HospitalInspections.org

Based on observation, and interview, it was determined the facility failed ensure the building was maintained in that tile was chipped, and there were holes in the walls and floor in three of three areas (Emergency Room, Medical Surgical Unit and Surgical Services). Failure to ensure the building was free of sharp edges, holes in the wall and holes in the floor had the potential for injury. The failed practice had the potential to affect any patient who was placed in Room #26 or had procedures in the Minor Procedure Room. Findings follow:

A. Observation of the Medical Surgical Unit Room #26 at 2:10 PM on 01/14/19, showed two pieces of two inch wide blue tape placed over the center portion of the shower entry way. During an interview with the Maintenance Assistant at 2:14 PM on 01/14/19, he stated that the tile was chipped so the blue tape was placed over the chipped tile to prevent a patient from injuring themselves.
B. Observation in the Minor Procedure Room at 2:30 PM on 01/14/19 showed three sets of two holes each, in the wall approximately five feet from the floor. On the right side of the three sets of holes were two holes in the wall also approximately five feet from the floor. During an interview with the Director of Maintenance at 2:36 PM on 01/14/19, the above findings were verified.
C. Observation in the Minor Procedure Room at 2:30 PM on 01/14/19 showed a hole, one inch in diameter, in the floor, midway of the left wall as one entered the door. During an interview with the Director of Maintenance at 2:36 PM on 01/14/19, the above findings were verified.

Based on observation and interview, it was determined the facility failed to ensure the safety of patients, staff and visitors in that an electrical outlet and phone wiring jack was not afixed to the wall and was hanging by exposed wires, thus enabling wires to be tampered and manipulated by hand in one (#31) of three (#26, #31, and #37) patient rooms and one of one Minor Procedure Room. Failure to ensure the electrical wiring and the phone wiring jack were not accessible had the potential to allow contact with the electrical wiring and the manipulation of the phone wiring and jack. The failed practice had the potential to affect any patient, staff, or visitor who had the potential to come in contact with the wiring. Findings follow:

A. Observation in Patient Room #31 at 2:00 PM on 01/14/19 showed an electrical outlet pulled out from the wall approximately ¾ of one inch, with exposed electrical wires visible and touchable from the wall to the outlet. The room air conditioning and heating unit was plugged into the electrical outlet. The Director of Maintenance verified the findings in an interview at 2:02 PM on 01/14/19.
B. Observation in the Minor Procedure Room at 2:30 PM on 01/14/19 showed an approximately 16 inch length of phone wiring with a phone jack hanging on the distal end of the wiring, hanging from a hole in the wall, approximately 18 inches from the floor. The Director of Maintenance verified the findings in an interview at 2:36 PM on 01/14/19.



Based on observation and interview, it was determined that one of one electrical panel feeding power to the refrigerator in the storage area of the kitchen and Medical Records Department, on the Administrative Wing had exposed electrical wires. Failure to ensure electrical wires were not accessible to patients, visitors and unauthorized staff, had the potential to allow tampering of the exposed wires. The failed practice had the potential to affect the Medical Records department and the foods stored in the kitchen refrigerators in the storage area. Findings follow:

A. Observation in the Administrative Wing at 9:45 AM on 01/15/19 showed a 14 inch by 25 inch hole above the electrical panel with electrical wiring visible and accessible through the hole.
B. During an interview on 01/15/19 at 9:45 AM, the Director of Maintenance the findings in A.

Based on observations and interview, it was determined the facility failed to assure the building was clean and tidy in three of three (Emergency Room (ER), Medical Surgical Unit and Operating Room #1 (OR) units in that the building was not clean, there were holes in the walls and floors, and paint was peeling/chipped/bubbled. Failure to assure the building was clean, walls and floors were intact, and that surfaces were continuous did ensure the structure was clean and ready for patient care. The failed practice had the potential to affect any patient whose care was rendered and received in the ER, the Medical Surgical Unit and Operating Room #1. Findings follow:

A. Observation in ER Room #1 at 1:25 PM on 01/14/19 showed the air conditioning/heating unit with a large amount of dust underneath the unit and on the front grill.
B. Observation in ER Room #3 at 1:40 PM on 01/14/19 showed large cobwebs stringing from the ceiling to the left side of the beige supply cabinet. The air conditioning/heating unit had bugs and trash on top of the grids, the side panels showed multiple stains of various colors and sizes, and the window blinds were covered in dust and cobwebs.
C. During an interview at 1:41 PM on 01/14/19, the Environmental Services/Emergency Preparedness (EVS/EPP) verified the findings in A and B.
D. Observation in the Medical Surgical Unit, Room #31, at 2:00 PM on 01/14/19 showed the air conditioning/heating unit with a large amount of dust and lint on top of the unit. Observation of the shower showed a dirty washcloth draped over the shower curtain rod. Observation of the bedside chair showed two rips in the seat; one approximately 2 ½ inches long, and one 1½ inches long. The Director of Nursing stated at the time of the observation, that Room #31 was supposed to be clean and ready for a patient and verified the findings in D. Also the light fixture over the bed was chipped and missing a piece allowing access by patient or visitors to exposed electrical wires. The Maintenance Assistant verified the findings during an interview at 2:00 PM on 01/14/19.
E. Observation in the Medical Surgical Unit, Room #26, at 2:10 PM on 01/14/19 showed peeling paint behind the toilet in the bathroom. The Maintenance Assistant verified the findings during an interview at 2:14 PM on 01/14/19.
F. Observation in the Medical Surgical Unit, Room #37, at 2:20 PM on 01/14/19, showed multiple brownish-black spots of multiple sizes all over the floor of the entire room; an 18-inch length of telephone cord connected to the phone sitting on the nightstand was also covered in a brownish-black stain. Observation in the same room showed the air conditioning/heating unit was covered in a large amount of lint, dust, and bits of trash on top of the unit. During an interview with the EVS/EPP Manager at 2:22-2:25 PM on 01/14/19, he stated that the brownish-black substance was mastic glue seeping up from under the tiles.
G. Observation in the Medical Surgical Unit Dirty Supply Room at 1:55 PM on 01/14/19 showed peeling paint on all walls and the ceiling. A 1½ inch diameter hole in the wall, was observed above the door, approximately two inches below the ceiling. A hole in the right corner of the tile around the hopper was observed as well. The Director of Maintenance verified the above findings during an interview at 1:59 PM on 01/14/19.
H. Observation in OR #1 at 3:00 PM on 01/14/19 showed a narrow silver edging between the flooring and the sheet rocked walls; on the 16 foot wall to the left of the door there was separation between the silver edging and the sheetrock with small pieces of the sheetrock missing above the silver edging at various points along the wall; there was chipped paint around the wall vent (the wall vent was approximately two feet by two feet) on the south wall of OR #1; peeling/bubbled paint was observed along the edges of wall cabinets on the south wall of OR #1 as well. The Director of Maintenance verified the above findings during an interview at 3:09 PM on 01/14/19.
I. Observation in OR #1 at 3:00 PM on 01/14/19 showed bugs, rat pellets, dirt, lint and some type of coiled brown larvae organism in the corner behind the equipment tower. During an interview at 3:10 PM on 01/14/19, the Surgery Director/Swing Bed/Discharge Planner stated that housekeeping cleaned the OR and she had not checked behind housekeeping.
J. During an interview with at 9:30 AM on 01/15/19 the EVS/EPP Manager stated that housekeeping did not move any of the equipment in the OR to clean under or behind the equipment.


40282

Based on observation and interview, it was determined the facility failed to assure the patient care equipment was clean and tidy in one of one Minor Procedure Room and one (#37) of three (#26, #31 and #37) Medical Surgical Unit Rooms. Failure to assure patient care equipment was clean and surfaces were continuous did not ensure these areas to be clean and ready for patient care. The failed practice had the potential to affect any patient whose care was rendered and received in the Minor Procedure Room and the Medical Surgical Unit Room. Findings follow:

A. Observation in Minor Procedure Room at 01/14/19 at 2:30 PM showed a patient care Intravenous (IV) pole with a basket attached with dirty zip ties and a dirty bandage wrap wrapped around the basket and pole. The Director of Nursing verified these findings at 2:35 PM on 01/14/19.
B. Observation in Medical Surgical Unit, Room 37, on 01/14/19 at 2:20 PM showed a room divider curtain with multiple stains and visual dirt. Environmental Services/Emergency Preparedness Manager verified these findings at 2:25 PM on 01/14/19.

Based on policy and procedure review, clinical record review and interview, it was determined the facility failed to follow its policy and procedure in that nine of nine (#1-9) patients were not triaged upon presentation to the Emergency Room (ER) using the Emergency Severity Index (ESI). Failure to follow the triage policy did not assure patients received the required level of care in the timeframe dictated by the triage assessment. The failed practice had the potential to affect Patients #1-9, and any other person who presented to the ER for treatment. Findings follow:

A. Review of the policy and procedure titled, "Triage," received on 01/14/19, from the Director of Nursing (DON), showed all persons who presented to the ER were to be triaged using the ESI scale in order to prioritize when the person would be seen by a physician or other qualified medical personnel.
B. Review of the clinical records for Patients #1-#9 showed no evidence of an ESI score upon presentation to the ER.
C. During an interview with the DON at 3:05 PM on 01/17/19, she stated that the location for the ESI scoring had disappeared from the electronic clinical record and the scoring had not been done.

Based on observation and interview, it was determined Pharmacy Services failed to conform to Malignant Hyperthermia Association of the United States (MHAUS) acceptable standards of practice for medication administration Succinylcholine in that the facility failed to:
1) Have a policy and a process in place to treat a Malignant Hyperthermia Emergency.
2) In one (Emergency Department) of three (Emergency Department, Surgical Services and Medical Surgical) areas toured Succinylcholine was available for patient use without having a stock Dantrolene, which was the medication recommended to treat Malignant Hyperthermia, in case of the emergent event.

By not adhering to the acceptable standards of practice as set forth by MHAUS, the facility could not assure they were prepared for a Malignant Hyperthermia Emergency and could not assure a positive patient outcome in the emergency. The failed practice had the likelihood to affect all patients admitted for procedures. Findings follow:

A. Record review of MHAUS's current recommendations (as of 1-19-19) showed facilities that stock Succinylcholine, even if just for an emergent situation, should stock Dantrolene and be prepared for a Malignant Hyperthermia event.
B. During a tour of the facility on 01/14/19 from 1:10 PM to 3:30 PM, observation showed three vials of Succinylcholine stocked in the medication refrigerator in the Emergency Department.
C. During an interview on 01/15/19 at 11:20 AM, the Director of Pharmacy verified the facility did not have a policy or process in place to treat a Malignant Hyperthermia Emergency and they stocked Succinylcholine.

Based on observation and interview, it was determined the facility failed to identify and control the spread of infections in that unopened needles and syringes were available for patient use in the Operating Room (OR). The failed practice had the potential for cross contamination in that staff could not be certain if the needles and syringes were clean and ready for patient use. The failed practice had the potential to affect any patient whose care was rendered in OR #1 and whose care required the use of needles and syringes. Findings follow:

Observation in OR #1 at 3:00 PM on 01/14/19 showed a yellow bin with seven three milliliter syringes with needles attached. All seven syringes and needles were out of original packaging and it could not be ascertained if they were clean or dirty. The Director of Nursing verified the findings during an interview at 3:01 PM on 01/14/19.


40282

Based on observation and interview, it was determined the Infection Control /Quality Assurance (IC/QA) Manager failed to identify and control infections in that twelve of twelve esophageal dilators were unwrapped in one of one (#1) OR (Operating Room). The failed practice did not assure that the equipment had been cleaned or sterilized and stored in a manner to ensure protection from damage or contamination. The failed practice had the potential to affect all patients having surgical procedures. Findings follow:

A. During tour of the Surgical Unit on 1/14/19 at 2:40 PM, 12 unwrapped esophageal dilators were found on a surgical stretcher in OR #1.
B. During interview with the Surgery Director/Swing Bed/ Discharge Planner on 01/14/19 3/17 at 2:44 PM, she stated that she did not know why the dilators were there because they do not use them for any surgical procedures.
C. During interview with LPN (Licensed Practical Nurse) # 1 on 01/15/19 at 9:45 AM, she stated that she was cleaning out cabinets, laid them on the stretcher, and failed to remove them.


Based on observation and interview, it was determined the IC/QA Manager failed to identify and control infections in that one of one laryngoscope blade was found in the Trauma Room of the Emergency Department unwrapped. The failed practice did not assure the equipment had been cleaned or sterilized and stored in a manner to ensure protection from damage or contamination. The failed practice had the potential to affect all patients who needed the use of a laryngoscope for intubation. Findings follow:

A. During tour of the Emergency Department's Trauma Room on 01/14/19 at 1:10 PM, 1 of 1 laryngoscope blade was found in unwrapped in 3rd drawer of the crash cart.
B. During an interview on 01/14/19 at 1:12 PM, the Director of Nurses verified the unwrapped laryngoscope blade and she was unable to determine its sterility.


Based on observation and interview, it was determined the IC/QA Manager failed to identify and control infections in that one of one intubation stylet was found in the Trauma Room of the Emergency Department unwrapped. The failed practice did not assure the equipment had been sterilized and stored in a manner to ensure protection from damage or contamination. The failed practice had the potential to affect all patients who needed intubation. Findings follow:

A. During tour of the Emergency Department's Trauma Room on 01/14/19 at 1:10 PM, 1 of 1 intubation stylet was found unwrapped in the crash cart.
B. During an interview on 01/14/19 at 1:10 PM, the Director of Nurses verified she was unable to determine the sterility of the intubation stylet.

Based on policy and procedure review, clinical record review and interview, it was determined the facility failed to perform a nutritional screening for 3 (#15, #16 and #20) of 7 (#14-20) inpatients. Failure to perform an initial screening of each patient's nutritional status did not ensure the patient was monitored for nutritional care. The failed practice had the potential to affect Patient #15, #16 and #20. Findings follow:

A. Review of the policy and procedure titled, "Nutritional Screening/Monitoring," received on 01/14/19, showed an initial screening of each patient's nutritional status was to be conducted by a licensed nurse within two hours of admission to determine the nutritional risk and the need for nutritional care.
B. Review of the policy and procedure titled, "Nutrition Screening and Assessments," received from the DON at 11:05 AM on 01/18/19, showed a nutrition screening was to be completed for each patient admitted to the hospital within 24 hours of admission by a Registered Nurse (RN). The Dietary Manager was to obtain the patient information and determine if the patient was at risk, complete a screening sheet on each patient, and patients scored at risk would be reassessed by the Dietary Manager every three days and patients scored not at risk would be reassessed every seven days. Review of the above policy and procedure showed the information was to be charted in the medical record on the screening sheet.
C. Review of the clinical records of Patients #15, #16 and #20 showed no nutritional assessments. During an interview with the Director of Nursing from 11:52 AM to 11:55 am on 01/18/19, she verified the clinical records of Patient #15, #16 and #20 showed no nutritional assessments.
D. During an interview with the Dietary Manager at 11:39 AM on 01/18/19, she stated that she did not have access to documentation or a scoring mechanism in the electronic record that showed the patient to be at risk or not at risk. During the above interview the Dietary Manager, stated that she assessed every inpatient one time and did not re-assess every three days if at risk, or every seven days if not at risk.

Based on policy and procedure review, clinical record review and interview, it was determined a Registered Nurse (RN) failed to evaluate/re-assess the patient's care and health condition every four hours as required by policy and procedure for 6 of 6 (#14-#19) inpatients. The failed practice did not assure a RN had evaluated/reassessed the patient's response to treatment and care. Failure to perform RN assessments every four hours did not ensure the facility followed policy as well as provided the appropriate level of care as required by the policy. The failed practice affected Patients #14-#19 and had the likelihood to affect any patients admitted to the hospital. Findings follow:

A. Review of the policy and procedure titled, "Initial Patient Assessment and Reassessment," received on 01/14/19 from the Director of Nursing (DON), showed all patients should be reassessed at least every four hours by a RN, and was to be documented in the Nurses' notes.
B. Review of Patient #14's clinical record showed four of four (01/11/19 - 01/14/19) 7 AM to 7 PM shifts did not have RN assessments documented every four hours.
C. Review of Patient #15's clinical record showed two (01/08/19 and 01/09/19) of three (01/07/19 - 01/09/19) 7 AM to 7 PM shifts and one (01/06/19) of three (01/06/19 - 01/08/19) 7 PM to 7 AM shifts did not have RN assessments documented every four hours.
D. Review of Patient #16's clinical record showed two of two (01/02/19 and 01/03/19) 7 AM to 7 PM shifts and one (01/01/19) of three (01/01/19 to 01/03/19) 7 PM to 7 AM shifts did not have RN assessments documented every four hours.
E. Review of Patient #17's clinical record showed three of three (12/27/18-12/29/18) of 7 AM to 7 PM shifts and two (12/26/18 and 12/27/18) of four (12/26/18 - 12/29/18) 7 PM to 7 AM shifts did not have RN assessments documented every four hours.
F. Review of Patient #18's clinical record showed three of three (12/06/18 - 12/08/18) of 7 AM to 7 PM shifts and two (12/07/18 and 12/08/18) of four (12/05/18 - 12/08/18) 7 PM to 7 AM shifts did not have RN assessments documented every four hours.
G. Review of Patient #19's clinical record showed one (11/29/18) of two (11/28/18 and 11/29/18) 7 AM to 7 PM and two (11/28/18 and 11/29/18) of three (11/27/18 - 11/29/18) 7 PM to 7 AM shifts did not have RN assessments documented every four hours.
H. During an interview with the Director of Nurses at 12:20 PM on 01/18/19, she verified the findings in A through G.

Based on observation, policy review, and interview, it was determined the facility failed to ensure surgical services was organized to protect the health and safety of patents as evidenced by the following:

Based on interview, it was determined the facility failed to ensure a tracheotomy kit was available in one of one (#1) Operating Room (OR). Failure to ensure a tracheotomy kit was available for use in the operating room did not ensure the facility was prepared to meet the patient's medical needs in the event of an emergency. The failed practice affected all patients who have undergone procedures in the operating rooms of the facility. Findings follow:

A. Observation in OR #1 at 2:35 on 01/15/19 showed no tracheotomy kit available for use.
B. During an interview at 2:35 on 01/15/19, LPN (Licensed Practical Nurse) #1 stated that the tracheotomy kit was kept in Emergency Department.


Based on policy and procedure review, review of manufacturer's instructions, observation and interview, it was determined that the facility failed to prevent and control the spread of infection in handling and monitoring one of one bottle of Rapicide (high level disinfectant) in that it was not dated when opened, there was no quality control testing before each day of use, and the temperature of the Scope Room was not monitored to ensure a temperature of 15-30 degrees Centigrade. The failed practices did not ensure the Rapicide's integrity and accuracy as a high level disinfectant. The failed practice has the potential to affect all patient whose care required high level disinfectant equipment. Findings follow:

A. Review of the policy and procedure titled, "Rapicide Testing," received on 01/14/19, showed the Rapicide Solution was to be checked with test strips before each day of use. If the Rapicide was not in use, it was to be tested every fourteen days and documented to ensure the efficiency of the solution. On 01/18/19 at 9:00 AM, a log of the Rapicide testing was requested. No log was presented.
B. Review of the manufacturer's instructions received on 01/14/19 showed the Rapicide solution was good for 28 days after opening and the solution should be stored at a temperature of 15-30 degrees Centigrade.
C. Observation in the Scope Room at 2:15 PM on 01/15/19 showed one bottle of Rapicide that was not dated when opened; there as no evidence the temperature of the room was monitored.
D. Findings in C were verified by LPN (Licensed Practical Nurse) #1 at 1:35 PM on 01/15/19.
E. Findings in A were verified by the Surgery Director/Swing Bed/ Discharge Planner at 12:15 PM on 01/18/19.


Based on review of the OR Log and interview, it was determined the facility failed to ensure a dedicated Registered Nurse (RN) was available to perform the role of a Circulating Nurse during five of five surgical procedures performed on 01/10/19. The failed practice did not ensure that a dedicated RN was available during the procedure to intervene and provide care if needed. The failed practice affected all patients having surgical procedures. Findings follow:

A. Review of the OR Log on 01/15/19 at 9:00 AM showed five patient surgical procedures were performed on 01/10/19 with no Circulating Nurse.
B. During an interview with LPN #1 on 01/15/19 at 9:02 AM, she stated that a Circulator Nurse was not needed because she had everything ready for the surgery.


Based on review of clinical records and interview, it was determined the facility failed to assure an assessment was completed by a RN of the patient's status in the recovery room for three (#11-#13) of four (#10-#13) patients. The failed practice did not assure patients were stable in the recovery room area and stable for discharge. The failed practice affected all patients who underwent surgical procedures in the facility. Findings follow:

A. Review of Patient #11-#13's clinical record on 01/18/19 showed no evidence of a recovery room assessment by a RN.
B. During interview with RN # 2 on 01/17/19 at 10:30 AM, she stated that she stabilized the patient in the procedure room. The patient was conscious, talking and vital signs were stable. She took the patient to the recovery room, gave report to the LPN and waited for the first set of vital signs to make sure patient remained stable.
C. Findings in A were verified by Director of Nurses (DON) on 01/18/19 at 12:30 PM.


Based on policy review and interviews, it was determined the policies and procedures for the end of day cleaning and terminal cleaning were not specifically
outlining the responsibilities of who would perform the cleaning and type of cleaning procedures after each patient procedure, the end of the day and terminal.
Failure to ensure the congruency of all three policies and procedures did not assure the OR was cleaned and sterile for surgical procedures, and ensure all staff were knowledgeable in the responsibilities and cleaning techniques. The failed practice had the the potential to affect every patient having a surgical procedure.

A. Three of three policies reviewed for end of day cleaning or terminal cleaning for the operation room did not specifically outline the responsibilities of who would perform the cleaning and the type of cleaning procedures after each patient procedure, the end of the day and terminal as follows:
1) Review of Outpatient Surgery's policy titled, "Cleaning and Sanitizing the OR," received on 01/14/19, showed following:
a) Through cleaning of furniture and equipment;
b) Cleaning and disinfection of kick buckets;
c) Cleaning of cabinet doors and operation room doors;
d) Cleaning of scrub sinks;
e) Cleaning of transport and utility carts;
f) Mopping of floors; and
e) Cleaning of equipment.
2) Review of Infection Control's policy titled, "Guidelines for Infection Control O.R. Environment," received on 01/14/19, showed following:
a) Furniture and cabinets were cleaned with the detergent solution;
b) Walls were checked for soiled spots and cleaned with germicidal solution;
c) Scrub sinks are scrubbed with an abrasive;
d) Halls offices, closets, lounges were cleaned with mopped daily by housekeeping; and
e) Weekly each operation room was cleared of all equipment and the floor scrubbed.
3) Review of Environmental Services policy titled, "Surgery Room," received on 01/17/19 at 9:00 AM showed the following:
a) Mop surgery room 1 and 2 with 1/203 Lysol per gallon water;
b) Change water to mop hall, recovery room, lounge, nurse's lounge and hall;
c) Clean mop bucket and mop thoroughly and put them in surgery where they would be kept for use only in surgery; and
d) Lysol was a phenolic disinfectant cleaner.
B. During an interview with the Environmental Services/Emergency Preparedness (EVS/EPP) Manager on 01/17/18 at 10:16 AM, he confirmed that environmental personnel followed the "Surgery Room" policy for the end of day and/or terminal cleaning.
C. During an interview with Registered Nurse ( RN) #2 on 01/17/19 at 10:30 AM, Surveyor #2 asked " If she or any OR staff performed any terminal cleaning or end of day cleaning." RN #2 stated "No." She stated that "I clean after each procedure, but not at the end of the day."
D. During an interview with the Surgery Director/Swing Bed/ Discharge Planner on 01/18/19 at 9:30 AM, she stated that she did not know of any of the nurses performing terminal cleaning.
E. During an interview with the IC/QA Manager on 01/17/19 at 10:45 AM, she stated that she had not observed any personnel perform any end of day cleaning or terminal cleaning in the OR. She stated that she had not provided any formal training for environmental services personnel regarding end of day cleaning or terminal cleaning of the OR.


Based on Policy and Procedure Manual review and interview, it was determined the facility failed to develop and implement a policy and procedure addressing the Do Not Resuscitate (DNR) status of operative patients. Failure to develop and implement a policy and procedure addressing the DNR status of operative patients did not allow the surgeon, the surgical services staff, patients and family members to be knowledgeable, accepting and approving of what steps would be undertaken in the event of the cardiac or respiratory arrest of a patient during surgery. The failed practice affected all patients who underwent a surgical procedure in the facility. Findings follow:

A. Review of the Surgical Services Policy and Procedure Manual showed there was no policy or procedure that addressed a surgical patient's DNR status of the operative patient.
B. During an interview with the Surgery Director/Swing Bed/Discharge Planner at 9:45 AM on 01/18/19, she stated the facility did not have a policy and procedure which addressed the DNR status of the operative patient.


Based on Policy and Procedure Manual review and interview, it was determined the facility failed to develop and implement a policy and procedure addressing patient identity for operative patients. Failure to develop and implement a policy and procedure addressing patient identity did not allow the surgeon, the surgical services staff, and hospital staff to be knowledgeable of the patients ordered surgical procedures. The failed practice affected all patients who underwent a surgical procedure in the facility. Findings follow:

A. Review of the Surgical Services Policy and Procedure Manual showed there was no policy or procedure that addressed a surgical patient's identity.
B. Findings in A were verified by the Surgery Director/Swing Bed/ Discharge Planner on 01/18/19 at 9:15 AM.


Based on Policy and Procedure Manual review and interview, it was determined the facility failed to develop and implement a policy and procedure addressing aseptic surveillance and practice, including scrub techniques for surgical services. Failure to develop and implement a policy and procedure addressing aseptic and scrub techniques did not allow the surgeon and the surgical services staff to be knowledgeable of the proper scrub technique for surgical procedures. The failed practice affected all patients who had undergone surgical procedures. Findings follow:

A. Review of the Surgical Services Policy and Procedure Manual, showed there was no policy or procedure that addressed surveillance of aseptic practice and scrub techniques for surgical services.
B. A policy and procedure for aseptic surveillance and scrub techniques was requested on 01/15/19 at 1:30 PM and 01/16/19 at 2:45 PM. No policy was provided.
C. Findings in A and B were verified by the Surgery Director/Swing Bed/ Discharge Planner on 01/18/19 at 9:09 AM.


Based on review of policy and procedure and the Operating Room Register, it was determined the facility failed to include one (total time of the operation including beginning and end of case) of the eleven (patient's name; patient's identification number; date of the operation; total time of the operation; name of the surgeon and any assistant(s); name of nursing personnel (scrub and circulating); type of anesthesia used and name of person administering it; operation performed; pre and post-op diagnosis; and age of patient) required elements on the operating room log. Failure to include all required elements in the operating room log did not allow the facility to track and trend potential problems. Findings follow:

A. Review of Outpatient Surgery policy and procedure titled "Registry" showed a required list of information to be included and completed on the operation room register but it did not include the total time of the operation.
B. Review of the Operating Room Register showed it did not contain documentation of the required total time which includes the start and end time of the operation.
C. The above findings were verified by the LPN #1 on 01/15/19 at 9:00 AM.


Based on clinical record review and interview, it was determined that four of four (#10-#13) surgical records did not have the time of the operation included in the Operative Report. The failed practice did not ensure staff had complete information to care for the post-surgical patient prior to transition of the patient to the next level of care. The failed practice had the likelihood to affect all patients who had a procedure performed at facility. Findings follow:

A. Review of operative reports on 11/18/19 from 10:45 to 11:45 AM showed there was no time for the procedure in the operative report for Patients #10-#13.
B. The above findings in A were verified with the Surgery Director/Swing Bed/Discharge Planner on 01/18/19 at 12:07 PM.

Based on review of the Emergency Preparedness Plan and interview, it was determined the facility failed to develop policies and procedures outlining the use of volunteers, how the volunteers would be qualified, what duties the volunteers could perform, and who would authorize the use of volunteers in the event of an emergency or disaster. Failure to develop and procedure which defined the use, qualifications, duties and who had the authority to authorize the use of volunteers could result in the delay of care for injured individuals. The failed practice had the potential to affect all patients, staff, and community members in the event of an emergency or a disaster. Findings follow:

Review of the Emergency Preparedness Plan showed no policy, procedure, or mechanism which outlined the use of volunteers in the event of an emergency or a disaster. During an interview with the Environmental Services/Emergency Preparedness Manager at 1:40 PM on 01/16/19 he verified the above and stated there was no policy or procedure that outlined the use of volunteers.