HospitalInspections.org

Based on interview and document review it was determined the unified healthcare system governing body failed to ensure that separately certified hospitals did not float nursing and other staff between those hospitals on an as needed basis.

The findings included:

An interview was conducted during the entrance conference on 02/01/2016 at 12:38 p.m., with Staff #1, #5, and #16. Staff #1 informed the surveyors the hospital had a unified governing body (Board of Trustees) that had oversight of separately certified hospitals within the healthcare system.

An interview was conducted on 02/02/2016 at 11:45 a.m., with Staff #31. Staff #31 reported surgical department nursing staff was exchanged between two separately certified hospitals within the health care system. Staff #31 reported to a surveyor "If they are short or we are short, they call or we call and ask for help. They go over and meet with the charge nurse. They aren't put in a skill set with something they aren't comfortable with. They are given a brief orientation." Staff #31 reported there were times when the facility tried to plan ahead, but there was potential for "last minute" unplanned changes and staff could be placed at a sister hospital or ambulatory surgery center.

An interview was conducted on 02/01/2016 at 3:12 p.m., with Staff #16 and #63 during the review of the healthcare organization chart. The surveyor requested information regarding the hospital's policy for "floating" nursing staff between separately certified sister hospitals. Staff #63 stated, "There are times when if [Name of sister hospital] is short and we have staff (nursing), we will send/pull staff from here. They have to have had competencies (verified) for where they are going." Staff #63 explained the healthcare system in their general orientation informed staff of the possibilities of being shared between hospitals. Staff #63 denied there was a nursing "float pool" among the hospitals within the healthcare system.

An interview was conducted on 02/01/2016 at 3:38 p.m., with Staff #16. Staff #16 reported the hospital did not have a policy for "floating" nursing staff between separately certified hospitals in the healthcare system. Staff #16 stated, "All staff have the potential to be pulled to [Name of sister hospital] and from there here." Staff #16 verified "If you were scheduled to work here, came in but if they (a sister hospital) were in need. There is a potential that you could be pulled there."

An interview was conducted on 02/02/2016 at 2:45 p.m., with Staff #34 regarding Patient #25's missed morning dose of insulin. Staff #34 stated, "...I'm in the float pool, I'm not too sure how it works on this floor. I work for [Name of sister hospital] they float me where they need me. Staff #34 reported he/she was part of the nursing staff at the sister hospital.

An interview was conducted on 02/03/2016 at 8:40 a.m., Staff #56. Staff #56 stated, "I usually try to call or text when they are pulled, at about 6:00 a.m., but sometimes they are sent after they get here. The charge nurse keeps up with the schedule. "

An interview was conducted on 02/04/2016 at 11:05 a.m., with Staff #47 a physical therapist. Staff #47 stated, "People float from [Name of sister hospital] to help, or if it's slow I float to [Name of sister hospital] to help. Today I am busy so I wouldn't float."

An interview and review of the "[Name of sister hospital] Float Log" was conducted on 02/04/2016 at 3:35 p.m., with Staff #9. Staff #9, stated "I keep a log of the staff pulled from here to [Name of sister hospital]. All of our staff can go to either hospital." Staff #9 and the surveyor reviewed one log sheet from March 2015 through January 2016. The review revealed thirty (30) of the thirty-four entries pulled nursing staff from their assigned hospital to the separately certified sister hospital.

A review was conducted of the "float/pulled" log for each unit. The logs revealed that nurses, certified nursing assistants, and surgical technicians were "floated/pulled" between their assigned hospital and other certified entities within the healthcare system.

An interview was conducted on 02/04/2016 at approximately 2:45 p.m., with Staff #16 and #63. The surveyor informed Staff #16 and #63 of the above findings. Staff #63 reported it had been the "unwritten" policy to utilize staff wherever needed between hospitals in the healthcare system. Staff #16, #63, and the surveyor reviewed the requirements as stated in this regulation. Staff #63 verified according to the regulation nursing and other staff was not to be moved "ad hoc" between separately certified hospitals. Staff #63 stated, "We are not meeting the requirement but I'm not sure how we can."

Based on observation and staff interview, the facility staff failed to ensure the personal privacy for one (1) of fourteen (14) patients who were observed during the survey, Patient #44.

The findings included:

On 2/1/16 at 1:40 p.m. during a tour and subsequent observations on the 3rd floor nursing unit, the surveyor observed Patient #44 sitting on the side of his/her bed. The door was open and the patient did not have a privacy curtain in the room. Patient #44 was observed with no clothing on the upper and lower portion of his/her body and had what appeared to be a hospital gown laying haphazardly (wadded) in his/her lap. The patient could be seen from the hallway and there were two sets of visitors that passed by the room and were able to see the patient exposed in his/her room. The surveyor continued up the hallway and upon returning to the nurses station, Patient #44 was still exposed with the door open and could be seen from the hallway and by anyone who came to the nurses desk.

On 2/1/16 at 4:15 p.m., the surveyor discussed the observations at the end of day meeting with Staff # 1 and Staff #8 regarding the lack of personal privacy for Patient #44.

Based on observations and staff interview, it was determined the facility staff failed to ensure that the confidentiality of patient medical records was safeguarded.

Findings include:

At 1:40 PM on 2/1/2016, the surveyor observed a computer on wheels outside of Room #308. There was no staff near the computer, the privacy curtain was pulled around the bed in room #308 where Staff #17 was working with the patient, and information for
Patient #22 was pulled up on the computer screen and able to be seen by anyone in the hall.

This finding was discussed with Staff #5, 16, and 63 on 2/2/2016 between 4:00 to 4:30 PM.

Based on staff interview, clinical record review, and facility document review, it was determined the facility staff failed to ensure a restraint order was written by the physician for one (1) of six (6) patients in the sample who had physical restraints. Patient # 49.

The findings included:

Patient #49 was admitted to the facility on 11/18/15 and required the application of restraints due to documented behaviors of attempting to pull out and dislodge intravenous lines and telemetry monitoring. The patient was documented as confused, agitated, and combative toward staff. Review of the medical record revealed a hand written document dated 11/23/15 and timed at 2215 (10:15 p.m.,), "Restraint Orders" which evidenced the alternatives attempted and the type of restraint, however the document was not signed by the physician.

On 2/3/16 at 9:56 a.m., the surveyor requested the assistance of Staff # 63 (Chief Nursing Officer) to navigate the electronic medical record (EMR) for Patient #49 to locate the restraint order written by the physician. After a review of the physician's orders, Staff #63 stated, "I can't find the order...there should be a complete order in the EMR, but I don't see it..."

Review of the facility policy "Restraint and Seclusion Policy" revealed, in part: "...When restraints must be used, those Restraints will be ordered and applied in a manner that complies with both the Medicare Conditions of Participation and Standards governing the use of restraints established by The Joint Commission, and the Virginia Department of Behavioral Health and Developmental Services (DBHDS) Human Rights Regulations...1. Restraints may be used only in accordance with an order given/written by the physician or Allied Health Professionals (APHs based on their scope of practice who are credentialed to do so)...The physician/credentialed AHP order must include: a. date and time b. clinical justification for use..."

Based on clinical record review, staff interview and facility document review, the facility staff failed to ensure a plan of care was developed for (1) of six (6) patients, in the survey sample, who required the use of physical restraints. Patient # 49.

The findings included:

Patient #49 was admitted to the facility on 11/18/15 and required the application of restraints due to documented behaviors of attempting to pull out and dislodge intravenous lines and telemetry monitoring. The patient was documented as confused, agitated, and combative toward staff.

On 2/3/16 at 9:56 a.m., the surveyor requested the assistance of Staff # 63 (Chief Nursing Officer) to navigate the electronic medical record (EMR) for Patient #49 to locate the plan of care for the use of restraints. After a review of the plan of care documented in the record, Staff #63 stated, "I can't find the care plan for the restraints...there should be a care plan, in the EMR, but I don't see it..."

Review of the facility policy "Restraint and Seclusion Policy" revealed, in part: "...When restraints must be used, those Restraints will be ordered and applied in a manner that complies with both the Medicare Conditions of Participation and Standards governing the use of restraints established by The Joint Commission, and the Virginia Department of Behavioral Health and Developmental Services (DBHDS) Human Rights Regulations...3. Nursing staff must develop and modify the patient's individual plan of care relative to the use and evaluation of the effectiveness of less restrictive measures, the patients response to the less restrictive measures, and the patient's response to the restraints. The patient should be regularly reassessed; the individual plan of care should be modified accordingly...Staff will individualize and complete the patient's plan of care..."

Based on staff interview and record reviews, it was determined the facility staff failed to ensure that hospital policy and procedure for removal of restraints was followed, for 1 of 6 patients in the survey sample, who were restrained.

Findings include:

For Patient #47, the restraint was removed without approval of the physician or RN. The facility policy for patient restraint states "Only a physician or RN may authorize a patient's early release from restraints".

Documentation in the record of Patient #47 for 2/24/2015 at 00:00 (12:00 AM) is that "soft restraints applied by two other RN's" At 00:16 (12:16 AM) on 2/24/2015 there is documentation that "...Police handcuffed pt. and purse given to [parent], contents not inventoried. Pt refusing lab draw and demanding to leave. Soft restraints applied (see paperwork). Police at bedside; asked that soft restraints be maintained as there was concern pt would injure [him/herself] in handcuffs. Nurse notified; verbal order obtained".

At 0237 (2:37 AM) there was a late entry for 00:01 2/24/15 (clarification: Pt was placed in TAT at 0001 hours by this RN after Verbal Order from (doctor's name) and discussion with Deputy".

At 1:42 AM there was documentation that at "00:30 (12:30 AM) 2/24/15 (patient more somnolent with medication, police removed one behavioral restraint from patient without RN approval, restraint left on one arm because the patient is still being delusional and slightly combative when spoken to by the MD)".

This finding was discussed with Staff #20 at the time of discovery.

Based on interview and document review it was determined a registered nurse (RN) failed to perform an initial nursing assessment for one (1) of thirty-nine (39) patient records reviewed as part of the survey sample. (Patient #11)

The findings included:

A review of Patient #11's active electronic medical record (EMR) was conducted on 02/02/2016 with Staff #8 and #18. Patient #11 was admitted to the hospital on 01/31/2016 for confusion, difficulty with speech and weakness. Patient #11 had initially been included in the survey sample related to discharge planning. Review of Patient #11's EMR revealed the patient did not have a documented initial nursing assessment performed by a registered nurse. Staff #8 and Staff #18 verified the findings.

Staff #16 and #63 was informed of the findings at the end of the day meeting at approximately 4:45 p.m. on 02/03/2016. The surveyor requested any clarifying documents related to Patient #11's initial nursing assessment. The request included downtime forms or other documentation that the assessment might have been performed on a paper document and not yet scanned into the patient's active EMR.

No further documentation was offered prior to survey exit on 02/05/2016.

Based on observations, staff and patient interviews, and medical record reviews, it was determined the facility staff failed to ensure that 2 of 39 patients whose records were reviewed did not include a nursing care plan which included all nursing care needs.

Findings include:

The care plan for Patient #8, admitted 1/29/2016 for shortness of breath, started acute hemodialysis on 2/1/2016. Patient #8 had an AV graft (arteriovenous) in his/her left arm which was not ready for use. The plan of care did not include monitoring the AV graft, or ensuring it was protected from things such as blood draws or blood pressure measurements in that arm.
The surveyor observed a CPAP (continuous positive airway pressure) machine sitting at the bedside of Patient #23 on 2/3/2016 at approximately 10:00 Am. CPAP is a treatment that uses mild air pressure to keep the airways open. Patient #23 had an order dated 2/1/2016 for CPAP NOS-POS airway pressure routine HS (bedtime). The care plan for Patient #23 did not include CPAP. In an interview with Staff #56, the charge nurse, at 11:00 AM on 2/2/2016 stated: "Nurses don't get training for CPAP, we call respiratory". The facility's CPAP/BiPAP protocol/procedure provided to the surveyor states that the RT (respiratory therapist) or nursing will visually inspect the patient's equipment, if the patient's home equipment is available.
These findings were discussed with Staff #56, a charge nurse, at approximately 1:00 PM on 2/3/2016.

Based on observations and staff interviews, it was determined the facility staff failed to monitor the clinical activities of contract non-employee licensed nurses to ensure that they were adequately supervised by an appropriately qualified hospital-employed RN (registered nurse).

Findings include:

On 2/1/2016 at 2:15 PM the surveyor observed a contract nurse initiate dialysis for Patient #8. When checking the conductivity during the machine set up, the surveyor observed that the contract nurse did not perform the activity as recommended by the manufacturer. The contract dialysis nurse disconnected the hansen connector on the side of the machine and drained water into the cell cup of the meter without measuring, and only performed the conductivity check one time, placing the meter back on the dialysis cart outside the room without rinsing the cell cup.

Directions for use (DFU) for the meter, the meter used by the contract staff to check conductivity, includes instructions to use the dipper end of the cell plunger to measure the correct amount of water, then pour the water into the cell cup. The plunger should then be dropped into the cell cup and lifted half way out of the cell and dropped back in 3-4 times before discarding the sample, repeating these steps at least 3 times. The directions also state: "Note: this procedure must be conscientiously performed for samples at working (body) temperature to avoid artificially high readings. When finished with the meter, rinse the cell cup with clean water, preferable RO, distilled, or deionized".

On 2/1/2016 between 2:15 PM and 2:40 PM, the surveyor observed a contract RN (registered nurse) initiate dialysis for Patient #8 and noted that he/she did not practice proper hand hygiene. At 2:15 PM, with gloved hands, the nurse took Patient #8's vital signs, checked the CVC (central venous catheter) site, which was bleeding under the dressing, removed his/her gloves, and took a cell phone from his/her scrub top pocket, texted his/her supervisor, then placed the phone back into his/her pocket. He/she sanitized their hands, donned gloves and a mask, placed a mask on the patient, placed a sterile field under the CVC, then re-checked Patient #8's blood pressure. The RN took off one glove and his/her mask, silenced the machine with the gloved hand, removed that glove then went to the dialysis cart sitting just outside the door to the room while wearing an isolation gown, reached around the isolation gown with an ungloved hand, got phone out of scrub pocket, texted, put phone back in pocket, retrieved supplies from the cart, and carried them into the room and sat them on the bed with the patient. He/she then got another mask, donned gloves without first sanitizing hands, and initiated dialysis via the CVC. The RN did not wear eye protection during the initiation of dialysis, other than eyeglasses, and after the blood lines were connected, he/she clamped the blood lines to the patients gown, handling the lines with ungloved hands. The MMWR (Mortality and Mortality Weekly Report) for October 25, 2002 issued by the CDC (Centers for Disease Control) recommends that in the health care setting hands be decontaminated after contact with inanimate objects, including medical equipment, in the immediate vicinity of the patient, and after removing gloves.
Staff #64 was interviewed on 2/2/2016 at approximately 12:30 PM, Staff #64, the Director of Nursing, was interviewed regarding the supervision of contract non-employee dialysis RN's, and he/she stated "They are supervised by their manager (manager's name), and she and we have monthly meetings".
A discussion of the above findings was shared with Staff #64 on 2/2/2016 at approximately 12:30 PM.

Based on observation and staff interview it was determined the facility staff failed to ensure:
A. Medications and fluids for intravenous use were stored appropriately;

B. Staff possessed knowledge for handling hazardous medications:

C. IV tubing was labeled with a date and time to ensure that they were changed per facility policy;

D. Medications were administered according to standards of practice; and

E. Medications were administered as ordered by the physician.

The findings included:

A. 1. On 2/4/16 at 11:40 a.m. the surveyor and Staff #23 observed in the clean supply room on the fourth floor the following:
Two bags of Lactated Ringers 5% (five percent) Dextrose solution with a sticker which read, "Do Not Use after 3/2/16" The bag of solution was out of the protective wrapper.

The following was observed in the medication room:
- 1 bag of 5% Dextrose 250 ml (milliliters) solution which had been removed from the protective outer wrapper. The expiration date was 8/1/17
- 5 bags of 0.9% Sodium Chloride Injection 100 ml bag with a sticker that read, "Do Not use after 2/9/16" but were out of the outer protective wrapper. Expiration date 8/2016
- 3 bags 0.9% Sodium Chloride injection 50 ml bag out of the protective wrapper. Expiration date 9/2016 and 3/2017.
- 4 bags 0.9% Sodium Chloride Injection 100 ml bags out of the protective wrapper. Expiration date 8/2017.
- 1 bag 5% Dextrose Injection 50 ml bag out of the protective wrapper expiration date 8/2016.

Staff # 23 was present at the time of discovery.

On 2/4/16 at 4:45 p.m. the above observations were discussed with Staff #1, 8, and 63.


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B. During an interview with Staff #52 on 02/04/16 at 11:45 a.m., a surveyor asked a Registered Nurse (RN) giving medications on the fourth floor how is he/she able to identify medications that are P or U listed. Staff #52 stated, "We throw all of our meds into the box in the med room, I don't know which is 'P' or 'U'." A surveyor asked Staff #52 to pull up the EMAR (Electronic Medication Administration Record) to see if it includes that information. Staff #52 was unable to locate that information on the EMAR.

According to www.3epa.gov: "The P list and the U list (discarded commercial chemical products) - These two lists are similar in that both list as hazardous certain commercial chemical products when they are discarded or intended to be discarded. These listings consist of commercial chemical products having the generic names listed, off-specification species, container residues, and spill residues. The difference is that the chemicals on the P list are identified as acute hazardous wastes and those on the U list are identified as toxic wastes. Some chemicals on both lists may also be designated to have other properties. Wastes included on the P and U lists can be found in the regulations at 40 CFR 261.33."

During an interview with Director of Pharmacy (Staff #24) and Staff #53 on 02/04/16 at 1:45 p.m., a surveyor inquired how does the facility staff identify medications that are on the P and U list and handled during administration. The Director of Pharmacy stated there are "Pop-ups or something that come up when those drugs are on the MAR (Medication Administration Record)." The Director of Pharmacy continued to acknowledge the facility's IT Pharmacist has been reviewing the facility's entire medication list. The Director of Pharmacy stated, "We put a lot of stuff on the dashboard and electronically."

An interview was conducted with the Director of Pharmacy (Staff #24) in the conference room on 02/04/16 at 2:35 p.m. He/She stated, "We are working on the 800 (Hazardous Materials Chapter of the USP) which goes into effect in July... We are working on the federal list and matching it with the drugs on our formulary....I can't speak to the previous black box system because that predates me. I do know we are making a conscious effort not to create alert fatigue for staff by having multiple alerts and pop-ups on the EMAR."

On 02/04/16 at 2:35 p.m. the Director of Pharmacy presented the surveyor with a document titled "Pharmaceutical Waste Program" and "Waste Flow." The documents revealed what goes in the black pharmaceutical waste bins that are to be in the medication rooms or other secured areas in non-nursing units. "What goes in the bins: Any Unused Pharmaceuticals, Unused Pills, Partially Used Vials, Partially Used IV Bags, TPN's, Warfarin/Nicotine Wrappers, Insulin Preparations, Antibiotic IV Solutions. What doesn't go in the bins: No Sharps, No RMW, No Narcotics or controlled medications, Empty plain IV bags (D5W, etc.) - discard in regular trash." The document did not show any evidence identifying any medications that are P or U listed or how to handle during administration.

The policy titled "Medications: Dispensing, Returning and Wasting" states in part: "To define procedures for handling (dispensing, returning, and wasting) medications retrieved from an automated dispensing medstation. Wasting Medications: 2. A non-controlled medication (Schedule VI or OTC) that is damaged, expired and/or not intact (i.e. unused pills, partially used vials, IV bags, TPN, insulin, or warfarin and nicotine wrappers) will be disposed in the designated black pharmaceutical waste container present in each department....."

On 02/05/16 at approximately 12:00 p.m., the survey team reviewed the concerns with the administrative team during the exit conference.


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A 2. While touring the facility's storage areas for IV fluids in the OR (operating room), SDS (same day surgery) on 2/2/2016, and the third and fourth floors on 2/4/2016, three surveyors observed that some IV fluids on each of these units had been removed from the protective overwrap. These findings were discussed with Staff #34, the OR manager on 2/2/2016 at 11:30 AM. The findings were also discussed with Staff #41 RN (registered nurse) the hospital risk manager, Staff #52 RN charge nurse forth floor, and Staff #56 third floor charge RN, on 2/4/2016 at approximately 11:30 AM.

The surveyors were given a copy of (name of manufacturer) medical information regarding shelf life of IV solutions out of overwrap which stated "This letter regarding general IV solutions includes information of an off-label nature. (Name of manufacturer) does not suggest or recommend the use of general IV solutions in any manner other than as described". "Product stability once the overwrap has been removed is dependent upon several factors such as the solution and drug, the type of container, the type of overwrap, temperature, and humidity. The overwrap serves as a protective barrier to control the amount of water vapor that evaporates from the solution. Once the overwrap is removed, the rate of evaporation increases. As the fluid level decreases, the content of the bag becomes progressively more concentrated. At a certain point, enough water loss may occur such that the contents of the bag are technically beyond the labeled specification and range. The overwrap can also protect against drug oxidation and photochemical inactivation of the drug, depending on the type of overwrap used".

The labels on the IV solutions observed by the surveyors to be out of the overwrap included the following instructions "Do not remove units from overwrap until ready for use; use all units promptly when pouch is opened. The overwrap is a moisture barrier the inner bag maintains sterility after removing the overwrap check for minute leaks by squeezing.

A discussion of the above findings was held with Staff # 16, and he/she was interviewed regarding whether the storage areas for IV solutions were monitored for temperature and relative humidity on 2/4/2016 at 2:00 PM; he/she stated "the humidity and temperature are not monitored in the storage rooms or medication rooms".

At 11:30 AM on 2/2/2016, while touring the SDS (Same Day Surgery) and PACU (Post Anesthesia Care Unit) medication room, the surveyor, accompanied by Staff #31, observed a 1 liter bag of LR (lactated ringers) spiked with tubing and available for use hanging on an IV pole. There were also several 1 liter bags of IVF out of the overwrap but not spiked, hanging on an IV pole. Staff #31 stated that staff "open up enough IV fluids for 2 days of cases". Staff #31 took down the spiked bag of LR and emptied it into the sink.

At 3:30 PM on 2/2/2016 the surveyor observed a computer on wheels medication cart sitting outside of Room #304; Patient #7's information was pulled up on the screen, the privacy curtain in Room 304 was pulled, blocking the view of the cart from the room. The medication drawer labeled for room 304 was not closed, and this drawer, along with the rest of the drawers containing patient medications were not locked, and could be opened. The unlocked and unattended medication cart and the open computer screen with Patient #7's information was brought to the attention of Staff #35, who was administering medications to Patient #7 in room 304, at the time of discovery.

C. While observing Staff #48, an RN, conducting a medication pass on 2/3/2016 at
8:55 AM, the surveyor noted that the secondary tubing for the antibiotic Rocephin did not have a change date label. The surveyor asked Staff #48 what the hospital policy was in regards to labeling IV tubing. Staff #48 stated "the tubing should have a date sticker on it, they have been falling off a lot lately".

While observing Staff #37, an RN, conducting a medication pass on 2/3/2016 at 9:40 AM, the surveyor noted that the primary IV tubing did not have a change date label, and asked Staff #37 about the hospital policy; he/she stated "yes, it should have one". Staff #37 replaced the tubing and applied a date label to the tubing.

The facility's policy for "IV (Peripheral) Insertion, Care and Maintenance" includes "Caring for IV Site" "Steps" "...3. Assess the delivery system confirm no leakage at connections, IV bag is labeled and the tubing is tagged for date change....All tubing must be labeled with date to be changed. Prefer day of week sticker with change date written".

D. The surveyor observed Staff #37 administer Solu-Medrol 40 milligrams (mg) IVP (intravenous push) to Patient #30 at 9:40 AM on 2/3/2016. Staff #37 did not monitor the rate of administration during the delivery of the Solu-Medrol; however, the surveyor monitored the rate using the second hand of his/her watch and noted that Staff #37 administered the IVP Solu-Medrol over 25 seconds.

The facility's "Medication Administration Methods" policy states to "Utilize drug reference materials, Pharmacist. IV push medications should be given at the recommended rates of administration. More rapid administration may contribute to adverse patient outcomes". Staff # 16 gave the surveyor a copy of medication guidelines on 2/3/2016 at 11:40 AM and stated "These guidelines are attached to the policy. It is the expectation they be given this way". The guidelines included the following information regarding dosage/dilution/delivery when administering IV Push Solu-Medrol: "Highly variable dosing depending on indication; typical dose 10-125 mg. Use diluent supplied and give doses of up to 125 mg over 3-15 min".

E. At 12:30 PM on 2/2/2016 while observing Staff #62 perform glucose monitoring for Patient #25, the patient stated "I didn't have my insulin at breakfast because everything got messed up, that is why my sugar is high now. The day nurse thought the night nurse gave it but she didn't, there was a communication mix-up". The surveyor also observed an unopened pouch containing Levofloxin injection in 5% dextrose 750 mg/5 mg/ml(milliliter) which did not contain a name label sitting on the counter at the sink in Patient #25's room. The surveyor interviewed Staff #34, the nurse assigned to Patient #25 for the day shift, at 2:45 PM on 2/2/2016 regarding the AM insulin dose and he/she stated "When I went in to give his/her Solu-Medrol and do hourly rounds around 10:18 AM, I realized he/she hadn't had the morning insulin when it came up in beige on the EMAR (electronic medication administration record)". I just told him/her since it was so close to time for the next dose, I would wait to see what the 12:00 sliding scale blood sugar was and give additional insulin if needed". The surveyor noted that the 12:00 PM blood sugar measured 355, and per the sliding scale, required 6 units sliding scale insulin coverage to be administered. When asked if the doctor was notified, Staff #34 stated "No, I didn't call the doctor". "This morning I don't think the pharmacy had come up with the insulin yet, and that's why I thought the night nurse had given the morning insulin. I am in the float pool, I am not too sure how it works on this floor, I work for (name of hospital), they float me where they need me depending on what the need is. I float at (name of hospital) most of the time.

The above findings were discussed with Staff #5, 16, and 63 at approximately 4:30 PM on 2/4/2016.

Based on interview and document review it was determined the facility staff failed to ensure:

A. Medical records were accurate for one (1) of thirty-nine (39) patient records reviewed. (Patient #9)

B. Medical record forms utilized identified the hospital and were not generic to the healthcare system.

C. The discharge summary was completed within the thirty day time frame for one (1) of eleven (11) discharge records in the patient sample (Patient #37)

D. Pre-Operative Checklist were completed for one (1) of thirty-nine (39) patient records reviewed. (Patient #7)

The findings included:

A. A review of Patient #9's electronic medical record (EMR) was conducted on 02/02/2016 with Staff #8 and #18. Patient #9 had multiple admissions to the hospital during the moths of November 2015 and December 2015. Patient #9 was diagnoses with Stage IV metastatic Cancer. Documentation in Patient #9's EMR described the patient as "Caucasian" and as being "African American." The surveyor inquired which of the notations were correct. Staff #18 informed the surveyor he/she would clarify. The surveyor inquired who would be responsible to ensure information entered into a patient's record was correct. Staff #18 stated, "Ultimately, it is the person making the entry." Staff #18 reported health information monitor a selected sample of medical records to review for quality.

An interview was conducted on 02/02/2016 at approximately 3:30 p.m., with Staff #18. Staff #18 presented an addendum to Patient #9's EMR to specify the correct ethnicity.

B 1. The hospital is a part of a healthcare system of multiple individually certified hospitals. Review of medical records revealed forms, which were generic only listing the name of the healthcare system without identifying the individual hospital. Other forms had check boxes for specific hospital listed under the title of the healthcare system. Review of medical records revealed the following findings:

Patient #19's Emergency Department (ED) registration and General Consent listed only the healthcare system's name.

Patient #20's Emergency Department (ED) registration and General Consent listed only the healthcare system's name.

Patient #39's "Documentation of Consent to Operation or Procedure" form did not specify which of the listed hospitals the procedure would occur. The checkboxes at the top of the form had not been checked.

Patient #43's Emergency Department (ED) registration and General Consent listed only the healthcare system's name.

Patient #49's Restraint order form listed only the healthcare system's name.

Patient #50's Restraint order form listed only the healthcare system's name.

Patient #53's "H & P (History and Physical) Update/OP Note (Operation Note)" and the patient's "General Consent for treatment and services listed only the healthcare system's name. Staff had failed to check the appropriate box on Patient #53's "Documentation of Consent to Operation or Procedure" form and the patient's "Anesthesia Consent" form.

An interview was conducted during the end of the day meeting at 5:15 p.m. on 02/04/2016. Staff #16 and #63 was informed of the findings. Staff #16 reported the patient's sticker applied to the forms identified which hospital the forms had been utilized. Review of patient stickers did not list the actual name of the hospital. In small print the initials of the hospital prints on the patient label which could be obscured. Staff #16 verified on the forms that have checkboxes to identify which hospital the staff filling out the form failed to check the box that identified the hospital.


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B 2. Review of Patient #32's electronic medical record (EMR) indicated the patient had been admitted to the facility on 01/28/15. Patient #32's parent signed the general consent for treatment form on 01/28/15, but the consent failed to specify the location of the facility treatment was being provided.

Review of Patient #37's EMR indicated the patient had been admitted to the facility on 01/28/15. Patient #37 signed the general consent for treatment form on 01/28/15, but the consent failed to specify the location of the facility treatment was being provided.

Review of Patient #38's EMR indicated the patient had been admitted to the facility on 02/09/15. Patient #38 signed the general consent for treatment form on 02/09/15, but the consent failed to specify the location of the facility treatment was being provided.

Review of Patient #45's EMR indicated the patient had been admitted to the facility on 01/09/16. Patient #45 signed the general consent for treatment form but did not date the form, and the consent failed to specify the location of the facility treatment was being provided.

C. One (1) of eleven discharge records in the patient sample (Patient #37) revealed the discharge summary failed to be completed within thirty (30) days.

Review of Patient #37's electronic medical record (EMR) was conducted on 02/03/16 with Staff #41. Patient #37's EMR indicated the patient had been admitted to the facility for an induction of labor by Women's Health and Surgery Center on 01/28/15. Patient #37's "Discharge Summary" revealed Patient #37 was discharged to home on 01/31/15 and to follow up for wound care and examination in the office within a week. The infant was delivered and transferred to (Name of Outside Facility) for further care.

The review of Patient #37's "Discharge Summary" revealed the electronically signed discharge instructions documented the patient had received both discharge education and a copy of the discharge instructions. However, the "Discharge Summary" revealed the physician signed the discharge summary on "03/31/15 at 04:32 P" and Patient #37 was discharged home on 01/31/15; which revealed the physician signed the discharge summary more than thirty (30) days after discharge.

An interview was conducted with Staff #16 and Staff #41 on 02/03/16. Staff #41 reported Patient #37's EMR did not have evidence the patient's "Discharge Summary" was signed by the physician within the required thirty (30) days, failing to be promptly completed.

The review of the policy titled "Medical Records, Management of" revealed in part: "To ensure that a complete and accurate medical record is maintained appropriately for each patient seen....3. Each inpatient and outpatient will have a medical record maintained. The record will be: a. Accurately documented....c. Completed within 30 days after discharge....."


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D. A review of Patient #7's medical record revealed that he/she had surgery for placement of an AV (arteriovenous) fistula on 2/1/2016. The assessment day of surgery/Endoscopy and Pre-Operative Checklist document dated 2/1/2016 was not complete. The PreOp/Endoscopy Assessment Checklist document consists of 2 sections, one side to be completed and signed by the Unit RN, and one side to be completed and signed by the SDS (same day surgery) RN. The document lacked signatures of the Unit RN and the SDS RN, VS (vital signs) were not complete, and there were multiple sections left blank on both sides of the paperwork.

Staff #56, the third floor RN charge nurse, was made aware of the above findings at approximately 11:00 AM on 2/3/2016.

Based on findings identified during the Life Safety Code survey, the Condition level citation of Physical Environment is being cited in the health portion of the survey.

Based on observation, staff interview and clinical record review, the facility staff failed to:
1. Practice and implement proper infection control procedures regarding patients in isolation, utilize proper use of PPE (personal protective equipment) and perform hand hygiene;
2. Handle blood glucose monitoring equipment in a manner to prevent the potential spread of infection; and
3. Disposal of potentially contaminated supplies.

The findings include:

1. On 2/1/16 at 1:40 p.m. during a tour and subsequent observations on the 3rd floor nursing unit, the surveyor observed Room 324 to have a large yellow pack hanging beside the door containing various items: gloves, masks, yellow fluid impervious gowns, and other patient care items. There was no signage on the door to indicate if the patient was on isolation. The surveyor also observed room 327 to have the same "pack" and the patient was also observed to have a security officer in the room sitting with the patient and there was no signage on the door indicating whether the patient was on isolation.

The surveyor asked Staff # 56 ( Registered Nurse) what the large yellow "packs" were for. Staff #56 stated they were used to contain the supplies for patients who were on isolation. The surveyor asked if Room 324 was on isolation. Staff #56 stated, "Yes" and the surveyor inquired as to whether there should be a sign on the door for identification. Staff #56 stated, "Yes, there should be a sign on the door for contact precautions." The surveyor inquired as to the status of Room 327 and was also informed by Staff #56 that the patient was on contact precautions and that there should be a sign on the door. The surveyor had observed the one-to-one security officer sitting with the patient in Room 327 and observed the security officer to only be wearing gloves and his/her security uniform. The sign for contact precautions, which had been placed on the door by Staff #56 stated staff should wear gowns and gloves when entering the room. The security officer was not wearing a gown in Room 327. After the surveyor made the observation, the Charge Nurse went to the door of the room and handed the officer a yellow isolation gown.

On 2/2/16 at 8:15 a.m. the surveyor returned to the 3rd floor and observed Room 327. The patient (Patient #44) had a one-to-one sitter in the room who was not wearing a gown, only gloves and scrub uniform. After the surveyor made rounds on the unit and returned to the room, the sitter had put on a yellow isolation gown.

On 2/4/16 at 11:10 a.m., the surveyors observed a volunteer with a therapy dog entering and exiting Room 326 which was identified as contact isolation. The volunteer did not use hand hygiene, don gloves or a gown, and allowed the therapy dog to enter the room. The volunteer and dog were seen entering other patient rooms who were not on isolation after exiting the isolation room.

On 2/4/16 at 4:40 p.m. and on 2/5/16 at 11:30 a.m., the observations were discussed with Staff #18, and 63.


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2. The surveyor observed Staff #62 perform assisted blood glucose monitoring for Patients #24, #11, and #25 on 2/2/2016 between 12:00 PM and 12:30 PM. After entering Room #314 to obtain Patient #24's blood sugar, Staff #62 reached into his/her pocket with a gloved hand to get another lancet after an unsuccessful attempt to obtain a blood sample; he/she sat the glucometer on the bedside table, moved it onto the sink counter, then took Patient #24's vital signs before setting the glucometer on the the mobile computer station. Staff #62, then removed his/her gloves and sanitized his/her hands. Staff #62 then picked up the contaminated glucometer with ungloved hands and began typing information into the computer.

At 12:20 PM, Staff #62 went into Patient #11's room. Staff #62 donned gloves, and laid the glucometer, a lancet, alcohol prep pads, and the container of test strips on the bed with Patient #11. After retrieving a test strip from the container, Staff #62 put the container in the pocket of his/her scrub top. After obtaining the blood sugar, and checking Patient #11's vital signs, Staff #62 used the phone in the patient's room to call the nurse and report blood sugars prior to removing his/her contaminated gloves and sanitizing his/her hands.

At 12:30 PM, Staff #62 went into Room 405, laid the glucometer on the arm of the chair in which Patient #25 was sitting. Staff #62 removed the test strip container from his/her scrub pocket, obtained the patient's blood sugar, and sat the contaminated glucometer on the sink counter. The nurse walked into the room and the blood sugar was reported to him/her. Staff #62 removed his/her gloves, sanitized his/her hands, then picked up the contaminated glucometer and placed it on the rolling computer station.

The glucometer was not cleaned or disinfected between Patients #24, #11, or #25, and the container containing the test strips was not sanitized after being carried into each room and placed into the pocket of Staff #62's scrub top.

On 2/1/2016 between 2:15 PM and 2:40 PM, the surveyor observed a contract RN (registered nurse) initiate dialysis for Patient #8 and noted that he/she did not practice proper hand hygiene. At 2:15 PM, with gloved hands, the nurse took Patient #8's vital signs, checked the CVC (central venous catheter) site, which was bleeding under the dressing, removed his/her gloves, and took a cell phone from his/her scrub top pocket, texted his/her supervisor, then placed the phone back into his/her pocket.

He/she sanitized their hands, donned gloves and a mask, placed a mask on the patient, placed a sterile field under the CVC, then re-checked Patient #8's blood pressure. The RN took off 1 glove and his/her mask, silenced the machine with the gloved hand, removed that glove then went to the dialysis cart sitting just outside the door to the room while wearing an isolation gown, reached around the isolation gown with an ungloved hand, got phone out of scrub pocket, texted, put phone back in pocket, retrieved supplies from the cart, and carried them into the room and sat them on the bed with the patient. He/she then got another mask, donned gloves without first sanitizing hands, and initiated dialysis via the CVC. After connecting the blood lines and starting the blood pump, he/she clamped the blood lines to the patients gown, handling the lines with ungloved hands.

The MMWR (Mortality and Mortality Weekly Report) for October 25, 2002 issued by the CDC (Centers for Disease Control) recommends that in the health care setting hands be decontaminated after contact with inanimate objects, including medical equipment, in the immediate vicinity of the patient, and after removing gloves.

The contract dialysis RN did not wear eye protection during the initiation of dialysis, other than his/her eyeglasses.
The surveyor observed a contract RN discontinue dialysis for Patient #8 on 2/2/2016 at 12:45 PM. During hemodialysis wastes from the patient's blood diffuse through the membrane of a dialyzer and into the dialysate. Used dialysate then goes into a drain. The surveyor observed that the lines carrying the used dialysate from the dialysis machine were lying beside a drain in the bathroom floor. Used dialysate collected on the bathroom floor around the drain during Patient #8's dialysis treatment. The surveyor observed the contract RN put towels on the floor, move the towel around using his/her feet, then pick up the towels and put them in a laundry bag in the patient's room. The nurse did not use cleaning agents to clean the floor where the used dialysate had collected. The contract nurse did not ask the EVS (environmental services) staff to clean the bathroom floor.
An interview was held with Staff #36 at 2:30 PM on 2/2/2016 regarding cleaning practices in rooms where dialysis has been performed. Staff #36 stated "Each room gets 4 touch times during the day; at around 8:00 AM there is an AM freshen when the trash is taken out of the room; again around 11:00 AM when surfaces including the floors are cleaned; around 2:00 PM there is a PM freshen, then around 8:00 PM for a turn down. If the nurse doesn't call us to mop after they finish dialysis, the EVS staff would not mop except during one of the freshen-ups".

Housekeeping practices should minimize the potential for transmission of microorganisms, including proper methods to clean and disinfect equipment and environmental surfaces in areas where hemodialysis is performed.

"The June 2003 MMWR (Morbidity and Mortality Weekly Report) Guidelines for Environmental Infection control in Health Care Facilities published by the CDC (Centers for Disease Control) recommends the following for cleaning spills of blood or body and body substances:
Cleaning Spills of Blood and Body Substances
Promptly clean and decontaminate spills of blood or other potentially infectious materials (293--300). Category IB, IC (OSHA: 29 CFR 1910.1030 § d.4.ii.A)
Follow proper procedures for site decontamination of spills of blood or blood-containing body fluids (293--300). Category IC (OSHA: 29 CFR 1910.1030 § d.4.ii.A)
1. Use protective gloves and other PPE appropriate for this task (293). Category IC (OSHA: 29 CFR 1910.1030 § d.3.i, ii)
2. If the spill contains large amounts of blood or body fluids, clean the visible matter with disposable absorbent material, and discard the used cleaning materials in appropriate, labeled
containers (293,298,299,301,302). Category IC (OSHA: 29 CFR 1910.1030 § d.4.iii.B)
3. Swab the area with a cloth or paper towels moderately wetted with disinfectant, and allow the surface to dry (293,301). Category IC (OSHA: 29 CFR 1910.1030 § d.4.ii.A)
Use germicides registered by the EPA for use as hospital disinfectants and labeled tuberculocidal or registered germicides on the EPA Lists D and E (i.e., products with specific label claims for HIV or hepatitis B virus [HBV]) in accordance with label instructions to decontaminate spills of blood and other body fluids (293,301,303). Category IC (OSHA 29 CFR 1910.1030 § d.4.ii. A memorandum 2/28/97; compliance document [CPL] 2-2.44D [11/99])
An EPA-registered sodium hypochlorite product is preferred, but if such products are not available, generic sodium hypochlorite solutions (e.g., household chlorine bleach) may be used.
1. Use a 1:100 dilution (500--615 ppm available chlorine) to decontaminate nonporous surfaces after cleaning a spill of either blood or body fluids in patient-care settings (301,304).
Category IB
2. If a spill involves large amounts of blood or body fluids, or if a blood or culture spill occurs in the laboratory, use a 1:10 dilution (5,000--6,150 ppm available chlorine) for the first
application of germicide before cleaning (279,301). Category IB."


3. At 11:30 AM on 2/2/2016 while touring the SDS (same day surgery unit) in the company of Staff #31, the surveyor observed Staff #32 pick up a bag of IVF out of the overwrap, and an IV tubing still in the packaging from SDS room 2 and set it down on the nursing station counter. At 11:35 AM, Staff #32 picked up the IVF and tubing and returned them to the clean supplies. This observation was discussed with Staff #31 at the time of occurrence.

At approximately 10:00 AM on 2/3/2016, the surveyor observed an open bottle of sterile water labeled "single use only does not contain bacteriostatic, discard after use" sitting on top of the closet in Room 312, that of Patient #23. Patient #23 stated "they fill up my machine with that". The patient had a CPAP (continuous positive airway pressure) machine sitting at the bedside. CPAP is a treatment that uses mild air pressure to keep the airways open. A telephone interview with Staff #66, the respiratory therapy supervisor, regarding the policy and procedure for CPAP use was conducted at 12:00 PM on 2/3/2016. He/she stated "There is not a procedure that says to use bacteriostatic water, that's part of our AARC (American Association of for Respiratory Care) guidelines, which means we should be using sterile water, in other words, it should be common sense. I understand that at one point we had sterile water for inhalation, non-pyrogenic and bacteriostatic in the par level, but I'm not sure if it's still in the system. I will check and have it added back in if it isn't".

These findings were discussed with Staff #5, 16, and 63 at approximately 4:00 PM on 2/4/2016.

Based on interview and document review it was determined the facility staff failed to ensure discharge evaluation was performed to decrease the risk of readmission for two (2) of nine (9) discharged patients included in the survey sample. (Patient #12 and #15)

The findings included:

1. A review of Patient #12's active electronic medical record (EMR) was conducted on 02/02/2016 with Staff #8 and #18. Patient #12 was readmitted to the facility on 01/30/2016 with a fever and was diagnosed with urosepsis. The review revealed the initial nursing screening for discharge planning did not trigger for a case management consult. During the review of Patient #12's EMR Staff #18 reported the initial nursing discharge screening failed to include the patient had been discharged from the facility on 12/28/2016 with home health services and the patient attended the facility's anticoagulant clinic. Staff #18 reported both factors if entered would have prompted a case management consult to ensure continuity of care.
[Urosepsis is a severe illness that occurs when an infection starts in the urinary tract and spreads into the bloodstream. Urosepsis can be life-threatening if it is not treated immediately.]

2. A review of Patient #15's electronic medical record (EMR) was conducted on 02/02/2016 with Staff #8 and #18. Patient #15 was readmitted to the facility on 05/18/2015 for shortness of breath. Review of Patient #15's EMR included a "History and Physical" that read in part: "...presented to the hospital because of worsening shortness of breath, progressively worsening for more than a week, increasing lower extremity edema. Also, reporting some wheezing and nonproductive cough ... The patient is reported orthopnea ... was unable to use nebulizer treatment at home because [he/she] ran out of medication ..." Review of Patient #15's discharge medications and instructions included" "Albuterol Sulfate 2.5 mg [milligram]/3 mL [milliliter] (0.083%) Solution for Nebulization. Directions 3 mL by inhalation every four hours as needed. Reason for taking: shortness of breath." Patient #15's EMR did not contain a case management consult. Patient #15's EMR did not contain evidence the physician contacted or ordered case management related to Patient #15 not having his/her medications for respiratory treatment resulting in exacerbation of respiratory symptoms and readmission to the hospital. Staff #18 verified the findings and reported the physician should have contacted case management for possible arrangements to assist with obtaining medications or to determine the reason Patient #15 had ran out of medication.

[Orthopnea is the inability of a person to breathe easily unless sitting straight up or standing erect.]
[Nebulizer is a device used to reduce liquid medication to an extremely fine mist in order to deliver medication to the deep part of the respiratory tract.]

Based on interview and document review it was determined the facility staff failed to ensure patients screened for discharge risk were evaluated timely for two (2) of nine (9) discharged patients included in the survey sample. (Patients #16 and #40)

The findings included:

1. A review of Patient #16's electronic medical record (EMR) was conducted on 02/02/2016 with Staff #8 and #18. Patient #16 was admitted to the facility on 04/10/2015 and discharged five days later with home services for physical therapy. Patient #16's EMR contained one case management notation, which read in part: "Met with patient at bedside this afternoon. Patient to be discharged home today with home physical therapy. Patient states [he/she] will go to [names of to retail stores] to purchase cane." Staff #18 verified Patient #16's EMR only had one entry from case management. Staff #18 verified Patient #16's EMR did not have an assessment of the patient's ability to maneuver in the home setting.

2. A review of Patient #40's electronic medical record (EMR) was conducted on 02/04/2016 with Staff #16. Patient #40 was admitted to the facility for pain and fever on 01/30/2016. Patient #40's EMR documented the initial nursing screening for discharge triggered a case management consult. As of the review on 02/04/2016 at 8:46 a.m. the case management evaluation had not occurred. The surveyor requested the expected time frame for completion of initial case management evaluations when consulted. Staff #16 reviewed the calendar and reported the patient came in on a Saturday. Staff #18 was contacted and reported the facility has case management coverage on the weekends for discharge. Staff #18 reported the staff covering the weekends generally do not perform new patient evaluations but are available for managing unscheduled weekend discharges of patients. Staff #18 reported the expectation would be that case management would evaluate the patient by the following Monday or Tuesday depending on the number of admissions. The surveyor informed Staff #18 that Patient #40 had been admitted on 01/30/2016, a Saturday, but as of Thursday 02/04/2016 the patient had not been seen by case management. Staff #18 stated, "That type of delay should not occur."

An interview was conducted on 02/04/2016 at 4:10 p.m., with Staff #42. Staff #42 reported he/she had been responsible to perform Patient #40's initial discharge evaluation. Staff #42 stated, "I got behind there were a lot of admissions and I didn't perform the evaluation. Staff #42 reported he/she felt the facility had enough case management staff between the hospital and their sister hospital; but that assistance was not available related to the survey.

Based on interview and document review it was determined the facility staff failed to document the provision of a list of available home health services to one (1) of four (4) patients discharged with post hospital needs. (Patient #16)

The findings included:

A review of Patient #16's electronic medical record (EMR) was conducted on 02/02/2016 with Staff #8 and #18. Patient #16 was admitted to the facility on 04/10/2015 and discharged five days later with home services for physical therapy. Patient #16's EMR contained one case management notation, which read in part: "Met with patient at bedside this afternoon. Patient to be discharged home today with home physical therapy. Patient states [he/she] will go to [names of to retail stores] to purchase cane". Staff #18 verified Patient #16's EMR only had one entry from case management. Staff #18 verified Patient #16's EMR did not have an assessment of the patient's ability to maneuver home setting. Staff #18 verified Patient #16's EMR did not document a list of home health services providing physical therapy had been given to the patient or the patient's family a choice in services.

Based on interviews and document reviews it was determined facility staff failed to perform the required time out to identify the right patient and right procedure for two (2) of two (2) obstetrical Caesarian section patients included in the survey sample. (Patient #2 and #37)
The findings included:

1. An interview was conducted on 02/01/2016 at approximately 2:00 p.m., with Patient #2 as part of the validation process. Patient #2's electronic medical record (EMR) was reviewed as part of the survey process for active patients. Patient #2's EMR documented the patient arrived at the hospital's emergency department (ED) on 01/31/2016 related to frequency of contractions. ED staff assessed and escorted Patient #2 to the labor and delivery (L/D) unit. Patient #2 was triaged by L/D staff on 01/31/2016 at 2:35 a.m. and admitted to the L/D unit. Patient #2's EMR documented the patient was prepped for a Caesarian section, a surgical procedure for delivery of the infant. Patient #2's EMR documented on 01/31/2016 the procedure start time was 4:47 a.m., anesthesia was administered at 4:47 a.m., the incision time was 5:17 a.m., and the time out for verification of right patient/right procedure was 5:22 a.m. - five minutes after the incision. The procedure stop time was documented as 6:43 a.m. on 01/31/2016.

An interview and review of Patient #2's EMR was conducted on 02/04/2016 at 8:21 a.m., with Staff #16 and #41. Staff #16 and Staff #41 verified the findings. Staff #41 reported the staff "probably documented the time out late" or after the fact. Staff #16 and #41 agreed the only documentation within Patient #2's EMR indicated the "time out/surgical pause" was performed after the incision. Staff #41 acknowledged one of the purposes of the time out/surgical pause was to ensure patient safety: the right procedure on the right patient.

According to the World Health Organization (WHO): "The WHO Surgical Safety Checklist is a simple tool that helps surgical teams adhere to basic standards of care in the operating room. While the items on the Checklist seem like common sense its use has been shown to demonstrably reduce avoidable surgical complications and death throughout the world ... Before making the first surgical incision, a momentary pause should be taken by the team in order to confirm that several essential safety checks are undertaken. These checks involve all team members ... Confirm the patient ' s name, procedure and where the incision will be made ... The ' time out ' or ' surgical pause ' : In surgery, there are few examples of systematic improvements in safety; however, over the past several years in the United States and other industrialized countries, a ' time out ' or ' surgical pause ' has been introduced as a standard component of surgical care (27). This is a brief, less than one minute pause in operating-room activity immediately before incision, at which time all members of the operating team-surgeons, anesthetists, nurses and anyone else involved-verbally confirm the identity of the patient, the operative site and the procedure to be performed. It is a means of ensuring clear communication among team members and avoiding ' wrong-site ' or ' wrong-patient ' errors. It has been made mandatory in the United States and a few other countries ...".


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2. The electronic medical record (EMR) for Patient #37 was reviewed on 02/03/16. Patient #37 was admitted on 01/28/15 for an induction of labor. On 01/28/15 it was documented in the EMR in the area labeled "Impression" "...status post induction with urgent cesarean section and delivery of an infant...... " The surveyor was unable to locate in the clinical record, any pre-operative "time out" documentation used to verify essential information to minimize the risk of medical errors prior to initiating the surgical procedure. On 02/03/16, the surveyor requested further information regarding the verification prior to initiating Patient #37's cesarean section surgical procedure.

The surveyor, along with assistance from facility staff (Staff #41) who was navigating the EMR, were unable to locate any documentation verifying a "time out" was performed to verify patient essential information prior to the incision. On 02/04/16 Staff #16 presented the surveyor with the following information of the surgical procedure for Patient #37: "The cesarean section started on 01/28/15 at 21:44 and ended at 22:45. Time out documented at 04:00." The surveyor inquired to Staff #16 if the time out documentation was at 04:00 on the following day 01/29/15. Staff #16 verified, "Yes the documentation was the next day. They probably did the time out prior to the surgery but they did not document it until the next day."

On 02/05/16 at approximately 12:00 p.m., the survey team reviewed the concerns with the administrative team prior to the exit conference.