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100 HOSPITAL DRIVE

BENNINGTON, VT 05201

MAINTENANCE OF PHYSICAL PLANT

Tag No.: A0701

Based on observation and staff interview, the hospital failed to assure the condition of the floor in Central Sterile Services was properly maintained in a manner to assure the safety and well-being of all patients. Findings include:

During an initial tour of Central Sterile Processing (CSP) on 1/13/14 at 12:50 PM accompanied by the Director of Perioperative Services and the Nurse/Liaison for CSP the following observation was made in the CSP area, where sterile and non-sterile medical and surgical supplies and equipment are decontaminated, processed, sterilized and stored for patient use:

In the decontamination room, a receiving area for the cleaning of soiled, contaminated and used items, a portion of the tiled floor in the instrument cleaning area was divided by metal plank sections measuring approximately 15 inches wide and 4 feet long which covered floor pipes. The section surfaces were pitted and soiled with grime and accumulated dirt within the continuous gaps between the metal planks. Although it was confirmed there was a specific housekeeping schedule for cleaning the floor in the decontamination room, it was evident the flooring and metal planks had not received the necessary cleaning and maintenance to ensure a sanitary environment. The Director of Perioperative Services confirmed the present condition of the metal floor planks was unacceptable.

POST-ANESTHESIA EVALUATION

Tag No.: A1005

Based on record review and staff interview, Anesthesia Services failed to conduct post-anesthesia evaluations for 2 of 7 applicable patients. (Patients # 9, 19) Findings include:

1. Patient #9 was admitted to the hospital on 11/2/13 for a repair of a fractured hip and fractured humerus. Surgery was performed on 11/3/13 during which time Patient # 9 was administered general anesthesia. The patient was admitted to the hospital and recovered over a 5 day period. There was no evidence in the electronic medical record (EMR) or paper chart that a post-anesthesia evaluation was completed within 48 hours post procedure to evaluate the patient's recovery from anesthesia. The absence of this evaluation was confirmed by the Quality and Regulatory Compliance Specialist on 1/15/14 at 1:45 PM.

2. Patient #19 was admitted to the hospital on 1/2/14 for a wound infection related to a hip replacement. Since admission, Patient #19 has consented twice and was administered anesthesia for 2 separate surgical procedures. Per review of the inpatient record which included both a paper chart and EMR, there was no evidence Patient #19 received a post-anesthesia evaluation within 48 hours of being administered anesthesia for either surgical procedure. This omission was confirmed by the Quality and Regulatory Compliance Specialists on 1/15/14 at 11:30 AM and later in the afternoon by a member of Anesthesia Services.

Per interview on the morning of 1/14/14 a staff anesthesiologist confirmed his/her department did have a process for conducting the post-anesthesia checks within 48 hours of administering anesthesia for those patients who remain hospitalized. The physician indicated a specific form was recently developed to assure the requirement was met and if the form was not utilized, evidence of the post anesthesia evaluation would be recorded on a physician progress note.