HospitalInspections.org

Based on review of medical records (MR), facility policies and procedures and interviews with the staff, it was determined the facility failed to ensure:

1. Staff followed the facility policy for reporting of animal (dog) bites in the Emergency Department (ED). This did affect MR # 4, one of two MR's reviewed for dog bites in the ED.

2. Physician orders were written for blood transfusion. This did affect MR # 23, one of three MR's reviewed for blood transfusions.

3. Staff followed the physicians order and/or facility policy for:

a. Blood transfusion. This did affect MR # 20, one of three MR's reviewed for blood transfusions.

b. Vital signs (VS), blood pressure (BP), pulse, respiration rate, and temperature every 4 (four) hours. This affected MR # 12, MR # 13, and MR # 18, three of eleven inpatient record reviews.

c. Neuro (neurological) checks as ordered. This affected MR # 12, one of two record reviews for Medical Detoxification (Med-Detox) care.

d. Dietary consult and tube feeding infusion. This affected MR # 25, in one of one record reviews for a tube feeding.

e. Care of a gastrostomy (G-tube). This affected MR # 25, in one of one record reviews with a PEG (percutaneous endoscopic gastrostomy).

These deficient practices had the potential to negatively affect all patients receiving care at this facility.

Findings include:

Facility Policy Subject: Animal Bite
Department: ED
Reviewed: March 2021

Policy:

It is the policy of Clay County Healthcare Authority to provide appropriate guidelines for administering treatment to patients in the ED.

Procedure:

A. Patients arriving at the ED with animal bites will receive the following care:

...5. Report all animal bites to Clay County Health Department...

Facility Policy Subject: Blood or Blood Products Transfusion
Department: Nursing Service Facility Wide
Reviewed: 5/11/21

CCHA (Clay County Hospital Authority) will safely and expediently administer blood and blood products.

Intervention:

1. Verify physician's orders for the number and type of transfusion.

...11. Vital signs are to be taken prior to start of transfusion; 15 minutes after starting transfusion and within 1 (one) hour following the completion of the transfusion ("Post-Transfusion")...

Facility Policy Subject: Nutritional Assessment of Patients by the Clinical Dietician
Department: Nutritional Services
Reviewed: December 2022

Policy:

...shall have a consultant Dietician available to assess nutritional needs when needed for high-risk nutritional needs. Assessment should be completed within 72 hours of admission ...

Facility Policy Subject: Enteral Tube Feeding
Department: Medical/Surgical Unit Nursing Service
Reviewed: 5/21 (online)

Policy:

...to provide and implement a plan of care for delivery of nutrients via a gastrostomy ...
Assessment:

1. Physician's order for feeding shall include type, amount, frequency and strength of nutritional formula and amount of water used for flushing.

...3. Assess gastrostomy site for redness, tenderness, bloody or purulent drainage or edema.

...Procedure:

1. Enteral tube feeding shall be administered per physician's order.

...4. Stoma residual shall be checked every 8 hours or per physician's order ...

5. Feeding shall be held if residual is greater than 100 ml (milliliter).

...9. Check for tube placement ...at least once per shift for continuous feedings ...

10. ...If there is more than 100 ml of residual contents, hold the feeding ...

Procedure for Continuous Infusion:

1. If continuous feeding...

...4. Check for tube placement...Do this at least once a shift...Check for residual in stomach at least once per shift ...

Documentation:

1. Date and time;

2. Condition of gastrostomy tube exit site;

3. Document presence of bowel sounds...

4. Amount of residual aspirated when checking tube placement;

...6. Response of patient to procedure ...

1. MR # 4 was admitted to the ED on 4/23/23 with a complaint of a dog bite to the left calf (lower leg).

Review of the ED Nurses Patient Progress Notes dated 4/23/23 at 1:26 PM revealed, "attempted to fax dog bite info (information) over multiple times, attempted to call Clay Co (County) Health Dep (Department). Unable to leave message. Form sent to medical records". There was no documentation Clay Co Health Dep was notified of the dog bite per facility policy and procedure.

An interview was conducted on 8/3/23 at 12:43 PM with Employee Identifier (EI) # 1, Chief Nursing Officer (CNO), who confirmed there was no documentation the staff notified Clay Co Health Dep per facility policy and procedure.

2. MR # 23 was admitted to the facility on 7/27/23 with a primary diagnosis of Dyspnea.

Review of the Nursing Patient Progress Notes dated 7/28/23 at 10:44 AM revealed, "PRBC (Packed Red Blood Cell's), unit one started at this time". There was no physician's order for the one unit of PRBC's. The nursing staff failed to ensure a physician's order was written for the one unit of PRBC's per the facility policy.

An interview was conducted on 8/3/23 at 12:41 PM with EI # 1, who confirmed the staff failed to ensure a physician's order was written for the one unit of PRBC's per the facility policy.

3. MR # 20 was admitted to the Outpatient Department on 6/23/23 with a diagnosis of Anemia due to antineoplastic chemotherapy.

Review of the MR revealed a physician's order dated 6/22/23 which read, "...please draw type and cross and once completed please administer two units PRBC...per hospital protocol. Please check vital signs ...after each transfusion".

Review of the Nursing Patient Progress Notes dated 6/23/23 at 3:00 PM revealed, "second unit PRBC infused and discontinued". There was no documentation of vital signs after the transfusion was completed (post-transfusion) as ordered and per the facility policy.

An interview was conducted on 8/3/23 at 12:32 PM with EI # 1, who confirmed the staff failed to check vital signs per the physician's order and the facility policy.




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4. MR # 12 was admitted to the Med-Detox unit on 7/28/23 with diagnosis, Alcohol Abuse.

MR review revealed physician's orders dated 7/28/23 at 8:47 PM, VS tid (three times a day), Orthostatic vitals (BP lying, sitting, standing) q (every) shift, and Neuro checks q 4 hrs (hours) x 24 hrs, then q 6 hrs x 48 hrs, then q shift.

Review of the nursing documentation revealed initial VS were documented on 7/28/23 at 9:00 PM, and again at 10:53 PM, and no blood pressure was documented. The initial neurological assessment check was documented on 7/28/23 at 9:20 PM.

Further record review revealed the next VS were documented 7/29/23 at 8:00 AM, and at 8:00 PM, and not tid. The neuro assessment checks were documented on 7/29/23 at 8:19 AM and at 7:20 PM, and not every 4 hours.

MR review revealed a Nurse Patient Progress Note (PPN) dated 7/30/23 with neuro assessment documentation at 7:55 AM, and at 10:05 PM. The neuro assessments were not documented q 6 hrs as ordered.

Further review of the 7/30/23 MR revealed VS were documented at 10:10 AM, and not tid as ordered. There was no Orthostatic VS documented on 7/30/23.

Record review revealed on 7/31/23 VS were documented at 8:00 AM and 8:00 PM, and not tid. No Orthostatic VS was documented on 7/31/23.

Review of the MR documentation dated 8/1/23 revealed VS were documented at 8:00 AM, and at 9:15 AM the temperature and pulse were documented, and no BP was documented. Staff failed to monitor and document VS tid. There was no Orthostatic VS documented 8/1/23.

Staff failed to follow physician orders, perform and document VS tid, and q shift Orthostatic VS. Staff failed to perform and document neuro assessment checks per physician orders.

An interview was conducted on 8/3/23 at 12:27 PM with EI # 1, who confirmed staff failed to follow physician orders for VS and neuro checks.

5. MR # 13 was admitted on 7/29/23 with a diagnosis of Small Bowel Obstruction.

Record review revealed an order dated 7/29/23 at 9:44 PM for VS q 4 hrs.

MR review revealed on 7/30/23 VS were documented at 10:12 AM, and not again to 8:00 PM, which was greater than q 4 HR.

Further record review revealed no BP was documented on 7/30/23 from 8:00 PM until 7/31/23 at 4:00 AM, which was greater than 4 hrs.

An interview was conducted 8/3/23 at 12:22 PM with EI # 1, who confirmed staff failed follow physician order for VS.

6. MR # 25 was admitted on 6/6/23 with a diagnosis of Sepsis Pneumonia and was discharged 6/9/23 at 11:55 AM.

Record review revealed physician's orders dated 6/6/23 at 12:11 AM, Hold order NPO (nothing by mouth); 6/6/23 at 12:19 AM, Dietician consult; 6/7/23 at 7:52 AM-Glucerna tube feeding 30 cc (cubic centimeter)/hour; and 6/8/23 at 7:46 AM, increase feeding (tube feeding) to 50 cc/hr.

Staff failed to ensure the tube feeding order included the amount of water and frequency of G- tube flushes.

Review of the Initial Physical Assessment dated 6/6/23 at 1:07 AM revealed documentation, abdomen, soft non-tender, G-tube, type of Ostomy/Condition: NA (not applicable).

MR review revealed Nurse PPN documentation dated 6/6/23 at 7:15 AM that revealed abdomen, soft non-tender, G-tube, type of Ostomy/Condition: NA. At 7:30 PM, the nurse documented, abdomen soft, non-tender, non-distended. Staff failed to document G-tube site assessment on 6/6/23.

Review of the PPN dated 6/7/23 at 7:43 AM revealed abdomen, soft, non-tender, non-distended and ostomy condition: NA. At 9:30 AM, "Glucerna PEG Tube feeding started at 30 ml/hr ". There was no documentation staff verified G-tube placement, and no documentation staff assessed the G-tube site for redness, tenderness, bloody or purulent drainage or edema.

Further review of the 6/7/23 PPN documentation revealed at 5:35 PM "Glucerna tube feeding increased to 40 cc/hr". There was no physician order for Glucerna 40 cc/hr feeding. There was no documentation staff checked the residual contents and held the feeding if there was more than 100 ml of residual contents.

Review of the PPN dated 6/8/23 revealed at 8:01 AM the tube feeding was infusing Glucerna 50 cc/hr, abdomen soft non-tender, non-distended.

Review of the PPN dated 6/9/23 at 7:44 AM revealed abdomen, soft, non-tender, non-distended, flat, Ostomy condition: NA.

There was no documentation staff checked for G-tube placement at least once per shift, checked for residual in stomach at least once per shift per continuous feeding, and held if greater than 100 ml on 6/7/23, 6/8/23, and 6/9/23. There were no G-tube site assessments documented. There was no documentation staff provided G-tube flushes with water. There was no documentation a dietary consult was completed.

An interview was conducted 8/2/23 at 11:45 AM, EI # 2, Director of Care Coordination, who confirmed staff failed to follow physician orders for feeding infusion rate, and failed to ensure a dietary consult was conducted. Staff failed to follow the facility policy for G-tube assessment and continuous enteral feeding.



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7. MR # 18 was admitted to the facility on 3/5/23 with a diagnosis of Right Knee Replacement to the Swing-Bed unit.

Review of the physician's orders dated 3/25/23 revealed VS q 4 (four) hrs.

Review of the Patient Progress Notes (PPN) revealed VS documented on 3/25/23 at 10:28 AM, 4:08 PM and 9:01 PM which was greater than four hours as ordered by physican.

Further review of the PPN dated 3/26/23 revealed VS documented at 8:00 AM and 4:00 PM with no other documentation of VS for that day.

An interview was conducted on 8/3/23 at 1:31 PM with EI # 1, who confirmed the VS were not documented per the physician's orders.

Based on the facility policy and procedures, observation, and interview it was determined the faciltity failed to secure patient information.

This had the potential to negatively affect all patients receiving care at this facility.

Findings include:

Facility Policy Subject: Medical Record and Storage Retention
Department: Rehab (Rehabiliation) Therapy Services-Physicial, Occupational, & (and) Speech
Reviewed: 8/23

Policy:

It is the policy of Clay County Healthcare Authority that medical records shall be retained on all patients...

A. The patient records shall be preserved safely...

Procedure:

F. Records will be housed safely within the outpatient rehab therapy department...

Facility Policy Subject: Secure Filing of Medical Records
Department: Health Information Management Services
Reviewed: 12/22

Policy:

It is the policy of Clay County Hospital that the medical records are maintained in a secure and confidential manner.

Procedure:

A. Medical records housed... shall be kept in secure areas at all times. Medical records shall not be left unattended in areas accessible to unauthorized individuals.

...C. File rooms... shall remain locked at all times.

A tour was conducted on 8/1/23 at 3:50 PM with EI # 12, Licensed Physical Therapist Assistant (LPTA) of the Outpatient Physical Therapy (OPT) department. The surveyor observed patient medical records placed on two (2) open faced book shelves in a room with a curtain used for the door next to the patients treatment area. The surveyor inquired about the unsecure and unattended patient medical records. EI # 12 reported when patients are seen in the room next to the files, a staff member is with them at all times.

The surveyor also observed an unlockable filing cabinet in the front receptionist/lobby area. During the tour the surveyor observed no staff member present at the front receptionist/lobby area. The surveyor asked EI # 12, what was housed in the filing cabinet? EI # 12 reported the most current patient medical records are kept there.

An interview was conducted on 8/3/23 at 12:30 PM with EI # 13, Physical Therapy Director, who confirmed the facility failed to safely secure patients medical record information per facility policy.

Based on observations, facility policy and procedure, and interviews it was determined the facility failed to ensure all out of date drugs and biologicals were not available for patient use.

This deficient practice had the potential to affect all patients receiving medications at this facility.

Findings include:

Facility Policy Subject: Mulitdose Vial Use...
Department: Physical Therapy
Reviewed: 8/23

Policy:

It is the policy of Clay County Healthcare Authority to provide safe effective use of multi-dose medication vials...

Procedure:

When multi dose vials are opened a label is applied to the vial with date that the vial is opened and the date on which the vial with unused portion is discarded (28 days after opening).

...Be certain to discard the vial with unused portion of medication 28 days after opening

A tour was conducted on 8/1/23 at 3:50 PM with EI # 12, Licensed Physical Therapist (LPTA) of the Outpatient Physical Therapy (OPT) department. The surveyor observed two dexamethasone injection 5 ml (milliter) multi-dose vials that had been opened/puntured and had no label of open dates located in a box for patient use. EI # 12 reported the multi-dose injectable dexamethasone vials were puntured many times and the medication was injected onto a pad for multiple patients use and treatment.

An interview was conducted on 8/3/23 at 12:30 PM with EI # 13, Physical Therapist Director, who confirmed the staff failed to ensure out of date drugs were not available for patient use per the facility policy.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined the facility was not constructed, arranged and maintained to ensure patient safety. This had the potential to negatively affect all patients served by the facility.

Findings include:

Refer to Life Safety Code violations for findings.

Based on observations, review of hospital policy and procedure, and interviews, it was determined the staff failed to ensure supplies available for patient use were not expired.

This had the potential to negatively affect all patients receiving care at this facility.

Findings include:

Facility Policy Subject: Expired Supply Monitoring
Department: Nursing Service House Wide
Reviewed: 5/2021

Policy: It is the policy of Clay County Healthcare Authority to ensure an acceptable level of safety and quality for patients in this facility...

Procedure:

A. All supply storage areas shall be inspected for expired items (or items that will expire before the next checked) weekly by a charge nurse assigned designee.

B. Central supply will monitor for out of date supplies while restocking.

...F. Return all out of date supplies to Central Supply for tracking purposes.

1. A tour of the facility Emergency Department (ED) was conducted on 8/1/23 at 10:00 AM with Employee Identifier (EI) # 4, Registered Nurse (RN). During the tour the following expired supplies were observed and available for patient use:

ED Room # 2:

a. (Intravenous) IV start kit times (x) 1 with an expiration date of 7/31/22.

b. IV Extension Set x 1 with an expiration date of 6/30/22.

c. IV Adapter Clave x 3 with an expiration date of 6/30/22.

d. Hemoccult Sensa x 4 with an expiration date of 4/2023.

An interview was conducted on 8/1/23 at 10:40 AM with EI # 4, who confirmed the above supplies were expired and available for patient use.



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2. A tour and observations on 8/1/23 at 10:10 AM were conducted on the medical unit "holding room" adjacent to the medication room, with EI # 6, RN.

Expired Emergency cart and airway supplies included:

a. Two Bright Blade Pro, fiber optic disposal laryngoscope blades, expired 9/8/22, and 11/17/22.

b. One Greenline laryngoscope blade expired 4/2019.

c. Endotracheal tubes, Sheridan uncuffed 2.5 mm (millimeter), one cuff expired 5/31/21, one cuff 6.8 mm expired 3/2020, one cuff 4.0 mm expired 3/2020, one cuff 4.5 mm expired 3/2020, one cuff 1.6 mm expired 1/20/22.

d. Three Clave male adaptors, expired 6/30/22.

An interview was conducted on 8/1/23 at 10:35 AM with EI # 6 who confirmed the above patient supplies available for patient use were expired.

3. A tour of the Nuclear Medicine Department was conducted on 8/1/23 at 2:30 PM with EI # 9, Nuclear Medicine Technician.

Expired supplies observed in the Cardiac Stress Lab included:

a. One package of infant radiotranslucent electrodes, expired 12/7/2020.

b. One package of adult/child radiotranslucent electrodes, expired 12/7/2020.

An interview was conducted on 8/1/23 at 2:43 PM with EI # 9 who confirmed the electrodes were expired and available for patient use.

4. A tour of the Outpatient service supply closet was conducted 8/3/23 at 9:50 AM with EI # 11, RN, Outpatient department.

Expired supplies observed in the Outpatient services included:

a. Four number 8 French (FR) cath (urinary catheter) packages expired 1/31/23.

b. One 22 FR Dover-Silicone coated Latex Foley catheter expired 4/2018.

An interview was conducted on 8/3/23 at 9:58 AM with EI # 11 who confirmed the catheter supplies were expired and available for patient use.

Based on observations, facility policies and procedures, the Center for Disease Control and Prevention (CDC) Injection safety recommendations, the CDC Environmental Checklist for Monitoring Terminal Cleaning, and staff interviews, it was determined the facility failed to ensure staff:

1. Cleaned the intravenous (IV) medication rubber septum and the IV solution bag rubber port with alcohol before piercing.

2. Performed hand hygiene according to facility hospital policy.

3. Performed terminal room cleaning according to hospital policy, and CDC Environmental Monitoring recommendations.

4. Used disposable equipment (syringe and needle) for single use only.

This deficient practice affected MR (medical record) # 15, and had the potential to negatively affect all patients admitted to the hospital.

Findings include:

Facility Policy Subject: Hand Hygiene
Department: Infection Control
Reviewed: 6/2023

Subject: Hand Hygiene

...provide clear guidelines on hand hygiene to ...reduce transmission of pathogenic microorganisms to patients and personnel in health-care settings.

...Definitions:

...Decontaminate hands: To reduce bacterial counts on hands by performing antiseptic hand rub or antiseptic handwash ...

...Procedure:

Indications for handwashing and hand antisepsis:

...3. Decontaminate hands before having direct contact with patients.

...6. Decontaminate hands after contact with patient's intact skin ...taking a pulse ...lifting/moving a patient ...

7. Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care.

8. Decontaminate hands after contact with inanimate objects ...

9. Decontaminate hands after removing gloves ...

Centers for Disease Control and Prevention

Injection Safety

...Medication Preparation Questions

...2. How should I draw up medications?

Parenteral (intravenous) medications should be accessed in an aseptic manner. This includes using a new sterile syringe and sterile needle to draw up medications while preventing contact between the injection materials and the non-sterile environment. Proper hand hygiene should be performed before handling medications and the rubber septum should be disinfected with alcohol prior to piercing it.

...Page last reviewed: June 20, 2019

Facility Policy Subject: Cleaning Patient Room Discharge/Transfer or Occupied
Department: Environmental Services
Reviewed: 5/2019

Policy:

...patient rooms shall be cleaned when a patient has been discharged...

Procedure:

...B. Wash bed frame, mattress ...furniture, and light fixtures. Turn the mattress and clean both sided completely. Use ...germicidal solution ...Wash dresser, drawers ...clothes locker ...

...H. Damp mop floor ...

Facility Policy Subject: Iontophoresis
Department: Physical Therapy
Reviewed: 8/2023

Description:

Iontophoresis is the administration of soluble salts and other drugs into the body...

Procedure:

...Any unused medication and the syringe will be disposed of properly.

CDC Environmental Checklist for Monitoring Terminal Cleaning

...Evaluate the following priority sites for each patient room ...High-touch Room Surfaces ...Bed rails/controls ...Bedside table handle ...Room sink, Room light switch. Room inner doorknob, Bathroom light switch ...

1. Observations of care were conducted on 8/1/23 at 10:50 AM on the medical unit with EI (Employee Identifier) # 6, RN (Registered Nurse). EI # 6 retrieved one vial of IV Vancomycin and one bag 0.9 % IV normal saline (NS) solution and performed hand hygiene.
EI # 6 removed the Vancomycin vial cap, pierced the vial with the reconstitution device needle without first cleaning the Vancomycin vial rubber septum with alcohol. After reconstituting the Vancomycin vial, EI # 6 connected the Vancomycin to the NS solution rubber port but failed to clean the rubber port with alcohol before connecting the Vancomycin vial.

EI # 6 entered MR # 15's patient room, gloved, without first performing hand hygiene. EI # 6 cleaned the IV site hub with alcohol, flushed with saline, removed his/her gloves, and documented at the bedside computer.

EI # 6 failed to perform hand hygiene after flushing MR # 15's IV.

EI # 6 then donned gloves without first performing hand hygiene, cleaned the IV hub with alcohol, and connected the Vancomycin. MR # 15 complained of discomfort at the IV site, and the Vancomycin was unable to infuse, EI # 6 removed gloves, but failed to perform hand hygiene after glove removal. EI # 6 exited the room.

EI # 6 failed to follow CDC recommendations for IV medication preparation and failed to follow the facility hand hygiene policy.

An interview was conducted on 8/3/23 at 2:45 PM with EI # 1, Chief Nursing Officer, who confirmed staff failed to follow IC guidelines for hand hygiene and IV medication preparation/administration.

2. A terminal cleaning of a patient room after patient discharge was conducted on 8/1/23 at 1:10 PM with EI # 5, Environmental Service Aide on the medical unit.

EI # 5 entered a patient room located on the Medical Detoxification/Medical Surgical unit and left the keys in the cleaning cart. EI # 5 cleaned the mattress top, pillows, overbed table, bathroom, placed clean linens on the bed, and mopped the floor on the way out of the room.

EI # 5 failed to clean the following high-touch surfaces:
a. Mattress bottom

b. Bed rails and bed control

c. Bedside table/handle/drawers

d. Room and bathroom light switches

e. Room and bathroom inner doorknobs

f. Room sink and surrounding countertop

g. Clothes locker-(patient belongings were left in the locker)

An interview was conducted on 8/1/23 at 1:45 PM with EI # 5 who confirmed he/she completed the terminal room clean and failed to clean the above high-touch surfaces areas.



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3. An observation of an unsampled patient was conducted on 8/1/23 at 3:01 PM for Outpatient Physical Therapy (OPT). EI # 12, Licensed Physical Therapist Assistant (LPTA), failed to perform hand hygiene before patient care.

EI # 12 assisted patient with left leg exercise. EI # 12 handed a theraband to the patient and failed to perform hand hygiene.

EI # 12 then obtained ice packs and electrode pads and placed on the patient's left hip. EI # 12 failed to perform hand hygiene after the patient's care.

An interview was conducted on 8/3/23 at 12:30 PM with EI # 13, Physical Therapist (PT), who confirmed the staff failed to ensure proper hand hygiene during patient care per the facility's policy.

4. A tour was conducted on 8/1/23 at 3:50 PM with EI # 12 of the OPT department.

The surveyor observed one used 10 cc (cubic centimeter) syringe with needle attached in a box with a multi-dose vial of medication. EI # 12 reported the syringe with needle has been used multiple times to withdrawal medication from the vial and injected onto a pad for patient's care of iontophoresis.

An interview was conducted on 8/3/23 at 12:30 PM with EI # 13, who confirmed the staff failed to dispose the single use syringe with needle after use per the facility's policy.

5. Observation of care was conducted on 8/2/23 at 11:35 AM to observe MR # 15 for respiratory therapy.

EI # 14, Registered Respiratory Therapy Director, performed hand hygiene, entered MR # 15's room, donned gloves, obtained the patient's vital signs. EI # 14 failed to remove contaminated gloves and perform hand hygine.

EI # 14 opened the liquid medication for the breathing treatment, then with the same contaminated gloves poured the liquid medication into a nebulizer mask and placed onto MR # 15's face. Upon completion of the breathing treatment EI # 14 removed the nebulizer mask from MR # 15's face. EI # 14 again failed to remove contaminated gloves and perform hand hygiene.

An interview was conducted on 8/2/23 at 11:55 AM with EI # 14, who confirmed the contaminated gloves should have been removed and hand hygiene performed during patient's care per the faciltiy's policy.

Based on observations, and interview with EI (Employee Identifier) # 7, OR (operating room) Nurse Manager, the surgery staff failed to ensure a roster of surgeons with the surgical specialty privileges was maintained in the surgical service department.

This had the potential to negatively affect all patients requiring surgical services at the facility.

Findings include:

A tour of the surgery service department and observations of care were conducted 8/2/23 from 7:30 AM to 10:50 AM.

The surveyor inspected the patient recovery area, the central sterile unit, the OR (operating room) interchange area, the two OR suites, and OR staff breakroom. There was no roster of the surgeons with the surgical priviledge/specialty in the surgery service department.

An interview was conducted 8/2/23 at 1:20 PM with EI # 7. The surveyor asked EI # 7 if there was a roster of current surgeons privileged with the surgeon specialty posted in the surgery service area? EI # 7 was not able to locate the roster in the surgery department or on his/her department computer.

EI # 7 confirmed there was no roster with the hospital surgeons with specialty privileges available in the surgical service department.

Based on observation, surgery service policy, and interview with EI (Employee Identifier) # 7, Operating Room (OR) Nurse Manager, it was determined staff failed to ensure the OR back door entrance was secure.

This affected an unsampled patient having an outpatient surgical procedure on 8/2/23 and had the potential to negatively affect all inpatients and outpatients treated in the OR.

Findings include:

Facility Policy Subject: Surgical Services Safety
Department: Surgery Services
Reviewed: 7/2020

Policy:

..policy...to provide safety standards...rules for the Surgical Service Team.

...24. No visitors in surgery or recovery room. Only authorized personnel shall enter surgery or recovery room suite...

A tour of the hospital surgery service department and observations of care were conducted on 8/2/23 from 7:30 AM to 10:50 AM. At 7:30 AM, the surveyor entered the Surgery Service department through a secure front entrance with assistance of a surgery service environmental staff member. All surgery service staff were in the OR in a colonoscopy case.

After touring the recovery area, and the Central Sterile area, the surveyor entered the OR entrance door to the area of the two surgical suites. There were no surgery staff present in the interchange area (space between the two operating rooms). The surveyor observed the OR interchange entrance back door ajar, not secure, and the surveyor was able to see sunlight from the open space between the ajar door and the door frame. At approximately 8:05 AM, EI # 7, exited the OR Procedure Suite, into the interchange area. The surveyor alerted EI # 7 to the open door. EI # 7 immediately closed the door.

An interview was conducted on 8/2/23 at 8:05 AM with EI # 7 who confirmed the back door OR suite entrance was open, and not secure. Staff failed to ensure only authorized personnel were able to enter surgery or the recovery room suite.

Based on review of medical records (MR), surgery service policy, and interview it was determined the facility failed to ensure all outpatient procedures had a documented history and physical examination completed 30 days prior or 24 hours after admission for scheduled procedure.

This affected MR # 16, one of one outpatient surgery records reviewed and had the potential to affect all patients admitted to the facility for outpatient services.

Findings include:

Facility Policy: Subject: History and Physical (H&P)
Department: Outpatient Care
Revised: 5/2023

Policy:

...establish guidelines for completion of H&P for outpatient surgery patients.

All outpatient surgery patients...shall have a H&P on the chart at the time of surgery...dated within 30 days to scheduled surgery.

...H&P must be updated with any changes documented the day of surgery by the physician...The H&P assessment can be performed on the same day as the surgical procedure...as long as the results of the H&P are placed in the patient's MR prior to transport to the surgery department...

It is the responsibility of the outpatient nurse to verify...H&P is on the chart dated within 30 days and updated day of procedure...

Record review revealed MR # 16 was admitted to outpatient surgery 8/1/23 for a colonoscopy.

MR review revealed a H&P completed 5/4/23, which was greater than 30 days before the outpatient surgery procedure on 8/1/23.

Further review revealed a document titled, "One Day Surgery" dated 8/1/23, with documentation a H&P was dictated at Clay County Hospital on 8/1/23. There was an Operative Note with service date and physician signature 8/1/23 that revealed H&P reviewed with no changes.

There was no H&P in the MR completed within 30 days of the 8/1/23 surgical procedure.

An interview was conducted 8/3/23 at 12:12 PM with Employee Identifier # 1, Chief Nursing Officer, who verified the 5/4/23 H&P was completed greater than 30 days.

Based on observation, facility policy and procedure, the AORN (Association of preoperative Registered Nurses (AORN), and the Malignant Hypothermia Association of the United States (MHAUS) recommendations, and staff interview, it was determined the anesthesia department failed to ensure 36 vials of Dantrolene were available in OR (operating room).

This affected an unsampled patient on 8/2/23 who required general anesthesia, and had the potential to negatively affect all surgery patients.

Findings include:

Facility Policy Subject: MH (Malignant Hyperthermia) Management of Patient
Department: Anesthesia
Revised: December 2016 (online)

Policy:

...outline the proper procedure for the management of a patient with MH.

...Procedure:

B. If MH is suspected...

1. Stop anesthesia...

2. Change all rubber devices on the anesthesia machine...

3. Hyperventilate with 100 % O2 (oxygen)...

4. Notify Pharmacy of clinical picture...Administer Dantrolene...as soon as possible...As a large quantity may be necessary, a sufficient supply must be available in the Surgical Services Department, extra vials are available in the Pharmacy...

Outpatient Surgery

A Division of AORN

Always be Prepared for MH

Providers must be ready to act swiftly when MH is in play...stocking a dedicated MH cart...MHAUS recommends stocking your cart with 36 vials, each to be diluted at the time of use with 60 ml (milliliter) sterile water...

A tour and interview of the anesthesia department was conducted on 8/2/23 at 12:45 PM, with EI (Employee Identifier) # 8, Certified Registered Nurse Anesthetist.

EI # 8 and the surveyor toured the anesthesia workroom and inspected the emergency box which contained the MH supplies. There were 24 vials of Dantrolene and not the recommended 36 vials stored in the surgical service department as recommended by the AORN and MHAUS.

An interview was conducted on 8/2/23 at 1:10 PM with EI # 8, who confirmed there was not 36 vials of Dantrolene stored in surgery per recommendations, available in the event of a MH emergency.

Based on facility policy and procedure, MR (medical record) review, and staff interview, it was determined staff failed to ensure all patients who received outpatient (OPT) services were provided appropriate discharge instructions.

This affected MR # 21, one of three OPT infusion record reviews, and had the potential to affect all patients receiving OPT services.

Finding include:

Facility Policy Subject: Discharge Guidelines from OPT Care Services
Department: OPT Care
Reviewed: April 2023

Policy:

...Discharge instruction sheets are given to outpatients after...observation...medication administration.

Procedure:

...5. Discharge instruction sheet must include activity, diet, treatment, medication, follow up appointment...

6. Patient...shall receive a complete verbal explanation of instructions along with a copy of the instruction sheet.

MR # 21 presented on 6/30/23 for an OPT infusion, "Feraheme (iron) per protocol".

Record review revealed at 2:15 PM the Feraheme infusion was complete and at 2:55 PM discharged home.

There were no verbal discharge instructions documented. The MR failed to include a copy of the Discharge instruction sheet.

An interview was conducted on 8/3/23 at 12:30 PM, with Employee Identifier # 1, Chief Nursing Officer, who confirmed staff failed to ensure outpatient staff provided and documented verbal and written discharge instructions per facility policy and procedure.