HospitalInspections.org

The facility failed to ensure the Condition of Participation: CFR 482.12 Governing Body was met by failing to ensure:

1. Members of the Medical Staff abided to hospital policies and procedures, in addition Administrative staff failed to cross-train staff on hospital policy and procedures. (Refer to A-0049)

2. A member of the Medical Staff documented in a patient's medical record when they should have, when an invasive procedure was performed on the patient that was not clinically indicated. (Refer to A-0049 )

3. A member of the Medical Staff notified immediately a patient's family, when a procedure was performed on the wrong patient. (Refer to A-0049)

4. Policies related to disruptive or unprofessional behavior (personal conduct that affects or potentially may affect patient care negatively) were implemented by all Medical Staff members. (Refer to A-0049)

5. Authorization from the California Department of Public Health was received, prior to its using licensed in-patient space, to provide care to Ambulatory Infusion Center patients. (Refer to A-0063)

The cumulative effect of these systemic practices resulted in the failure of the facility to deliver care in compliance with the Condition of Participation: Governing Body.

Based on interview and record review, the facility failed to ensure members of the Medical Staff were accountable to the Governing Body as evidenced by:

1. A time out was not performed for invasive procedures.

2. A member of the Medical Staff did not document in a patient's medical record when they should have, when an invasive procedure was performed on the patient that was not clinically indicated.

3. A member of the Medical Staff did not notify a patients family, when a procedure was performed on the wrong patient.

4. Policies related to disruptive or unprofessional behavior (personal conduct that affects or potentially may affect patient care negatively) were not implemented by a Medical Staff member.

These failures had the potential to place patients health at risk in a universe of 135 patients.

Findings:

1a. On April 25, 2018 the medical record for Patient 1 was reviewed. Documentation revealed the 72 year old Hispanic female presented to the Emergency Department (ED) via ambulance on March 15, 2018 with diagnosis of altered level of consciousness and a blood pressure of 97/64. A medical screening examination (MSE) was performed by Physician 1 at 7:10 PM. At 7:18 PM, multiple orders were prescribed by Physician 1 and the patient was triaged as an Emergency Severity Level (ESI) Priority 3 - "Potentially Unstable." Patient 1 was placed in room 9.

A review of the medical record for Patient 2 was conducted on April 25, 2018, documentation revealed Patient 2 a 64 year old Caucasian female, presented to the ED via ambulance on March 15, 2018 at 6:35 PM (29 minutes prior to Patient 1's arrival) with diagnosis of respiratory problems and a blood pressure of 123/79. An MSE was performed by Physician 1 at 6:41 PM, multiple orders were prescribed by Physician 1 and the patient was triaged as an ESI Priority 3 - "Potentially Unstable." Patient 2 was placed in room 6.

During a review of Patient 2's Chest x-ray (an imaging test that uses small amounts of radiation to produce pictures of the organs, tissues, and bones of the body) dated March 15, 2018 7:14 PM indicated, "Moderate to large right pneumothorax with suggestion of a mild degree of tension pneumothorax with mediastinal shift (towards one side of the chest cavity) to the left.

On April 25, 2018 at 12 PM, an interview was conducted with Physician 1. Physician 1 stated he had two (2) similar patients arrive within 30 minutes of each other with similar orders for both. Physician 1 stated he received a telephone call from the Radiologist around 7:30 PM informing him that Patient 2 had a tension pneumothorax (an abnormal collection of air between the lung and the chest wall). Physician 1 stated, "After looking at the x-ray, I looked at my patient list and went into room 9." The EMT (Emergency Medical Technician) was there, I asked him to get me supplies. Physician 1 was asked if he looked at the patient's arm band for identification prior to beginning the procedure, Physician 1 stated, "Yes, I glanced at it but it didn't register with me that I was in the wrong room."

As the interview continued, Physician 1 was asked if the procedure was a life-threatening emergency (needing to be done immediately or possible death could occur to the patient), Physician 1 stated, "There was an urgency but not an emergency." Physician 1 was asked to recall what occurred next, Physician 1 stated, I cleaned the patient's chest wall and proceeded to perform the "needle thoracostomy" (insertion of a needle into the patient's chest for the release of the abnormal collection of air in the chest). Physician 1 stated, "I hit the rib, I stopped, left the room and then realized I was in the wrong room." After I realized I was in the wrong room I ordered a chest x-ray to make sure I didn't cause any harm to the patient.

Physician 1 was asked if a "Time-out" (a deliberate pause in activity involving clear communication that includes active listening and verbal confirmation of the patient, procedure, site and side among all members of the surgical/procedural team) was performed prior to the procedure, Physician 1 stated, "No."

A review of the Policy Number T-107 titled "Time Out for Invasive Procedures (Universal Protocol)" revised date 9/15, under the "Purpose" section documentation revealed the following:

"To promote patient safety by providing verification of correct patient, procedure and site if applicable, for invasive/surgical procedure(s)."

Further review of the policy under the "Procedure" section documentation revealed the following:

"...5. A Time Out will be performed for all cases, except in an emergency if the risks outweigh the benefits."

A review of the facility's "Medical Staff Bylaws and General Rules and Regulations," revised and approved: July 2017, under section "2.5 Basic Responsibilities of Medical Staff Membership" documentation revealed the following:

"The ongoing responsibilities of each member of the Medical Staff include:

"...b. Abiding by the Medical Staff Bylaws, Rules and Regulations, and Medical Staff and hospital policies and procedures."

On April 27, 2018 at 10 AM, an interview was conducted with the Director of Quality Management (DQM). The DQM was asked when procedures are performed in the ED if a "Time Out (a deliberate pause in activity involving clear communication that includes active listening and verbal confirmation of the patient, procedure, site and side among all members of the surgical/procedural team) should be performed, the DQM stated, "Yes, it's a hospital wide procedure, it pertains to this case in the ED."

During the patient's stay in the ED on March 15, 2018 it was determined that the patient had a tension pneumothorax and was in need of a "Needle Thoracostomy." During the patient's record review no documented evidence could be located to indicate that at "Time-out" procedure was done prior to the patient having an invasive procedure performed. The "Needle Thoracostomy procedure was done on March 15, 2018 at 7:52 PM.

c. On April 27, 2018 a clinical record review was conducted for Patient 12. Patient 12's clinical record revealed Patient 12 revealed the patient presented to the Emergency Department on April 13, 2018 with a diagnosis of a recurrent right pneumothorax. During the Patient's visit it was determined that the patient was in need of having chest tubes placed. No documented evidence could be located to indicate that at "Time-out" procedure was done prior to the patient having an invasive procedure performed. The chest tubes were inserted on April 13, 2018 at 5:23 AM.

On April 27, 2018 at 10:20 AM, an interview was conducted with the Director of the Emergency Department (DED). The DED stated, she was not aware that a "Time-out" was not performed on Patient 12 prior to his having chest tubes inserted. The DED further stated that the Registered Nurse floated from the "Observation Unit." The DED was asked if she provided training to the nurse's that are cross-trained to work in the ED regarding the "Time-out" procedure, the DED stated, "No."

2. On April 25, 2018 at 8 AM, an interview was conducted with the Emergency Department Director (EDD). The EDD stated she did not find out about a procedure performed on the wrong patient until the following day (March 16, 2018 at approximately 2:55 PM). The EDD stated that she reviewed Patient 1 and Patient 2's ED medical records, "I saw no documentation of the needle thoracostomy performed on Patient 1 in the record," I called him (Physician 1) and informed him that he needed to document the incident in the patient's record.

Documentation of the procedure performed on the wrong patient (Patient 1) was not done until March 16, 2018 at 2:44 PM, approximately 19 hours and 14 minutes later.

3. On April 25, 2018 a review of Patient 1's medical record revealed Physician 1 did not attempt to contact Patient 1's family to inform them that a procedure that was not medically indicated was performed on the patient until March 19, 2018 at 4:59 PM, approximately 3 days and 21 hours after the event. Physician 1 further stated, "I left a message, no one returned the telephone call."

Further review of Patient 1's medical record revealed Patient 1 was admitted to the telemetry unit following her ED visit. A review of nursing notes revealed the following:

a. March 16, 2018 at 8:30 PM, patient's daughter called to check on patient's condition
b. March 18, 2018 at 6:10 PM, daughter visited on
c. March 19, 2018 at 4 PM, daughter called
d. March 20, 2018 at 10:20 PM, daughter called
e. March 21, 2018 at 2 PM, daughter called
f. March 21, 2018 at 5:03 PM, daughter called

No documented evidence could be located that Physician 1 attempted to contact the patient's daughter before or after the March 19, 2018 4:59 PM.

On April 25, 2018 at 8 AM, an interview was conducted with the Emergency Department Director (EDD). The EDD was asked how soon should notification be made to the family in this type of event, the EDD stated, "Immediately."



34959

4. During an interview with the Physician (P 2) before performing a procedure on April 26, 2018 at 8:35 AM, when asked how do you ensure your going to perform the procedure to the correct patient? P 2 was loud in a rude manner and stated, "I don't like being bombarded with questions."

During an interview with the Director of Quality and Medical Staff (DOQMS) on April 26, 2018 at 1:47 PM, she stated that the incident occurred in the Cath lab (an examination room in a hospital with diagnostic imaging equipment used to visualize the arteries and chambers of the heart and treat any abnormalities found). The Respiratory Therapist (RT 1) asked P 2 if she needed to leave or stay further towards the end of a procedure. P 2 used profanity (foul language) towards RT 1.

During an interview with the Respiratory Therapist (RT 1) on April 27, 2018 at 9:18 AM, RT 1 stated that toward the end of a procedure she asked if she needed to leave or stay further in the Cath lab and P 2 stated "shit" and also that she was incompetent and not to ask stupid questions. RT 1 further stated that P 2 did not apologize to her.

During a review of the Medical Executive Committee meeting dated December 14, 2017 indicated, "P 2's use of profanity while addressing a staff member..."

During a review of the facility's policy and procedure "Professional Conduct Standards" dated September 2013, included the following:.."Exhibiting language, action, attitude and behavior which consistently convey to patients, families, colleagues, and all other members of the Hospital's health care team a sense of compassion and respect for human dignity. Refraining from language or behavior which a reasonable adult would consider to be foul, abusive, or threatening. Treating patients, staff and all persons functioning in any capacity within the Hospital with courtesy, respect, and human dignity. Using abusive language, including repetitive sarcasm. Making rude or demeaning comments..."

During a review of the facility's policy and procedure "Disruptive Behavior Algorithm (a set of rules to be followed)" dated April 2013, included the following:..."All individuals within the Hospital should be treated courteously, respectfully and with dignity. To that end, the Hospital provides education to all staff regarding the Hospitals Code of Conduct. The Medical Staff also requires all Practitioners to conduct themselves in a professional and cooperative manner..."

During a review of the facility's policy and procedure, "Professional Standards Committee", undated, included the following:.."Duties of the Professional Standards Committee shall include the review identified concerns related to a Provider's behavior and compliance with expected standards of professionalism as defined in the Professional Conduct Standards and Disruptive Behavior Algorithm Medical Staff Policies. The Professional Standards Committee will oversee the performance of all Focused Professional Practice Evaluations related to disruptive behavior and /or recurrent Rule Violations..."

Based on observation, interview, and record review, the facility failed to obtain authorization from the California Department of Public Health, prior to its using licensed in-patient space, to provide care to Ambulatory Infusion Center patients. This failure created the potential of not having the licensed space available for in-patient usage in the event of a catastrophic event.

Findings:

On April 24, 2018 at 8:10 AM, a request was made tour the 3400 unit of the facility. During a concurrent interview with the Quality and Patient Safety Supervisor (QPSS), the QPSS confirmed that the 3400 unit was closed. The QPSS was asked if the beds were in suspension or if the beds were still licensed, the QPSS stated she was not sure.

An observation of the 3400 unit was conducted on April 24, 2018 at 8:20 AM. During the tour, observations revealed the door to the medication room was unlocked. Observations revealed the medication room contained multiple supply carts and a crash cart. A review of the crash cart log revealed documentation that the crash cart was checked daily in the "closed unit." Further review of the crash cart log revealed the crash cart was designated for the "AIC." The QPSS was asked what "AIC" stood for she stated "Ambulatory Infusion Center."

As the interview continued with the QPSS, she stated she was calling the Manager of the AIC to come to the 3400 unit.

On April 24, 2018 at 9:03 AM, an interview was conducted with the Nurse Manager (NM 1) of the Post Anesthesia Care Unit (PACU), AIC and Gastrointestinal unit. NM 1 was asked if AIC patients were receiving care on the 3400 unit, NM 1 replied, "Yes, they were up here yesterday." As the interview continued NM 1 stated that they use rooms 3404 and 3406 and if needed they will also use room 3408. The NM stated that the patients are usually here for four (4) to six (6) hours depending on the type of infusion they are receiving.

During the interview, NM 1 stated we try to keep the patients down in PACU depending on the census, yesterday we had 26 patients plus add-on's were weren't able to keep them (the AIC patients) downstairs. The NM was asked if the AIC patients were receiving an out-patient service in an in-patient licensed space, the NM stated, "Yes."

On April 24, 2018 at 1:43 PM, an interview was conducted with the Director of Perioperative Infusion and Speciality Services (DOPISS). The DOPISS stated sometimes patients are going up to the 3400 unit to receive their infusions, when asked how long this practice has been occurring the DOPISS stated "Off and on for about a year due to the construction occurring throughout the facility.

The DOPISS confirmed the AIC is an out-patient service. The DOPISS was asked if out-patients can receive treatment up there (3400 unit), the DOPISS replied, "No." The DOPISS was asked who provided her with permission to place out-patients in the 3400 unit, the DOPISS stated, "It was a joint decision with leadership."

On April 24, 2018 at 3:10 PM, an interview was conducted with the Vice President of Professional and General Services (VPPGS). The VPPGS stated, "It's a space issue, we have grown over the years and we felt this was the best location for the AIC, I didn't know I needed permission."

Based on observation, interview, and record review, the facility failed to ensure patients receive care in a safe environment as evidenced by:

1. One of 31 sampled patients (Patient 1) had an invasive procedure performed on her, that was not clinically indicated.

2. Policies related to disruptive or unprofessional behavior (personal conduct that affects or potentially may affect patient care negatively) were not implemented by Physician (P 2).

3. There was no documentation that the care plan (a document that identifies nursing orders for a patient and serves as a guide to nursing care) for soft limb restraints (soft restraints that are applied to a person's arms or legs) were initiated and the reassessment of soft limb restraints were not done on March 22, 2018 at 6:00 AM, for Patient 16.

4. There was no documentation on April 23, 2018 that the crash cart (a cart that carries medicine and equipment for use in emergency resuscitations) located in the neonatal intensive care unit (specializing in the care of ill or premature newborn infants) was checked daily.

5. The Registered Nurse (RN 8) did not remove her personal protective equipment (gown,and disposable gloves) after she administered medications to Patient 26, when she exited the isolation room (a patient is placed in the room to implement infection control and the prevention of contagious disease).

6. There was no documentation that the pre procedure check list (a document that is completed before patient has a procedure that indicates the right patient, right site, procedure, consent, medications given to patient to treat any heart problems, blood products available, and any known allergies) was done for Patient 30.

These failures had the potential for patients that received care and services in the facility, not to have their assessed needs met in a safe environment and created a potential risk of safety in the delivery of care in a universe of 135 patients.

Findings:

1. On April 25, 2018 the medical record for Patient 1 was reviewed. Documentation revealed the 72 year old Hispanic female presented to the Emergency Department (ED) via ambulance on March 15, 2018 with diagnosis of altered level of consciousness and a blood pressure of 97/64. A medical screening examination (MSE) was performed by Physician 1 at 7:10 PM. At 7:18 PM, multiple orders were prescribed by Physician 1 and the patient was triaged as an Emergency Severity Level (ESI) Priority 3 - "Potentially Unstable." Patient 1 was placed in room 9.

A review of the medical record for Patient 2 was conducted on April 25, 2018, documentation revealed Patient 2 a 64 year old Caucasian female, presented to the ED via ambulance on March 15, 2018 at 6:35 PM (29 minutes prior to Patient 1's arrival) with diagnosis of respiratory problems and a blood pressure of 123/79. An MSE was performed by Physician 1 at 6:41 PM, multiple orders were prescribed by Physician 1 and the patient was triaged as an ESI Priority 3 - "Potentially Unstable." Patient 2 was placed in room 6.

During a review of Patient 2's Chest x-ray (an imaging test that uses small amounts of radiation to produce pictures of the organs, tissues, and bones of the body) dated March 15, 2018 7:14 PM indicated, "Moderate to large right pneumothorax with suggestion of a mild degree of tension pneumothorax with mediastinal shift (towards one side of the chest cavity) to the left.

On April 25, 2018 at 12 PM, an interview was conducted with Physician 1. Physician 1 stated he had two (2) similar patients arrive within 30 minutes of each other with similar orders for both. Physician 1 stated he received a telephone call from the Radiologist around 7:30 PM informing him that Patient 2 had a tension pneumothorax (an abnormal collection of air between the lung and the chest wall). Physician 1 stated, "After looking at the x-ray, I looked at my patient list and went into room 9." The EMT (Emergency Medical Technician) was there, I asked him to get me supplies. Physician 1 was asked if he looked at the patient's arm band for identification prior to beginning the procedure, Physician 1 stated, "Yes, I glanced at it but it didn't register with me that I was in the wrong room."

As the interview continued, Physician 1 was asked if the procedure was a life-threatening emergency (needing to be done immediately or possible death could occur to the patient), Physician 1 stated, "There was an urgency but not an emergency." Physician 1 was asked to recall what occurred next, Physician 1 stated, I cleaned the patient's chest wall and proceeded to perform the "needle thoracostomy" (insertion of a needle into the patient's chest for the release of the abnormal collection of air in the chest). Physician 1 stated, "I hit the rib, I stopped, left the room and then realized I was in the wrong room," after I realized I was in the wrong room I ordered a chest x-ray to make sure I didn't cause any harm to the patient.

Physician 1 was asked if a "Time-out" (a deliberate pause in activity involving clear communication that includes active listening and verbal confirmation of the patient, procedure, site and side among all members of the surgical/procedural team) was performed prior to the procedure, Physician 1 stated, "No."

On April 25, 2018 at 8 AM, an interview was conducted with the Emergency Department Director (EDD). The EDD stated on the night of the incident in which a procedure was performed on the wrong patient an EMT and up to three (3) Registered Nurse's (RN) were in Patient 1's room (room 9) at the time Physician 1 entered and performed a "Needle Thoracostomy" on the wrong patient.

The EDD stated EMT 1 was preparing to perform an EKG (electrocardiogram-a test to check the electrical activity of the heart) on Patient 1 and that a registry nurse was scheduled to resume the care of the patient but she was going to be a few minutes late so RN 1 (day shift nurse) was giving report (status of the patient) to RN 2 (night shift nurse who was assigned to assist throughout the ED).

On April 25, 2018 at 7:30 AM, an interview was conducted with EMT 1. EMT 1 stated that Physician 1 entered the patient's room and asked him for supplies, "I got needles and Chlorahexadine (antibacterial liquid to clean the skin), he starting prepping the patient for a procedure." No specific nurse was helping him. EMT 1 was asked if a "Time-out" was performed prior to the physician proceeding with the invasive procedure, EMT 1 stated, "No."

As the interview continued, EMT 1 stated after Physician 1 attempted the procedure and got no release of air, he left the room, he was gone long enough for me to get the EKG. EMT 1 further stated when he (Physician 1) returned, he stated the procedure was done on the wrong patient.

On April 25, 2018 at 1:05 PM, a telephone interview was conducted with RN 1. RN 1 stated Patient 1 arrived in the ED right around change of shift, I was setting her up on the monitor, I had her for about 10 minutes. RN 1 proceeded to state I gave report to RN 2, I was suppose to give report to registry but they were running late.

As the telephone interview continued, RN 1 stated I had already given report and went to turn in my Vocera (communication system) when "I don't remember who" said the patient had a tension pneumo, my first inclination (thought) was "What did I miss." Physician 1 was at the patient's bedside, he was already cleaning the chest wall with Chlorahexadine, I was thinking what else could I have done, I stayed and watched because I had never seen a thoracostomy before. RN 1 was asked if she observed or participated in a "Time-out," RN 1 stated, "No, and I don't feel that I was involved, I just wanted to be present to learn, I hadn't clocked out yet."

RN 1 was asked if a "Time-out" was done, RN 1 stated, "No," RN 1 was then asked if she knew what a "Time-out" was, RN 1 replied, "Yes." RN 1 was asked is there usually a nurse at the bedside when a procedure is being done, RN 1 stated, "Yes." RN 1 was then asked who's responsibility is it to do a "Time-out," RN 1 replied, "Both the doctor and the nurse."

On April 27, 2018 at 10 AM, an interview was conducted with the Director of Quality and Medical Staff, who stated, "A nurse should be involved whenever a procedure is performed."

A review of the Policy Number T-107 titled "Time Out for Invasive Procedures (Universal Protocol)" revised date 9/15, under the "Purpose" section documentation revealed the following:

"To promote patient safety by providing verification of correct patient, procedure and site if applicable, for invasive/surgical procedure(s)."

Further review of the policy under the "Procedure" section documentation revealed the following:

"...5. A Time Out will be performed for all cases, except in an emergency if the risks outweigh the benefits."


34959

2. During an interview with Physician (P 2) before performing a procedure on April 26, 2018 at 8:35 AM, when asked how do you ensure your going to perform the procedure to the correct patient? P 2 was loud in a rude manner and stated "I don't like being bombarded with questions."

During an interview with the Director of Quality and Medical Staff (DOQMS) on April 26, 2018 at 1:47 PM, she stated that the incident occurred in the Cath lab (an examination room in a hospital with diagnostic imaging equipment used to visualize the arteries and chambers of the heart and treat any abnormalities found). The Respiratory Therapist (RT 1) asked P 2 if she needed to leave or stay further towards the end of a procedure. P 2 used profanity (foul language) towards RT 1.

During an interview with the Respiratory Therapist (RT 1) on April 27, 2018 at 9:18 AM, RT 1 stated that toward the end of a procedure she asked if she needed to leave or stay further in the Cath lab and P 2 stated "shit" and also that she was incompetent and not to ask stupid questions. RT 1 further stated that P 2 did not apologize to her.

During a review of the Medical Executive Committee meeting dated December 14, 2017 indicated, "P 2's use of profanity while addressing a staff member..."

During a review of the facility's policy and procedure "Professional Conduct Standards" dated September 2013, included the following:.."Exhibiting language, action, attitude and behavior which consistently convey to patients, families, colleagues, and all other members of the Hospital's health care team a sense of compassion and respect for human dignity. Refraining from language or behavior which a reasonable adult would consider to be foul, abusive, or threatening. Treating patients, staff and all persons functioning in any capacity within the Hospital with courtesy, respect, and human dignity. Using abusive language, including repetitive sarcasm. Making rude or demeaning comments..."

During a review of the facility's policy and procedure "Disruptive Behavior Algorithm (a set of rules to be followed)" dated April 2013, included the following:..."All individuals within the Hospital should be treated courteously, respectfully and with dignity. To that end, the Hospital provides education to all staff regarding the Hospitals Code of Conduct. The Medical Staff also requires all Practitioners to conduct themselves in a professional and cooperative manner..."

During a review of the facility's policy and procedure "Professional Standards Committee", undated included the following:.."Duties of the Professional Standards Committee shall include the review identified concerns related to a Provider's behavior and compliance with expected standards of professionalism as defined in the Professional Conduct Standards and Disruptive Behavior Algorithm Medical Staff Policies. The Professional Standards Committee will oversee the performance of all Focused Professional Practice Evaluations related to disruptive behavior and /or recurrent Rule Violations..."

3. During a review of the medical record for Patient 16, the record indicated Patient 16 was admitted on March 19, 2018 with a diagnosis of Diabetic Ketoacidosis (Diabetic ketoacidosis is a complication of diabetes that occurs when compounds called ketones build up in the bloodstream. Ketones are produced when the body breaks down fats instead of sugars, which happens when the body does not produce enough insulin to process sugar properly).

During a review of the physician orders dated March 22, 2018 at 3:33 AM, indicated:.."Use restraints for twenty-four hours (not to exceed twenty-four hours), restraint is indicated due to the following indications attempts to pull out tubes and lines, and to promote healing and safety use the following restraint: soft limb..."

During a review of the assessment (the registered nurse will document the reassessment of restraints every two hours) form for restraints indicated there was no documentation proof that the reassessment of restraints were done on March 22, 2018 at 6:00 AM.

During a review of the medical record for Patient 16, there was no documentation that a care plan for soft limb restraints were done.

During an interview with the Registered Nurse (RN 6) on April 26, 2018 at 10:50 AM, the RN 6 confirmed there was no documentation that the reassessment of restraints were done on March 22, 2018 at 6:00 AM. The RN 6 also confirmed there was no documentation that a care plan for soft limb restraints were done.

During a review of the facility's policy and procedure "Restraints for Non-Combative, Non-Violent Patients"dated January 11, 2018 indicated:..."Nursing monitoring will be done every fifteen minutes and documented every two hours at a minimum. Monitoring will be accomplished by observation, interaction with the patient,or related direct examination of the patient by qualified staff..."The registered nurse will complete the nursing assessment and reassessment related to a patient in restraint which will include neurological (disorder of the nervous system), circulatory (moves blood through the body), skin integrity of restrained body part, nutrition, hydration status (normal state of body water), elimination needs, level of distress, agitation, physical, psychological status, cognitive functioning, patient's comfort, response to the restraint or seclusion intervention, signs and symptoms of injury associated with application of restraint, range of motion in extremities, assist patient out of restraint and properly reapply restraint every two hours while awake, and reassessment for possible discontinuation of physical restraint or seclusion..."In areas where care plans are used, the use of restraints will be reflected in the patient's nursing care plan within six hours..."

4. During a review of the crash cart log dated for the month of April 2018 indicated there was no documentation that the crash cart located in the neonatal intensive care unit was checked on April 23, 2018.

During an interview with the Registered Nurse (RN 7) on April 24, 2018 at 7:52 AM, the RN 7 confirmed there was no documentation that the crash cart was checked on April 23, 2018. The charge nurse was supposed to check the crash cart daily.

During a review of the facility's policy and procedure "Emergency Crash Cart Availability and Readiness"dated January 11, 2018 indicated:..."Crash carts in open patient care areas will be checked every twenty four hours at a minimum seven days a week by nursing, or designated staff..."

5. During a review of the medical record for Patient 26, the record indicated Patient 26 was admitted on April 23, 2018 with a diagnosis of acute on Chronic Diastolic Congestive Heart Failure (the cardiac output is not adequate enough to meet the demands of the body) and history of Methicillin-resistant Staphylococcus Aureus (causes infections in different parts of the body and is resistant to certain antibiotics, including penicillin, and making it challenging to treat) of the wound (in which the skin is torn, cut or punctured) to left knee.

During a medication observation on April 25, 2018 at 8:11 AM, the Registered Nurse (RN 8) did not remove her personal protective equipment (gown,and disposable gloves) after she administered medications to Patient 26, when she exited the isolation room (a patient is placed in the room to implement infection control and the prevention of contagious disease).

During an interview with the Clinical Educator Coordinator (CEC) on April 25, 2018 at 8:12 AM, the CEC confirmed that the RN 8 should have removed personal protective equipment before exiting the isolation room.

During a review of the facility's policy and procedure "Guidelines for Isolation Precautions"dated May 2017 indicated:..."Prior to leaving the patient room or moving into the clean area, remove gown first by pulling the sleeve over the gloves and taking care not to touch the outside, contaminated part of the gown. Remove gloves, Remove mask, faceshield or respiratory protection, and perform hand hygiene preferably with alcohol hand sanitizer..."

6. During a review of the medical record for Patient 30, the record indicated Patient 30 was admitted on March 8, 2018 with a diagnosis of fluid in the lungs and metastatic cancer (spreads to a different part of the body from where it started).

During a review of the medical document titled "Procedural Safety Checklist Universal Protocol Surgery" (a document that confirms the surgical team has completed the tasks before it proceeds with the procedure) dated March 9, 2018 for Patient 30 indicated, the pre procedure checklist was not done before the pleurx catheter (used for draining the excess fluid that surrounds the lungs) placement to the right chest procedure was performed.

During an interview with the Director of Perioperative Infusion and Speciality Services (DOPISS) on April 27, 2018 at 10:43 AM, the DOPISS stated that the pre procedure checklist should have been completed by the operating room (where procedures are performed) or the intensive care unit (a unit where special medical equipment and services are provided for patients who are seriously injured or ill) nurses before Patient 30's pleurx catheter placement to the right chest procedure was performed.

During a review of the facility's policy and procedure "Time Out for Invasive Procedures (Universal Protocol)" dated September 2015, included the following..."To promote patient safety by providing verification of correct patient, procedure, and site if applicable, for invasive surgical procedures. In the pre-procedure area and prior to the start of any invasive procedure, confirmation of correct patient, procedure, and site if applicable will be completed and documented in a collaborative manner by the clinical team..."

Based on interview and record review, the facility failed to ensure the medical staff adapted and enforced the bylaws to carry out its responsibilities as evidenced by:

1. A time out was not performed for invasive procedures.

2. Policies related to disruptive or unprofessional behavior (personal conduct that affects or potentially may affect patient care negatively) were not implemented by a Medical Staff member.

These failures had the potential to place patients health at risk in a universe of 135 patients.

Findings:

1. During a review of the medical record for Patient 1 on April 25, 2018, documentation indicated Patient 1 was a 72 year old Hispanic female, presented to the Emergency Department (ED) via ambulance on March 15, 2018 at 7:04 PM, with a diagnosis of altered level of consciousness and a blood pressure or 97/64. A medical screening examination (MSE) was performed by Physician 1 at 7:10 PM. At 7:18 PM, multiple orders were prescribed by Physician 1 and the patient was triaged as an Emergency Severity Level (ESI) Priority 3-"Potentially Unstable." Patient 1 was placed in room 9.

A review of the medical record for Patient 2 on April 25, 2018, documentation revealed Patient 2 a 64 year old Caucasian female, presented to the ED via ambulance on March 15, 2018 at 6:35 PM (29 minutes prior to Patient 1's arrival) with diagnosis of respiratory problems and a blood pressure of 123/79. An MSE was performed by Physician 1 at 6:41 PM, multiple orders were prescribed by Physician 1 and the patient was triaged as an ESI Priority 3-"Potentially Unstable." Patient 2 was placed in room 6.

During a review of Patient 2's Chest x-ray (an imaging test that uses small amounts of radiation to produce pictures of the organs, tissues, and bones of the body) dated March 15, 2018 7:14 PM indicated, "Moderate to large right pneumothorax with suggestion of a mild degree of tension pneumothorax with mediastinal shift (towards one side of the chest cavity) to the left.

On April 25, 2018 at 12 PM, an interview was conducted with Physician 1. Physician 1 stated he had two (2) similar patients arrive within 30 minutes of each other with similar orders for both. Physician 1 stated he received a telephone call from the Radiologist around 7:30 PM informing him that Patient 2 had a tension pneumothorax (an abnormal collection of air between the lung and the chest wall). Physician 1 stated, "After looking at the x-ray, I looked at my patient list and went into room 9." The EMT (Emergency Medical Technician) was there, I asked him to get me supplies. Physician 1 was asked if he looked at the patient's arm band for identification prior to beginning the procedure, Physician 1 stated, "Yes, I glanced at it but it didn't register with me that I was in the wrong room."

As the interview continued, Physician 1 was asked if the procedure was a life-threatening emergency (needing to be done immediately or possible death could occur), Physician 1 stated, "There was an urgency but not an emergency." Physician 1 was asked to recall what occurred next, Physician 1 stated, I cleaned the chest wall and proceeded to perform the needle thoracostomy (insertion of a needle into the patient's chest for the release of the abnormal collection of air in the chest). Physician 1 stated, "I hit the rib, I stopped, left the room and then realized I was in the wrong room," after I realized I was in the wrong room I ordered a chest x-ray to make sure I didn't cause any harm to the patient.

Physician 1 was asked if a "Time-out" was performed, Physician 1 stated, "No." Physician 1 was further asked if it was an emergency (immediate)

A review of the Policy Number T-107 titled "Time Out for Invasive Procedures (Universal Protocol)" revised date 9/15, under the "Purpose" section documentation revealed the following:

"To promote patient safety by providing verification of correct patient, procedure and site if applicable, for invasive/surgical procedure(s)."

Further review of the policy under the "Procedure" section documentation revealed the following:

"...5. A Time Out will be performed for all cases, except in an emergency if the risks outweigh the benefits."

A review of the facility's "Medical Staff Bylaws and General Rules and Regulations," revised and approved: July 2017, under section "2.5 Basic Responsibilities of Medical Staff Membership" documentation revealed the following:

"The ongoing responsibilities of each member of the Medical Staff include:

"...b. Abiding by the Medical Staff Bylaws, Rules and Regulations, and Medical Staff and hospital policies and procedures."

b. On April 27, 2018 a clinical record review was conducted for Patient 2. Patient 2's clinical record revealed Patient 2 presented to the ED via ambulance on March 15, 2018 at 6:35 PM with diagnosis of respiratory problems and a blood pressure of 123/79. An MSE was performed by Physician 1 at 6:41 PM, multiple orders were prescribed by Physician 1 and the patient was triaged as an ESI Priority 3 - "Potentially Unstable."

During the patient's stay in the ED on March 15, 2018 it was determined that the patient had a tension pneumothorax and was in need of a "Needle Thoracostomy." During the patient's record review no documented evidence could be located to indicate that at "Time-out" procedure was done prior to the patient having an invasive procedure performed.

c. On April 27, 2018 a clinical record review was conducted for Patient 12. Patient 12's clinical record revealed Patient 12 revealed the patient presented to the Emergency Department on April 13, 2018 with a diagnosis of a recurrent right pneumothorax. During the Patient's visit it was determined that the patient was in need of having chest tubes placed. No documented evidence could be located to indicate that at "Time-out" procedure was done prior to the patient having an invasive procedure performed.

On April 27, 2018 at 10:20 AM, an interview was conducted with the Emergency Department Director (EDD). The EDD stated, she was not aware that a "Time-out" was not performed on Patient 12 prior to his having chest tubes inserted. The EDD further stated that the Registered Nurse floated from the "Observation Unit." The EDD was asked if she provided training to the nurse's that are cross-trained to work in the ED regarding the "Time-out" procedure, the EDD stated, "NO."



34959

2. During an interview with Physician (P 2) before performing a procedure on April 26, 2018 at 8:35 AM, when asked how do you ensure your going to perform the procedure to the correct patient? P 2 was loud in a rude manner and stated "I don't like being bombarded with questions."

During an interview with the Director of Quality and Medical Staff (DOQMS) on April 26, 2018 at 1:47 PM, she stated that the incident occurred in the Cath lab (an examination room in a hospital with diagnostic imaging equipment used to visualize the arteries and chambers of the heart and treat any abnormalities found). The Respiratory Therapist (RT 1) asked P 2 if she needed to leave or stay further towards the end of a procedure. P 2 used profanity (foul language) towards RT 1.

During an interview with the Respiratory Therapist (RT 1) on April 27, 2018 at 9:18 AM, the RT 1 stated that toward the end of a procedure she asked if she needed to leave or stay further in the Cath lab and P 2 stated "shit" and also that she was incompetent and not to ask stupid questions. RT 1 further stated that P 2 did not apologize to her.

During a review of the Medical Executive Committee meeting dated December 14, 2017 indicated, "P 2's use of profanity while addressing a staff member..."

During a review of the facility's policy and procedure "Professional Conduct Standards" dated September 2013, included the following:.."Exhibiting language, action, attitude and behavior which consistently convey to patients, families, colleagues, and all other members of the Hospital's health care team a sense of compassion and respect for human dignity. Refraining from language or behavior which a reasonable adult would consider to be foul, abusive, or threatening. Treating patients, staff and all persons functioning in any capacity within the Hospital with courtesy, respect, and human dignity. Using abusive language, including repetitive sarcasm. Making rude or demeaning comments..."

During a review of the facility's policy and procedure "Disruptive Behavior Algorithm (a set of rules to be followed)" dated April 2013, included the following:..."All individuals within the Hospital should be treated courteously, respectfully and with dignity. To that end, the Hospital provides education to all staff regarding the Hospitals Code of Conduct. The Medical Staff also requires all Practitioners to conduct themselves in a professional and cooperative manner..."

During a review of the facility's policy and procedure "Professional Standards Committee", undated included the following:.."Duties of the Professional Standards Committee shall include the review identified concerns related to a Provider's behavior and compliance with expected standards of professionalism as defined in the Professional Conduct Standards and Disruptive Behavior Algorithm Medical Staff Policies. The Professional Standards Committee will oversee the performance of all Focused Professional Practice Evaluations related to disruptive behavior and /or recurrent Rule Violations..."

Based on observation, interview, and record review, the facility failed to ensure:

1. Licensed nursing staff intervened when a "Time-out" procedure was not conducted prior to an invasive procedure performed on the wrong patient and two (2) other patients prior to an invasive procedure being performed on them.

2. Nursing staff failed to notify their superiors of a procedure performed on the wrong patient in a timely manner.

3. There was documentation that the care plan (a document that identifies nursing orders for a patient and serves as a guide to nursing care) for soft limb restraints (soft restraints that are applied to a person's arms or legs) were initiated and the reassessment of soft limb restraints were not done on March 22, 2018 at 6:00 AM for Patient 16.

4. There was documentation on April 23, 2018 that the crash cart (a cart that carries medicine and equipment for use in emergency resuscitations) located in the neonatal intensive care unit (specializing in the care of ill or premature newborn infants) was checked daily.

5. The Registered Nurse (RN 8) removed her personal protective equipment (gown,and disposable gloves) after she administered medications to Patient 26, when she exited the isolation room (a patient is placed in the room to implement infection control and the prevention of contagious disease).

6. There was documentation that the pre procedure check list (a document that is completed before patient has a procedure that indicates the right patient, right site, procedure, consent, medications given to patient to treat any heart problems, blood products available, and any known allergies.) was done for Patient 30.

These failures had the potential for patients that received care and services in the facility, not to have their assessed needs met in a safe environment in a universe of 135 patients.

Findings:

1a. During a review of the medical record for Patient 1 on April 25, 2018, documentation indicated Patient 1 was a 72 year old Hispanic female, presented to the Emergency Department (ED) via ambulance on March 15, 2018 at 7:04 PM, with a diagnosis of altered level of consciousness and a blood pressure or 97/64. Patient 1 was triaged as an Emergency Severity Level (ESI) Priority 3-"Potentially Unstable." Patient 1 was placed in room 9.

A review of the medical record for Patient 2 on April 25, 2018, documentation revealed Patient 2 a 64 year old Caucasian female, presented to the ED via ambulance on March 15, 2018 at 6:35 PM (29 minutes prior to Patient 1's arrival) with diagnosis of respiratory problems and a blood pressure of 123/79. Patient 2 was triaged as an ESI Priority 3-"Potentially Unstable." Patient 2 was placed in room 6.

During a review of Patient 2's Chest x-ray (an imaging test that uses small amounts of radiation to produce pictures of the organs, tissues, and bones of the body) dated March 15, 2018 7:14 PM indicated, "Moderate to large right pneumothorax with suggestion of a mild degree of tension pneumothorax with mediastinal shift (towards one side of the chest cavity) to the left.

On April 25, 2018 at 12 PM, an interview was conducted with Physician 1. Physician 1 stated he had two (2) similar patients arrive within 30 minutes of each other with similar orders for both. Physician 1 stated he received a telephone call from the Radiologist around 7:30 PM informing him that Patient 2 had a tension pneumothorax (an abnormal collection of air between the lung and the chest wall). Physician 1 stated, "After looking at the x-ray, I looked at my patient list and went into room 9."

At the interview continued with Physician 1, Physician 1 stated EMT 1 (Emergency Medical Technician) was there, I asked him to get me supplies. Physician 1 was asked if he looked at the patient's arm band for identification prior to beginning the procedure, Physician 1 stated, "Yes, I glanced at it but it didn't register with me that I was in the wrong room." Physician 1 was asked if a "Time-out" procedure was conducted prior to his performing the procedure, Physician 1 stated, "No."

On April 25, 2018 at 1:05 PM, a telephone interview was conducted with RN 1. RN 1 stated Patient 1 arrived in the ED right around change of shift, I was setting her up on the monitor, I had her for about 10 minutes. RN 1 proceeded to state I gave report to RN 2, I was suppose to give report to registry but they were running late.

As the telephone interview continued, RN 1 stated I had already given report and went to turn in my Vocera (communication system) when "I don't remember who" said the patient had a tension pneumo, my first inclination (thought) was "What did I miss." Physician 1 was at the patient's bedside, he was already cleaning the chest wall with Chlorahexadine, I was thinking what else could I have done, I stayed and watched because I had never seen a thoracostomy before. RN 1 was asked if she observed or participated in a "Time-out," RN 1 stated, "No, and I don't feel that I was involved, I just wanted to be present to learn, I hadn't clocked out yet."

RN 1 was asked if a "Time-out" was done, RN 1 stated, "No," RN 1 was then asked if she knew what a "Time-out" was, RN 1 replied, "Yes." RN 1 was asked is there usually a nurse at the bedside when a procedure is being done, RN 1 stated, "Yes." RN 1 was then asked who's responsibility is it to do a "Time-out," RN 1 replied, "Both the doctor and the nurse."

A review of the medical record for Patient 2 on April 25, 2018, documentation revealed Patient 2 a 64 year old Caucasian female, presented to the ED via ambulance on March 15, 2018 at 6:35 PM (29 minutes prior to Patient 1's arrival) with diagnosis of respiratory problems and a blood pressure of 123/79. An MSE was performed by Physician 1 at 6:41 PM, multiple orders were prescribed by Physician 1 and the patient was triaged as an ESI Priority 3-"Potentially Unstable." Patient 2 was placed in room 6.

On April 27, 2018 at 10 AM, an interview was conducted with the Director of Quality and Medical Staff, who stated, "A nurse should be involved whenever a procedure is performed."

A review of the Policy Number T-107 titled "Time Out for Invasive Procedures (Universal Protocol)" revised date 9/15, under the "Purpose" section documentation revealed the following:

"To promote patient safety by providing verification of correct patient, procedure and site if applicable, for invasive/surgical procedure(s)."

Further review of the policy under the "Procedure" section documentation revealed the following:

"...5. A Time Out will be performed for all cases, except in an emergency if the risks outweigh the benefits."

b. On April 27, 2018 a clinical record review was conducted for Patient 2. Patient 2's clinical record revealed Patient 2 presented to the ED via ambulance on March 15, 2018 at 6:35 PM with diagnosis of respiratory problems and a blood pressure of 123/79. An MSE was performed by Physician 1 at 6:41 PM, multiple orders were prescribed by Physician 1 and the patient was triaged as an ESI Priority 3 - "Potentially Unstable."

During the patient's stay in the ED on March 15, 2018 it was determined that the patient had a tension pneumothorax and was in need of a "Needle Thoracostomy." During the patient's record review no documented evidence could be located to indicate that at "Time-out" procedure was done prior to the patient having an invasive procedure performed.

c. On April 27, 2018 a clinical record review was conducted for Patient 12. Patient 12's clinical record revealed Patient 12 revealed the patient presented to the Emergency Department on April 13, 2018 with a diagnosis of a recurrent right pneumothorax. During the Patient's visit it was determined that the patient was in need of having chest tubes placed. No documented evidence could be located to indicate that at "Time-out" procedure was done prior to the patient having an invasive procedure performed.

On April 27, 2018 at 10:20 AM, an interview was conducted with the Director of the Emergency Department (DED). The DED stated, she was not aware that a "Time-out" was not performed on Patient 12 prior to his having chest tubes inserted. The DED further stated that the Registered Nurse floated from the "Observation Unit." The DED was asked if she provided training to the nurse's that are cross-trained to work in the ED regarding the "Time-out" procedure, the DED stated, "No."

2a. On April 25, 2018 at 12:30 PM, an interview was conducted with Charge Nurse 1 (CN) who was on duty the night of March 15, 2018. CN 1 was asked how soon after the procedure that was performed on the wrong patient was she informed about the incident, CN 1 stated within 15 to 20 minutes, one of our registry nurse's informed me.

As the interview continued with CN 1, CN 1 was asked if she notified the House Supervisor on duty that night, CN 1 stated, "Yes." CN 1 was asked if and when she notified the Director of ED, CN 1 stated she failed to notify her Director but that she spoke with her the following day. CN 1 was asked if she had been trained in "Chain of Command," CN 1 replied, "Yes."
When asked what was your reason for not notifying your Director, CN 1 stated, "I just got busy and forgot to do it."

On April 25, 2018 at 8 AM, an interview was conducted with the Emergency Department Director (EDD). The EDD stated she was not made aware of the incident until the next day March 16, 2018 at 2:55 PM. The EDD further stated the ED Manager was reviewing Mida's (incident report system) and saw this event. The EDD further stated, "I should have been informed immediately."

On April 25, 2018 at 9:15 AM, an interview was conducted with House Supervisor (HS 1). HS 1 stated I was informed by Charge Nurse (CN 1) about the procedure done on the wrong patient around midnight. I told CN 1 to make sure she filled out a Midas report and asked if she had called her supervisor, CN 1 said she hadn't yet, I told her not to forget.

As the interview continued with HS 1, HS 1 was asked if she informed her "Chain of "Command," HS 1 stated, "I was busy, no I didn't." HS 1 was asked if she had been trained in "Chain of Command," HS 1 stated, "Yes, it should have been done."


On April 27, 2018 at 10:40 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON confirmed HS 1 did not follow "Chain of Command," she should have notified the "Admin On-Call," which was not done."



34959

3. During a review of the medical record for Patient 16, the record indicated Patient 16 was admitted on March 19, 2018 with a diagnosis of Diabetic Ketoacidosis (Diabetic ketoacidosis is a complication of diabetes that occurs when compounds called ketones build up in the bloodstream. Ketones are produced when the body breaks down fats instead of sugars, which happens when the body does not produce enough insulin to process sugar properly).

During a review of the physician orders dated March 22, 2018 at 3:33 AM, indicated:.."Use restraints for twenty-four hours (not to exceed twenty-four hours), restraint is indicated due to the following indications attempts to pull out tubes and lines, and to promote healing and safety use the following restraint: soft limb..."

During a review of the assessment (the registered nurse will document the reassessment of restraints every two hours) form for restraints indicated there was no documentation proof that the reassessment of restraints were done on March 22, 2018 at 6:00 AM.

During a review of the medical record for Patient 16, there was no documentation that a care plan for soft limb restraints were done.

During an interview with the Registered Nurse (RN 6) on April 26, 2018 at 10:50 AM, the RN 6 confirmed there was no documentation that the reassessment of restraints were done on March 22, 2018 at 6:00 AM. The RN 6 also confirmed there was no documentation that a care plan for soft limb restraints were done.

During a review of the facility's policy and procedure "Restraints for Non-Combative, Non-Violent Patients"dated January 11, 2018 indicated:..."Nursing monitoring will be done every fifteen minutes and documented every two hours at a minimum. Monitoring will be accomplished by observation, interaction with the patient,or related direct examination of the patient by qualified staff..."The registered nurse will complete the nursing assessment and reassessment related to a patient in restraint which will include neurological (disorder of the nervous system), circulatory (moves blood through the body), skin integrity of restrained body part, nutrition, hydration status (normal state of body water), elimination needs, level of distress, agitation, physical, psychological status, cognitive functioning, patient's comfort, response to the restraint or seclusion intervention, signs and symptoms of injury associated with application of restraint, range of motion in extremities, assist patient out of restraint and properly reapply restraint every two hours while awake, and reassessment for possible discontinuation of physical restraint or seclusion..."In areas where care plans are used, the use of restraints will be reflected in the patient's nursing care plan within six hours..."

4. During a review of the crash cart log dated for the month of April 2018 indicated there was no documentation that the crash cart located in the neonatal intensive care unit was checked on April 23, 2018.

During an interview with the Registered Nurse (RN 7) on April 24, 2018 at 7:52 AM, the RN 7 confirmed there was no documentation that the crash cart was checked on April 23, 2018. The charge nurse was supposed to check the crash cart daily.

During a review of the facility's policy and procedure "Emergency Crash Cart Availability and Readiness"dated January 11, 2018 indicated:..."Crash carts in open patient care areas will be checked every twenty four hours at a minimum seven days a week by nursing, or designated staff..."

5. During a review of the medical record for Patient 26, the record indicated Patient 26 was admitted on April 23, 2018 with a diagnosis of acute on Chronic Diastolic Congestive Heart Failure (the cardiac output is not adequate enough to meet the demands of the body) and history of Methicillin-resistant Staphylococcus Aureus (causes infections in different parts of the body and is resistant to certain antibiotics, including penicillin, and making it challenging to treat) of the wound (in which the skin is torn, cut or punctured) to left knee.

During a medication observation on April 25, 2018 at 8:11 AM, the Registered Nurse (RN 8) did not remove her personal protective equipment (gown,and disposable gloves) after she administered medications to Patient 26, when she exited the isolation room (a patient is placed in the room to implement infection control and the prevention of contagious disease).

During an interview with the Clinical Educator Coordinator (CEC) on April 25, 2018 at 8:12 AM, the CEC confirmed that the RN 8 should have removed personal protective equipment before exiting the isolation room.

During a review of the facility's policy and procedure "Guidelines for Isolation Precautions"dated May 2017 indicated:..."Prior to leaving the patient room or moving into the clean area, remove gown first by pulling the sleeve over the gloves and taking care not to touch the outside, contaminated part of the gown. Remove gloves, Remove mask, faceshield or respiratory protection, and perform hand hygiene preferably with alcohol hand sanitizer..."

6. During a review of the medical record for Patient 30, the record indicated Patient 30 was admitted on March 8, 2018 with a diagnosis of fluid in the lungs and metastatic cancer (spreads to a different part of the body from where it started).

During a review of the medical document titled "Procedural Safety Checklist Universal Protocol Surgery" (a document that confirms the surgical team has completed the tasks before it proceeds with the procedure) dated March 9, 2018 for Patient 30 indicated, the pre procedure checklist was not done before the pleurx catheter (used for draining the excess fluid that surrounds the lungs)placement to the right chest procedure was performed.

During an interview with the Director of Perioperative Infusion and Speciality Services (DOPISS) on April 27, 2018 at 10:43 AM, the DOPISS stated that the pre procedure checklist should have been completed by the operating room (where procedures are performed) or the intensive care unit (a unit where special medical equipment and services are provided for patients who are seriously injured or ill) nurses before Patient 30's pleurx catheter placement to the right chest procedure was performed.

During a review of the facility's policy and procedure "Time Out for Invasive Procedures (Universal Protocol)" dated September 2015, included the following..."To promote patient safety by providing verification of correct patient, procedure, and site if applicable, for invasive surgical procedures. In the pre-procedure area and prior to the start of any invasive procedure, confirmation of correct patient, procedure, and site if applicable will be completed and documented in a collaborative manner by the clinical team..."