HospitalInspections.org

Based on observation, record review and interview the facility failed to ensure there is a comprehensive infection control system to prevent and control infections and cross contamination in the surgical environment using aseptic technique, in 3 of 5 staff observed (E, F and G).

Findings include:

Review of facility policy titled Hand Hygiene Guidelines dated 1/16/04 states "Hands are to be washed thoroughly with an alcohol-based rub...after direct contact with a patient's skin...after removing gloves"

Review of facility policy titled Aseptic Technique dated 3/23/99 states under #3 "Unscrubbed surgical team members will move from unsterile to unsterile area, maintaining awareness of the need for distance from the sterile field...#4 Sterile field will be constantly monitored and maintained...The back table (sterile field containing instruments) should be within view of the scrub person".

Review of facility policy titled Skin Preparation of Patients, reviewed 3/15, states under 5. "Basic skin preparation principles include:...Start at the incision site and move in a circular motion outward...Do not move back towards the incision site with the same applicator."

On 10/20/15 at between 9:01 AM and 10:06 AM the following was observed:

At 9:01 AM Nurse F assisted Patient #7 onto the operating room table and proceeded to don gloves without performing hand hygiene.

At 9:06 AM Certified Registered Nurse Anesthetist E donned sterile gloves in preparation for a spinal block without performing hand hygiene.

At 9:12 AM Nurse Anesthetist E returned to the head of the operating room table after administering a spinal block and walked next to the open instrument table with less than 1 foot distance between self and instruments.

At 9:23 AM Nurse F applied Povidone Iodine in preparation for the procedure that is a cystocopy (use of scope through urethra into the bladder. Nurse F did not being the prep at the perineum, the surgical site, rather at the pubis, above the perineum and proceeded to paint down to the inner thigh and perineum, wiping back and forth toward the perineum on each leg. Upon completion of the prep, Nurse F removed gloves and documented on the computer without performing hand hygiene.

At 9:26 AM Scrub Technician G turned his/her back to the open instruments on the surgical table while connecting and placing the scope and suction tubing for surgery, and when assisting Doctor L donning a surgical gown.

The above observations were discussed with Manager C on 10/20/15 at 10:30 AM who stated staff are expected to perform hand hygiene before sterile procedures, after touching the patient and removing gloves, staff are to prep surgical areas from incision site outwards per policy. Manager C added staff should not turn their backs to the sterile field, as well as un-gowned staff are to maintain distance from the sterile field.

Based on record review and interview the facility failed to ensure surgical medical records have a post anesthesia evaluation that includes at minimum, Cardiopulmonary status, Level of consciousness, follow-up care, observations and/or complications, 6 of 10 medical records reviewed (2, 4, 5, 6, 9 and 10).

Findings include:

Facility policy titled Documentation requirements for the Medical Record, dated 3/1/12 states under Anesthesia Documentation #4 Post Anesthesia "Documentation of : Assessment of vital signs, Assessment of patient's mental status."

Patient #2's medical record review revealed Patient #2 had a cystocopy (view the bladder with a scope) procedure on 7/16/15. The post anesthesia note written on 7/16/15 at 1:48 PM states "Suctioned, extubated with head lift and reg (regular) respirations. VSS (vital signs stable), patent airway after uneventful anesthetic..." This note does not constitute a complete post anesthesia note that includes Cardiopulmonary status, Level of consciousness, follow-up care and/or observations.

Patient #4's medical record review revealed Patient #4 had a removal of a bunion and correction to a hammertoe on 9/18/15. The post anesthesia note written on 9/18/15 at 9:47 AM states "Pt (patient) to phase 2 after uneventful MAC (monitored anesthesia care)/ankle block anesthetic. No c/o (complaint) pain or recall, no N&V (nausea and vomiting). VSS, awake, alert, reg respirations" This note does not constitute a complete post anesthesia note that includes Cardiopulmonary status.

Patient #5's medical record review revealed Patient #5 had an appendix removed on 8/20/15. The post anesthesia note written on 8/20/15 at 8:35 PM states "Pt awake, alert cooperative. Pt denies pain, denies PONV (post operative nausea vomiting), Tolerated (sic) proc (procedure) well..." This note does not constitute a complete post anesthesia note that includes Cardiopulmonary status, Level of consciousness, follow-up care and/or observations.

Patient #6's medical record review revealed Patient #6 had hip surgery on 7/13/15. The post anesthesia note written on 7/13/15 at 2:06 PM states "Pt in PACU (post anesthesia care unit) after fairly uneventful anesthetic. Needed phenylephrine (to raise blood pressures) for pressure support but otherwise stable. Responds, vss, adequate airway..." This note does not constitute a complete post anesthesia note that includes Cardiopulmonary status, Level of consciousness, follow-up care and/or observations.

Patient #9's medical record review revealed Patient #9 had knee surgery on 5/11/15. There is no post anesthesia note in the medical record.

Patient #10's medical record review revealed Patient #10 had wound and exploratory surgery on 4/21/15. The post anesthesia note written on 4/21/15 at 3:44 PM states "LMA (laryngeal mask airway) out with regular respirations, to pacu with adequate airway, hemodynamically stable, no c/o pain or recall of procedure..." This note does not constitute a complete post anesthesia note that includes Cardiopulmonary status, Level of consciousness, follow-up care and/or observations.

The above findings for Patient records #2, 4, 5 and 6, are confirmed in interview with Manager C and Certified Registered Nurse Anesthetists D and E on 10/19/15 at 4:30 PM who agreed the content of the post anesthesia notes should have more information. Patients #9 and 10's medical records were confirmed with Certified Registered Nurse Anesthetist E on 10/20/15 at 3:45 PM.