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Based on observation, staff interviews, and review of maintenance records between April 6 and April 9, 2015, the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

Findings:

The facility was found to contain the following deficiencies.
K 11: facility did not provide a common separation wall with sealed wall penetrations
K 12: unprotected construction type for the building;
K 18: corridor doors that did not latch;
K 25: improperly constructed and maintained smoke barriers;
K 29: the facility did not enclose hazardous rooms with closers on all doors, rated doors, and doors held-open with the required safe guards.
K 35: the facility did not provide sufficient exit width
K 38: egress paths were not clear at all times, doors were lockable in the egress path, and not sufficient ceiling height;
K 46: the facility did not provide and maintain emergency illumination of the interior means of egress for at least 90 minutes after a power failure.
K 48: the facility did not maintain a written evacuation plan that contained all the elements with staff trained on life safety procedures K 52: the facility did not maintain the fire alarm system according to NFPA 70 and 72 requirements with compliant fire alarm testing.
K 56: deficiencies in the sprinkler system;
K 62: the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25
K 70: provided portable space heating devices that did comply with code requirements
K 76: improper distance between oxygen storage and combustibles and tanks not restrained;
K 77: the facility did not provide medical gas piping by not clearly identifying zone shut off valves
K 130: the facility did not provide suite travel distance under the required limits
K 145: the facility did not provide a proper Type I emergency electrical system.
K 147: deficiencies in the electrical systems.

Refer to the the full description at the cited K tags.

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.

Based on observation, staff interviews and review of maintenance records, the facility did not construct, install and maintain a proper ventilation and temperature control system in pharmaceutical, food preparation, and other appropriate areas. The facility did not have and a ventilation system. This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

Findings:

On April 6, 2015 at 11:42 am, observation revealed on the lower level floor in the Maintenance Office, that the ventilation to the space could not be confirmed to be compliant with accepted standards. There is no ventilation in the windowless office. It is required to have 15 CFM per person of outside air Guidelines for Design and Construction of Health Care Facilities The Facility Guidelines Institute 2010 (FGI Guidelines) and American Society of Heating, Refrigerating and Air Conditioning Engineers (ASHRAE) Standard 170.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Physical Plant Director).

Based on observation, staff interviews and review of maintenance records, the facility did not construct, install and maintain a proper ventilation and temperature control system in pharmaceutical, food preparation, and other appropriate areas. The facility did not have and a ventilation system that was installed and maintained in accordance with manufacturer recommendations. This deficiency occurred in 2 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

Findings:

On April 6, 2015 at 4:00 pm, observation revealed on the 1st floor in the patient bathrooms, that the ventilation to the space could not be confirmed to be compliant with acceptable standards. During the winter when the temperature is below 24 F, the make-up air for the patient bathrooms shuts down ('trips out') because of the cold temperature and will not stay on. This has been the case for at least the past two winters (13-14, and 14-15). The supply air then probably comes from either the corridor or through the window cracks in the patient rooms or a combination of the two Using window cracks or the corridor as your supply air is prohibited. It is required to have 10 exhaust air changes, and the air be neutral to the corridor per Guidelines for Design and Construction of Health Care Facilities The Facility Guidelines Institute 2010 (FGI Guidelines) and American Society of Heating, Refrigerating and Air Conditioning Engineers (ASHRAE) Standard 170.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Physical Plant Director).

Based on observation, staff interviews, and review of maintenance records between April 6 and April 9, 2015, the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

Findings:

The facility was found to contain the following deficiencies.
K 11: facility did not provide a common separation wall with sealed wall penetrations
K 12: unprotected construction type for the building;
K 18: corridor doors that did not latch;
K 25: improperly constructed and maintained smoke barriers;
K 29: the facility did not enclose hazardous rooms with closers on all doors, rated doors, and doors held-open with the required safe guards.
K 35: the facility did not provide sufficient exit width
K 38: egress paths were not clear at all times, doors were lockable in the egress path, and not sufficient ceiling height;
K 46: the facility did not provide and maintain emergency illumination of the interior means of egress for at least 90 minutes after a power failure.
K 48: the facility did not maintain a written evacuation plan that contained all the elements with staff trained on life safety procedures K 52: the facility did not maintain the fire alarm system according to NFPA 70 and 72 requirements with compliant fire alarm testing.
K 56: deficiencies in the sprinkler system;
K 62: the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25
K 70: provided portable space heating devices that did comply with code requirements
K 76: improper distance between oxygen storage and combustibles and tanks not restrained;
K 77: the facility did not provide medical gas piping by not clearly identifying zone shut off valves
K 130: the facility did not provide suite travel distance under the required limits
K 145: the facility did not provide a proper Type I emergency electrical system.
K 147: deficiencies in the electrical systems.

Refer to the the full description at the cited K tags.

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.

Based on record review and interview the facility failed to ensure policies and procedures for the provision of clinical services are reviewed by medical staff and are current, relevant and based on accepted standards of practice. This has the potential to affect all patients receiving care at this facility.

Findings:

During an interview on 4/8/2015 at 9:30 a.m., CEO F and DON A described the process for the development of patient care policies and procedures. Patient care policies are the responsibility of each department's respective manager. Policies are developed with input from staff and information obtained from the rural Wisconsin "co-op roundtable." CEO F stated policies are reviewed annually at the safety committee meeting.

Review of facility safety committee meeting minutes do not include evidence of policy and procedure review. Safety committee membership does not include representation from the medical staff.

DON A stated "the process [for policy and procedure development and review] needs work."

On 4/8/2015 at 4:15 p.m., CEO F presented a "Corrective Action Plan addressing Policies and Procedures" dated 4/8/2015. There was no evidence that review of the facility's policy and procedure process started prior to the survey.

Based on observation, record review and interview the facility failed to label opened multi-dose medications and monitor medications for expiration in 5 of 8 departments observed in which medications are stored (OR, OB, Med-Surg, Radiology, Rehab) and failed to ensure that sample drugs stored in the outpatient department were received, handled and dispensed appropriately in 1 of 8 hospital departments (outpatient).


34337

Findings:

Inpatient Departments:
During observation of the medication room on the Medical-Surgical inpatient unit on 4/7/2015 at 8:45 a.m. the room contained the following medications: 1 opened, undated Maalox bottle; 1 opened, undated Nitroglycerin bottle; 1 opened, undated Milk of Magnesia bottle.

Observations of the radiology department with Co-managers R and S
on 4/6/15 at 1:50 p.m. reveals a cabinet with VARIBAR (barium sulfate suspension in nectar and thin honey consistencies) that was opened and undated. During interview with Co-managers R and S, 4/6/15 at 1:50 p.m., R and S stated that they did not have pharmacy policies to define how long this barium suspension could remain in patient use after opening.

During observation of the storage ante room in OB delivery room #1 on 4/7/2015 at 10:30 a.m.: 1 opened bottle of Hydrogen Peroxide dated 4/5/2013 with a manufacturer expiration date of 3/2015; 1 opened, undated Alcohol bottle bottle with a manufacturer expiration date of 4/2015.

Observation of the OB department crash (emergency) cart, with Respiratory Department Manager T at 2:14 p.m. on 4/6/15, reveals the following expired medications: HESPAN- 6% hetastarch in 0.9% sodium chloride solution, 500 ml. (milliliter) intravenous solution bag, expired 3/15; and a 100 ml. intravenous bag of 5%. Dextrose solution , expired 3/15. These expired crash cart medications were verified by T at 2:30 p.m. on 4/6/15.

During interview with OB RN U on 4/7/15 at 2:20 p.m., U states that the documentation of the monthly evaluation of the OB crash cart cannot be found. U stated there was no documented evidence to show that this cart had been checked to ensure that all emergency medications were present and not expired.

During observation of the OR storage room on 4/7/2015 at 2:40 p.m.: 2 open, undated tubes of lubricant.

Observation of the rehabilitation therapy department with Physical Therapist V at 1:07 p.m. on 4/6/15, reveals the following expired biologicals:17 syringes of "Dexamethasone 3 mg. (0.75 ml.) in bacteriostatic water .75 ml. for a total volume equaling 1.5 ml., expires: 3/27/2015...". These expired biologicals were verified by V and Pharmacist W at 1:30 p.m. on 4/6/15.

During an interview on 4/7/2015 at 8:45 a.m., Pharmacy Tech Q stated medication bottles should be "labeled when opened" and are "good for one year or until the expiration date." Pharmacy Tech Q stated the pharmacy department is responsible for monitoring medications for expiration throughout the hospital and staff who opens a medication is responsible to label with the date opened.

Outpatient Department:
During interview with OPD RN Q on 4/7/15 at 10:45 a.m., Q stated that drugs contained in brown paper bags a locked drawer were patient samples brought into the outpatient clinic by physicians. Q stated that when these drugs are brought in, the nurses count them and place them in a paper bag with labeling of their drug name and dosage. Q states that upon physician request that these samples are given to clinic patients by the nursing staff. Q states these sample drugs are given to patients without a written medical orders for dispensation, and that the department keeps a log of drugs dispensed.

Observations of these medication bag labels, at date and time of interview, reveals: Lyrica (treats pain and seizures) 50 mg.; Lyrica 75 mg.; Flector Patch ANTIMF 1.3% (topical pain patch) and Invokana (used for blood sugar control in Type 2 Diabetes) 30 mg.

Record review of a "Drug Sample Log-MHLC Hospital" on 4/7/15 at 11:15 a.m. reveals the log records the date, manufacturer's name, drug name and patient's medical record number, dose, lot number, expiration date, quantity given, size given, and staff initials. Medications samples given from 9/8/13 through 10/9/14 are:
Celebrex (anti inflammatory),
Flector patch (anti inflammatory),
Lovaza ( lowers triglyerceride levels),
Levitra (for treatment of erectile dysfunction), and
Avodart (for treatment of enlarged prostate gland).

Continued interview with RN Q reveals that the hospital does not have a policy for dispensing drug or biologic samples to patients on 4/7/15 at 11:15 a.m.

Interview with hospital Pharmacist K on 4/7/15 at 2:45 p.m. reveals that there is no hospital policy for sample drug dispensing. K stated that they are not suppose to be giving out sample drugs in the hospital.

Based on observation and interview the facility failed to ensure proper ventilation of clean and soiled utility rooms in 2 of 7 utility rooms observed (Rooms 111 and 112).

Findings:

On 4/6/2015 at 3:10 pm, observation and interview revealed on the lower floor, room 112, that the soiled utility room had the air flow going from the room into the corridor, from dirty to clean. The ventilation to the space could not be confirmed to be compliant with acceptable standards. There is a supply grill in the dirty supply room creating a positive pressure. The room should be negative pressure, per FGI Guidelines and ASHRAE 170. This observed situation was not compliant with 42 CFR 485.635 (a)(3)(vi).

On 4/6/2015 at 3:15 pm, observation and interview revealed on the lower floor, room 111, that the clean utility room had the air flow going from the corridor into the room, from dirty to clean. The ventilation to the space could not be confirmed to be compliant with acceptable standards. There is a return/exhaust grill in the clean supply room creating a negative pressure. The room should be positive pressure, per FGI Guidelines and ASHRAE 170. This observed situation was not compliant with 42 CFR 485.635 (a)(3)(vi).

Based on interview, record review and observations, the facility failed to ensure that recognized dietary hygiene and food safety practices were followed in 1 of 4 dietary areas (food preparation).

Findings:

During interview with Dietary Manager J on 4/8/15 at 11:30 a.m., J stated that the dietary department follows the ServSafe and Wisconsin Food Code standards of practices.

The 4/8/15 record review of National Restaurant Association ServSafe, 6th Edition Coursebook documents under under:
Section 4-9 that "wear a clean hat or other hair restraint when in the preparation area...A hair restraint will keep hair away from food and keep the food handler from touching it...".
In Section 5-9 under "Time-Temperature abuse happens any time food remains between 41 degrees Fahrenheit and 135 degrees Fahrenheit. This range is called the temperature danger zone...A thermometer is the most important tool used to prevent time temperature abuse. You should regularly record food temperatures and the times they are taken".

At 11:45 a.m. on 4/8/15, observations of the patient preparation tray line reveals that 2 of 3 staff (X and Y) preparing patient trays have ineffective hair restraint. The fringes and wisps of their hair, at their hairlines, were protruding from under the hairnets worn. When Manager J was told at 11:50 a.m., these staff immediately corrected their hairnet placement.

At 12:00 p.m. on 4/8/15, Manager J was asked to provide temperatures testing of hot foods cooked for the patient's lunch menu. J stated that the kitchen staff do not test temperature of foods cooked for patients. J stated that the kitchen staff does not temperature test foods held for serving after cooking. J stated that there is no permanent documentation of any temperatures taken during cooking or serving.

Based on observation, interview and record review, the facility failed to ensure that nursing staff administering medications observed the patient ingesting medications given, in 1 of 3 staff observed to administer medications (Z).

Findings:

The 4/8/15 record review of hospital policy "Medication Administration Verifications, issued 2/15" documents that policy purpose is to ensure that all medications administered to patients are done safely, completely, and medication errors are avoided...". Further review of the policy reveals that it does not document that nursing staff administering medications have to ensure that all medications given to the patient are ingested by observation.

On 4/7/15 at 8:50 a.m. RN Z was observed to administer medications to Patient #2. Z sat the medicine cup of pills on the overbed table in front of the patient, and turned around with back to patient to put medication bin back into locked cabinet. Z then went into the bathroom to wash hands. Z did not observe Patient #2 swallow all medications provided.

During interview with DON A at the daily exit conference on 4/7/15 at 5 p.m., A stated that the nurses should be watching patients take their medications.

Based on observation, record review and interview the facility failed to develop and maintain surgical policies and procedures based on current standards of practice and failed to follow infection control per policy in 1 of 1 surgical department; failed to ensure terminal clean in 1 of 1 OR (OR #1); failed to practice immediate use sterilization of equipment per standards of practice; failed to prepare skin pre-operatively per current standards of practice in 1 of 1 inpatient surgical observation (Pt. #11); failed to maintain Malignant Hyperthermia kit per policy; and failed to document time out procedures in 5 of 5 surgical inpatients (#11, 12, 13, 14, 15) and 3 of 3 surgical outpatients (#7, 8, 9). This has the potential to affect all patients receiving surgical services at this facility.

Findings:

Surgical Services
During an interview on 4/6/2015 at 2:00 p.m., OR Mgr B stated the surgery department does not follow any particular standard of practice. Staff attends the rural Wisconsin "co-op" roundtables to gather information for policy and procedure development. Mgr B stated a lot of the surgical department's policies and procedures were "long standing" and "we change the policy as we change how we do things." Mgr B stated that all the policies are reviewed on a schedule and had been most recently reviewed in 2013, but was unable to confirm the source from which surgical practice policies derived.

Infection Control
Facility policy "Attire in OR" dated 4/24/2014 states in part: "Street clothing or personal scrub clothing are not allowed in OR." The facility does not address personal items in the OR.

Facility policy "Beverages & Food in Departments" dated 11/7/2011 states "OR: No food or snacks are allowed at the desks."

During Pt. #11's surgery, on 4/6/2015 at 12:25 p.m., a vendor representative was observed using a personal cell phone in the OR.

On 4/7/2015 at 2:00 p.m., the desk within the secured area of the surgical department was found to contain staff member's personal items including food and snacks, a staff member's personal purse and a cellular telephone. OR Tech O stated at the time of the observation "we can have water or snacks if covered" and that personal cell phones were allowed at the nurses station in the secured area of the department.

OR Mgr B stated on 4/8/2015 at 12:30 p.m. that purses, food and other personal items are not allowed in the secured area of the surgery department and "purses are supposed to be in lockers."

Cleaning of the Surgical Suite
Facility policy "Cleaning Surgical Suite" reviewed 3/2009 states in part: "Wall and Ceiling Washing: 1. Frequency-as needed ...3. All light fixtures will be cleaned as needed ...2.a. The exhaust ceiling vent will be vacuumed as needed ...3.b. The tops of all doors, cabinets and solid top shelving will be cleaned...weekly."

During an interview on 4/6/2015 at 2:00 p.m., OR Mgr B stated the walls and ceilings in the OR "used to be cleaned every month" but "not anymore." OR Mgr B stated that housekeeping isn't scheduled to come and do any type of cleaning in the OR suite, but OR staff completes a terminal clean of the OR daily which includes equipment and floor. Per OR Mgr B, maintenance comes 3 times per year to clean vents. Mgr B was unable to provide documentation of cleaning for the walls, ceilings or vents in the OR suite.

During an interview on 4/7/2015 at 2:00 p.m., EVS Mgr D stated "no" EVS staff does not come into to do any type of cleaning in the OR.

Immediate Use Sterilization
Facility policy "Wrapping, Sterilization, Distribution and Quality Control of Sterile Instruments" dated 3/18/2013 does not include guidance for the appropriate use of immediate use sterilization versus terminal sterilization.

The CDC "Guideline for Prevention of Surgical Site Infection, 1999" states in part: "3. (5) Flash sterilization of surgical instruments...flash sterilization is not intended to be used for either reasons of convenience or as an alternative to purchasing additional instrument sets or to save time."

Review of the facility's OR log contains documentation of 7 dates between 1/1/2015 and 4/6/2015 in which 2 orthopaedic surgical cases were performed: 1/5/2015, 1/26/2015, 1/28/2015, 2/2/2015, 3/16/2015, 3/23/2015 and 4/6/2015. The flash sterilization log includes documentation of flash sterilization for orthopaedic surgical instruments on the same dates: 1/5/2015, 1/26/2015, 1/28/2015, 2/2/2015, 3/16/2015, 3/23/2015 and 4/6/2015.

During an interview on 4/6/2015 at 11:15 a.m., OR Tech P stated flash/immediate use sterilization is used "daily". Per OR RN M, there is "only one set of major instrumentation" used for hip and knee surgeries. On days when there is more than one case scheduled, those instruments are "flash sterilized between cases."

Surgical Prep
Facility policy "Surgical Prep" dated 11/17/2006 states: "I. Surgical Prep - Conventional Method: A. Procedure for Scrub: 1. Open sterile prep tray containing two steril prep basins and Betadine soap and warm sterile water. a. One with 18 folded fluffs to which you add Betadine soap and warm sterile water...5. Scrub area for 3-5 minutes. 6. Remove excessive soap and water with sterile towel...II. Duraprep or Chloraprep: ...E. Allow to air dry."

Review of manufacturer's recommendations for the facility's betadine scrub prep on 4/7/2014 at 8:20 a.m. do not include diluting the product with sterile water prior to use. The manufacturer also recommends allowing the product to dry for 3 minutes after application.

On 4/6/2015 at 11:30 a.m. OR RN H prepared Pt. #11's pre-operative skin scrub by pouring betadine solution into a basin. RN H then opened a bottle of sterile water and added the sterile water into the basin with the betadine. At 12:15 p.m., MD used the prepared solution to scrub Pt. #11's surgical site for approximately 3 minutes. At 12:17 p.m., before the betadine scrub had dried, MD prepped Pt. #11's surgical site with chloraprep solution.

Pt. #11 was admitted to the facility on 4/6/2015 for a right total knee replacement. Pt. #11's MR, reviewed on 4/7/2015 at 1:15 p.m., includes an "OR Nurses Operative Report" documenting a scrub solution of Betadine and a prep solution of Chloroprep. There is no documentation of the dry time for either solution.

Pt. #12 was admitted to the facility on 4/6/2015 for a left total knee replacement. Pt. #12's MR, reviewed on 4/7/2015 at 1:50 p.m., includes an "OR Nurses Operative Report" documenting a scrub solution of Betadine and a prep solution of Chloroprep. There is no documentation of the dry time for either solution.

Pt. #13 was admitted to the facility on 3/16/2015 through 3/19/2015 for a left total knee replacement. Pt. #13's MR, reviewed on 4/7/2015 at 2:05 p.m., includes an "OR Nurses Operative Report" documenting a scrub solution of Betadine and a prep solution of Chloroprep. There is no documentation of dry time for either solution.

Pt. #14 was admitted to the facility on 3/9/2015 through 3/12/2015 for a right total hip replacement. Pt. #14's MR, reviewed on 4/8/2015 at 1:00 p.m., includes an "OR Nurses Operative Report" documenting a scrub solution of Betadine and a prep solution of Chloroprep. There is no documentation of the dry time for either solution.

Pt. #15 was admitted to the facility on 2/9/2015 through 2/12/2015 for a right total knee replacement. Pt. #15's MR, reviewed on 4/8/2015 at 1:25 p.m., includes an "OR Nurses Operative Report" documenting a scrub solution of Betadine and a prep solution of Chloroprep. There is no documentation of the dry time for either solution.

Malignant Hyperthermia
Facility policy "Malignant Hyperthermia Diagnosis and Management of" dated 3/2005 states in part: "C. 3. ...dantrolene sodium should be administered...until the symptoms subside or until a total of 450 mg has been given..."

The Malignant Hyperthermia Association of the United States recommends a minimum of 36 vials of 20 mg dantrolene sodium to be kept on hand in the event of a Malignant Hyperthermia emergency.

The post-anesthesia recovery room was observed on 4/7/2015 at 2:20 p.m. The Malignant Hyperthermia kit stored in the room was found to contain 18 vials of 20 mg dantrolene sodium, a total dose of 360 mg, less than standard recommendations and less than the amount stated in the facility's policy.

During an interview on 4/6/2015 at 1:35 p.m., CRNA N stated the dantrolene sodium vials were purchased "about a year ago" and the facility did not keep dantrolene sodium on hand prior to the most recent purchase. CRNA N was unable to state who was responsible for ongoing training or quality assurance of the dantrolene sodium.

Time Out Procedures
Facility policy "Time Out Policy--Protocol for Prevention of Wrong Person, Wrong Procedure or Wrong Site" dated 12/1/2006 states in part: "Verification of correct patient, procedure, and site will be documented on the appropriate pre-operative and intra-operative charting."

Pt. #11's OR Nurses Operative report from 4/6/2015, reviewed on 4/7/2015 at 1:15 p.m., documents a surgical incision time of 12:25 p.m. and a surgery end time of 1:20 p.m. Time out is documented "Time out completed immediately prior to procedure" but the time is documented as 1:35 p.m., after the surgery end time.

Pt. #12's OR Nurses Operative report from 4/6/2015, reviewed on 4/7/2015 at 1:50 p.m., documents a surgical incision time of 8:15 a.m. and a surgery end time of 9:20 a.m. Time out is documented "Time out completed immediately prior to procedure" but the time is documented as 9:35 a.m., after the surgery end time.

Pt. #13's OR Nurses Operative report from 3/16/2015, reviewed on 4/7/2015 at 2:05 p.m., documents a surgical incision time of 8:10 a.m. and a surgery end time of 9:25 a.m. Time out is documented "Time out completed immediately prior to procedure" but the time is documented as 9:40 a.m., after the surgery end time.

Pt. #14's OR Nurses Operative report from 3/9/2015, reviewed on 4/8/2015 at 1:00 p.m., documents a surgical incision time of 8:15 a.m. and a surgery end time of 9:30 a.m. Time out is documented "Time out completed immediately prior to procedure" but the time is documented as 9:40 a.m., after the surgery end time.

Pt. #15's OR Nurses Operative report from 2/9/2015, reviewed on 4/8/2015 at 1:25 p.m., documents a surgical incision time of 8:10 a.m. and a surgery end time of 9:20 a.m. Time out is documented "Time out completed immediately prior to procedure" but the time is documented as 9:30 a.m., after the surgery end time.

The 4/8/15 record review of Patient #7 ' s 11/25/14 surgical procedure (Transforaminal Lumbar Injection) for pain relief reveals that neither CRNA AA, nor the surgical nursing staff documented the time out procedure as required by hospital policy. Review of CRNA AA ' s documentation reflects that procedure was started " following a time out " .
The 4/8/15 record review of Patient #8 ' s 2/4/15 surgical procedure (Right Sacroiliac joint injection) for pain relief reveals that neither CRNA BB, nor the surgical nursing staff documented the time out procedure as required by hospital policy. Review of CRNA BB ' s documentation reflects that procedure was started " following a time out " .
The 4/8/15 record review of Patient #9 ' s 3/18/15 surgical procedure (Right Rib intercostal nerve block at Thoracic 8, 9 and 10) for pain relief reveals that neither CRNA BB, nor surgical nursing staff documented the time out procedure as required by hospital policy. Review of CRNAs BB ' s documentation does not reflect that a " time out " procedure was completed.
During interview with RN M on 4/8/15 at 5 p.m., M stated that hospital procedure was not followed.
OR Mgr B stated on 3/8/2015 at 12:30 p.m. that inpatient intraoperative documentation is done "retroactively."

Based on interview, the facility failed to ensure that all patient care services are evaluated, in 1 of 1 contracted EVS services provided (hospital and patient linens).

Findings:

During interview with Housekeeping Manager D on 4/7/15 at 8 a.m., D states that the hospital linens and patient linens are done per a hospital contract with Superior Health Linens. D states that there is no evaluation of the off-site linen service to verify that patient linens are handled and stored using sanitary techniques. D states that the hospital has not approved chemical detergents used by the linen service to ensure patient safety. D states that there is no submission of QA (quality assurance) data from this contracted service to ensure quality services are provided to the hospital.