HospitalInspections.org

Based on observation, interview and record review the facility failed to provide nursing services in an organized manner when,

a.) the nursing staff did not perform the facility required Standing order for EKG (electrocardiogram) for a patient over 50 years of age and did not inform the physician the patient was complaining of chest pain prior to the procedure. The patient went into cardiac arrest during the procedure, resuscitation efforts failed and the patient died. (Patient #11)

b.) Patient #11's consent form had an abbreviated surgical procedure.

Findings include:

Review of the facility provided Anesthesia-Pre- Operative Standing Orders (undated) reflected,
"1. EKG for patients >50 years of age, or any patient with history of known coronary artery disease, CHF, arrhythmia, pacemaker, defibrillator, if copy unavailable or older than 90 days...."

Review of Patient 11's medical records reflected a 60-year-old male admitted on 12/16/18 for a planned Colonoscopy and EGD (Esophagogastroduodenoscopy).

Review of the nurse's notes dated 12/16/16 reflected,
6:00 a.m., "...Pt[sic] complaints of pain, diaphoretic, Pt offered to go to ER refused,... 'I've been to the ER that's why I'm here...'
6:35 a.m., "...pt [sic] appeared diaphoretic and complaining of pain in his chest...."

The notes did not reflect the nurses contacting the physician to inform him of the patient's condition and did not reflect an EKG (electrocardiogram) had been performed on 12/16/16 as part of the admission standing orders and following the complaint of chest pain.

During an interview on the afternoon of 6/20/18, in the administrative office, Staff #11, Director of Surgery when asked why the nurses didn't inform the physician of the chest pain and why they didn't do an EKG stated, " ...The nurses thought, well, the doctor is going to see him before surgery so they didn't tell him .... They didn't know they had standing orders for the EKG."

b.) Review of the facility provided policy Consents, Permits, & Releases (dated 3/5/18) reflected, "...Surgical, special diagnostic or therapeutic procedures must be legibly written or typed on the consent for. Note: No abbreviations are acceptable on consent forms...."

Review of Patient #11's Pre-operative orders reflected an order to obtain consent for Colon/EGD. The consent form reflected the consent was written for Esophagogastrodenoscopy [sic] the correct spelling is Esophagogastroduodenoscopy.

During an interview on the afternoon of 6/20/18, in the administrative office, Staff #10, Chief Nursing Officer confirmed the finding.

Based on observation, interview and record review the facility's Surgical Services failed to follow their policies that are designed to assure the achievement and maintenance of high standards of medical practice and patient care when a non-staff member was observed chewing gum in the procedure room and not washing their hands before donning sterile gloves and the rubber diaphragm on medications were not being sanitized before accessing with a needle risking contamination of the surgical site.


Findings include:

On the morning of 6/21/18, during a tour of the facility's procedure room, Staff #13 was noted chewing gum with his mouth open while putting on sterile gloves used to clean the surgical site for a spinal injection. Staff #13 continued to chew the gum throughout the procedure and during the cleaning and set-up for the next procedure. Staff #13 was observed wiping down the patient table and instruments, picking-up trash from the floor, then changing into fresh sterile gloves without first washing or disinfecting his hands.

On observation on the morning of 6/21/18 revealed Staff#14, Scrub tech removing the dust tops from Xylocaine, Methylprednisolone and normal saline bottles, he then presented the medications to the surgeon to access the bottles. The rubber diaphragm tops had not been sanitized. Staff #14 repeated the actions with the next patient's medications.

During an interview on the morning of 6/21/18, in the surgical suite, Staff #11, Director of Surgery when informed of the findings corrected the staff's actions.

Review of the APIC (The Association for Professionals in Infection Control and Epidemiology) Position Paper: Safe Injection, Infusion and Medication Vial Practices in Healthcare (July 30, 2009) reflected,
" ...Vials ... Cleanse the access diaphragm of vials using friction and 70% alcohol or other antiseptic. Allow to dry before inserting a device into the vial ...."

Review of the facility provided policy Standard Precautions (dated 3/2/18) reflected, " ...Food and drink will not be taken into the semirestricted [sic] or restricted areas of the perioperative suite ...After use perioperative personnel will remove gloves, discard them, and perform hand hygiene ..."