HospitalInspections.org

Based on interviews, medical record and document reviews, it was determined the facility failed to prevent injury to Patient #1 during a surgical procedure.

The findings include:

On 5-3-21 at 1:10 p.m., the Surveyor conducted a review of the medical record. The record reveals Patient #1 came to the facility to have a surgical procedure on the left shoulder for relief of arthritis pain in that joint.

The Surgical Case Record documents, "Patient had a skin tear post op under left eye...skin tear is about 2 cm (centimeters)." The form "ORM Assessment (document used in the recovery room)" reveals a "face 2 cm lac (laceration) below the left eye" under the heading of "skin problems". No further explanation of the injury was found in the medical record.

On 5-3-21 at 2:10 p.m., the Surveyor conducted an interview with Staff Member #8, an OR (Operating Room) RN, who stated that "[Patient #1] didn't come in with it [laceration (cut) below the left eye]. I noticed it after the surgery after, we finished taking [the Patient] to the PACU (post anesthesia care unit)." Staff Member #8 explained that sometimes the tape can cause this when the drapes are removed but the "staff is mostly careful". Staff Member #8 again stated, "when we were leaving [the OR] we noticed the cut, but I don't remember how it happened."

On 5-4-21 at 12:45 p.m., the Surveyor conducted an interview with Staff Member #9, who stated, "I don't remember this patient but sometimes the patients will rub their eyes and scratch them."

On 5-3-21 the Surveyor conducted an interview with Staff Member #7 who stated, "I remember this patient." Staff Member #7 stated that they noticed the cut "after the drape was taken down but nobody knew how it happened". Staff Member #7 also stated that "Everything was done normally."

On 5-4- at 4:15 p.m., the Surveyor conducted an interview with Staff Member #13, a surgeon, who stated that Staff Member #13 was not aware of it and no one brought it to Staff Member #13's attention until the Patient showed the picture in the office. Staff Member #13 stated, "At the time of the surgery, I didn't see it [laceration below the left eye]. [The Patient] told me about it in the office and showed me a picture of it." Staff member #13 went on to explain that sometimes when the tape is removed (tape is used to secure the drapes placed on patients during a surgical procedure), it can cause skin injuries if not done carefully.

On 5-3-21 the Surveyor conducted further document review.
The policy "Patient Rights Policy 831-917" states in part, "You have the right to:
quality care in a safe setting....be informed if something goes wrong with your care".

The policy "Scope of Care of the Perioperative Operating Room Personnel, 6600-1" states in part, "The surgical team in collaboration with the surgeon and Anesthesia provider ensures a safe environment optimal surgical outcomes and continuity of care for each patient ".