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Based on interview, review of the hospital's infection control committee composition, and hospital medical staff minutes, the hospital failed to designate in writing the individual responsible for infection control for the hospital.


The findings are:


On 05/15/15 at 11:40 a.m., review of the hospital's Infection Control Committee composition revealed, "the Infection Control Committee shall consist of at least: 1) Active Medical Staff members representing appropriate clinical services, one of whom shall be designated chair (Infection Control Officer)....", but did not identify the individual responsible as the infection control officer. On 05/15/15 at 12:00 p.m., the Centers for Best Practice Director revealed the hospital identifies the infection control officer as the chairman of the infection control committee.

Based on observations, interview, and review of hospital policy and procedures, 1 of 1 Certified Registered Nurse Anesthetist (CRNA 1) failed to ensure the anesthesia cart used during a surgical case was cleaned after the case, 1 of 4 Registered Nurses (RN 1) failed to disinfect a medication port and/or septum, 1 of 4 Registered Nurses (RN 4) failed to disinfect a medication septum, 2 of 4 Registered Nurses (RN 1 and 3) failed to perform hand hygiene, and 1 of 1 Medical Doctors (MD 1) failed to perform hand hygiene.

The findings are:

On 05/14/15 from 4:30 p.m.- 4:50 p.m., observations in the operating room surgical area revealed staff cleaned operating room suite 5 after a surgical procedure, CRNA was observed to enter operating room 5, retrieve the anesthesia cart and machine without cleaning or disinfecting the cart or the anesthesia machine before exiting the surgical suite with the used supplies from the previous surgical case on the cart. On 05/14/15 at 4:50 p.m., the Director of Anesthesia/Perioperative Services revealed, "CRNA is responsible for cleaning the anesthesia cart after an operating room case that is completed after 2:30 p.m..

Hospital policy, titled, "Operating Room Cleaning", reads, " The Operating Room will be maintained at the highest possible level of environmental sanitation and all staff will carry out their responsibilities in a manner to meet or exceed established standards. O.R. (operating room) staff does between case and "after last case" cleaning. Cleaning includes soiled linen and trash removal, sharps change out, wipe down of lights, table and other pieces of equipment, mopping floors and removing gross contamination from surfaces (OR (operating room) tables, stands, floors, etc)....".

On 05/15/15 at 12:36 p.m., observations revealed Registered Nurse RN 3 failed to perform hand hygiene upon entering Patient 12's room for pre-surgical interview.

On 05/15/15 at 12:41 p.m., observations revealed Medical Doctor MD 1 failed to perform hand hygiene upon entering Patient 12's room for pre-anesthesia interview.




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On 05/15/15 at 12:05 p.m., observations of Registered Nurse 1 revealed the nurse exited the pre-op room wearing gloves. On 05/15/15 at 12:09 p.m., observations revealed Registered Nurse 1 removed gloves, charted on orange pad, placed a pen in his/her pocket, opened a cabinet door to remove fluids, and exited the pre-op room without performing hand hygiene after glove removal. On 05/15/15 at 12:18 p.m., observations of Registered Nurse 1 revealed the nurse opened a new vial of Xylocaine, inserted a clean/new needle with a syringe, withdrew medication from the bottle, but failed to clean the medication septum prior to withdrawing medication.

On 05/15/15 at 12:23 p.m., observations revealed Registered Nurse 1 established intravenous (IV) access, removed gloves, donned clean gloves, mixed the IV antibiotics, attached the IV antibiotics to injection port without cleaning the injection port, charted and placed stickers on the forms in the patient's chart, exited the room, walked over to the cart outside the pre-op room, opened the cart drawer, but failed to perform hand hygiene after removal of his/her gloves and prior to exiting the pre-op room. On 05/15/15 at 12:28 p.m., Registered Nurse 1 reported the hospital policy is to wash hands after removing gloves, and stated, "No I'm not suppose to walk out of the patient's room with gloves on".

On 05/15/15 at 4:00 p.m., observations of Registered Nurse 4 revealed the nurse walked into the room, spiked the vial of medication, and hung the medication for administration but failed to clean the medication septum prior to spiking the medication vial. On 05/15/15 at 4:03 p.m., Registered Nurse 4 revealed, "It has a sterile top, but yes, it should have been cleaned".

Hospital policy, titled, "Infection Control", reads, "....wash hands before donning gloves and immediately after gloves are removed....2....Remove gloves promptly after use....and wash hands immediately to avoid transfer of microorganisms to other patients or environments....".

Hospital policy, titled, "Single Dose Multi-Dose Vials", reads, "...2b. Cleanse the access diaphragm of multidose vials with 70% alcohol before inserting a device into the vial.

Based on observation, interview and review of manufacturer's guidelines, 1 of 1 surgical scrub technicians observed failed to allow proper drying time for the application of ChloraPrep One-Step post application.


The findings are:


On 05/15/15 at 2:05 p.m., review of manufacturer's guidelines revealed "ChloraPrep One-Step,....dry surgical sites (e.g. abdomen or arm) use gentle repeated back and forth strokes for 30 seconds, moist surgical sites (e.g., inguinal fold) use gentle repeated back and forth strokes for 2 minutes, do not allow solution to pool; tuck prep towels to absorb solution and then remove, allow the solution to completely dry (minimum of 3 minutes on hairless skin; up to 1 hour in hair). Do not blot or wipe away....".

On 05/15/15 at 1:41 p.m., observations of Patient 10 in the operating room revealed Registered Nurse 1 applied the ChloraPrep one-step by Registered Nurse 1 and then Surgical Technician 1 immediately applied sterile drapes to the patient's operative site without allowing the ChloraPrep one-step to dry. On 05/15/15 at 2:10 p.m., the Director of Anesthesia/Perioperative Services verified the ChloraPrep prep is to dry for 3 minutes.

Based on record review and interview, the hospital failed to ensure an informed consent for anesthesia type was in the patient's chart for 12 of 12 patient charts reviewed. (Patient 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12)


The findings are:


On 05/15/15 at 4:20 p.m., review of Patient 7's chart revealed the patient was admitted to the hospital on 05/04/15 for a total vaginal hysterectomy. Review of the patient's consent form dated 04/28/15 at 4:15 p.m. revealed there was no documentation as to the type of anesthesia the patient would receive for the procedure.

On 05/15/15 at 5:07 p.m., review of Patient 8's chart revealed the patient was admitted to the hospital on 05/08/15 for excision of a ganglion cyst left middle finger. Review of the patient's consent form dated 05/11/15 at 11:47 a.m. revealed there was no documentation as to the type of anesthesia the patient would receive for the procedure.

On 05/15/15 at 5:30 p.m., review of Patient 9's chart revealed the patient was admitted to the hospital on 05/04/15 for a cysto transurethral resection of bladder tumor with mitomycin installation post resection. Review of the patient's consent dated 05/04/15 at 8:45 a.m. revealed there was no documentation as to the type of anesthesia the patient would receive for the procedure.

On 05/15/15 at 5:45 p.m., review of Patient 10's chart revealed the patient was admitted to the hospital on 05/11/15 for a left ectopic pregnancy. Review of the patient's consent form dated 05/11/15 at 3:51 p.m. revealed there was no documentation as to the type of anesthesia the patient would receive for the procedure.

On 05/15/15 at 6:15 p.m., review of Patient 11's chart revealed the patient was admitted to the hospital on 05/14/15 for a flexor tendon laceration right small finger. Review of the patient's consent form dated 05/14/15 at 10:57 a.m. revealed there was no documentation as to the type of anesthesia the patient would receive for the procedure.

On 05/15/15 at 6:30 p.m., review of Patient 12's chart revealed the patient was admitted to the hospital on 05/15/15 for a diagnostic laparoscopy with laparoscopic cholecystectomy and lysis of adhesions. Review of the patient's consent form dated 05/14/15 at 5:10 p.m. revealed there was no documentation as to the type of anesthesia the patient would receive for the procedure.












31395

On 05/15/15 at 4:24 p.m., review of Patient 1's chart revealed a consent signed for "hardware removal with total knee revision, right" dated 04/22/15 with no documentation of the type of anesthesia used in the procedure.

On 05/15/15 at 4:58 p.m., review of Patient 2's chart revealed a consent signed for "right total knee arthroplasty" dated 05/05/15 with no discussion of the type of anesthesia used in the procedure.

On 05/15/15 at 5:20 p.m., review of Patient 3's chart revealed a consent signed for "opened right inguinal hernia repair with possible bowel resection" dated 05/13/15 with no discussion of the type of anesthesia used in the procedure.

On 05/15/15 at 5:45 p.m., review of Patient 4's chart revealed a consent signed for "arteriovenous fistula placement left upper extremity, cephalic" dated 05/11/15 with no discussion of the type of anesthesia used in the procedure.

On 05/15/15 at 6:00 p.m., review of Patient 5's chart revealed a consent signed for "left mastectomy, immediate reconstruction to left breast" dated 05/14/15 with no discussion of the type of anesthesia used in the procedure.

On 05/15/15 at 6:20 p.m., review of Patient 6's chart revealed a consent signed for "exploration of right forearm with removal of foreign body" dated 05/15/15 with no discussion of the type of anesthesia used in the procedure.

On 05/15/15 at 5:20 p.m., Quality Review Specialist revealed the anesthesia consent and surgical consent is one in the same.

Based on review of the Operating Room (OR) register and interview, the hospital failed to ensure that all specified data was included on the operating room register to include but was not limited to: total time of the procedure, names of scrub personnel and circulating nurse, type of anesthesia, and failed to ensure that responsible staff was knowledgeable in retrieving the required data for the operating room register.


The findings are:


On 05/14/15 at 4:30 p.m.. review of the hospital's operating room register revealed the operating room register did not include all of the required data.
On 05/14/15 at 4:45 p.m., Manager 1 revealed, "We have a lot of information in different parts of the records in the computer. I pull all sorts of information to look at on a monthly basis for my quality information.

On 05/14/15 at 5:45 p.m., the hospital produced a second operating room register that had no data related to inclusive or total time of the operation, name of nursing personnel (scrub and circulating), type of anesthesia used, and name of person administering it, pre and post-op diagnosis, and the age of the patient. On 05/14/15 at 5:50 p.m., Director 1 revealed, "we have all those things in the computer. It's just a matter of pulling it from different parts of the record and putting what you want on a sheet".

On 05/15/15 at 9:50 a.m., the Chief Nursing Officer submitted an operating room log/register that was printed on 05/14/12 after the surveyors exited. The Chief Nursing Officer reported, "The staff didn't know how to print what you needed. Unfortunately, only certain people can print or have access to certain information. By the time I knew there was an issue and was notified, it was 8:00 p.m. before we had the document".

Based on observations, interview, and review of hospital policy and procedures, 1 of 1 Certified Registered Nurse Anesthetist (CRNA 1) failed to ensure the anesthesia cart used during a surgical case was cleaned after the case, 1 of 4 Registered Nurses (RN 1) failed to disinfect a medication port and/or septum, 1 of 4 Registered Nurses (RN 4) failed to disinfect a medication septum, 2 of 4 Registered Nurses (RN 1 and 3) failed to perform hand hygiene, and 1 of 1 Medical Doctors (MD 1) failed to perform hand hygiene.

The findings are:

On 05/14/15 from 4:30 p.m.- 4:50 p.m., observations in the operating room surgical area revealed staff cleaned operating room suite 5 after a surgical procedure, CRNA was observed to enter operating room 5, retrieve the anesthesia cart and machine without cleaning or disinfecting the cart or the anesthesia machine before exiting the surgical suite with the used supplies from the previous surgical case on the cart. On 05/14/15 at 4:50 p.m., the Director of Anesthesia/Perioperative Services revealed, "CRNA is responsible for cleaning the anesthesia cart after an operating room case that is completed after 2:30 p.m..

Hospital policy, titled, "Operating Room Cleaning", reads, " The Operating Room will be maintained at the highest possible level of environmental sanitation and all staff will carry out their responsibilities in a manner to meet or exceed established standards. O.R. (operating room) staff does between case and "after last case" cleaning. Cleaning includes soiled linen and trash removal, sharps change out, wipe down of lights, table and other pieces of equipment, mopping floors and removing gross contamination from surfaces (OR (operating room) tables, stands, floors, etc)....".

On 05/15/15 at 12:36 p.m., observations revealed Registered Nurse RN 3 failed to perform hand hygiene upon entering Patient 12's room for pre-surgical interview.

On 05/15/15 at 12:41 p.m., observations revealed Medical Doctor MD 1 failed to perform hand hygiene upon entering Patient 12's room for pre-anesthesia interview.




31395

On 05/15/15 at 12:05 p.m., observations of Registered Nurse 1 revealed the nurse exited the pre-op room wearing gloves. On 05/15/15 at 12:09 p.m., observations revealed Registered Nurse 1 removed gloves, charted on orange pad, placed a pen in his/her pocket, opened a cabinet door to remove fluids, and exited the pre-op room without performing hand hygiene after glove removal. On 05/15/15 at 12:18 p.m., observations of Registered Nurse 1 revealed the nurse opened a new vial of Xylocaine, inserted a clean/new needle with a syringe, withdrew medication from the bottle, but failed to clean the medication septum prior to withdrawing medication.

On 05/15/15 at 12:23 p.m., observations revealed Registered Nurse 1 established intravenous (IV) access, removed gloves, donned clean gloves, mixed the IV antibiotics, attached the IV antibiotics to injection port without cleaning the injection port, charted and placed stickers on the forms in the patient's chart, exited the room, walked over to the cart outside the pre-op room, opened the cart drawer, but failed to perform hand hygiene after removal of his/her gloves and prior to exiting the pre-op room. On 05/15/15 at 12:28 p.m., Registered Nurse 1 reported the hospital policy is to wash hands after removing gloves, and stated, "No I'm not suppose to walk out of the patient's room with gloves on".

On 05/15/15 at 4:00 p.m., observations of Registered Nurse 4 revealed the nurse walked into the room, spiked the vial of medication, and hung the medication for administration but failed to clean the medication septum prior to spiking the medication vial. On 05/15/15 at 4:03 p.m., Registered Nurse 4 revealed, "It has a sterile top, but yes, it should have been cleaned".

Hospital policy, titled, "Infection Control", reads, "....wash hands before donning gloves and immediately after gloves are removed....2....Remove gloves promptly after use....and wash hands immediately to avoid transfer of microorganisms to other patients or environments....".

Hospital policy, titled, "Single Dose Multi-Dose Vials", reads, "...2b. Cleanse the access diaphragm of multidose vials with 70% alcohol before inserting a device into the vial.

Based on record review and interview, the hospital failed to ensure an informed consent for anesthesia type was in the patient's chart for 12 of 12 patient charts reviewed. (Patient 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12)


The findings are:


On 05/15/15 at 4:20 p.m., review of Patient 7's chart revealed the patient was admitted to the hospital on 05/04/15 for a total vaginal hysterectomy. Review of the patient's consent form dated 04/28/15 at 4:15 p.m. revealed there was no documentation as to the type of anesthesia the patient would receive for the procedure.

On 05/15/15 at 5:07 p.m., review of Patient 8's chart revealed the patient was admitted to the hospital on 05/08/15 for excision of a ganglion cyst left middle finger. Review of the patient's consent form dated 05/11/15 at 11:47 a.m. revealed there was no documentation as to the type of anesthesia the patient would receive for the procedure.

On 05/15/15 at 5:30 p.m., review of Patient 9's chart revealed the patient was admitted to the hospital on 05/04/15 for a cysto transurethral resection of bladder tumor with mitomycin installation post resection. Review of the patient's consent dated 05/04/15 at 8:45 a.m. revealed there was no documentation as to the type of anesthesia the patient would receive for the procedure.

On 05/15/15 at 5:45 p.m., review of Patient 10's chart revealed the patient was admitted to the hospital on 05/11/15 for a left ectopic pregnancy. Review of the patient's consent form dated 05/11/15 at 3:51 p.m. revealed there was no documentation as to the type of anesthesia the patient would receive for the procedure.

On 05/15/15 at 6:15 p.m., review of Patient 11's chart revealed the patient was admitted to the hospital on 05/14/15 for a flexor tendon laceration right small finger. Review of the patient's consent form dated 05/14/15 at 10:57 a.m. revealed there was no documentation as to the type of anesthesia the patient would receive for the procedure.

On 05/15/15 at 6:30 p.m., review of Patient 12's chart revealed the patient was admitted to the hospital on 05/15/15 for a diagnostic laparoscopy with laparoscopic cholecystectomy and lysis of adhesions. Review of the patient's consent form dated 05/14/15 at 5:10 p.m. revealed there was no documentation as to the type of anesthesia the patient would receive for the procedure.












31395

On 05/15/15 at 4:24 p.m., review of Patient 1's chart revealed a consent signed for "hardware removal with total knee revision, right" dated 04/22/15 with no documentation of the type of anesthesia used in the procedure.

On 05/15/15 at 4:58 p.m., review of Patient 2's chart revealed a consent signed for "right total knee arthroplasty" dated 05/05/15 with no discussion of the type of anesthesia used in the procedure.

On 05/15/15 at 5:20 p.m., review of Patient 3's chart revealed a consent signed for "opened right inguinal hernia repair with possible bowel resection" dated 05/13/15 with no discussion of the type of anesthesia used in the procedure.

On 05/15/15 at 5:45 p.m., review of Patient 4's chart revealed a consent signed for "arteriovenous fistula placement left upper extremity, cephalic" dated 05/11/15 with no discussion of the type of anesthesia used in the procedure.

On 05/15/15 at 6:00 p.m., review of Patient 5's chart revealed a consent signed for "left mastectomy, immediate reconstruction to left breast" dated 05/14/15 with no discussion of the type of anesthesia used in the procedure.

On 05/15/15 at 6:20 p.m., review of Patient 6's chart revealed a consent signed for "exploration of right forearm with removal of foreign body" dated 05/15/15 with no discussion of the type of anesthesia used in the procedure.

On 05/15/15 at 5:20 p.m., Quality Review Specialist revealed the anesthesia consent and surgical consent is one in the same.