HospitalInspections.org

Twenty-four patient medical records were reviewed. It was determined that 4 out of 24 patients did not receive the Permission and Acknowledgment form. This form includes information pertaining to use and disclosure of health information, the health information exchange inclusion and consent to obtain electronic medication history. A member of the patient access team was interviewed and stated that all patients should receive this form during the registration process. The form can be electronically signed, or printed, signed, and scanned into the system. These 4 patients were determined to be unable to sign the form. However there was no documentation indicating that this was completed and placed in their medical records.

Based on review of medical records and policies and procedures, it was determined that renewal orders for restraints were not obtained in a timely manner for two patient's reviewed.
Patient #14 was in 4 point violent restraints on 7/8/15 while in the Emergency Department. Patient restraints were initiated on 7/8/15 at 2000. The patient remained in restraints past the 4 hour renewal time. Restraints were not renewed until 7/9/15 at 0018, past the 4 hour requirement for renewal of violent restraints.

Patient #15 was in 4 point violent restraints on 7/29/15 while in the Emergency Department. Patient restraints were initiated on 7/29/15 at 1440. The patient remained in restraints past the 4 hour renewal time of 1840. The restraints were not renewed until 7/29/15 at 2125, more than 6 hours later and 2 hours past the 4 hour requirement for renewal of violent restraints.

Based on review of medical records and policies and procedures, it was determined that the hospital failed to release 2 patients from restraints at the earliest possible time.
Patient #¿¿14 was in 4 point violent restraints on 7/8/15 while in the Emergency Department. A review of the Q15 minute checks of the patient revealed that patient #14 was asleep from 2130 to 0000. The patient remained in 4 point restraints during this time. The patient was not released from the restraints at the earliest possible time when the violent behavior stopped.
Patient #15 was in 4 point violent restraints on 7/30/15 while in the Emergency Department. A review of the Q15 minute checks of the patient revealed that patient #15 was asleep from 0400 to 0600. The patient remained in 4 point restraints during this time. The patient was not released from the restraints at the earliest possible time from when the violent behavior stopped.

Based on observation and review of the hospital's Quality Assurance and Performance Improvement Program (QAPI), review of the hospital's safety event log with related incidents for surgical procedure posting, review of the requested data on surgical site markings, and interviews of the Risk Management/Quality Staff and the Administrative Nursing Staff on both days of the survey it was revealed that the hospital failed to address and intervene on identified problems related to high risk/high volume surgical services in the general OR and the Sherwood Outpatient Ambulatory Surgical Center in a timely manner.

The findings were:
Review of the QAPI information with regard to the Quality and Safety Committee (QSC) Meeting minutes from March 2015 to July 2015 revealed that there was no evidence that an problems in the two surgical areas were identified and therefore lacked immediate action plans/interventions to ensure patient safety.

A review of requested data related to surgical postings for patients for the period of December 20014 to July 2015 revealed that there were 6 incorrect surgical postings that involved inaccurate surgical information received from community physicians' offices. In June 2015, 6 months after the issue was first identified, a formal review of this issue and the related posting process was conducted. The process was changed in that the Post Anesthesia Care Unit (PACU) Registered Nurse (RN) would review the patient's chart against the surgical posting 24 hours prior to each surgery/procedure for accuracy and completeness. The plan also included the RN meeting with the physician's office manager related to the incorrect surgical information until a "trend" was identified. The plan did not specify what constituted a "trend" and and what the goal was for reducing the number of incidents.

A review of the QAPI related to the surgical site markings allegation revealed that there was no documentation pertaining to the identified problem in any of the QAPI documentation, even though an interview of the Risk Manager on 8/12/15 revealed that the problem came to light in January 2015. The Risk Manager conveyed that the surgical site marking process had been validated as an issue, was being worked on, and would be forwarded to the QSC.

While the issue had been under review for approximately 8 months, even after 3 notifications by staff to the hospital administration between January 2015 and June 2015, the issue continued to be in progress with no formal action plan implemented or other action taken to address the identified problem.

Based on reviews of medical records, policy and procedure and staff interviews, it was determined that the hospital failed to follow patient safety standards for marking of the surgical site.

The hospital's Clinical Policy and Procedure "Universal Protocol" states that the purpose of the protocol is to ensure patient safety by providing a Universal Protocol, guidelines and procedures for verification of the correct site, correct procedure, and correct patient for "all surgical and non-surgical invasive procedures." This protocol applies to the entire institution. The hospital developed a "time-out" procedure for the correct identification of the patient, procedure and site/side for "all surgical and non-surgical invasive procedures" including anesthesia procedures: regional anesthesia, spinal or epidural anesthesia and introduction of invasive monitoring catheter, etc. The policy also applies to all areas of the hospital performing surgical and invasive procedures.


Based on review of patient #12's medical record by the surveyor, it was determined that patient #12 had a central line placed at the bedside. Review of the universal protocol/surgical/invasive procedure verification form revealed that it was signed by the Physician Assistant (PA) who completed the procedure indicating that the site was exempt from marking. In addition, under verification of site , the PA wrote his initials under N/A (non-applicable). Despite the fact that the form states the site was not marked the PA stated when interviewed by the surveyor that he had marked the site.


A central line per the site marking policy is not an exempt procedure and should have been marked by the PA. By signing the exempt marking area of the form it was determined that the site was not marked before the procedure which from a patient safety standpoint placed the patient at potential risk for wrong side/site surgery.