HospitalInspections.org

Based on observation, review of policies, and staff interview the facility failed to ensure that equipment available for use on patients was not expired in 1 of 5 operating rooms (cesarean section operating room). The findings were:

Observation on 3/4/20 at 3:20 PM showed 20 patient care items in the cesarean section operating room were outdated. Items included primary intravenous (IV) sets, IV catheters (needles), chlora-prep units, blood draw vials, IV stop-cock extension tubing, and rolls of medix tape. Expiration dates ranged between 7/2014 and 2/2019. Interview on 3/4/20 at 3:30 PM with the director of surgical services revealed that the facility expectation was all items available for patient use should not be expired.

Review of the "Infection Prevention and Employee Illness Program Overview & Plan" dated 2020 revealed the goal was to "to reduce the risk of infection developing in patients related to the use of devices and procedures required in their care" (paragraph 3).

Based on observation, medical record review, staff interview, and policy and procedure review, the facility failed to ensure access to medical records was limited to individuals with a need to know that information for 1 of 1 storage areas (off site medical storage room). This failure resulted in the lack of adequate medical record security. In addition, the facility failed to properly execute informed consents for 2 of 20 patients (#10,#16) with informed consents. Also, the facility failed to ensure post anesthesia evaluations were completed for 4 of 7 patients (#15,#16,#18,#19) reviewed for a post anesthesia evaluation after surgery.

Refer to C1120 regarding access to medical records concerning employees who had no need to know the information contained in those records. Refer to C1110 regarding incomplete execution of informed consents for 2 of 20 patients review for consents. Refer to C1144 regarding facility failure to ensure post anesthesia consents were completed for 4 of 7 patients reviewed for post anesthesia evaluations after surgery.

Based on medical record review, and staff interview the facility failed to properly execute informed consents for 2 of 20 (#10, #16) patients reviewed for informed consents. The findings were:

1. Review of admission and diagnosis documentation showed patient #10 was admitted to the facility on 3/1/20 with a diagnosis of term pregnancy for a caesarian section. Review of the 3/1/20 "Operative Report" showed the patient received spinal analgesia. Review of the 2/11/20 "Anesthesia Provider Declaration" showed it included the following, "I have explained the contents of this consent form to the patient or patient's representative and have answered all the patient's questions, and to the best of my knowledge, the patient has been adequately informed and has consented." Further review showed the area for signature, date, and time for the anesthesia provider was left blank.

2. Review of the anesthesia record for patient # 16 showed the patient was admitted on 2/13/20 for a right sacroiliac fusion. Review of the Anesthesia Informed Consent for Anesthesia showed the Anesthesia Provider Declaration with the following statement; "I have explained the contents of this consent form to the patient or patient's representative and have answered all the patient's questions, and to the best of my knowledge, the patient has been adequately informed and has consented." Further review showed the area for signature, date and time was left blank.

3. Interview on 3/5/20 at 1:30 PM with director of surgical services revealed the process for the anesthesia consents was for the anesthesia provider to sign the consent after interviewing the patient and explaining the type of anesthesia that will be used.

Based on observation and staff interview, the facility failed to ensure access to medical records was limited to individuals with a need to know that information for 1 of 1 storage areas (off site medical storage room). The findings were:

Observation on 3/5/20 at 9 AM of the offsite medical record storage area revealed a storage area in the basement of a downtown building in two rooms, with boxes of records stored on shelves. Access to the rooms and the building was via maintenance men with the key on their individual key rings. The rooms were dry and with sufficient space for access to all records. Interview with maintenance mechanic #1 on 3/5/20 at 9:15 AM revealed the keys to medical record offsite storage were only in the control of the maintenance personnel. All other staff needed to contact and be escorted by maintenance staff if they desired entry into the storage building. Interview with the CNO on 3/5/20 at 10:25 revealed the senior staff did not know that the keys to the storage area were not under the control of the medical records department. It was further revealed the expectation of the facility was to comply with the regulations and have the medical records department have complete control of all medical records.

Based on medical record review, and policy and procedure review the facility failed to ensure a post anesthesia evaluation was completed for 4 of 7 patients (#15, #16, #18, #19) reviewed for post anesthesia evaluation after surgery. The findings were:

1. Review of admission and diagnosis documentation showed patient #15 was admitted to the facility on 2/25/20 with diagnoses which included duodenitis and a prior cholecystectomy. Review of the 1/8/20 "Anesthesia Record" for the patient's cholecystectomy procedure showed the patient received general anesthesia. The review showed an area for "Postanesthesia Note." Continued review showed the postanesthesia note area was signed. However, the anesthesia professional failed to date and time the note. Review of the entire medical record showed this was the only area for a postanesthesia note from an anesthesia professional.

2. Review of the anesthesia record showed patient #16 had a sacral iliac fusion under general anesthesia on 2/13/20. Review of the Postaneshesia Note showed a signature and date but lacked a time.

3. Review of the anesthesia record showed patient #18 had carpal tunnel surgery on 3/3/20. Review of the postanesthesia note showed a signature but lacked a date and time.

4. Review of the anesthesia record showed patient #19 had a colonoscopy on 3/4/20. Review of the postanesthesia note failed to show a signature, date or time.

5. Interview on 3/5/20 at 1:30 PM with the director of surgical services revealed the expectation was for the anesthesia professional to sign the postanesthesia note.

6. Review of the Anesthesia Department policy with a revision date 3/19, showed "...12.b. Outpatients will be seen before discharge noting any problems or complications..."