HospitalInspections.org

Based on record review and staff interview it has been determined that the hospital failed to meet the Condition of Participation of Patient's Rights relative to care in a safe setting for 1of 1 sample patient, Patient ID # 1.

Findings are as follows:

1. The hospital failed to provide care in a safe setting for Patient ID #1 relative to the process of performing a final surgical count resulting in an unintended retained surgical sponge that was used during the procedure. (refer to A-144)

Based on record review, policy review and staff interview, it has been determined that the hospital failed to follow its own policy relative to the Operating Room (OR) staff performing surgical instrument counts for 1 of 1 sample patient, Patient ID #1, resulting in a retained surgical sponge.

Findings are as follows:

Review of Patient ID #1's Operative Note dated August 31, 2021 revealed s/he is a 2-year-old who underwent an outpatient procedure for surgical repair of a palatal fistula (an abnormal opening between the nasal and oral cavities after a cleft palate repair). The note further states that "All [surgical] counts were correct at the end of the case."
Of note, following intubation (placing a tube in the trachea for breathing), and prior to the initiation of the surgical procedure, a 4-inch x 4-inch sponge packing was intentionally placed by the surgeon in Patient ID #1's throat to prevent any surgical material from going into the patient's airway or throat during the procedure.
The patient was discharged home following the procedure by the hospital with the sponge unintentionally remaining in the patients throat.

Within several hours of being discharged Patient ID #1 presented back to the hospital's Emergency Department (ED) with, difficulty breathing, not being able to keep food down, and having bloody vomit.

Upon provider examination, Patient ID #1 was noted to have increased work of breathing, s/he was desaturating (when the percentage of oxygen in your blood is lower than it should be) and was having increased secretions.

Given his/her recent surgery, Anesthesia services and Plastic Surgery were consulted and determined the patient should be intubated. The Anesthesia Procedure Note dated 9/1/2021 at 1:04 AM, states, in part, that Patient ID #1 was "intubated via glidescope [a video device that helps health care providers see a patient's airway during intubation] due to [an] object blocking [the patients] airway. Upon inspection with [the] glidescope, [the obstruction] was a lap pad [the 4-inch x 4-inch sponge] used as a throat pack during [the] surgical case. After intubation ...[the] throat pack [was] removed using...forceps."

Patient ID #1 remained in the hospital Pediatric Intensive Care Unit overnight and was extubated and discharged the following day.

The hospital's policy entitled "Surgical Counts," which was last updated in December 2019, states, in part,

"I. Purpose: To provide direction to perioperative personnel in tracking and documenting disposable and reusable items during operative and procedural cases to prevent retained surgical items (RSIs) ...The expected outcome is that the patient will be free from unintended retained surgical material used during the procedure.

II. Policy: All perioperative team members are responsible for the prevention of RSIs ...

III. Procedure ...The Final count is not considered complete until all items (e.g., sponges ...) are removed from the wound and returned to the scrub person ..."

During an interview with the Director of Risk Management on 9/7/2021 at approximately 2:00 PM, she stated that the Surgical Technologist, Staff A, and the Circulating Nurse, Staff B, acknowledged that they conducted the final count prior to the sponge being removed from the pateint's throat. This deviation from policy resulted in the retained sponge. She further acknowledged that the staff failed to follow the hospitals policy for surgical count which resulted in the retained sponge.

During an interview with the Director of Surgical Services and the Vice President and Associate Chief Nursing Officer of Surgical Services on 9/8/2021 at 8:30 AM, they acknowledged that the final count should not be performed until the last sponge is removed from the patient. They further acknowledged that the surgeon, Circulating Nurse and Surgical Technologist are equally responsible for surgical count accuracy.

Based on record review and staff interview it has been determined that the hospital failed to provide a service which is well organized and provided in accordance with acceptable standards of practice relative to implementation of appropriate count procedures for 1 of 1 sample patient who underwent a surgical procedure and was found to have a retained surgical item, Patient ID # 1.

Findings are as follows:

Review of Patient ID #1's Operative Note dated August 31, 2021 revealed s/he is a 2-year-old who underwent an outpatient procedure for surgical repair of a palatal fistula (an abnormal opening between the nasal and oral cavities after a cleft palate repair). The note further states that "All [surgical] counts were correct at the end of the case." Of note, after intubation (placing a tube in the trachea for breathing), and prior to the initiation of the surgical repair, a 4-inch x 4-inch sponge packing was intentionally placed by the surgeon in Patient ID #1's throat to prevent any surgical material from going into the patient's airway or throat during the procedure. The patient was later discharge to home by the hospital with the sponge unintentionally remaining in place.

Within several hours of being discharged Patient ID #1 presented to the hospital's Emergency Department (ED) with, difficulty breathing, not being able to keep food down, and having bloody vomit.

Upon provider examination, Patient ID #1 was noted to have increased work of breathing, s/he was desaturating (when the percentage of oxygen in your blood is lower than it should be) and was having increased secretions. Given his/her recent surgery, Anesthesia services and Plastic Surgery were consulted and determined the patient should be intubated.
The Anesthesia Procedure Note dated 9/1/2021 at 1:04 AM, states, in part, that Patient ID #1 was "intubated via glidescope [a video device that helps health care providers see a patient's airway during intubation] due to [an] object blocking [the patients] airway. Upon inspection with [the] glidescope, [the obstruction] was a lap pad [the 4-inch x 4-inch sponge] used as a throat pack during [the] surgical case. After intubation...[the] throat pack [was] removed using...forceps."

Patient ID #1 remained in the hospital Pediatric Intensive Care Unit overnight and was extubated and discharge the following day.

During an interview with the Director of Risk Management on 9/7/2021 at approximately 2:00 PM, she acknowledged that the staff failed to conduct the final count after the surgeon completed his procedure.

During an interview with the Director of Surgical Services and the Vice President and Associate Chief Nursing Officer of Surgical Services on 9/8/2021 at 8:30 AM, they acknowledged that the final count should not be performed until the last sponge is removed from the patient. They further acknowledged that the surgeon, Circulating Nurse and Surgical Technologist are equally responsible for surgical count accuracy.