HospitalInspections.org

22764

Based on interview and record review, the facility failed to ensure:

1. The results of additional surgical counts (counting of sponges, needles, and surgical instruments other than the initial count and the final count) was documented (as correct or incorrect) for 26 of 30 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 27, 28, and 29) in accordance with the facility policy; and,

2. Operating Room (OR) staff performed a surgical count before closing the surgical wound for one patient (Patient 9) in accordance with the facility policy.

These failed practices resulted in the potential for items to be left in patients during different phases of the surgical procedure, harm, or death.

Findings:

The facility policy titled, "Surgical Counts," was reviewed on July 29, 2015. The policy indicated counts were to be performed on all procedures as follows:

a. Before the procedure to establish a baseline;

b. Before closure of a cavity within a cavity;

c. Before wound closure;

d. At skin closure or end of procedure; and,

e. At the time of permanent relief of the scrub person and/or circulating nurse.

The policy further indicated documentation should include, "result of the surgical count," (correct or incorrect).

1. During an interview with OR registered nurse (RN) 1 on July 29, 2015, at 9:50 a.m., the RN stated they performed a minimum of three surgical counts on every procedure, one prior to the surgery starting (initial), one before closing the wound (additional), and one after closing the skin (final). The RN stated all of the counts must be correct before moving on to the next step in the surgical procedure.

During an interview with Surgical Technician (ST) 1 on July 29, 2015, at 10 a.m., the ST stated they performed a minimum of three surgical counts on every procedure, and a fourth (additional) count for certain circumstances (a cavity within a cavity or change in staff during the procedure).

A review of the, "Operating Room Intraoperative Records," representing 30 sampled patients, indicated the initial and final counts were performed on all of the procedures, with the final count documented as, "correct."

The records further indicated for 26 of the 30 patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 27, 28, and 29), the additional count(s) were documented as completed, with no indication of the status of the count (correct or incorrect).

Failure of the OR staff to document the results of the additional surgical counts resulted in the potential for sponges, sharps, or instruments to be left in the patient.



25937

2. The record for Patient 9 was reviewed. Patient 9 was admitted to the facility on July 26, 2015, for a "Hernia Repair" (a surgical procedure).

The Intraoperative Record indicated two counts (Initial and final) were performed by the Operating Room Registered Nurse, (OR RN2) and an OR tech.

On July 29, 2015, at 2:45 p.m., the Interim Director of Perioperative Services (IDPS) was interviewed. The IDPS stated, Patient 9's surgical procedure required a minimum of three counts per facility policy, (Initial, before wound closure, and final).

The IDPS further stated, OR RN2 had not completed the mandatory inservice training and accompanying quiz, where the policy and procedure "Surgical Counts," was reviewed. The IDPS stated the policy indicated a minimum of three surgical counts was to be performed on all surgical procedures.



29542