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Based on interview and record review, the facility failed to ensure all staff were trained regarding abuse for one of 38 sampled staff (Labor and Delivery [L&D] Manager). There was no documentation of abuse training upon hire.

This deficient practice had the potential for L&D patients, who can be victims of abuse, not be properly identified and protected from their abusers, and incidences of abuse not being properly reported.

Findings:

On 3/3/2021 at 1:04 p.m., during interview and concurrent record review of personnel files with the Staff Educator (SE) she stated the LDM had no documentation of receiving abuse training after hire date. The SE stated abuse training is done upon hire, during hospital orientation and is repeated annually during on-line training.

A review of Provision of Care policy, dated October 2019, indicated the following:
1. The facility is dedicated to ensuring safe patient care with dignity compassion and human kindness, which means we must heal without harming.
2. We must keep patients safe by creating a culture of safety by training all employees to prevent harm and reduce human error rate.
3. Patient assessments are the foundation of all disciplines and includes screening for nutritional risk, skin injury risk, signs of abuse or neglect, and pain or comfort needs by the appropriate disciplines.
4. Patient rights include general consent for care, spiritual care, and evaluation of care.
5. Nursing and other licensed professionals are reviewed prior to hiring for validation of experience and abilities with hospital orientation to ensure services are provided in compliance with training, policies and procedures, standards of care, delivery of care processes, computer systems training and skills validation testing.

Based on observation, interview, and record review, the facility failed to ensure that one of 38 sampled patients (Patient 5) received adequate pain relief with pain level at three out of 10 (zero as no pain, and 10 as severe pain).

This deficient practice had the potential to result in further pain, causing physical and/or psychological harm.

Findings:

During observation, on 3/2/21 at 11:15 a.m., Patient 5 was seen lying in bed, mumbling, but alert and oriented. Patient 5's left leg was in a long leg splint and was complaining of soreness on his left side. During a concurrent interview with Registered Nurse (RN 5) she stated that Patient 5 received morphine (medication for pain relief) six milligrams (mg) intravenous (through the vein) push about one hour ago, and that she requested change in pain medication (med) from the doctor.

During record review of "Order Sheet," indicated morphine injection (inj) two to six mg PRN (as needed) was ordered on 3/1/21 at 11:44 p.m. For pain scale of one to three, administer morphine two mg, for a pain scale of four to six, administer morphine four mg, and pain scale from seven to 10 administer morphine six mg.

During record review of "Medication Administration," indicated RN 5 administered morphine six mg on 3/2/21 at 8:44 a.m., for Patient 5's pain scale of 10 out of 10.

During record review of "Medication Administration," dated 3/2/21 at 8:59 a.m., indicated RN 5 reassessed Patient's 5 pain scale as six out of 10. Patient 5's acceptable pain intensity of three out of 10 was not met and RN 5's action indicated she completed a "Request change in pain medication," but did not indicate who it was requested from.

During concurrent interview and record review, on 3/2/21 at 2:30 p.m., with Medical-Surgical Department Manager (MSM) verified that RN 5 did not document a follow-up request for the doctor to change Patient 5's pain med therefore, no new or additional med was ordered to relieve Patient 5's pain. MSM stated, "Pain greater than three will require further assessment. The findings and course of action will be documented in the EHR (electronic health record - a digital version of a patient's paper chart)."

During concurrent interview and record review, on 3/3/21 at 11:00 a.m., with MSM stated that in a case where no other pain med was ordered, the nurse would call the doctor to obtain an order, and that usually, was an order for breakthrough (a sudden and brief flare-up) pain.

During record review of facility's job description for an RN titled, "Job Standards, Professional Practice," undated, indicated: RN "Provides effective, comprehensive evidence-based nursing care to achieve desired health outcomes. Organizes and prioritizes patient care activities balanced with the needs and comfort of the patient. Collaborates with other disciplines to insure comprehensive, holistic, and effective plan of care."

Based on interview and record review the facility failed to ensure all staff were screened annually for tuberculosis (TB, a potentially serious infectious disease that mainly affects the lungs) per policy and had medical clearance from a physician prior to working on the floor for two of 38 sample selected staff (Registered nurse [RN 2] and Labor and Delivery Manager[LDM]).

These deficient practices had the potential to result in the spread of TB from one person to another.

Findings:

During interview and concurrent record review, on 3/3/21 at 1:40 p.m., with Employee Health (EH), RN 2 did not have annual TB screening in her health file. EH stated the annual requirements include influenza (flu) vaccine, respirator fit testing, and TB screening. The facility conducted an annual wellness fair in 10/2020, and RN 2 received the flu vaccine and was fit-tested for a respirator. EH stated she will follow-up RN 2 when she gets back from vacation.

During record review of "Employee TB Screening," indicated all employees known to have a positive tuberculin skin test (TST, skin test to determine TB) at any time must complete the TB questionnaire annually.




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2. On 3/3/2021 at 10:40 a.m., during an interview and concurrent record review of personnel files with Employee Health (EH), EH stated that Labor and Delivery Manager (LDM) had no documentation of medical clearance to work upon hire. The EH stated all employees of the facility must have documentation of a medical clearance by a physician prior to working. The EH stated was unable to find a policy regarding medical clearance but stated it should be done prior to working on the floor.

Based on observation, interviews and record reviews, the facility failed to ensure staff were competent in safe and effective food handling practices when two Food Service Workers (FSW) were not competent with respect to testing the concentration of the sanitizer to ensure it was effective in sanitizing food contact surfaces for two of two sample selected FSW (FSW1 and FSW2). This failure was evident when (FSW1) and (FSW2) did not follow manufactures guidance when testing the concentration of the sanitizer.

This failure had the potential to result in ineffectively sanitizing the food contact surfaces used to prepare patient food. Ineffective sanitizing of food contact surfaces had the potential to result in unsafe food handling practices that affected the food served to 181 patients, staff and visitors in the hospital.

Findings:

During an observation of the kitchen preparation area, on 3/1/2021 at 3:15 p.m., FSW1 stated he uses the sanitizer in the red bucket to sanitize the food contact surfaces and counters. During a concurrent observation and interview, FSW1 demonstrated how he tested the concentration of the sanitizer. FSW1 stated that the sanitizer solution is prepared and is dispersed from the hose premixed by the manufacture. FSW1 dropped the test strip in the bucket with sanitizer solution and waited a full minute. FSW1 then took out the test strip from the sanitizer solution with the direction of the Nutrition Services Manager (NSM) and repeated the same process one more time, tearing a new testing strip and dropping it in the testing solution. FSW1 then stated that the color of the test strip changed from yellow to green. FSW1 did not know how to read the test strip and how to compare the test strip to the color chart posted on the wall per manufacture guidelines. FSW1 did not know what the normal range for the sanitizer solution is and did not know how long to immerse the test strip in the solution.

During an interview with the NSM, on 3/1/2021 at 3:20 p.m., she stated FSW1 should have place the test strip in the sanitizer solution for 10 seconds and then compare the change in color to the color chart. NSM stated the recommended range for sanitizer is 150-400 part per million (PPM) per manufactures guidelines. NSM stated that she would provide in service to her staff. NSM stated the sanitizer solution is dispersed automatically premixed by the manufacture to provide adequate levels.

During another observation, on 3/2/2021 at 3:20 p.m., FSW2 demonstrated how he checks/tests the effectiveness of the sanitizer solution. FSW2 immersed the test strip in the sanitizer solution and stated that he will wait for 15 seconds. FSW2 then compared the strip to the color chart and stated it is at 200 PPM and it should be at 500 PPM to be effective. FSW2 stated he will discard the solution because it is at 200 PPM and will fill the buckets with new solution. FSW2 stated the normal level for the sanitizer solution is 500 PPM.

During an interview, on 3/2/2021 at 3:25 p.m., with the NSM she stated the normal range is 150-400 PPM. NSM stated she would provide an in-service to staff on how to test the effectiveness of sanitizer solutions.

During an interview, on 3/4/2021 at 11:00 a.m., the Food Service Director (FSD) stated that another in-service has been planned for 3/18/2021 that will include infection control in the kitchen and will address food storage, hand hygiene, sanitizer effectiveness, and reporting and addressing out of range temperatures. FSD stated that all issues identified would be added in the quality indicators assessment meeting and rounds.

A record review of the job descriptions for Food Service worker indicated a competency requirement in food safety that "cleans and sanitizes work station including Checking PPM of sanitizer solution and changing sanitizer buckets every 2 hours or sooner as needed."

A review of the hospital policy titled "FNS Sanitation Food Contact Surfaces", Policy No. IC136 (2019), indicated, "Sanitizing solutions are used to clean all work areas based on manufacturer recommendations."

A review of the Manufacturer recommendation for the sanitation range testing posted on the sanitizer dispensing area, indicated, 1.Testing solution should be at room temperature 65-75 degrees Fahrenheit, 2.Withdraw and tear off approximately 2 inches of the paper from dispenser, dip test paper for 10 seconds in the test solution, 3.compare colors immediately with colors on the test paper package to determine PPM (ALWAYS COMPARE AGAINST PACKAGE SCALE), 4.testing solution should be between 150-400PPM parts per million.

Based on observation, interviews and record reviews, the facility failed to:

1. Ensure Food Service Worker (FSW3) working in the dish machine area washed hands and changed gloves when removing the clean and sanitized dished from the dish machine (Refer to A749).

2. Ensure refrigerators in the nourishment room (Room 627, Room 527), on 5th floor lounge Labor and Delivery unit (L&D) and transitional care unit (TICU) maintained food storage temperatures to ensure time and temperature control for safety [(TCS) foods are capable of supporting bacterial growth that can result in food borne illness when not safely stored and prepared] of food stored in the refrigerator. The patient census was 185 in addition to staff and visitors (Refer to A749).

3. Provide a clean and sanitary environment in the L&D operating room scrub area. The patient census in L&D was 8 (Refer to A749).

4. Prevent transmission of infection, in the telemetry medication room, by utilizing a corrugated box for storage and having tape residue on the glucometer (a device to measure blood sugar level) carrying case. The patient census in telemetry was 32 (Refer to A749).

5. Ensure one of 38 sampled employees, Registered Nurse (RN 2), had current documentation of annual tuberculosis [(TB) - a highly contagious disease infectious disease) screening to prevent TB transmission TB (Refer to A749).

The cumulative effect of these systemic failures resulted in the facility's inability to ensure the Condition of Participation (CoP) for infection control.

Based on observations, interviews and record reviews, the facility failed to ensure infection control practices were followed when:

1. One Food Service Worker (FSW3) working in the dish machine area did not wash hands and change gloves when removing the clean and sanitized dished from the dish machine.

2. Refrigerators in nursing station nourishment room (Room 627, Room 527, fifth floor lounge labor and delivery [L&D] and trauma intensive care unit [TICU]) did not maintain safe food storage temperatures for TCS foods stored in the refrigerator. (Time and Temperature Control for Safety foods are foods capable of supporting bacterial growth that can result in food borne illness when not safely stored and prepared).

3. Mineral deposits, rust stains, and tape residues were found around the three of three scrub sinks (station for doctors and other operating room staff to scrub their hands and arms before a surgical or invasive procedure) in the L&D Operating Room, and a corrugated box inside a medication room.

4. Registered Nurse (RN 2) did not receive an annual tuberculosis (TB, a potentially serious infectious disease that mainly affects the lungs) screening, per policy for one of 38 sampled staff.

These deficient practices had the potential to result in food borne illness in a medically vulnerable patient population of 185 patients, an outbreak or increase infections in the facility.


Findings:

1. During an observation of the dish machine area, on 3/1/2021 at 3:30 p.m., (FSW3) was loading dirty dishes in the dish machine to be washed and sanitized. FSW3 then moved over to the next task and proceeded to pull out and remove the clean and sanitized pots and pans without changing gloves and washing hands. The FSW3 touched the clean and sanitized dishes with the same gloves used to load the dirty dishes. During a concurrent interview, FSW3 stated that he did not change his gloves and wash hands before touching the clean and sanitized dishes. FSW3 also stated that when he does not wash hands after handling dirty dishes, he could contaminate the clean dishes. FSW3 stated he will re load pots and pans and sanitize again.

During an interview, 3/21/2021 at 3:30 p.m., with the Nutrition Service Manager (NSM), she stated that usually two people work in the dishwashing room. When one person is working in the dish machine area, that staff should remove gloves and wash hands put on new gloves then touch clean and sanitized dishes. NSM stated staff should change gloves and wash hands when moving from one task to another. The NSM stated she would provide in-service on hand hygiene.

During an interview with the NSM and Food Service Director (FSD) on 3/4/2021 at 11:00 a.m., the NSM stated that in-services have been provided regarding testing the sanitizer and hand hygiene. The FSD stated that another in-service has been planned for 3/18/2021 that will include infection control in the kitchen and will address food storage, hand hygiene, sanitizer effectiveness and reporting and addressing out of range refrigerator and freezer temperatures. The FSD stated that all issues identified during this survey would be added in the quality indicators assessment meeting and rounds.

A review of the job description for the Food Service Worker indicated a competency requirement in Food Safety that "Has knowledge and demonstrates proper sanitizing and drying of all service ware (pots, pans, utensils, trays, etc.; has knowledge and demonstrates proper hand washing techniques and has knowledge and demonstrates proper glove use."

A review of facility policy titled "Hand Washing", Policy No. IC129 (no date), indicated, "Wash hands after smoking, drinking, eating, using bathroom, handling money, soiled glass or dinnerware, garbage ..."

A review of the 2017 U.S. Food and Drug Administration Food Code indicated, "The FDA has identified poor personal Hygiene including hand washing as foodborne illness risk factor. Handwashing is a critical factor in reducing pathogens that can be transmitted from hands to food or to food contact surfaces." It further indicated, "Food service workers should be careful not to contaminate clean and sanitized food contact-surfaces with unclean hands."

2. During an observation of the nourishment room number 627, on 3/2/2021 at 10:20 a.m., the temperature of the below the counter refrigerator was 44 degrees Fahrenheit (F). Inside the refrigerator were juices and milk for patients. A temperature check of the milk carton indicated it was 42 F. There was no temperature recorded on the temperature log for 3/2/2021.

During an observation of the nourishment room number 527 in L&D unit, on 3/2/2021 at 10:30 a.m., the temperature of the below the counter refrigerator was 43 F. Inside the refrigerator were milk for patients. A temperature check of the milk carton indicated it was 43.7 F. There was no temperature recorded on the temperature log for 3/2/2021.

During an observation of the nourishment room in five West, on 3/2//2021 at 10:35 a.m., the temperature of the below the counter refrigerator was at 43 F. Inside the refrigerator were juices, milk and turkey sandwiches for patients. A temperature check of the milk carton indicated it was at 48 F. A temperature check of the turkey sandwiches indicated it was at 41 F. There was no temperature recorded on the temperature log for 3/2/2021.

During an observation of the nourishment room in TICU unit, on 3/2/2021 at 10:45 a.m., the temperature of the below the counter refrigerator was at 42.5 F. Inside the refrigerator were milk for patients. A temperature check of the milk carton indicated it was 48 F. There was no temperature recorded on the temperature log for 3/2/2021.

During an interview, on 3/2/2021 at 10:47 a.m., with the NSM, she stated that dietary staff check the temperature of the nourishment refrigerator once a day. The NSW stated that food and nutrition services is responsible for checking temperature and maintaining the temperature logs for the refrigerator units on patient floors. Food and nutrition services is also responsible for stocking the refrigerator with juices, milk and snacks for patients. The NSM further stated that dietary staff had not made the rounds to check temperatures yet. Since the temperature was not checked yet for the day, the NSM could not determine how long the milk had been out of temperature. The NSM also stated that when temperatures are not at normal range, the dietary staff would report it to the Supervisor who will call maintenance. The NSM stated there has not been any issues with refrigerator temperatures recently. The NSM discarded all sandwiches and milk from the refrigerators.

During an interview with facilities maintenance staff (FM1), on 3/2/2021 at 10:30 a.m., he stated that his department does preventive maintenance on the refrigerator units. FM1 stated once a month they check refrigerator units for temperatures, ice accumulations, defrost as needed and identify any problems with the units. The FM1 does not recall if any of the units he assessed had any temperature problems.

During a concurrent interview with Facilities Director (FD), on 3/2/2021 at 10: 32 a.m., he stated that Food and Nutrition services department is responsible for the daily temperature checks of the refrigeration units in the nourishment rooms on the patient floors. The FD stated that if any of the refrigerators does not meet temperature levels Food and Nutrition department calls the facilities and maintenance department for an assessment. The FD also stated that there are no work orders requested for the refrigerator units in Room 627, Room 527, 5th floor lounge L&D and TICU.

During an interview with FSD, on 3/3/2021 at 2:30 p.m., she stated that maintenance assessed all refrigerators in the nourishment areas and set the temperatures at a lower level for a refrigerator so the milk can maintain a temperature below 41 F. The FSD also stated that staff checks temperature on a daily basis and had not reported any prior temperature problems. The FSD stated that she understands that milk at temperature above 41 F could have adverse effects on patients. All food was discarded immediately. The FSD stated the dietary staff continued to observe and check the temperature of the refrigerators on 3/2/2021 and 3/3/2021 and the milk cartons three times to assure the temperature is adequate and maintained less than 41 F.

During an interview with FD, on 3/4/2021, at 9:00 a.m., he stated that facilities and maintenance department recognized the critical situation with the elevated milk temperatures and immediately assessed all refrigerators. The Facilities department created a work list and the maintenance staff worked on the refrigerators. Facilities did not find physical problems with the refrigerators but adjusted the thermostat of the refrigerators to a lower level. Multiple checks were also made by Facilities and maintenance and found no further issues with refrigerator temperatures.

During an interview with Patient Safety Manager (PSM), on 3/4/2021 at 9:30 a.m., she stated that monitoring temperatures for the nourishment refrigerators are very important to ensure patients receive safe food. PSM also stated hospital considering centralized temperature monitoring for nourishment refrigerators.

During an interview with Infection Preventionist (IP), on 3/4/2021 at 11:40 a.m., she stated infection control is part of hospital wide Environment care committee who meets once a week and rounds together. IP stated the committee which includes facilities department, infection control department as a group rounds two times a year in clinical areas and one-time a year in non-clinical areas. The IP stated during her infection control rounds all refrigerators in the units are checked for temperature accuracy of the unit and food that is stored inside and other physical problems with the refrigerator unit such as accumulation of ice, door not closing. The IP stated elevated refrigerator temperatures are not common findings during her rounds and that refrigerator temperatures should be in range for safe food storage. The IP also stated hospital has moved to centralized temperature monitoring for pharmacy and will consider for nourishment refrigerators on the patient units.

A review of the hospital's policy titled, Refrigerator/freezer Temp logs (PC021), undated indicated, "Refrigerator food temp range 34 to 41 degrees F (+/-2 degrees F). Make sure that all refrigerators are in good working order to maintain the proper holding temperature. If food is found out of temp take immediate corrective action." Additionally, the policy indicated, "Temps are recorded on monthly temp log ...Make sure that all freezers and refrigerators have temps are logged at least two time a day ..."

A review of the 2017 U.S. Food and Drug Administration Food Code time/temperature control for safety food shall be maintained at 135 °F or above or at 41 ºF or less.


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3. On 3/1/2021 at 3:34 p.m., during initial tour of the operating room in L&D with Labor & Delivery Manager (LDM), three of three scrub sinks were observed with mineral deposits and rust stains on the faucets, and tape with tape-residue were observed in the scrub sink area.in a concurrent interview the LDM stated she was not aware of the mineral deposits on the scrub sinks and the tape with tape residue in the scrub sink area.

A record review of Joint Commission Resources - Environmental Infection Prevention, dated 2018, indicated the following environmental contamination prevention strategies:
1. Equipment - review manufacturer's instructions and relevant national guidelines for equipment and check equipment components that may rust or deteriorate.
2. Preventive maintenance and deep cleaning - routinely assess surfaces to help reduce the burden of contamination by removing tape or another adhesive residue.
3. Environmental cleaning interventions can improve the thoroughness of cleaning and reduce contamination on surfaces.

A record review of Reducing Medical Tape Cross Contamination - Tips and Advice, dated 2/23/2018 indicated tape is a reservoir of microorganisms - even worse a fomite (objects or materials that are likely to carry infection, like clothes, utensils and furniture). Tape is a vehicle for cross contamination when it is carried from room to room, left in high traffic areas, or passed from person-to-person and becoming a vector (an organism that does not cause disease itself, but spreads infection by conveying pathogens from one host to another) for transmitting pathogens.


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During concurrent interview and record review, on 3/3/21 at 1:40 p.m., with Employee Health (EH), RN 2 did not have annual TB screening in her health file. The EH stated the annual requirements include influenza (flu) vaccine, respirator fit testing, and TB screening. Facility conducted an annual wellness fair in 10/2020, and RN 2 received the flu vaccine and was fit-tested for a respirator. EH is currently unable to conduct a TB screen for RN 2 as RN 2 is on vacation. EH stated she will follow-up.

During record review of "Employee TB Screening," undated indicated all employees known to have a positive TST (tuberculin skin test) at any time must complete the TB questionnaire annually.

Based on interview and record review, the facility failed to adhere to its policy and procedure on prevention of retained surgical items (RSI) by not performing a proper sponge count during cholecystectomy (surgical removal of the gallbladder) for one of 38 sampled patients (Patient 22).

This deficient practice resulted in Patient 22 experiencing prolonged abdominal pain postoperatively (after surgery) and eventually undergoing repeat surgery to remove the retained surgical item.

Findings:

During a record review of Patient 22's medical records indicated on 7/2/2020, Patient 22 underwent laparoscopic cholecystectomy (operation performed in the abdomen or pelvis using small incisions with the aid of a camera) then was converted to open cholecystectomy (incision opening in the abdomen or pelvis around six inches or more) and was discharged from the hospital on 7/5/2020. On 8/9/2020, Patient 22 was readmitted with abdominal pain and subsequently underwent exploratory laparotomy (operation in which the abdomen is opened, and abdominal organs are examined for injury or disease) with removal of a retained foreign body.

During a record review of Patient 22's "Intra-Op Nursing Record" dated 7/2/2020 at 5:25 p.m., indicated under the Count Verification section that both the Closing Count (count performed before wound closure begins) and the Final Count (performed when surgical items are no longer in use and all are passed off the field) were documented as "Correct" and that the surgeon was notified of the results of both counts.

During a record review of Patient 22's, Operative Report, dated 7/2/2020 at 5:36 p.m., indicated the counts were "reported as correct x 2."

During a record review of Patient 22's, "Operative Report, dated 8/11/2020 at 12:41 a.m., indicated the patient underwent exploratory laparotomy during which a foreign body, a laparotomy sponge in its entirety, was removed and passed off as specimen to the laboratory.

During a record review of Patient 22's, Surgical Pathology Report, dated 8/12/2020 indicated the specimen submitted to the laboratory included an abdominal foreign body which, on gross examination, consisted of a piece of hemorrhagic (bloody) surgical gauze measuring 10 x 8 x 4 centimeters (cm) in size, weighing 97 grams, with no attached tissue seen grossly.

During an interview, on 3/3/21 at 10:05 a.m., the facility's Chief Medical Officer (CMO) stated that upon discovery of the retained lap sponge (laparotomy sponge, a padded sponge used in surgery for absorption and during retraction) following an otherwise uneventful cholecystectomy, that necessitated a patient (Patient 22) to undergo repeat surgery to remove the retained item, an RCA (root cause analysis, a structured method used to analyze serious adverse events) was triggered. The CMO stated the facility's investigation into the incident found that the operating room (OR) staff had not followed proper protocol. The CMO added that the case was reviewed by the relevant quality committees, including Surgery and Trauma Committees and the hospital Quality Improvement Committee, and was presented to the Community Board (governing body) at its August 2020 meeting.

During a review of the hospital's policy on prevention of RSI and concurrent interview with the Director of Surgical Services (DSS), on 3/4/2021 at 09:50 a.m., the DDS stated the incident involving a retained lap sponge was a "never event" (serious and costly errors in the provision of healthcare services that should never happen), and it immediately triggered an RCA. The DSS stated following the investigation, the facility concluded that two surgical staff involved in Patient 22's cholecystectomy on 7/2/2020, both of whom were responsible for ensuring correct sponge counting, did not follow the proper process for prevention of RSIs, pointing out that the most important step in the procedure, the "Show Us" step, was skipped. The DSS stated the two employees were disciplined and presented with a letter of warning due to their violation of the hospital policy. The DSS added that in response to this event, the facility re-educated and retrained the entire OR staff on the RSI prevention policy. The DDS also stated the facility has been conducting audits of sponge accounting of ten OR cases per month, with accurate counting documented every month since the event.

During an interview, on 3/3/2021 at 2:10 p.m., and follow-up interview on 3/4/2021 at 1:30 p.m., the scrub tech (ST, a surgical technologist who is a member of the surgical team) who participated in the operation in question stated the "show me" step is where mistakes can be made. When asked whether the circulating nurse (RN 2, a registered nurse who works in the OR outside the sterile field and records the progress of the operation, accounts for the instruments and handles specimens) actually showed him all ten sponges, one in each of the ten pockets of the holder, and whether he visually verified the count with the circulator at the close of the procedure, the tech replied, "I might have just glanced at it. I think I put a lot of trust in her (RN 2), and she probably trusted me too."

The facility's policy and procedure titled "Prevention of Retained Surgical Items (RSI)," dated 1/24/2018 indicated delineates the Sponge Accounting System employed by the facility consisting of following steps:

a. Surgical sponges are to be added to the field ONLY in multiples of ten (10).
b. Sponges are counted using the 3S's ("See, S-E-P-A-R-A-T-E, Say") during all IN and OUT counts.
c. Sponges are placed in the pockets of hanging blue-backed plastic sponge holders following the defined practice.
d. Doctors must perform a methodical wound exam at the closing count in every case.
e. All the sponges (used and unused) must be in the sponge holders at the end of the case to have a correct final count.
f. After the final sponge count, the circulating nurse must perform a "Show Us" step with another person to visually verify that there are "no empty pockets" and all sponges have been accounted for.