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Based on observations in the post anesthesia care unit (PACU), review of 30 medical records and an interview with the manager of surgical services, it was determined that the hospital used a standing order sheet for pain control in the PACU for one patient (patient #5).

The PACU utilized a standing order sheet for pain control for patients over 12 years old. This order sheet contained range orders for fentanyl, hydromorphone, and morphine (IV pain medications) and also allowed the RN to choose which of the 3 medications to administer to the patient. The Certified Registered Nurse Anesthetist (CRNA) or anesthesiologist used this standing order form to select a "box" containing instructions for as needed (PRN) pain medications indicated for moderate to severe pain (5-10). In this "box" fentanyl 25-50 mcg IV, hydromorphone 0.2-0.5 mg IV, and morphine 2-5mg IV were all listed for the RN to choose which drug and which dose to administer for pain control. This sheet was reviewed with Lisa Block, , on 7/27/2015 and (name), the manager of surgical services, on 7/28/20105. Both confirmed that it did contain range orders.

Failing to have specific drug and dosage orders for a patient placed the patient at risk for potential harm and may have resulted in the nurse to performing outside of his or her scope of practice.

Three of ten observations revealed that hospital staff failed to perform proper hand hygiene, failed to wear personal protective equipment, failed to properly clean reusable equipment and failed to ensure that family members were properly attired for visitation in the isolation unit.

1. Observations of 5 staff members during a trans-esophageal echocardiogram (TEE) were conducted in the Catheter Lab on 7/?/2015 from 8:17 am to 9:10 am. One staff member present for the procedure failed to perform proper hand hygiene and failed to properly clean intravenous line port hubs and medication vial hubs prior to access. One staff member carried personal items into the procedure room.

Patient #9, suspect for heart valve vegetation, was taken to the Cath lab for a TEE ( transesophageal echocariogram). The Physician, Cardiac Physician Assistant (PA), RN, Sonographer and Anesthesiologist were present during this procedure. On arrival to the Cath lab the patient was placed on the cardiac monitor by the RN. The RN completed a brief assessment and documented his findings. The physician and the PA arrived 8:27 am. The physician carried her red purse into the procedure room and placed the purse on the pull down documentation station. Before donning her personal protective equipment (PPE) the physician moved the purse to hang inside of the procedure room door handle. The anesthesiologist arrived to the procedure room at 8:45 am. The anesthesiologist did not wash his hands after his arrival. The time out was completed at 8:46 am. The anesthesiologist proceeded to draw medications for sedation. The rubber hubs to the medication vials were not cleaned with alcohol prior to entering the vials with the needle. The anesthesiologist then proceeded to access the PIV line port with a new 3-way stop cock without cleaning the IV line port with alcohol. The anesthesiologist injected medication into the IV which caused burning to the patient. The anesthesiologist left the room to get additional medication without washing hands or using hand sanitizer and returned to the room with medication, again without washing his hands. At 8:57 am the anesthesiologist received a phone call. He reached into his top scrub pocket to retrieve his phone. After the call he placed the phone back in his pocket. At 8:58 am the anesthesiologist donned gloves, without prior hand washing. The procedure was completed at 9:03 am.


2. Observations of the Emergency Department (ED) were made on 7/27/2015 at 10:00 am. An RN wearing gloves was observed touching multiple surfaces including a keyboard, a telephone and a counter top in the public area. The same RN entered a patient's room wearing the same gloves. The RN left the room wearing the same gloves. She then re-entered the room still wearing the same gloves. Hand washing was not observed before or after the RN's entrance to or exit from the patient's room.

Failure to perform proper hand washing, appropriately donning PPE and effectively cleaning medication access ports prior to use place patients at risk for potential infection and harm. Also, exposing patients and medical staff to personal items, i.e. purse, places the patient and the provider at risk for exposure to harmful pathogens.


3. Based on review of a 28 patient medical records, a tour of the 3-South medical surgical area on 7/27/2015, observation of contact isolation practices and interviews of the licensed nursing staff, it was determined that contact isolation practices were not conducted in total as needed for the protection of patients and staff. This was evident for 1 of 28 patients reviewed during the survey. The findings were:
During the morning tour of 3-South Unit, patient #15 was observed to be on contact isolation. An interview of the licensed nursing staff revealed the patient had Methicillin Resistant Staphylococcus Aureus and Vancomycin Resistant Enterococci in the urine (both easily transmitted and highly contagious bacteria). The surveyor observed a person identified by staff as the patient's family member inside the patient's room wearing a yellow isolation gown on but not wearing gloves. The surveyor notified the Charge Nurse who on interview confirmed after observation that the patient's family member indeed was not wearing gloves as was required. After surveyor intervention, the charge nurse advised the patient's family member that gloves must be worn.

Failure by staff to consistently monitor visitors in the isolation unit for required protective measures potentially exposes visitors, staff and other patients to the risk of contracting spreading of infection.

4. Based on observations of a trans-esophageal echocardiogram (TEE), an interview with the sonographer, and review of documents it was revealed that the hospital failed to properly pre-clean the TEE probe at the completion of the procedure.


A TEE for patient #9 was observed on 7/28/2015 from 08:17 to 09:10 AM. At the completion of the procedure, the physician placed the soiled TEE probe into a red biohazard bag that was held by the sonographer who then carried it to the small sink located inside the procedure room. The sonographer is responsible for the cleaning process of TEE probes. The sonographer used Asepti-Zyme (a pre-soak and detergent for the Tee probe) to wipe the probe. No soaking of the probe was done as recommended. Within 30 seconds of wiping and rinsing the probe the sonographer then placed it in the high level disinfectant container that was located in the same procedure room.

An interview with the sonographer confirmed that Asepti-Zyme is used to clean the TEE probe. The manufacturer's instructions for the Asepti-Zyme stated to add ½ fluid ounce of detergent to 1 gallon of water, presoak instruments for 1-5 minutes and rinse items thoroughly. No measuring devices or markings were in the sink used to pre-clean the probe to indicate that the solutions were properly mixed.

Also observed during the TEE probe cleaning process was the presence of the RN and anesthesiologist in the pre-cleaning area. The sonographer was wearing appropriate personal protective equipment (PPE) for the cleaning process. The RN and anesthesiologist were both standing next to the sink in which the cleaning took place in the procedure room and no PPE was worn by either staff to protect against potential splash and harm.

A policy regarding instructions for the TEE probe cleaning process was requested. A policy specific to where the cleaning process should occur was provided. However, the hospital did not provide a policy specific to the actual cleaning process. A policy entitled "High Level Disinfection Using Cidex OPA"' was reviewed. This policy did state "if recommended, fully submerge the instruments in an enzymatic detergent and water for cleaning." The hospital failed to provide specific instructions for the cleaning of the TEE probe which could lead to potential transmission of infectious micro-organisms.

Based on a review of 1 of 4 closed outpatient surgical records and 1 of 30 total medical record reviews, it was revealed that the patient discharge instructions were illegible, and instructions regarding pain medications to be taken following discharge were unclear.


Patient #19 was a young adult male who presented for an outpatient laparoscopic appendectomy on 7/13/2015. Following the uncomplicated procedure, patient #19 was given a discharge form, "Patient Discharge Instructions," completed by the physician and RN.


The form had a pre-printed heading entitled, "Medication/Dosage/Frequency." Illegible physician handwriting on multiple lines followed. On 7/28/15 at approximately 11:00 am the form was read to the surveyor by an RN as follows, "Percocet, May take Tylenol or Motrin. Remove outer dressing in 3 days ___ steri-strips in place. See instruction sheet." No dose or frequency for the medications were noted on the form. Additionally, Percocet contains Tylenol. There was no indication that the patient was given this information, or instructed not to take Percocet and Tylenol together. On the same patient instruction sheet under a heading entitled "Nursing Discharge Instructions," an RN had written, "You may take Motrin or Aleve at 9:30 pm or later."


Review of the pre-printed instruction sheet failed to further clarify dosage of any medication written by the physician, but stated in part, "You may switch to Tylenol or Ibuprofen as directed by your surgeon when the pain improves." The form revealed that patient #19 was given one prescription. However, no documentation of the actual prescription was found in the patient's record which was likely for Percocet and which would have clarified the dose and frequency.


An interview with the nurse at 11:00 am revealed that all instructions are reviewed verbally with each patient prior to discharge from the outpatient surgery center. However, the information taken home by the patient gave illegible and unclear direction as to how the patient would care for himself. Based on all information, the hospital failed to provide clear and complete discharge instruction for patient #19.