HospitalInspections.org

Based on record review and interview, the provider failed to ensure:
*Nursing care plans were prepared and implemented for all same day surgery patients.
*Nursing care plans were prepared and implemented at the time of admission for all in-patients.
Findings include:

1. Review of patient 27's entire pre-operative medical record revealed no nursing care plan had been prepared or implemented in the pre-operative area.

Interview on 3/7/11 at 1:30 p.m. with registered nurse (RN) F revealed nursing care plans were not prepared or implemented in the pre-operative area.

Interview on 3/7/11 at 1:40 p.m. with operating room manager D revealed nursing care plans were not prepared or implemented in the operative area.

Interview on 3/7/11 at 1:45 p.m. with post-anesthesia care unit manager (PACU) G revealed:
*Nursing care plans were not prepared or implemented in the post-operative area.
*Same day surgery patients did not have nursing care plans.
*In-patients would not have a care plan started until after being admitted to the in-patient floor.

Interview on 3/8/11 at 8:45 a.m. with director of nursing A and quality services manager B revealed:
*They confirmed PACU manager G's statements above.
*No policy and procedure existed for the preparation and implementation of nursing care plans.
*They agreed nursing care plans were an integral part of the nursing process and delivery of care.

Based on observation, interview, and policy review, the provider failed to ensure medications were properly secured in the operative area. Findings include:

1. Observation on 3/7/11 at 11:00 a.m. of the operative area revealed:
*Multiple non-narcotic medications were being stored in open roll top type cupboards in the central hallway of the operative area.
*In unattended operating room 4 the anesthesia cart had on top of it a partially used vial of succinylcholine and glycopyrrolate. That cart also had a partially full insulin syringe marked lidocaine on it.

Interview on 3/7/11 at 11:05 a.m. with operating room manager D revealed:
*The roll top cupboards in the central hallway were opened every morning upon opening the operative area. Those cupboards were then left open the entire day until the operative area was closed for the day.
*The keys for those cupboards were kept in a drawer at the main operative area desk.
*The anesthesia medications found on the top of the anesthesia cart in operating room 4 should have been secured.

2. Observation on 3/8/11 at 10:15 a.m. of unattended operating room 12 revealed the anesthesia cart was unlocked and was found to have multiple vials of schedule II-V narcotics, anesthetizing agents and other prescription medications in it.

Interview on 3/8/11 at 10:15 a.m. with chief anesthetist E revealed:
*Anesthesia carts should be locked at all times when not in use.
*She agreed the medications in the anesthesia cart above were subject to diversion.

Review of the provider's policy on floor stock medications revised November 2010 revealed all drug storage areas would be secured and locked to ensure medications were inaccessible to visitors, patients, and unauthorized staff.

Based on observation and interview, the provider failed to ensure all operating room staff and physicians who were directly exposed to radiation were tested for levels of radiation exposure. Findings include:

1. Observation on 3/7/11 at 4:00 p.m. of patient 27's surgical procedure revealed:
*Fluoroscopy was used during the surgical procedure.
*The physician and surgical technician stood approximately one foot or less from the c-arm tube head when it was running.
*The nurse, radiology technician, and the anesthetist were approximately three to four feet from the c-arm tube head when it was running.
*No shielding was used by the team members other than lead aprons.
*The only person in the room with a radiation badge on was the radiology technician.

Interview on 3/7/11 at 4:05 p.m. with radiology technician H revealed:
*Physicians did not wear radiation badges.
*The only staff that wore radiation badges in the operating room were those that were always in the surgical cases that required extended exposure.
*She agreed different distances from the radiation source caused different amounts of exposure.

Interview on 3/8/11 at 8:45 a.m. with director of nursing A and quality services manager B revealed no policy had been developed related to the checking of staff and physicians for levels of radiation exposure.



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2. Interview with radiology manager N on 3/8/10 at 1:30 p.m. revealed:
*The provider did not have a personnel radiation monitoring policy.
*The provider required only radiologic technoligists to be monitored.

Based on observation, interview, and record review, the provider failed to ensure the manufacturer's written preventative maintenance and cleaning plan was followed and documented for three of three sterilizers and two of two instrument washers. Findings include:

1. Interview on 3/8/11 at 10:00 a.m. with sterilization team leader M revealed:
*The provider had two Steris washers and three Steris autoclaves.
*The sterilization team had no scheduled daily or weekly cleaning or preventative maintenance of any of the above washers or sterilizers.
*She was not aware of a policy that outlined the cleaning or preventative maintenance of the washers or autoclaves.

Interview on 3/8/11 at 1:00 p.m. with director of environmental services L revealed:
*He did not do any daily or weekly cleaning or preventative maintenance of the washers or autoclaves.
*The general maintenance of the washers and autoclaves was contracted out. That contract would not cover the daily and weekly cleaning and preventative maintenance.
*He was aware the manufacturer's manuals for the washers and autoclaves called for daily and weekly cleaning and preventative maintenance.
*It would have been the responsibility of the sterilization technicians to perform the daily and weekly cleaning and preventative maintenance.
*He agreed the daily and weekly cleaning and preventative maintenance of the washers and the autoclaves was an integral part of ensuring the safety and quality of the sterilization process.

Based on observation, interview, and record review, the provider failed to monitor and maintain appropriate levels of humidity in 13 of 13 operating rooms. Findings include:

1. Observations on 3/7/11 from 11:00 a.m. through 2:30 p.m. of the operative area revealed the operating rooms had no humidostats.

Interview on 3/7/11 at 11:50 a.m. with operating room manager D revealed:
*Maintenance was in charge of monitoring the humidity in the operating rooms.
*He was not aware of any requirements for humidity levels in the operating rooms.

Interview and record review on 3/8/11 at 1:00 p.m. with director of enviromental service L revealed:
*The operating rooms humidity settings were being maintained below 30 percent.
*The operating rooms humidity levels were monitored at the main duct of the air handler. That main duct was far away from the actual operating rooms.
*He agreed humidity in each operating room could not accurately have been monitored using the current system.
*He was not aware of a policy or procedure related to humidity levels in the operating room.

Interview on 3/8/11 at 2:30 p.m. with quality specialist C revealed:
*She served as the provider's infection control officer.
*She agreed operating room humidity level monitoring was important for proper infection control and patient safety.
*She was not aware of the State of South Dakota administrative rule that required operating room humidity to be kept between 45-60 percent.

Review of the Association of periOperative Registered Nurses, Perioperative Standards and Recommended Practices, 2010 Edition, Denver, CO, page 223, revealed humidity in the operating room should have been maintained at 30-60 percent.

Based on observation, interview, record review and policy review, the provider failed to ensure:
*Operating room walls were maintained to ensure they were a cleanable surface.
*Single-use items opened in the operating room were disposed of after each procedure.
Findings include:

1. Observation on 3/7/11 at 11:15 a.m. of the walls in operating room two revealed:
*The south and east walls of the operating room had multiple areas of torn and missing wall paper.
*Some of the areas noted missing were the size of a playing card or larger.
*The wall board below the wall paper was exposed in all areas of damage. Some of the areas of damage also penetrated the wall board.

Interview on 3/7/11 at 11:20 a.m. with operating room manager D revealed:
*He agreed the walls in operating room two were non-cleanable and would be considered an infection control risk.
*Operating room two had been in regular use.

2. Observations on 3/7/11 from 11:00 a.m. through 2:30 p.m. of the operating area revealed:
*In operating rooms two, three, and four multiple endotracheal tubes were found open on the top of the anesthesia carts.
*Non-cleanable foam padding was found in multiple locations throughout the operative area.

Interview on 3/7/11 at 11:22 a.m. with chief anesthetist E revealed:
*She agreed the endotracheal tubes were likely left open from case-to-case.
*Endotracheal tubes opened in the operating rooms were a single-use device and should have been disposed of if opened.
*She agreed using a endotracheal tube opened during a previous case was an infection control breach.

3. Observation on 3/7/11 at 4:40 p.m. of the cleaning of the operating room used for patient 27's operation revealed non-cleanable foam padding used during the patient's operation was being saved for re-use.

Interview on 3/7/11 at 4:45 p.m. with anesthetist I, registered nurse J, and surgical technician K revealed non-cleanable foam padding was regularly saved for re-use during other surgeries.

4. Interview on 3/9/11 at 9:00 a.m. with director of nursing A, quality services manager B, and quality specialist C revealed:
*No policy or procedure existed related to operating room wall cleaning or maintenance.
*All agreed it was important to maintain cleanable walls in the operating rooms.
*Cleaning of the operating room walls occurred once a week unless they were visually soiled. No documentation of that once a week cleaning was available.
*All agreed operating room walls in the above noted condition were a breach in infection control.
*All agreed the opened endotracheal tubes noted above and the re-use of non-cleanable foam padding was a breach in infection control.

Review of the Association of periOperative Registered Nurses, Perioperative Standards and Recommended Practices, 2010 Edition, Denver, CO, pages 241-251, revealed:
*Items exposed to a patient that were non-cleanable should have been disposed of.
*Walls should be a cleanable surface and be cleaned on a weekly basis. That cleaning should be documented to ensure proper cleaning had occurred.