HospitalInspections.org

Based on medical record review and staff interview the facility failed to ensure medical records were complete for 3 of 3 surgical records reviewed (#24, #25, #26). The findings were:

1. Review of the preoperative record for patients #24,#25, and #26 showed the area for the preoperative call had several check boxes which were blank. Further review showed the preoperative checklist was blank. The area for current medications was blank, and the admission documentation was not completed.

2. Interview on 3/9/22 at 10:50 AM with the operating room (OR) manager confirmed the preoperative records had several blank areas. She stated she made the preoperative phone calls, but did not fill in the blanks because she was the only one who made the calls. She further stated she did not complete the admission information because the only thing the surgerical team looked at was the vital signs, and the surgical staff took the paperwork before she was done with it. She also stated the only procedures they were currently doing endoscopy procedures twice a month. She further stated the surgery team came from another hospital, and they told her they did not review the preoperative checklist for endoscopy patients.

Based on medical record review and staff interview, the facility failed to ensure the medical record contained the date and time as required for 3 of 3 (#24, #25, #26) surgical records reviewed. The findings were:

1. Medical record review for patient #24 and patient #26 showed the patients were admitted on 3/4/22 to the facility for outpatient procedure. The following concerns were identified:
a. The preoperative records did not have an area for the nurse to time the signature.
b. Page one of the Conscious Sedation Record did not have an area for the nurse to date and time the signature, under the discharge criteria. Further, page two of the Conscious Sedation Record did not have an area for the physician and nurse to time the signature.
c. Review of the Special Procedures Discharge Instructions showed it did not have an area for the physician and the nurse to date and time the signature.
d. Review of the Anesthesia Consent showed it did not have an area for the anesthesia provider to time the signature.
e. Review of the Anesthesia Record showed it did not have an area for the anesthesia provider to date and time the signature.
f. Review of the Informed Consent for surgical and diagnostic procedures showed it did not have an area for the physician to time the signature.
g. Review of the History and Physical showed the signature was not timed.
h. Review of the Endoscopy Orders showed the physician and nurse signatures were not timed.

2. Medical record review for patient #25 showed the patient was admitted on 3/4/22 for an outpatient procedure. The following concerns were identified:
a. The preoperative record did not have an area for the nurse to time the signature.
b. Page one of the Conscious Sedation Record did not have an area for the nurse to date and time the signature, under the discharge criteria. Further, page two of the Conscious Sedation Record did not have an area for the physician and nurse to time the signature.
c. Review of the Special Procedures Discharge Instructions showed it did not have an area for the physician and the nurse to date and time the signature.
d. Review of the Anesthesia Consent showed it did not have an area for the anesthesia provider to time the signature.
e. Review of Anesthesia Record showed it did not have an area for the anesthesia provider to date and time the signature.
f. Review of the Informed Consent for surgical and diagnostic procedures showed it did not have an area for the physician to time the signature.
g. Review of the History and Physical showed the signature was not timed.

3. Interview with the OR manager on 3/9/22 at 10:50 AM confirmed the documentation did not have the required dates and times for the signatures.

Based on staff interview and policy and procedure review, the facility failed to ensure COVID-19 vaccine requirement policies addressed all required areas. The findings were:

Review of the policy titled, "COVID 19 Vaccination," issued on 11/16/21, showed the policy failed to include additional precautions to protect patients, staff, and visitors related to employees exempt from COVID-19 vaccination. Review of COVID-19 testing information showed exempt employees were testing weekly. Interview with the director of nursing services and risk manager on 3/10/22 at 1:30 PM confirmed the policy failed to address additional precautions required for staff who were exempt from COVID-19 vaccination.

Based on observation, staff interview, policy review, and review of manufacturer's instruction for disinfection the facility failed to ensure procedures were followed to prevent infections in 1 of 1 random observation of equipment cleaning. The findings were:

1. Observation on 3/10/22 at 12:43 PM showed CNA #1 cleaned a vital signs machine after obtaining vital signs. The CNA used a PDI Sani-wipe cloth and wiped down the blood pressure cuff, the cords and the machine. The following concerns were identified:
a. The CNA wiped the equipment with the cloth for less than a minute.
b. Interview with the CNA on 3/10/22 at 12:45 PM confirmed her practice after obtaining vital signs was to take a sani-cloth wipe and wipe the blood pressure cuff, the cords, and the machine. She also stated after she wiped the equipment down she placed a green sticker on the machine to indicate it had been sanitized. She further stated she was not aware there was a wet contact time to achieve proper disinfection.
c. Interview with the inpatient manager on 3/10/22 at 12:49 PM revealed she was not aware the wipes had a 2 minute wet contact time.
d. Review of the Equipment Cleaning and Disinfection: Patient Care Equipment policy dated 1/10/22, showed "...General Considerations... C. All shared patient care equipment will be disinfected between uses for every patient. Surfaces must be in direct contact with the disinfectant to achieve disinfection...E. Follow equipment manufacturer's instruction for use for recommended disinfecting agent(s), cleaning and disinfection method, and storage..."
e. Review of the PDI Sani-Wipes instruction for disinfection showed "surfaces must have a 2 minute wet contact time to achieve disinfection."