HospitalInspections.org

Based upon observation and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs of all patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 485.62(c), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care, resulting in the potential for negative outcomes up to and including death in the event of a fire. Findings include

See the individually and below cited K-tags dated December 2, 2020.
K-0223
K-0291

Based on observation, interview and policy review the facility failed to ensure staff compliance with nationally accepted standards of practice and enforce facility policies to assure achievement and maintenance of aseptic and sterile practice while donning acceptable operating room attire in the semi-restricted and restricted areas of the surgical corridor and suite, resulting in the potential for contamination of sterile equipment, cross contamination among three surgical patients in the surgical setting at the time of observation and poor surgical outcomes. (See additional tag C-1144) Findings include:

On 12/02/2020 at 0925 during a tour of the surgical Operating room sterile corridors, with Staff L (Director of Surgical Services), while looking through the double doors of the sterile corridor, a female was observed to be dressed in a blue scrub top with a long sleeve shirt underneath her scrub uniform and approximately 3 inches of dark colored pants hanging out below the pant legs of the light blue scrub pants. Staff L was asked if that female was an employee and if so, what was her role. Staff L stated, "that is our CRNA [Certified Registered Nurse Anesthetist]." Staff L was further queried regarding acceptable operating room attire and if wearing street clothing under provided and facility laundered scrubs was an acceptable practice. In addition the facility's surgical attire policy was requested.
Staff L stated, "absolutely not an acceptable practice, we provide laundered scrubs and jackets ... I will catchup with her and have a discussion." Note, at the time of observation this surveyor was not wearing the required scrub attire to enter the surgical area and was unable to interview the CRNA. All other surgical staff were observed to be wearing the facility provided scrubs which included pants, tops and scrub jackets covering arms.

On 12/03/2020 at 1000 an interview with Staff L the Director of Surgical Services was conducted. Staff L stated, "I did talk to (CRNA Staff T) about wearing her personal clothing under her scrubs. I approached her yesterday and confirmed that the shirt and pants under her scrubs were personal clothes that she wore in from the outside. When I directed her to change out of her personal clothes and said (XXX) you cannot wear your clothes into the OR (operating room), she (Staff T) gave push back (XXX) said what I have been doing this for 16 years, I have two more cases and I am not changing. A scrub technician (Staff R) also mentioned the street clothes and said she tried to get her (Staff T) to put on a jacket to at least cover the arms to which the CRNA stated nope I'm good!"

On 12/03/2020 at 1020 a telephone interview was conducted with Staff R (Surgical Scrub Technician). Staff R was queried whether it was an acceptable practice to wear street clothing under scrubs into the restricted surgical areas. Staff R was also queried regarding national guidelines, best practices and if there were facility policies regarding surgical attire. Staff R stated, "yes, we follow AST (Association of Surgical Technicians) and AORN (Association of perioperative Registered Nurses), yes we have policies. Wearing street clothing into the OR is not an acceptable practice. I am familiar with the CRNA, she is always cold. I order the scrubs and jackets for the OR and I always make sure there are plenty since she is always cold. I even place jackets in the warmer for her so she doesn't wear her personal clothes under her scrubs ...Yesterday I did see that she had on her own clothing under her scrubs and at the time I was already scrubbed in and super busy, opening up and setting up, so I couldn't go get her the jacket. I did mention to her that there were jackets available and that she should put one on. She just said nope all set. I later mentioned this to (Staff L). I try to do everything I can to make sure we are doing things in a safe way, but she (the CRNA Staff T) does her own thing and I can not tell her what to do, I am a tech and she is the CRNA. This is something that happens with her and I try to solve it by making sure I order plenty of scrubs, by warming jackets for her, but it is uncomfortable for me to say much more than that."

On 12/03/2020 review of Policy Titled: "Surgical Attire", Effective date August 21,2013 last revision date 6/2018. Page one of three under "Procedure: 1. A. Restricted: Traffic shall be restricted to authorized personnel and patients. NO Street clothes shall be worn in the restricted area. Health care workers shall wear hospital laundered scrub attire. Arms are to be covered with appropriate scrub jacket ...additional garments shall be completely contained or covered with in the scrub attire." Page two of three "II. All individuals who enter the restricted area and semi-restricted area of the surgical suite should wear hospital laundered surgical attire intended for use only within the surgical suite."

Based on interview and record review, the facility failed to provide post anesthesia assessments in a timely sequence prior to discharge for three of three (1#, 2#, 3#) surgical patient records reviewed for anesthesia recovery by a qualified practitioner, resulting in the potential for poor outcomes due to unrecognized anesthesia related problems. Findings include:

On 12/03/2020 at 0955, during review of the patient medical records (one surgical and two endoscopy patients), it was noted that there was minimal time (three minutes) for surgical patient #1, to no time (zero minutes) for endoscopy patients #2 and #3, between the recorded stop time of anesthesia and the recorded evaluation by the Anesthesia Provider (Staff T) declaring the patient stable for discharge.

On 12/03/2020 during record review it was revealed that patient #1 was an 86-year-old male that underwent a right inguinal hernia repair requiring "intravenous, general anesthesia and monitoring". According to the "Anesthesia Record" CRNA (Certified Registered Nurse Anesthetist) Staff T, documented the stop time of anesthesia as "847" and the "Patient evaluation by Anesthesia Provider Prior to Discharge from Recovery Area" was recorded as "850" (a total of three minutes) on 12/2/2020. Further review of patient #1's medical record revealed, Staff S (post-surgical care Registered Nurse) documented discharge of patient #1 on 12/2/2020 to be 0955.

On 12/03/2020 during record review it was determined patient #2 was a 68-year-old female that underwent a colonoscopy (exam used to detect changes or abnormalities in the large intestine) requiring intravenous anesthesia. Staff T recorded the "Anesthesia stop" at "1053" and the "Patient Evaluation by Anesthesia Provider Prior to Discharge from Recovery Area" was recorded as 12/2/2020 at 1053 (zero minutes between anesthesia stop and time recorded stable for discharge).

On 12/03/2020 continued record review revealed patient #3 was a 56-year-old female that underwent an EGD (esophagogastroduodenoscopy a scope that allows an examination of the lining of the esophagus, stomach, and duodenum) requiring intravenous anesthesia. Staff T recorded the "Anesthesia stop" at "1115" and the "Patient Evaluation by Anesthesia Provider Prior to Discharge from Recovery Area" was recorded as 12/2/2020 at 1115 (zero minutes between anesthesia stop time and documented stable for discharge).

On 12/03/2020 at 1045 an interview was conducted with Staff L (the Director of Surgical Services). Staff L was queried regarding the timing or lack thereof, between anesthesia stop time and the Anesthesia Providers evaluation for stable to discharge, and if there was a policy regarding the above mentioned. Staff L reviewed the medical records giving special attention to the "Anesthesia Record" and stated, "no these times cannot be right, I don't know why she would document it like that, it doesn't make sense. How could she do the discharge evaluation at the same time she stopped anesthesia. I don't get it I will have to review these with her. Yes, there is a policy and I will provide it."

On 12/03/2020 at 1100 an interview was conducted with Staff B (Risk Management and Quality). Staff B was queried regarding medical record audits including previous medical record audits, and if there were any concerning findings related to documentation of the post anesthesia evaluation and discharge of surgical patients in a safe manner. Staff B stated, "yes we have completed record reviews in the past that show the CRNA's (Certified Registered Nurse Anesthetist) were completing the patient evaluation prior to discharge before the patient was even transitioned to PACU (post anesthesia care unit). The audits have shown the CRNA's were documenting the completion of the assessment stating the patient is stable for discharge, but the timing was often documented before the patient was transitioned to the PACU ...yes we have addressed this issue in the past. This was addressed on the last recertification."

On 12/03/2020 the facility policy titled "Anesthesia Care Postoperative" revised date 1/2016 was reviewed. Under "Procedure:" number one, the policy states "Outpatient surgery patients will be evaluated prior to discharge with follow up documentation ..." under number three the policy states, "The anesthesia provider and the operating physician shall evaluate the patient prior to discharge from the recovery area" Reference: "American Association of Nurse Anesthetists"