 year old male admitted on 05/26/2011 for a right eye/nuclear sclerosis cataract extraction (surgical procedure). Review of a "Operative Notes" (immediate post-operative note) document revealed the surgeon signed and dated the form at 0900 on 05/26/2011. Review of the intraoperative record for the surgical procedure performed on 05/26/2011 revealed documentation by staff the patient entered the operating room at 1059. Further review revealed a procedure start time at 1105 and the procedure stop time at 1111 (131 minutes after the surgeon signed and dated the operative note).

Continued record review for Patient #16 revealed the patient was admitted on 06/23/2011 for a nuclear sclerosis-left eye cataract extraction (surgical procedure). Review of a "Operative Notes" (immediate post-operative note) document revealed the surgeon signed and dated the form at 0900 on 06/23/2011. Review of the intraoperative record for the surgical procedure performed on 06/23/2011 revealed documentation by staff the patient entered the operating room at 0958. Further review revealed a procedure start time at 1005 and the procedure stop time at 1009 (69 minutes after the surgeon signed and dated the operative note).

Interview with the Surgical Nursing Director on 12/01/2011 at 1745 confirmed the surgeon had documented, dated, and signed the operative reports prior to performing the procedures on 05/26/2011 and 06/23/2011. Interview confirmed the surgeon failed to follow hospital policy.