HospitalInspections.org

Based on a review of facility documents, observation, and interview with staff (EMP), it was determined that the facility failed to provide adequate staffing of qualified personnel necessary to furnish surgical services after standard hours of operation for Surgical Services for one of three medical records reviewed (MR1).

Findings include:

A review on December 5, 2012, of the facility's policy "Staffing Policy for the Operating Room and Post Anesthesia Care Unit," dated August 2010, revealed "1. Purpose ... To provide optima [sic] distribution of personnel for quality patient care, while providing equal and fair time schedules for personnel ... IV. Informational ... The OR and PACU are staffed as follows: Operating Room ... 6 RN's 7a-3:30p (Fri.) ..."

A review of MR1 revealed that the patient was brought into the operating room on Friday, October 5, 2012, at 4:30 PM, after standard hours of operation for surgical services. Further review of MR1 revealed that there was one registered nurse present during the surgical procedure.

An interview on December 5, 2012, at 12:00 PM, with the Director of Patient Care Services, EMP4 revealed that a minimum of two RN's/Tech's should have been present during the surgical procedure listed for MR1. EMP4 indicated that there should be a minimum of three RN's/Tech's during a complex procedure and a minimum of two RN's/Tech's during less complex procedures.

During the interview it was confirmed that the facility did not have a policy to address staffing of the operating room after standard hours of operation, minimum number of staffing required during different type of procedures, or that they followed a nationally recognized professional organization regarding staffing protocols during a procedure.