HospitalInspections.org

Based on interviews, and document review, the facility failed to ensure a Registered Nurse (RN) who served as a circulating nurse was available during every surgical procedure.

Findings:

On 02/06/17 at 10 am, the Chief Nursing Officer (CNO) stated patients received moderate sedation for some pain management procedures, such as radiofrequency ablation (RFA).

02/07/2017, Staff B stated those staff present for pain management procedures receiving moderate sedation were as follows: the physician, one registered nurse (RN), and the radiology technician. Staff B stated the RN administered sedation and monitored the patient during the procedure. Staff B stated there was no RN present during the procedure performing the duties of circulation nurse.

The hospital policy titled, "Procedural Sedation" documented "administration of moderate sedation requires that a minimum of 2 individuals be immediately available; the person who performs the procedure who is credentialed to order the sedation, and a registered nurse who is educated in sedation and has the sole responsibility of monitoring the patient." (Solely responsible for monitoring would exclude RN from performing circulating RN duties include supervising the technician, infection control and safety monitoring, etc.)

Based on personnel record review, policy review, and staff interview the hospital failed to:

a. verify contracted staff's professional licenses were valid and/or up to date for three of three employee records (Staff T, U, and V) reviewed.

b. ensure all staff meet minimum qualifications; and training/education requirements for two of twenty-seven personnel files (Staff T and V) reviewed.

Findings:

On 2/9/17 at 08:00 AM, surveyor requested the hospital's personnel records. Two (Staff T and V) of twenty-seven personnel records were not provided.

On 2/9/17 at 08:30 AM, personnel records review presented the following:

~ Staff U's personnel file did not contain a current professional license.

~ Two (Staff T and V) of twenty-seven personnel records did not include qualifications and/or training/education requirements to ensure compliance.

On 2/9/17 at 2:00 PM, a policy titled, "Competency Requirements-RN & LPN" were reviewed. The policy stated, " ...prior and throughout employment, Registered and Licensed Practical Nurses maintain evidence of current Oklahoma licensure and nursing competency ..."

On 2/9/17 at 2:25 PM, an interview was conducted with Staff B who reported the hospital does not possess personnel files for Staff T and V containing professional license, qualifications and training/education competencies.

Based on observation and policy review the hospital failed to ensure patient records were secure from unauthorized access at all times and in all locations.

Findings:

On 2/6/17 at 12:17 PM during a tour of Pre-OP #1 location, surveyor observed a patient's record opened, on a bedside table in a high traffic area with no staff present to maintain the confidentiality of the patient's record.

On 2/6/17 at 12:17 PM during a tour of Pre-OP #1 location, surveyor observed a document on a bedside table in a high traffic area without staff present; the document exposed multiple patients' information such as patient's name, date "02/06/2017", times of surgery, and type of anesthesia the patient is scheduled to receive.

On 2/6/17 at 12:31 PM during a tour of Pre-Op #2 location, surveyor observed two clipboards containing multiple patients' labels; including patient's name, date of birth, age, sex, medical record number, and laboratory results.

On 2/9/17 at 2:00 PM, a policy titled, "Hybrid Medical Records" was reviewed. The policy stated, " ...the paper medical records shall be maintained in a safe and secure area ..."

On 2/9/17 at 2:00 PM, a policy titled, "Confidentiality of Protected Health Information" was reviewed. The policy stated, " ...Oklahoma Surgical Hospital (OSH) will safeguard the contents of medical records ...from unauthorized disclosure ...all OSH employees and associates are responsible for protecting PHI that is obtained, handled, learned, heard, or viewed in the course of his/her work or association with the hospital ..."

Based on medical record review, policy review, and staff interview the hospital failed to ensure healthcare providers completed date, time, and/or authenticate in written or electronic form for nine (Patient #1, 3, 7, 10, 12, 14, 16, 17, 18) of the twenty-one patient medical records reviewed.

Findings:

On 2/9/17 at 11:30 AM, medical records review presented the following:

~five of twenty-one medical records (Patient #1, 7, 10, 12, and 18) did not include dates on physician's orders.

~six of twenty-one medical records (Patient #1, 3, 7, 10, 12, and 18) did not include times on physician's orders.

~three of twenty-one medical records (Patient #14, 16, and 17) did not include dates, times, or signatures on physician's orders.

On 2/9/17 at 2:00 PM, a policy titled, "Physician Orders" were reviewed. The policy stated, " ...order should reflect the date and time signed ..."

On 2/9/17 at 2:25 PM, the CNO confirmed all physician orders should be dated, timed, and signed; also verbalized this issue has been ongoing.

Based on medical record review, policy review, and staff interview the hospital failed to ensure licensed healthcare providers implemented the hospital's policy for verbal and/or telephone orders for two (Patient #5 and 9) of the twenty-one medical records reviewed.

Findings:

On 2/9/17 at 11:30 AM, medical records were reviewed. Patient #5 and #9 medical record contained verbal orders that did not include read-back verification.

On 2/9/17 at 2:00 PM, a policy titled, "Physician Orders" were reviewed. The policy stated, " ...licensed healthcare provider must read back the verbal order to the physician for confirmation, i.e. r.b.v.o. stands for read back verbal order ..."

On 2/9/17 at 2:25 PM, the CNO confirmed all verbal and telephone orders should include a read-back verification.

Based on observations and staff interviews, the hospital failed to ensure ventilation and temperature were properly controlled in the sterile surgical supply area.

Findings:

On 02/08/17 at 11:34 am, during a tour of the operating department, a large room of sterile surgical supplies were observed.

On 2/7/17, the surveyors requested the test & balance annual inspection reports for the hospital, including the sterile supply area for 2016, 2015, and 2014, and none were provided.

The Director of Support Services stated there was no test & balance inspection reports for the sterile supply area, and could not be determined to be positively ventilated as required..

Based on observations, interviews, and document review, the infection control preventionist failed to:
a. enforce the hospital's policies for infection control, and
b. implement, and evaluate processes to mitigate the risk of infections and communicable diseases in the areas of hand hygiene, environment, supplies / personal protective equipment, and
endoscopic reprocessing.

This had the potential to impact the approximately 12,000 surgical procedures per year performed in 20 surgical suites. The hospital's surgical subspecialties included general, orthopedic, urology, gynecological, ears/nose/throat, and plastics. The hospital performed endoscopy in 2 procedure rooms. All patients received care in the Pre-op (operative), Post-op, and PACU (post anesthesia recovery unit), and the inpatient units had an average daily census of 49.

Findings:

In the accompaniment of the Director of Nursing, multiple tours were conducted throughout the hospital.

Hand Hygiene
The hospital 's policy titled, "Hand Hygiene " dated 7/01/16 was reviewed. The policy showed the indications for performing hand hygiene, which included: hand hygiene should be performed each time the patient threshold is crossed, after contact with inanimate objects( including medical equipment) in the immediate vicinity of the patient, before and after removing gloves, and before and after contact with body fluids, excretions, mucous membranes, non-intact skin, or wound dressing, as long as hands are not visibly soiled.

The hospital's quality reports, titled "Hand Hygiene Compliance 2016" was reviewed. The report showed a overall 89% compliance rate. In October 2016, the report showed the lowest rating of the year as 67% rate for all of the hospital service areas. The Chief Nursing Officer (CNO) stated the hand hygiene surveillance program consisted of the infection Control Preventionist conducting observations and secret shoppers (selected staff secretly observing their peer's performance). In response to the tour observations in PACU, the CNO stated the program needed to increase observations in the PACU.

Pre-op:
On 02/06/2017 at 12:14 pm., during a tour of the Pre-op area (with the CNO), the surveyor observed a nurse enter and exit isolation room # 11 without performing hand hygiene.

Post-op:
On 02/07/17, during a tour of the Post-op area (with the CNO), the following hand hygiene deficiencies were observed:
~A technician (Staff X) removed linens from a contaminated stretcher with bare hands, disinfected the stretcher with bare hands, and applied new linens with contaminated hands. The technician opened the linen cart lid with contaminated hands.
~A technician removed contaminated gloves without performed hand hygiene.

PACU:
On 02/08/2017, during a tour of the PACU area (with the CNO), the surveyor observed the PACU staff not performing hand hygiene after:
~ touching the patient and the patient's bed,
~pulling the cubicle curtains for patient privacy, and
~typing on the charting computer.
Two of three surgical staff failed to perform hand hygiene after rendering patient care.

Environment

1st floor Pre-testing:
On 02/06/17 at 12:01 pm., surveyor observed Sanicloth, disinfection wipes, in a storage area that were outdated 04/16. Observation confirmed by Staff H.

Pre-op:
On 02/07/17 at 12:10 pm., the surveyors observed an open countertop at the nursing desk. The area contained 2 tubes of blood in a rack, and I-Stat (a blood analysis system) testing monitors, and its cartridges. The CNO stated the I-Stat was utilized frequently to obtain quick chemistry results. The CNO stated a tube of blood was obtained from the patient, then transferred by hand into testing cartridges. This counter was in a high traffic area, and increased the risk of blood exposures.

Inpatient Units:
On the afternoon of 02/06/17, the soiled utility rooms were observed. The 7th floor utility's trash bin was full and 3 white plastic bags containing trash were lying on the floor. The 8th floor utility trash bin was full and 2 white and 1 red plastic bags were lying on the floor. Staff EE stated the soiled utility trash was picked up for disposal once a day. This practice increases the risk of of floor contamination. Trash bag contents can leak on the floor, and can also attract pests and rodents.

Supplies / Personal Protective Equipment

Pre-op:
On 02/06/17 at 12:10 pm, surveyor observed IV tubings on a counter within the splash zone of the hand washing sink. This practice resulted in the increased risk of the IV tubing being contaminated.

On 02/06/17 at 12:17 pm., the surveyors inspected pre-op rooms that the CNO identified as ready for use. Water bottles that had been opened were found in rooms #11, #18 (2 bottles), #16, #17, and #20. The CNO stated the pre-op staff provided patients with a single-use bottle of water used to administer pre-medication. An open water bottle, an open IV tubing, and trash in trashcan was found in room #12.

The hospital policy titled, "Laundry and Linens" dated 12/16 was reviewed. The policy documented clean linens carts must remain covered at all times.

On 02/06/17, during the tour of Pre-op area hallway, 2 large carts of uncovered clean linens were observed.

Dressing Room:
The hospital policy titled, "Laundry and Linens" dated 12/16, defined the suitable areas for storing clean linens which included...a closet or room used soley for the purpose of storing clean linen. No policy was provided which addressed the storage of clean surgical scrubs.

On 02/08/17 at 11:35 am, during the tour of the surgical dressing room, at the room's entrance, the surveyor oberved uncovered shelves filled with unworn surgical scrubs.

(Center for Disease Control refers to both linens and surgical scrubs as healthcare texiles. "Guidelines for Environmental Infection Control in Health-Care Facilities" dated 06/03. This guideline documented, "package, transport, and store clean textiles and fabrics by methods that will ensure their cleanliness and protect them from dust and soil during interfacility loading, transport, and unloading.")

Surgical Corridor:

The hospital's policy titled, "Attire-Operating Room" dated 10/16 showed "...masks will not be left hanging down from the neck." On 02/08/17, 3 staff were observed with used masks hanging from their neck.

The hospital's policy titled, Attire-Operating Room" dated 10/16, showed all personnel must cover head and facial hair. On 02/06/17, in the surgical corrdior and PACU, 2 male staff were observed wearing skull caps with their hair exposed. On 09/16, CMS authored a Response to the ACS (American College or Surgeons)". The response documented, "The ACS Statement on OR Attire is in conflict with all other nationally recognized guidelines and standards. The language ACS used that a skull cap is "symbolic of the surgical profession," is not an acceptable argument. I am sure we all want the safest care for patients and that is to wear standardized PPE that includes complete hair covering."

PACU:
On 02/06/17, the surveyor observed the arrival of a patient transpored by surgical staff into a PACU bay. Surveyor observed bagged specimens and paperwork being transported on the foot of the patient's bed, and making them at risk of being contaminated.

Endoscopic reprocessing

Decontamination area:
On 02/06/17, the CNO stated endoscopes were disinfected using the high level disinfectant, Rapicide. The CNO stated the staff followed manufacturer's instructions for use. Staff EE stated test strips were not tested for conformance to validate disinfectant minimum effective concentration when each new bottle was opened.

Based on hospital policy review, medical record review, and staff interview the hospital failed to follow its policy and notify the organ procurement organization (OPO) within 1 hour in the event of a death for one (Patient #11) of two medical records reviewed.

Findings:

On 2/7/17 at 8:45 AM, a policy and procedure document titled, "Postmortem Preparation and Transport of Deceased Patient" revised on 09/01/2015 was reviewed. The policy and procedure stated, "...Notify the OPO within 1(one) hour of the patient's death ..."

On 2/9/17 at 11:30 AM, medical records were reviewed. Medical record documented Patient # 11 expired on 4/26/2016 at 12:43 AM; OPO was notified at 2:00 AM.

On 2/9/17 at 11:45 AM, Staff B reported the hospital will contact the OPO within one hour in an event of a death.

Based on staff interviews and document review, the hospital failed to conduct a surgical fire risk assessment prior to each surgery or other invasive procedures that require the presence of ignition and fuel sources and an oxidizer.

Findings:

On 02/06/17 at 10 am, the Chief Nursing Officer (CNO) stated the hospital provided gastrointestinal (GI) endoscopy and pain management services.

The hospital policy titled, "Fire Safety in Perioperative Services" dated 11/16, documented "Endo suite" as a hospital area at risk for fire.

On 02/06/17 at 10:30 am, Staff G stated (GI) endoscopy procedures utilize oxygen, alcohol [fuel], and cautery [ignition] during the performance of procedures. (These elements increased the risk of surgical fires). Staff G stated these 3 elements also are present during pain management procedures, such as radio frequency ablation (RFA).

On 02/9/17, Staff B and Staff F stated the GI endoscopy and pain management (RFA) services did not perform fire risk assessment before performing procedures.

(Food and Drug Administration article titled, "Preventing Surgical Fires: FDA Safety Communication" dated 10/13/11 recommended to reduce the risk of surgical fires by conducting a fire risk assessment at the beginning of each procedure amongst other interventions.)

Based on staff interviews and document review, the hospital failed to ensure post-anesthesia evaluation were performed for all endoscopic procedures. This failure increased the risk of an unstable patient being be discharged.

Findings:

The hospital's "Medical Staff Rules and Regulations" dated 09/11, were reviewed. The regulations documented, "Every patient receiving anesthesia shall receive post-anesthesia follow-up by a physician with findings recorded not more than 48 hours after surgery."

On 02/09/17 at 2 pm, the Chief Nursing Officer (CNO) stated the hospital provided gastrointestinal (GI) endoscopy services. The CNO stated Certified Registered Nurse Anesthetists (CRNA), under the supervision of anesthesiologist, administered moderate anesthesia care for these procedures.

On 02/09/17 at 2:30 pm, surveyors reviewed 4 medical records of patients who had endoscopic procedures. 2 of 4 patients did not have a post-anesthesia evaluation. (Patient #13 & Patient #15)