HospitalInspections.org

The hospital must be maintained to ensure the safety of the patient and to provide facilities for for diagnosis and treatment for the special hospital services, providing quality health care in a safe environmen t and in a safe and effective manner.

This CONDITION is not met as evidenced by:

Based on staff interviews, patient medical record review and document review, the hospital failed to maintain the the emergency power for the operating rooms while Patient 1 was having neurosurgical procedure anterior/posterior cervical fusion with allografts (donor bone) of cervical disc C5,C6, C7 and T1 (thoracic disc) with laminectomy. The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality care in the operating room in a safe environment that resulted in Patient 1 requiring hand ventilation with ambubag for 15 minutes to sustain respirations and the surgical incision remained open during the power failure that had the potential for infection, blood loss, and cardiopulmonary arrest. These failures resulted in Patient 1's surgery being discontinued and Patient 1 required going back to the operating room the next day, on 12/23/11, to have the above mentioned procedure. (refer to A 702).

Based on staff interviews, patient medical record review and document review, the hospital failed to maintain the emergency power in the operating room in order to safe guard patient care. The failure of the emergency power system to the operating room number four during which time Patient 1 was undergoing general anesthesia and surgery on her neck for an anterior/posterior cervical dissection and fusion with allograft (surgically opening the neck in order to cut tissue down to the spine and fuse that portion of the patient's neck bones and place donor bone in the spine) put Patient 1 at risk for serious, if not life threatening consequences such as cardiopulmonary arrest, infection and blood loss.

Findings:

During observational tour on surgical/medical wing of the fifth floor of the facility, on 12/23/12 at 10:45 a.m., it was noted that call bells were not working. When interviewed, facility Engineering Staff A explained that the area of the community had suffered a power failure on 12/22/11. During a concurrent interview on 12/23/11, Administrative staff B stated that there had been three patients in the operating room area at the time of the power failure. This loss of power to the hospital including the hospital electrical system which powers the operating rooms' lights and the equipment (such as the anesthesia machines).

When asked for a written accounting of the situation, Executive Director for the Facilities Planning, Staff C e-mailed the following to the Department in an e-mail report of 12/ 23/11 to the Office of Statewide Health Planning and Development (OSHPD): "At approximately 8:55 December 22, 2011 (the hospital) experienced ...power failure loss due to a contractor digging up a main line affecting 3700 customers...two 750 kw (kilowatt) generators attempted to come on line..." The report further states that the hospital engineering team tried to re-establish voltage to the hospital through the hospital's #2 emergency generators, both of which failed. Both generator #1 and generator # 2 failed on 12/ 22/11. "Within 5 minutes of generator #2 failing, the remaining generator #1 failed resulting in the hospital experiencing a complete loss of power" the report further stated.

The surgery schedule for 12/22/11 was reviewed on 12/23/11 at 11:30 a.m., and the surgery schedule confirmed that Patient 1 was in OR (operating room) four at the time of the power failure.

Review of the operative report of 12/22/11 for Patient 1, Physician D wrote, that Patient 1 was having her neck surgery at the time of the power failure. Physician D wrote the following: "Sharp dissection was taken down through the left side through the skin and subcutaneous tissues...There was some scar tissue in the midline (of Patient 1's neck) and this was carefully dissected to avoid neurovascular (nerve or blood vessel) injury...A finger was then used to palpate the carotid pulse and define the carotid artery. ( a major blood vessel which carries blood to the brain)...An incision was made into the (cervical, neck) C7- T1(thoracic, chest) disk space with a knife, after confirmation with (X-ray) radiographic imaging to confirm that the C7-T1 appropriate position....."Unfortunately the lights and electricity went completely out and at that time the anesthesia machine, as well as the overhead light in the operating room went out and there was a complete blackout for a period of 30 seconds. During that time the anesthesiologist was able to hand ventilate and provide the breathing for the patient with an Ambu-bag device for Patient 1. At that time, I removed the retractors from the anterior cervical spine (front of the neck down to the spine) and packed the wound (surgical area) with antibiotic soaked sponges (gauze used in surgery). After that time, the generators took over and we had approximately 2 more minutes of power, in which case again the power went out again for 15 minutes. During the 15 minutes that the power was out the patient was completely covered with a sterile towel until the power came back on again 15 minutes later. At that time, I (Physician D) felt that is was unsafe to continue the operation." Physician E (anesthesiologist) noted on the Anesthesia Record for Patient 1, the "power out on the generator"at 9:05 a.m.. Also noted on the Anesthesia Record was that the surgery had started at 7:35 a.m. and ended at 10:16 a.m., the surgery was listed at "Attempted anterior/posterior cervical fusion".

The second acute care hospital's operative report dated 12/23/11, indicated that Patient 1 required going back to surgery for the neurosurgical procedure anterior/posterior cervical fusion with allograft bone placement and laminectomy of C5, C6, C7, and T1 the next day after the above mentioned incident.