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Based on observation, staff interview and policy review, the facility failed to follow anesthesia policies for 1 of 1 patient (#2) who was observed receiving anesthesia. The findings were:

Observation on 7/12/10 from 4:15 PM to 5 PM, showed staff proceeded with the surgery for patient #2 without calling a "time out." However, review of the documentation in the interoperative nurse's note showed it had been done. The operating room circulation nurse acknowledged in an interview on 7/12/10 at 5:15 PM that the "time out" did not occur as it should have according to facility policy. She also verified the documented error. Review of the anesthesia policies, approved 3/22/10, revealed the required "time out" consisted of the surgical team verbally verifying the correct patient, procedure, surgeon, and site.

Based on observation, staff interview and review of policies, the facility failed to develop and implement policies and procedures to ensure outdated vials of multidose medications were not available for patient use. The findings were:

Observation with the DON on 7/12/10 at 3:15 PM showed multidose medication vials of Zofran and lidocaine were opened, but not dated to indicate the date they were first opened. Interview with the DON, at that time, revealed the practice of labeling opened vials to ensure they were discarded within twenty-eight days was an unnecessary practice. She said the facility's policy allowed opened multi-dose medication vials to be used for the duration of the manufacturer's stamped expiration date if there were no visible changes in the solution or evidence of contamination. A review of the facility's policy verified the DON's statement.

During an interview on 7/14/10 at 1 PM the pharmacist told the surveyors that he would research this issue and fax the information to the surveyors. On 7/21/10 the pharmacist sent the following fax to the state survey agency: "CDC [and] Wyoming State Board of Pharmacy recommend dating all multi-dose vials when opened and discarding after twenty-eight days or if the manufacturer's dating is sooner. On refrigerated vaccines CDC still goes with the manufacturer's date." Review of the fax also showed the pharmacist acknowledged the facility's current policy did not comply with the recommended standard of practice and needed to be revised.

Based on observation, staff interview, and review of sterilization records and infection control policies, the facility failed to ensure staff used safe injection practices during observations of anesthesia administration for 1 of 1 patient (#2) who was observed receiving anesthesia. Further, the facility failed to restrict the use of abbreviated sterilization ("flash") to urgent, interoperative situations. In addition, the governing body failed to designate in writing an individual with the roles and responsibility of the infection control officer. The findings were:

1. Observation on 7/12/10 of perioperative care for patient #2 showed the CRNA did not cleanse the intravenous injection ports prior to injecting each medication. This was observed from 4:15 PM to 5 PM when the CRNA administered separate injections of propofol, rocuronium, fentanyl, morphine and succinylcholine. Interview with the DON on 7/12/10 at 5:20 PM verified that the failure to cleanse intravenous ports was not an acceptable standard of practice.

The Association for Professionals in Infection Control and Epidemiology (APIC) standards for safe injection practices, published in the American Journal of Infection Control, April 2010, recommends IV ports, vial stoppers, and access diaphragms be disinfected prior to each use. CDC Guidelines for Safe Injection, released March 2008, recommends aseptic technique be used when administering parenteral [injectable] medications. Aseptic technique include disinfecting the rubber septum prior to entering multi-use medication vials.

2. The facility's sterilization records were reviewed on 7/13/10 at 10:25 AM; these logs showed an abbreviated sterilization process ("flash") was routinely used to turn around a limited number of instrument sets for eye surgery one day a week when a visiting optometrist performed procedures at the facility. Sterilization logs for 7/8/10 showed "...eye instruments..." were flash sterilized seven times. Interview with the surgical technician on 7/13/10 at 10:40 AM revealed a full sterilization cycle could not return instruments fast enough to accommodate the optometrist's schedule. She added he routinely scheduled ten patients for procedures on his weekly visit. The technician further stated the optometrist brought two instrument sets with him when he visited and these sets were flash sterilized between successive patients.

Review of infection control policies on 7/13/10 at 2:20 PM showed a policy governing the "Use of flash sterilizer in the OR [operating room]," dated 5/29/08. This facility policy restricted the use of flash sterilization to urgent situations in which an instrument was dropped or contaminated and required for the ongoing case. There were no provisions for allowing full sets to be flashed between routine scheduled cases or procedures.

Interview with the DON on 7/14/10 at 9:10 AM revealed the facility monitored the use of flash sterilization and had reduced the incidence of flash use in the past year. She acknowledged eye instrument sets were routinely flashed between patients and accounted for the most of the flash use at the hospital. The DON added the policy on restricted use of flash sterilization was current and was to be observed for all cases and procedures that required sterile surgical instruments.

3. Review of infection control policies and procedures on 7/13/10 and again on 7/14/10 failed to uncover evidence to show the governing body had designated one or more individuals to perform the duties of the infection control officer. Both the administrator and the DON acknowledged in an interview on 7/14/10 at 1:35 PM that the infection control nurse had not been appointed in writing by the governing body.


27095

Based on observation, staff interview, and review of medical records, the facility failed to ensure 4 of 8 transfusion events for two sample patients (#13, #14) who received transfusions were completely and accurately documented. The findings were:

1. Review of medical records on 7/13/10 and 7/14/10 included three patients that received a total of 8 units of blood during their admissions. Detailed review of the transfusion documents revealed two patient records (#13, #14) with the following discrepancies:

a. Patient #13 received three units of pRBCs on 5/6/10. The transfusion flowsheet in the patient's record included an entry for unit #W0423 10 039472. Two separate nursing staff members signed the transfusion flowsheet attesting the patient and the unit of blood had a group and type of O+. However, laboratory records reviewed on 7/13/10 at 3:35 PM showed the patient repeatedly tested A+ and the unit in question was also A+. The discrepancy in the recorded blood group and type was undetected by nursing personnel and remained unresolved until the survey.

The patient also received unit #W0423 10 039465. The transfusion flowsheet included an entry noting the total transfusion volume included 30 ml (milliliters) of normal saline along with the unit, for a total of 434 ml. The laboratory manager stated in interview on 7/13/10 at 4:10 PM the total volume of a unit of pRBCs is between 275-325 ml. He further stated a total transfusion of one unit of pRBCs with 30 ml of normal saline "...would not total 434 ml..."

b. Patient #14 received a total of three units of pRBCs on 5/20/10. The transfusion flowsheets for two of these events (units #W0423 10 040074 and W0423 10 041320) were incomplete and inaccurate. Documentation for the transfusion of unit W0423 10 040074 failed to include full nursing assessments for edema and IV site appearance. The flowsheet also included a statement that a total volume of 450ml was transfused. As noted in the previous interview with the laboratory manager, the volume estimate was in error.

Documentation for the transfusion of unit W0423 10 041320 was also incomplete, lacking complete nursing assessments for temperature, lung sounds, edema, and patient tolerance of the procedure.

2. The DON stated in interview on 7/14/10 at 9:45 AM the criteria noted on the transfusion flowsheet were essential monitors for patient safety during the transfusion. She acknowledge this information should have been recorded completely and accurately. The DON could not account for the undiscovered error in recording patient #13's blood group and type, as well as the group and type of the unit s/he received at the hospital.


27095

Based on medical record review and staff interview, the facility failed to develop and implement policies for post-anesthesia follow up reports. This failure was noted during the review of post-anesthesia documentation for 4 of 5 sample patients (#2, #14, #16, #18) who received anesthesia. The findings were:

Review of the medical records, including the "Post Anesthesia Notes" section, for patients #2, #14, #16, and #18 revealed no documentation of a postanesthesia follow-up report that included cardiopulmonary status, level of consciousness, follow-up care and observations. During interview on 7/14/10 at 9 AM, the DON confirmed the documentation in the medical records was accurate; she further stated that the facility did not have a policy or system for ensuring post-anesthesia follow up reports were being done. Review of the current policy and procedures entitled, " Duties and Responsibilities of CRNA", "Anesthetist Discharge Responsibilities", and "Completion of Anesthesia Record", showed no procedures for documenting post-anesthesia follow-up reports and evaluations of proper anesthesia recovery.


27095

Based on staff interviews, and review of quality assessment and performance improvement (QAPI) committee meeting reports, the facility failed to integrate outpatient services, ambulance services and medical staff into the facility-wide QAPI program. The finding were:

Review of the QAPI committee reports provided by the director of quality failed to show evidence that emergency services, outpatient, and medical services actively participated in the facility's QAPI program. During interview on 7/14/10 at 10:55 AM, the director of quality verified the lack of involvement from these three services, and acknowledge the need for their active participation.

Based on policy and procedure review, staff interview, and review of personnel files, the facility failed to develop written policies and procedures that address pre-employment screening for findings of abuse and neglect to patients. The facility further failed to complete background screens for seven of seven sampled employees (#1, #2, #3, #4, #5, #6, #7). In addition, the facility failed to check the State Survey Agency certified nurse aide registry for findings of patient abuse or neglect prior to hiring five of five sample CNAs (#6, #7, #8, #9, #10). The findings were:

Review of personal files for current employees revealed the facility did not complete a pre-employment screening for employees #1, #2, #3, #4, #5, #6 and #7. Review of personnel records for all of the CNAs currently employed by the facility showed the facility did not check with the State Survey Agency certified nurse aide registry for findings of patient abuse or neglect prior to employing CNAs #6, #7, #8, #9 and #10. Interview with the Human Resource Director on 7/13/10 at 3:10 PM revealed staff were not aware of the requirement for pre-employment background screens and checking the nurse aide registry. At that time, she also verified the facility lacked policies and procedures for pre-employment screening.