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Based on interview, medical record review, and policy review, the hospital failed to provide the patient a phone number and address for lodging a grievance with the State agency.
Findings:
~On 11/2/2016 at 3:30 P.M., Staff V reported to the surveyor the "Conditions of Admission", "Advance Directive Acknowledgement", and "Joint Notice of Privacy Practices" were the current forms given to the patients upon admission.
~On 11/2/2016 at 3:30 P.M., the "Conditions of Admission", "Advance Directive Acknowledgement", and "Joint Notice of Privacy Practices" documents were reviewed. The documents did not include State agency information.
~Review of the hospital's policy #457 Ver: #4 titled "Patient Rights and Responsibilities," approved on 02/20/2012, was not consistent with the forms "Conditions of Admission", "Advance Directive Acknowledgement", and "Joint Notice of Privacy Practices" provided to each patient on admission. The policy documented, "...right to file a grievance with the Oklahoma State Department of Health..." "...may contact them at this address or by telephone at..."

Based on observations, interviews, and document review, the Infection Control Preventionist failed to develop and implement an infection program in accordance to standards of practice for infection control.

Findings:

1. On 11/04/2016, during a tour of surgical department, includied the semi-restricted and restricted areas, the staff were observed wearing navy scrubs.
~ The Chief Nursing Officer (CNO) stated clinical staff assigned to the semi-restricted and restricted areas were allowed to wear employee owned surgical scrubs that were laundered at home. The CNO stated the facility provided commercially laundered surgical attire for the physicians.
~ On 11/02/2016 at 10:30 am, Staff H stated staff laundered their own surgical scrubs and had been no guidelines as to how to launder them.
~The hospital policy titled, "Attire in The Operating Room 10/2013" was reviewed. The policy documented, "All employee owned reusable OR [operating room] attire shall be laundered according to specific guidelines outlined in the Employee Laundered Surgical Attire Policy and Procedure in the Hospital Policy and Procedure manual." The surveyors requested the policy regarding home laundering guidelines that was cited, and the Infection Preventionist stated that there was no such policy.

On 11/04/2016 at 10:30 am, while touring the restricted in the surgical suites, and in sterile processing staff were seen wearing shoes without shoe covers. Some shoes appeared dirty. The CNO stated staff were allowed to wear shoes to and from home, and were only required to wear shoe covers if they were near the operating field.
~The hospital policy titled, ""Attire in The Operating Room 10/2013" was reviewed. The policy documented, "Shoe covers shall be worn if it is anticipated that splashes or spills will occur. When shoe covers are worn, they are to be changed whenever torn, soiled or wet. Shoe covers are to be removed whenever leaving the surgical suite."

2. On 11/04/2016 at 10:25 am, during a tour of the surgical department, five metal racks were seen within the surgical corridor. The racks contained the following number of blue wrapped sterile instruments and other surgical supplies: Rack 1- 14 wrapped instruments, Rack 2- 8 wrapped instruments, Rack 3- 10 wrapped instruments, Rack 4- 20 wrapped instruments, and Rack 5- 33 wrapped instruments.

The Director of Surgery stated the corridor permanently housed the racks, with sterile wrapped instruments and surgical supplies. The corridor was a main egress of high traffic and lead to the surgical suites and surgical service areas. The Surgical Director stated the instruments and supplies were stored in the corridor due to lack of space in the department.
~The Facility Manager stated the ventilation for the surgical corridor was not monitored.
~ (Sterile wrapped surgical instruments require a low traffic environment with monitored ventilation that is maintained within the guidelines for temperature and humidity.)

3. On 11/04/2016, during a tour of the endoscopy department, bronchoscopes and gastrointestinal endoscopes were seen hanging in covered storage. Each scope was tagged with a thirty day expiration date.
~The Infection Control Preventionist stated the staff would reprocess the scopes every 30 days if used.
~The hospital policy titled, "The Cleaning of Low Use Gastrointestinal and Respiratory Endoscopes 09/16" was reviewed. The policy documented, "No scope will go longer than thirty days without being processed."
~(The Society of Gastrostroenterology Nurses and Associates's article titled "Standards of Infection Prevention in Reprocessing of Flexible Gastrointestinal Endoscopes 2016" documented, "... authors of a recent systematic review concluded that endoscopes can be stored for 7 days if they have been effectively reprocessed to remove all pathogens and almost all other microorganisms, and are stored in a way that keeps them completely dry and free from environmental and human contamination .)

Based on observation, interview, and document review, the facility failed to ensure a Registered Nurse (RN) who served as a circulating nurse was available during every surgical procedure.

Findings:

On 11/02/2016 at 10:30 am, Staff H stated most patients having gastrointestinal endoscopy procedures received moderate sedation (Fentanyl and Versed) that was administered by a registered nurse and supervised by the gastroenterologist.

Staff H stated two registered nurses (RN) and the physician performed the endoscopic procedures. Staff H stated one RN administered moderate sedation and monitored the patient, with no other responsibilities. The second RN performed the functions of the technician. Staff H said there was no RN exclusively performing the responsibilities of a circulating RN.

The surveyors requested the hospital job description for a circulator RN and was given a document titled ,"Registered Nurse in Surgery." The document defined the qualifications and responsibilities of this role.

Patient #12's medical record was reviewed. Patient #12 had two endoscopic procedures. There were only two RN's documented as assisting the physician with the performance of the procedures.

(2016 The Association of periOperative Registered Nurses's position statement, regarding the role of a circulating nurse, documented, "at a minimum, one perioperative RN circulator should be dedicated to each patient undergoing an operative or other invasive procedure and be present during that patient ' s entire intraoperative experience".)

Based on observation, staff interview and document review, the hospital failed to ensure surgical fire risk reduction measures were performed prior to each surgery or other invasive procedures.

Findings:

On 11/02/2016 at 10:30 am during a tour of the endoscopy procedural area and on 11/03/2016 at 1:45 pm, during the surgical unit tour, oxygen, alcohol [fuel], and cautery [heat] were observed. (These elements increased the risk of surgical fires)

On 11/04/2016, during an interview, the Director of the Cardiac Cath Lab stated oxygen, alcohol, and cautery were also present in all cath labs. This Director stated the cath staff did not perform a surgical fire risk assessment prior to heart cath procedures.
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The hospital policy title, "Prevention of Surgical Fires 10/13" was reviewed. This policy does not include instructions for staff to perform a fire risk assessment prior to each surgery or other invasive procedures.

Ten medical records were reviewed for documentation of a fire risk assessment prior to surgery or other invasive procedures. The findings were as follows:
~ 2 of 6 surgeries failed to document a fire risk assessment,
~ 3 of 3 cardiac caths failed to document a fire risk assessment, and
~ 1 of 1 endoscopies failed to document a fire risk assessment.