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SPOONER HEALTH SYSTEM
No Description Available
Tag No.: C0276
Based on observation and interview, the facility failed to ensure medications are not available for unauthorized access, in 1 of 4 areas (OR), and 1 of 2 staff (D) observed. This deficiency potentially affects all 2 Surgical Pts treated during survey.
Findings include:
Per interview with OR MGR B on 6/30/14 at 1:00 PM the Anesthesia Medication Cart should be locked when unattended.
Per observation on 6/30/14 at 11:00 AM Housekeeper D began mopping in OR 1, the Anesthesia Cart was unlocked and unattended, allowing for unauthorized access. CRNA C entered OR 1 at approximately 11:03 AM and confirmed interview at 11:05 AM the cart is not locked.
PATIENT CARE POLICIES
Tag No.: C0278
Based on observation and interview, the facility failed to ensure there is a comprehensive infection control program to monitor and prevent potential infections and cross contamination, in 1 of 2 staff (C) observed performing tasks. This deficiency potentially affects all 2 Surgical Pts treated at the facility during survey.
Findings include:
Per review interview with OR MGR B on 6/30/14 at 1:00 PM, staff should have linen contained in a linen bag when transporting to decontamination room,and staff should not place items on the cleaned OR table.
Per observation on 6/30/14 at 11:05 AM, CRNA C removed items from the top of the Anesthesia Medication Cart, placed them on the towel covering the cleaned Anesthesia Cart OR table, and placed a binder and clipboard on the OR table. CRNA C cleaned the medication cart and returned the items on the cart. CRNA C did not reclean the OR table. CRNA C proceeded to take the used towels from the Anesthesia carts and carried them under the arm through the sterile corridor to the decontamination room.
No Description Available
Tag No.: C0302
Based on record review and interview, the facility failed to ensure documents are complete including signature, dates and times, in 1 of 1 newborn MR (#2). This deficiency directly affects Pt#2 and potentially affects all future newborns.
Findings include:
Pt #2's MR review on 6/30/14 at 12:40 PM revealed the Newborn exam for Pt #2 born 6/29/14 is partially complete and is not signed, dated and timed. This is confirmed in interview with DON A on 6/30/14 at 12:40 PM adding the document should be completed at the time of the exam.