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Based on observation, document review and staff interview, it was determined the CAH failed to ensure all staff in the surgery department followed policies to prevent the possibility of transmission of infection, potentially affecting all patients receiving surgical services.
Findings include:

1. A tour of the surgery department and observation of surgical procedures was conducted with the Surgical Director (E #3) on 4/12/16 at 9:00 AM. During the observation of the surgical procedure for Pt #5 the following was observed: CRNA (E #4) was observed wearing a watch and a ring on the right index finger. E#4 was wearing scrub top and pants with another hospital logo. E#4 licked bare fingers while reviewing pages of Pt #5's surgical record, then proceeded to prepare medications without hand hygiene and /or donning gloves. E# 4's cell phone buzzed during the procedure. E#4 removed it from front pocket, viewed the phone, returned phone to pocket then proceeded with patient care. E#4 did not perform hand hygiene after handling the phone. Due to Pt #5 exhibiting decreasing oxygen saturation during the procedure, E#4 inserted a nasal airway after 2 unsuccessful attempts. E#4 did not wear gloves or complete hand hygiene prior to or between attempts at insertion. Fluids from the nasal passage were observed, along with topical anesthetic.

2. The CAH policy titled "Attire of Personnel in the Surgical Suite" dated 09/03 was reviewed on 4/12/16 at 11:30 AM. The policy indicates under I. POLICY, "The OR is considered to be a controlled environment therefore; all persons entering this area will be required to wear surgical clothing as provided by this facility." The policy titled "Infection Control" dated 07/15 was reviewed on 4/12/16 at 11:45 AM. The policy indicates under III RESPONSIBILITY, " All OR and PACU personnel will perform patient care activities in a manner that decreased the possibility of cross contamination." Under V. PROCEDURE, 2.6 Anesthesia personnel should wear disposable gloves when touching the patient's mucus membranes (intubation, suctioning, extubation etc). Standard precautions will be observed at all times. Under 12.3 Gloves shall be used when handling or touching any item that comes into contact with the patient's respiratory tract."

3. On 4/12/16 at 8:30 AM, an interview was conducted with the RN Surgery Director (E#3). E #3 was asked if staff are allowed to wear jewelry into the OR area (restricted). E#3 provided the policy and stated," It is a known policy jewelry is not to be worn. We follow AORN (Association of periOperative Registered Nurses) standards." E#3 agreed the observations during the OR procedure indicated infection control policies and standards were not being followed.

Based on document review and staff interview, it was determined in 1 of 4 (Pt #19) patient with wounds, the nurse failed to notify the physician of a Stage II open ulcer. This failure has the potential to affect all patients with skin breakdown.

Findings include:

1. The policy revision date 10/14, titled "Pressure Ulcer" was reviewed on 4/14/16 at 2:30 PM. The policy indicates under "V. PROCEDURE, 15.0 Notify the physician when other interventions are needed. 16.0 Notify physician if redness persists in an area or if an open area is noted on skin. Obtain physician's order for definitive pressure ulcer care."

2. The clinical record of Pt #19 was reviewed on 4/14/16 at 1:30 PM. Pt #19 was admitted to the CAH on 2/16/16 with diagnoses of dehydration and upper respiratory infection. Documentation in the initial nursing assessment of 2/16/16 indicated Pt #19 arrived from the SNF with a Stage II decubitus ulcer of the coccyx. There is no documentation to indicate the nurse notified the physician of the open ulcer and no orders for treatment were obtained.

3. On 4/14/16 at 2:00 PM, an interview was conducted with the Inpatient Director ( E#2). E#2 reviewed the record of Pt #19 and agreed there was no report to the physician and no orders for treatment.

A. Based on document review and staff interview, it was determined in 2 of 13 (Pt #2, #4) clinical records reviewed, the CAH failed to ensure history and physicals were completed within the required timeframe. This has the potential to affect all patients receiving services.
Findings include:

1. The CAH Rules and Regulations revised 12/2015 was reviewed on 4/13/16. The Rules and Regulations under "Section 2: Medical Records 4. ...A complete history and physical examination shall be recorded within twenty-four (24) hours of admission...".

2. The clinical record of Pt #2 was reviewed on 4/11/16 at 2:30 PM. Pt #2 was admitted on 4/9/16 with diagnosis of Chronic Obstructive Pulmonary Disease (COPD). The history and physical was not completed by the physician until 4/11/16, over the 24 hour timeframe.

3. The clinical record of Pt #4 was reviewed on 4/11/16 at 2:45 PM. Pt #4 was admitted on 4/9/16 with diagnosis of altered mental status. The history and physical was not completed by the physician until 4/11/16, over the 24 hour timeframe.

4. On 4/11/16 at 3:00 PM, an interview was conducted with the Inpatient Director (E #2). E #2 reviewed the history and physicals for Pt # 2 and Pt #4. E# 2 verified the history and physicals were not completed within the 24 hour timeframe.

B. Based on document review and staff interview, it was determined in 2 of 2 (Pt #5, #6) surgical records reviewed, the CAH failed to ensure the post-operative anesthesia follow-up was timed, potentially affecting all patients receiving surgical services.

Findings include:

1. The CAH Rules and Regulations revised 12/2015 was reviewed on 4/13/16. The Rules and Regulations under, "Section 2: Medical Records 8. CLINICAL ENTRIES. All clinical entries in the patient's records shall be accurately dated, timed and authenticated and legible...".

2. The clinical record of Pt #5 was reviewed on 4/13/16. Pt #5 was admitted on 4/12/16 for inguinal hernia repair. The "Post-Op Anesthesia Follow-Up" did not indicate a time of follow-up assessment.

3. The clinical record of Pt #6 was reviewed on 4/13/16. Pt #6 was admitted on 4/12/16 for a colonoscopy. The "Post-Op Anesthesia Follow-Up" did not indicate a time of follow-up assessment.

4. On 4/13/16 at 11:00 AM, an interview was conducted with the Surgical Director (E #3). E #3 reviewed the "Post-Op Anesthesia Follow-Up" of Pt #5 and #6. E #3 stated, there is no time documented and it should have been".

C. Based on document review and staff interview it was determined in 3 of 5 (Pt #13, #17, #18) ED transferring records reviewed, the CAH failed to ensure the transfer records were complete.

Findings include:

1. The CAH policy revision date, 11/07, titled, "Transfer to Other Health Facilities" was reviewed on 4/14/16. The policy under "8.0 Documentation on the Authorization for Transfer form 8.2 Section 1 Certify that either: 8.2.1.1 No emergency medical condition exists, sign and date the form and stop there....8.3 Section 2 (check one) 8.3.1 The patient requests transfer...8.4 Section 3 8.4.1 Unstable patients must have section A-E....".

2. The clinical record of Pt #13 was reviewed on 4/13/16 at 2:00 PM. Pt # 13 was admitted to the ED with chief complaint psychiatric evaluation. Pt #13 was transferred to psychiatric hospital for inpatient care. The "AUTHORIZATION FOR TRANSFER" was not completed in Section 1, Section 2 or Section 3.

3. The clinical record of Pt # 17 was reviewed on 4/14/16 at 9:30 AM. Pt # 17 was admitted to the ED with chief complaint of suicidal ideation and alcohol intoxication. Pt #17 was transferred to psychiatric hospital for inpatient care. The "AUTHORIZATION FOR TRANSFER" was not completed in Section 2.

4. The clinical record of Pt # 18 was reviewed on 4/14/16 at 10:00 AM. Pt #18 was admitted to the ED with chief complaint of seizure activity. Pt #18 was transferred to an inpatient hospital. The "AUTHORIZATION FOR TRANSFER" was not completed in Section 3.

5. On 4/14/16 at 11:00 AM, an interview was conducted with the Chief Nursing Officer (E # 1). E #1 reviewed the ED transfer forms of Pt # 13, #17, and # 18. E# 1 verified the transfer forms were not completed per policy.