HospitalInspections.org

Based on staff interview and review of medical records and incident reports, it was determined the hospital failed to ensure surgical patients received care in a safe setting. This directly impacted 1 of 14 surgical patients (#19) whose records were reviewed and had the potential to impact all surgical patients. This resulted in the inability of the hospital to ensure further adverse events would not occur. Findings include:

Patient #19's medical record documented a 59 year old female who was admitted for acute appendicitis on 11/25/14. She had an appendectomy on 11/25/14 and was discharged on 11/27/14.

Patient #19's "Discharge Summary," dated 11/27/14 at 10:03 AM, stated "During the procedure, the patient slid off the Operating Room table." A physician progress note, dated 11/26/14 at 6:07 AM, stated Patient #19's operation was complicated by a fall from the Operating Room table. It stated she slid off when the table was placed in a head down position. It stated she did not appear to suffer any injuries from the fall. A physician progress note, dated 11/27/14 at 9:59 AM, stated Patient #19 was discharged home and would complete a 7 day course of antibiotics due to intraoperative contamination during the fall.

The Manager of General, Vascular, and Trauma Surgery was interviewed on 12/18/14 beginning at 3:45 PM. The Manager stated Patient #19 had a safety strap across her thighs and one arm was strapped to an arm board when she fell from the OR table. She stated hospital staff had not determined a cause for the incident.

An untitled incident report, not dated, stated Patient #19 had fallen from the OR table. The report stated she was secured to the table with a safety belt and arm straps. The report did not assign a cause for the event. The report stated the "Team" was looking into ways to "further secure" patients. No specific actions were documented to prevent further incidents of this type.

The Director of Perioperative Services was interviewed on 12/19/14 beginning at 11:35 AM. He confirmed the incident. He stated the OR table was tilted to the side and with the head down. He stated he did not know the cause of the incident. He stated he had not completed an investigation of the incident. He stated no formal actions had been taken in response to the event. He stated he did not know of the time frame for completion of the investigation or for further action.

The hospital failed to ensure a thorough investigation had been conducted following the incident. The hospital failed to take immediate steps to prevent similar incidents from occurring.