HospitalInspections.org

Based on record review and interview, the hospital failed to ensure the operating rooms (OR) were supervised by an experienced Registered Nurse.

This failed practice had the potential to negatively affect the patient outcome due to the potential that surgical issues would go unrecognized for the 117 outpatient and 80 inpatient who had surgeries and the 57 patients who had endoscopic procedures in 2017.

Findings:
On 03/30/18 at 9:00 am, the surveyor requested the job description of the OR Manager; none was provided.

On 03/27/18 at 12:00 pm, Staff F was identified as the new OR Manager, and Staff A, the DON, was identified as her supervisor.

The personnel file for Staff F showed prior work experience in home health and hospice. The file showed the completion of document titled, "RN/LPN/Nurse Tech Employee Orientation Checklist" (completed 06/13)" which did not contain competencies relative to the OR. The file contained the following acknowledgement statements (signed 11/28/17) that the following policies were read: Autoclave Procedures, Laryngoscope Blade Cleaning, Auxiliary Water Tube, Flash Sterilization, and Single Biopsy Forceps.

On 03/28/18 at 1:00 pm, Staff F stated he/she began the role of the OR Manager in 08/17 and was learning.

On 03/30/18 at 8:45 am, Staff A stated he/she had no OR experience.

Based on record review, interview and observation the hospital failed to:

I. ensure the medical staff reviewed, revised and approved ED policies and procedures for stroke and chest pain based on current nationally accepted guidelines and standards of practice. This failed practice had the potential to cause serious harm to suicidal/homicidal and stroke patients presenting to the ED. (Refer to Tag A-0457)

II. ensure 1:1 monitoring with visual observation for a sampling of three (Patient #2, 9, and 13) of three patient medical records reviewed who entered the emergency department (ED) with suicidal/homicidal ideations and plans. This failed practice resulted in one patient (Patient #9) who was able to walk out of the hospital unnoticed by staff and was found smoking unattended. This failed practice had the potential to cause serious harm to all patients presenting to the ED with suicidal/homicidal ideation. (Refer to Tag A-0144)

III. perform an environmental risk assessment to identify potential environmental safety risks and removal of sharp objects and equipment that could be used as a weapon for a sampling of three (Patient #2, 9, and 13) of three patient medical records reviewed who entered the emergency department (ED) with suicidal/homicidal ideations and plans. This failed practice had the potential to cause serious harm to all patients presenting to the ED with suicidal/homicidal ideation. (Refer to Tag A-0144)

IV. ensure all staff working in the ED had education and training on triage, performance of a suicide risk assessment, management of suicidal/homicidal patients including monitoring and securing the patient's environment while in the ED. These failed practices had the potential to cause serious harm to patients presenting to the ED with suicidal/homicidal ideation.

V. ensure the adequate staffing needs of the ED met the needs of the patients entering the ED in a timely manner as evidenced by 12 patients leaving against medical advice (AMA) and 28 patients leaving without being seen (LWBS) for a time period of 01/01/18 to 01/15/18 and 2/16/18. This failed practice had the potential to cause delays in care and worsening of health condition due to lack of early intervention for the 28 patients who left without being seen and 12 patients who left prior to the completion of their treatment.