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Based on interview and documentation review it was determined the Hospital failed to ensure the intraoperative record for one of eleven medical records reviewed was accurately written.

Findings included:

Review of Patient #1's 9/22/10 intraoperative record indicated during the initial count of sponges, needles and sharps Circulating Nurse # 2, Surgical Technician #1 and the Registered Nurse First Assist performed the count.

Circulating Nurse #1 (CN #1) was interviewed in person, on 10/25/10 at 9:35 AM with a nursing union representative present at CN #1's request. CN #1 said while he/she had been busy obtaining information and supplies need for Patient #1's procedure, the Registered Nurse First Assist had done the initial counted with Surgical Technician #1 and Circulating Nurse #2. CN #1 said he/she had documented their participation in the count by adding their initials in the designated space.

The Registered Nurse First Assist (RNFA) was interviewed in person on 10/25/10 at 11:10 AM with a nursing union representative at the RNFA request. The RNFA said he/she helped drape Patient #1 but did not recall being in the room when the initial count was done.

CN #1 said there had been two surgical technician student in the OR the day of Patient #1's procedure and one of them, Surgical Technician Student #1, had been assigned to work with Surgical Technician #1 during Patient #1 case. CN #1 said when he/she had documented Surgical Technician Student #1, participation in the counts, during the first, third and exit counts, he/she had used the wrong initials, he/she had used Surgical Technician Student #2's initials rather than Surgical Technician Student #1's initials.

Based on interview and documentation review it was determined the Hospital was not in compliance with the Condition of Participation for Surgical Services because it failed to ensure acceptable standards of practice were followed to prevent the retention of surgical sponges.

Please refer to A-0942, A-0944, and A-0951

Based on interview and documentation review it was determined the Hospital failed to ensure the OR was effectively supervised and that all sponge counts were correct in one out of eleven applicable medical records reviewed.

Findings included:


Review of Patient #1's intra-operative documentation indicated Circulating Nurse #1 was assigned as the circulating nurse during Patient #1's surgical procedures.

Review of the Team Leader in the OR's job description indicated it was the responsibility of the team leader to supervises the care of all patients assigned and within the surgical specialty assigned.

Circulating Nurse #2 (CN#2) was interviewed in person on 10/25/10 at 10:25 with a nursing union representative present at CN#2's request. CN #2 said he/she was the assigned team leader for gynecological services.

Although there were supervisory staff present during the initial counts and in the OR proper during Pateint #1's procedure a miscount did occur and Patient #1 retained a sponge.

Based on interview and documentation review it was determined the Hospital failed to ensure the circulating nurse duties were performed in accordance with approved policies of the Hospital in one of eleven applicable medical records reviewed.

Findings included

The Hospital policy that addressed surgical sponge counts was reviewed. The Policy stated an initial sponge count shall be done on all surgical procedures. Sponges will be separated, counted audibly and concurrently viewed during the count procedure by two individuals, one of whom will be a registered nurse circulator. When additional sponges are added to the field they will be counted at that time and recorded as part of the count documentation to keep the count current and accurate.

Review of Patient #1's intra-operative documentation indicated during the initial count of sponges, needles and sharps Circulating Nurse #2 (CN#2), Surgical Technician #1 and the Registered Nurse First Assist performed the count. Documentation did not indicate if one staff member relieved another after a portion of the count had been completed.

CN #1, who had been assigned as the circulating nurse for Patient #1's procedure, was interviewed in person on 10/25/10 at 9:35 AM with a nursing union representative was present at CN#1's request. CN#1 said he/she was busy with confirming which surgeon would be starting Patient #1's procedure and was not present in the OR for the initial count. The initial count was performed by the Registered Nurse First Assist, Circulating Nurse #2 and Surgical Technician #1.

CN #2 was interviewed in person on 10/25/10 at 10:25 AM with a nursing union representative present at CN#2's request. CN#2 said he/she did not recall performing the initial count. However he/she probably had help set up the OR while CN#1 was busy with Patient #1. CN#2 said during counts both a circulating nurse and a surgical technician count at the same time.

The Registered Nurse First Assist (RN First Assist) was interviewed in person on 10/25/10 at 11:10 AM a nursing union representative was present at the RN Fist Assist's request. The RN First Assist said he/she did not recall if he/she was in the room during the initial.

Surgical Technician #1 was interviewed in person on 10/25/10 at 10:45 AM. Surgical Technician #1 said his/her sponge count for Patient #1's case was correct. He/she said the initial count, according to the intra-operative documentation was perfomred by him/herself and CN #2 and the RN First Assist.

Although the Hospital policy indicated two individuals should perform the count documentation indicated three staff member performed the count, one of which was not a circulating nurse. In addtition CN #2 and the RN First Assist did not recall participating in the initial count.

Based on documentation review it was determined the Hospital failed to ensure the policy for surgical sponge counts was enforced and performed in accordance with the Hospital policy in one of eleven applicable medical records reviewed.

Findings included:

The Hospital policy that addressed the surgical sponge count was reviewed. The Policy stated sponges will be separated, counted audibly and concurrently viewed during the count procedure by two individuals, one of whom will be a registered nurse circulator.

Review of Patient #1's intraoperative record indicated the initial sponge count was performed by three staff members, the Registered Nurse First Assist, Circulating Nurse # 2 and Surgical Technician #1 and not two staff members as specified in the Policy. In addition documentation did not identify which staff member actually participated in the count at any given time during the initial count and that a circulating nurse was present during the whole initial count as specified in the Hospital policy.