HospitalInspections.org

Based on observations and records reviewed the Hospital failed to adhere to its' policy for conducting Time Outs.

1.) According to the Hospital policy titled "Universal Protocol" dated 1/6/2020, the purpose of conducting the Universal Protocol is to verify the correct procedure, the correct patient and the correct site.

The Surveyor observed the Time Out at 8:50 A.M. on 1/12/2021 in Operating Room #2 for the procedure on Patient #5. The Surveyor observed CRNA #1 stopped all of her activities during the Time Out. CRNA #1 was positioned on the left side of Patient #5's operative site and could not have viewed and attested to viewing the site marking on Patient #5's right ear during the Time Out.

The Surveyor interviewed the Nurse Manager of the Main Operating Room at 9:00 A.M. on 1/12/2021. The Nurse Manager said viewing and attesting to the site marking is a part of the Surgical process for a Time Out. The Nurse Manager agreed that CRNA #1 was not positioned to be able to see the marked site.

2.) According to the Hospital policy titled "Universal Protocol" dated 1/6/2020, during the Time Out all activities are suspended to the extent possible without compromising patient safety.

The Surveyor observed the Time Out at 9:30 A.M. on 1/12/2021 in Surgi-center Room #63 for the procedure on Patient #6. When the surgeon asked if the team was ready for the Time Out, Anesthesiologist #1 asked to postpone until he collected an additional set of vital signs. Anesthesiologist #1 then announced that he was ready for the Time Out. However, Anesthesiologist #1 continued to view the computer and perform a few key strokes during the Time Out. Anesthesiologist #1 did not suspend all activities as the Hospital's policy requires.