HospitalInspections.org

Based on document review and interview, Salina Surgical Hospital failed to provide documentation to the appropriate agencies regarding a plan to add onto the existing building. Failure of the facility to follow the regulations put all patients, employees, and visitors at risk of safety and environmental dangers.

Findings include:

- Tour of the facility on 2/7/2017 revealed a storage room addition to the surgical area which had been completed and stocked with medical supplies and equipment. Entrance into the room is through a semi restricted corridor accessible by surgical staff only. The entire room is sprinklered, well lit, and fire extinguishers are available. No anesthetic gases are stored in the room.

- Document review on 2/6/2017 revealed written communication between the State of Kansas and the building architect on 1/24/2017 indicating renovation/construction plans were not submitted to the required licensing agency prior to the building of the addition.

Interview on 2/6/2017 with CEO Staff Y confirmed the plans had not been submitted as required and "the web site was very difficult to maneuver and confusing."

- Policy titled "Infection Prevention in Construction, Renovation and Maintenance" reviewed on 2/9/2017, directed " ...Minimize the risk for acquisition of healthcare associated infections (HAI's) to patients that may result when fungi or bacteria are dispersed into the air via dust or water aerosolization during construction, renovation, or maintenance activities ..."

- Governing Body Policy review on 2/8/2017 directed "...Establishes a mechanism to fulfill all applicable obligations under local, state, and federal laws and regulations... ...Ensures that facilities and personnel are adequate and appropriate to carry out the organizations mission... ...Ensure compliance with CMS (Centers for Medicare and Medicaid Services) requirements..."

Based on observation and interview the Salina Surgical Hospital failed to store medical records in a manner which prevents damage or destruction by having 8 boxes of medical records on the floor in the medical records storage area. Failure to keep medical records off the floor put the records at risk for being damaged or destroyed.

Findings include:

- Tour of the facility on 2/6/2017 at 10:00 am revealed a secure storage room in the facility basement housing paper medical records. 8 boxes of an unknown number of medical records were stacked on the floor waiting for transport to an offsite storage facility.

Interview with Medical Records Staff V acknowledged the boxes and affirmed they were labeled and logged for transport to the storage facility and were "only on the floor waiting to be moved." All other medical records were stored on wire racks in the storage room.

Based on observation, documentation, and staff interview the facility failed to assure the hospital pharmaceutical services are administered according to professional standards for the preparation of drugs in the inpatient unit. This failure had the potential to affect all inpatients receiving medications.

Findings include:

- Staff LL, Registered Nurse (RN), observed on 2/7/17 at 7:50am revealed staff LL at the nurse's desk on the inpatient unit preparing an antibiotic for IV (intravenous) use and IV fluids for a patient.

- Staff LL, RN, observed on 2/7/17 at 8:35am revealed staff LL at the nurse's desk on the inpatient unit preparing a medication for IV (intravenous) use for a patient.

- Staff LL, RN, observed on 2/7/17 at 9:20am revealed staff LL at the nurse's desk on the inpatient unit preparing medication for IV use for a patient

Administrative Staff T and Y interviewed on 2/7/17 at 11:00am explained the medication cabinet has a pull out shelve for the nurses to use to prepare the patient medications. Staff T also explained they are limited in space.

- Observations on the inpatient unit on 2/7/15 from 7:30am to 12:00pm did not reveal any staff using the shelve below the medication cabinet for medication preparation.

- Review of the Institute For Safe Medication Practices (ISMP) 2011 article on 2/8/17 directed," ...workspaces where medications are prepared are orderly and free of clutter ...medication preparation areas in the pharmacy and on patient care units are isolated and relatively free of distractions, interruptions, and noise ..."

Based on observation, staff interview, policy review and document review the Hospital's Infection Control Officer failed to ensure staff were not recapping needles (Staff I and W), failed to ensure staff did not reuse needles (Staff I), failed to ensure staff followed safe injection practices (Staff W and Y), failed to ensure hand hygiene was performed at required times for six of six staff members observed (Staff Y, II, JJ, KK, LL, MM), failed to ensure surgical attire was worn properly for one of one staff member (Staff M) and failed to ensure housekeeping staff followed manufacturer's guidelines when using toilet bowel cleaner (Staff JJ) . These deficient practices had the potential to expose all patients and healthcare workers to infectious diseases.

Findings include:

- RN Staff W observed on 2/7/2016 at 8:30 AM injecting Lidocaine (a medication used to numb an area of the skin) into Patient #2's right forearm then recap the needle, RN Staff W was unsuccessful at starting the intravenous (IV) line and called for RN Staff I to have them start the IV. RN Staff I removed the cap from the same needle and syringe used by RN Staff W, prepped the skin with alcohol and injected lidocaine into Patient #2 left wrist area.

Quality Assessment Performance Improvement RN Staff P interviewed on 2/8/2017 at 10:15 AM said the Hospital policy does not direct staff to "not" recap needles. They have educated the staff that once the needle is used the best practice is to not recap the needle and to get a new syringe with a new needle to inject the lidocaine.

- Policy titled Sharps, Handling of for Safety and Disposal of reviewed on 2/9/2017 at 11:00 AM directed: ..."1. a. Clinical staff will not recap, break or otherwise tamper with used needles" ... ... "d. In no instance will a nurse reuse a needle." ...

- RN Staff W observed on 2/7/2016 at 10:20 injecting medications into Patient #2 intravenous line without cleaning the hub before the first injection or before the two subsequent injections.

- CRNA Staff Y observed on 2/7/2016 at 10:24 AM in the surgery suite injecting medication into Patient #2 intravenous line without cleaning the hub with alcohol.

- CRNA Staff Y observed on 2/7/2016 at 11:04 AM putting on gloves without washing hands or using hand sanitizer then touching patient, disconnecting endotracheal tube, and assisting with transfer from operating table to the bed.

CRNA staff Y interviewed on 2/7/2017 at 11:10 AM and said that they usually clean the hub before injecting medications and doesn't know why they didn't this time.

- Policy titled Medication Administration reviewed on 2/9/2017 at 11:00 AM directed: ..."B. Infusion Therapy ...7. Cleanse injection port with alcohol wipe. 8. Attach syringe into port" ...

- RN Staff I observed on 2/7/2016 at 6:20am in the preoperative area initiated an intravenous (IV) site and drew blood for lab testing on Patient 1 while wearing gloves. RN Staff I removed one glove, picked up the syringe with blood for the lab draw with the hand that was still gloved, and left Patient 1's room. No hand washing was observed. RN Staff I returned to the room without gloves on and applied hand sanitizer when entering the room.

- RN Staff MM observed on 2/8/2016 at 10:30 am in room 3 changed the surgical site dressing of Patient 21. RN Staff MM cleaned the surgical site and applied the dressing while wearing gloves. S/he left the room while wearing the gloves, entered a storage room and obtained a blanket from the blanket warmer, and returned to Patient 21 and applied the blanket to the surgical site. S/he removed the gloves and washed her/his hands.

Interview with RN Staff MM acknowledged "You are right, I should have washed my hands. This just makes me nervous."

- Policy review of "Hand Hygiene" directed " ...Hand hygiene is the single most important means of preventing the health care worker from transmitting infection to patients and themselves. Hand hygiene requires the use of an antimicrobial agent and is indicated following contact with patients and contaminated or possibly contaminated items... ...c. Remove gloves after caring for a patient..."

According to the Center for Disease Control and Prevention hand hygiene should be performed:
1. Before eating. 2. Before and after having direct contact with a patient's intact skin (taking a pulse or blood pressure, performing physical examinations, lifting the patient in bed). 3. after contact with blood, body fluids or excretions, mucous membranes, non-intact skin, or wound dressings. 4. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. 5. If hands will be moving from a contaminated-body site to a clean-body site during patient care. 6. after glove removal. 7. After using a restroom.

- CRNA Staff F observed on 2/7/2016 at 8:10 am in surgical suite 1 while administering anesthesia to Patient 1 reached into a bag hanging on a wall hook next to the anesthesia cart and obtained a chap stick/lip gloss tube from the bag. He/she faced the wall, pulled down his/her surgical mask, applied the chap stick/lip gloss, replaced the mask, and turned back toward the surgery table.

- Policy review of "Surgical Attire in the Operating Room" directed " ...Surgical masks will be worn where open sterile supplies or scrubbed personnel are present. Instructions and recommendations for wearing a surgical mask are: a. the surgical mask should cover the mouth and nose and be secured in a way that prevents venting at the sides of the mask ..."

- Medical Staff M observed on 2/7/2016 at 7:10 am sitting in the preoperative nursing station with surgical mask hanging from his/her neck.

Interview with Medical Staff M confirmed the presence of the mask and stated "I did not know that I had to remove it if I wasn't wearing it for surgery."

- Policy review of "Surgical Attire in the Operating Room" directs " ...Heath care workers should don a new mask before each procedure and replace or discard the mask after it has been taken down or if it becomes wet or soiled..."

- Staff KK, CNA (Certified Nurse Aide) observed on 2/7/17 at 8:00am revealed staff KK entered patient room 413 checked on patient eating their breakfast, and exited the patient's room. Staff KK failed to perform hand hygiene when entering and exiting the patient's room.

- Staff KK, observed on 2/7/17 at 8:25am revealed staff KK retrieved a Styrofoam cup from the dietary kitchen on the unit, entered patient room 405, gave the cup to the patient and exited the room. Staff KK failed to perform hand hygiene when entering and exiting the patient's room.

- Staff LL, RN (Registered Nurse), observed on 2/7/17 at 7:50am revealed staff LL entered patient room 413 to administer an IV (intravenous) antibiotic through the PICC (peripherally inserted central catheter). Staff LL failed to perform hand hygiene when entering the patient's room.

- Staff LL, observed on 2/7/17 at 9:00am revealed staff LL retrieved a heparin (a medication to prevent blood from clotting) flush syringe and a vial of normal saline from the medication cabinet and set them in the patient's drawer in the medication cabinet. Staff LL sat at the nurse's station, sneezed into their uniform top, documented on the computer, retrieved patient's medication (heparin flush and normal saline), drew up the normal saline from a mufti-dose vial into a syringe. Staff LL failed to perform hand hygiene before preparing medication and after sneezing.

Policy titled Hand Hygiene reviewed on 2/7/2017 at 4:40 PM directed: ..."2. Hand Sepsis Using Alcohol-based Hand Rub, Indications for use: ...b. Before preparing medications" ...

- Staff II and JJ, housekeeping staff observed on 2/7/17 between 9:30am to 10:17am revealed staff II and JJ cleaning a discharged patient room (#405). Staff II failed to perform hand hygiene one time after removing their gloves and staff JJ failed to perform hand hygiene one time after removing their gloves. Staff JJ observed cleaning the toilet revealed they flushed the toilet, squirted the "Crew" disinfectant in the toilet, using a swab applicator swab the inside of the toilet and flushed the toilet. Interview with staff JJ revealed they did not know the exact amount of "Crew" disinfectant they used.

Staff HH, housekeeper supervisor, interviewed on 2/7/17 at 10:30am explained the staff has had education regarding hand hygiene. Staff HH was unfamiliar with the manufacturer's guidelines regarding the use of the "Crew" disinfectant.
Failure to follow the manufacturer's guidelines for disinfecting the toilet bowl has the potential to affect all patients.

- Review of the manufacturer's guidelines for the "Crew" disinfectant on 2/7/17 at 4:20pm directed "...remove water from bowl by forcing out trap ...apply 1-2 ounces of this ready-to-use product evenly onto surface to be cleaned and disinfected...swab entire surface...allow this product to remain wet on surfaces at least 10 minutes..."

Based on observation, interview, and record review, Salina Surgical Hospital failed to perform surgical procedures in a safe manner by failing to provide adequate amount of medication for the treatment of Malignant Hyperthermia (a life-threatening condition causing severe high body temperature usually triggered by exposure to drugs used for general anesthesia) and failing to limit movement into and out of the surgical suite during procedures. Failure to provide oversight of all activities in the surgical area put all patients at risk of inappropriate, insufficient, and unsafe care resulting in the medical staff inability to respond appropriately in an emergency and potential exposure of the patient to bacterial contamination.


Findings Include:


- Observation on 2/7/2016 of a cart labeled "Malignant Hyperthermia" revealed 17 vials of Dantrolene (medication used to treat Malignant Hyperthermia (MH).

Surgical Supervisor RN Staff K interviewed on 2/7/2016 at 9:55am acknowledged the 17 vials of medication, "a vial must have been broken and I was not aware of it. We should have 18 vials on hand. We are able to obtain an additional 18 vials of Dantrolene from Salina Regional Hospital if we need to. They keep one and one/half doses on hand." Nursing Director RN Staff T interviewed on 2/7/2016 at 10:05 am confirmed that additional Dantrolene could be obtained if needed from Salina Regional Hospital.

- Policy "Malignant Hyperthermia" reviewed on 2/7/2016 directed " ...Contact SRHC Pharmacy to obtain the additional vials of Dantrolene to treat an MH crisis (SRHC Pharmacy #452-7160) ..."

- On 2/7/2017 verification of the time required to obtain additional Dantrolene was conducted at 2/7/2017 at 10:05am following the policy directions. A mock Malignant Hyperthermia emergency was called by RN Staff K and a call was placed to the SRHC Pharmacy to obtain additional Dantrolene. Staff RN K left the facility and went to Salina Regional Hospital Pharmacy, obtained an additional vial of Dantrolene along with a signed ticket by a staff pharmacist stating the Hospital had an additional 18 vials available for the facility use. The timed round trip was clocked at 5 minutes and 14 seconds.

The Malignant Hyperthermia Association of the United States (MHAUS) describes Malignant Hyperthermia as a potentially fatal disease passed down through families. The signs of MH include muscle rigidity, rapid heart rate, high body temperature, muscle breakdown and increased acid content. Immediate treatment with the drug Dantrolene usually reverses the signs of MH. It is recommended that 36 vials of Dantrolene be available for use within 10 minutes of the decision to treat a patient for MH.


- Observation on 2/7/2017 in OR room #1 during the surgical procedure for Patient #1, 44 year old, admitted for a laparoscopic (surgical approach using small incisions through the abdominal wall) hysterectomy (removal of the uterus) and salpingoophorectomy (removal of the ovaries). The surgery start time was 7:55am and end time was 9:40am. A total of 7 medical and staff members were present. Two doors into the surgical suite provide access from separate hallways in the surgical area. The traffic flow during Patient #1 procedure was monitored. The doors from the front and back halls into the suite were opened and staff entered and/or exited a total of 29 times during the procedure.

Policy "Traffic Patterns in the Operating Room" directed " ...Movement of personnel in and out of operating rooms is kept to a minimum while surgery is in progress. Doors to operating rooms are closed except when personnel are entering or exiting ..."

A review of the AORN (Association of perioperative Registered Nurses) recommendations to decrease surgical site infections (SSIs), the researchers concluded that the evidence supports implementing interventions to decrease door openings and traffic in the OR. (AORN.org, 2014)

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Based on record review, staff interview, and document reviewed the hospital failed to ensure a comprehensive History and Physical was completed or updated prior to surgery requiring anesthesia not more than 30 days before or 24 hours after the admission for four of twenty medical records reviewed (#3, #6, #8, and #10). This deficient practice placed patients at risk for inadequate care because of the incomplete information/documentation regarding their medical history, assessment of their health status and the needs of the patient.


Findings include:


- Patient #3's open medical record reviewed on 2/8/17 revealed an admission date of 2/3/2017 for an epigastric hernia repair and laparoscopic colostomy and discharged on 2/7/17 lacked evidence of a complete history and physical. The medical record contained a form labeled history and physical that read as follows; Past History-For Additional Information See Nursing History and Current Medications/Reconciliation-For Additional Information See nursing History (Both of these were typed and circled). A complete history and physical was on the chart dated 8/15/16 (more than 5 months old).The medical record lacked evidence the physician performed a past history or provided or reviewed current medications.


- Patient #6's closed medical record review on 2/8/2016 revealed a 43 year old patient admitted for left total knee arthroplasty (surgical replacement of the knee joint) on 12/28/2016. The preoperative history and physical completed by Medical Staff G lacked evidence of review of allergies, referenced the nursing history for past history and reconciliation of medications, and a SOAP note (documentation of subjective, objective, assessment, and plan) written 12/13/2016 at an office appointment.


- Patient #8's closed medical record reviewed on 2/8/2017 revealed an admission date of 12/9/2016 for left total knee replacement and discharged on 12/18/2016 lacked evidence of a completed history and physical. The medical record contained a form labeled history and physical that referenced the nursing history for past history, nursing medication reconciliation and for additional information it directed the reader to see office notes, one that was dictated on 9/29/2016 and one that was dated 12/10/2015.


- Patient #10's closed medical record reviewed on 2/8/17 revealed an admission date of 10/3/16 for left total knee replacement and discharged on 11/2/16 lacked evidence of a complete history and physical. The medical record contained a form labeled history and physical that read as follows; Past History-For Additional Information See Nursing History and Current Medications/Reconciliation-For Additional Information See nursing History (not circled). A hand written note read; see office notes. Review of the office notes revealed a date of 4/12/16 that contained; past medical history, previous surgeries, family history, and social history. The medical record lacked evidence the physician performed a past history or current medication/reconciliation.


Medical Staff Rules and Regulations reviewed 2/8/2016 direct " ...All H & P's will be performed in accordance with CMS regulations pertaining to the surgical procedure setting. The history and physical examination shall be as defined in the facility's clinical policies and procedures ..."

The facility was unable to provide policies and procedures for the elements required for a preoperative medical history and physical.

Medical Staff Rules and Regulations reviewed on 2/8/2016 direct " ...a medical history and physical examinations shall be completed and documented no more than 30 days before or 24 hours after admission or registrations, but prior to surgery or a procedure requiring anesthesia services ..."


Administrative Staff Y, Director of Nursing Staff T and Quality Improvement Staff P interviewed on 2/9/2017 at 9:30 and said the form that was used was the history and physical and the physicians look at the nursing history and they follow the medical staff rules and regulations.


Document titled Joint Commission Medical Record Documentation Requirements 2011 reviewed on 2/9/2017 revealed the following:
History & Physical (H&P) Timeliness & Components:
o H & P must be completed and documented within 24 hrs following admission of the patient, but prior to surgery or a procedure requiring anesthesia services (including moderate sedation).
o H&P Exams performed within 30 days prior to admission may be used if the following requirements are met:
- Physician writes an update note which is written on or attached to the H&P.
- The words "re-examined the patient" must be present. Required by CMS.
- The H&P and any updates/assessments must be included in the medical record within 24 hrs of admission, but prior to surgery or other procedures whichever comes first.
o H&P performed more than 30 days prior to admission, outpatient, observation, or outpatient surgery does not comply with timeliness requirements and a new H&P must be performed.
o H&P Required Components: Chief Compliant, Details of Present Illness, Relevant Past, Social and Family History, Physical Examination, Statement on conclusions