HospitalInspections.org

Based on findings from medical record (MR) review, document review and interview, (1) in 3 of 10 MRs time outs were not documented correctly. (2) In 1 of 10 MRs a physicians order was not consistent with the procedure consent form. (3) 2 of 10 MRs contained unapproved abbreviations on procedure consent forms. This lack of documentation does not accurately portray the care provided to the patients.

Findings related to (1):

-- Review of the facility's policy and procedure (P&P) titled "Universal Protocol Procedure/Site/Side Verification," last reviewed 6/2015, indicated a time out is done to conduct a final verification of the correct patient, site/side, procedure. It is performed in the location where the procedure will be done, after the patient is prepped and draped and immediately prior to starting the procedure. It must be documented by the RN on the checklist on the back of the consent. An additional confirmatory time out should be undertaken if a new surgeon/physician arrives and is assuming primary responsibility for the case, or if the patient/operative site is re-draped. The name of the patient and the procedure should be verified during the second time out.

-- Review of the facility's "Checklist Verification Form," undated, indicates a time out is to be completed after the patient is prepped and draped and immediately prior to incision/insertion to be initialed by the procedure RN. An additional confirmatory time out is done after re-draping, repositioning, new physician.

-- Per MR review, Patient #2's "Checklist Verification Form," dated 4/11/17, lacked nursing documentation that a second (additional confirmatory) time out was done during her procedure for a Ultrasound Guided Left Breast Biopsy and Right Breast FNA (fine needle aspiration).

-- Per MR review, Patient #1's "Checklist Verification Form," dated 5/15/17, lacked nursing documentation that a second (additional confirmatory) time out was done during her procedure for Bilaterally Ultrasound Guided Breast Biopsies.

-- Per MR review, Patient #3's "Checklist Verification Form," dated 6/15/17, lacked nursing documentation that a second (additional confirmatory) time out was done during her procedure for Bilateral Ultrasound Guided Breast Biopsies.

-- Per interview with Staff A (RN) on 7/7/17 at 11:30 am, a second time out was not performed during Patient #1's procedure. He/she acknowledged not completing the time out documentation for Patient #2 and Patient #3.

Findings related to (2):

-- Review of the facility's P&P titled "Universal Protocol Procedure/Site/Side Verification," last reviewed 6/2015, indicated verification of the correct patient, procedure, site/side must occur pre-procedure.

-- Per review of Patient #2's MR, a provider order dated 4/10/17 was for Fine Needle Aspiration any area, right side (right breast). However, the patient signed a procedure consent for Ultrasound Guided Left Breast Biopsy and R. (right) Breast FNA (fine needle aspiration). There was no provider order for the Left Breast Biopsy in the MR.

-- Per interview with Staff A on 7/10/17 at 9:35 am, he/she acknowledged the above finding.

Findings related to (3):

-- Review of the facility's P&P titled "Universal Protocol Procedure/Site/Side Verification," last reviewed 6/2015, indicated consent documentation must not contain abbreviations or acronyms.

-- Per review of Patient #2's procedure consent dated 4/11/17, the documented nature of the procedure was "Ultrasound Guided Left Breast Biopsy and R. Breast FNA".

-- Per MR review of Patient #'1's procedure consent dated 5/15/17, the documented nature of the procedure was "Bilaterally Ultrasound Guided Breast Biopsies, R+L".

-- Per interview with Staff A on 7/10/17 at 9:35 am, he/she acknowledged the above findings.