HospitalInspections.org

Based on document review and interview, it was determined that for 3 of 4 patients' (Pt.#2, Pt. #9, and Pt. #10) clinical records reviewed for suicide risk assessment and reassessments, the hospital failed to ensure that staff completed the suicide risk re-assessments for behavioral health patients as required.

Findings include:

1. The hospital's policy titled, "Suicide Risk Assessment" (revised 03/2022) was reviewed and required, "It is the policy (name of hospital) and the Adult Mental Health Unit to assess each patient every shift for suicidal ideation or thoughts. Each RN (Registered Nurse) is to assess the patient every shift and document that as a part of their nursing reassessment ... Early awareness and assessment of suicidal intent is a major aspect of preventing its occurrence."

2. The clinical record for Pt. #2 was reviewed on 10/22/24. The intake report dated 8/15/2024 indicated that Pt.#2 was transferred from another hospital on 8/15/2024 for paranoia and delusion (believes someone is trying to harm [Pt.#2]). The patient has a history of bipolar disorder. The clinical record lacked documentation that a suicide risk reassessment was completed for the day and evening shifts on 08/16/24 through 08/20/24.

3. The clinical record for Pt. #9 was reviewed on 10/23/24. Pt. #9 was admitted to 5-South (Adult Behavioral Health Unit) on 10/21/24 with a diagnosis of aggressive behavior. The clinical record lacked documentation that a suicide risk assessment was completed for the day and evening shifts on 10/22/24 and 10/23/24.

4. The clinical record for Pt. #10 was reviewed on 10/23/24. Pt. #10 was admitted to 5-South on 10/05/24 with a diagnosis of schizophrenia (mental disorder affecting the ability to think and behave clearly). The clinical record lacked documentation that a suicide risk reassessment was completed by the nurse for the following dates: 10/06/24, 10/08/24, and 10/22/24.

5. An interview was conducted with the Chief Nursing Officer (CNO/E #1) on 10/23/24 at approximately 1:15 PM. E #1 stated that suicide risk assessment and re-assessments should be conducted on all patients every shift by the nurse and document the assessment in the clinical record. E #1 confirmed that for (Pt.#2, Pt.#9, and Pt.#10) the suicide risk re-assessments were not documented in their clinical records.

A. Based on document review, observation, and interview, it was determined that for 1 of 1 operating room (OR) cleaning and disinfection observed in (OR #1), the hospital failed to ensure that the operating room was maintained clean and disinfected as required by policies governing surgical care.

Findings include:

1. The hospital's policy titled, "Environmental Cleaning" (revised 01/2023) was reviewed and required, "A. Effective housekeeping will be established and maintained to reduce and control the possibility of cross-contamination and infection of the patient and assigned employees ..."

2. The hospital's policy titled, "Aseptic Technique in the O.R. (Operating Room)" (revised 05/2022) was reviewed and required, "I. Policy: Basic principles of asepsis and aseptic technique shall be strictly adhered to in creating and maintaining a sterile field for every surgical procedure ... ensure and provide a safe environment for the surgical patient by controlling sources of contamination that may cause surgical site infections."

3. On 10/21/2024 between 10:50 AM to 12:30 PM, an observational tour of the Surgical Department including the Operating Room (OR #1) was conducted along with the Nurse Supervisor (E #2) and the Surgical Assistant (E #3). During the observation of cleaning and disinfection of the OR #1 after a procedure and during set up of the OR the following was observed:

-At 11:52 AM to 12:00 PM, E #6 (Enviromental Staff/EVS) was observed disinfecting equipment including an IV (intravenous pole), E #6 wiped the bottom of the pole, then wiped the top of the pole. E #6 then walked over to the garbage receptacle, lifted the lid with gloved hands instead of using the foot pedal to discard garbage then continued to move two mayo stands (small surgical tables) that had already been disinfected without performing hand hygiene. E #6 then started to mop the floor, E #6 was observed picking up something from the floor and discarded the item into the garbage receptacle, and again moved the two mayo stands without performing hand hygiene. There was also a brown leather purse on the bottom shelf of a table that was near the entrance of the OR, this item remained in the OR during and after the disinfection of the OR and when the next patient was brought into OR #1 at 12:15 PM. Additionally there was no visible alcohol based rub for staff to perform hand hygiene.

4. An interview was conducted with the Charge Nurse of the OR (E #4) on 10/22/2024 at approximately 2:15 PM. E #4 stated that during the cleaning and disinfection of the OR after a procedure, staff are required to perform hand hygiene and don new gloves prior to touching equipment that has already been disinfected. E #4 was asked where the alcohol based rub was located in OR #1. E #4 stated that E #4 puts the alcohol based rub under a cabinet. E #4 stated that personal items such as bags or purses are not allowed in the OR. E #4 confirmed that the brown purse belonged to the surgeon.

B. Based on document review, observation, and interview, it was determined that for 2 of 5 staff (Surgical Assistant E#2 and Anesthesiologist/MD #2) the hospital failed to ensure that the policy regarding surgical attire was not followed by not ensuring hair was completely covered by a head covering in the operating room.

Findings include:

1. The hospital's policy titled, "Surgical Attire" (revised 09/2022) was reviewed and required, "III. Guidelines: 1. Persons who enter the semi-restricted and restricted areas of the OR will wear appropriate OR scrub attire ... 7. All persons entering restricted areas of the surgery department ... Head covers/surgical hats must cover all exposed head and facial hair ... 12. Universal precautions will be adhered to all times in the OR."

2. On 10/21/2024 between 10:50 AM to 12:30 PM, an observational tour of the Surgical Department including the Operating Room (OR #1) was conducted along with the Nurse Supervisor (E #2) and the Surgical Assistant (E #3). During the observation of a set up of OR #1 the following was observed:

-At 12:00 PM to 12:15 PM, during the set up of OR #1, an OR Technician (E #5) and the Surgical Assistant (E #3) started to prepare the sterile field to set up surgical equipment and supplies. E #3 was assisting E #5 in opening sterile packages and dropping onto the sterile field, E #3 had arm hair exposed during this time. An Anesthesiologist (MD #2) entered the room during this time and had approximately 3-4 inches of hair exposed at the neck.

3. An interview was conducted with the Charge Nurse of the OR (E #4) on 10/22/2024 at approximately 2:18 PM. E #4 stated that staff are required to have all hair covered, including facial and arm hair when entering the semi-restricted and restricted areas.

C. Based on document review, observation, and interview, it was determined that for 1 of 1 Anesthesiologist (MD #2) observed for medication preparation, the hospital failed to ensure that staff adhered to the hospital's policy governing surgical care.

Findings include:

1. The hospital's policy title, "Medication in the O.R. (Operating Room)" (revised 09/2022) was reviewed and required, "I. Policy: Ensure that the safe medication practices are followed within the intra-operative setting. 6. All medications containers (syringes, medications cups, basins) and other solutions on and off the sterile field must be labeled even if there is only one medication involved ... need to occur when medications have been removed from the original packaging ... 7. Discard any solution or medication found in the OR without an identification label in the biohazardous sharps container ..."

2. On 10/21/2024 between 10:50 AM to 12:30 PM, an observational tour of the Surgical Department including the Operating Room (OR #1) was conducted along with the Nurse Supervisor (E #2) and the Surgical Assistant (E #3). During the observation of a set up of OR #1 the following was observed:

-At 12:13 PM, the Anesthesiologist (MD #2) was observed by the anesthesia cart preparing a medication from a new vial that was taken out of the locked medication drawer. MD #2, did not label the syringe after the preparation of the syringe. MD #2 set the syringe on top of the cart and left the room for approximately 5 minutes leaving the unlabeled syringe unattended on top of the cart.

3. An interview was conducted with the Charge Nurse of the OR (E #4) on 10/22/2024 at approximately 2:15 PM. E #4 stated that after a medication is prepared, the medication should be labeled and not left unattended.