HospitalInspections.org

Based on interview and document review, the hospital failed to ensure Quality Assurance/Performance Improvement (QAPI) projects were implemented and integrated into the hospital's quality improvement program for the following services: organ and tissue donation, ambulance services and surgical services. This had the potential to affect all current and future patients of the hospital.

Findings include:

The Quality Assessment & Performance Improvement Plan (QAPI) was approved on 11/25/14. Documentation indicated: The QAPI plan applies to all departments, services, practitioners, and staff involved in the delivery of care. Each department/service will report to the Quality Council at least annually or more frequently as identified on the Appendices or as requested by the Quality Council. The Facility Services/Departments and contract Services list included the following: Ambulance and Surgical/Anesthesia Services and Organ procurement (Life Sources). The QAPI plan identified the Quality Council will meet at least four times a year and additionally as necessary.

When interviewed on 9/22/15, at 11:15 a.m. the performance improvement/risk manager (PI/RM) indicated the Quality Council meets four (4) times during the year and reviews the evaluation/ progress each service department has made relative to their indicators and goals identified at the beginning of the year. It was noted the ambulance and surgical/anesthesia services had not submitted any data for two consecutive quarters of 2015; first quarter (1st) (January-March) and second (2nd) quarter (April-June). Documentation was lacking to indicate the identified services had monitored and tracked progress of QAPI indicators and goals to identify, evaluate and act upon potential problems and opportunities for further improvement in patient care delivery.

When interviewed on 9/23/15, at 1:10 p.m. the performance improvement risk manager (PI/RM) verified Organ Procurement Organization (OPO) data was no implemented as a part of the Quality Council Review.

A quality goal dashboard for contract services dated 6/23/15 lists "Organ Procurement Organization [life source] #deaths referred to organ procurement organization goal as 100%" the report does not list any data for 2014.

A policy entitled organ, tissue and eye procurement dated 4/05, does not refer to quality improvement data, analysis or reporting.

Based on interview and document review, the facility failed to ensure telephone/verbal orders were authenticated within 48 hours for 5 of 23 medical records reviewed (P15, P17, P7, P10 and P4.

Findings include:

Review of patient (P)-15's electronic medical record (EMR) indicated registered nurse (RN)-E received a telephone order from medical doctor (MD)-B for a clinical referral to home health on 5/19/15, at 7:56 a.m. Further review revealed MD-B had not authenticated the written order until 5/26/15 at 4:50 p.m. (7 days later).

Review of P17's EMR indicated RN-F received a telephone order from MD-C for a regular diet on 3/3/15, at 3:30 p.m. Further review revealed MD-C had not authenticated the written order until 3/6/15, at 5:54 p.m. (3 days later).

Interview with registered nurse (RN)-B on 9/22/15, at 9:30 a.m. confirmed MD-B and C had not authenticated the telephone orders that were placed on 5/19/15 and 3/3/15 within the required 48 hours.


33560


During a chart review on 9/22/15, at 8:30 a.m. the findings include:

Review of P7 was admitted for a recent bleed, gastric polip and anemia on 6/4/15.
-A verbal order (V.O.) was given for Narcan (for emergency treatment of known or suspected opioid overdose, as manifested by respiratory and/or central nervous system depression) every two minutes as needed on 6/7/15. The medical doctor (MD)-N authenticated the order four days later on 6/11/15.
-A V.O. was given for a (blood test) traponen level (measure of proteins released when the heart muscle has been damaged, such as occurs with a heart attack) on 6/7/15. MD-N authenticated the order four days later on 6/11/15.
-A V.O. was given for an electrocardiogram gram (EKG) on 6/7/15. MD-N authenticated the order four days later on 6/11/15.
-A verbal order was given for a chest X-ray on 6/7/15. MD-N authenticated the order four days later on 6/11/15.

PP-4 was admitted diarrhea and salmonella on 6/9/15.
- A V.O. was given for a blood test arterial blood gas on 6/9/15. MD-O authenticated the order four days later on 6/13/15.
-A V.O. was given for a nebulizer to be given to P-4 four times a day on 6/9/15. MD-O authenticated the order four days later on 6/13/15.
-A V.O. was given for a regular diet on 6/9/15. MD-O authenticated the order four days later on 6/13/15.

P-10 was admitted following blunt trauma on 4/20/15.
-A V.O. was given for physical therapy on 4/22/15. MD-L authenticated the order three days later on 4/25/15.
-A V.O. was given for occupational therapy on 4/22/15. MD-L authenticated the order three days later on 4/25/15.

An interview on 9/22/15, at 8:30 a.m. with registered nurse (RN)-B verified the verbal order authentication being outside of the acceptable parameters.

An interview on 9/22/15, at 10 a.m. with health information manager (HIM) stated the physician should not do telephone or verbal orders because they have remote access to their home to write orders.

An interview with RN-A stated I have never seen any number of how many verbal orders are out of compliance. I don't collect or see that information.

An interview on 9/22/15, at 3 p.m. with the performance improvement/risk manager (PI/RM) stated being unaware of any reports related to the use and authentication of verbal orders or telephone orders to monitor compliance. There was a discussion at the medical executive committee (MEC) in June. The MEC wanted each physicians to receive their own data. No other action plan was developed.

A policy entitled "orders--verbal, telephone, written and routine" dated 10/03, indicated "due to the risk for various types of medial errors associated with verbal/telephone communication of orders, it is the policy of WRH [worthington regional hospital] to minimize/discourage the use of verbal and telephone orders whenever possible". "Verbal/telephone orders...The prescribing LIP [licensed independent practitioner] with authenticate, verbal and telephone orders within 48 hours".

Sanford worthington medical center medical staff rules and regulations revised 3/25/15 indicated "Telephone and Verbal Orders: ... verbal orders shall be signed, with time and date, at the next visit and within 48 hours..."

Based on observation, interview and document review, the hospital was found to be out of compliance with Life Safety Code Requirements. These findings had the potential to affect all patients in the Acute Care Hospital and clinics.

Findings include:

Please refer to Life Safety Code inspection tags K11, K29, K50, K52, K62, K72, K144, K154, K155, K147, K29 and K62.

Based on observation, interview and document review, the Sanford Worthington Medical Center Acute Care Hospital (ACH) was found not to be in compliance with the Condition of Participation of Surgical Services CFR 482. 51. The ACH failed to ensure the safe use of electrocautery devices resulting in a risk for fire in the operating room and/or risk for patient burns for 1 of 2 patients (P)-1 observed during surgical procedures where the surgeon and/or surgical staff failed to operate the electrocautery device as directed by hospital policy and manufacturer recommendation. In addition, the ACH failed to ensure standards of infection control practice related to surgical attire were followed by all staff. This had the potential to affect all patients undergoing surgery at the ACH by medical doctor (MD)-A.

Findings include:

A surgical circumcision for P1 was observed on 9/22/15, at 11:58 a.m. P1 was observed to utilize oxygen per face mask during the surgical procedure. During the procedure, it was noted an electrosurgical (cautery) device was utilized by MD-A and was placed on top of the drape covering the patient's upper abdomen. MD-A failed to place the electrocautery device into the holster twice during the procedure:

1) At 12:10 p.m. MD-A was observed to utilize the cautery pencil and place it on top of the patient's draped abdomen. After 3 minutes, the certified surgical technician (CST)-A removed the cautery device from the drape and placed it into the holster.
2) At 12:15 p.m. MD-A was again observed to place the cautery device on top of P1's drape instead rather in the holster provided. The cautery device remained on the drape for approximately 10 minutes before CST-A placed it back into the holster.

During this surgical procedure, it was observed that MD-A wore street shoes without surgical shoe covers while performing the surgical procedure in the surgical suite.

During interview with CST-A on 9/22/15 at 12:30 p.m., CST-A confirmed MD-A had failed to holster the cautery device as required. CST-A confirmed MD-A had placed the cautery pencil/device onto P1's drape twice during the surgical procedure. CST-A further stated that when she'd noticed the device had been placed on the drape, she would remove it and place it in the holster as soon as her hands were free to do so. CST-A stated she was aware of the time frame the cautery was left on the drape, but she was unable to remove it to place it in the holster as she was assisting with the procedure and did not have a free hand. CST-A verified it was common practice for MD-A to place the cautery onto the drape rather than holstering it during surgical procedures. CST-A further stated she would have intervened sooner if the cautery had been placed higher on the body, because that would have made it a higher risk situation.

A review of the hospital's incident/accident reports for the past year revealed no incidents of fire/injury had occurred related to the use of an electro cautery devices.

When interviewed on 9/23/15, at 1:00 p.m. the director of surgical services (DSS) stated all surgical staff have been trained regarding safe use of the electro cautery pencil as well as the required attire while in a surgical suite. DSS acknowledged it was common for MD-A not to follow the hospital's surgical attire policies.

Review of the facility's policy, Electrosurgical Safety dated 6/2015, revealed staff guidance to assure the uniformity of action and accuracy in the safe operation of electrocautery equipment. The policy indicated the electrocautery should be used in a manner which would prevent inadvertent injury to the patient and/or staff members. The policy also indicated the active electrode of the electrocautery equipment should be used in a manner that minimized potential for injury, fire and electromagnetic interference. "The active electrode should be placed in a clean, dry, well insulated holster when not in use."

Review of the undated manufacturer's guidance for use of the cautery pencil, with the subject title Warning Fire Hazard, directed staff: "Do not place active instrument near or in contact with flammable materials such as gauze or surgical drapes. Electrosurgical instruments that are activated or hot from use can cause fire. When in use, place the cautery pencil in a holster and safely away from flammable materials and patients".

Based on interview and document review, the hospital failed to ensure an operative report was dictated and/or written immediately following surgery that included surgical techniques, findings, and tissues removed or altered for 1 of 5 (P15) surgical records reviewed.

Findings include:

Review of P15's surgical record indicated the patient had an exploratory laparotomy with colostomy surgical procedure on 5/12/15, at 3:11 p.m. Medical Doctor (MD)-B performed the surgical procedure. The surgical procedure end time was 5:47 p.m. An immediate surgical operative report had not been completed following surgery until the following day, 5/13/15 at 12:25 p.m. by MD-B.

Interview with registered nurse (RN)-B on 9/2/15, at 9:00 a.m. confirmed an immediate operative dictation and/or written report had not been completed timely. RN-B verified the operative report was completed on 5/13/15.