HospitalInspections.org

Based on record review, staff interview, review of the hospital policy entitled "Sponge, Sharps, Instrument Count" and review of the AORN (Association of Operating Room Nurses) "Perioperative Standards and Recommended Practices", it was determined that the hospital failed to ensure that hospital policies governing surgical care are designed to assure the achievement and maintenance of high standards of medical practice and patient care, and failed to follow perioperative standards and recommended practices, related to surgical counts, for relevant patient ID #1.

Findings are as follows:

A review of the hospital policy entitled "Sponge, Sharps, Instrument Count" under "Purpose", states: "...to ensure that the patient in not injured as a result of a retained foreign body".

Under "Practice I", Item #1 states; "Sponges should be counted on all procedures in which the possibility exists that a sponge could be retained".

Item #3 states "Sponge Counts should be taken: A. Before the procedure to establish a baseline for subsequent counts".

A review of the AORN "2011 Perioperative Standards and Recommended Practices" states under Retained Surgical Items, "Recommendations II; Radiopaque surgical soft goods (eg, sponges, towels, textiles) opened onto the the surgical field should be accounted for during all procedures".

Under 11.b., it states "counts of soft goods should be performed before the procedure to establish a baseline.........(ie, initial count), and "at skin closure at the end of the procedure when counted items are no longer in use (ie, final count)".

A review of the clinical record for patient ID # 1 revealed a "Laparoscopy, Open Cholecystectomy" on 2/28/11. The Operative Report revealed that "bleeding was controlled by cautery". It was also noted that "instrument and sponge counts were correct". A Jackson Pratt drain was placed. On 3/4/11, the patient was transferred to the rehabilitation unit. The patient was discharged to home on 4/1/11.

On 8/18/11, the patient presented to the hospital with complaints of pain in the upper abdomen for approximately one month. The medical record indicates that the surgeon had seen the patient in the office in April of 2011, and "was doing well". An abdominal CT scan revealed an "intra-abdominal subcutaneous abscess in the region of the transverse colon towards the abdominal wall". In addition, there was a question of "a linear area below the fascia" identified as a foreign body.

The patient was taken back to the Operating Room on 8/18/11, where a "Drainage of a subcutaneous intra-abdominal abscess and removal of a foreign body" took place. During the removal of purulent tissue, the linear area was identified by fluoroscopy. The area was opened wider and revealed a Bovie pad.

During an interview on 9/20/11 at 8:45 AM with the Perioperative Charge Nurse, it was determined that the Bovie scratch pad was not utilized during the surgery, but had been opened onto the sterile field, as it was in the "quick kit" (surgical instrument pack) utilized. It was also determined that the Bovie Pad had not been included in the initial surgical sponge count.

During an interview on 9/20/11 at 9:40 AM with the Circulating Nurse, it was reported that when the initial count had been done with the Scrub Technician, the Bovie pad had not been included in the initial surgical count, as "it is usually not part of the packet used. Because it had not been counted, it was not looked for at the end of the case". She also reported that she had "no idea how the Bovie pad got into the abdominal cavity".

It was determined that the hospital failed to include the Bovie scratch pad in the perioperative sponge count as recommended by AORN standards. In addition, the hospital policy failed to assure achievement of high standards of medical practice and patient care, as the Bovie scratch pad was not included in the surgical sponge count when it was opened onto the sterile field.

Based on record review, it was determined that the hospital failed to ensure that Operative Reports include the time of surgery for 8 of 8 relevant sample patients (ID 's 1, 2, 3, 4, 5, 6, 7, and 8).

Findings are as follows:

CMS (Center for Medicare and Medicaid Services) Interpretive Guidelines state that "The Operative Report includes at least:...... dates and times of surgery".

A review of the Operative Reports for patient ID #'s 1, 2, 3, 4, 5, 6, 7, and 8 revealed no evidence that the times of surgery were included in these reports.