HospitalInspections.org

Based on reviews of documents and interview with staff, it was determined the hospital failed to ensure there are established and written policies relative to care and services provided in the outpatient surgical services department. This has the potential to affect the quality of care provided to all patients who receive outpatient surgical services.

Findings include:

1. The Nurse Manager of surgical services was interviewed on 5/29/2012 at about 1:30 p.m. She stated she is the manager for all surgical services provided, including the outpatient services. She stated the patients who present in the morning of surgery and who are discharged to home on the same day of the surgery are cared for in the Patient Access Center (PAC). The polices relative to the care of patients in the PAC were requested for review.

2. On 5/30/2012 the Joint Commission Coordinators (JCC) were interviewed at about 3 p.m. relative to policies for the PAC. They confirmed there are no written and established policies for patients who are being cared for in the PAC.

Based on medical record review and staff interview, it was determined the hospital failed to provide an operating room register that is complete and up to date. This has the potential to adversely affect all patients by not providing pertinent patient information which could cause negative outcomes.

Findings include:

1. A review of the facility's "Master Log" for the Operating Room (OR) revealed the pre-operative diagnosis and the post-operative diagnosis are not provided. A "N/A" are entered in both of these areas.

2. One of the Joint Commission Coordinators (JCC) was interviewed on 5/30/12 at 1230 p.m. She agreed that the facility is aware that the lack of this information on the OR register/Master Log is a problem and the information should be present on the form. She further states the lack of information is a result of a "glitch" in the system, and the person who is currently "working on it" is out of the facility attending a conference.