HospitalInspections.org

Based on review of facility policy, medical records (MR) and interview with staff (EMP), it was determined that Holy Spirit Hospital failed to ensure the physical safety of the patient for one of 10 MR (MR1) reviewed.

Findings include:

A review on November 22, 2010, of "Holy Spirit Hospital Clinical Nurse Practice" entitled, "Sharps, Sponge, Instrument Count in the OR" last reviewed April 2010 revealed, " ... C. Sponge Guidelines and Precautions: Only items that are radiopaque or have radiopaque marker should be used in a wound ... "

A review on November 22, 2010, of the Holy Spirit Health System position description for RN First Assistant-OR revealed, "... Duties and Responsibilities: ... 3. Provides patient positioning, retraction, hemostasis, knot tying, closure of layers and assists the surgeon at the completion of the surgical procedure ... 12. Performs assigned responsibilities according to department policies, procedures, standards and regulations and within stated time frames ... "

A review on November 22, 2010, of MR1 revealed that the patient had robotic assisted laparoscopic surgery on November 5, 2010.

An interview conducted on November 22, 2010, at 11:10 AM with EMP1 confirmed that the patient had surgery on November 5, 2010, and that the bulb of a bulb syringe was used to maintain a pneumoperitoneum (insufflation of carbon dioxide in the peritoneum so that internal structures can be visualized). Further interview confirmed that the patient called the physician's office with complaints of pain on November 11, 2010. The bulb was removed from the patient's vagina on November 11, 2010, in the physician's office.
EMP1 confirmed that the bulb should have been removed on November 5, 2010, after the surgery had been completed.