HospitalInspections.org

Based on review of facility documents and staff interviews (EMP), it was determined that Mount Nittany Medical Center failed to provide care in a safe setting in one of one records reviewed.

Findings include:

Review of "Mount Nittany Health Reportable Events, Policy 1009, Effective Date: 7/1/1985, Last Review Date: 7/20/2-12 ... Title: Reportable Events. Policy: There are four (4) types of events referenced in this policy: Reportable Events. Sentinel Events, Serious Events, and Infrastructure Failure Events. Policy: It is the policy of Mount Nittany Medical Center that any Medical Center employee or physician who discovers, witnesses, or becomes aware of a reportable event will complete and EVENT REPORT. The EVENT REPORT is a prompt, accurate and confidential account of the details of an event, and is intended to notify the Risk Management Office that an event has occurred. Also, once identified a potential sentinel event, serious event, or infrastructure failure will be reviewed by the Chief Executive Officer, Risk Manager, and Chief of Staff or Environment of Care Chairman, as appropriate. Purpose: This policy sets forth the requirements of Mount Nittany Medical Center to identify, report, track, and initiates appropriate action with respect to occurrences that are defined as Reportable events, incidents, serious events and infrastructure failures. ... e. The completion of an Event Report Form does not replace the normal responsibility for communication among physicians, nurses, and support services, nor does the Event Report Form take the place of proper clinical documentation in the medical record. However, charting of an occurrence in the Nurses' Notes must be limited to medically relevant information. f. Except as noted below, the completed Event Report must be given to the Shift Supervisor or Department Director prior to the end of the shift, even if the effect of the event is not known. g. The Supervisor or Department Director will evaluate the event, verify the accuracy and completeness of the Event Report and take appropriate action. The Supervisor or Department Director will verify that a physician has been notified or determine that notification is not clinically relevant, and sign the Event Report. h. Those physicians who desire to indicate their review of the Event Report may do so by signing in there space provided. ... m. Physician-related Event Reports may be forwarded directly to the Risk Management Office without a Supervisor's or Department Director's signature. n. All Event Reports shall be forwarded to Risk Management within 24 hours of the event. If the Manager or Supervisor is not available within the first 24 hours of the incident, a message (written or voice mail) will be sent to the Manager that the Incident Report has been completed. The Manager will follow-up with Risk Management as appropriate. o. Risk Management and the Patient Safety Committee Event Report Sub-committee will screen all and take appropriate action as deemed necessary, including, but not limited to notifying the Medical Center's insurance carrier of the event and appointing a Root Cause Analysis Team. p. Event Report information may initiate the Medical Staff Quality Improvement Peer Review Process. ... ."

A review of "Ecolab Material Safety Data Sheet. Aseptic-Solid Enzyme ... 2. Hazards ... Warning Causes Eye and Skin Irritation. May Cause Allergic Respiratory Reaction. Avoid contact with eyes, skin and clothing. Avoid breathing dust. Use only with adequate ventilation. Wash thoroughly after handling. Potential acute health effects... Skin: Irritating to skin. ... Ingestion: No known significant effects or critical hazards. ... ."

1) A review of MR1, "Admit Date/Time 05/14/12 1042 ... Reason for visit: Colonoscopy/Screening ... Scope Used: 419 Steris Cycle 1851. Date Processed: 5/14/12. Processor 3. Procedure Start Time: 1126. Procedure End Time 1155 ... Notes. 1126-rectal exam- scope inserted - 1145 prep is poor- changing scopes to try to get better suction - long colon- tol. well - 1154 cecum viewed from above valve - prep very poor 1155 exam ended - Tol. well ... ."

2) An interview was conducted with EMP6, on October 16, 2012, at 10:46 AM, "I witnessed this with Dr. ... . Dr. suctioned the scope in the enzymatic solution then reinserted it into the patient, it happened very quickly. Normally, there are two basins on the cart, the enzymatic solution and a basin of saline. I moved the saline to my side, because the scope was clogging, and I was using it quite a bit. When I saw this happen, I did not say anything to the doctor. I am quite sure the CRNA saw it. I came out of the room and talked with EMP4. EMP4 told me to fill out the Incident Report. ... I did not remember that we got a second scope for the patient until today. ... The issue I have with this, is that the patient had a poor prep and this was a 10 year colonoscopy screening. It is my opinion that the procedure was of poor quality." (se)

3) An interview was conducted with EMP3 on October 16, 2012 at 10:50 AM. "This Incident should have been documented in the medical record. There is no documentation in the record that this event occurred. ... What bothers me is that this Event could have been avoided if the nurse would have stopped the physician when they saw the doctor using the enzymatic solution. This is a culture issue that needs to change."