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Based on record review and interview, the CAH failed to ensure medication variances and notification of the practitioner of medication variances were documented in the patients' records for 2 (Patient #22, #23) of 2 (Patient #22, #23) patient records reviewed for medication variances. Findings:

Review of the CAH's policy for Medication Errors, 14-03 revealed in part, "Medication errors shall be reported in a timely manner to the practitioner who ordered the drug. If the practitioner who ordered the drug is unavailable, the error shall be reported to the attending practitioner or another responsible practitioner."

Patient #22
Review of the CAH's medication variance report for Patient #22 dated 5/22/19 revealed, "Wrong dose of medication Zosyn given to patient; patient was supposed to get Zosyn 2.25 mgs and received Zosyn 3.375 mg."

Review of Patient#22's EMR, assisted by S3RN, chart navigator, revealed there was no documentation of the medication variance in the patient's medical record and no documentation of practitioner notification of the variance in the EMR. S3RN verified Patient #22's EMR lacked the above referenced documentation.

Patient #23
Review of the CAH's medication variance report for Patient #23 dated 3/01/19 revealed, "I noticed that the Dopamine drip was infusing using mcg/min, not mcg/kg/min. Dosage ordered was 2.5 mcg/kg/min. Pump rate was at 0.1 cc/hr. Patient was receiving much less of the actual dosage ordered."

Review of Patient #23's EMR, assisted by S4IT, chart navigator, revealed there was no documentation of the medication variance in the patient's medical record and no documentation of the practitioner notification of the variance in the EMR. S4IT verified Patient #23's EMR lacked the above referenced documentation.

An interview was conducted with S3RN on 1/08/2020 at 10:30 a.m. S3RN confirmed the nurses are instructed to document the notification of the variance to the physician and the variance in the EMR.

Based on observation, record review, and interview the hospital failed to ensure infection control polices and nationally recognized guidelines were followed in the surgical services area. This deficient practice was evidenced by observations of 3 (S8MD, S6CRNA, S7CST) surgical staff with hair not completely covered in the OR and restricted areas during the preparation and performance of surgical procedures. Findings:

Review of AORN Guidelines for PeriOperative Practice (2018) revealed in part that Personnel entering the semi-restricted and restricted areas should cover the head, hair, ears, and facial hair. (Surgical Attire, Recommendation III).

Review of hospital policy #6104801 titled, "Access to the Surgical Suite/Attire", provided by S5SurgDir as current, revealed clean surgical attire, including head covering would be worn in the semi-restricted areas and restricted areas of the surgical or invasive procedure setting. Further review revealed all persons would cover head and facial hair, including sideburns and the nape of the neck, when in the semi-restricted and restricted areas of surgery...

An observation 01/07/2020 at 8:40 a.m. revealed S6CRNA entered the endoscopy room wearing a disposable skull cap, rolled up, with his hair exposed at the side and back of his head.

In an interview 01/07/2020 at 9:05 a.m. S9ST and S10RN verified S6CRNA was wearing a skull cap, with head hair exposed, while in the restricted areas.

An observation 01/07/2020 at 9:45 a.m. of OR staff, during the opening of surgical supplies and instruments in OR 1 in preparation for a surgical procedure, revealed S7CST had approximately 1- 2 inches of hair exposed at the front of her surgical hat, and approximately 1-3 inches exposed from the side of her head. S7CST confirmed the findings at the time of observation.

An observation 01/07/2020 at 10:15 a.m. revealed S8MD entered OR1 after performing a surgical scrub. Further observation revealed he was wearing a disposable skull cap with the hair at the back lower portion of his head and sides of his head exposed.

In an interview 01/07/2020 at 10:17 a.m. S5SurgDir confirmed the observation. S5SurgDir confirmed it was their policy that all hair was covered in the restricted and semi-restricted areas and that they followed AORN guidelines. When asked if this was how S8MD and (male) CRNAs routinely wore their surgical head coverings, S5SurgDir had no answer and shrugged her shoulders.