HospitalInspections.org

Based on staff interview and record review, the hospital failed to ensure Patient 2 was given informed consent in receiving blood transfusions. Findings:

Patient 2's record indicated she received one unit each of packed red blood cells (PRBC) on 1/21/10 at 1:22 and 1:46 p.m. after undergoing a femoral-popliteal bypass (operation to improve blood supply to the legs) at the hospital's catheter laboratory.

On 1/21/10 at 2:30 p.m., Patient 2 was admitted to the coronary care unit. A nurse ' s note on 1/21/10 at 5:15 p.m. described the patient as "anxious/restless" and alert and oriented to person, place and situation. At 5 p.m. and 6 p.m., the patient received an additional two units of blood. The record did not indicate blood transfusions were given in emergency situations and lacked documentation the patient had signed a consent for the transfusions.

The hospital's policy, "Patient Consent" revised on 03/09 outlined the administration of blood products except in emergency situations required informed consent and documented verification of consent.

On 2/3/09 at 11:45 a.m., an administrative nurse acknowledged an informed consent for the 5 p.m. and 6 p.m. blood transfusions was not available in the record.

Based on staff interview and one of three sampled records of patients having physical restraints applied, the hospital failed to renew a physician's order for the use of wrist restraints for Patient 1. Findings:

Patient 1's record indicated he was placed under left and right wrist restraints on 1/30/10 through 2/2/10 to treat behaviors that included attempting to pull out lines (medical devices such as an intravenous line). The restraint order expired on 2/2/10 at 3:29 p.m. There was no physician's order for the renewal of the wrist restraints that had been in use from 2/1/10 at 3:30 p.m. through 2/2/10 at 8:00 a.m.

The hospital's "Restraint Policy," revised on 08/09 outlined the continued use of restraints beyond 24 hours required a new order and renewal was to be issued no less often than once each day.

On 2/3/10 at 11:30 a.m., an administrative nurse confirmed the lack of a physician's order to support the continued use of restraints.

Based on documentation in the hospital's quality program, it was found that relevant data had not been incorporated into the program. Findings:

The hospital's quality program consists of two committees; the Quality Council and Performance Improvement, and Patient Safety Committee. All departments of the hospital submit their performance studies (quality indicators) to one or both committees for analysis and review.

During a review of the surgery department on 2/2/10 it was noted the department utilized a sterilizer for quick sterilization of surgical instruments. The sterilizer is known as a "Gravity" displacement type with the manufacturer's manual referring to it as a "flash sterilizer."

The Association for the Advancement of Medical Instrumentation (AAMI) 2008 Perioperative Standards and Recommended Practices states the following: "Use of flash sterilization should be kept to a minimum." In addition, "Flash sterilization should be used only when there is insufficient time to process by the preferred wrapped or container method. Flash sterilization should not be used as a substitute for sufficient instrument inventory."

A review of the Central Processing Department (which oversees the sterilizer) Quality Report Card for the year of 2009 indicates the sterilizer was used between 13% to 37% of the time in relation to the number of surgical cases performed. The 2009 average use of this sterilizer was 26.5%. Hospital staff was not able to provide documentation the sterilizer was being used in situations recommended by AAMI. Additionally, hospital staff stated the numbers presented in this quality report were high.

Although quality data was collected in 2009 for the high use of this sterilizer it was never presented to the hospital quality committees for analysis and review.

Based on documentation in 1 of 9 physician credential files reviewed, the medical staff failed to enforce its bylaws in regards to carrying out its responsibilities. Findings:

On 2/3/10, physician credential files were reviewed. During the review, it was noted that a staff psychiatrist had privileges to perform Electroconvulsive Therapy (ECT) with no proctoring requirement. This is a specialized procedure known as Electroshock therapy. The therapy consists of the induction of convulsions by the passage of an electric current through the brain.

The Medical Staff Bylaws 6.3-3 Term of Proctoring Period states, "That each department will establish terms for proctoring with a minimum number of cases . . . applicable to particular clinical privileges."

There was no evidence the medical staff had established a minimum number of cases for the privileging of ECT therapy.