HospitalInspections.org

Based on review of facility documentation, facility tour and employee interviews (EMP), it was determined that the facility failed to ensure multi-dose medication vials were used and discarded per facility policy.

Findings include:

Review, at approximately 2:10 PM on March 15, 2019, of facility policy, "Multiple Use of Single Dose Vial or Syringe," review date October 19, 2011, revealed, "... Policy: It is the policy of Corry Memorial Hospital that a single dose vial or syringe is to be used for one patient only one time and discarded. ... In a Critical Care setting such as ER or OR, a single dose vial or syringe may be utilized for more than one dose, provided that: a) it is used for the same patient, b) this occurs over a time span of less than 1 hour, ... e) the drugs are kept secured during this time f) the remaining medication is appropriately wasted when the nurse leaves the patient bedside ..."

1. At approximately 12:18 PM on March 7, 2019, when asked where the anesthesia medications were located, EMP18 stated, "I have them in a container. Would you like me to go get them from the other room?" EMP18 returned to Operating Room 1 with a container that was retrieved from an anesthesia cart in another operating room.

At approximately 12:19 PM on March 7, 2019, when asked if the container of medications [that was retrieved from an anesthesia cart in another operating room upon request] contained any multidose vials, EMP18 stated, "Yes. I have them right here [Pulling out one vial of opened Labetalol 100 mg and and one opened vial of Zofran 10 mg]. ... I just take everything in this container with me from case to case." EMP18 confirmed the multi-dose vials of Labetalol 100 mg and Zofran 10 mg had been previously opened/accessed.

2. At approximately 12:19 PM on March 7, 2019, when asked if the transporting of the medications [including multidose vials] with [him/her] between cases was compliant with the facility's policies, EMP18 stated, "I don't know. I just started doing this when I started here. If there's medications in both carts, and I don't use them, they're just going to expire."

Based on review of facility documentation and medical record review (MR), as well as employee interviews (EMP), it was determined that the facility failed to document the dry time of alcohol based skin preparations in accordance with manufacturer guidelines and facility policy for two of two surgical records reviewed (MR19 and MR20).

Findings include:

Review, at approximately 2:45 PM on March 15, 2019, of facility policy, "Use of Alcohol-based Skin Preparations in Anesthetizing Locations," effective date February 10, 2010, revealed, "... Procedure: 1. All Alcohol based solutions will be used according to manufacturer/supplier instructions and warnings. ... A. [Alcohol based surgical prep solution] 26 ml Surgical Solution ... 3. Preps will be completed and allowed to dry prior to draping or use of an ignition source (e.g. cautery, laser) until completely dry. (Minimum of 3 minutes on hairless skin) ... Charting: ... 2. All Preps used will be documented on the Peri Operative Form in the patient's electronic record. ..."

Review, at approximately 8:25 AM on March 18, 2019, of the manufacturer instructions, "[alcohol based surgical prep solution] Surgical Solution Application Instructions," copyright 2005, revealed, "... Dry Allow solution to dry thoroughly on skin (approximately 2-3 minutes) ..."

1. Review, at approximately 12:09 PM on March 7, 2019, of MR19 revealed no documentation of dry time of the alcohol based surgical prep solution used on the patient.

This finding was confirmed by EMP14 at approximately 12:12 PM on March 7, 2019.

2. Review, at approximately 12:10 PM on March 7, 2019, of MR20 revealed no documentation of dry time of the alcohol based surgical prep solution used on the patient.

This finding was confirmed by EMP14 at approximately 12:12 PM on March 7, 2019.

3. At approximately 12:12 PM on March 7, 2019, when asked where the dry time of would be found, EMP14 stated, "We don't [document the dry time]. ..."

4. At approximately 12:31 PM on March 7, 2019, when asked what the facility's policy was for the documentation of the dry time of [Alcohol based surgical prep solution], EMP2 stated, "Our policy is three minutes. ..."

Based on review of facility documentation and medical record review (MR), as well as employee interviews (EMP), it was determined that the facility failed to ensure that a complete pre-anesthesia evaluation was recorded in the medical record per facility Medical Staff Rules And Regulations, for one of two surgical records reviewed (MR 20).

Findings include:

Review, at approximately 1:30 PM on March 15, 2019, of "Corry Memorial Hospital Medical Staff Rules And Regulations," updated June 2012, revealed, "... 28.2 Pre-Anesthesia Procedures: (a) A pre-anesthesia evaluation will be performed for each patient who receives anesthesia by an individual qualified to administer anesthesia within 48 hours immediately prior to an inpatient or outpatient procedure requiring anesthesia services. (b) The pre-anesthesia evaluation will be recorded in the medical record and will include: (1) a review of the medical history, including anesthesia, drug and allergy history; (2) an interview and examination of the patient; (3) notation of any anesthesia risks; (4) identification of potential anesthesia problems that may suggest complications or contraindications to the planned procedure (e.g., difficult airway); (5) development of a plan for the patient's anesthesia care (i.e., discussion of risks and benefits); and (6) any additional pre-anesthesia data or information that may be appropriate or applicable (e.g., stress tests, additional specialist consultations). The elements of the pre-anesthesia evaluation in (1) and (2) must be performed within the 48-hour time frame."

1. Review, at approximately 12:15 PM on March 7, 2019, of MR20 revealed an incomplete hand-written Pre-Anesthesia Evaluation located at the bottom of the Anesthesia Record. Review of the content of the information revealed no drug and allergy history, no interview with the patient, no anesthesia risks, no identification of potential anesthesia problems that would suggest contraindications to the planned procedure and no development of a plan for the patient's anesthesia care, as required per the "Corry Memorial Hospital Medical Staff Rules and Regulations," updated June 2012.

2. At approximately 12:15 PM on March 7, 2019, when asked where the Pre-Anesthesia Evaluation would be found in the medical record, EMP14 stated, "They [anesthesia] started writing the information on the bottom of this form ["Anesthesia Record"] to condense the amount of forms to be completed about three weeks ago. ... Any charts within the last few weeks will not have this ["Anesthesia Assessment"] completed because they [anesthesia] stopped doing them and just write the information down here [on the bottom of the "Anesthesia Record]."

3. At approximately 12:26 PM on March 7, 2019, when asked if [he/she] was completing a Pre-Anesthesia Evaluation on each patient prior to the scheduled procedure, EMP18 stated, "When I started here, I just started writing some information on one of the other forms, so I don't have to fill out two papers."

4. Review, at approximately 12:15 PM on March 18, 2019, of the Pre-Anesthesia Evaluation that was completed for MR20, revealed no completed Pre-Anesthesia Evaluation Form.