HospitalInspections.org

Based on medical record review, job description review, personnel file reviews and staff interviews, the hospital failed to ensure qualified personnel in the Operating Room by failing to provide orientation and competency validation for 1 of 3 Surgical Techs reviewed.

The findings include:

Closed medical record review for Patient (Pt) # 12 revealed the Patient was admitted to the named hospital on 07/14/2015 with a preoperative diagnosis of left renal calculus (kidney stone). Review of the Operative Report revealed "...OPERATIONS: Cystoscopy (procedure looking inside the bladder using a thin lighted tube)....flexible ureterorenoscopy (visualizing the interior of the ureter [carries urine from the kidney to the bladder] and kidney for removal or crushing of stones), with holmium laser lithotripsy (laser that breaks up kidney stones for removal). ..." Review of the Intraoperative Record revealed "...COUNTS.... Circulator: (First and Last Name of Registered Nurse [RN] # 1) Scrub: (First and Last Name of Surgical Technician [Surg Tech] # 1)....SAFE SURGERY CHECKLIST....Circulator (First and Last Name of RN # 1)....Scrub (First and Last Name of Surg Tech # 1). ..." Review of the Operative Report revealed the procedure was completed without complications and Pt # 12 was transferred to the Recovery Room in stable condition. Review of "Encounter Information" revealed Pt # 12 was discharged home on 07/14/2015 at 2150.

Review of "Job Description Summary" for a Surgical Technician, effective date 03/10/2013, revealed "...Job Summary Performs routine/designated technical functions before, during and after the operative procedure and clerical functions under the direction/supervision of the Registered Nurse and/or surgeon/physician to provide optimal/quality care and patient safety consistent with (Hospital Name)'s mission, philosophy, goals, standards, and bylaws....Additional Knowledge, Skills, and Abilities....Successful completion of specialty/subspecialty orientation. ..."

Review of Personnel File for Surg Tech # 1 revealed a job description for a Surgical Technician signed by Surg Tech # 1 on 12/05/2014. File review failed to reveal an orientation packet related to scrub tech responsibilities was started upon hire and failed to reveal any competencies related to scrub tech duties.
Review of Training Transcript revealed ongoing education, but did not reveal any orientation or competencies for scrub duties.

Review of a Personnel File revealed Surg Tech # 3 worked through an agency with a date of hire of 06/29/2015. Review revealed a Surgical Services Competency form for Experienced Surgical Techs was completed on 07/01/2015, signed off by RN # 2, an Education Specialist, as well as another RN and Surg Tech.

Review of Personnel File for Surg Tech # 2 revealed a hire date of 05/25/1992. Review revealed documentation of completed 2014 and 2015 Competency Assessment Forms for a Surgical Technologist, including validator initials and dates of completion.

Interview with RN # 1, on 08/12/2015 at 1445, revealed there was one occasion when she was concerned about staff competency. RN # 1 stated it was a "cysto" (Cystoscopy) case, but she did not recall the patient name or date. RN # 1 identified Surg Tech # 1, stating the Tech generally did not function in that role. Interview revealed RN # 1 spoke with Manager # 1. Further interview revealed the case proceeded with Surg Tech # 1 as the scrub tech.

Interview with Manager (Mgr) # 1, on 08/12/2015 at 1515, revealed a day when a surgeon wanted to get a Cystoscopy done and there were limited personnel available at the time. Interview revealed the surgeon told Mgr # 1 he did not need a person to scrub, just needed the set up done. Interview revealed Surg Tech # 1 was hired into the organization as a Surg Tech, but was not working in the OR in that capacity. She worked in the sterile core (area with sterile surgical equipment/ instruments/ supplies). Mgr # 1 stated the Tech had graduated from a Surgical Tech program and done procedures and the Manager thought "setting up a room would be something she could do". Interview revealed he asked her about this and "she was comfortable". Further interview revealed Mgr # 1 was in the hospital during the case and went into the room. The surgeon, he stated, did ask Surg Tech # 1 to hand him things, such as the fiber (laser fiber - a flexible light guide to the stone). Afterwards, the Manager stated, Surg Tech # 1 said she wanted orientation if they were going to ask her to do the scrub tech role on a recurring basis. Continued interview revealed Surg Tech # 1 had not performed as a scrub tech in the OR since then.

Interview with RN # 2, Education Specialist, on 08/13/2015 at 0900, revealed Surg Tech # 1 was previously at the hospital as a sterile processing/ distributing tech and when she was rehired she went back to the sterile core. Interview revealed there were no apparent changes, Surg Tech # 1 returned to tasks she had been previously doing. RN # 2, interview revealed, was not aware of the role / job description of Surg Tech. If she had known, interview revealed, orientation would have been "totally different", she would have been oriented as a Surg Tech.

Interview with Surg Tech # 1 on 08/12/2015 at 1550 revealed she was hired as a Surg Tech, but works in the Sterile Core. Interview revealed she was originally hired in 2009, laid off in June 2014, and returned to work in December 2014. Interview revealed one time when there were a number of surgery cases in progress and Mgr # 1 asked her to go in and set up an OR room. Interview revealed Surg Tech # 1 had concerns "that I had not done cysto's". Interview revealed Surg Tech # 1 did clinical rotations at the named hospital while in Surg Tech school and had trained as a scrub tech during that time, but had not functioned as a Surg Tech while an employee of the hospital. During the cysto case, interview revealed, the surgeon used a laser and she "held the fiber" and "he asked me to hand him things... I did" Interview revealed the RN circulating nurse was in the room, pulled items from the cabinet, handed them to the Surg Tech, and Surg Tech # 1 gave them to the surgeon. Further interview revealed the case "went fine". Afterwards, Surg Tech # 1 said she told the manager that "before I do anything else, I would like training." Continued interview revealed Surg Tech # 1 had not received orientation since the case and would not do a cysto again, "not until I have orientation. ..."

Based on policy and procedure review, medical record reviews, and staff and physician interviews the facility failed to ensure an individual qualified to administer anesthesia completed and documented a post anesthesia evaluation that included the required elements and time frames identified in hospital policy for 5 of 12 patient records reviewed (#4, #7, #9, #10, #12).

Review of Hospital Policy and Procedure "Pre-Anesthetic and Post-Anesthetic Responsibilities", dated 12/2014, revealed "...PURPOSE: ....The Anesthesiologist/CRNA (Certified Registered Nurse Anesthetist) assesses the patient the day after the administration of anesthesia....To identify and treat post-anesthesia complications....POLICY: ....4) Post-anesthesia visits are made by an Anesthesiologist/CRNA to in-patient and SDS (Same Day Surgery) patients the day following surgery. The post-operative assessment is performed and documented by an Anesthesiologist/ CRNA and will include: a) Respiratory function b) Cardiovascular function c) Mental Status/ LOC (level of consciousness) d) Temperature e) Pain Scale f) Nausea and Vomiting g) Postoperative hydration h) Other potential complications i) Follow-up care (if needed)....6) If the patient is discharged from the hospital prior to the visit, the chart is reviewed and an attempt is made to contact the patient by phone. At the time of the visit/call, a note is made on the Pre-Anesthesia Record regarding the absence of (sic, or) presence of anesthesia-related complications and treatment prescribed. ..." Policy review did not reveal clarity on actions to ensure a post-anesthesia evaluation was completed within a specified time frame for all surgical patients, including outpatients.
1. Closed Medical Record Review for Patient (Pt) # 4 revealed the Patient, a 54 year old, underwent outpatient surgery for a Right Knee Arthroscopy (surgery using a tiny camera to look inside the knee) on 06/10/2015 at 1502. Review of Anesthesia Record revealed documentation by a CRNA that Pt # 4 was taken to the Recovery Room (or PACU - Post anesthesia Care Unit) at 1549 in stable condition. Vital signs at 1549 were documented as Temperature (T) 98.2, Blood Pressure (BP) 164/95, Pulse (P) 88, Respirations (R) 11, SaO2 (measures oxygen in the blood) 98, Nasal Oxygen 3 liters per minute, and the patient condition was documented as stable. Further review of Anesthesia Record revealed a section labeled "DELAYED POSTOPERATIVE COURSE" with documentation of BP 147/88, P 79, R 22, Temp 98.1. Review revealed LOC (level of consciousness), pain score, nausea/vomiting, and hydration were not documented and blocks to record that the patient was visited, the record was reviewed, and there were no anesthesia complications were left unchecked. Further review revealed the spaces for date, time, and anesthestist signatures were blank. Record review failed to reveal any other documentation of a post anesthesia evaluation on Pt # 4.
Interview with Administrative Staff # 1 and # 2 on 08/12/2015 at 1600 revealed they did not find medical record documentation of a post anesthesia evaluation completed either in person or by telephone on Pt # 4 that included all required components. Interview revealed Pt # 4 had outpatient surgery and was not in the hospital for a postoperative day one (1) anesthesia visit.
Interview with MD # 1 on 08/13/2015 revealed when patients are transferred from the OR (Operating Room) to PACU, Anesthesia gives report to a PACU nurse detailing information on the surgery and patient condition. After that, for outpatients, Anesthesia orders a protocol or pathway with discharge criteria for nursing to follow. Anesthesia personnel, interview revealed, may not see patients again during hospitalization unless "they fall off the pathway". Interview confirmed Anesthesia had not been conducting a complete post anesthesia evaluation on these patients.
2. Closed Medical Record Review on Pt # 7 revealed the Patient, a 51 year old, underwent outpatient surgery for a cystoscopy (procedure to look inside the bladder using a thin lighted tube) on 07/21/2015 at 2328. Review of the Anesthesia Record revealed CRNA documentation that Pt # 7 was transported to the RR from the OR at 2353. Vital signs at 2353 were documented as T 97.9, BP 98/66, P 78, R 9, SaO2 100% and patient condition was documented as vital sign stable and the patient "arousable" and on 3 liters of oxygen by nasal cannula. Review revealed that under "DELAYED POSTOPERATIVE COURSE" was documentation that T was 98.1, BP 128/75, P 66, R 12, LOC drowsy, and the pain scale, nausea/vomiting, and hydration were stated to be zero (0). Record review failed to reveal documentation that Pt # 7 was visited by anesthesia personnel, the record was reviewed, or that there were no anesthesia complications nor did it reveal a name, date, or time associated with the data. Record review failed to reveal any other documentation to indicate a post anesthesia evaluation was completed.
Interview with Administrative Staff # 1 and # 2 on 08/12/2015 at 1600 revealed they did not find medical record documentation of a post anesthesia evaluation completed either in person or by telephone on Pt # 7 that included all required components. Interview revealed Pt # 7 had outpatient surgery and was not in the hospital for a postoperative day one (1) anesthesia visit.
Interview with MD # 1 on 08/13/2015 revealed when patients are transferred from the OR to PACU, Anesthesia gives report to a PACU nurse detailing information on the surgery and patient condition. After that, for outpatients, Anesthesia orders a protocol or pathway with discharge criteria for nursing to follow. Anesthesia personnel, interview revealed, may not see patients again during hospitalization unless "they fall off the pathway". Interview confirmed Anesthesia had not been conducting a complete post anesthesia evaluation on these patients.
3. Closed Medical Record review on Pt # 10 revealed the Patient, a 58 year old, underwent an outpatient Cystoscopy on 07/21/2015 at 1756. Review of the Anesthesia Record revealed CRNA documentation that Pt # 10 was transferred to RR at 1833. Review of Anesthesia Record revealed the CRNA documented an Immediate Postoperative course but did not document the time it was completed. Review revealed vital signs were T 97.7, B 125/80, P 98, R 20, SaO2 96% and the condition was documented as "VSS (vital signs stable), awake, airway patent". Review revealed the Delayed Postoperative Course showed vital signs and LOC documented, but did not document pain scale, nausea/vomiting, hydration, whether the patient was visited, if the record was reviewed or if there were any anesthesia complications, and it did not reveal the date, time, or signature of the person who wrote the vital sign and LOC information. Further record review failed to reveal any other documentation to indicate a post anesthesia evaluation was completed.
Interview with Administrative Staff # 1 and # 2 on 08/12/2015 at 1600 revealed they did not find any medical record documentation of a post anesthesia evaluation completed either in person or by telephone on Pt # 10 that included all required components. Interview revealed Pt # 10 had outpatient surgery and was not in the hospital for a postoperative day one (1) anesthesia visit.
Interview with MD # 1 on 08/13/2015 revealed when patients are transferred from the OR to PACU, Anesthesia gives a report to a PACU nurse detailing information on the surgery and patient condition. After that, for outpatients, Anesthesia orders a protocol or pathway with discharge criteria for nursing to follow. Anesthesia personnel, interview revealed, may not see patients again during hospitalization unless "they fall off the pathway". Interview confirmed Anesthesia had not been conducting a complete post anesthesia evaluation on these patients.
4. Closed Medical Record review on Pt # 12 revealed the Patient, a 53 year old, underwent an outpatient cystoscopy with ureteroscopic stone manipulation on 07/14/2015 at 1802. Review of the Anesthesia Record revealed Pt # 12 was transferred to RR at 1836 and the immediate postoperative course was documented by a CRNA at that time. Review revealed vital signs were T 98.2, BP 148/91, P 101, R 16, SaO2 96%. Review revealed the Pt # 12 was "stable" and on 3 liters of oxygen per minute. Further review revealed vital signs were documented again under the section "Delayed Postoperative Course" as T 98.2, BP 149/89, P 81, R 14, and the LOC was "alert". Record review did not reveal documentation of pain scale, nausea/vomiting, hydration, or whether the patient was visited, the record reviewed, or any anesthesia complications. Further, the review did not reveal the signature of the person taking the vital signs nor the date and time they were taken. Record review failed to reveal any other documentation to indicate a post anesthesia evaluation was completed.
Interview with Administrative Staff # 1 and # 2 on 08/13/2015 revealed no documentation was found to indicate a postanesthesia evaluation that included all required components was completed on outpatient surgery patients.
Interview with MD # 1 on 08/13/2015 revealed when patients are transferred from the OR to PACU, Anesthesia gives a report to a PACU nurse detailing information on the surgery and patient condition. After that, for outpatients, Anesthesia orders a protocol or pathway with discharge criteria for nursing to follow. Anesthesia personnel, interview revealed, may not see patients again during hospitalization unless "they fall off the pathway". Interview confirmed Anesthesia had not been conducting a complete post anesthesia evaluation on these patients.
5. Closed Medical Record review on Pt # 9 revealed the Patient, a 48 year old, underwent outpatient surgery for a cystoscopy on 08/06/2015 at 1902. Review of the Anesthesia Record revealed Anesthesia time documented as 1845 - 1945. Record review failed to reveal the 2nd page of the Anesthesia Record, where the immediate and delayed postoperative course would be documented. Record review failed to reveal any documentation that a postanesthesia evaluation was completed.
Interview with Administrative Staff # 1 and # 2 on 08/12/2015 at 1600 revealed they could not locate any medical record documentation of a post anesthesia evaluation completed either in person or by telephone on Pt # 10. Interview revealed Administrative Staff had talked with staff members who recalled documenting on the record, but confirmed that no record of the documentation was found.
Interview with MD # 1 on 08/13/2015 revealed when patients are transferred from the OR to PACU, Anesthesia gives a report to a PACU nurse detailing information on the surgery and patient condition. After that, for outpatients, Anesthesia orders a protocol or pathway with discharge criteria for nursing to follow. Anesthesia personnel, interview revealed, may not see patients again during hospitalization unless "they fall off the pathway". Interview confirmed Anesthesia had not been conducting a complete post anesthesia evaluation on these patients.
NC00108728