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Based on surveyors observations, review of facility documents and interviews with facility staff, the facility failed to provide surgical services in accordance with acceptable standards of practice.

Findings:

1. There was no documentation staff designated as peri-operative personnel had education, training, and competency in peri-operative care and services. Training and education records were reviewed for the surgical services staff. Recent training included topics unrelated to peri-operative processes, such as the history of handwashing, wound care, and the pro's and con's of using hand lotion. There was no evidence the surgical staff had been trained in surgery-specific topics. There was no documentation of skills competency for staff working in the surgical services department. See tag 0942.

2. Review of Quality Assurance Performance Improvement included specific indicators designated for Surgical Services. The indicators listed included "time out", "no surgical check list" and "follow up call not consistently being done". There was no documentation the QAPI for surgical services included all of the critical areas such as anesthesia and central sterilization practices.

3. Peri-operative medical records were not complete and did not indicate the type of surgical preparation, safety measures, medications, fluids, physiological assessment, and care provided to the patient. There was no documentation of pre-operative nursing assessment, post-anesthesia nursing assessment, location of surgical wounds and dressings applied, and no documentation of a nursing assessment prior to discharge or transfer from the post- operative care area. See tag 0941.

4. Staff identified as central sterilization employees were not aware of current sterilization and disinfection practices. Sterilization logs did not include documentation of all sterilization loads run each day. There was no documentation of the items sterilized in each load.The facility had no mechanism to identify items that had been sterilized incorrectly. There was no documentation the staff reviewed and signed each sterilizer load print-out to verify a complete and correctly performed sterilization cycle.

5. Sterilization and high level disinfection processes and procedures specific to the hospital were not documented in the surgery policy and procedure manual. See tag 0951.

6. There are no policies and procedures written, reviewed, and approved through medical staff and governing body specific to the post anesthesia phase through transfer and discharge. See tag 0957.

Based on surveyors observations, review of facility documents and interviews with facility staff, the facility failed to provide surgical services in an organized manner with qualified personnel in accordance with acceptable standards of practice.

Findings:

1. Two of two operating room personnel did not have current job descriptions, departmental competencies, and evaluation of skills for the jobs each stated they were performing. There is no evidence personnel have the training and competency to perform the specialized skills.

In an interview on 5/8/2012 Staff G told surveyors she was in charge of surgery and oversaw preoperative and postoperative care areas as well as central sterile. The job description provided to surveyors did not have documentation it was reviewed and signed by Staff G. The job description referred to another hospital. There was no documentation in Staff G personnel file indicating Staff G was the operating room supervisor in charge of the preoperative and postoperative areas as well as central sterile. There was no documentation Staff G had current training in perioperative standards, central sterilization protocols, and pre/postoperative management of patients.

Staff F a surgical technician did have documentation of training as a scrub technician through a technology program. There was no documentation in Staff F's personnel file Staff F had current education, competency in standards of perioperative practice, infection control, sterilization practices and had been reviewed and evaluated and competent to perform the duties.

There was no documentation staff designated as peri-operative personnel had education, training, and competency in peri-operative care and services. Training and education records were reviewed for the surgical services staff. Recent training included topics unrelated to peri-operative processes, such as the history of handwashing, wound care, and the pro's and con's of using hand lotion. There was no evidence the surgical staff had been trained in surgery-specific topics. There was no documentation of skills competency for staff working in the surgical services department

2. On 5/8/12 surveyors requested operating room policies. Surveyors were provided a manual of policies that did not have a table of contents. The policy provided did not include all required elements. Some of the policies were not appropriate for the facility and the services it provided. There was no policy and procedure indicating current sterilization practices. There were no policies regarding anesthesia and all required elements.

3 On 5/8/12 surveyors reviewed three surgical/procedure charts.

Patient #1's medical record indicated the intravenous fluids (IVF) Dextrose 5% Lactated Ringers 1000 ml were infused by the certified registered nurse anesthetist (CRNA) in the operating room There was no documentation throughout the perioperative phase more IVF's were infused or discontinued after the 1000 ml were completed in the operating room. There was no documentation of the amount of fluids infused in the recovery room. The only documentation provided on the patient during the immediate postoperative recovery phase was ""patient low (arrow pointing down) B/P (blood pressure)-new orders received". There were no orders on the chart. There was no other documentation on the patient status during the postoperative phase. There was no documentation of the patient's condition at the time of transfer. There was no documentation where the patient transferred.

Patient #2's medical record indicated the patient underwent a surgical procedure for abscess removal. There were no signed orders for the medications and intravenous fluids ordered during the perioperative period. There was no date, time, or route of administration of medications given during the procedure. There was no prep, drape, safety strap documented for the intraoperative phase.

Patient#3's medical record did not have documentation of surgical prep, safety strap, or dressings applied during the intraoperative phase. There was no assessment prior to transfer/discharge of the patient from the post anesthesia care unit.


4. On 5/8/2012 surveyors reviewed sterilization logs and tapes with Staff F and G Staff . Staff was not aware of elements to review on the sterilizer tapes to insure the sterilizer had successfully completed a full cycle. There was no documentation indicating the sterilizer logs were reviewed by infection control. There was no indication all sterilization and high level disinfection processes were evaluated by infection control or the surgical services personnel. There were no policies and procedures specific to the hospital sterilization equipment reviewed, approved, and implemented through the medical staff and governing body.

At the time of the revisit 5/8/12 this deficiency had not been corrected.

Based on interviews with staff, review of personnel files and policy and procedures the facility failed to insure the surgical services were supervised by a qualified registered nurse with ongoing education, competency and training in surgical services. On 5/8/2012 surveyors reviewed Staff G, Operating Room Supervisor's personnel records. Documentation in the file did not indicate any training in the operating room other than on the job. There was no documentation indicating Staff G had current education and training as the Operating Room Supervisor. On 5/8/2012 Staff G told surveyors she had been given access to outside resources such as Association of Perioperative Nursing (AORN) there was no current training appropriate for the management and supervision of the operating room and the operating room staff. In an interview on 5/8/2012 Staff G told surveyors she was not aware the sterilization logs were not being documented according to policy. Staff G was not aware of appropriate documentation standards. Staff G could not identify problems with the sterilization log documentation. Staff G told surveyors education provided after the first survey included topics unrelated to peri-operative processes, such as the history of handwashing, wound care, and the pro's and con's of using hand lotion. Review of the handwashing inservice provided did not cover surgical hand hygiene. Review of quality indicators for surgical services were "time out performance", "surgical check list", and follow up call not being done consistently." There was no documentation provided to surveyors the operating room supervisor had the education and training to identify pertinent critical problems found in the initial survey. There was no documentation Staff G had current specific training to oversee the perioperative areas.

Based on review of policy and procedures the facility failed to provide policy and procedures specific to the perioperative care provided at the facility.

Findings:

1. On 5/8/12 surveyors requested operating room policies. Surveyors were provided a policy manual that did not include a table of contents. The manual did not have policies covering all of the required elements. There were no policies regarding current surgical hand hygiene, use of alcohol based sanitizers, post-anesthesia protocols, discharge criteria, monitioring and documentation througout the perioperative process. Many of the policies were not specific to the facility, types of patients provided surgical care, procedures performed, equipment in the department, layout of the department and the coordination of care throughout the hospital.

2. There are no policies and procedures written, reviewed, approved and implemented governing the care provided during the recovery room phase.

3. There are no policies and procedures written, reviewed, approved, and implemented governing the central sterile processing equipment and processes.

4. The above findings were provided to the administration at the exit conference on 5/8/2012. No further documentation was provided.

Based on review of medical records, hospital documents, and personnel interviews the facility failed to provide immediate postoperative care according to acceptable standards of practice.

Findings:

1. There are no policies and procedures written, reviewed, approved, and implemented governing the care provided during the use of anesthesia and recovery room phase.

2. 3 of 3 surgical/procedure medical records reviewed did not have documentation of the patient's status immediately post operative, during the recovery phase, and at discharge.

3. 3 of 3 surgical/procedure medical records reviewed did not have post anesthesia care orders. There were no orders specific to the immediate postoperative care episode. Documentation indicated patients received oxygen, medications, and frequent monitoring of vital signs. The orders did not reflect the type of care provided to the post surgical patients.

4. 3 of 3 surgical procedure medical records did not include the patient status at the time of discharge. There was no documentation the anesthesia provider or the physician assessed and cleared the patient for discharge. There was no discharge criteria developed, reviewed, approved, and implemented to provide for a safe discharge.

5. Several of the surgical/procedure patients did not have documentation a registered nurse assessed or cared for the patient during the immediate postoperative phase.

6. These findings were reviewed with the administration on 5/8/2012. No further documentation was provided.