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Based on interviews and record reviews the hospital failed to ensure that nationally recognized standards for infection control guidelines were developed and implemented in the surgical services department to avoid sources and transmission of infections. This failed practice was evidenced by no revised policy in place that addressed the most current nationally recognized professional standards for 1) terminal cleaning and damp dusting of the surgical suites and 2) event related sterility.
Findings:
1) A review of the AORN (Association or peri-Operative Registered Nurses) Perioperative Standards and Recommended Practices, 2013 edition, under the section entitled "Environmental Cleaning "- Recommendation I, revealed that all horizontal surfaces in the operating room should be damp dusted before the first scheduled surgical procedure of the day using a clean, lint-free cloth moistened with an EPA registered hospital detergent/disinfectant to prevent microbial-laden dust from being dispersed throughout the environment. Recommendation IV, revealed that surgical operating rooms and scrub/utility areas in the surgical services department should be terminally cleaned daily when the scheduled procedures are completed for the day and each 24-hour period during the regular work week. The Recommendation further revealed that unused operating rooms should be terminally cleaned once during each 24-hour period to decrease the number of pathogens, dust and debris that is created during the day.
A review of the hospital's policy, entitled "Housekeeping Procedures" for the surgical services department provided by S9RN OR/OPS Manager as the most current, revealed the policy was revised on January 2013 and that the policy referenced the AORN Perioperative Standards and Recommended Practices, 2004 edition.
In an interview on 02/17/14 at 2:10 p.m. with S9RN OR/OPS Manager she indicated the surgical services department followed the AORN Perioperative Standards and Recommended Practices. S9RN indicated that the operating rooms were terminally cleaned only if the operating room was used that day and they were not terminally cleaned on a daily basis. S9RN further indicated that the operating rooms were not damp dusted prior to the first procedure of the day. S9RN indicated that the hospital's "Housekeeping Procedures" policy for the surgical services area did not reflect the most current nationally recognized professional standards for terminal cleaning and damp dusting of the surgical areas..
2) A review of the AORN Perioperative Standards and Recommended Practices, 2013 edition, under the section entitled "Packaging Systems"-Recommendation VIII, revealed that sterile packages should be considered sterile until an event occurred to compromise the package barrier integrity. The Recommendation further revealed that loss of sterility of a sterile item is event related and that the sterility of an item does not change with the passing of time but is affected by a particular event or environmental conditions, such as; multiple handling, compression during storage, moisture, storage conditions, exposure to contaminants and seal breakage and that hospitals should develop policies to determine how they would store and monitor these sterile packaged items.
In an interview on 02/17/14 at 1:45 p.m. with S9RN OR/OPS Manager, she was asked about the surgical services policy on sterile packaged items and how the continued sterility of these items were monitored over time. S9RN indicated she did not have a policy that addressed event related sterility and indicated she was not very familiar with the concept of event related verses time related sterility as documented in the AORN Perioperative Standards and Recommended Practices.

Based on interviews and record reviews the hospital failed to ensure that the nursing staff in the surgical services department, 1) adhered to nationally recognized professional standards of practice for the use of soft goods (surgical sponges) in surgical procedures and 2) followed their policy for safe practice for the surgical patient for the use of soft goods (surgical sponges) in surgical procedures. This failed practice was evidenced by the surgical services department failing to follow current nationally recognized professional standards of practice and failing to follow their policy for accountability for surgical soft goods (surgical sponges) during surgical procedures.

Findings:
A review of the AORN Perioperative Standards and Recommended Practices, 2013 edition under the section entitled "Recommended Practices for Prevention of RSI's (Retained Surgical Items)"-Recommendation II revealed that all soft goods used in the surgical wound should be radiopaque and should be accounted for and recorded during all surgical procedures to establish a baseline for subsequent counts to prevent RSI's. The Recommended Practice revealed that the risk exists for RSI's even in the smallest of incisions because the risk for retention cannot be predicted. The Recommendation further revealed that non-radiopaque gauze materials should not be used on the sterile surgical field during a surgical procedure.

A review of the hospital policy entitled "Accountability for Sponges, Sharps, and Instruments" with a revision date of September 2009, provided by S2CNO and S9RN OR/OPS Manager as the most current, revealed that all surgical sponges used in the surgical wound shall be radiopaque to provide safe practice for the surgical patient, prevent patient injury and adhere to professional standards. The policy further revealed that all sponges would be accounted for prior to the patient exiting the surgical suite and that an x-ray would be obtained if the surgical sponge count was incorrect.

In an interview on 02/18/14 at 10:00 a.m. with S9RN OR/OPS Manager, she indicated that the surgical services department followed the AORN Perioperative Standards and Recommended Practices. S9RN indicated that the surgery department performed minor surgical procedures (such as, excision of lesions, incision and drainage of abscesses, cataract removals). S9RN indicated that the surgical department did not use radiopaque surgical sponges for their surgical procedures and only used non-radiopaque gauze sponges in all their surgical procedures. S9RN further indicated that the non-radiopaque gauze sponges are not x-ray detectable and are not always counted when opened on the sterile surgical field if the nurse felt the surgical procedure would not involve a large enough incision. S9RN indicated that the nurses routinely only documented that the sharp and instrument counts were correct on the Intraoperative record. S9RN was asked about the hospital 's policy on "Accountability for Sponges, Sharps, and Instruments" for the surgical services department. S9RN indicated that the surgical services department did not adhere to the policy and further indicated that she was not aware of the current professional standards of the AORN Perioperative Standards and Recommended Practices.

Based on record review and interview the hospital failed to ensure patients' medical records were promptly completed within 30 days after discharge as evidenced by 37 medical records delinquent greater than 200 days and 14 medical records delinquent greater than 90 days.
Findings:

Review of the hospital's Medical Staff Bylaws revealed in part the following, "...10. A discharge summary shall be written or dictated on all medical record of patients hospitalized within thirty (30) days and in all instances the content of the medical record shall be sufficient to justify the diagnosis and warrant the treatment and the end result. All summaries shall be authenticated by the responsible party. The patient's medical record shall be complete at time of discharge, including progress notes and final diagnosis(es)..."

Review of the hospital's Deficiency Report by Physician, given to the surveyor as the current list of delinquent medical records, revealed the following:
S14MD had 34 medical records over 200 days delinquent and 4 records over 90 days delinquent.
S17MD had 2 medical records over 200 days delinquent and 6 records over 90 days delinquent.
S18MD had 3 medical records over 90 days delinquent.
S19MD had 1 medical record over 200 days delinquent and 1 record over 90 days delinquent.

An interview was conducted with S11Director of HIM (Health Information Management) on 2/17/14 at 2:30 p.m. She reported she was aware of the problem with delinquent medical records. She went on to report the current process is (1) Placement of written notification weekly (Friday) in the physician's assigned mailbox. (2) Monthly notification by letter. (3) Report during Medical Staff meetings (every other month) with Administration signing the report. (4). Hand delivered notificaiton to the physicians' offices with the medical record. S11Director of HIM further reported in April 2013 the medical staff bylaws were changed and suspension of physicians for delinquent medical records was removed due to lack of enforcement.

A phone interview was conducted with S15MD, Medical Director on 2/19/14 at 11:20 a.m. He reported he was aware of the delinquent medical record issue at the hospital and was not sure how to solve the issue at this point. He further reported certified letters had been sent to the physicians with delinquent medical records in the past by S16MD, Chief of Staff.

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Based on interviews and record reviews the hospital failed to ensure that operating practitioners who supervised the CRNAs (Certified Registered Nurse Anesthetists) during surgical procedures had in addition to their routine credentialing, the required delineation of anesthesia privileges and the supporting certifications to supervise CRNAs. This failed practice was evidenced by 1 (S20MD) out of 3 (S15MD, S16MD, S20MD) operating practitioners, who supervised CRNAs during surgical procedures, of having no documented evidence of supporting certifications (BLS, ACLS) or the specific delineation of anesthesia privileges granted to the operating practitioner by the Medical Staff's Credentialing Committee to supervise another practitioner (CRNA).

Findings:
A review of the hospital's Medical Staff Bylaws, as provided by S2CNO as the most current, revealed that the anesthesia services of the hospital would be under the direction of the Medical Director of Surgery and anesthesia services and would be provided by CRNAs.

In an interview on 02/18/14 at 11:00 a.m with S13CRNA, she indicated that she was one of the CRNAs who administered anesthesia to surgical patients. S13CRNA indicated that she was supervised by the operating practitioner (surgeon) who was performing the operative procedure. S13CRNA indicated that the operating practitioner (surgeon) would be responsible for "running the code" if the patient coded. S13CRNA further indicated that the supervising operating practitioners were BLS (Basic Life Support) and ACLS (Advanced Cardiovascular Life Support) certified.

In an interview on 02/1914 at 12:10 p.m. with S2CNO she indicated that the operating practitioner (surgeon), who was performing the operative procedure, would be responsible for the supervision of the CRNAs according to the Medical Staff Bylaws. S2CNO further indicated that the operating practitioner, supervising the CRNAs, should be BLS and ACLS certified.

In a phone interview on 02/19/14 at 12:45 p.m. with S16MD Chief of Staff, he was asked about the Medical Staff Bylaws regarding the supervision of the CRNAs during a surgical procedure. S16MD indicated that the operating practitioner performing the surgical procedure was responsible for the supervision of the CRNAs and that anesthesia services at the hospital were under the direction of the Medical Director and the Chief of Staff. S16MD indicated that S20MD was qualified to supervise the CRNA. S16MD further indicated that all operating practitioners who supervised CRNAs were BLS and ACLS certified and are competent in "running a code" and in intubation and resuscitation.

A review of the credentialing file for S20MD, Ophthalmologist, revealed S20MD was re-appointed to the medical staff in April 2013. A further review of S20MD's credentialing file revealed his BLS certification had expired in 2013 and there was no documented evidenced of a current ACLS certification and no delineation of privileges requested by S20MD or approved by the Medical Staff for any anesthesia supervisor privileges.

In an interview on 02/19/14 at 12:00 p.m. with S21Credentialing she indicated that all the credentialing information she had on S20MD was in S20MD's credentialing file that was submitted to the surveyors.

On 02/19/14 copies of the BLS and the ACLS certifications were requested from S2CNO for S15MD, S16MD and S20MD. S2CNO indicated she did not have any documentation of a current BLS or an ACLS certifications for S20MD.