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Based on record review the facility failed for 1 of 5, (Patient #1), to ensure that the medical staff document attempted but failed spinal injections performed.

Findings:

Review of the facility ' s interview with Anesthesiologist #1 revealed that Anesthesiologist #1 attempted three times to perform the spinal injection, (the first two attempts failed). Review of the medical record did not reveal any documentation of the two failed attempts.

Based on medical record review the facility failed for 1 of 5, (patient #1), to ensure that properly executed informed consents were completed.

Findings:

1. Review of the medical record revealed Consent for Anesthesia completed for patient #1. The form was signed by the patient and witnessed by the nurse. The form did not include a space for Anesthesiologist #1 to sign. The consent form did not state what kind of anesthesia was going to be performed or that the patient had the risks and benefits explained to her by Anesthesiologist #1. The form did not document the alternatives forms of anesthesia were possible. Review of the medical record did not reveal any other forms of documentation that Anesthesiologist #1 discussed the consent form with the patient #1.

2. Review of the medical fro patient #1 revealed a Consent for Surgical/Invasive Procedure dated 03/16/2013. The consent form described the procedure as "Vaginal delivery-including any repairs of episiotumy or lacerations, or use of a vacuum or forceps to aid with pushing". Review of the consent form revealed the section for the physician's signature indicating that he explained risks and benefits and alternatives were explained to the patient.

Based on observation, staff interview and policy review the facility failed to ensure that infection controls policy and procedures are implemented.

Findings:

1. A Tour of the facility was conducted after the entrance conference. Observation during the tour at 10:58 AM revealed that room 162 was posted for airborne precautions. Observed to the right side of the door revealed a hand sanitizer mounted on the wall. Two HEPA style masks were observed hanging on the hand sanitizer. Additionally, the door separating room 162 and the hall revealed that the door was approximately 5 to 8 inches open.

Interview at 10:58 AM on 08/05/2013 with the administrative representative accompanying this surveyor on the tour revealed that patient occupying the room was in respiratory isolation and that the room was a negative pressure room. The administrative representative stated that for the room to function as a negative pressure room, the door must be completely be closed. The administrative representative stated that it was a breach in infection control practice to hang the masks on the hand sanitizers mounted outside of the patient room.

3. Observation during the tour at 11:05 AM revealed a physician standing in the nursing station working on a computer. A face mask was observed pulled down hanging around the physician ' s neck.

Review of the facility ' s policy and procedure titled SURGICAL ATTIRE IN THE SURGICAL SERVICES revealed on page 2 of 3 section OR ATTIRE WITHIN THE OR SUITE part D. #3 " Masks are either on or off, they must never hang around the neck. "

Based on observation, staff interviews, and medical record review, the facility failed to enforce infection control policy and procedures for 1 of 1 physician that was known to not for meet infection control standards.

Findings:

Based on observations, staff interviews, facility record reviews and medical record reviews revealed that the facility failed to ensure that the medical staff and nursing staff net Infection Control Standards.

Findings:

1. Review of the medical record for patient #1 revealed that she presented to the hospital on 06/16/2013 in active labor. The medical revealed that Anesthesiologist #1 performed a spinal epidural for pain control. The delivery progress quickly and resulted in an uncomplicated delivery of a baby boy.
Review of the medical record revealed a nursing note entered at 2235 that stated " PT REQUESTING PAIN MEDS DUE A HEADACHE. MOTRIN 800 MG GIVEN PO WELL TOLERATED. At 2335 " PT SAID THE PAIN IS LESS NOW, BUT STILL THERE " . Nursing note at 0017 revealed PT CRYING. PT SAID I HAVING A TERRIBLE HEAD ACHE B/P 120/57 PULSE 113 " OXYCODONE 5 MG GIVEN. WELL TOLERATED. PT INSTRUCTED TO DRINK LIQUIDS. GATORADE GIVEN: Nursing note at 0100 " PT C/O HEADACHE. CRYING, DR NOTIFIED. NEW ORDERS NOTED. " Nursing note at 0125 revealed, " DILAUDID 1 MG GIVEN I.V. WELL TOLERATED. PHENERGAN 12/5 MG GIVEN I.V. WELL TOLERATED. " . Nursing noted at 0130 revealed " L/R BOLUS 1 LETER GIVEN WILL TOLERATED. " . Nursing note at 0214 revealed " PT SLEEPING. NO SIGNS OF DISTRESS NOTED NOS/S OF PAIN OR HEADACHE NOTED AT THIS TIME. WILL CONTINUE TO MONITOR. " . Nursing note at 0330 revealed " WENT TO PT ' S ROOM. PT SNORING LOUD. Nursing note at 0400 revealed " VS TAKEN B/P 125/62, PULSE 92, and TEMP 98.0 RESP 18. " Nursing note at 0500 revealed " I WENT INTO PT ' S ROOM TO CHECK HER. PT RESTING IN BED. DRY SALIVA NOTED ON PT ' S MOUTH. PT UNRESPONSIVE AT THIS TOME. CHARGE NURSE CHARLOTTE NOTIFIED. RAPID RESPONSE PAGED. CODE PAGED. CPR INITIATED. SEE CARDIO PULMONARY RECORD IN PT ' S CHART. NURSING NOT AT 0535 REVEALED " PT INTUBATED. " . Nursing note at 0640 revealed " PT TRANSFERRED TO ICU ROOM 6. REPORT GIVEN TO NURSE SHIRLEY " . The patient was evaluated by the medical staff, including a CT of the head the revealed diffused cerebral edema with transtentorial herniation and effacing foramen magnum. The patient was transferred to Shands at UF for further management. While at Shands at UF the patient expired.

Interview on 08/05/2013 at 10:00 AM with the OB nurse that was present when Anesthesiologist #1 performed the spinal injection revealed that Anesthesiologist #1 did not wear masks when performing spinal injections.

Interview with Medical Director of Anesthesia Services on 08/05/2013 at 1:30 PM revealed that Anesthesia Services are a contacted service. He stated that Anesthesiologist #1 " Dr. #1 never wore a mask or gown when performing a spinal injection in OB " When asked if her wore a gown he stated that he wore his own scrubs that he wore in from home. He stated that he always wore gloves. The medical director stated that Anesthesiologist #1 routinely preformed spinal injection instead of the more common procedure of epidural injections.

Review of the facility ' s investigation revealed that when interviewed about the incident Anesthesiologist #1 stated that he " He never has worn a mask or gown for the insertion on an epidural or spinal in OB for pain management. He always wears gloves, and his personal OR scrubs. "

Review of the facility ' s policy and procedure titled SURGICAL ATTIRE IN THE SURGICAL SERVICES revealed at the bottom of the header " Applies to: SURGICAL SERVICES/OBSTETRICAL SERVICES " . Review of page 1 of 3 under PURPOSE revealed " To provide guidelines for attire worn within the semirestricted and restricted areas of the surgical environment. The human body is a major source of microbial contamination in this environment. Surgical attire which includes scrub clothes, hair covering, masks, protective eyewear, and other protective barriers, is worn to provide a barrier to contamination that may pass from personnel to patient as well as form patient to personnel. "

Review of PROCEDURE #1 revealed " At no time shall street clothes be worn with in the restricted areas of Surgical/Obstetrical Suites. "
Review of the facility ' s policy and procedure titled SURGICAL ATTIRE IN THE SURGICAL SERVICES revealed on page 2 of 3 section: OR ATTIRE WITHIN THE OR SUITE part D. #1 " Disposable, high filtration effiency mask must be worn at all times in the OR suite. "

Review of Centers for Disease Control and Prevention/Safe Injection Practices Coalition ' s Injection safety guidelines revealed " Wear a surgical mask when placing a catheter or injecting material into the spinal canal or subdural space " .

The Medical Examiner report for patient #1 revealed the Probable cause of death was " Acute necrotizing meningitis with cerebritis and infective vasculitis " .

Review of the CDC Pathology Report for patient #1, dated 06/18/2013, revealed under Diagnosis " Brain autopsy: Suppurative meningitis with rare Gram-positive cocci in chains, molecular evidence of viridans group Streptococcus infection. Under Comments the report revealed " Findings are Suppurative meningitis with Gram-positive cocci in chains and molecular evidence of viridans group Streptococcus species infection. The viridans group streptococci are frequently negative by Streptococcus species immunohistochemistry. The patient was reported to have received an epidural injection. Although viridans group meningitis may have multiple etiologies including the translocation of oral flora, viridans group meningitis has been previously reported in association with intrapartum epidural injections. Correlation with clinical history and other laboratory assays is recommended. " .