HospitalInspections.org

Based on document review, staff interview and observation it was determined the facility failed to ensure medical staff complied with the facility policy on Tobacco Use. This failure has the potential to violate a patient's right to receive care in a safe setting.

Findings include:

1. Review of the facility policy titled "Tobacco Use", last reviewed 07/11/16, revealed it states, in part: "This policy is applicable to CAMC Health System, Inc. and subsidiaries (each a "Company") to provide tobacco free facilities and grounds for workforce which includes employees, medical staff, volunteers, vendors, patients and visitors...The use of all tobacco (including but not limited to cigarettes, cigars, pipes, chewing tobacco and snuff) or tobacco-like products (including but not limited to E-cigarettes or any electronic smoking device designed to be used in a manner similar to the use of a tobacco product) is prohibited on properties or facilities owned, leased, or maintained by the Company..."

2. Review of the "Medical Staff Credentials Policy", dated 12/17/14, revealed it states in part, under section 2.B.1: "As a condition of consideration for appointment or reappointment, and as a condition of continued appointment, every applicant and appointee specifically agrees to the following: to abide by all Bylaws, policies, and Rules and Regulations of the Hospital and Medical Staff in force during the time the individual is appointed."

3. Review of the facility policy titled, "Employee Handbook", last revised 01/01/16, revealed it states in part, under the section labeled 'Tobacco Use': "The company is committed to providing a safe and healthy environment for employees, patients, and visitors...the use of all tobacco (including but not limited to cigarettes, cigars, pipes, chewing tobacco, and snuff) or tobacco-like products (including but not limited to E-cigarettes or any electronic smoking device designed to be used in a manner similar to the use of a tobacco product) by employees is prohibited on company property or facilities that are owned, leased, or maintained by the company during work time."

4. An interview was conducted on 12/20/16 at 7:54 a.m. with the Peri-Operative Medical Director. He confirmed he had talked to Medical Doctor (MD) #1 regarding the use of tobacco in the Operating Room (OR) Suite area. He also confirmed he had verbally reported this issue to the President of Integrated Healthcare Providers Incorporated.

5. An interview was conducted on 12/20/16 at 1:01 p.m. with MD#1. The Associate Chief Medical Officer was also in attendance. MD#1 produced a can with a tobacco-like product labeled "Smokey Mountain Herbal Snuff Classic Tobacco Free". He and the Associate Chief Medical Officer both confirmed his use of the product. MD#1 confirmed he had been confronted by the Peri-Operative Medical Director regarding using tobacco in the OR Suite area. He denied having the product in his mouth in the restricted area of the OR. He also denied spitting in a cup, a bottle or a trash can.

6. On 12/19/16 at 12:45 p.m., a sign was observed on the second floor outside the OR doors stating, "Tobacco products are prohibited in the Surgery Department".

7. A tour of the OR was conducted on 12/20/16 at 8:22 a.m. with the Director of Surgical Services. During a tour of the Recovery Room, a semi restricted area, a trash can near the nurse's station was observed to have what appeared to be spit and three (3) wads of a tobacco- like substance in it. There were no other contents noted in the trash can. These findings were confirmed by the Director of Surgical Services.

Based on document review, staff interview and observation it was determined the facility failed to ensure all medical staff abide by all bylaws, policies and rules and regulations of the facility and medical staff. This failure has the potential to adversely affect the safety of all patients.

Findings include:

1. Review of the facility policy titled "Tobacco Use", last reviewed 07/11/16, revealed it states, in part: "This policy is applicable to CAMC Health System, Inc. and subsidiaries (each a "Company") to provide tobacco free facilities and grounds for workforce which includes employees, medical staff, volunteers, vendors, patients and visitors...The use of all tobacco (including but not limited to cigarettes, cigars, pipes, chewing tobacco and snuff) or tobacco-like products (including but not limited to E-cigarettes or any electronic smoking device designed to be used in a manner similar to the use of a tobacco product) is prohibited on properties or facilities owned, leased, or maintained by the Company..."

2. Review of the "Medical Staff Credentials Policy", dated 12/17/14, revealed it states in part, under section 2.B.1: "As a condition of consideration for appointment or reappointment, and as a condition of continued appointment, every applicant and appointee specifically agrees to the following: to abide by all Bylaws, policies, and Rules and Regulations of the Hospital and Medical Staff in force during the time the individual is appointed."

3. Review of the facility policy titled, "Employee Handbook", last revised 01/01/16, revealed it states in part, under the section labeled 'Tobacco Use': "The company is committed to providing a safe and healthy environment for employees, patients, and visitors...the use of all tobacco (including but not limited to cigarettes, cigars, pipes, chewing tobacco, and snuff) or tobacco-like products (including but not limited to E-cigarettes or any electronic smoking device designed to be used in a manner similar to the use of a tobacco product) by employees is prohibited on company property or facilities that are owned, leased, or maintained by the company during work time."

4. An interview was conducted on 12/20/16 at 7:54 a.m. with the Peri-Operative Medical Director. He confirmed he had talked to Medical Doctor (MD) #1 regarding the use of tobacco in the Operating Room (OR) Suite area. He also confirmed he had verbally reported this issue to the President of Integrated Healthcare Providers Incorporated.

5. An interview was conducted on 12/20/16 at 1:01 p.m. with MD#1. The Associate Chief Medical Officer was also in attendance. MD#1 produced a can with a tobacco-like product labeled "Smokey Mountain Herbal Snuff Classic Tobacco Free". He and the Associate Chief Medical Officer both confirmed his use of the product. MD#1 confirmed he had been confronted by the Peri-Operative Medical Director regarding using tobacco in the OR Suite area. He denied having the product in his mouth in the restricted area of the OR. He also denied spitting in a cup, a bottle or a trash can.

6. On 12/19/16 at 12:45 p.m., a sign was observed on the second floor outside the OR doors stating, "Tobacco products are prohibited in the Surgery Department".

7. A tour of the OR was conducted on 12/20/16 at 8:22 a.m. with the Director of Surgical Services. During a tour of the Recovery Room, a semi restricted area, a trash can near the nurse's station was observed to have what appeared to be spit and three (3) wads of a tobacco- like substance in it. There were no other contents noted in the trash can. These findings were confirmed by the Director of Surgical Services.