HospitalInspections.org

Based on review of Medical Staff Credentialing files and interview, the facility failed to assure seven (#1,#2-5,#7-9) of ten (#1-10) Medical Staff had a current TB (Tuberculin) skin test. The failed practice did not assure staff, patients and visitors were not exposed to infectious disease and had the potential to affect all persons in the facility. Findings follow:

A. Review Medical Staff Credentialing files revealed no evidence TB skin testing was performed for #1,#2-5,#7-9.
B. Findings were verified with the Medical Staff Credentialing Coordinator on 11/30/11 at 1115.

Based on review of the Operating Room Log and interview, it was determined the Operating Room Log did not contain pre-operative and post operative diagnoses. Failure to include all required elements in the operating room log did not allow the facility to track and trend potential problems. Findings follow:

A. During review of the electronic Operating Room Log, it was revealed the log did not contain documentation of pre-operative and post-operative diagnoses.
B. The above findings were verified by the Pre-operative/Post Anesthesia Care Unit Director at 0955 on 12/01/11.