HospitalInspections.org

Based on record review, policy review and interview, the facility failed to ensure that operating room (OR)staff safely follow policy and procedures, which creates the potential for harm to patients. Findings include:

During review of the medical record for patient #1 on 03/28/2012 at 1030, it revealed that the patient had fallen off the OR table after being sedated and intubated.

A review of policy number: 40.3.044 titled Positioning of the Surgical/Obstetrical Patient for a Procedure reads in the section of Supportive Data: " Special attention must be paid to patient dignity, safety and comfort. " In the section titled Protocol it reads in the third section #2. " There should be an adequate number of personnel and/or devices to safely transfer and/or position the patient. " It goes on to further read on page 3 #13. " Safety belt in place if possible, according to procedure (i.e. open hearts, total joints) " and " Documentation of patient positioning should include but not be limited to: #5 Presence and position of a safety strap. "

During an interview with the Director of Quality on 03/28/2012 at 0900, she confirmed the findings. A interview/meeting was held with RN #1, RN #2, Certified Surgical Tech (CST) #1 & #2, Director of Quality and Director of Patient Care Services on 03/28/2012 at 1330, it revealed that on 12/14/2012 during repositioning of the patient on the OR table the staff stepped away from the unsecured patient and the patient fell off the table to the floor.