HospitalInspections.org

Based on interview and record review, the hospital failed to ensure staff developed and updated a nursing care plan (a comprehensive, interdisciplinary [group of healthcare providers from different fields who work together] approach to patient care from entry into the hospital until discharge) for one of 30 sampled patients (Pt) 12 when the staff identified a patient care need and did not create interventions or goals to address the need.

This failure had the potential to place Pt 12 at risk to not have his nursing care needs met.

Findings:

During a concurrent interview with the Informatics Specialist (IS) and record review of Pt 12's clinical records, on 9/10/19 at 1:22 p.m., he stated the staff created a care plan of impaired gas exchange (too much or not enough oxygenation and/or carbon dioxide removal in the lungs) on 9/1/19. The IS stated, " ...I don't see an intervention ..." The IS validated there were no interventions or goals listed.

During a concurrent interview with the Clinical Manager (CM) and record review of Pt 12's clinical records, on 9/10/19 at 3:14 p.m., she stated care plans are created after the patient's admission to the hospital and adjusted throughout the hospitalization. The CM stated care plans are identified and developed based on the patient's needs. The CM stated a care plan consisted of interventions and goals. The CM validated Pt 12 had an identified problem of impaired gas exchange and there were no interventions or goals listed. The CM stated Pt 12 had open heart surgery and the staff were weaning (slowing removing) him off oxygen to prepare him to be discharged home. The CM stated it was important for Pt 12 to have interventions and an identified goal.

A review of the hospital policy and procedure titled, "Interdisciplinary Plan of Care" dated 4/15/14, indicated, "... III. Policy ... D. The development, implementation, and maintenance of a patient's plan of care is an interdisciplinary process ....V. Procedure ... 3. Initiate the evidence based plan of Care based on the patient's comprehensive assessment and medical care of the provider responsible for the patient ... a. Complete the documentation of goals at the end of each shift and review and revise the interventions as appropriate ..."

Based on observation, interview, and record review, the hospital failed to ensure the achievement and maintenance of high standards of medical practice and patient care when one of three previously cleaned and sterilized surgical instrument tray sets contained damaged and missing instruments.

This failure had the potential to cause patient harm, and/or delay surgery.

Findings:

During a concurrent observation and interview, on 9/9/19 at 1:33 p.m., the Manager of Sterile Processing Department (MSPD) examined the contents of a surgical instrument tray and compared the contents to the list of instruments expected to be in that tray. The MSPD identified one pair of scissors with a nick in the blade, one forceps tool (tweezer-like tool for holding objects during surgery) with a misalignment (could not close properly) at the tip, and a retractor (tool used for holding objects out of the way during surgery) was scratched. Two additional instruments listed on the inventory sheet were missing from the tray. The MSPD stated the surgical tray contained an error rate of five out of 72 instruments. The MSPD stated the tray "failed," and the errors should have been caught before the tray was packed. The MSPD stated the damaged and missing instruments "... could have caused patient harm, or a delay in surgery."

A review of the hospital policy and procedure titled, "Surgical Instrument Handling and Tray Preparation" dated 7/16/19, indicated, " ... III. PROCEDURE A. Inspection ... 2. Inspect instrument operation and functionality including looking for: ... c. Correct alignment; d. Corrosion, pitting, burrs, nicks, cracks; e. Wear and chipping of inserts and plated surfaces; f. Missing parts ..." and " ...C. Assembly ... 2. Assemble trays in their designated order with the assistance of a count sheet for each instrument set to ensure correct instruments, arrangement, and their required quantities..."

A review of AAMI (Association for the Advancement of Medical Instrumentation - an organization for advancing the development, and safe and effective use of medical technology) - "Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities", CDC (Centers for Disease Control) Guidelines, and AORN (Association of perioperative Registered Nurses - leaders in advocating for excellence in perioperative [during the course of an operation] practice and healthcare) guidelines, their recommendations, indicated the following: "Instruments should undergo an inspection for proper function and cleanliness. 1. Instruments should be inspected for a) cleanliness b) proper functioning and alignment, corrosion, pitting, burrs, nick, and cracks, sharpness of cutting edges c) any other defects ... 2. Instruments in disrepair should be labeled and taken out of service until properly repaired or replaced ..."