HospitalInspections.org

Based on observation, hospital policy review, staff interview, and patient interview, it was determined the hospital failed to ensure 1 of 5 patients (Patient #53), whose procedures were observed, were informed of and retained a copy of their patient's rights. This had the potential to prevent patients from exercising their rights. Findings include:

A hospital policy "Patient's Rights and Responsibilities (QUAL)," approved 3/02/16, was reviewed. The policy included:

- "West Valley Medical Center provides each patient with a written statement of patient rights at the time of registration, and again at the time any patient or patient's representative has questions regarding their rights."

The hospital failed to follow their policy and provide Patient #53 a copy of his patient's rights. Examples include:

Patient #53 was an alert and oriented 35 year old male who was admitted for outpatient surgery on 12/01/16, for a laparoscopic right inguinal hernia repair and whose pre, intra, and post-operative care was observed. The OR Manager and Risk Management Clinical Quality Coordinator (RMCQC) were also present during the observation.

Patient #53 and his spouse were interviewed on 12/01/16, beginning at 8:35 AM. When asked if he had received a copy of his patient's rights, Patient #53 stated no. Patient #53's spouse was asked if she had a copy of Patient #53's patient's rights and she also stated no. Patient #53's spouse stated someone had informed them they would receive a copy of all of their paperwork upon discharge from the hospital. Patient #53's spouse presented what appeared to be a hospital receipt and stated it was the only paper she was provided.

Patient #53's record included a signed copy of patient's rights and responsibilities, dated 12/01/16 at 8:00 AM; however, a copy of the written statement of patient rights, at the time of registration, was not provided to Patient #53 or his spouse.

The Infection Preventionist (IP), OR Manager, and RMCQC were interviewed together on 12/01/16, beginning at 12:50 PM. They confirmed all patients should receive a copy of their patient's rights upon admission and stated hospital policy was not followed for Patient #53.

The hospital failed to follow their policy and provide Patient #53 a copy of his patient's rights.

Based on staff interview and review of Idaho state laws and medical records, it was determined the hospital failed to ensure the rights of 1 of 3 patients, who were placed on involuntary holds (Patient #8) and whose records were reviewed, were protected. The hospital failed to allow the patient to refuse treatment and failed to follow state statutes. This resulted in the unlawful detainment of the patient and the failure to protect his right to due process. Findings include:

Idaho state law at Title 66 Chapter 3, 66-320 states a "...person may be detained at a hospital...[if a] peace officer or a physician...has reason to believe that the person is gravely disabled due to mental illness or the person's continued liberty poses an imminent danger to that person or others, as evidenced by a threat of substantial physical harm...Whenever a person is taken into custody or detained under this section without court order, the evidence supporting the claim of grave disability due to mental illness or imminent danger must be presented to a duly authorized court within twenty-four (24) hours from the time the individual was placed in custody or detained." The law then states a court will assign a designated examiner to review the case.

Idaho state law at Title 66 Chapter 3, 66-320 further states "(3) if the director of the facility [hospital] determines that the patient should be hospitalized under the provisions of this chapter, the patient may be detained up to three (3) days, excluding Saturdays, Sundays and legal holidays, for the purpose of examination by a designated examiner and the filing of an application for continued care and treatment...(d) A patient admitted for examination pursuant to section 20-520 or 18-211, Idaho Code, may not be released except for purposes of transportation back to the court ordering, or party authorizing, the examination."

State law was not followed by the hospital in relation to 1 of 3 patients (Patient #1) who were placed on involuntary holds by the hospital and were not allowed to leave the hospital. Examples inlcude:

Patient #8 was a 69 year old male who was admitted to the hospital on 8/05/16, and was discharged on 8/08/16. Diagnoses included altered mental status, acute encephalopathy, chronic narcotic use, and diabetes.

A nursing progress note, dated 8/06/16 at 5:38 PM, stated Patient #8 attempted to leave and was walking to the elevator doors. The note stated he was physically restrained and was given an IM injection of haldol, benadryl, and ativan.

A nursing note, dated 8/06/16 at 9:45 PM, stated Patient #8 wanted to leave the hospital. Again, the note stated he was given an IM injection of haldol, benadryl, and ativan.

A physician progress note, dated 8/06/16 at 3:45 PM, stated Patient #8's chief complaint was "altered mental status." The note stated "Neuro: Reports confusion (easily agitated). Psych: Reports: agitation (tangential thinking, slow ment)." The note stated Patient #8 was "...alert, (oriented times 2), is disoriented to time. No focal neurological or motor deficit. [Patient #8] became very angry and agitated. He refuses to do further testing and now is not mentally capable to make decisions for himself. He meets criteria at this point to be placed on a mental hold. IM haldol, benadryl, and ativan will be given now. Psychiatric consultation will be placed." An addendum to the note, dated 8/06/16 at 5:03 PM, stated Patient #8 "...required physical escort to his room, he was given IM haldol, IM benadryl, IM ativan. Physical restraints for 3 minutes. Sitting in room, lights are dark. Mental hold and psychiatric consultation placed."

The next physician progress note was dated 8/07/16, at 2:38 PM. It stated Patient 8 "...is on a mental hold, not complaining of anything today...The patient will continue on mental hold until full medical evaluation is completed."

The final physician progress note was the discharge summary dated 8/08/16, at 12:09 PM. It stated Patient #8 had a lumbar puncture and he was diagnosed with viral hepatitis. It stated he was oriented to self, place, and mostly to time. It stated "Psychiatry: normal affect, normal mood." It stated "Evaluated by psych and at the time of the operation mental status returned to normal and he felt there was no reason to maintain him on a hold or admit him to the psych unit. -Mental status appears to have resolved."

Patient #8 was discharged to home with his wife on 8/08/16.

There was no evidence the hospital followed a process to place Patient #8 on a mental hold even though he was prevented from leaving. There was no documentation that the legal process was initiated or that the court was notified of the hold. There was no documentation that Patient #8 was provided an evaluation by a Designated Examiner or given the opportunity to argue in court that he should be allowed to leave the hospital. There was no documentation Patient #8's hold was formally dropped before allowing him to leave the hospital.

Patient #8's physician was interviewed on 11/30/16, beginning at 11:25 AM. He stated he was not sure of the hold procedure. He stated a psychiatric nurse assisted him to complete the paperwork to file a mental hold for Patient #8. He stated he was not sure if the paperwork was filed with the legal authorities. He stated Patient #8 wanted to leave the hospital and was prevented from doing so.

Patient #8's medical record was reviewed with the Director of Advanced Clinicals, an RN, on 11/28/16, beginning at 3:15 PM. She confirmed the documentation and stated Patient #8 was prevented from leaving. She stated it was documented that Patient #8 was placed on a hold. She stated there was no documentation that the process was followed to place Patient #8 on a hold. She also confirmed there was no documentation the hold was discontinued by a court before the patient was discharged.

The hospital did not allow Patient #8 to refuse treatment. The hospital deprived Patient #8 of his physical freedom and his ability to participate in his care. When he requested to leave, the hospital detained him and then failed to notify the court which prevented him from receiving due process. The hospital discharged Patient #8 before a judgement was rendered that he was not a danger to himself or others.

Based on observation, hospital policy review, hospital document review, patient interview, and staff interview, it was determined the hospital failed to ensure the personal privacy of 1 of 1 ICU patients (Patient #54) who were interviewed about their patient's rights. This had the potential for inadequate patient privacy for all hospital patients being monitored by video surveillance. Findings include:

A hospital pamphlet given to patients upon admission, "Patient Rights and Responsibilities," revised 1/2016, was reviewed. The pamphlet included:

- "To be treated with consideration, respect and recognition of their individuality, including the need for privacy in treatment."

A hospital document "Consent for Photographing or Other Recording for Security and/or Health Care Operations," undated, was reviewed. The document included:

- "(Patient Initials [sic]) I consent to photographs, videotapes, digital or audio recordings, and/or images of me being recorded for security purposes and/or the practice's health care operations purposes (e.g. quality improvement activities)."

- "I understand that these images and/or recordings will be securely stored and protected."

A hospital policy "Photographing, Video Recording, Audio Recording, and Other Imaging of Patients, Visitors, and Workforce Members (HIM)," approved 7/29/16, was reviewed. The policy included 12 scenarios where photographs, audio/video recording, and/or video monitoring would be utilized. However, the policy did not include a scenario where video monitoring would take place via a stationary monitoring camera in a patient's room 24 hours per day, 7 days per week for the purpose of quality improvement activities, and did not include safeguards for patient privacy.

The hospital failed to protect patients' privacy. Examples include:

1. A tour of the ICU was conducted on 11/28/16, beginning at 10:35 AM, in the presence of the ICU Director and Risk Management Clinical Quality Coordinator (RMCQC). During the tour, stationary video monitoring cameras were observed in all ICU patient rooms. Each monitoring camera was mounted on the ceiling, oriented to face the patients' bed, and gave a full, detailed display of the room. The ICU Director stated the monitoring cameras did not record and were used for surveillance only.

When asked about the purpose of the monitoring cameras, the ICU Director stated they were used for patient safety and to reduce falls. When asked how the monitoring cameras were being utilized for quality improvement purposes, either unit-based or through the hospital QAPI program, the ICU Director stated she did not know and did not think the monitoring cameras were being used for that reason.

The display screen for the video feeds was located at the front ICU nurses station and was monitored by the telemetry tech. Each individual ICU room was displayed as one of 13 tiles on the nurses station monitor. The telemetry tech working at the time of the tour demonstrated how each room was displayed and how an individual room could be selected to fill the entire screen for increased detail and observation. When asked if the monitoring cameras could be turned off, both the telemetry tech and ICU Director first stated they were unsure, but later stated they could not. When asked how patient privacy was enforced during intimate personal care periods, the telemetry tech demonstrated how a "Post-It note" would be used to cover a patient's room tile on the display screen. When asked if the practice of covering the patient's room display with a sticky note was approved in a hospital policy, the telemetry tech stated she did not know.

During the tour, an ICU bedside RN and ICU Charge Nurse were interviewed together at approximately 11:25 AM. When asked if they were educated on the monitoring cameras purpose, they both replied no. When asked if they knew if the monitoring cameras could be turned off, they both replied no. When asked how they would protect patient's privacy if the monitoring cameras could not be turned off, they replied they would cover the patient's room display with a sticky note. Both RNs and the ICU Director were asked if the practice of covering the patient's room display with a sticky note was approved in a hospital policy, to which they stated no.

The display screen, with all 13 individual monitoring camera tiles, was easily viewable from either side of the nurses' station from both main hallways by other patients, employees, and the public. The ICU Director confirmed the display screen with private patient images could be viewed by anyone walking by the nurses station on either side in the main hallways. She confirmed the display screen would need to be covered, turned, or placed in a new location to protect patients' privacy.

Patient #54 was an alert and oriented 71 year old male who was admitted to the ICU on 11/27/16, for chest pain, and was an inpatient during the unit tour on 11/28/16. Patient #54 was interviewed in the ICU on 11/28/16, beginning at 1:30 PM. Patient #54 was asked if he understood why a monitoring camera was being used in his room, to which he replied he did not. He stated a RN told him the monitoring camera had to be used because "I was in the ICU," but remarked the RN did not elaborate further. Patient #54 stated he did not know if the camera could be turned off and stated it made him feel uncomfortable. When asked if anyone had explained the consent for video surveillance he had signed, Patient #54 stated he was unsure as he had "signed a lot of stuff."

The ICU Director was interviewed on 11/28/16, beginning at 1:57 PM, and Patient #54's interview comments were discussed. The ICU Director stated the monitoring cameras, video surveillance consent, and patient privacy concerns should have been fully explained to the patient.

2. A tour of the ED was conducted with the ED Director, ED Charge Nurse, Director of Quality and Risk Management, and the Clinical Quality Coordinator, on 11/29/16, beginning at 1:00 PM.

a. During the tour, a monitoring camera was noted in ED Room #6, which was used specifically for psychiatric patients. The display screen for the monitoring camera was located at the rear ED nurses station and was easily viewable from the left side hallway by patients, employees, and the public.

The CNO and Director of Quality and Risk Management were interviewed together on 11/29/16, beginning at 2:15 PM. They confirmed the ED display screen could be viewed by anyone on the left side hallway of the nurses station and stated it should be covered, turned, or placed in a new location to protect patients' privacy.

b. During the tour, 6 ED patient tracking boards were observed throughout the department. The tracking boards were large screen TV monitors which displayed information to track patients in the ED. These tracking boards were visible to patients, family members, and the public walking through the department. The monitors displayed the following information:

- The first 3 letters of the ED patient's first and last name

- Patient age

- Primary symptoms/diagnosis

- ED room number

- ED nurse assigned to the patient

- ED physician caring for the patient

One ED patient listed on the tracking board had "Psych," psychiatric, listed as his primary symptom/diagnosis.

When asked during the tour, the ED Director and Director of Quality and Risk Management confirmed the tracking boards displayed this information since they began using them several years ago. The ED Director stated the tracking boards were utilized to assist staff in monitoring patients in the ED for orders or pending orders, and which physician was in charge of the ED patient's care, and to aid in the flow of the department. They confirmed the boards were visible to staff, patients, and public walking through the ED. When asked about the patient information displayed on the tracking board they confirmed some of the information may be considered sensitive or private.

The hospital failed to protect patients' privacy.



00023

3. A tour of the Behavioral Health Unit was conducted with the Director of the unit on 11/29/16, beginning at 9:55 AM. During the tour, a patient was noted to be sleeping in room 306. In the nursing station, it was observed that a video feed displayed the patient while he slept. The Director of the unit stated there was continuous video monitoring of room 306. She stated staff were not able to turn off the video camera, even while the patient may be undergoing personal cares or dressing. She stated the patient had chosen to sleep in room 306 because it was quiet. She stated there was no clinical need for video surveillance of the patient.

Patients in room 306 were not afforded personal privacy.

The hospital failed to protect patients' privacy.

Based on medical record review, observation, hospital policy review, and staff interview, it was determined the facility failed to ensure thorough nursing care plans were developed, and/or followed, for 5 of 55 patients (#7, #8, #21, #22, and #41) whose care plans were reviewed. Lack of a complete care plan and failure to follow care plan interventions had the potential to result in patient care needs that were not addressed and interfered with coordination of patient care among disciplines. Findings include:

A hospital policy "Care Planning," approved 11/28/16, was reviewed. The policy included:

- "Priorities for care will be identified by reviewing the following and placed on the patient's care plan"

- "...Identification of the priority (need)"

- "...Plans/steps to meet the needs, based on the patient's individual needs."

The hospital failed to follow their policy and ensure thorough care plans were developed for patients. Examples include:

1. Patient #7 was a 61 year old female who was admitted on 11/26/16, with a diagnosis of acute kidney injury, constipation, and chronic pain, and was a current inpatient as of 11/28/16.

An ICU interdisciplinary meeting was observed on 11/28/16, beginning at 11:10 AM. Patient #7's hospitalist, assigned RN, and the ICU Charge Nurse were present for the meeting. Patient #7's assigned RN stated Patient #7 had been experiencing increased chronic and acute pain. Patient #7's hospitalist stated he was previously aware of her pain, but did not want to order anything new at that time.

Patient #7's electronic medical record was reviewed with the ICU Charge Nurse on 11/28/16, beginning at 12:55 PM. Patient #7's electronic medical record included a form "Health plan of care," dated 11/28/16, and completed by the assigned RN for the current shift. The following problems were identified on Patient #7's care plan:

- "Fluid volume
- Activity
- Gastrointestinal
- Injury risk"

"Pain" was not documented in Patient #7's care plan. The ICU Charge RN was asked if pain should be addressed in her care plan, to which she stated yes.

The hospital failed to follow their policy and ensure a thorough care plan was developed for Patient #7.



00023

2. Patient #41 was a 38 year old female who was admitted to the hospital on 11/18/16, for suicidal ideation and bipolar disorder. She was currently a patient as of 12/01/16.

The "Inpatient Admission History and Assessment," dated 11/18/16, at 5:17 PM, stated Patient #41 had a plan to harm herself by overdosing. The document stated she had a history of at least 5 prior psychiatric hospitalizations.

A physician progress note, dated 11/25/16, at 1:13 PM, stated Patient #41 was receiving electroconvulsive therapy for severe depression. The note stated she would have a PICC line placed to facilitate the procedures. The note stated Patient #41 was "...still having suicidal ideation with plans."

The PICC line was placed on 11/26/16. PICC lines provide direct access to the patient's heart via an intravenous tube. A PICC line provides several options for a suicidal patient who wishes to harm herself, such as blood loss from PICC line self-removal or injecting foreign substances directly into the line.

Patient #41's current POC, dated 11/29/16, included problems of self harm potential and PICC line. Interventions for self harm included 15 minute general checks and environmental rounding. Interventions for the PICC line included flushing the line periodically and assessing the insertion site. The POC did not include interventions to prevent Patient #41 from using the PICC line to harm herself.

The Director of the Behavioral Health Unit was interviewed on 12/01/16 beginning at 11:00 AM. She reviewed Patient #41's POC and stated it did not address the how staff would monitor the PICC line to prevent the patient from using it to harm herself.

Patient #41's POC was not complete.

3. Patient #8 was a 69 year old male who was admitted to the hospital on 8/05/16, and was discharged on 8/08/16. Diagnoses included altered mental status, acute encephalopathy, chronic narcotic use, and diabetes.

Patient #8's H&P, dated 8/05/16 at 9:52 PM, stated he took morphine, norco (hydrocodone, a narcotic), and Advil for pain. The H&P stated Patient #8's wife reported he had chronic pain and chronic narcotic dependence.

Due to Patient #8's mental status, no narcotic medications were ordered while he was hospitalized.

Patient #8's POC was updated on 8/05/16 at 10:22 PM, and again on 8/08/16 at 5:17 PM. Pain was not included in the POC.

Patient #8's medical record was reviewed with the Director of Advanced Clinicals, an RN, on 11/28/16, beginning at 3:15 PM. She stated pain was not included in his POC.

Patient #8's POC was not complete.



34507

4. Patient #21 was a 27 year old female who was admitted on 11/28/16, for pre-term vaginal delivery in the ED of Patient #22. The nursing care plans for Patient #21 and Patient #22 were not individualized to meet their current needs as follows:

Patient #21 was at 37 and 2/7 weeks gestation and delivered Patient #22 at 8:45 AM on 11/28/16. Her record documented she came to the ED by car and the L&D staff was called to the ED for a precipitous delivery. A precipitous delivery is when the mother experiences an unusually rapid labor and the infant is spontaneously delivered, often unexpectedly outside of a hospital or Labor and Delivery area (e.g. ED, car, parking lot).

Patient #21's record documented she received no prenatal care during her pregnancy and her urine tested positive for methamphetamines and amphetamines. Patient #22 was tested for illegal substances and tested positive as well. Child Protective Services (CPS) was notified by nursery staff of the positive urine drug test for Patient #21 and Patient #22. Patient #22 was placed on a hold by CPS.

- Patient #21's nursing care plan included discharge planning, safety, falls, infection, pain, age-related care, knowledge deficit, and postpartum anxiety. The nursing care plan did not address Patient #21's illegal drug use or involvement of CPS and social services.

- Patient #22's nursing care plan included discharge planning, safety, infection, age related care, hypothermia, and hypoglycemia. The nursing care plan did not address Patient #22's hold by CPS, exposure to illegal drugs, or involvement of social services.

During an interview on 11/29/16 at 9:45 AM, the Director of L&D confirmed the nursing care plan did not address the significant issues identified above for Patient #21 and Patient #22.

Patient #21's and Patient #22's nursing care plans were not individualized or updated to meet their current needs or circumstances.

Based on medical record review, observation, hospital policy review, and staff interview, it was determined the hospital failed to ensure patient medical record entries were complete and accurate for 1 of 5 surgical patients (Patient #53) whose records were reviewed. This resulted in inconsistent documentation of patients' allergies and had the potential for unsafe medication administration for all hospital patients. Findings include:

A hospital policy "Organizational Plan for Assessment and Reassessment," approved 8/17/16, was reviewed. The policy included:

- "Admission Assessment/Reassessment Criteria: ...Allergies".

The hospital failed to follow their policy and ensure complete and accurate patient allergy documentation. Examples include:

Patient #53 was an alert and oriented 35 year old male who was admitted for outpatient surgery on 12/01/16, for a laparoscopic right inguinal hernia repair and whose pre, intra, and post-operative care was observed.

Patient #53 was observed in pre-op holding on 12/01/16, beginning at 8:35 AM. He was noted to have an allergy band on his right wrist which stated "ALLERGY." Patient #53's pre-op RN was observed asking him to confirm his allergies as part of the pre-operative assessment. When asked what allergy he had, Patient #53 stated he was allergic to hydrocodone (a medication for pain) and penicillin (an antibiotic medication).

Patient #53's surgeon pre-op evaluation was observed on 12/01/16, at approximately 8:50 AM. The surgeon asked Patient #53 if he was allergic to any medication to which Patient #53 stated hydrocodone and penicillin.

Patient #53's medical record included a document "ADULT PRE-OP GENERAL SURGERY ORDERS," revised 6/2015, and signed by Patient #53's surgeon. The order did not document a date or time they surgeon signed it; however, the order was noted by an RN on 12/01/16, at 7:30 AM. The document included a section titled "Allergies & Sensitivities" which allowed space to list Patient #53's medication and/or environmental allergies. This section did not document he was allergic to hydrocodone and penicillin.

Patient #53's medical record included a document "ADULT POST-OP GENERAL SURGERY ORDERS DAY SURGERY," revised 4/2013, and signed by his surgeon. The order was signed by the surgeon on 12/01/16, at 10:45 AM and noted by a different RN on 12/01/16, at 11:50 AM. The document included a section titled "Allergies & Sensitivities" which allowed space to list Patient #53's medication and/or environmental allergies. This section did not document he was allergic to hydrocodone and penicillin. Additionally, the document included a section titled "Analgesia" which had pre-printed pain medications orders for moderate and severe pain. One medication ordered in this section for moderate pain, as denoted by a filled-in checkbox next to the medication name, was "HYDROcodone [sic]/APAP 10/325 mg 1 - 2 Tabs PO Q 4 hrs PRN moderate pain".

The OR Manager was interviewed on 12/01/16, beginning at 2:42 PM, and Patient #53's medical record was reviewed in her presence. She confirmed the pre and post-operative orders should have listed Patient #53's allergies. Additionally, the OR Manager confirmed hydrocodone was ordered for him despite his verified allergy. She stated the error should have been identified by the surgeon and the PACU RN.

The hospital failed to follow their policy and ensure complete and accurate patient allergy documentation for Patient #53.

Based on record review and staff interview, it was determined the hospital failed to ensure patient records included all reports of treatment and interventions for 1 of 11 patients (Patient #21) whose ED records were reviewed. This failure had the potential to negatively affect the care provided for the patient and the ability to appropriately monitor the patient's condition. Findings include:

Patient #21 was a 27 year old female who was admitted on 11/28/16, for pre-term vaginal delivery in the ED.

Patient #21's record included a form "Deliveries Unattended by a Physician or CNM." The form documented Patient #21 was 37 and 2/7 weeks pregnant and delivered the baby at 8:45 AM on 11/28/16, in the ED. The form stated she came to the ED by car and the L&D staff was called to the ED for a precipitous delivery (A precipitous delivery is when the mother experiences an unusually rapid labor and the infant is spontaneously delivered, often unexpectedly outside of a hospital or Labor and Delivery area (e.g. ED, car, parking lot).

The form additionally documented she was taken from the ambulance bay in the ED to ED room 12 and the newborn was delivered while wheeling her into the room. After delivery of the baby, Patient #21 and her baby were transported to the Family Maternity Center by L&D staff. Patient #21's L&D assessment was timed 9:49 AM on 11/28/16.

Patient #21's record did not include documentation from the ED regarding her presentation, triage, or delivery.

During an interview on 11/29/16 at 9:45, the Director of L&D confirmed there was no ED record for Patient #21.

During an interview on 11/30/16 at 2:50 PM, the Director of the ED confirmed there was no ED record for Patient #21.

The hospital failed to ensure Patient #21's record included all reports of treatment and interventions.

Based on hospital policy review, observation, and staff interview, it was determined the hospital failed to ensure physicians and nursing staff followed effective infection control practices, including hand hygiene. This directly affected 1 of 5 patients (Patient #53) whose procedures were observed, and had the potential to affect all patients. This had the potential to result in patients acquiring healthcare associated infections. Findings include:

A hospital policy "Hand Hygiene Policy (IC)," approved 11/24/15, was reviewed. The policy included:

- "Use soap and water OR [sic] an alcohol-based hand sanitizer for the following:...before and after use of gloves, standard or sterile".

A second hospital policy "Aseptic Technique (OR)," approved 8/19/16, was reviewed. The policy included:

- "All personnel working within the Perioperative Services must have a basic knowledge and appreciation of aseptic technique and contamination control".

- "The Perioperative Services Department will adhere to the Infection Control Committee and Infection Control Practitioner guidelines for infection control".

The hospital failed to follow their policies and guidelines. Examples include:

1. Patient #53 was an alert and oriented 35 year old male who was admitted for outpatient surgery on 12/01/16, for a laparoscopic right inguinal hernia repair and whose pre, intra, and post-operative care was observed. The OR Manager and Risk Management Clinical Quality Coordinator (RMCQC) were also present during the observation.

a. Patient #53's pre-surgical surgeon evaluation was observed on 12/01/16, beginning at 8:50 AM. During the pre-surgical evaluation, the surgeon asked Patient #53 if his surgical site had been previously marked; to which he responded no. Patient #53's surgeon removed a commercial dry-erase marker from the wall, used it to mark his groin surgical site, and then placed the marker back on the wall. A surgical pen was not used to mark his groin surgical site and the commercial marker was not cleaned before or after use.

The Infection Preventionist (IP), OR Manager, and RMCQC were interviewed together on 12/01/16, beginning at 12:50 PM. They confirmed the commercial dry-erase markers should never be used for marking surgical sites and stated after the marker had been used it should have been discarded. Additionally, they confirmed the observed action did not follow their aseptic technique policy or Infection Control Practitioner guidelines.

The hospital failed to follow their policy and guidelines.

b. Patient #53 was observed being transported via gurney to the OR suite at 9:50 AM. Prior to intubation, the Anesthesiologist delivered oxygen via an amboo bag and mask. When removing the mask from Patient #53, the mask was observed to fall to the floor. The contaminated mask was then picked up by the Anesthesiologist and placed on the anesthesia cart in the same area medications were prepared. The mask was not cleaned before it was returned to the anesthesia cart. Multiple medications were observed being prepared in this area during the surgical procedure. At the end of the procedure, at approximately 10:50 AM, the Anesthesiologist was observed placing the same, contaminated mask back on Patient #53's mouth after he was extubated.

The IP, OR Manager, and RMCQC were interviewed together on 12/01/16, beginning at 12:50 PM. They confirmed the oxygen delivery mask should have either been cleaned or replaced once it fell to the ground. Additionally, they confirmed the observed action did not follow their aseptic technique policy or Infection Control Practitioner guidelines.

The hospital failed to follow their policy and guidelines.

c. Patient #53 was observed being transported via gurney to the OR suite at 9:50 AM. Prior to the pre-surgical hair clipping of his groin area, the circulating RN was observed placing two long pieces of abdominal tape on the side of the gurney. During the hair clipping, one of the pieces of tape fell to the floor. The surgeon entered the OR suite at approximately 9:55 AM where he was observed to pick up the fallen piece of tape with gloved hands and immediately use it to remove Patient #53's clipped groin hair.

The IP, OR Manager, and RMCQC were interviewed together on 12/01/16, beginning at 12:50 PM. They confirmed the tape should have been discarded immediately after it fell to the ground and should have never been used to remove Patient #53's hair clippings. Additionally, they confirmed the observed action did not follow their aseptic technique policy or Infection Control Practitioner guidelines.

The hospital failed to follow their policy and guidelines.

d. At approximately 10:00 AM, once Patient #53 was in the OR suite, the circulating RN was observed to not wash his hands or use alcohol-based hand sanitizer prior to donning sterile gloves.

The IP, OR Manager, and RMCQC were interviewed together on 12/01/16, beginning at 12:50 PM. They confirmed the circulating RN should have used an approved method of hand hygeine prior to donning sterile gloves. Additionally, they confirmed the observed action did not follow their aseptic technique policy or Infection Control Practitioner guidelines.

The hospital failed to follow their policy and guidelines.

Based on staff interview, it was determined the hospital failed to ensure discharge plans were reviewed to ensure that they were responsive to discharge needs. This prevented the hospital from monitoring its discharge planning process. Findings include:

The Director of Case Management was interviewed on 11/30/16, beginning at 10:20 AM. She was asked for documentation to show discharge plans were reviewed to determine if they were responsive to discharge needs, she stated discharge plans were reviewed by the Utilization Review Committee as part of a larger review of patients who were readmitted to the hospital. She stated there was no specific documentation that a review of discharge plans had been conducted to determine if they were responsive to discharge needs.

The Director of Quality and Risk Management was interviewed on 12/02/16, beginning at 9:30 AM. He stated a program had been developed to review discharge plans but said it had not been implemented yet.

The hospital failed to review discharge plans to ensure that they were responsive to discharge needs.

Based on observation, policy, and interview it was determined the hospital failed to ensure a timeout was performed for 1 of 5 patients observed (Patient #6) during a procedure. This deficient practice had the potential to cause harm to the patients. Findings include:

The hospital's policy "SAFE PROCEDURAL AND SURGICAL VERIFICATION," last approved 8/19/16, stated the following:

"Time-Out (Immediately prior to the incision/or start of procedure):

Physician/proceduralist performing the procedure initiates Time-out. At a minimum this includes:
Surgeon/ proceduralist calls the time out.
Surgeon/ proceduralist ensures all activities [sic] ceases.
Surgeon/ proceduralist ensures active engagement of all team members.
Surgeon/ proceduralist ensures all questions and/or concerns are answered ...

Time-Out is a period of time after induction and before puncture or incision during which all activity and conversation in the procedure area ceases. All members of the surgical/procedural team participates in the positive verification of the patient, the intended procedure, and the visualization of the marked site of the procedure."

Patient #6 was a 67 year old male admitted on 11/28/16, for supraventricular tachycardia (a rapid heart rate that causes poor heart function, and often causing a fluttering sensation in the chest and/or lightheadedness). He had a planned electrophysiology study (also called EPS - a study of how electricity moves through the heart to cause it to pump).

An observation of the start of Patient #6's EPS study occurred on 11/28/16, beginning at 2:28 PM. Patient #6 was brought into the CCL suite at 2:29 PM and he was prepped for the procedure. At 2:48 PM the Cardiologist entered the room and spoke with the circulating RN regarding the procedure. Three other team members were in the CCL room; the CV Technician, an RN doing the monitoring, and an RN training on the monitor. The three team members were involved in other activities and did not appear to participate in the discussion with the Circulating RN and the Cardiologist. There was no team consensus on Patient #6's identification, procedure, allergies, or other potential concerns.

The RN training on the monitor was questioned, and she stated the conversation between the Circulating RN and the Cardiologist was the Time-Out. She stated "Yes, this is what this cardiologist does for the Time-Out."

The Director of Quality and Risk Management was present during the observation. He agreed no Time-Out was performed for Patient #6's procedure.

The hospital failed to ensure a Time-Out was performed prior to the start of the procedure on Patient #6.