HospitalInspections.org

Based on document review, observation, and interview, surgical services staff did not follow generally accepted standards of practice and/or facility policies and procedures (P&P). Specifically, 1) hand hygiene was not done as required. 2) Hair clipping in the operating room (OR) was not done as required. 3) Staff brought personal items into the OR. 4) Staff did not follow safety procedures with laser use. 5) The facility lacked a P&P pertaining to personal items in the OR and lacked instructions on laser use safety procedures.

See Findings in Tag A0951.

Based on document review, medical record (MR) review, and interview, 8 of 10 MRs reviewed, Patient #1 - Patient #8, the facility failed to ensure properly executed informed consent forms were completed prior to a surgical procedure. Specifically, anesthesia consent forms lacked required information.

Findings include:

-- Review of the facility's policy and procedure titled "Advanced Directives, Consents and Medical Decisions Management Plan," dated 10/17/2024, stated "written consent document form must contain at least the following: if the procedure is non-emergent, and is expected to involve either local or general anesthesia, the name of all physician(s), dentist(s), and podiatrist(s) who are reasonably expected to be involved in the procedure(s) ... name, signature, and date of provider(s) performing the procedure ... every blank should be filled in before the patient or responsible person signs and it is witnessed."

-- Review of Patient #1's MR revealed a Consent for Anesthesia Services Form had verbal consent documented by the patient's sister on 8/30/2024. This form indicated the patient would receive general anesthesia (causes the patient to be completely asleep during the procedure). The consent form provided an area for a practitioner signature. It stated, "I consent to the anesthesia service checked above and authorize that it be administered by _____ ... " The space for the practitioner's name was left blank.

-- Review of Patient #2's MR revealed a Consent for Anesthesia Services Form signed by the patient on 4/3/2025. This form indicated the patient would receive general anesthesia. The consent form provided an area for a practitioner signature. It stated, "I consent to the anesthesia service checked above and authorize that it be administered by _____ ... " The space for the practitioner's name was left blank.

-- Review of Patient #3's MR revealed a Consent for Anesthesia Services Form signed by the patient on 3/14/2025. This form indicated the patient would receive general anesthesia. The consent form provided an area for a practitioner signature. It stated, "I consent to the anesthesia service checked above and authorize that it be administered by _____ ... " The space for the practitioner's name was left blank.

-- Review of Patient #4's MR revealed a Consent for Anesthesia Services Form signed by the patient on 4/2/2025. This form indicated the patient would receive general anesthesia, and a nerve block (injecting of local anesthetic near a nerve or group of nerves to temporarily block pain). The consent form provided an area for a practitioner signature. It stated, "I consent to the anesthesia service checked above and authorize that it be administered by _____ ... " The space for the practitioner's name was left blank.

-- Review of Patient #5's MR revealed a Consent for Anesthesia Services Form signed by the patient and interpreter from language line information added on 3/13/2025. This form indicated the patient would receive general anesthesia, nerve block and invasive monitoring via an arterial line (inserting a catheter into a patient's artery to continuously monitor blood pressure). The consent form provided an area for a practitioner signature. It stated, "I consent to the anesthesia service checked above and authorize that it be administered by _____ ... " The space for the practitioner's name was left blank.

-- Review of Patient #6's MR revealed a Consent for Anesthesia Services Form signed by the patient on 4/9/2025. This form indicated the patient would receive general anesthesia and nerve block. The consent form provided an area for a practitioner signature. It stated, "I consent to the anesthesia service checked above and authorize that it be administered by _____ ... " The space for the practitioner's name was left blank.

-- Review of Patient #7's MR revealed a Consent for Anesthesia Services Form signed by the patient on 4/1/2025. This form indicated the patient would receive general anesthesia. The consent form provided an area for a practitioner signature. It stated, "I consent to the anesthesia service checked above and authorize that it be administered by _____ ... " The space for the practitioner's name was left blank.

-- Review of Patient #8's MR revealed a Consent for Anesthesia Services Form signed by the patient 2/24/2025. This form indicated the patient would receive general anesthesia. The consent form provided an area for a practitioner signature. It stated, "I consent to the anesthesia service checked above and authorize that it be administered by _____ ... " The space for the practitioner's name was left blank.

-- During interview of Staff A, Registered Nurse on 4/14/2025 at 9:00 am, they acknowledged the above findings.

Based on document review, observation, and interview, surgical services staff did not follow generally accepted standards of practice and/or facility policies and procedures (P&P). Specifically, 1) hand hygiene was not done as required. 2) Hair clipping in the operating room (OR) was not done as required. 3) Staff brought personal items into the OR. 4) Staff did not follow safety procedures with laser use. 5) The facility lacked a P&P pertaining to personal items in the OR and lacked instructions on laser use safety procedures.

Findings related to (1) include:

-- Review of the facility's P&P titled "Hand Hygiene," revised 10/2024, indicated handwashing or hand antisepsis is to be done immediately after glove removal.

-- Per observation on 4/14/2025 at 9:40 am, Staff B, Registered Nurse (RN) removed their gloves in the OR and left the OR to get the patient supplies. Staff B did not perform handwashing/hand antisepsis after removing their gloves. This finding was confirmed by Staff B at the time of observation.

-- Per observation on 4/14/2025 at 9:45 am, a surgical technologist removed their gloves and walked out into the core area (large hallway between ORs with clean and sterile supplies) to obtain surgical supplies for the upcoming case. They did not perform handwashing/hand antisepsis after removing their gloves. This finding was confirmed by Staff C, RN at the time of observation.

Findings related to (2) include:

-- Review of the facility's P&P titled "Pre-Operative/Pre-Procedure Management," revised 6/2024, indicated "should hair removal be recommended for a specific procedure, a clipper should be utilized ... When hair removal is required, it should be done as close to the start of surgery as possible. The removal of body hair is never to occur in the surgical suite, unless in a true emergent situation."

-- Per observation in the OR on 4/14/2025 at 10:45 am, a patient being prepared for brain surgery had their hair clipped in the OR suite prior to the surgery being performed. This finding was confirmed by Staff C, RN at the time of observation.

-- Per interview of Staff D, Interim Director of Surgical Services on 4/10/2025 at 9:50 am, surgeons should only clip patients' hair in the OR in an emergency situation or if patient was not prepped adequately.

-- Per interview of Staff E, RN on 4/11/2025 at 1:55 pm, surgeons have been clipping patients hair around the surgical site in the OR suite. There is a spot in the timeout section of the medical record (MR) to document whether a patient was clipped in the OR.

-- Per interview of Staff F, Chief of Surgery on 4/11/2025 at 4:00 pm, they were not aware that patients were being clipped in the OR and indicated they needed to be clipped in the pre-operative area.

-- Per interview of Staff G, RN on 4/14/2025 at 10:20 am, there needs to be a provider order in the MR to clip patients in the pre-operative area. It is mostly being done in the OR.

-- Per interview of Staff H, Nurse Manager on 4/14/2025 at 11:50 am, clipping of patients is mostly done in the OR. They are trying to have surgeons put in an order for it to be done in pre-op.

-- During interview of Staff D on 4/14/2025 at 12:10 pm, they acknowledged the above findings.

Findings related to (3) include:

-- Per interview of Staff I, RN on 4/10/2025 at 10:50 am, a certified registered nurse anesthetist (CRNA) recently entered the OR suite for a procedure with a large purse and placed it on the anesthesia cart.

-- Per interview of Staff E, on 4/11/2025 at 1:55 pm, anesthesia staff come into the OR with satchels, purses, coffee mugs, and briefcases. Staff E has not reported these concerns to administrative staff.

-- Per interview of Staff J, CRNA on 4/14/2025 at 10:30 am. Staff J indicated being trained at another facility, and they were allowed to bring personal items into the OR as long as they could be wiped down. Staff J brings their leather purse into the OR.

-- During interview of Staff D, on 4/14/2025 at 12:10 pm, they acknowledged the above findings. Staff D indicated there is no P&P that addresses bringing personal items into the OR. Staff D stated, it is an AORN (Association of periOperative Registered Nurses) standard that personal items not be brought into the OR. (AORN develops and maintains standards and guidelines for perioperative nursing practice, ensuring patient safety and quality care.)

Findings related to (4) include:

-- Review of the facility's education titled "Laser Safety in the Perioperative Suite," dated 1/2023, laser safety signs must be placed at all entrances to alert anyone entering the OR that the laser is in use. All staff must use eye protection approved for the specific laser. This education does not instruct staff on what should be documented in the MR.

-- Per review of facility P&Ps, they do not have a P&P to instruct staff on laser use.

-- Per interview of Staff K, Operating Room Nurse Manager on 4/10/2025 at 9:40 am, safety is very important in the OR, all staff are educated. There is a laser cart in the hall and a check list that should be completed in the MR. All staff should wear laser goggles including, the patient. There should be a safety sign placed on the outside of the OR door to alert any staff who enter room.

-- Per interview of Staff D, on 4/10/2025 at 9:50 am and 4/11/2025 at 3:30 pm, laser use in the OR requires a sign be placed on the door indicating laser in use. Safety goggles should be worn by all staff, sometimes surgeons opt not to.

-- Per interview of Staff I, RN on 4/10/2025 at 10:50 am, there are precautions that should be taken when using lasers in the OR. There should be a sign on the door that the laser is in use, and all staff should wear goggles. During a few cases Staff I participated in, no one was wearing goggles and no sign was placed on the door. There is a place in the MR to document the laser safety measures taken and Staff I stated it is not always filled out.

-- Per interview of Staff B, RN on 4/10/2025 at 11:20 am, other staff don't always put the laser sign on the door to alert other staff prior to entering the room.

-- Per interview of Staff L, Charge Nurse on 4/10/2025 at 2:35 pm, there is a laser safety cart available in the hall with goggles and signage for the door. Staff L does not think it is mandatory for everyone to wear goggles.

-- Per interview of Staff E, RN on 4/11/2025 at 1:55 pm, there is a safety checklist used when a laser surgery is performed. There should be a sign posted on the door. Goggles are available, but you can't force staff to wear them.

-- During interview of Staff D, on 4/14/2025 at 12:10 pm, they acknowledged the above findings. Staff D indicated there is no P&P pertaining to the use of lasers in the OR.