HospitalInspections.org

Based on observation, staff interview, and review of accepted standards of practice, the facility failed to ensure accepted standards of practice were followed during administration of injectable medications for 1 of 1 sample patient (#9) observed receiving surgery. The facility further failed to ensure staff handled used laryngoscope blades in a manner to prevent contamination during 1 of 1 surgery observation affecting 1 patient (#9). The findings were:

1. Observation of surgery for patient #9 on 5/19/15 from 7:45 AM to 9:30 AM revealed the following concerns:
a. Physician #5 was observed drawing up and administering medications to the patient. The observation revealed the physician did not disinfect the intravenous (IV) insertion port prior to administering the medications 5 times. During that time the physician was also observed piercing a vial of medication and withdrawing the medication into a syringe without first disinfecting the septum on the medication vial 4 times.
b. According to the Centers for Disease Control & Prevention (CDC) recommendations for Safe Injection Practices, updated 2011, the septum on the medication vial and IV ports should be disinfected before piercing. The Association for Professionals in Infection Control and Epidemiology (APIC) standards for safe injection practices, published in the American Journal of Infection Control, April 2010, recommends IV ports, vial stoppers, and access diaphragms be disinfected prior to each use.

2. Additional observation during surgery on 5/19/15 for patient #9 revealed the following concerns:
a. At 7:45 AM, after physician #5 used the larygealscope for endotracheal tube insertion, RN #1 placed the used larygealscope with the attached blade in the opened package and positioned it on the counter in the operating room. The used device remained on the counter surrounded by other items, including two cell phones, books, folders with papers, packaged cushions, linen, tape, and the physician's case for microscopic glasses until 9:40 AM.
b. When the surgical procedure was completed and prior to 9:40 AM, various members of the operating room staff departed from the room with items that had contact with the used larygealscope on the counter.
c. Interview with the surgical services director on 5/21/15 at 9:25 AM revealed placing the used larygealscope on the counter was not an acceptable standard practice.

Based on medical record review and staff interview, the facility failed to ensure a post-anesthesia evaluation was performed for 2 of 7 patients (#3, #5) who required that evaluation. The findings were:

1. Medical record review showed patient #3 had a Cesarean Section (surgery to assist with birth via the abdomen) on 5/18/15. Review of the anesthesia evaluation form revealed the facility failed to document a post-anesthesia evaluation (that area was blank) on the anesthesia form under "Post-Anesthesia Evaluation." Review of the entire medical record showed the facility failed to document a post-anesthesia evaluation.

2. Medical record review showed patient #5 had knee surgery on 5/13/15. Review of the anesthesia evaluation form revealed the facility failed to document a post-anesthesia evaluation (that area was blank) on the anesthesia form under "Post-Anesthesia Evaluation." Review of the entire medical record showed the facility failed to document a post-anesthesia evaluation.

3. Interview with the director of quality management on 5/20/15 at 1:25 PM confirmed the facility failed to document a post-anesthesia evaluation for patients #3 and #5.

Based on facility policy review and staff interview, the facility failed to ensure policies and procedures were reviewed by a group of professionals on an annual basis. The findings were:

Review of facility policies and procedures revealed the facility failed to review and/or revise the following policies annually:
a. The policy titled, "Blood Product Storage and Equipment Maintenance" was last reviewed on 2/16/14 (15 months).
b. The policy titled, "Medical Standards of Patient Transfers" was last revised on 2/15/12 (39 months) without any additional review dates.
c. The policy titled, "Case Management: Advance Directives/Patient Self-Determination Act" was last reviewed on 6/11/12 (35 months).
d. The policy titled, "Surveillance of Infections" was last revised on 5/2010 (60 months) without any additional review dates.
e. The policy titled, "Policy and Procedures and Practice Standards, Guideline and Templates" was last reviewed on 1/8/13 (28 months).
f. The policy titled, "Provision of Care Plan" was last reviewed on 1/8/13 (28 months).

Interview with the director of quality management on 5/20/15 at 1:25 PM confirmed the facility policies are not always reviewed timely.

Based on medical record review, patient rights review, and staff interview, the facility failed to ensure 2 of 2 patients (#14, #15) who required information concerning patient rights were given that information. The findings were:

Review of the medical records for patients #14 and #15 showed no information concerning patient rights. During an interview with the director of quality management on 5/20/15 at 1:25 PM, she provided a form which included a patient rights area that listed 18 separate patient rights. The director of quality management confirmed the facility failed to implement a tracking system to ensure a copy of those rights was provided to each patient.

Based on medical record review and staff interview, the facility failed to ensure 2 of 2 patients (#14, #15) were informed in writing concerning options of providing and/or formulating advanced directives. The findings were:

Review of the medical records for patients #14 and #15 revealed each record failed to have documented advanced directive information. During the review of patient #14's record, the documentation revealed the patient had not made a decision yet concerning advanced directives. Further review showed there was no follow-up information documented and no advanced directive information in the record. Review of the medical record for patient #15 showed there was no advanced directive information in the record. Interview on 5/20/15 at 1:25 PM with the director of quality management revealed the facility failed to ensure advanced directive information was documented in patient records.