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Based on clinical record review, document review and staff interview, it was determined the hospital failed to obtain the patient's permission for a student to be present during an invasive procedure.

Findings:

The clinical record for patient #3 documented a student was present during the patient's invasive procedure. There was no documentation found in the clinical record that indicated the patient consented to the presence of the student.

On 05/28/13, staff F was asked if the hospital notified patients that students may be present in the hospital and may participate in providing care. She stated patients were introduced to students when they were present, but she was not aware of written notification to patients regarding students.

She stated information about the hospital being a teaching facility and that students may be a part of the health care team was not included in the admission consent document signed by patients at the time of admission.

Staff G was asked to locate information on the student identified in the patient's clinical record. No information was found. She stated the hospital did not have that student on their roster and was not aware the student had been in the hospital.

Based on clinical record review, policy and procedure review, and staff interview, it was determined the hospital failed to ensure nursing staff who provided moderate sedation were not also assigned to circulating nurse responsibilities.

Findings:

A hospital policy, titled, "Moderate Sedation Administration Guidelines", documented, "... The RN monitoring and managing the patient shall have no other responsibilities during the procedure that would leave the patient unattended or compromise continuous monitoring..."

On 05/28/13, the clinical record for patient #3 was reviewed. The record documented staff L was the only nurse assigned to provide care to the patient during an invasive surgical procedure.

This nurse was assigned to provide moderate sedation to the patient and was also expected to act as the circulating nurse charged with supervising and assisting the other staff assisting with the surgical procedure.

The nurse was also required to document all information relevant to the procedure itself, all patient care provided and the patient responses, and was expected to document all information related to the moderate sedation.

The intraoperative documentation by the nurse was incomplete and limited. For example, there was no documentation of the patient's positioning during the procedure. There was no documentation of patient safety measures provided.

There was no documentation a scrub assistant was present. There was documentation a student was present, but no documentation of the student's discipline and school affiliation. There was no documentation of the student's level of participation during the procedure.

At the time of the survey, hospital administration had no record of the student and was not aware this person was active within the hospital.

The nurse did not document the administration of a local anesthetic administered to the patient and did not document who administered it. The physician's documentation indicated a local anesthetic was administered.

The nurse's documentation of moderate sedation was limited to vital signs, medications administered and the presence or lack of pain and the patient's level of consciousness. There was no documentation of the EKG rhythm. When lopressor and zofran were administered, there was no indication why these were given.

There was no documentation of the patient's response to these medications.

The physician documented the patient experienced nausea and vomiting that interrupted, and ultimately, terminated the procedure.

The training records for staff L were reviewed. There was no documentation the nurse was trained and qualified to provide care as a circulator during the surgical procedure.

Staff G stated the hospital had not really considered the procedure to be "surgery" and did not assign a nurse circulator to the case. She stated the nurse was usually assigned to recover patients after procedures and was not usually assigned to provide care during procedures.

Based on clinical record review and staff interview, it was determined the hospital failed to ensure physician's orders for the administration of intravenous fluids contained all the required elements and that the orders were correctly followed by the nursing staff.

Findings:

The clinical record for patient #3 documented the following physician's order, "... Start peripheral IV in right arm..."

The order did not include the type of IV (saline lock, intra-cath, etc.), the type and amount of IV solution to administer, and the rate of fluid administration.

The clinical record documented, "... IV of [normal saline] started in her [left] hand..." There was no documentation of the type of IV, the type of solution administered, the rate of fluid administered and how much IV fluid was ultimately administered during the patient's hospital stay.

On 05/28/13, staff G stated the orders for the IV were incomplete and unclear.

Based on clinical record review and staff interview, the hospital failed to ensure nursing staff obtained physician orders before administering medications.

Findings:

On 05/28/13, the surveyors selected and reviewed eight clinical records for patients who had invasive cardiac procedures.

The record for patient #3 documented the patient was given versed and fentanyl intravenously prior to a clinical procedure. There was no physician's order for the administration of these medications.

There was no documentation of a physician's order for the intravenous medications administered by the registered nurse during the procedure.

At 4:30 p.m., staff F and staff G confirmed these findings.

Based on clinical record review, policy and procedure review and staff interview, the hospital failed to ensure the clinical record documentation adequately reflected the care and services provided to the patients undergoing surgical procedures.

Findings:

1. The hospital's policy on moderate sedation administration guidelines, No: PT.Care-1 with an effective date of 8/10, documented requirements for pre-procedure, intra-procedure and post-procedure monitoring and documentation. The policy specifies "...all patient care areas that provide moderate sedation will provide uniform monitoring of the patient as outlined in this policy/procedure..."

According to Patient #5's medical record, reviewed on 05/28/2013, the patient had a surgical procedure, a transesophageal echocardiogram (TEE) at the bedside on 04/23/2013. The only entry in the nursing notes documented, "...1000 Dr. (physician's name) in to conduct TEE. Staff Nurse in Room to Assist..." On the form, "Nursing Documentation: Patient Response and Patient Progress", another nurse documented, "...Echo_ey performed at bedside. Administered Stat Drugs..." Nursing notes of the course of procedure (pre, intra and post) did not contain:
a. Policy required monitoring of the patient's vital signs, cardiac monitoring and pulse oximetry at least every fifteen minutes.
b. The patient's level of consciousness (with the exception of the notation in the medication administration record at 0956 that the the patient was sleeping with the administration of Fentanyl and Versed).
c. Notation that a "time out" was called to ensure appropriate patient and procedure.
d. The time the actual procedure started.
e. The time the procedure ended.
f. The patient's response to the procedure and medications.

The physician's documented procedure report recorded, "...The patient was sedated for the TEE. Local anesthesia was provided by benzocaine topical spray..." The nurse documented the sedation medications of Fentanyl and Versed (with the amount and route) on the medication administration record (MAR) at 0956 with the notation, "...Given prior to nurse verification/Reason: Given with Physician Supervision...-Patient Sleeping." The administration of the benzocaine topical spray is not documented.

2. The clinical record for patient #3 was reviewed. The intraoperative documentation by the nurse assigned to the patient was incomplete and limited. For example, there was no documentation of the patient's positioning during the procedure. There was no documentation of other patient safety measures provided, such as side rails, safety belt, etc.

There was no documentation of the physician who performed the procedure. There was no documentation a scrub assistant was present to assist the physician.

There was documentation a student was present, but no documentation of the student's discipline and school affiliation. There was no documentation of the student's level of participation during the procedure.

The nurse did not document the administration of a local anesthetic administered to the patient and did not document who administered it. The physician's documentation indicated a local anesthetic was administered.

The nurse's documentation of moderate sedation was limited to vital signs, medications administered and the presence or lack of pain and the patient's level of consciousness. There was no documentation of the EKG rhythm. When lopressor and zofran were administered during the sedation process, there was no indication why these medications were given.

There was no documentation of the patient's response to these medications.

The physician documented the patient experienced nausea and vomiting that interrupted, and ultimately, terminated the procedure. There was no documentation of this by the nurse.

At the time of discharge, there was no documentation of a complete assessment of the patient's condition prior to the patient leaving the hospital.

Staff F was asked if the procedure documentation was complete. She stated it was not. She stated the form used to document procedures was not adequate.