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Based on interview and document review, the hospital failed to respond to grievances in writing as required. This had the potential to affect all patients who potentially filed complaints with the hospital.

Findings include:

Grievances filed between 4/27/12, and 9/6/12, were reviewed. Documentation did not reflect whether a written response was provided to the patient and/or whether the patient was satisfied with the resolution. There were 68 grievances identified which ranged from long waits for call lights to be answered, poor treatment, and premature discharges.

A Concern Awareness Resolution Exploration (C.A.R.E.) was completed for each grievance. The form identified the date of concern resolution, however, there was no evidence that a written response had been provided to the patient, or whether the grievance had been resolved to the patient's satisfaction.

The hospital's policy #30.3545.-019 (last updated 5/26/09), did not address whether all formal and informal grievances required a written response. The policy stipulated, "If the grievance is not resolved, or if the investigation is not completed within 7 days, the hospital should inform the patient or representative that the hospital is still working to resolve his/her grievance and that the hospital will follow-up with a written response within 10 business days."

On 9/11/12, at 1:00 p.m. the Indian health advocate and director of quality care systems both verified the usual response to grievances was verbal. However, they also said that when a patient filed a written grievance, the hospital would respond in writing.

At 2:35 p.m. on 9/11/12, the director of quality care systems stated the hospital's current policy "needs adjustment."

Based on interview and document review, the hospital failed to follow a minor patient representative's refusal for a specific treatment for 1 of 1 patients (P49) when the variance report indicated treatment refusal.

Findings include:

The facility's grievances, filed between 4/27 and 9/6/12, were reviewed. A Patient Variance Report dated 7/10/12, indicated P49's parents, "Were adamant about the patient not receiving a rectal suppository." The report documented the parent's refusal had been communicated to the anesthesiologist by the certified registered nurse anesthetist prior to the start of surgery. According to the Anesthesia Record, P49 was anesthetized at 10:38 a.m. and a rectal suppository was administered at 10:44 a.m. The Patient Variance Report indicated the parents were unhappy with the administration of a rectal suppository, however, no further investigation was completed.

P49's medical record was reviewed. There was no reference to this concern documented in the physician's notes, anesthesia notes or nursing notes.

The clinical director of inpatient surgical services, and the interim administrator of peri-operative services, were interviewed on 9/14/12, at 11:45 a.m. They confirmed there was no documentation of any further investigation and stated there was no further information available.

Based on observation, interview, and document review, the hospital failed to provide side rails in compliance with U.S. Department of Health and Human Services, Food and Drug Administration (FDA) guidance Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment for 56 of 56 beds (including three seclusion rooms) on the medical and surgical units of the hospital. In addition, 12 of 12 patient room doors on the Senior Behavior Health Unit (SBHU) were in poor repair, potentially affecting all patients in the hospital's care.

Findings include:

On 9/13/12, at approximately 4:15 p.m. during a tour of the seclusion rooms on the medical, surgical unit, the bed rails were observed to have large inside gaps that could pose a risk for patient entrapment.

The medical surgical registered nurse (RN) manager-F, interviewed at the time of the observation, stated that patients requiring seclusion were placed in these rooms. RN-F stated that approximately 56 additional beds in the hospital were fitted with bed rails with similar gaps. RN-F measured the upper side rails gaps at 7 1/8 inches horizontally and 7 1/2 inches vertically. The lower side rail gaps measured 7 1/2 by 7 1/4 inches. RN-F confirmed the upper side rails contained the patient call system and had never been considered a potential safety hazard, despite the presence of disoriented or sedated patients. RN-F verified the side rail gaps did not meet the FDA guidelines for safe side rails.

On 9/14/12, at 1:00 p.m. the director of cardiovascular services, who was filling in for the director of nursing, confirmed the hospital had not established policies related to the assessment or use of the side rails to ensure they met FDA guidelines.

The Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment published on 3/10/06, recommended maximum openings of 4 3/4 inches within the bars of the side rails.


15508


The hospital failed to maintain patient room exterior doors on the SBHU unit in a cleanable, safe manner.

A physical plant tour of the SBSU was conducted at 3:15 p.m. on 9/10/12, with the director of quality care systems and the nurse manager. Twelve of 12 patient rooms' exterior wooden doors were observed to be scratched, gouged and had splintered edges on the lower half of each door. The doors presented a safety hazard and the surfaces were non-cleanable. Patients admitted to this unit would have had potential psychiatric diagnoses and dementia with severe behavior problems.

Maintenance employee-B was interviewed on 9/14/12, at 9:40 a.m. He stated that although the facility had no policy for preventive maintenance as it relates to the patient room doors, the expectation would be to keep the doors in good condition.

During observation and interview, the hospital failed to ensure confidential patient records were safeguarded and only authorized persons with a need to know were able to access those records. This had practice had the potential to affect all patients who received care at the hospital.

Findings include:

During an environmental tour at 4:13 p.m. on 9/11/12, the housekeeping director (HD) entered an unlocked door into a linen room on the first floor of the hospital. HD then went through another door that was propped open leading to a storage area. On the second floor of the storage area patient medical records were observed to be stored in an unlocked/unsecured manner. The HD verified at the time, that the door leading to the room was unlocked.

During interview and observation at 8:33 a.m. on 9/14/12, the director of cardiac services (DCS) opened the unlocked linen storage area. The DCS confirmed the door was unlocked and the door leading to the storage area was also unlocked and had been propped open. The DCS verified patient medical records were being stored in an unsecured area.

Based on interview and document review, the hospital failed to ensure an ongoing quality improvement program to reduce medication errors. This practice had the potential to affect all 67 hospitalized patients.

Findings include:

A review of medication errors log from 5/1/12 to 9/10/12 revealed a total of 297 medication errors were reported, as well as the unit where the error occurred. A total of 148 transcription/processing errors were identified as 97 errors that did not reach the patient, 30 errors that reached the patient but no harm was noted. Twenty errors reached the patient, and although no harm was noted, increased monitoring was required.

A review of the patient variance reports from 5/1/12 to 9/10/12, revealed a report dated 5/22/12, where a patient incorrectly received an infusion of an anticoagulation medication the imaging department. A variance report dated 6/27/12, a patient received the wrong antibiotic in the outpatient surgery area.

A review of the monthly Medication Error Summary reports from 4/12 to 7/12 revealed the report reviewed individual events for high risk medications, adverse drug reactions, Naloxene trigger tool, and anticoagulation tool results for the month. The total medication errors and percent of those errors that did not reach patient were reported, however, the report did not include an evaluation of the errors.

A review of the Medication Safety Team Meeting minutes from 1/27/11, 7/20/11, 9/20/11, 4/17/12 and 8/17/12, revealed the committee reviewed high risk drug errors, adverse drug reactions, Naloxene trigger tool and anticoagulation trigger tool data and recommended actions for any medication errors that resulted in temporary harm or greater including death for the patient.

A review of the minutes from the Annual Medication Safety Report for 2011 revealed the hospital tracked the outcomes of medication errors, and type or phase in which the error occurred. The report identified the phase in which the majority of medication errors occurred as transcription, for both 2010 and 2011.

On 9/13/12, at 3:10 p.m., the pharmacy director (PD) and pharmacist (PH)-A confirmed the above findings. The PD stated he was unaware of the medication errors reported on the variance reports and indicated the forms used for reporting were not correct. He confirmed the medication log was inaccurate, and he had not considered analyzing the accuracy of the report. PH-A indicated the hospital had completed education of all staff on general reporting of medication errors, however had not monitored the log for individual department reporting since the education.

Further, the PH-A confirmed the hospital developed actions for any event occurred that caused temporary harm and worse up to death of the patient. She stated the hospital also analyzed high risk medication, adverse drug reactions and trigger tool medications routinely, however confirmed the hospital had not considered analyzing the type/phase of medication errors in an attempt to improve the total medication errors in the hospital. The PD confirmed the hospital had not analyzed events that had occurred, that had reach the patient and required increased monitoring, including near missed.

On 9/14/12, at 11:35 a.m., the medical director (MD) reviewed the above data and confirmed the medication log was "not comprehensive." He confirmed the medication safety committee recommended action for only the medication errors that had an outcome of temporary harm or higher for the patient. The MD indicated the hospital had an intern in the recent past who looked at the medication reconciliation process in the hospital, that included from admission to discharge from the hospital. He provided documentation of a meeting held 6/5/12, which listed the intern had identified concerns with discharge process, and communication with different providers including the discharge summary. The MD indicated from the information, the committee had agreed the hospital's plan to integrate to one computer system would be helpful; however, confirmed the hospital had not analyzed medication events that did not cause harm for patients.

Based on interview and document review, the hospital failed to provide sufficient nursing staff on the medical/surgical unit to meet patients' needs in a manner acceptable to the patients, for 3 of 3 patients who were interviewed (P42, P43 and P44), and 4 of 9 patient grievances (P45, P46, P47, and P48) filed between 5/7/12 and 8/6/12. This had the potential to affect all patients receiving care on the hospital's medical/surgical units.

Findings include:

Patterns regarding a lack of timely response time to patient needs and requests was reflected in patient, family, and staff interviews, grievance reports, and call light response logs. The hospital lacked a policy directing staff such as how to ensure reasonable call light response times, designating who shared responsibility in answering the lights, and how patient acuity may have affected patient to nurse ratios, etc. Although Detail Call Reports by Location did not indicate if patient's needs were met, they did show the time the light was activated to the time it was canceled.

P43 complained of having to wait a long time for staff assistance after activating his call light during an interview on 9/12/12, at 11:55 a.m. The patient explained that he received a faster response from staff when he disconnected his bed alarm. The call report for P43 revealed that on 9/10/12, through 9/12/12, response times were as long as 20 minutes, 28 seconds.

P44 was interviewed on 9/13/12, at 11:45 a.m., and stated he had to wait a long time for nursing staff to respond to his call light. He stated the same was true during another hospital stay one month prior. The patient's wife was present at the time of the interview, and confirmed the patient's concern regarding lack of timely assistance from staff. The call reports dated 8/17/12, through 8/28/12, for P44's first admission dated 8/17/12, to 8/28/12, showed response times varied, but were as long as 24 minutes, 28 seconds on 8/26/12 and 18 minutes, 5 seconds on 8/28/12. P44's second admission call response times dated 9/10/12, to 9/13/12 showed several response times were as long as 20 minutes, 28 seconds.

P42 expressed concerns regarding call light response times in an interview on 9/12/12, at 12:10 p.m. stating, "Nursing isn't too prompt with answering the lights." The call reports dated 9/12/12, and 9/13/12, showed P42 called for help three times, as response times were up to 8 minutes, 25 seconds.

Nine Patient Grievances dated 5/8/12, through 8/6/12, were reviewed. Four of the nine grievances included complaints regarding long wait times when patients summoned help from staff.

A grievance report filed 8/6/12, indicated P45 called for pain medication at 7:12 p.m., but did not receive the medication until 8:16 p.m. (1 hour, 4 minutes later) The report stated the patient reported he was "pissed" and "if he would have had a car here, he would have driven home."

P46 filed a grievance report on 8/8/12, indicated P46 had stated she arrived at hospital at around 5:00 p.m., but was not seen by a nurse until 7:00 p.m. (two hours later). The report showed the patient informed the nurse that no one had been in to see her, and she had been at the hospital since 5:00 p.m. Documentation on the grievance report was consistent with the patient's complaint and included, "None of the admission was started, not even vital signs taken. The first vital sign recorded was at 2010, [8:10 p.m. or 3 hours, 10 minutes later] No interventions had been entered on the patient screen. First orders were scanned at 2203 [10:03 p.m. or 5 hours, 3 minutes later]."

P47's grievance report dated 7/1/12, indicated the patient reported that at 3:30 p.m. she asked for prune juice and medication for constipation, but received neither. She then requested pain medication three hours, 15 minutes later, but did not receive the medication for pain. Then forty-five minutes after the second request, the patient asked the nursing assistant to inform the nurse that her nephrostomy tube was leaking. However, the grievance report showed, "The patient never saw the nurse for any of these issues."

P48's wife expressed a number of different concerns regarding care her husband received on the medical/surgical unit in a grievance dated 5/7/12. P48's wife stated she did want her husband transferred from the intensive care unit (ICU) back to the medical/surgical unit. The rationale provided by the patient's wife was, "Because they do not answer his call lights and this causes her great concern about the care he is receiving." Specific examples of her concerns were relayed as follows: P48's roommate had called out for help "all night," to the point that P48 got out of bed and walked to the nursing station to summon help. Additionally, one morning she arrived at the hospital to find her husband cleaning up the bathroom floor because his roommate had been incontinent of urine and stool. P48's wife also reported, "has heard others [i.e. patient visitors] talking about the call lights not being answered when she was in the waiting room."

On 9/13/12, at 11:58 a.m. a registered nurse (RN)-F was interviewed regarding the concerns expressed by the patients. The RN stated, "Staffing problems can be an issue at times."

On 9/14/12, at 8:10 a.m. a nursing assistant (NA)-A stated, "We try to answer lights as quickly as we can." NA-A further stated that patients sometimes complained about having to wait a long time to receive a response to their calls for help from staff. The NA was unaware of any hospital policies related to expectations for call light responses other than "to get to them as soon as possible."

On 9/14/12, at 8:50 a.m. RN-H was interviewed and stated it "gets crazy" trying to assist patients in a timely manner due to the acuity (complexity of medical needs) of the patients.

On 9/14/12, at 10:45 a.m. RN-F described the staffing guidelines for the medical/surgical floor. The ratios were four patients to one nurse (4:1) during the day shift, 5:1 on the evening shift and 6:1 on the night shift. RN-F explained that the ratio was based on an average census of 36 patients on the unit. They census information was obtained from the midnight census report. When asked whether patient acuity was considered when determining staffing ratios, the RN replied, "Acuity is not formally incorporated into the staffing grid. The charge nurse can make a judgement to see if you can go beyond" (the specified ratio).

Based on interview and document review, the hospital failed to ensure medical records were complete for 15 of 30 patient (P22, P23, P17, P3, P1, P12, P27, P40, P39, P14, P15, P16, P18, P19, and P20) medical records reviewed.

Findings include:

The hospital's policy Organization and Function Manual, dated 12/4/04, directed staff to accurately date and authenticate all clinical entries in patients' medical records. In addition, operative reports were to be completed immediately after each surgical procedure.

Patients' record reviews revealed incomplete records such as numerous reports that did not include times, dates, and authentication as required and directed in the hospital policy.

A review of P22's left knee radiology report was completed on 9/13/12. Although the report had been electronically signed and dated by the radiologist (MD)-J, there was no time documented to indicate when the report had been signed.

A review of P23 operative cholangiogram radiology report was completed on 9/13/12. Although the report had been electronically signed and dated by the radiologist (MD)-I, there was no time documented to indicate when the report had been signed.

A review of P17 physical examination report was dictated and transcribed on 9/9/12. Although the report had been in the record since 9/9/12, the MD-K, had not authenticated the PE with a signature, time or date.

Interview with the health information manager on 9/12/12, at 9:35 a.m. confirmed the hospital had not ensured the medical records and physician's orders included signatures, dates and time as their policy indicated was needed.




15508


P3's history and physical report dictated on 10/21/11 was signed by physician-L, however, the signature had not been dated or timed.

P1 had a urology consult on 8/29/12, the report had been signed by physician, however, the signature had not been timed or dated.

P12 had a multidisciplinary staffing note dated 7/11/12, this report had been signed by the practitioner however, it had not been timed or dated.


28035


P27's Insulin Subcutaneous Dosing Orders dated 9/10/12, did not include a physician signature, date, or time. In addition, the standing order for Adult Nausea and Vomiting Treatment Order dated 9/10/12, did not include a date and time of the physician' signature.

P40's emergency room Transfer of Outpatient From SBMC-Physician's Orders form included the physicians signature and date, however, did not indicate a time.

P39's Pulmonary Function Report form indicated the test was completed on 7/31/12, and signed on 8/12/12. The report also lacked a time of the signature.

On 9/12/12, at 8:15 a.m. the respiratory manager (technician-A) stated the respiratory reports should have been dated and timed within one week of the procedure. The manager also stated the facility did not have a policy related the authentication of respiratory reports.

At the same time the director of respiratory therapy verified the respiratory reports should be authenticated with a date, time and signature within one week of the procedure.



28034


P14 was discharged from the hospital on 3/1/11. The following records lacked the date, time, and/or signature of the physician: the admission history, discharge summary, Electrolyte Replacement Protocol orders (transcribed on 2/24/11), Physician Progress Notes dated 2/23, 2/24, and 2/25, and 2/28/11, Operative Report (dictated 4/4/11).

P15, discharged from the facility on 6/7/11, however, the time admitting (5/26/11) and standing orders (5/27/11) were signed was lacking in the medical record.

P16, discharged from the facility on 5/1/08, and the medical record was incomplete related to a lack of date, time, and/or signatures by the physician for the following documents: Admission History and Physical dated 4/22/08, Discharge Summary, Restraint Order Form, Alcohol Detoxification/Withdrawal Protocol dated 4/22/08, Physician Admitting Orders dated 4/22/08, Pneumonia Treatment Core Orders, Adult In Patient Community Acquired dated 4/22/08, as well as Physician Progress Notes, 4/22/08, 4/23/08, 4/25/08, 4/26/08, 4/27/08, 4/29/08, 4/30/08 and 5/1/08.

P18 was discharged from the facility on 8/7/12. Physician signatures, and/or dates and times were incomplete in the medical record as follows: A Consultation Note 7/30/12, Electrolyte Replacement Protocol for Calcium transcribed on 7/28/12, Electrolyte Replacement Protocol-Phosphorus transcribed on 7/21/12, 7/23/12, Electrolyte Replacement Protocol-Potassium and Magnesium transcribed on 7/21/12, Adult Nausea and Vomiting Treatment Orders 7/22/12, Insulin Subcutaneous Correction Dosing Orders transcribed 7/31/12 and 8/3/12, Total Parenteral Nutrition (TPN) orders transcribed on 7/31/12, 8/1/12, 8/2/12, 8/3/12, 8/4/12, Pre and Post-Op Anesthesia/PACU Orders, fifteen progress notes from 7/24 to 8/6/12, and physician orders dated 7/28/12.

P19 was discharged from the hospital on 8/14/12. The medical record lacked physician signatures, and/or times and dates for orders dated 8/13 and 8/14/12, as well as progress notes dated 8/11, 8/13, and 8/14/12.

P20 was discharged from the hospital on 3/7/11, and the following records were not signed by the physician and/or timed and dated: Discharge Summary dictated 3/7/11 and an operative report dated 3/2/11 were unsigned until 4/14/11, a Bedside Glucose Test with Insulin Coverage Orders, Pre and Post Anesthetic Evaluation, dated 3/2/11, and progress notes, dated 3/3 through 3/7/11.

On 9/13/12, at 11:38 a.m., and medical records manager (MRM) confirmed the information was missing, and that the hospital policy was current. She stated all entries should have been signed, with date and time of signature. The MRM stated the facility policy directed dictated reports and notes were to be signed no later than 30 days after discharge. Although MR personnel frequently sent reminders to the physicians, a lack of timely authentication continued to be a problem.

Based on interview and record review, the hospital failed to ensure all physician orders were dated, timed and promptly authenticated for 2 of 3 patients (P17 and P6) medical records, and for pre and post operative anesthesia standing orders for 3 of 8 patients (P22, P34, and P35) records reviewed.

Findings include:

P17's physician's orders dated 9/9/12, for diet, PAC Dilaudid injection (narcotic starter pain killer pac), plan for Cinryze use and dressing change information did not include the time written. The verbal orders dated 9/9/12, at 12:10 p.m., to discontinue PAC Dilaudid had not been authenticated with a physician signature, date or time as of 9/12/12. The physician order dated 9/10/12, for Cinryze 1500 units IV, Zantac 150 mg (used for heartburn), Dilaudid 3 mg IV and Benadryl 50 mg IV, did not include a time signed.

P6's obstetric admission orders dated 9/10/12, did not include the time of the orders. P6 had written orders for treatment of nausea and vomiting that were not signed or dated. The post partum orders were signed and dated 9/11/12, but lacked the time. The routine labor orders were signed without a date or time. The physician's order to not administer a vaccination were not dated or timed. Interview with the obstetric manager, on 9/12/12, at 9:15 a.m., indicated physicians orders should be signed, dated and timed within 24 hours.

Interview with health information manager on 9/12/12, at 9:35 a.m. verified telephone orders as well as physician's orders were to be dated and timed when the practitioner signed the orders. She confirmed the hospital had not ensured the physician's orders included signatures, dates and time as their policy indicated was needed.



13611


P22 underwent a total knee arthroplasty under spinal anesthesia on 9/11/12. The pre-op and post-op anesthesia/PACU standing orders had not been signed, dated or timed by the anesthesiologist (MD-A).

P34 had undergone a dilation and curettage under general anesthesia on 9/12/12. The PACU standing orders had not been signed, dated or timed by the anesthesiologist (MD-B).

P35 had undergone an osteotomy under axillary block anesthesia on 9/10/12. The PACU standing orders had not been signed, dated or timed by the anesthesiologist (MD-B).



28034


Review of P20 medical record revealed a consultation had been done on 7/21/12, however, the consultation report lacked documentation of authentication with date and time by the physician.

On 9/13/12, at 11:38 a.m.,., the medical records manager (MRM) confirmed the above findings and stated all dictated reports were to include the signature with date and time of signature of the physician.

Based on interview and document review the hospital failed to ensure all verbal or telephone orders were signed, dated and timed in a timely manner for 9 of 30 (P7, P25, P17, P14, P15, P16, P18, P19, and P20).

Findings include:

P7's telephone orders dated 9/10/12, at 3:10 p.m. and 8:40 p.m. were not authenticated by the physician on 9/14/12. P25's verbal orders dated 9/10/12, at 2:25 p.m. and at 2:27 p.m. were authenticated by the physician on 9/12/12. On 9/14/12, at 8:00 a.m. the medical records director stated telephone/verbal orders should have been authenticated within 24 hours of receipt.


12831


P17's had a verbal order for Benadryl 50 mg intravenous every 4 to 6 hours as needed, however, the order was not signed, dated or timed. The verbal order, dated 9/9/12, at "1210" to discontinue PAC Dilaudid (pain medication) was not signed, dated or signed as of 9/12/12.

The health information manager (HIM) was interviewed on 9/12/12, at 9:35 a.m. and verified verbal and telephone orders were to be dated and timed when signed by the the practitioner. Facility policy directed verbal and telephone orders be signed within 24 hours. The HIM verified the lack of physician's signatures, dates and time on the orders in question.


28034


P14, discharged from the facility on 3/1/11, medical record revealed the following: Multiple verbal and telephone orders written on 2/22/11, 2/23/11, 2/24/11, 2/25/11, 2/26/11, 2/27/11 2/28/11 and 3/1/11, lacked documentation of the date and time the orders had been signed by the physician.

P15, discharged from the facility on 6/7/11, medical records revealed the following: Multiple verbal orders on 6/5/11 and 6/7/11 lacked documentation of the date and time the orders had been signed by the physician.

P16, discharged from the facility on 5/1/08, medical record revealed the following: Multiple verbal and telephone orders written on 4/22/08,4/23/08, 4/24/08, 4/25/08, 4/26/08, 4/27/08, 4/28/08, 4/29/08, 4/30/08 lacked documentation of the date and time the orders had been signed by the physician.

P18, discharged from the facility on 8/7/12, medical record revealed the following: Multiple verbal orders written on 7/26/12, 7/27/12, 7/28/12, 7/29/12, 7/30/12, 7/31/12, 8/2/12, 8/4/12, 8/5/12, and 8/6/12, lacked documentation of the date and time the orders had been signed by the physician.

P19, discharged from the facility on 8/14/12, medical record revealed the following: Multiple verbal orders on 8/12/12, 8/13/12 and 8/14/11, lacked documentation of the signature, date and time for the orders and a verbal order on 8/13/12 lacked documentation of the date and time the order had been signed by the physician.

P20, discharged from the facility on 3/7/12, medical record revealed the following: Multiple verbal orders on 3/2/12, 3/5/12, 3/6/12, lacked documentation of the date and time the orders had been signed by the physician.

On 9/13/12, at 11:38 a.m., the medical records manager (MRM) confirmed the above findings and stated the facility policy directed all entries were to be signed, dated and timed. She stated the facility expected all verbal or telephone orders were to be signed, dated and timed within 24 hours after the orders were written.

Based on interview and record review, the hospital failed to ensure physician's orders were followed and documented in the medical records for 2 of 30 patients (P2 and P14 ) whose medical records were reviewed.

Findings include:

P2's pre-surgical orders for P2 dated 8/27/12, requested the hospital obtain a urine pregnancy test. P2 had a planned surgery on 9/11/12, for a tonsillectomy with possible adenoidectomy. This surgery was completed on 9/11/12, at 8:20 a.m.. Review of the record on 9/12/12, indicated a urine pregnancy test had not been completed prior to surgery as ordered.

The nurse manager (RN-B) confirmed in an interview on 9/12/12, at 12:15 p.m. that a urine pregnancy test had not been completed as ordered before surgery. The RN reviewed the patient's medical record, inquired with laboratory staff, and had clinic information reviewed, and none of the inquiries showed the test was completed.


28034


P14's medical record revealed a pre-op order standing order for an electrocardiogram (EKG) prior to surgery for all patients with a cardiac history and listed specific examples of cardiac history that included chest/arm pain, angina, and irregular pulse. Review of the pre-anesthesia evaluation identified P14 had chronic atrial fibrillation (irregular pulse), coronary artery disease with congestive heart failure and chest pain and had a potassium level pre surgery of 2.8 (low). P14 underwent general anesthesia on 2/24/11, however, the record lacked documentation the EKG was completed prior to surgery.

On 9/12/12, at 2:05 p.m., the administrator of perioperative services confirmed the above findings. She confirmed P14 had cardiac problems, was elderly and stated she would have expected the EKG be completed prior to general anesthesia.

Based on observation, interview and document review the hospital failed to secure emergency medications in the facility. This practice had the potential to affect all 67 patients in the hospital.

Findings include:

Review of the facility policy titled Emergency drug supply, revised 5/12, identified emergency drug supplies would be maintained in all areas of the hospital where medications were administered or medical procedures performed. Accuracy of the contents of the emergency drug supply would be verified by a pharmacist before sealing the cart with a plastic tie and the cart would be monitored on a monthly basis for adequate supply and outdated drugs. Nursing staff would verify the integrity of the seal on a daily basis.

On 9/12/12, at 11:50 a.m., the pharmacy director (PD) confirmed the current facility policy and stated the blue plastic straps were used on all emergency supply carts stored in each department in the facility. He stated the blue straps were applied by pharmacy after the medication supplied was checked monthly, and nursing verified the presence of the strap on a daily basis. The PD confirmed the identification numbers on the straps were not tracked to prevent tampering or removal of the medications between the monthly inspection by pharmacy. The PD stated, "That is a concern."


28035


On 9/11/12, at approximately 1:30 p.m. a tour of the emergency department (ED) was conducted with the ED director and supervisor. Two emergency medical supply carts were stored in the ED. Both carts were sealed with a plastic, numerically coded band. The ED supervisor stated the staff checked the bands daily to ensure placement, however, did not monitor or track the numerical code identification numbers. The supervisor also stated that pharmacy staff tracked the use of the identification bands.

Based on observation, interview and document review the hospital failed to ensure only authorized personnel had access to locked medication rooms in the facility. This practice had the potential to affect all 67 patients in the hospital.

Findings include:

On 9/12/12, at 10:52 a.m., a tour of the medication room on the second floor, west nursing station was conducted with the pharmacy director (PD). The door to the medication room was located in the hallway of the nursing station, and an electronic keep pad was used to access the room. The medication room contained various cupboards, a locked refrigerator, an electronic medication dispensing machine, and a plastic box on a metal stand. The PD said the box contained pharmaceutical waste. An instructor and student were in the room.

The hospital's Hazardous Waste Management Plan (revised 6/11), directed staff to close pharmacy waste containers at all times when staff were not in attendance. Partial or full dose of medications were to be placed in the containers and a list of the various medications included coumadin, chemotherapy drugs, insulin, lidicaine with epinephrine. Medications listed as requiring hazardous waste disposal included premarin, insulins, depo provera, provera, dilantin, prograf, coumadin.

The hospital's Drug Storage policy (revised 10/05), identified all drug products were stored in designated, secured storage areas, medication carts or Pyxis (electronic dispensing) medication machines. However, the policy lacked identification of personnel who had access to the secured storage areas.

On 9/12/12, at 11:25 a.m., the PD confirmed the policies were current. He explained that licensed nurses had access to the code to the medication room. Housekeeping or maintenance staff removed the full containers as needed. The PD was aware nurses, housekeeping, and maintenance had access to the medication room, however, he was unaware if there were other personnel who were given the access code to the medication rooms. The PD confirmed the facility lacked a policy regarding limiting access to the secured medication rooms and pharmaceutical waste.

Based on observation, interview, and document, the hospital was found not in compliance with the Condition of Participation related to the Physical Environment (42 CFR 482.41) as evidenced by deficiencies issued as a result of a Life Safety Code Inspection. The hospital was found not in compliance with Life Safety Code standards.

Findings include:

Please refer to Life Safety Code inspection tags: K0038, K0054, K0056, K0072, and K0130 for additional information.

Based on observation, interview and document review the hospital failed to maintain the heart stop pads for the automated external defibrillator (AED) at the outpatient rehabilitation center, having the potential to affect all patients treated at the rehabilitation clinic.

Findings include:

During observation at 9:29 a.m. on 9/13/12, the AED equipment had two expired heart stop pads. One had expired on 7/05/12, and two expired on 6/03/12. The director of therapy services (DTS) confirmed the pads were expired at the time of the observation. DTS stated the biomedical technicians were responsible for checking the annual servicing of the machine. The physical therapy support staff stated the AED was only checked by biomedical technicians.

On 9/14/12, at 11:05 a.m. the biomedical technician (BT)-A stated the machine pads should have been checked by the rehabilitation staff monthly.

The AED Operational Checks manual (undated) directed staff to check expiration dates monthly for defibrillator electrode pads, and to replace them if they had exceeded the expiration date.

Based on observation, interview, and document review, the hospital failed to ensure standard infection control practices were followed during surgery for 1 of 3 patient surgical procedures (P33), to maintain lead aprons in a sanitary manner to prevent the transmission of disease for 18 of 54 recorded aprons, to properly disinfect multi-use glucometer machines between patients, and to develop an infection control program which included active surveillance of personnel illnesses to prevent, control, and investigate infections, and communicable diseases, as well as ensuring infection control education for 7 of 13 employees (RD-A, RN-I, RN-C, RN-H, RN-A, RT-B,a and SS-A) whose personnel files/education records were reviewed. The practices had the potential to affect all patients receiving care at the hospital.

Findings include:

P33 was observed while having a left total knee arthroplasty on 9/11/12, at 9:40 a.m. A licensed practical nurse (LPN)-A was observed opening sterile instruments. Although she was wearing a cotton surgical cap, hair was observed hanging out of the cap and down around the nape of her neck.

On 9/11/12, at 10:40 a.m. the clinical supervisor of the surgical suite stated that all hair should have been covered while staff were in the operating room.

A review of the hospital Dress Code policy (last revised 11/11), directed staff to cover all head and facial hair, including sideburns and neck hair in restricted areas.


28649


During observations at 1:16 p.m. on 9/11/12, a lead apron with a vinyl covering numbered 09-85 that had a tear at the seam measuring approximately 5 x 5 inches that was repaired using medical tape. The director of radiology services (DRS) confirmed the apron was torn and had not been repaired. DRS stated staff should have taken torn or ripped aprons out of use and should not have used tape to repair the tears. DRS verified tape presented an uncleanable surface.

The lead apron analysis records for 2012-2013 were reviewed. The analysis completed on 3/14/12, for apron 09-85 indicated it passed the test with no noted tears. Of the 54 reviewed aprons, 18 had indicate there were tears/cracks on the lead apron vinyl.

Imagining service manual (revised 6/11), indicated, "Each department is responsible for lead apron visual inspections. Carefully clean and inspect lead aprons and gloves identify any cracks, tears or seams that are unraveling. Material rips and tears on the seams of the apron need to be repaired. Contact Laundry Services at your facility campus to coordinate repairs. If the apron can not be repaired due to large material tears, it must be disposed of."

On 9/12/12, at 10:15 a.m. the imaging operation manager (IOM) confirmed staff had not sent the aprons to laundry to be repaired, but should have been instead of attempting to repair the aprons.



28035


Disinfecting agents were not used to clean glucometer machines as directed by the manufacturer recommended disinfecting guidelines. Thirteen medical surgical patients required daily blood sugar readings.

On 9/13/12, at approximately 11:30 a.m. a registered nurse (RN)-D was observed to obtain P7's blood sugar reading. RN-D removed the glucometer machine from the plastic storage case and wiped it with a disposable Clorox Disinfecting wipe. RN-D obtained the sample of blood and set the machine on the patients bed. Upon completion of the test reading RN-D placed the machine on the counter next to the sink while she washed her hands and then on top of the portable nursing documentation cart. RN-D then wiped the machine with a Clorox Disinfecting Wipe and immediately placed the machine on the computerized docking port at the nursing station.

Shortly thereafter a nursing assistant (NA)-A was observed to obtain P38's blood sugar using another multi-use glucometer machine. Upon completion of the blood sugar reading NA-A was observed to wipe the machine with a Clorox Disinfecting Wipe and immediately return the machine to the docking station.

The Clorox (bleach free) Disinfecting Wipes direction for use label noted that in order to disinfect the machine, enough wipes must be used for the machine to remain visibly wet for four minutes and to sanitize, enough wipes must be used for the machine to remain visibly wet for 30 seconds. Additionally the Clorox Disinfecting Wipes label did not indicate it was an effective disinfectant for HIV, tuberculosis, or hepatitis.

A hospital Cleaning of Non-Critical, Reusable Patient Care Equipment policy and procedure (dated 6/2/11), directed staff to follow the manufacturer's recommendations for cleaning and maintenance, and glucometers must be cleaned between each patient and before docking.

The Precision Xceed Pro Monitor glucometer operations manual indicated the manufacturer's maintenance recommendations identified acceptable cleaning solutions included alcohol and ammonia based cleaners and recommended the use of Sani-Cloth HB, Sani-Cloth Plus and Super Sani-Cloth wipes.

On 9/13/12, at 12:35 p.m. RN-E verified the hospital's medical surgical unit utilized multi-use glucometer machines. RN-E also verified staff wiped the machine with a Clorox Disinfecting Wipe then immediately placed the machine on the docking port which is located at each nursing station.

At 12:45 p.m. RN-D verified staff used the Clorox Disinfecting Wipes on all glucometer machines on the medical surgical unit after each patient use. At 1:55 p.m. RN-D verified staff did not not monitor for or allow for the recommended wet times as recommended for disinfecting and sanitizing. RN-D stated staff immediately placed machines on the docking station after being wiped with the Clorox wipes.

At 2:00 p.m. NA-A stated staff wiped the machine once with the Clorox wipe and immediately returned it to the docking port. NA-A also verified it was facility practice to monitor for prolonged wetness or wait for the machine to dry.

At 2:20 p.m. the infection control preventionist (RN-C) verified the medical surgical unit used the Clorox Disinfecting Wipes. RN-C also verified staff did not follow the product disinfecting directions and said they should have.

On 9/14/12, at 10:50 a.m. RN-C verified the Clorox Disinfecting Wipes was not an effective disinfectant against HIV, tuberculosis and hepatitis, which presented infection control risk/concerns. RN-C stated other departments were using the Sani-Cloth brand of disinfectant wipes, but was unsure why the medical surgical unit was not.

On 9/11/12, at 10:50 a.m. licensed practical nurse (LPN)-A stated she documented staff illnesses, however, the information was solely used by managers for performance purposes not for the tracking and trending of staff illnesses as required.

At approximately 11:00 a.m. the director of quality and risk and supervised the infection control program verified the hospital did not have a system in place for the monitoring of staff illnesses.

On 9/12/12, at 11:10 a.m. the director of rehabilitation and employee health services verified staff illnesses were not monitored as required.

Thirteen hospital personnel records were reviewed on 9/14/12 with the human resource manager (HRM). Seven of the employee records (RD-A, RN-I, RN-C, RN-H, RN-A, RT-B,a and SS-A) did not show evidence the employees had received infection control training as appropriate for their positions.

The staff included a registered dietitian (RD)-A hired 7/18/11, a registered nurse (RN)-I hired 10/31/11, RN-C hired 3/6/00, RN-H hired 6/28/12, RN-A hired 9/26/11, a recreation therapist (RT)-B hired 8/28/09, and a social worker (SS)-A hired 7/17/11.

On 9/14/12, at 1:22 p.m., the HRM confirmed the findings and said hospital policies were not available regarding infection control training for employees.

Based on interview and document review, the hospital failed to ensure all patient care staff received organ procurement (OPO) training initially, annually, when changes were made to policies, and when problems were noted for 7 of 7 employees whose personnel/training records were reviewed.

Findings include:

The following registered nurses did not have evidence in their personnel files of initial and/or annual organ procurement (OPO) education:

1) RD-A hired 7/18/11
2) RN-I hired 10/31/11
3) RN-C hired 3/6/00
4) RN-H hired 6/28/12
5) RN-A hired 9/26/11
6) RN-B hired 8/14/12
7) SS-A hired 7/17/11

On 9/14/12, at 1:22 p.m., the HRM confirmed the hospital staff had not received the required OPO training, nor was there a policy that directed staff regarding the provision of the training.

Based on observation, interview and document review, the hospital was not in compliance with the Condition of Participation for Surgical Services (CFR 482.51) due a failure to ensure the safe use of electrocautery devices. This resulted in a risk for fire in the operating room and/or risk for patient burns for 1 of 2 surgical patients observed (P33), and an immediate jeopardy (IJ) situation for P33 when the surgeon failed to operate the electrocautery device as directed by hospital policy and the manufacturer's recommendations during a surgical procedure. The hospital also failed to ensure adequate investigation, surgeon and other appropriate staff training, and monitoring after actual harm occurred for 2 of 2 patients (P41 and P32) who sustained burns from the improper use of an electrocautery device during a surgical procedure.

Findings include:

The IJ began when the improper use of an electrocautery device was observed on 9/12/12, from 9:50 a.m. until 9:58 a.m. Variance reports were reviewed on 9/12/12, at approximately 3:30 p.m. and on 9/13/12, at 8:45 a.m. The IJ was identified on 9/13/12, at 12:03 p.m. The on-call hospital administrator and the director of quality improvement were informed of the IJ on 9/13/12, at 12:03 p.m. The IJ was removed and the deficient practice corrected on 9/14/12, at 11:17 a.m.

The IJ that began on 9/13/12, was removed on 9/14/12, when the facility assured all registered nurses (RNs), certified surgical technicians (CSTs) and licensed practical nurses (LPNs) who worked in the surgical suites in the hospital as well as in Same Day Surgery had reviewed the Association of Operating Room (AORN) booklet titled Electrosurgery Use in the Operating Room and Procedure Areas, and had completed a post test. Staff not present were expected to review the current policy and AORN booklet before returning to work and were also expected to complete the post test. Clinical Supervisors from the hospital based surgical suites, and the Same Day Surgery department, reviewed the current policy on use of electrocautery devices. In addition, all RNs, CSTs and LPNs reviewed the current hospital policy titled Electrosurgery--Use of in the Operating Room (last revised 4/12). Communication/education of surgical medical staff credentialed to use the electrocautery devices occurred and communication with the Medical Executive Committee occurred. Audits of 10% of operative and invasive procedures using a Holster Audit tool would be initiated immediately and reported monthly.

Refer to findings at A0951 regarding the use of electrocautery equipment in the surgical suite.

MD-F was observed performing a surgical procedure for P-33 on 9/12/12, at 9:50 a.m. in the Same Day Surgery unit, located in the clinic. The patient was under general anesthesia and had a laryngeal-tracheal airway in place. Although a holster device to hold the electrocautery device had been placed on the patient's chest, the surgeon did not place the electrocautery in the holster following each use of the electrocautery. The surgeon used the electrocautery device at 9:51 a.m. and placed the tip of the device on the surgical drape which covered the patient. The surgeon again used the electrocautery device and placed it on the surgical drape at 9:52 a.m. Although the CST moved the device on the surgical drape, she did not put the device in the holster nor did she move the holster closer to the surgeon. The surgeon again used the electrocautery device at 9:52, 9:55, 9:56 and 9:58. The electrocautery device was placed on the surgical drape covering the patient by the surgeon following each use of the device.

The clinical supervisor of the Same Day Surgery unit, the clinical supervisor of the inpatient operating room suite, and the interim administrative director of perioperative services, were interviewed on 9/12/12 at approximately 10:05 a.m. They stated the hospital policy regarding the use of electrocautery devices within the surgical suite required the electrocautery device be placed in the holster following each use. They verified MD-F had not used the device in accordance with the hospital's policy. The clinical supervisor of the Same Day Surgery unit stated the cautery device used was manufactured by Valleylab.

The Valleylab manufacturer's booklet, revised 3/12, included the following warning : the device should not have "active accessories near or in contact with flammable materials (such as gauzes or surgical drapes), flammable gases, or high levels of oxygen. Electrosurgical accessories that are activated or hot from use can cause a fire. When not using active accessories, place then in a holster or in a clear dry, nonconductive, and highly visible area not in contact with the patient. Inadvertent contact with the patient may result in burns." The manufacturer's recommendations also warned of flammable substances such as alcohol based skin prepping agents, oxygen rich environments and nitrous oxygen in conjunction with sparking and heating associated with electrosurgery devices could provide an ignition source for a fire in the operating room.

A review of the policy provided by the hospital titled Electrosurgery--Use of in the Operating Room (last revised 4/12), included operator directions so that the active electrode of the device would be used in a manner that minimized the potential for injury. The policy indicated the active electrode should be placed in a clean, dry, well-insulated safety holster when not in active use.

A review of variance reports indicated two patients had received burns following the incorrect use of an electrocautery device.

A Patient Variance Report provided by the hospital dated 2/2/12, indicated P41 had sustained a burn on the right upper arm. The burn was noted following a surgical procedure in which an electrocautery device had been used. This event occurred in the hospital based surgical suite. The Operative Report was not dictated by MD-H until 3/11/12, and no mention was made of the burn the patient had received to the right arm. However, the Intra-Operative Record completed the day of surgery, by the registered nurse, noted a post procedure skin assessment had revealed the patient sustained a burn on the upper inner right arm.

The previous director of the hospital-based surgical services was interviewed on 9/13/12, at 10:25 a.m. He stated he had been the director when P41 sustained the burn on 2/2/12. He stated the pre and intra-operative nursing staff observed the burn on the patient's right arm immediately after the surgical drapes were removed. He stated the staff assumed the burn was from the electrocautery device as it had been used during the operative procedure. A skin assessment completed pre-operatively had not revealed any skin conditions on the patient's right upper arm. The previous director of the surgical services stated he'd discussed the event with the surgeon and staff present during the surgical procedure. He stated the discussion was not documented, and he was unsure if the director of quality improvement had been notified of the event. He stated no other staff education or surgeon education had been completed following the event. The director of hospital quality improvement was interviewed on 9/13/12, at 8:45 a.m. and stated she had been notified of the burn sustained by P41 "after the fact" and was not involved in the investigation of the event.

Another Patient Variance Report dated 7/3/12, indicated P32 had sustained a burn on the forearm following a repair of a deep laceration on the patient's finger. This event occurred in the hospital based surgical suite. The patient had received a one centimeter (cm) abrasion along the volar aspect of the forearm according to MD-G's Operative Report dated 7/3/12. The burn occurred when the patient's forearm rested on the tip of the cautery which had discharged.

A clinic office visit note dictated by MD-G dated 7/10/12, indicated a dressing was in place over a 1 cm radial forearm burn. The clinical supervisor of the hospital-based surgical suite, and the administrative director of perioperative services, were interviewed on 9/12/12, at 3:10 p.m. The clinical supervisor stated she was aware of the burn sustained by P32. Although the clinical supervisor stated she had reviewed the patient incident with staff at daily meetings, posted information related to the event, and monitored use of electrocautery in the operating rooms, there was no documented evidence the education had occurred. The administrative director of perioperative services stated she was unaware of the incident. The director of hospital quality improvement was interviewed on 9/13/12, at 8:45 a.m. She stated she had not been notified of the burn sustained by P32.

Although hospital variance reports indicated two patients had sustained burns from the use of electrocautery devices used by two different surgeons within the past seven months, there was no evidence of staff and surgeon training, staff education, or monitoring completed for the proper use of electrocautery devices. Following the burns, an observation of a surgical procedure revealed a third surgeon had also used an electrocautery device improperly and not according to hospital policy and manufacturer's recommendations.

Based on observation, interview and document review, the hospital failed to ensure policies were followed in accordance with acceptable standards of practice and patient care related to the safe use of electrocautery devices for 1 of 2 surgical patients observed (P33) and for 2 of 2 variance reports reviewed where surgical patients (P41 and P32) sustained burns, and to ensure physician's surgical orders were followed for 2 of 6 surgical patients (P2 and P14) medical records reviewed.

Findings include:

The hospital policy titled Electrosurgery--Use of in the Operating Room was not followed during observation of 1 of 2 surgical procedures and for 2 of 2 variance reports reviewed when an electrocautery device had been used.

MD-F was observed performing a surgical procedure for P-33 on 9/12/12, at 9:50 a.m. in the Same Day Surgery unit, located in the clinic. The patient was under general anesthesia and had a laryngeal-tracheal airway in place. Although a holster device to hold the electrocautery device had been placed on the patient's chest, the surgeon did not place the electrocautery in the holster following each use of the electrocautery. The surgeon used the electrocautery device at 9:51 a.m. and placed the tip of the device on the surgical drape which covered the patient. The surgeon again used the electrocautery device and placed it on the surgical drape at 9:52 a.m. Although the CST moved the device on the surgical drape, she did not put the device in the holster nor did she move the holster closer to the surgeon. The surgeon again used the electrocautery device at 9:52, 9:55, 9:56 and 9:58. The electrocautery device was placed on the surgical drape covering the patient by the surgeon following each use of the device.

The clinical supervisor of the Same Day Surgery unit, the clinical supervisor of the inpatient operating room suite, and the interim administrative director of perioperative services, were interviewed on 9/12/12 at approximately 10:05 a.m. They stated the hospital policy regarding the use of electrocautery devices within the surgical suite required the electrocautery device be placed in the holster following each use. They verified MD-F had not used the device in accordance with the hospital's policy. The clinical supervisor of the Same Day Surgery unit stated the cautery device used was manufactured by Valleylab.

A Patient Variance Report provided by the hospital, dated 2/2/12, indicated P41 had sustained a burn on the patient's right upper arm which was noted following a surgical procedure in which an electrocautery device had been used. This event occurred in the hospital based surgical suite. MD-H did not dictate the Operative Report until 3/11/12, and the report did not indicate the patient had received a burn on the right arm. However, the Intra-Operative Record, completed by the registered nurse and dated 2/2/12, indicated a post procedure skin assessment had revealed the patient had sustained a burn on the upper inner right arm. The previous director of the hospital-based surgical services was interviewed on 9/13/12, at 10:25 a.m. He stated he had been the director when P41 sustained the burn on 2/2/12. He stated the pre and intra-operative nursing staff had observed the burn on the patient's right arm immediately after the surgical drapes had been removed. He stated the staff assumed the burn was from the electrocautery device as it had been used during the operative procedure. A skin assessment completed pre-operatively had not revealed any skin conditions on the patient's right upper arm.

Another Patient Variance Report dated 7/3/12, indicated P32 had sustained a burn on the forearm following a repair of a deep laceration on the patient's finger. This event had occurred in the hospital based surgical suite. MD-G indicated on the Operative Report, dated 7/3/12, the patient had received a one centimeter (cm) abrasion along the volar aspect of the forearm which had occurred when the patient's forearm rested on the tip of the cautery which had discharged causing a 1 cm abrasion along the patient's forearm. A clinic office visit note dictated by MD-G dated 7/10/12, indicated a dressing was in place over a 1 cm radial forearm burn. The clinical supervisor of the hospital-based surgical suite and the administrative director of perioperative services were interviewed on 9/12/12, at 3:10 p.m. The clinical supervisor stated she was aware of the burn sustained by P32.

The clinical supervisor of the Same Day Surgery unit, the clinical supervisor of the inpatient operating room suite, and the interim administrative director of perioperative services were interviewed on 9/12/12, at approximately 10:05 a.m. They stated the hospital policy regarding the use of electrocautery devices within the surgical suite required the electrocautery device be placed in the holster following each use.

The hospital's Electrosurgery-Use of in the Operating Room policy (last revised 4/12), directed staff to use the active electrode of the device in a manner that minimized the potential for injury. The policy indicated the active electrode should have been placed in a clean, dry, well-insulated safety holster when not in active use.


12831


P2's medical record revealed a physician pre-surgery order was not carried out by the hospital staff as ordered. The pre-surgical physician orders for P2 dated 8/27/12, requested the hospital to obtain a urine pregnancy test.

P2 had a planned surgery on 9/11/12, for a tonsillectomy with possible adenoidectomy. This surgery was completed on 9/11/12, at 8:20 a.m. Review of the record on 9/12/12, indicated a urine pregnancy test had not been completed.

During interview with the registered nurse (RN) manager-B on 9/12/12 at 12:15 p.m.,she confirmed the urine pregnancy test had not been completed as ordered before surgery. RN-B reviewed the record and called the laboratory and had appropriate staff go into the clinic information to ensure the urine pregnancy test had not been completed. This inquiry confirmed the urine pregnancy test had not been completed as ordered.


28034


P14's medical record revealed a pre-op order standing order for an electrocardiogram (EKG) prior to surgery for all patients with a cardiac history and listed specific examples of cardiac history that included chest/arm pain, angina, and irregular pulse. Review of the pre-anesthesia evaluation identified P14 had chronic atrial fibrillation (irregular pulse), coronary artery disease with congestive heart failure and chest pain and had a potassium level pre surgery of 2.8 (low). P14 underwent general anesthesia on 2/24/11, however, the record lacked documentation the EKG was completed prior to surgery.

On 9/12/12, at 2:05 p.m., the administrator of perioperative services confirmed the above findings. She confirmed P14 had cardiac problems, was elderly and stated she would have expected the EKG be completed prior to general anesthesia.

Based upon interview and record review, the hospital failed to ensure post-anesthesia evaluations were completed for 10 of 12 patients (P29, P30, P34, P22, P35, P36, P2, P18, P6, and P8) reviewed who had received anesthesia for a surgical procedure.

Findings include:

The post-anesthesia evaluations did not reflect current standards of anesthesia care. The post-anesthesia evaluation did not include documentation of assessment of patients' respiratory status including respiratory rate, airway patency, and oxygen saturation, cardiovascular function, including pulse rate and blood pressure, mental status, temperature, pain, nausea and vomiting, and postoperative hydration.

P29 underwent an aortogram with placement of a left subclavian stent under monitored anesthesia care (MAC) on 9/6/12. The Anesthesia Record-Pre and Post Anesthetic Evaluation dated 9/6/12, at 7:00 p.m. indicated the only post-anesthesia assessment documented by the certified registered nurse anesthetist (CRNA)-E was "no anesthetic complications noted."

P30 underwent an emergency appendectomy under general anesthesia on 9/13/12. The Anesthesia Record-Pre and Post Anesthetic Evaluation dated 9/13/12, at 7:45 p.m. indicated the only post-anesthesia assessment documented by CRNA-B was "no anesthetic complications noted."

P34 underwent a dilation and curettage procedure under general anesthesia on 9/12/12. The Anesthesia Record-Pre and Post Anesthetic Evaluation dated 9/12/12, at 3:00 p.m. indicated the only post-anesthesia assessment documented by CRNA-B and medical doctor (MD)-B was "no anesthetic complications noted."

P36 underwent a colonoscopy under monitored anesthesia care (MAC) on 9/10/12. The "Anesthesia Record-Pre and Post Anesthetic Evaluation", dated 9/10/12, at 4:45 p.m. indicated the only post-anesthesia assessment documented by MD-B and CRNA-C was "no anesthetic complications noted."

P2 underwent a tonsillectomy under general anesthesia on 9/11/12. The Anesthesia Record-Pre and Post Anesthetic Evaluation dated 9/11/12, at 9:15 a.m. indicated the only post-anesthesia assessment documented by CRNA-A was "no anesthetic complications noted."

P22 underwent a total knee arthroplasty under spinal anesthesia on 9/11/12. The "Anesthesia Record-Pre and Post Anesthetic Evaluation", dated 9/11/12, at 2:00 p.m. indicated the only post-anesthesia assessment documented by the certified registered nurse anesthetist (CRNA-A) was "no anesthetic complications noted".

P35 underwent an osteotomy under axillary block anesthesia on 9/10/12. The Anesthesia Record-Pre and Post Anesthetic Evaluation dated 9/10/12, at 4:45 p.m. indicated the only post-anesthesia assessment documented by MD-B was "no anesthetic complications noted."

P18 underwent surgical repair of small bowel obstruction, under general anesthesia on 7/27/12. Review of the Anesthesia Record-Pre and Post Anesthetic Evaluation form revealed a pre anesthesia evaluation had been completed, however lacked documentation of an post anesthesia evaluation completed.

P6 underwent a post-partum procedure under monitored anesthesia care (MAC) on 9/8/12. The Anesthesia Record-Pre and Post Anesthetic Evaluation dated 9/8/12, at 11:00 p.m. indicated the only post-anesthesia assessment documented by MD-A and CRNA-C was "no anesthetic complications noted."

P8 underwent a esophagogastroduodenoscopy procedure under monitored anesthesia care (MAC) on 9/11/12. The "Anesthesia Record-Pre and Post Anesthetic Evaluation" dated 9/11/12, at 4:00 p.m., indicated the only post-anesthesia assessment documented by MD-A and CRNA-C was "no anesthetic complications noted".

A review of the job responsibilities for an anesthesiologist, signed by the medical director of the anesthesia department on 9/9/05, indicated the anesthesiologist would participate in the post-anesthetic visit and evaluation of the patient as described in the policy for Post-Anesthetic Evaluations.

On 9/13/12, at approximately 9:50 a.m. the anesthesiologist MD-A, stated the CRNA or anesthesiologist would document that no anesthetic complications were noted if no problems with the patient post anesthesia were identified.

The Director of Quality Improvement, and the Clinical Supervisor of the Surgical Suite, were interviewed by telephone on 9/20/12 at 1:10 p.m. They stated there was no hospital policy related to the content of the post-anesthesia evaluations required.