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Based on observation, staff interview and facility policy and procedure review, the facility failed to protect the personal medical information of eight (#3, #5, #10, #18, #27, #28, #29 and #30) of 17 post-surgical inpatients. The facility had a census of nine patients at the time of the survey.

Findings include:

Review of the facility's policy and procedure entitled HIPPA (Health Information Privacy Portability Act) with a most recent review date of 8/14 directed that Patients receiving medical care at the Surgical Hospital at Southwoods have an expectation that their medical information will be kept private. Item 3 m of the facility procedures direct that Patient information should never be left unattended. This included leaving patient information, whether stored on any media type, including paper or laptops or leaving patient information lying around in plain sight for others to see.

Observation on 06/18/15 at 8:07 AM revealed the Charge Nurse Report Sheet was observed on top of an open file basket located on the counter of the nurse station in the center of the facility's inpatient unit and accessible to all visitors and ambulating patients. This report sheet was observed to contain the patients' names of Patient #3, #5, #10, #18, #27, #28, #29 and #30, their physician's names, the patients' reported pain levels, their diagnoses, and other significant issues.

Interview with Staff B on 06/18/15 at 8:07 AM verified patients' medical information for the above referenced patients was opened and accessible to visitors and ambulating patients.

Based on observation and staff interview, the facility nursing staff failed to follow safe needle handling for one patient observed during tour of medication room. (Patient #30) The facility had a census of nine patients at the time of the survey.

Findings include:

Observation of insulin injection for one patient (#30) on 06/16/15 at 7:16 AM revealed Staff H was observed in the medication room to gather a syringe and needle from the counter drawer and prepare an insulin injection for Patient #30. Staff H reached into a medication room drawer and withdrew two packaged needles. Staff H used a larger needle to draw up the medication, removed the large needle and opened and attached a smaller subcutaneous needle and proceeded to Patient #30's room and injected Patient #30. Staff H was observed to use two hands to place the contaminated needle into its plastic protective cap and dispose in the sharps container located in Patient 30's room.

Interview with Staff I on 06/17/15 at 2:35 PM revealed the facility followed the Centers for Disease Control (CDC) guidelines for sharp and needle safety. Staff I verbalized staff were instructed to never use a two handed recap of a contaminated needle. Staff I verbalized the facility has safety needles and that staff are instructed to convert traditional needles to a safety needle following medication preparation and to use the safety mechanism to avoid needle stick exposure. Staff I explained this was also part of the on-going annual education project for the facility based on the current CDC guidelines. Staff I, verbalized, "No, it is not an accepted practice to use a two handed recap of contaminated needles."

This deficient practice was verified with Staff B on 06/18/15 at 10:35 AM during an environmental tour of the medication room. Staff B identified the drawer where traditional needle packages were stored. Staff B then pointed out the location of the shelving unit located behind this drawer where the safety needles were stored. Staff B verbalized that staff are instructed to prepare medications with traditional needles and then to convert to a safety needle prior or a needle-less device prior to the administration of medications.

Based on medical record review, staff interview and policy and procedure review, the facility failed to properly authenticate orders for five (#21, 22, #25, 26 and 28) of 30 patients reviewed for completeness of physicians' orders. The facility had a census of nine patients at the time of the survey.

Findings include:

1. Patient #25 was admitted to the facility for scheduled surgery on 06/17/15 for right modified radical mastectomy with breast reconstruction for the diagnoses of breast cancer. Review of the medical record revealed an "Anatomic Pathology Lab Requisition" (physician orders) form. The requisition (order) was not signed by any authenticating physician or physician's extenders' signature to validate the lab orders. This finding was verified with Staff C on 06/17/15 at 1:36 PM

2. Patient # 22 was admitted to the facility on 06/16/15 for scheduled surgery for bilateral breast reduction surgery. Review of the medical record revealed the Anatomic Pathology Lab Requisition form (physician orders) form failed to contain any authenticating physician or physician's extenders' signature to validate the lab orders. This finding was verified with Staff C on 06/18/15 at 8:42 AM.







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3. The medical record review for Patient #21 revealed an "Anatomic Pathology Lab Requisition" form. The form revealed tissue (sentinel nodes from the left breast and right and left breast tissue) removed during surgery was collected for examination by a pathologist. The requisition (order) was not signed by the surgeon or any facility staff member.

Staff C was made aware of the above finding regarding Patient #21 on 06/17/15 at 1:35 PM. At that time Staff C stated the form was required to be signed and stated it was usually the RN signing it.

4. The medical record for Patient #26 revealed an "Anatomic Pathology Lab Requisition." The form revealed tissue (left and right fallopian tubes and uterus/cervix) removed during surgery was collected for examination by a pathologist. The requisition (order) was not signed by the surgeon or any facility staff member.

5. The medical record review for Patient #28 revealed a laboratory requisition form dated 06/18/15 for a BMP (basil metabolic panel) and CBC (complete blood count) to be drawn. The requisition (order) was not signed by the physician.

The medical record for Patient #28 also contained an "Anatomic Pathology Lab Requisition." The form revealed tissue (right sentinel node and right breast tissue) removed during surgery was collected for examination by a pathologist. The requisition (order) was not signed by the surgeon or any facility staff member.

Review of the facility policy and procedure entitled Handling Specimens with a most recent review date of 07/14 directed staff that in order to ensure positive patient outcomes by assuring that specimens were handled according to laboratory protocols. The policy further directed that all specimens were to be initialed and timed.

Interview with Staff C on 06/17/15 at 1:36 PM revealed the operating room circulating nurses were to prepare all surgical specimens for transport to the off-site contracted pathology laboratory for testing. All laboratory requisition slips were to be completed as verbal orders signed by the registered nurse for the surgeon, who would cosign at a later time. Specimens were then transported to the facility's pathology room where they were picked up by courier service and transported to the off-site pathology laboratory for testing. Staff C verbalized all orders were to be authenticated with a signature.

Based on medical record review and staff interview, the facility failed to update a history and physical for one patient (#18) of 30 patients reviewed for updated history and physicals prior to surgical procedures. The facility had a census of nine patients at the time of the survey.

Findings include:

Review of the medical record revealed Patient #18 was seen by the physician on 06/12/15 when a complete history and physical was performed prior to a left total knee arthroplasty surgery scheduled for 06/16/15 for a diagnoses of chronic and severe left knee pain. Review of the facility's admission surgery form entitled Pre-Procedure Evaluation Note initiated on 06/16/15 revealed the form contained a boxed area that directed the necessity of the form to be completed on the day of surgery or procedure. The form read History and Physical and Medication Reconciliation form reviewed, patient examined and the opportunity to check status unchanged or status changed, see changes listed below as well as a place for the physician's signature with date and time lines. Review of this form and the medical record revealed there was no physician documentation that the history and physical had been updated and the patient examined prior to surgery on 06/16/25.

Interview with Staff B on 06/17/15 at 9:47 AM verified the medical record failed to contain evidence the physician had reviewed and examined the patient prior to surgery. Interview with Staff A at the same time revealed the facility's medical bylaws required the physician to review the history and physical prior to surgery.

Based on observation, staff interview and review of facility policy and procedure, the dietary manager failed to ensure expired or unlabeled foods were removed and sanitation pails were maintained at effective disinfectant levels. This deficient practice had the potential to negatively affect any patient who received nourishment from the facility. The facility had a census of nine patients at the time of the survey.

Findings include:

Review of the facility policy and procedure entitled Labeling and Dating with a most recent Review date of May 2013 directed that all food items will be properly labeled and dated. The policy and procedure directed the purpose was to minimize risk for food borne illness and to ensure all team members were aware of food expiration dates. The Sanitizer Solution Log directed the required concentration of solution must be 200 parts per million for use to disinfect stationary equipment, spray bottles and solutions for storing wiping cloths.

Tour of the facility's dietary service on 06/15/15 between 10:07 AM and 10:37 AM revealed the walk in cooler was observed a tray of deli style meets in zip lock bags. This tray contained two bags of deli meat that were unlabeled as to the contents. The package contained two hand written dates of 06/06/15 and 06/11/15. Staff W identified this product as deli ham that was opened on 06/06/15 and was to be discarded by the second date of 06/11/15. The cooler was observed to have a plastic storage container labeled tomato paste with a disposal date of 06/11/15. Also located on the cooler shelves was a plastic storage container identified as cannelloni beans with an initial date of 05/18/15 and dispose date of 05/23/15. Another container of kidney beans also contained the disposal date of 05/23/15. Also observed were a container identified as potato salad with a disposal date of 06/12/15.
The produce section of the cooler contained a bag of pre-diced celery with manufacturer's printed expiration date of 06/09/15. The ends of the diced celery were observed to be brown and mushy. A bag of shredded red and green vegetables failed to contain an identifying label or opening and disposal dates as required per interview with Staff W.

The reach in refrigerator was observed to contain chicken salad with a prepared date of 06/10/15 and a disposal date of 06/13/15. The container identified as tuna salad also contained a preparation date of 06/10/15 and a disposal date of 06/14/15.

Environmental tour of the food preparation area revealed an observation of a dietary staff member preparing the day's food. The sanitation bucket used to disinfect food preparation utensils and preparation surfaces was tested using the product's efficacy test strips. The test strip failed to obtain the recommended level of greater than 200 parts per million of disinfectant level. These findings were verified in interview with Staff W on 06/15/15 at 10:37 AM. Staff F verbalized it was the responsibility of all dietary staff to check for outdated or unlabeled food items. Staff F verbalized prepared foods expired three days after preparation. Staff F verbalized the dietary manager was the supervisor in charge of the dietary operation and responsible for oversight of the facility's kitchen and its compliance with food service regulations.

Based on observation , interview and document review the facility failed to be maintained in a manner safe from fire by failing to ensure that if the building had a common wall with a nonconforming building, the common wall was a fire barrier having at least a two-hour fire resistance rating constructed of materials as required for the addition, failed to maintain it smoke barriers from the passage of smoke, failed to maintain an intact one hour fire wall around the hazardous areas and failed to ensure the oxygen storage location of greater than 3,000 cu. ft. was enclosed by a one hour separation, that electrical panel location was enclosed by a one hour separation, that means of egress was reliable and free of objects, that doors in hazardous areas which included, but not limited to, areas used for general storage were self-closing or automatic-closing, that components of the water based sprinkler system were checked at least quarterly and that doors were arranged to be opened readily from the egress side whenever the building was occupied. Locks, if provided, were not to require the use of a key, a tool, or special knowledge or effort for operation from the egress side (A710).

Based on review of facility schematics, review of facility documentation, observation of the facility and staff interview and confirmation, the facility failed to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association. The facility had a census of nine patients at the time of the survey.

Findings include:

A review of the facility schematic, review of facility maintenance, testing and inspection documentation and observation of the facility was conducted on 06/16/15 through 06/18/15.

1. The facility failed to ensure that if the building had a common wall with a nonconforming building, the common wall was a fire barrier having at least a two-hour fire resistance rating constructed of materials as required for the addition. Please refer to K11.

2. The facility failed to maintain it smoke barriers from the passage of smoke. Please refer to K25.

3. The facility failed to maintain an intact one hour fire wall around the hazardous areas. Please refer to K29.

4. The facility failed to ensure the oxygen storage location of greater than 3,000 cu. ft. was enclosed by a one hour separation; failure to ensure the electrical panel location was enclosed by a one hour separation; failure to ensure that means of egress was reliable and free of objects; failure to ensure that doors in hazardous areas which included, but not limited to, areas used for general storage were self-closing or automatic-closing; failure to ensure that components of the water based sprinkler system were checked at least quarterly and failure to ensure that doors were arranged to be opened readily from the egress side whenever the building was occupied. Locks, if provided, were not to require the use of a key, a tool, or special knowledge or effort for operation from the egress side. Please refer to K130.

Based on observation and interview, the facility failed to ensure nursing staff followed aseptic technique when preparing injectable medications for one (Staff D) of two nurses observed preparing injectable medications. The active census at the time of the survey was nine.

Findings include:

1. A form entitled Competency Assessment-Aseptic Technique was reviewed. Per the form at bullet #2, Vial Manipulation, nursing staff are taught to remove the "protective tab from vial stopper" and swab the "stopper with an alcohol swab."

On 06/16/15 Staff D was observed preparing medications for administration. At approximately 8:20 AM Staff D withdrew a vial of Protonix 40 milligrams from the Pyxis (automated medication dispensing system). Staff D popped the cap off of the vial and proceeded to draw up the medication into a syringe. Staff D failed to wipe the septum with alcohol (for disinfection purposes) prior to piercing it with the syringe.

Staff B and Staff D confirmed this finding at the time of observation.

Based on medical record review and policy review, the facility failed to ensure a post-anesthesia evaluation was completed and documented by an individual qualified to administer anesthesia prior to discharge after surgery or after a procedure requiring anesthesia services for five (Patient #31, #33, #34, #35 and #36) of five surgical records reviewed of patients who received general anesthesia. The facility had a census of nine patients at the time of the survey.

Findings include:

1. The medical record review for Patient #31 revealed Patient #31 had surgery with general anesthesia on 06/15/15. The medical record did not contain a post-anesthesia evaluation by an individual qualified to administer anesthesia.

2. The medical record for Patient #33 revealed Patient #33 had a procedure with general anesthesia on 06/15/15. The medical record did not contain a post-anesthesia evaluation by an individual qualified to administer anesthesia.

3. The medical record review for Patient #34 revealed Patient #34 had a procedure with general anesthesia on 06/15/15. The medical record did not contain a post-anesthesia evaluation by an individual qualified to administer anesthesia.

4. The medical record review for Patient #35 revealed Patient #35 had surgery with general anesthesia on 06/15/15. The medical record did not contain a post-anesthesia evaluation by an individual qualified to administer anesthesia.

5. The medical record review for Patient #36 revealed Patient #36 had surgery with general anesthesia on 06/15/15. The medical record did not contain a post-anesthesia evaluation by an individual qualified to administer anesthesia.

The facility's Post-Anesthesia Evaluation (AN12.05) policy read a post-anesthesia evaluation must be completed and documented no later than 48 hours after surgery or a procedure requiring anesthesia services. The evaluation is required any time general, regional or monitored anesthesia has been administered to a patient.

Based on medical record review, staff interview and policy and procedure review, the facility failed to properly authenticate orders for five (#21, 22, #25, 26 and 28) of 30 patients reviewed for completeness of physicians' orders. The facility had a census of nine patients at the time of the survey.

Findings include:

1. Patient #25 was admitted to the facility for scheduled surgery on 06/17/15 for right modified radical mastectomy with breast reconstruction for the diagnoses of breast cancer. Review of the medical record revealed an "Anatomic Pathology Lab Requisition" (physician orders) form. The requisition (order) was not signed by any authenticating physician or physician's extenders' signature to validate the lab orders. This finding was verified with Staff C on 06/17/15 at 1:36 PM

2. Patient # 22 was admitted to the facility on 06/16/15 for scheduled surgery for bilateral breast reduction surgery. Review of the medical record revealed the Anatomic Pathology Lab Requisition form (physician orders) form failed to contain any authenticating physician or physician's extenders' signature to validate the lab orders. This finding was verified with Staff C on 06/18/15 at 8:42 AM.







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3. The medical record review for Patient #21 revealed an "Anatomic Pathology Lab Requisition" form. The form revealed tissue (sentinel nodes from the left breast and right and left breast tissue) removed during surgery was collected for examination by a pathologist. The requisition (order) was not signed by the surgeon or any facility staff member.

Staff C was made aware of the above finding regarding Patient #21 on 06/17/15 at 1:35 PM. At that time Staff C stated the form was required to be signed and stated it was usually the RN signing it.

4. The medical record for Patient #26 revealed an "Anatomic Pathology Lab Requisition." The form revealed tissue (left and right fallopian tubes and uterus/cervix) removed during surgery was collected for examination by a pathologist. The requisition (order) was not signed by the surgeon or any facility staff member.

5. The medical record review for Patient #28 revealed a laboratory requisition form dated 06/18/15 for a BMP (basil metabolic panel) and CBC (complete blood count) to be drawn. The requisition (order) was not signed by the physician.

The medical record for Patient #28 also contained an "Anatomic Pathology Lab Requisition." The form revealed tissue (right sentinel node and right breast tissue) removed during surgery was collected for examination by a pathologist. The requisition (order) was not signed by the surgeon or any facility staff member.

Review of the facility policy and procedure entitled Handling Specimens with a most recent review date of 07/14 directed staff that in order to ensure positive patient outcomes by assuring that specimens were handled according to laboratory protocols. The policy further directed that all specimens were to be initialed and timed.

Interview with Staff C on 06/17/15 at 1:36 PM revealed the operating room circulating nurses were to prepare all surgical specimens for transport to the off-site contracted pathology laboratory for testing. All laboratory requisition slips were to be completed as verbal orders signed by the registered nurse for the surgeon, who would cosign at a later time. Specimens were then transported to the facility's pathology room where they were picked up by courier service and transported to the off-site pathology laboratory for testing. Staff C verbalized all orders were to be authenticated with a signature.