HospitalInspections.org

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Based on medical record review, document review, and interview, in one (1) of four (4) medical records reviewed, the facility failed to ensure that occurrences involving patient safety are thoroughly investigated and corrective actions implemented (Patient #11).

This failure may result in reoccurrence of adverse outcomes.

Findings:

Review of the Occurrence Report for Patient #11, dated 3/5/19 at 5:35 PM, documented the patient was scheduled for vaginal hysterectomy (surgical procedure to remove all or part of the uterus), repair of pelvic floor with mesh, and cystoscopy (a procedure where the doctor visually examines the urethra and the bladder for the presence of abnormal growths, strictures, and other problems). The patient was brought to the Operating Room (OR), intubated, and anesthesia was administered. The cystoscopy was completed but the vaginal hysterectomy was aborted due to a special speculum (Hardy Duddy) the surgeon requested that was not available during the surgery. The Occurrence Report documented that on 3/11/19 at 10:16 AM, a debriefing with the surgeon, and OR leadership was completed to address issues leading to the event.

There was no documented evidence the facility identified the cause of the problem, implemented a systemic action plan to correct the problem, and monitored the effectiveness of actions taken.

On 5/10/19 11:00 AM, during interview, Staff I, Director of Perioperative Services, stated that after the incident, staff members were debriefed and a communication issue was identified.

Staff I was unable to provide documentation of the meeting and reviews that were completed related to the incident.

This finding was acknowledged by Staff L, Chief Nursing Officer who was present during the interview.

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Based on observation, interview, and document review, the facility did not ensure that its policy and procedure on "Cleaning and Sanitizing Patient Equipment" was implemented.

These lapses in environmental safety and quality may potentially place patients and staff at risk for injury or infection.

Findings:

Review of the facility's policy titled "Cleaning and Sanitizing Patient Equipment," last revised on 1/2016, documented that dirty equipment that has been cleaned and disinfected would be covered with a plastic bag and placed in the Clean Utility Room or the department's designated area for clean equipment.

During environmental inspection of the Operating Room (OR) on 5/1/19 between 11:00 AM to 12:30 PM, the following observations were made in the presence of Staff I, Director of Perioperative Services, Staff J, Manager of Materials Management, and Staff L, Chief Nurse Executive:

-Four (4) portable "C-arm machines" and two (2) extensions were observed uncovered with plastic bags in the OR hallway adjacent to OR Room #s 5 and 6;

-Two (2) bins in the OR Medication Room were filled with surgical headlights (placed on head by OR staff to provide illumination during procedures) and were not covered with plastic bags;

-Three (3) Flash Paks (a rigid container use for sterilization) in the sub sterile rooms between OR #s 3 and 4, and OR #s 8 and 9 were noted dirty and rusty with dark brown and black materials in the basket and at the bottom of the three paks.

During interview with Staff I on 5/1/19 at 12:30 PM, she confirmed that clean equipment should be covered with a plastic bag.

During interview with Staff J on 5/1/19 at approximately 12:30 PM, she stated they do not have a schedule for the cleaning and disinfection of the flash paks. Staff J stated that the flash paks are sent to central supply unit when they need cleaning.

These findings were acknowledged by Staff L, Chief Nurse Executive during the unit inspection.

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Based on medical record review, document review and interview, the facility failed to ensure that:

(1) Surgical services were furnished in accordance with generally accepted standards in one (1) of four (4) medical records reviewed to assure the safety of patients (Patient #11);
(2) Water temperature in the scrub sink was maintained at an acceptable range and pressure gradient in the OR was monitored a per facility's policy.

This failure may place patients at risk for harm during the perioperative period.

Findings include:

1. A review of the Occurrence Report for Patient #11, dated 3/5/19 at 5:35 PM, documented the patient was scheduled for vaginal hysterectomy (surgical procedure to remove all or part of the uterus), repair of pelvic floor with mesh, and cystoscopy (a procedure where the doctor visually examines the urethra and the bladder for the presence of abnormal growths, strictures, and other problems). The patient was brought to the Operating Room (OR), intubated, and anesthesia was administered. When the procedure was in progress, the surgeon requested for a specific speculum that was not available. As a result, the surgeon performed the cystoscopy and aborted the remaining procedures.

On 5/10/19 at 10:40 AM, an interview with Staff J, Manager of Materials Management was conducted in the presence of Staff I, Director of Peri-Operative Services and Staff L, Chief Nursing Officer.

As per Staff J, each surgeon has a preference card, where their preferred instruments and equipment are listed before the surgeon's first scheduled case. The preference cards are modified by the OR team as needed. The surgeon's special speculum was ordered on 2/26/19 and arrived on 3/1/19. The procedure date was on 3/5/19.

Review of the Preference Card for the Surgeon revealed that it was created on 2/28/19 at 5:05 PM and modified on 3/8/19 at 3:27 PM for the procedure Vaginal Hysterectomy. The Preference note indicated a Hardy Duddy weighted speculum set.

There was no documented evidence of a timely update of the surgeon's preference card. There was a seven-day gap from the receipt of the speculum on 3/1/19 to the date the Preference Card was updated on 3/8/19.

Review of the hospital's policy on "Perioperative Scheduling Management" dated 2/19/2019 lacked guidance on the timelines of updating surgeons' preference cards.

These findings were acknowledged by Staff I, J, and L.


2. During the tour of the facility's Operative rooms on 5/01/2019 between 11:00 AM - 12:00 PM, it was observed that the water temperature of the scrub sinks was approximately 90-degree Fahrenheit as measured by the Lead Engineer.


As Per CDC (Center for Disease Control) recommendation, and Facility Guidelines Institute (FGI), 2010 edition. Table 2.1-5, the range of water temperature in health care facilities is 105° - 120°F.

On 5/01/19 at approximately 11:30 AM, during interview with Staff I, Director of Surgical Services, she acknowledged findings.


- Review of hospital policy and procedure titled "Maintaining Appropriate Pressure, Temperature and Humidity relationships" revised on 5/19, states that Operating Rooms pressure relationship should be monitored continuously.

Review of OR Monitoring Logs revealed that pressure relationship in the OR was monitored monthly and as needed.

Failure to continuously monitor OR's pressure in relation to the corridor may cause a breach in infection control.

During interview on 5/2/19 at approximately 1:30 PM with Staff Cc, Director of Safety and Security, he acknowledged the above findings.




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Based on medical record (MR) review, document review, and interview, in one (1) of 10 medical record reviewed, the facility failed to ensure that a psychiatric patient who presented with agitation was appropriately monitored and was stable for discharge (Patient #2).

Findings include:

Review of the medical record for Patient #2 identified a 51 year old male who presented to the Emergency Department (ED) on 02/21/19, at 5:39 AM for alcoholic intoxication and psychiatric evaluation post altercation with another resident at an adult care facility. The patient's medical history was significant for bipolar and schizoaffective disorder. At 7:08 AM, the patient received Lorazepam (Anti-anxiety medication) 2 mg intramuscularly for agitation, and a four-point limb restraint application from 7:09 AM to 7:16 AM for behavioral management. A physician order for discharge was documented at 8:03 AM. A psychiatric screening examination documented by a Licensed Social Worker on 2/21/19 at 8:13 AM, revealed the patient was psychiatrically cleared for discharge.

There was no documented evidence of continued monitoring of the effect of medication management on the patient's behavior as the patient was discharged less than one hour after administration of Lorazepam.

The patient returned to the ED on 2/21/19 at 1:36 PM, less than five hours after discharge for increased agitation that required an involuntary admission to the psychiatric inpatient unit for treatment.

On 5/6/19 at 10:17 AM, during interview with Staff B, Emergency Department Director, he acknowledged findings.