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Based on record review and interview, the Hospital failed to ensure for one (Patient #7) patient of ten sampled patients, that the Universal Protocol was followed for Patient #7's radiological procedure.

Findings include:

The Hospital's policy and procedure titled Universal Protocol, dated 4/18/19, indicated that all invasive procedures in the operating room, procedure areas and inpatient and ambulatory areas will adhere to the Universal Protocol. The Universal Protocol process is a three step process and are:

1) Pre-procedure/pre-operative area verification
2) Proper site marking and
3) A time out

Patient #7's medical record, dated 8/16/19, indicated that an ultrasound guided aspiration of a bursa (site not identified) was performed.

The interventional radiologist's documentation for Patient #7, dated 8/16/19 at 2:42 P.M., indicated a timeout was performed; however, all the elements of the Universal Protocol were not documented as required by Hospital policy and procedure. The staff who participated in the time out were not identified. All the elements of a Universal Protocol were not documented and the elements of a time out that include the correct patient, the correct procedure, the correct site, the correct position, the correct equipment were not documented in Patient #7's medical record.

Based on record review and interview the Hospital failed for two (Patient #3 and Patient #8) patients of ten sampled patients to have a completed and documented history and physical (H&P) in the patient's electronic health record prior to their operative procedures.

Findings include:

The H&P Update Note for Patient #3, dated 8/27/19 at 7:13 A.M., indicated that the Attending Surgeon electronically signed that he reviewed the history and performed a pertinent physical examination on Patient #3, dated 8/21/191, and that no changes have occurred; however, there was no documentation that the Attending Surgeon performed a system assessment. The only documentation for the physical exam was that Patient #3 had weakness of his/her right hand.

The H&P Update Note for Patient #8, dated 8/23/18 at 7:40 A.M., indicated the Attending Surgeon electronically signed that he reviewed Patient #8's H&P examination; however, when the H&P was performed it was not dated and did not include a medical physical examination of Patient #8.

The Surveyor interviewed the Director of Peri-Operative Services during surgical record review on 8/27/19 at 12:30 P.M. The Director of Peri-Operative Services said she did not see a completed physical examination of either patient.

Based on interview and record review, the Hospital failed to ensure a timely post-procedural note was written for one (Patient #1) patient out of ten sampled patients, after Patient #1's kidney biopsy.

Findings include

Patient #1's record, dated 7/9/19, indicated that a CT needle biopsy was ordered and the reason for the exam was a kidney mass. The record indicated that, at 1:26 P.M., the procedure began and at 1:44 P.M. the procedure ended.

The interventional radiologist who performed the procedure dictated a report regarding the procedure on 7/11/19, two days after the CT needle biopsy.

The Medical Staff Rules and Regulations, dated June 2019, Section 6.2 (b) Post Procedure Protocol, indicated that an operative report must be documented immediately after an operative procedure.