HospitalInspections.org

Based on MR review, policy/procedure review, and staff interview, in 9 out of 9 out of a total of 10 closed surgical MR reviewed (Pt. # 1, 2, 3, 4, 5, 6, 7, 9, and 10), this facility failed to ensure that surgical patients are protected from fire by ensuring that the alcohol based skin preparation (prep) was dry prior to starting surgery. Failure to ensure that flammable alcohol based skin preps are dry during the time out process in surgery could lead to patient surgical fires.

Findings include:

Facility policy #654 Titled, "Universal Protocol-Site Marking," was reviewed on 10/12/2010 at 4:20 p.m. This policy does not address measures for patient safety when using alcohol-based skin preparations.

A phone interview with Surgical RN D was conducted on 10/12/2010 at 12:48 p.m. In response to the question, "Where are you documenting if an alcohol-based skin prep is dry on the time-out procedure?" RN D responded, "We do not document alcohol dry time."

During MR reviews conducted on 10/12/2010 between 12:40 p.m. and 3:30 p.m., it was discovered that the following Pt.'s who had an alcohol based skin preparation prior to their surgeries did not have documentation in their time-out procedures indicating that the skin prep was dry. All of these Pt.s had Chlorhexidine, an alcohol based product, for their skin preps:

Pt. # 1, 2, 3, 4, 5, 6, 7, and 9.

Pt. #10 had a Hibiclens scrub with an alcohol paint prior to the surgical procedure of a hip replacement. Hibiclens is not alcohol based, but the alcohol paint (process where isopropyl alcohol from a bottle is used to cleanse the area using a gauze pad) is.

These findings were confirmed at the time of the MR reviews by RN E.

Based on MR review and staff interview, this facility failed to properly document on the post-anesthesia evaluation (eval) form by: 1) failing to include a time the evaluation was completed, thereby not establishing that an adequate amount of time for anesthesia recovery has taken place in 4 out of 10 closed MR reviewed (Pt.s # 1, 2, 4, and 5); and
2) failing to identify a second documentor on the post-anesthesia eval form, thereby failing to establish if the second documentor is qualified to gather this data after anesthesia in 4 out of 10 closed MR reviewed (Pt. #1, 3, 5 and 9).

Findings include:

A MR review was conducted on Pt. #1's MR on 10/12/2010 at 12:40 a.m. On the post anesthesia eval form, there is no time documented to indicate when this evaluation was completed. It is also apparent that a second documentor, other than anesthesia, completed the documentation on the eval form, but there is no signature from the second documentor to identify who it is.

A MR review was conducted on Pt. #2's MR on 10/12/2010 at 12:55 p.m. On the post anesthesia eval form, there is no time documented to indicate when this evaluation was completed.

A MR review was conducted on Pt. #4's MR on 10/12/2010 at 1:28 p.m. On the post anesthesia eval form, there is no time documented to indicate when this evaluation was completed. It is also apparent that a second documentor, other than anesthesia, completed the documentation on the eval form, but there is no signature from the second documentor to identify who it is.

A MR review was conducted on Pt. #5's MR on 10/12/2010 at 1:50 p.m. On the post anesthesia eval form, there is no time documented to indicate when this evaluation was completed. It is also apparent that a second documentor, other than anesthesia, completed the documentation on the eval form, but there is no signature from the second documentor to identify who it is.

A MR review was conducted on Pt. #9's MR on 10/12/2010 at 3:20 p.m. It is apparent that a second documentor, other than anesthesia, completed the documentation on the eval form, but there is no signature from the second documentor to identify who it is. This second documentor wrote down the wrong date the eval was completed and did not indicate a time.

These findings were confirmed at the time of discovery by RN E.