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Based on observation, interview, medical record review, and hospital record review, the hospital failed to ensure the QAPI program completely implemented the POC for the IUSS monitoring in response to the Complaint Validation survey completed on 12/4/15. In addition, the QAPI program failed to collect and review the hand hygiene data as per the hospital's policy.

These failures created the increased risk of persistent poor practices and substandard healthcare to the patients.

Findings:

1. During a tour of the surgical services area on 3/9/16 at 0920 hours, the IUSS log for January and February 2016 was reviewed with RN S. RN S stated the hospital was aware of the deficient practices in the IUSS process identified during the Complaint Validation survey completed on 12/4/15.

RN S stated the hospital began a process for tracking and monitoring of IUSS performed in the ORs which included an IUSS log and audit tool. RN S stated the logs would be analyzed and the findings were reported to QA.

Review of the CMS-2567 Statement of Deficiencies and Plan of Correction for the Complaint Validation survey completed on 12/4/15, showed the IUSS log would be reviewed monthly by the OR leadership and the findings would be reported to the Quality and Risk Management for analysis and evaluation of any necessary actions.

Review of the IUSS log showed on 1/16/16, IUSS was performed 30 times. On 2/16/16, IUSS was performed 20 times. However, there was no documented evidence to show these log entries were reviewed and analyzed.

Further review of the January and February 2016 logs showed documentation the IUSS was required due to a "damaged wrapper" six times for each month.

During an observation and concurrent interview with the Manager of SPD on 3/10/16 at 1020 hours, the Manager stated the SPD staff utilized sterile wrappings to wrap instrument trays. The Manager stated he was not included in the OR or the QA committee meetings and had not seen the damaged wraps. The Manager stated the possible causes for damaged wraps could be rough package handling, processing, and storage. Without seeing the damaged wrap, the Manager of SPD stated there was no way he could determine the causes and make improvements.

During an interview with the Executive Director Quality Improvement on 3/10/16 at 1020 hours, the Director confirmed the SPD Manager was not involved in the IUSS QA project. The Director stated the January and February 2016 IUSS logs were not tabulated for analyses. The Director stated the logs should be analyzed for the reasons the IUSS was required, if the sterile parameters were met, and to ensure the log was reviewed by the management team. The Director further stated the Executive Director of Surgical Services resigned recently and there was a lack of leadership to review the IUSS log.

Review of the hospital's documentation indicated an IUSS log dated 12/15/15, showed the IUSS rate in December 2015 was 6% and the results for "cysto tray, X stop geipi, and Dr. B tray" were identified. However, review of the Operating Room Committee meeting minutes dated 2/11/16, did not show documented evidence the Committee reviewed, discussed, and made recommendations for the IUSS process.

On 3/10/16 at 1020 hours, the medical record for Patient 48 was reviewed with RN S. The patient had a surgical procedure on 3/8/16. RN S stated the IUSS was performed for additional instruments for this patient.

Review of the hospital's documentation showed the IUSS was performed twice on 3/8/16, for the patient as follows:

- The load digit #030803 showed "Hip Extra's" and the reason for the IUSS was the instrument was "unsterile."

- The load digit #030804 showed "Echlon Revision Trays X3" and the reason for the IUSS was "unsterile."

RN S stated for the load digit #030803, the instrument was used in a previous case. Due to the need for the patient's procedure, the instrument was sent to SPD for cleaning and was brought back to the OR to sterilize using the IUSS. RN S stated the staff should document, "Instrument(s) used in prior case" as the reason for the IUSS.

RN S stated for the load digit #030804, the instrument trays were brought in by the vendor during the procedure. In this case, the staff performing the IUSS should document, "Loaner Tray(s)" as the reason for the IUSS.

RN S stated the staff chose the same reason, "Unsterile," for both uses of the IUSS; however, this did not accurately reflect the reasons why the IUSS was used.


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2. During an interview with QA Staff 2 on 3/10/16 at 1100 hours, she stated the hospital's hand hygiene program was revised.

On 3/10/16, review of the data from the revised hand hygiene auditing process showed multiple departments reported only partial data or had not reported their data for January and February 2016. Of the 39 reporting entities (staff or departments), only four provided the expected quantity of data.

In an interview with QA Staff 1 on 3/10/16 at 1120 hours, she stated 20 audits were to be turned in by each unit and the deadline to turn in the hand hygiene audits was by the end of each month. QA Staff 1 stated not all departments turned in the hand hygiene data.

QA Staff 1 stated she tried to determine department by department why the data was not submitted and was assisting the departments with education and data collection. QA Staff 1 stated many departments, such as the NICU was behind and turned in only five of the expected 40 hand hygiene audits.

Based on observation, interview, and document review, the hospital failed to ensure an effective infection control system was in place for measures to identify, investigate, report, prevent, and control infections and communicable diseases within the hospital as evidenced by:

1. The temperature and humidity levels in three SC campus ORs, decontamination room, and clean room were not rechecked to ensure the readings were within the required levels after the adjustments were made. In addition, the OR staff failed to consistently notify the Engineering Department when the temperature and humidity levels were out of range.

2. The US staff did not follow the hospital's P&P and the manufacturer's instructions for the use of disinfectant wipes when cleaning and disinfecting the US probe and gurney pad.

3. Observation of the EVS staff cleaning the LH OR and WC OR showed the staff failed to the hospital's P&P during the cleaning procedure resulting in a potential cross contamination, a dusty piece of equipment was found in a clean OR on the LH campus, and rusty equipment was not removed from the two WC ORs.

4. The hospital failed to ensure the national guidelines for healthcare worker immunization were implemented because the guidelines were enforced for hospital staff but not for the medical staff.

5. Surgeon surveillance for surgical site infections was not defined in the infection control plan.

6. There was no process to track and verify the disinfection of the high risk intubation devices used in the OR and Respiratory Department.

These failures created the increased risk of the spread of infections to the patients in the hospital.

Findings:

1. The temperature and humidity levels in three SC campus ORs, decontamination room, and clean room were not rechecked to ensure the readings were within the required levels after adjustments were made. In addition, the OR staff failed to consistently notify the Engineering Department when the temperature and humidity levels were out of range. Cross reference to A0951, example #1.

2. Review of the hospital's P&P titled Ultrasound Probes/Transducers, Cleaning and Disinfection dated 6/14, showed the following cleaning procedure for transducers/probes used on intact skin:
* Wash probe with soap and water using a clean wash cloth or paper towel for transducer/probes used on intact skin.
* Disinfect with a hospital-approved disinfectant.
* It is critically important to observe the contact (wet) time recommended by disinfectant manufacturer (usually found on the disinfectant label).

Review of the Disinfection Products and Contact Times provided by the hospital showed a PDI Sani Cloth-HB is used for ultrasound machines in radiology and its contact/wet time is 10 minutes. The manufacturer's instructions showed the surface must remain continuously wet for 10 minutes; if dry before 10 minutes; reapply for total 10 minutes of wet contact time.

For all surfaces and equipment, the PDI Super Sani Cloth is used and it had a two minute wet contact time.

On 3/9/16 at 1055 hours, the cleaning procedure of the US room was observed in the Breast Center in the presence of the Director Professional Development and Director of the Breast Center.

US Tech 2 started to clean the the room at 1055 hours and finished at 1058 hours. At 1055 hours, US Tech 2 wiped an US probe using a PDI Sani-Cloth HB wipe and draped the wipe over the US probe. At 1057 hours, US Tech 2 wiped a gurney pad by using a PDI Super Sani Cloth wipe. At 1058 hours, US Tech 2 discarded both wipes to the trash can stating she was finished. Observation of the surfaces of the gurney pad and the US probe showed the surfaces were dry.

US Tech 2 stated a PDI Sani-Cloth HB had a 10 minute dry time and the PDI Super Sani Cloth had a two minute dry time. When asked what "dry" time meant, US Tech 2 stated she could not touch the surface and should leave it alone for 10 minutes when she used the PDI Sani-Cloth HB wipe, and for two minutes when she used the PDI Super Sani-Cloth wipe.

US Tech 2 was asked whether the surface of the US probe was wet or dry. US Tech 2 stated it seemed dry, but she was unable to tell since she was unable to touch the US probe surface.

The Director Professional Development confirmed the gurney pad was not wet for two minutes as per the manufacturer's instruction for use.

During an interview and concurrent hospital record review with the Director Professional Development on 3/10/16 at 0850 hours, the Director confirmed US Tech 2 did not follow the hospital's P&P and the manufacturer's instruction for use of the PDI Sani-Cloth HB and the PDI Super Sani Cloth when she cleaned and disinfected the US probe and gurney pad.


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3. Observation of the EVS staff cleaning the LH OR and the WC OR showed the staff failed to follow the hospital's P&P during the cleaning procedure resulting in a potential cross contamination, a dusty piece of equipment was found in a clean OR on the LH campus, and rusty equipment was not removed from the two WC ORs. Cross reference to A0951, example #2.


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4. Review of the CDC Guidelines for Immunization for Health Care Worker showed the following:
* "Healthcare workers include physicians, nurses, emergency medical personnel, dental professionals and students, medical and nursing students, laboratory technicians, pharmacists, hospital volunteers, and administrative staff."

* "...recommends that health care providers receive vaccinations for diseases for which routine vaccination or documentation of immunity is recommended because of risks in the workplace (i.e. hepatitis B, seasonal influenza, measles, mumps, rubella, pertussis, and varicella)."

* "Healthcare personnel should receive a single dose of Tdap (a vaccine that includes tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis, that prevents the diseases of Diphtheria, Tetanus, and Whooping Cough) as soon as feasible upon hire if they have not been vaccinated previously."

* "Healthcare organizations should review health care provider vaccination and immunity status at the time of hire and at least annually thereafter."

Review of a hospital letter to the Medical Staff Members dated 2/12/16, showed the hospital conveyed the CDC's recommendations for immunization. The letter read, "We would like to call your attention to other CDC vaccination recommendations that are mandatory for hospital employees and strongly recommended for all physicians."

In an interview with Medical Staff Services 1 on 3/10/16 at 0955 hours, she stated physicians were sent a letter on 2/12/16, regarding health clearance and vaccination information, but compliance was not mandatory. Medical Staff Services 1 stated compliance with health clearance and immunization status verification was mandatory for other hospital staff. Medical Staff Services 1 stated only 20 to 30 medical staff members voluntarily complied by providing information.

In an interview with MD 1 on 3/10/16 at 0957 hours, the physician estimated that 5% of the medical staff had complied with the written request.

During a review of the Annual Infection Prevention Plan dated 4/29/15, the plan's stated goal was, "The Infection Prevention Program aims to minimize the risk of transmitting infections to patients, healthcare workers, physicians, volunteers, and visitors." The plan contained a section referencing the activities of the employee health department in tracking infections, exposures, and other indicators, but did not contain a reference to similar tracking for the medical staff.

In an interview with the Infection Prevention Program Manager on 3/10/16 at 1345 hours, he concurred the medical staff health screening and immunization pursuant to the CDC guidelines were not included in the Infection Control Plan, and that they should be.

5. During a review of the Annual Infection Prevention Plan dated 4/29/15, the plan showed surveillance mechanisms for identifying surgical site infections could include, "Post-discharge surgical site infection surveillance reports sent to physicians' offices." However, the plan did not show which surgeries, or under which circumstances the surgeon surveillance for post-operative infection would be completed.

During an interview with the Infection Prevention Program Manager on 3/9/16 at 0830 hours, the Manager stated surgeon surveillance was not identified as one of the mechanisms for identifying outpatient surgical site infections by the Manager. However, during a second interview on 3/9/16 at 1330 hours, surgeon surveillance was a technique identified by the Manager as being used for multiple types of surgeries.

In a follow-up interview with the Infection Prevention Program Manager on 3/10/16 at 1345 hours, he concurred that delineation of when the surgeon surveys for surgical site infections would be used was not included in the Infection Control Plan, and that it should be. The Manager stated he would revise the plan to include the information.

6. In an interview with the Anesthesia Tech on 3/9/16 at 0910 hours, he stated the OR had five of the McGrath laryngoscope devices (a device to aid the intubation of the trachea) and the respiratory therapy department had one. The Tech explained when one of the devices was used in the OR, he was called right away by the anesthesiologist to begin sterile processing of the device, and to take it to SPD for completion of the sterile processing. However, he stated the whole cleaning process was done by SPD during the nights and weekends when he was not on duty. The Tech stated the staff used the McGrath devices frequently.

During an observation in the surgical storage area on 3/9/16, three plastic boxes labeled to contain OR McGrath intubation devices were observed. The boxes showed stickers indicating the date and load when they were sterilized. McGrath #2 was sterilized on 3/7/16, load 4. McGrath #3 was sterilized on 3/5/16, and McGrath #6 was sterilized on 3/9/16.

The fourth OR owned McGrath #5 was sterilized on 3/9/16, and was in use in an OR. The fifth OR owned McGrath was not located.

McGrath #4 was found in the respiratory therapy area and the SPD sticker indicated it was sterilized on 3/7/16, load 6.

Review of patient records from the OR surgical log dated 3/7/16, showed two patients (Patients 44 and 45) were intubated with the use of a McGrath device, one at 0720 hours and one at 0801 hours. The anesthesia care ended at 1221 and 1007 hours, respectively.

On 3/9/16, during a review of the sterile processing log for the plasma sterilizer loads from 3/7/16, the log showed McGrath devices were processed at 0930 and 1855 hours in loads 4 and 6. McGrath #4 belonging to respiratory therapy was sterilized in load 6 at 1855 hours, leaving only one McGrath documented as sterilized from the OR. Two intubations using the McGrath were documented early in the morning of 3/7/15.

During an interview with the Manager SPD on 3/9/16 at 0930 hours, he stated it would be better to document the number of the McGrath device that was sterilized, so that processing could be tracked.


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Based on observation, interview, and record review, the hospital failed to ensure a safe and effective environment and maintain high standards of care for patients receiving surgical services as evidenced by:

1. The temperature and humidity levels in three SC campus ORs, decontamination room, and clean room were not rechecked to ensure the readings were within the required levels after adjustments were made. In addition, the OR staff failed to consistently notify the Engineering Department when the temperature and humidity levels were out of range.

2. Observation of the EVS staff cleaning the LH OR and WC OR showed the staff failed to the hospital's P&P during the cleaning procedure resulting in a potential cross contamination, a dusty piece of equipment was found in a clean OR on the LH campus, and rusty equipment was not removed from the two WC ORs.

3. The nursing staff failed to administer Versed (sedative medication) as per the physician's order during a procedure for one of three sampled patients (Patient 34) reviewed receiving surgical services at the SC campus.

4. An OR RN's competency for Standardized Procedures was not completed on 2/15/16, as per the hospital's response to the CMS-2567 Statement of Deficiencies and Plan of Correction for the Complaint Validation survey completed on 12/4/15.

These failures created the risk of substandard healthcare outcomes to the patients receiving surgical services in the hospital.

Findings:

1. Review of the hospital's P&P titled Temperature and Humidity Levels in the Operating and Procedure Rooms revised 12/15 showed the relative humidity and temperature of each room would be maintained as follows:

* OR and Procedure Rooms: 63 to 73 degrees F of temperatures and 20 to 60% of the relative humidity.
* SPD Dirty: 60 to 65 degrees F of temperatures and 20 to 60% of the relative humidity.
* SPD Prep & Pack: 68 to 73 degrees F of temperatures and 20 to 60% of the relative humidity.

The P&P showed the circulating/charge nurse will record the temperature and humidity at the beginning of the shift. If there is any variance, he/she will first attempt to correct by adjusting the setting in the room. If the temperature and/or humidity are not corrected immediately, he/she is responsible for notifying the manager/designee.

The P&P also showed the charge nurse/manager would not allow any case to start in a room that is not at the appropriate temperature and/or humidity. If the temperature and/or humidity cannot be corrected, the case will be relocated to another procedural area or rescheduled.

During a tour of the SC campus surgical department on 3/9/16 at 0840 hours, the OR Manager and ST 3 were interviewed. When asked which staff was responsible to recheck the temperature and/or humidity after an adjustment, the OR Manager stated the nurse who checked the initial temperature and humidity would recheck it. When the same question was asked of ST 3, he stated the engineering staff came back and rechecked the reading after adjusting the temperature and humidity.

Review of the SC campus OR schedule showed the ORs were open on the following dates:

* OR 1 was open from 3/1 through 3/4, and on 3/8/16.
* OR 2 was open 3/1, 3/2, and 3/8/16.
* OR 3 was open 3/3, 3/7, and 3/8/16.

Review of the Temperature and Humidity Log for the three ORs, SPD, and the decontamination room at the SC campus for March 2016 showed the following:

* For OR 1:

- The temperature level was below 63 degrees F on 3/2, 3/3, 3/7, and 3/8/16. Engineering was contacted, but the temperatures were not rechecked for these dates.

- The humidity was above 60% from 3/1 through 3/8/16, except on 3/5 and 3/6/16, when the ORs were closed; however, the humidity levels were not rechecked for these dates.

- On 3/4/16, the humidity was above 60%. There was no documentation to show engineering was contacted and the humidity level was not rechecked.

* For OR 2:

- The temperature level was below 63 degrees F from 3/1 through 3/9/16, except 3/5 and 3/6/16, when the ORs were closed. The temperature setting was increased on 3/7 and 3/8/16. However, when rechecked, the temperature did not reach 63 degrees F on 3/7/16 and was not rechecked on 3/8/16.

- The humidity was above 60% from 3/1 through 3/4/16. Engineering was contacted from 3/1 through 3/3/16, but the humidity levels were not rechecked for these dates.

- On 3/4/16, engineering was not contacted and the humidity level was not rechecked.

* For OR 3:

- The temperature level was below 63 degrees F on 3/7 and 3/8/16. The temperature setting was increased on both dates, and the temperature reached 64 degrees F on 3/7/16. However, the temperature reading was not rechecked on 3/8/16.

- The humidity was above 60% from 3/1 through 3/4/16. Engineering was contacted from 3/1 through 3/3/16, but the humidity levels were not rechecked for these dates.

- On 3/4/16, engineering was not contacted and the humidity level was not rechecked.

* For SPD:

- The temperature level was below 68 degrees F on 3/7 and 3/8/16. Engineering was contacted, but the temperature was not rechecked on both dates.

- The humidity was above 60% on 3/1, 3/2, and 3/4/16. Engineering was contacted on 3/1 and 3/2/16, but the humidity levels were not rechecked.

- On 3/4/16, engineering was not contacted and the humidity was not rechecked.

* For decontamination room:

- The humidity was above 60%, but engineering was not contacted and the humidity level was not rechecked on 3/1/16.

During an interview and concurrent record review with the OR Manager on 3/14/16 at 0915 hours, the OR Manager verified there was no documented evidence the temperature and humidity levels were maintained after adjustment. The OR Manager also verified there was a discrepancy on which staff was responsible to recheck the temperature and humidity levels; the hospital's P&P did not specify who was responsible for rechecking.


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2. Review of the hospital's P&P titled Cleaning & Disinfection of Operating and Procedure Rooms approved 6/15, showed a safe clean environment is provided for the patients and staff. The reference for the hospital's P&P was the AORN's Peri-Operative Standards and Recommended Practices.

According the AORN's Guideline for Perioperative Practice, 2015 Edition, Guideline for Environmental Cleaning showed the patient should be provided with a clean and safe environment. Peri-operative areas should be terminally cleaned. Areas and equipment that are not cleaned may become environmental reservoirs for dust, debris, and microorganisms. Absorbent or nonintact surfaces may become reservoirs for microorganisms and may harbor pathogens. Damaged or worn coverings should be replaced.

According to the AORN's Guideline for a Safe Environment of Care, Part 2 showed the following:

* All surfaces (e.g., floors, walls, ceilings, cabinets) should be durable, smooth, and cleanable. Surfaces that are durable, smooth, and cleanable allow for ease of cleaning and assist in preventing buildup of dirt and debris in crevices.

* The integrity of structural surfaces (doors, floors, cabinets) should be maintained and surfaces should be repaired when damaged. Damage to structural surfaces may create a reservoir for the collection of dirt and debris that cannot be removed during cleaning.

a. On 3/9/16 at 0920 hours, the cleaning of LH campus OR 2 after a procedure was observed with the OR Charge Nurse (RN S) and Operations Manager Recovery Room. The following was identified:

* Three cleaning personnel were in the OR. PCT 1 and PCT 2 cleaned five pillows with wet sani-cloth wipes and stacked all the pillows together immediately without waiting for the pillow surfaces to dry. PCT 2 placed all the still wet pillows on the back table; however, the backtable was not yet disinfected, cross contaminating the pillows.

* The OR had two see through dividers. There was accumulated dust on the divider racks.

b. The cleaning of WC OR 1 was observed on 3/9/16 beginning at 1440 hours, accompanied by the Director of Professional Development and Manager of the Women's Center.

During the breakdown of the OR, ST 8 removed a pillowcase from the wedge positioning cushion. The wedge was wrapped in a porous white surgical tape. When asked how the wedge cushion would be disinfected between patients, ST 8 stated she "assumed it was wiped down."

When the cushion was shown to the Director of Professional Development, the Director stated the wedge cushion was supposed to have been replaced as the porous tape was difficult to disinfect.

EVS 1 and EVS 2 proceeded to clean OR 1. EVS 2 proceeded to use a cloth soaked in disinfectant solution to clean the overhead lights and the OR table. EVS 2 then quickly wiped the wedge cushion. EVS 2 discarded the dirty cloth and without changing her gloves and performing hand hygiene, she removed a clean cloth from the bucket and continued to clean equipment in the OR. This sequence was repeated four more times before EVS 2 removed her dirty gloves and performed hand hygiene.

EVS 2 continued to clean the OR and failed to change gloves and perform hand hygiene three more times between using a clean cloth.

c. During the tour on 3/9/16 at 0920 hours in the LH campus surgical services area, an Allen tower (tall blue metal pole) was observed with accumulated dust and a piece of debris. RN S stated the OR EVS staff were responsible to clean it.

d. During a tour of the WC OR's on 3/9/16 at 0910 hours, with ST 8 and the Director of Professional Development, the Mayo stands in each of the two ORs were observed with rust on the legs and feet of the stands. ST 8 stated the Mayo stands were ordered a month ago.

A review of the Quality Council minutes dated 1/21/16, showed all rusty equipment was assessed and repaired or replaced.

Review of the CMS-2567 Statement of Deficiencies and Plan of Correction for the Complaint Validation survey completed on 12/4/15, showed an immediate survey of all procedure areas including the WC OR's was completed on 12/2/15, and all rusty equipment was immediately removed.

During an interview with the Executive Director of Quality Improvement on 3/9/16 at 1000 hours, the infection prevention rounds for 2/16 were reviewed. The rounds documentation showed the WC OR's had no rusty equipment. The Director stated the Mayo stands must have been missed on the rounds.


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3. An interview and concurrent review of Patient 34's medical record was conducted with RN U on 3/9/16 at 1500 hours.

The patient was admitted to the hospital for a surgery on 3/1/16 at 0729 hours, and was discharged on 3/1/16 at 1140 hours.

Review of the order signed by the physician on 3/1/16 at 0825 hours, showed midazolam (same as Versed) 1 mg every two minutes as needed for conscious sedation during GI procedure.

Review of the intraop (intra-operative) Administered Meds (medication) form for Patient 34 showed the the following:

- at 0829 hours, 1 mg of Versed was administered;
- at 0830 hours, 2 mg of Versed was administered;
- at 0831 hours, 1 mg of Versed was administered; and
- at 0845 hours, 1 mg of Versed was administered.

This showed Patient 34 received the Versed every one minute, from 0829 to 0831 hours, instead of the ordered every two minutes. Also, 2 mg of Versed was administered at 0830 hours instead of the 1 mg dose. The nursing staff did not administer the Versed to the patient as ordered by the physician.

There was no documented evidence to show the physician ordered to administer 2 mg Versed to Patient 34 during the procedure.

RN U confirmed the finding.

4. Review of the CMS-2567 Statement of Deficiencies and Plan of Correction for the Complain Validation survey completed on 12/4/15, showed the hospital's POC included RN J's performance evaluation to be signed by the evaluator by 2/15/16, and RN J's competency for Standardized Procedure completed by 2/15/16.

An interview and concurrent document review was conducted with the Executive Director Quality Improvement and Director Professional Development on 3/10/16 at 1150 hours. The Directors were asked to show documentation RN J's competency for Standardized Procedures was completed on 2/15/16 as per the hospital's POC.

On 3/10/15 at 1335 hours, the Director Professional Development provided the Monitor Progress: Clinical Skills for RN J. Review of the document showed nine standardized procedures were assigned to RN J, due on "3/25/11." The standardized procedure included emergent cardiopulmonary intervention, hypoglycemina (low blood sugar) treatment, patient discharge from an out patient unit, acute respiratory conditions requiring interventions, and rapid response team guideline. The section of Date Completed showed RN J completed nine standardized procedures on 3/10/16, not by 2/15/16, as per the hospital's POC.

Based on interview and medical record review, the hospital failed to ensure the H&P was updated prior to the surgery as per the General Medical Staff Rules and Regulations for one of three sampled patients (Patient 34) who received surgical services at the SC campus. This could create the risk of substandard healthcare outcomes to the patient.

Findings:

Review of the hospital's General Medical Staff Rules and Regulations updated 3/15 showed non inpatient services (which include outpatient operative and invasive procedures as well as observation patients) require a history and physical. An H&P examination performed by a physician who is not a member of the medical staff may be accepted if all required elements of the H&P are addressed and the H&P is dated within 30 days prior to the surgery or procedure and is cosigned/dated by the primary surgeon/practitioner specialist, who becomes the owner of the H&P. The practitioner performing the surgery or procedure must also perform the H&P update prior to the surgery or procedure.

An interview and concurrent review of Patient 34's medical record was conducted with RN U on 3/9/16 at 1500 hours.

The patient was admitted to the hospital for a surgery on 3/1/16 at 0729 hours, and was discharged on 3/1/16 at 1140 hours.

Review of Patient 34's medical record showed the H&P was completed on 2/3/16 at 1754 hours.

Review of the Case Tracking Events section of the case information form dated 3/1/16, showed Patient 34 entered the procedure room at 0815 hours. The procedure was completed and the patient left the room at 0908 hours. The patient was in the recovery room from 0908 until 0945 hours.

Review of the intraop (intraoperative) Administered Meds (medications) form showed Patient 34 received fentanyl (pain medication) and Versed (sedative medication) several times during the procedure.

However, review of the History and Physical Update showed the surgeon documented the update on 3/1/16 at 0924 hours, after the procedure was completed for Patient 34 at 0908 hours. The form showed the H&P was reviewed; the patient was assessed; and no change had occurred in the patient's condition since the H&P was completed. The risks and benefits of chosen anesthetic/sedation were discussed with the patient.

RN U confirmed the finding.