HospitalInspections.org

Based on review of facility consent forms, and staff interview, the facility failed to disclose information related to physician presence in the facility. The census was 4. The findings were:

Review of the "South Lincoln Medical Center Authorization for Treatment and Payment" form showed it failed to disclose information related to the presence of a physician in the facility 24 hours a day/7 days a week. Interview on 6/8/21 at 9:45 AM with the DON confirmed the facility did not have a physician on-site 24 hours a day/7 days a week. She further stated they did not disclose this information to the patients, and they did not have that information in writing to give to the patients.
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Based on observation and staff interview the facility failed to ensure the inventory of emergency supplies was maintained for 1 of 3 patient rooms (cast room/patient overflow room) in the emergency department. The findings were:

1. Observation on 6/9/21 at 11:20 AM of the cast room/patient overflow room showed the following items were expired:
a. A container full of sterile nasopharangeal calcium alginate tipped applicators with an expiration date of 6/1/20.
b. 10 blue topped vacutainers, to collect blood, with an expiration date of 3/31/21.
c. One tube lubricating jelly with an expiration date of 07/16.
d. A 0.25 liter bottle of ultra sound gel with an expiration date of 08/20.
e. 4 Merocel nasal dressings, with an expiration date of 4/1/17.
f. 1 pack of 4-0 Vicryl suture with an expiration date of 8/31/20.

2. Interview with the acute care and emergency manager on 6/9/21 at 11:25 AM verified these items in the cast room/overflow room were available for patient use.
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Based on review of temperature and humidity logs and staff interview the facility failed to adequately monitor the temperature and humidity levels in the surgical suite (OR 1, OR 2, Sub-sterile room, instrument room, decontamination room, sterile processing room and sterile supply room) during 1 of 2 months reviewed (April 2021). The findings were:

1. Review of the temperature and humidity logs for the surgical suite (OR 1, OR 2, Sub-sterile room, instrument room, decontamination room, sterile processing room and sterile supply room) for April 2021, showed 8 days (4/1, 4/2, 4/5, 4/6, 4/7, 4/8, 4/12, 4/15), where the temperature and humidity were not recorded. Interview on 6/8/21 with the surgical services supervisor revealed they were having problems consistently logging the temperature and humidity in the surgical suite.

2. Review of the Association of Perioperative Registered Nurses 2018 Edition of Perioperative Standards and Recommendations showed the following standards were included in Environment of Care Part 2, Recommendation IV "The health care organization should create and implement a systematic process for monitoring HVAC performance parameters and a mechanism for resolving variances. The HVAC system is intended to reduce the amount of environmental contaminates (eg, microbial-laden skin squames, dust, lint) in the surgical suite. The restricted areas are intended to be the cleanest; therefore the HVAC requirements for the restricted areas are the most stringent.." Review of Recommendation IV.b. showed "Personnel who identify an unintentional variance in the predetermined HVAC system parameters should report the variance..." Further review showed the following parameters: Operating room temperature range 68 degrees Fahrenheit (F) -75 degrees F.
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Based on policies and procedure review, review of medical staff meeting minutes, and staff interview, the facility failed to routinely review patient care policies. The findings were:

1. Review of the patient care policy and procedure manuals showed multiple policies were categorized in each of the following sections: (1) Trauma, (2) Acute Care, (3) Obstetrics, (4) Emergency Services (5) Surgical Services (6) Swing Bed, and (7) Infection Control. Further review of the policy and procedures manuals showed no evidence policies had been reviewed biennially as required. The revision dates on policies ranged from 3/2008 - 9/2020. Review of the medical staff meeting minutes from 1/2021 - 5/2021 showed only one policy had been reviewed, the Vital Sign Policy.

2. Interview on 6/8/21 at 9:30 AM with the surgical services supervisor revealed the policies for her department were outdated and they went through medical staff for approval. Interview on 6/9/21 at 9:45 AM with the DON verified the patient care policies were outdated and had not been revised/reviewed for several years. She also stated there was a process for the policies to go through the medical staff for approval. Interview on 6/10/21 at 11:00 AM with the acting CEO revealed the CEO had resigned and the facility had other priorities to address, and the policy review process had been placed on hold.
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Based on medical record review, staff interview and physician interview the facility failed to ensure clinical records were accurately and completely documented for 3 of 22 records (#17, #18, #19) reviewed. The findings were:

1. Review of the medical record for patient #17 showed an admission date of 4/14/21 with a diagnosis of induction of labor. Review of the surgical consent showed the patient gave consent for a cesarean section, which was signed by the surgeon. The following concerns were identified:
a. Review of the consent for anesthesia services showed two consents. One consent had the patient name giving consent for a spinal or epidural analgesia/anesthesia and a general anesthesia, which was signed by the patient. However, the consent failed to name the anesthesia provider, or address any considerations, and there was no date, time or witness to the patient's signature. The second consent for anesthesia services only showed consent for general anesthesia, but did not name the anesthesia provider, nor address any considerations and there was no time on the signature. Interview with the surgical services supervisor on 6/9/21 at 3:30 PM confirmed there should only be one consent, and should be filled out completely by the anesthesia provider.
b. Review of the anesthesia record dated 4/15/21 showed the procedure was "Labor epidural" and named the surgeon. Further review of the anesthesia record showed the area for "Pre-Anesthesia Evaluation" was filled in with the proposed procedure as "Epidural - Cesarean Section." Additionally, the record showed in the remarks box the patient was intubated. Interview on 6/9/21 at 3:30 PM with the surgical services director revealed there should have been a new anesthesia record for the cesarean section, because it was a new procedure, and the current anesthesia record did not accurately reflect the procedure.
c. Review of the nursing operative record dated 4/15/21 showed the patient had general anesthesia.
d. Review of the post-operative report dated 4/16/21 and electronically signed by the surgeon showed the patient had a primary low transverse section and the anesthesia type was epidural. Interview on 6/10/21 at 10:47 AM with the surgeon stated prior to the incision he called to the CRNA involved in the case who told him the patient was asleep, and he thought she meant the medications she used got her sleepy enough to proceed with the procedure. He confirmed there was a miscommunication and was not aware the patient had general anesthesia.

2. Review of the medical record for patient #18 showed an Advance Directive form with the patient's signature, but no date nor a witness signature and date.

3. Review of the consent for anesthesia services for patient #19 did not have the name of the anesthesia provider administering the anesthesia, nor did it address any considerations.
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Based on observation and staff interview the facility failed to meet the Condition of Participation for Surgical Services related to the availability of emergency equipment (tracheotomy set). The findings were:

Observation of the surgical suite on 6/8/21 at 9:30 AM failed to show a tracheotomy set was available to be used in an emergency to establish an airway. Interview on 6/8/21 at 3:45 PM with the CRNA, revealed if she had trouble with a patient's breathing/airway, she had a cricoidotomy set which would be hooked to a large bore needle with an adaptor to breath and an endotracheal tube. She stated the facility did not have a tracheotomy set. Interview on 6/8/21 at 4:00 PM with the operating room supervisor confirmed the surgical services department did not have a tracheotomy tray.
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Based on medical record review, review of the agreement, and staff interview, the facility failed to ensure a training program was in place for donation issues and how to work with the organ procurement organization (OPO). The findings were:

Review of the OPO agreement showed it was signed on 2/13/21. The agreement showed education was available to hospital staff upon request at least annually. Review of the medical records for deceased patients #6 and #7 showed the 24 hour donation referral line was contacted by a registered nurse and the patients were not candidates for donation so no further action was required. Interview with the DON on 6/9/21 at 10:05 AM verified there was no list of personnel who were classified as a designated requests at the facility. Further, she was unable to locate any inservice education to show hospital staff had been educated on donation issues and working with the OPO.
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Based on medical record review and staff interview, the facility failed to ensure a comprehensive assessment was completed for 2 of 2 sample residents (#12, 22) who remained in the swing-bed unit for 14 days or greater. The findings were:

1. Review of the medical record showed resident #12 was admitted to the swing bed unit on 2/17/21 and was discharged on 3/7/21. Review of the nursing assessments completed at day 14 and later showed the comprehensive areas including communication, vision, dental and nutritional status and discharge planning were not included.

2. Review of the medical record showed resident #22 was admitted to the swing bed unit on 10/26/21 and was discharged on 2/10/21. Review of the nursing assessments completed at day 14 and later showed the comprehensive areas including communication, vision, dental and nutritional status and discharge planning were not included.

3. Interview with the DON on 6/9/21 at 10:05 AM verified the assessments were completed as an initial physical assessment and were then ongoing in a flow sheet format which did not include all of the required areas.