HospitalInspections.org

Based on record review and interview, it was determined that the hospital could not provide evidence that each patient's representative (the hospital is a children's hospital) had received patient's rights information in advance of furnishing or discontinuing care for 20 of 20 patients. (Patient identifiers: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 and 20)

Findings include:

1. The surveyors chose a sample of 10 inpatient and 10 outpatient medical records to review.

For 3 of 20 patients (patients 7, 14 and 17), there was no "Patient Acknowledgement" form in the patient's medical records.

Seventeen of 20 patient medical records contained "Patient Acknowledgement" forms that included that statement, "I acknowledge that I have received a copy of Shriners Hospitals for Children's Notice of Privacy Practices" but the form did not have evidence that the patients had received patient rights information (Patients 1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, 15, 16, 18, 19 and 20).

2. In an interview with the chief nursing officer (CNO) on 10/24/13 at 11:45 AM, she stated that they had recently added "and patient rights" to the statement the patient's representatives signed, but that the corrected form had not made it to the appropriate areas in the hospital.

Based on record review and interview, it was determined that the hospital could not provide evidence that each patient or patient's representative had received advance directives information for 20 of 20 patients. (Patient identifiers: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 and 20)

Findings include:

1. The surveyors reviewed 20 patient medical records. None of the records contained documentation that the patients or patient's representatives had received advanced directives information.

2. In an interview with the registered nurse (employee 3) responsible for admissions to the hospital 10/24/13, she stated that since the hospital's patients were under age 18, they didn't need advance directives. Employee 3 showed the surveyors a copy of the hospital's electronic medical record which included a space in the preadmission history titled, "Advance Directive." Next to the "Advance Directive," there were three checkboxes: "yes," "no," and "Not applicable due to age." Employee 3 stated that they checked the not applicable box.

Based on observation and interview, it was determined the hospital did not ensure a safe setting for the tracking of missing surgical instruments. Specifically, one of twenty patients medical records lacked documented evidence that surgical instruments were accounted for. (Patient identifier:15).

Findings include:

On 10/22/13 at 2:30 P.M., a surgical suite tour and a review of the Operating Room (OR) nursing record was completed. On the OR nursing record of patient number 15, the surgical patients records indicated that an "Instrument Count Correct" was "n/a" (indicating that counting instruments in surgery was not applicable).

In an interview with the Surgical Director (SD) conducted on 10/22/13, the SD stated that there has never been a count of the surgical instruments in the surgery room at this hospital that she was aware of. There has been a surgical count involved for the sponges and needles, but not instruments. After surgery the instruments are taken to central supply where they are cleaned and counted. This process can occur several hours to the next day after surgery.

An interview with the Central Sterile Lead Technician (CSLT) and the Director of Surgery was completed on 10/22/13. The CSLT stated there had been four (4) scissors missing in the last year. The CSLT stated that a documented record of notification of missing instruments was not kept. The resolution process was to go look in the surgery room for the missing instruments and check with the nurses. It was assumed by the CSTL that the missing scissors were taken by the interns that performed surgery. This was confirmed by the Director of Surgery on 10/22/13.

In an interview with the Medical Director and Administrator was completed on 10/22/13. The Medical Director and Administrator both stated they were not aware of the missing surgical instruments. The Medical Director stated that it would be impossible to count all of the instruments in the surgery and that having a surgical instrument lost in the patient would not occur. The Medical Director stated that continuous x-rays are done and any instrument would be seen in the patient during that time. When continuous x-ray was not done, the surgical opening would be so small, for example on the feet that an instrument would not physically fit inside.

A review of the hospital's policy and procedure for "ACCOUNTABILITY OF SPONGES, NEEDLES, BLADES AND INSTRUMENTS" was completed on 10/22/2013. The policy had been reviewed 9/2012 by the surgical staff.

Per the policy, "Needles, blades and instruments broken or disassembled during a procedure shall be accounted for in their entirety" and "The surgeon is notified whenever a needle, sponge or instrument is missing". Further, "Standardization of instrument trays alert staff when instruments are missing. Instruments broken, dull or disassembled during a procedure are tagged by the scrub nurse to call for attention by the Central Sterile Technician."

The hospital's policy of accounting for the surgical instruments relied upon the "Standardization of instrument trays". The official count was being left to the Central Sterile Technician during reprocessing to find discrepancies. No record of documented occurrence notifying the physician had been implemented. Per the interview on 10/22/13 with the CSLT, 4 scissors were missing in the last year that were never reported per hospital policy.