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Based on observation, interview and record review, the facility failed to follow their policy and procedure for providing informed consent by anesthesia to patient before having patients sign the consent for anesthesia. The facility was having patients sign the anesthesia consent at the time of pre-registration before seeing and being evaluated by anesthesia.

This deficient practice had the likelihood to cause harm in all patients.

Findings include:


Patient #29 was observed on 09/28/2015 being pre-admitted for a surgical procedure by staff #36. Staff #36 placed the Anesthesia Consent in front of the patient and stated, "This is your consent for anesthesia". Patient #29 signed the consent without question.

A review of the document titled INFORMED CONSENT: Anesthesia revealed
PROCEDURE:

Concept of Informed Consent:
Must consist of:
The risks, drawbacks, complications and expected benefits or effects of anesthesia
Alternate choices of and to anesthesia
The nature of the treatment
The risks, drawbacks, complications and expected benefits or effects of such treatment
Potential problems related to recuperation
Any alternatives to the procedure and their risks and benefits
The likelihood of success
Possible result of non-treatment
That the patient understands the information
That the patient has been verbally informed about the anesthesia or procedure
That the patient has had the opportunity to ask questions
Is needed for procedures designated by Texas Medical Disclosure list and is needed for any procedure where anesthesia is planned.

Obtaining Informed Consent:
It is the attending physician's and/or surgeon's responsibility to discuss the need for a procedure requiring anesthesia with the patient and/or surrogate decision maker.
The anesthesia provider is responsible for providing the discussion with the patient regarding anesthesia.
The anesthesia informed consent form is prepared by the anesthesia provider or nurse and is supplemented through written additions that give further information relevant to the patient's condition ........

An interview on 9/28/2015 with staff #35 and staff #36 revealed it was the practice of the facility to have all Anesthesia Consent sign by the patient prior to Anesthesia seeing the patient. Staff confirmed they were not following the facility's policy for informed consent.

Based on observation, document review and interview the facility failed to:

A. ensure there was evidence discharge teaching was being done. It was the practice of the facility to have patients' sign their discharge instructions in the pre-operative area when the patient was being made ready for surgery.
While observing patient #29 on 9/28/2015 being made ready for surgery staff #36 placed a paper in front of the patient and said this is your discharge paper work and we're going to get you to sign in now. The patient signed the paper. No family was with the patient.
An interview on with staff #36 revealed it was the practice of the facility to have the discharge teaching paper work signed before the patient went to surgery.
An interview 9/29/2015 with staff #15 and staff #37 in the endoscopy area both staff confirmed the patient signed their discharge teaching papers before the procedure.
B. ensure a sanitary environment for the sterile processing of surgical instruments.
A tour of the facility was conducted on 09/28/2015 with the infraction control practitioner, staff #4 and the director of surgery, staff #15. The tour revealed the sterile processing are dirty and in need of cleaning and maintenance. The floors were stained, dull and had no finish. A cloth was taken and wiped on the floor in the corner of the room. The cloth was covered with lint and dirt. Staff #4 and #15 were in agreement the floors were not clean. The dirt that was wiped up on the cloth was from the lack of cleaning and not from days use.
A floor to ceiling cabinet was inspected and found to be overflowing with equipment and supplies. Each of the packaged supplies that were removed was found to be expired with dates from 2008. There were large bundles of red rubber catheters out of their sterile packages and then taped together. These expired supplies were available to be used for patient care. Staffs #2 and #4 were asked to join the tour and verify the findings. An agreement with the surveyor, staff #2, #3, #4 and #15 that the expired supplies found in the floor to ceiling cabinet were too numerous to count. The sterile processing tech was asked why these expired items were being kept and she stated I can just re-sterilize them.
On inspection of a closet in the Sterile Processing Area two small cardboard boxes were inspected. The two boxes were sticky boxes left by the exterminator. (The sticky boxes are used by the exterminator on the next visit to the facility you inspect what type of insect the facility has and treat according to the findings.) The sticky boxes had the appearance of being there for a long time. Cob weds and dust covered the boxes. One of the box had the entire bottom (sticky area) covered in dead bugs. The second box was so full you could not see through it because of dead bugs.
The only sink in the Sterile Processing area faucets were corroded and pitted and not able to be cleaned or disinfected. The drain in the sink was found to be in the same condition (corroded and pitted). In the cabinet under the sink the drain pipes were corroded and pitted with water leaking from them. The cabinet's bottom had a foam rubber mat covering it. When the mat was peeled back it revealed the bottom of the cabinet was covered in rust. High caked on dust was found throughout the sterile processing area. As the surveyor whipped a finger across the top of the autoclave it returned a large volume of dust that was caked to the finger. Clumps of dirt fell straight to the floor.


C. ensure staff followed established policies and participated in unsanitary practices in the surgical department by failing to:

1. provide evidence the required quality control testing was being done on the Cidex OPA Solution Test Strips. Without the quality control testing of the strips the facility could not ensure the endoscopy scope, vaginal probes or any other equipment processes in the Cidex were properly disinfected.
2. provide evidence the preventive maintenance was being done on the autoclaves(steam sterilizer used to sterilize surgical instrument) located in the sterile processing department and the two autoclaves located in the Surgical Department.
3. provide appropriate sterile processing of surgical instruments. The facility was using flash sterilization routinely to process surgical instruments for the convenience of a quick turnaround for surgical sets. Flash sterilization shall be avoided whenever possible.
4. provide quality control for flash sterilization. Flash Sterilization: Quality Control Program required the biologicals to be sent to the sterile processing area. The staff responsible for sterile processing did not know how to incubate the biologicals. (Biologicals are filled with bacteria spores. They are a test used to ensure a steam sterilizer reaches the required temperature to kill the bacteria.)
5. provide required air exchange checks for the Decontamination Area. The area was not being checked to ensure there was a negative air flow. Air exchange and air flow ensures contaminated air is not leaking into the surgical area.
6. provided biological testing according to manufactures recommendations.
The staff responsible for sterile processing did not know the appropriate time to incubate the biologicals. (Biologicals are filled with bacteria spores. They are a test used to ensure a steam sterilizer reaches the required temperature to kill the bacteria.)

An observation on 9/29/2015 was made of the endoscopy scope processing area. The staff was observed as they walked through the process of handling and cleaning a scope. Staff skipped the procedure for running the quality control testing of the Cidex Test Strips,
An interview on 09/29/2015 with staff #15, #37 and #38 in the scope processing room when asked how the quality controls were run on the Cidex OPA Solution Test Strips,staff #37 and #38 stated they used drops. Staff #37 and #38 stated they had moved the drops and they could not be located at this time. Staff #15 was asked, they use drops, the response yes, I guess.
An interview on 09/30/2015 with staff #1, #2, #3, #15 and #19 were asked to provide evidence the Cidex OPA Solution Test Strips were having the required quality control test prior to being used. No evidence was provided.
During the review of the Use of Cidex OPA Solution Test Strips policy it was determined the facility was not following their policy. The personnel in the Respiratory Department, Surgical Department and the Endoscopy Department were not following the policy and running the required controls on the cidex solution test strips.
A review of the facility's policy titled "Use of Cidex OPA Solution Test Strips" revealed
"III. PROCEDURE
Nursing Actins: Rationale:
1. Don personal protective equipment Gloves. Fluid-Repellent gown. Eye protection
2. Check the date on the test strip bottle
3. Record the date that the bottle of Cidex OPA Test Strips was opened on the Container label.
4. Prepare the control solutions to perform the quality Control (QC) test: Verify the expiration date on the Cidex OPA Solution

Full strength Cidex OPA Solution may be
Used as the positive control

Prepare a negative control by diluting 1
Part full strength Cidex
Label each solution
5. Following the Instruction for Use, Dip 3 Test strips into each of the prepared solutions One at a time for 1 full second
6. Check for the following test results. Positive control solution strips should appear completely purple.
Negative control solution strips should either remain blue or exhibit an incomplete change to purple.
7. If the results of the QC test indicate that the test strip is not functioning properly, discard the remaining strips.
8. Cidex OPA Solution will be tested for the MEC prior to each use.
9. Dip entire pad at the end of the test strip into the container. Hold in the test strip solution for 1 full second before removing.
10. Remove excess solution from the indicating pad by standing the strip upright on a paper towel.
11. Read the results of the color reaction on the indicating pad exactly 90 seconds after the test strip was removed from the solution.
12. The indicating pad will be completely