The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

COMMUNITY HOSPITAL OF SAN BERNARDINO 1805 MEDICAL CENTER DRIVE SAN BERNARDINO, CA 92411 Jan. 8, 2018
VIOLATION: MEDICAL STAFF Tag No: A0338
The facility failed to ensure the condition of participation CFR 482.22 Medical Staff was met by failing to ensure:

1. Patient 1 did not receive proper diagnosis and treatment. This failure resulted in the delay in surgery for Patient 1. (Refer to A-0358)

2. The facility failed to provide evidence of tuberculin skin test (a test to determine the presence of infection with (TB) tuberculosis (a bacterial infection of the lungs) annual screening for 1 of eleven sampled medical staff. This failure had the potential to spread undetected TB infection to a universe of 167 patients in the facility. (Refer to A-0347)


The cumulative effect of these systemic practices resulted in the failure of the facility to deliver care in compliance with the Condition of Participation: Medical Staff.
VIOLATION: SURGICAL SERVICES Tag No: A0940
The facility failed to ensure the Condition of Participation: CFR 482.51 Surgical Services was met by failing to ensure:

1. Patient 1 did not receive proper diagnosis and treatment. This failure resulted in the delay in surgery for Patient 1. (Refer to A-0951)

2. One of two autoclave machines (used to sterilize surgical instruments) had a large amount of dark brown staining within the chamber. This failure had the potential for the spread of infection in a universe of 167 patients. (Refer to A-0951)

3. The temperature in the sterile supplies and suture room (a room where the operating room department kept surgical instruments and stitches used to hold the edges of a surgical incision) located in the operating room department temperature was out of range (82.2 Fahrenheit). This failure had the potential for the spread of infection in a universe of 167 patients. (Refer to A-0951)

4. The humidity levels were out of range in the four operating rooms (where the surgeon performs surgeries) and the two caesarean section rooms (rooms where the surgeon performs a surgical procedure in which one or more incisions are made through a mothers abdomen and uterus to deliver a baby). The temperature level was out of range in caesarean section room number two. This failure had the potential for the spread of infection in a universe of 167 patients. (Refer to A-0951)

5. The facility failed to provide an updated policy on humidity and temperatures normal range levels for the sterile processing department and operating room areas that were based on Association of Perioperative Registered Nurses(AORN). This failure had the potential for the spread of infection in a universe of 167 patients. (Refer to A-0951)

6. Documentation of the humidity levels were out of range in the sterile processing and distribution department ( they sterilize, prepare, pack, and store the surgical instruments), and operating rooms were out of range. This failure had the potential for the spread of infection in a universe of 167 patients. (Refer to A-0951)

The cumulative effect of these systemic practices resulted in the failure of the facility to deliver care in compliance with the Condition of Participation: Surgical Services.
VIOLATION: OPERATING ROOM POLICIES Tag No: A0951
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observations, interviews, and record reviews, the hospital failed to ensure the delivery of surgical services were provided in accordance with standard of practice when:

1. Patient 1 did not receive a proper diagnosis and treatment. This failure resulted in the delay in surgery for Patient 1.

2. One of two autoclave machines (used to sterilize surgical instruments) had a large amount of dark brown staining within the chamber. This failure had the potential for the spread of infection in a universe of 167 patients.

3. The temperature in the sterile supplies and suture room (a room where the operating room department kept surgical instruments and stitches used to hold the edges of a surgical incision) located in the operating room department temperature was out of range (82.2 Fahrenheit). This failure had the potential for the spread of infection in a universe of 167 patients.

4. The humidity levels were out of range in the four operating rooms (where the surgeon performs surgeries) and the two caesarean section rooms (rooms where the surgeon performs a surgical procedure in which one or more incisions are made through a mothers abdomen and uterus to deliver a baby). The temperature level was out of range in caesarean section room number two. This failure had the potential for the spread of infection in a universe of 167 patients.

5. The facility failed to provide an updated policy on humidity and temperatures normal range levels for the sterile processing department and operating room areas that were based on Association of Perioperative Registered Nurses(AORN). This failure had the potential for the spread of infection in a universe of 167 patients.

6. Documentation of the humidity levels were out of range in the sterile processing and distribution department ( they sterilize, prepare, pack, and store the surgical instruments), and operating rooms were out of range. This failure had the potential for the spread of infection in a universe of 167 patients.

Findings:

a). During a review of the medical record for Patient 1 on January 3, 2018 at 1:56 PM the admission record indicated Patient 1 was admitted on [DATE] and discharged on [DATE] with a diagnosis of acute urinary tract infection (an infection of the urinary tract).

During a review of the Nursing assessment dated [DATE] at 5:53 PM, indicated: "Patient 1 complained of vomiting and low abdominal pain for two days. Patient is a seven day post partum (the period following birth).


During a review of the Emergency Department Physician Notes dated August 14, 2017 at 6:03 PM and written by the Emergency Department Physician Assistant (ER PA 1) indicated: "The twenty-eight year old female presented with vomiting x 2 days. Patient 1 claimed approximately ten episodes and denied diarrhea (loose stools) or dysuria (painful or difficult urinating). Patient 1 was post partum (the period following birth) x 7 days.


During the review of the medical record for Patient 1 was conducted with the Quality Coordinator Registered Nurse (QCRN) on January 8, 2018 at 8:40 AM indicated there was no documentation that the Emergency Department Physician (ER MD 1) saw the patient on August 14, 2017.


During a concurrent interview with the QCRN confirmed that there was no documentation that the ER MD 1 saw patient on August 14, 2017.


b). During a review of the medical record for Patient 1 on January 3, 2018 at 1:57 PM the admission record indicated Patient 1 was admitted on [DATE] with a diagnosis of small bowel obstruction (a mechanical or functional obstruction of the intestines which prevents the normal movement of the products of the digestion. The signs and symptoms include abdominal pain and vomiting. In mechanical obstruction is the cause of about 5 to fifteen percent of cases with severe abdominal pain of sudden onset requiring admission to hospital) and passed away on August 17, 2017.


During a review of the Emergency Department Physician Notes dated August 15, 2017 at 9:50 AM and written by the Emergency Department Physician Assistant (ED PA 2) indicated: "Twenty-eight year old female complained of lower back pain and abdomen pain for two days. Patient 1 reported her back pain was in the center, and denied injury. Pain was worse with movement and touch. Abdomen pain in the left lower quadrant that began at 01:00 this AM. History of a caesarean section that was done eight days ago and also had history of previous caesarean sections (a surgical procedure in which one or more incisions are made through a mothers abdomen and uterus to deliver a baby). Patient 1 reported that this pain was different. Patient 1 was seen in the emergency department yesterday (August 14, 2017) with the same issue. Patient also reported heavy vaginal bleeding..."


During a review of the CT of the abdomen and pelvis without a contrast (x-ray tests that produce cross-sectional images of the body using x-rays and a computer) dated August 15, 2017 at 10:50 AM indicated: "Distal small bowel obstruction (a mechanical or functional obstruction of the intestines which prevents the normal movement of the products of the digestion. The signs and symptoms include abdominal pain and vomiting. In mechanical obstruction is the cause of about 5 to fifteen percent of cases with severe abdominal pain of sudden onset requiring admission to the hospital).

During a review of the Emergency Department Physician Notes dated August 15, 2017 at 3:50 PM and written by the Emergency Department Physician (ED MD 2) indicated: ..."Care was transitioned to the Obstetrics and Gynecology (a physician that delivers babies and specializes in treating diseases of the female reproductive organs) (OBGYN MD 1) at 1:00 PM. At 3:30 PM her heart rate had increased to 180's. Her blood pressure had dropped in the high 60's. Her pulse was palpable but rapid. There was approximately one liter of nasogastric tube (insertion of a plastic tube through the nose, past the throat and down the stomach) output which was dark in color and tested positive for hemacult (abnormal bleeding is occurring in the digestive tract). The OBGYN MD 1 was contacted from the emergency department and updated her about the patient's condition, expressing that the patient was critically ill and would require intensive care unit care. The OBGYN MD 1 stated she was currently at another hospital . The OBGYN MD 1 arrived at this hospital's emergency department at around 5:00 PM as well as Physician (MD 1) . The MD 1 called the (On Call Surgeon MD1) to request emergent surgical consultation for possible ischemic bowel (narrowing of the arteries that supply blood and oxygen to the intestines. As the narrowing worsens, the arteries become unable to supply enough oxygen to meet demand. This can cause abdominal pain and damage to the intestines). The ED MD 2 went off shift at 6:00 PM. At that time patient had not yet been taken to the operating room."

During a review of the Nursing progress notes dated August 15, 2017 at 7:15 PM written by the Intensive Care Unit Registered Nurse (ICU RN 1) indicated: "Received patient from the emergency department. Patient 1 was oriented but drowsy. Patient 1 was cool and clammy. Lung sounds were clear. Patient 1 was complaining of pain to lower back and abdomen was distended. Unable to get blood pressure reading. One was in the 70's. Patient was still complaining of pain.."

During a review of the Nursing Progress Note dated August 15, 2017 at 10:35 PM written by the Intensive Care Unit Registered Nurse (ICU RN 2) indicated: "The On Call Surgeon MD 1 was at the bedside, spoke with Patient one's family and discussed surgery to be done..."

During a review of the operative report dated August 18, 2017 at 7:25 PM, written by the On Call Surgeon MD 1 indicated: "Preoperative diagnosis was septic schock (a condition in which the blood pressure falls dangerously and it may occur in patients with serious infections) with small bowel obstruction and the post operative diagnosis were Septic shock with small bowel obstruction, severe ischemia with patchy necrosis of the entire small bowel (restriction of blood supply to the organ and the death of most of the cells in the organ), from just below the ligament of Treitz (a bad smooth muscle extending from the junction of the duodenum and jejunum) to just above the ileocecal valve (a sphincter muscle valve that separates the small intestine and the large intestine), and small bowel obstruction, due to a knuckle of distal ileum (final section of the small intestine) stuck within the superior aspect of the closure of the cesarean section which she had seven days ago..."

During a review of the final autopsy report (a post mortem exam to discover the cause of death) dated August 23, 2017 at 10:30 AM, indicated: "Cause of Death were complications of diffuse small bowel ischemic necrosis (damage to part of the intestine. It is due to a decrease in the blood supply to the area), including acute myocardial infarction
(a heart attack happened when the blood vessels that supply blood to the heart (coronary arteries) are blocked and leaded to heart failure) and multi-organ failure (a progressive dysfunction of two or more organ systems in a critically ill patient)."

During an interview with the Surgeon (S 2) on January 4, 2018 at 2:24 PM, he stated that the Emergency Department Physician Assistant (ER PA 1) should have recommended a (KUB) Kidneys, Ureters, and Bladder (x-ray of the abdomen, providing information about abdominal organs).


During an interview with the On Call Surgeon MD 1 on January 4, 2018 at 3:36 PM, the Emergency Department Physician Assistant (ED PA 2) that saw the patient in the emergency department told me that Patient 1 was stable.


During an interview with the On Call Surgeon MD 1 on January 4, 2018 at 3:37 PM, the On Call Surgeon MD 1 stated, whoever closed the caesarean section is at fault. The Emergency Department Physician Assistant ( ER PA 1) should have called the Obstetrics and Gynecology because patient 1 was a post op caesarean section for seven days.
which is a common complication of a status post C-section.

During an interview with the Physician (MD 1) on January 5, 2017 at 9:34 AM, the MD 1 stated he saw her in the emergency department and her abdomen was distended and was tachycardia (high pulse rate). The Emergency Department Physician Assistant (ER PA 1) should have ordered a KUB (KUB) Kidneys, Ureters, and Bladder (x-ray of the abdomen, providing information about abdominal organs) and Cat scan (x-ray tests that produce cross-sectional images of the body using x-rays and a computer).


During an interview with the Emergency Department Physician (ER MD 1) on January 5, 2018 at 9:59 AM, the ER MD 1 stated he trusted the Emergency Department Physician Assistant (ER PA 1) assessment of Patient 1 and also stated he cannot be everywhere at the same time.


During an interview with the Emergency Department Physician (ED MD 2) on January 5, 2018 at 10:52 AM, the ED MD 2 stated he spoke with the Obstetrics and Gynecology (OBGYN MD1) and I told her the patient was unstable. We should have seen the patient sooner and called a second surgeon and placed Patient on a monitor (monitors the patients heart rate blood pressure, and heart electrical wave activity) sooner. The ED MD 2 also stated they had limited number of monitors and that's why patient was in the emergency department hallway.


During an interview with the Obstetrics and Gynecology (OBGYN MD 2) on January 5, 2018 at 11:38 AM, the OBGYN MD 2 stated that the facility should enforce two surgeons because they only had one surgeon on call.


During an interview with the Chief of Surgery (COS) on January 5, 2018 at 2:45 PM, stated that the physicians should've called any available surgeon and followed the chain of command because she was never notified regarding patient 1. I would have called another available surgeon.


During an interview with the President of Medical Staff (POMS) on January 8, 2018 at 10:29 AM, stated that next time the physicians will have better communication among them and have other opportunities for improvement for example,the time frame for which the consultants should see the patient.


A review of the facility's "Medical Staff Rules and Regulations" dated March 22, 2017 indicated: ..."In the event that the Emergency Department physician requests an in person consultation, the consultant on-call should attend to the patient in the Emergency Department and perform an appropriate consultation. The timeframe of the in-person consultation shall be dependent upon the urgency of the patient's medical condition. In the event that the on-call physician cannot respond because of situations beyond his or her control, the alternate covering physician will be contacted..."



2. During a tour of the hospital sterile processing and distribution area on January 3, 2018 at 1:54 PM, one of two autoclave machines (used to sterilize surgical instruments) had large amounts of dark brown staining within the chamber.

During a concurrent interview with the Sterile Processing Manager (SPM) confirmed there were large amounts of dark brown stains within the autoclave chamber and stated that it might be water build up within the chamber.

During a review of the manufacturer IFUs undated indicated: "The association of perioperative Registered Nuses (AORN) recommends regular chamber cleaning in its equipment maintenance supplement to ensure autoclave/sterilizer continues to perform to your expectations. Over time, substance accumulate on chamber walls and can contaminate packs and hinder sterilizer performance."

3. During a tour of the the sterile supplies and suture room (a room where the operating room department kept surgical instruments and stitches used to hold the edges of a surgical incision) on January 2, 2018 at 2:29 PM, located in the operating room department, the temperature was out of range (82.2 Fahrenheit).

During a concurrent interview with the Plant Operator (PO) confirmed that the temperature was 82.2 Fahrenheit and that it was out of range. The (PO) also stated that the normal temperature ranges were (68-73 Fahrenheit).

A review of the facility's policy and procedure titled, "Temperature and Humidity Sensitive Areas"dated January 2010, included the following: "A relative humidity that is too high can result in damp or moist supplies with added opportunity for mold and microbial growth. It can also contribute to excess perspiration and occasional "sweat through" when combined with high temperatures. A relative humidity that is too low can result in excessive bacteria-carrying dust; it also increases the risk of electrostatic charges which pose a fire hazard in an oxygen rich environment or when flammable agents are present. The temperature and humidity in all operating, cardiac cath, labor and delivery, endoscopy, and critical care rooms shall be maintained within acceptable standards in order to inhibit bacterial growth and prevent infection, as well as promote patient comfort and safety..."

According to the CDC "Healthcare Infection Control Practices Advisory Committee Guideline for Disinfection and Sterilization in Healthcare Facilities", "...the sterile storage area should have controlled temperatures and may be as high as 75 degrees Fahrenheit and the relative humidity should be 30% to 60% in all work area except sterile storage, where the relative humidity should not exceed 70%."

4. During a tour of the hospital four operating rooms and the two caesarean section rooms on January 2, 2018 at 5:27 PM the following rooms had the humidity levels and temperature levels out of range:

a. Operating room number one the humidity level was 27.1 %

b. Operating room number two the humidity level was 27.0 %

c. Operating room number three the humidity level was 22.0 %

d. Caesarean section room number one: 20.0 %

e. Caesarean section room number two: the temperature was 73.9 degrees Fahrenheit and humidity level was 19.0 %.

A review of the facility's policy and procedure titled, "Temperature and Humidity Control Surgical Suites" dated June 2015, included the following: "Temperature in each surgical suite shall be maintained between 68 and 73 degrees Fahrenheit and humidity shall be maintained between 35% and 60%. Engineering will continue to monitor, adjust as possible, and notify the House Supervisor when rooms are back in range. If any unit continues to be out of range then hourly rechecks of out of range unit will be made and engineering will notify house supervisor of change, no change, status until unit is back in range on an hourly basis..."

5. During an interview with the infection control nurse (ICN) on January 3, 2018 at 2:10 PM, stated that the hospital adopted and followed the nationally recognized infection control guidelines Association of Perioperative Registered Nurses and Centers for Disease Control. The ICN also stated that the facility was not following the policy's for monitoring temperatures and humidity levels.

During an interview with the Interim Chief Nursing Officer (ICNO) on January 2, 2018 at 5:35 PM, stated that the facility does not have a current policy reflecting the current AORN guidelines in monitoring the temperature and humidity levels.

A review of the facility's current policy and procedure titled, "Temperature and Humidity Control Surgical Suites" dated June 2015, included the following: "Temperature in each surgical suite shall be maintained between 68 and 73 degrees Fahrenheit and humidity shall be maintained between 35% and 60%. Engineering will continue to monitor, adjust as possible, and notify the House Supervisor when rooms are back in range. If any unit continues to be out of range then hourly rechecks of out of range unit will be made and engineering will notify house supervisor of change, no change, status until unit is back in range on an hourly basis..."


6. During a review of the sterile processing and distribution department ( they sterilize, prepare, pack, and store the surgical instruments) logs dated for the Month of December 2017 indicated the humidity levels were out of range for the following dates:

1. The decontamination room: (room where the surgical instruments are sterilized):

a. December 6, 2017 the humidity level was 25%

b. December 7, 2017 the humidity level was 25%

c. December 8, 2017 the humidity level was 23%

d. December 9, 2017 the humidity level was 23%

e. December 10, 2017 the humidity level was 28%

f. December 11, 2017 the humidity level was 26%

e. December 12, 2017 the humidity level was 25%

f. December 13, 2017 the humidity level was 25%

g. December 14, 2017 the humidity level was 18%

h. December 15, 2017 the humidity level was 22%

i. December 16, 2017 the humidity level was 24%

j. December 17, 2017 the humidity level was 25%

k. December 18, 2017 the humidity level was 23%

l. December 19, 2017 the humidity level was 25%

m. December 20, 2017 the humidity level was 23%

n. December 21, 2017 the humidity level was 25%

o. December 22, 2017 the humidity level was 28%

p. December 23, 2017 the humidity level was 23%

q. December 24, 2017 the humidity level was 20%

r. December 26, 2017 the humidity level was 21%

s. December 27, 2017 the humidity level was 24%

t. December 28, 2017 the humidity level was 21%

u. December 29, 2017 the humidity level was 27%

v. December 30, 2017 the humidity level was 26%


2. The central supply prep and pack (They prepare and pack the surgical instruments):

a. December 1, 2017 the humidity level was 29%

b. December 3, 2017 the humidity level was 25%

c. December 4, 2017 the humidity level was 20%

d. December 6, 2017 the humidity level was 25%

e. December 7, 2017 the humidity level was 28%

f. December 8, 2017 the humidity level was 26%

g. December 9, 2017 the humidity level was 20%

h. December 11, 2017 the humidity level was 27%

i. December 12, 2017 the humidity level was 25%

j. December 13, 2017 the humidity level was 25%

k. December 14, 2017 the humidity level was 15%

l. December 15, 2017 the humidity level was 21%

m. December 16, 2017 the humidity level was 21%

n. December 17, 2017 the humidity level was 23%

o. December 18, 2017 the humidity level was 24%

p. December 19, 2017 the humidity level was 26%

q. December 20, 2017 the humidity level was 28%

r. December 22, 2017 the humidity level was 25%

s. December 23, 2017 the humidity level was 26%

t. December 24, 2017 the humidity level was 20%

u. December 25, 2017 the humidity level was 20%

v. December 26, 2017 the humidity level was 21%

w. December 27, 2017 the humidity level was 22%

x. December 28, 2017 the humidity level was 21%

y. December 29, 2017 the humidity level was 21%

z. December 30, 2017 the humidity level was 23%


During a review of the operating rooms logs dated for the Month of December 2017 indicated the humidity levels were out of range for the following dates:

3. Operating room number one:

1. December 3, 2017 the humidity level was 30%

2. December 4, 2017 the humidity level was 28%

3. December 5, 2017 the humidity level was 25%

4. December 6, 2017 the humidity level was 22%

5. December 7, 2017 the humidity level was 25%

6. December 8, 2017 the humidity level was 24%

7. December 9, 2017 the humidity level was 21%

8. December 10, 2017 the humidity level was 20%

9. December 11, 2017 the humidity level was 23%

10. December 12, 2017 the humidity level was 21%

11. December 13, 2017 the humidity level was 21%

12. December 14, 2017 the humidity level was 16%

13. December 15, 2017 the humidity level was 14%

14. December 16, 2017 the humidity level was 23%

15. December 17, 2017 the humidity level was 25%

16. December 18, 2017 the humidity level was 22%

17. December 19, 2017 the humidity level was 25%

18. December 20, 2017 the humidity level was 23%

19. December 21, 2017 the humidity level was 26%

20. December 22, 2017 the humidity level was 25%

21. December 23, 2017 the humidity level was 23%

22. December 24, 2017 the humidity level was 20%

23. December 25, 2017 the humidity level was 20%

24. December 26, 2017 the humidity level was 20%

25. December 27, 2017 the humidity level was 22%

26. December 28, 2017 the humidity level was 26%

27. December 29, 2017 the humidity level was 23%

28. December 30, 2017 the humidity level was 22%

4. Operating room number two:

1. December 3, 2017 the humidity level was 29%

2. December 4, 2017 the humidity level was 25%

3. December 5, 2017 the humidity level was 28%

4. December 6, 2017 the humidity level was 25%

5. December 7, 2017 the humidity level was 25%

6. December 8, 2017 the humidity level was 24%

7. December 9, 2017 the humidity level was 20%

8. December 10, 2017 the humidity level was 21%

9. December 11, 2017 the humidity level was 25%

10. December 12, 2017 the humidity level was 25%

11. December 13, 2017 the humidity level was 20%

12. December 16, 2017 the humidity level was 24%

13. December 17, 2017 the humidity level was 23%

14. December 18, 2017 the humidity level was 26%

15. December 19, 2017 the humidity level was 26%

16. December 20, 2017 the humidity level was 26%

17. December 21, 2017 the humidity level was 29%

18. December 22, 2017 the humidity level was 29%

19. December 23, 2017 the humidity level was 22%

20. December 24, 2017 the humidity level was 20%

21. December 25, 2017 the humidity level was 20%

22. December 26, 2017 the humidity level was 21%

23. December 27, 2017 the humidity level was 23%

24. December 28, 2017 the humidity level was 27%

25. December 29, 2017 the humidity level was 23%

26. December 30, 2017 the humidity level was 21%

5. Operating room number three:

1. December 3, 2017 the humidity level was 25%

2. December 5, 2017 the humidity level was 25%

3. December 6, 2017 the humidity level was 29%

4. December 7, 2017 the humidity level was 23%

5. December 8, 2017 the humidity level was 24%

6. December 9, 2017 the humidity level was 20%

7. December 10, 2017 the humidity level was 26%

8. December 11, 2017 the humidity level was 22%

9. December 12, 2017 the humidity level was 23%

10. December 13, 2017 the humidity level was 20%

11. December 16, 2017 the humidity level was 23%

12. December 17, 2017 the humidity level was 25%

13. December 18, 2017 the humidity level was 28%

14. December 19, 2017 the humidity level was 25%

15. December 20, 2017 the humidity level was 26%

16. December 21, 2017 the humidity level was 29%

17. December 22, 2017 the humidity level was 29%

18. December 23, 2017 the humidity level was 22%

19. December 24, 2017 the humidity level was 20%

20. December 25, 2017 the humidity level was 20%

21. December 26, 2017 the humidity level was 20%

22. December 27, 2017 the humidity level was 23%

23. December 28, 2017 the humidity level was 27%

24. December 29, 2017 the humidity level was 25%

25. December 30, 2017 the humidity level was 22%

6. Operating room number four:

1. December 1, 2017 the humidity level was 27%

2. December 2, 2017 the humidity level was 34%

3. December 3, 2017 the humidity level was 25%

4. December 4, 2017 the humidity level was 28%

5. December 5, 2017 the humidity level was 32%

6. December 6, 2017 the humidity level was 28%

7. December 7, 2017 the humidity level was 26%

8. December 8, 2017 the humidity level was 23%

9. December 9, 2017 the humidity level was 27%

10. December 10, 2017 the humidity level was 26%

11. December 11, 2017 the humidity level was 26%

12. December 12, 2017 the humidity level was 24%

13. December 13, 2017 the humidity level was 27%

14. December 16, 2017 the humidity level was 24%

15. December 17, 2017 the humidity level was 23%

16. December 18, 2017 the humidity level was 25%

17. December 19, 2017 the humidity level was 23%

18. December 20, 2017 the humidity level was 25%

19. December 22, 2017 the humidity level was 28%

20. December 24, 2017 the humidity level was 24%

21. December 25, 2017 the humidity level was 21%

22. December 26, 2017 the humidity level was 20%

23. December 27, 2017 the humidity level was 25%

24. December 28, 2017 the humidity level was 28%

25. December 29, 2017 the humidity level was 23%


During an interview with the Plant Manager (PM) on January 3, 2018 at 8:48 AM, the PM confirmed that the humidity levels for the dates of December 2017 were out of range in the sterile processing department, and operating rooms. The PM stated that they should have called in a work order to fix the humidity levels.


According to the CDC "Healthcare Infection Control Practices Advisory Committee Guideline for Disinfection and Sterilization in Healthcare Facilities", "...the sterile storage area should have controlled temperatures and may be as high as 75 degrees Fahrenheit and the relative humidity should be 30% to 60% in all work area except sterile storage, where the relative humidity should not exceed 70%."


A review of the facility's current policy and procedure titled, "Temperature and Humidity Control Surgical Suites" dated June 2015, included the following: "Temperature in each surgical suite shall be maintained between 68 and 73 degrees Fahrenheit and humidity shall be maintained between 35% and 60%. Engineering will continue to monitor, adjust as possible, and notify the House Supervisor when rooms are back in range. If any unit continues to be out of range then hourly rechecks of out of range unit will be made and engineering will notify house supervisor of change, no change, status until unit is back in range on an hourly basis..."
VIOLATION: EMERGENCY SERVICES Tag No: A1100
The facility failed to ensure the Condition of Participation 482.55: Emergency Services was met by failing to ensure:

1. Patient 1 did not receive proper diagnosis and treatment. This failure resulted in the delay in surgery for Patient 1. (Refer to A-1103)

The cumulative effect of these systemic practices resulted in the failure of the hospital to deliver care in compliance with the Condition of Participation Emergency Services.
VIOLATION: INTEGRATION OF EMERGENCY SERVICES Tag No: A1103
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the facility failed to ensure Patient 1 received a proper diagnosis and treatment. This failure resulted in the delay in surgery for Patient 1.


Findings:


a). During a review of the medical record for Patient 1 on January 3, 2018 at 1:56 PM the admission record indicated Patient 1 was admitted on [DATE] and discharged on [DATE] with a diagnosis of acute urinary tract infection (an infection of the urinary tract).

During a review of the Nursing assessment dated [DATE] at 5:53 PM, indicated: "Patient 1 complained of vomiting and low abdominal pain for two days. Patient is a seven day post partum (the period following birth).


During a review of the Emergency Department Physician Notes dated August 14, 2017 at 6:03 PM and written by the Emergency Department Physician Assistant (ER PA 1) indicated: "The twenty-eight year old female presented with vomiting x 2 days. Patient 1 claimed approximately ten episodes and denied diarrhea (loose stools) or dysuria (painful or difficult urinating). Patient 1 was post partum (the period following birth) x 7 days.


During the review of the medical record for Patient 1 was conducted with the Quality Coordinator Registered Nurse (QCRN) on January 8, 2018 at 8:40 AM indicated there was no documentation that the Emergency Department Physician (ER MD 1) saw the patient on August 14, 2017.


During a concurrent interview with the QCRN confirmed that there was no documentation that the ER MD 1 saw patient on August 14, 2017.


b). During a review of the medical record for Patient 1 on January 3, 2018 at 1:57 PM the admission record indicated Patient 1 was admitted on [DATE] with a diagnosis of small bowel obstruction (a mechanical or functional obstruction of the intestines which prevents the normal movement of the products of the digestion. The signs and symptoms include abdominal pain and vomiting. In mechanical obstruction is the cause of about 5 to fifteen percent of cases with severe abdominal pain of sudden onset requiring admission to hospital) and passed away on August 17, 2017.


During a review of the Emergency Department Physician Notes dated August 15, 2017 at 9:50 AM and written by the Emergency Department Physician Assistant (ED PA 2) indicated: "Twenty-eight year old female complained of lower back pain and abdomen pain for two days. Patient 1 reported her back pain was in the center, and denied injury. Pain was worse with movement and touch. Abdomen pain in the left lower quadrant that began at 01:00 this AM. History of a caesarean section that was done eight days ago and also had history of previous caesarean sections (a surgical procedure in which one or more incisions are made through a mothers abdomen and uterus to deliver a baby). Patient 1 reported that this pain was different. Patient 1 was seen in the emergency department yesterday (August 14, 2017) with the same issue. Patient also reported heavy vaginal bleeding..."


During a review of the CT of the abdomen and pelvis without a contrast (x-ray tests that produce cross-sectional images of the body using x-rays and a computer) dated August 15, 2017 at 10:50 AM indicated: "Distal small bowel obstruction (a mechanical or functional obstruction of the intestines which prevents the normal movement of the products of the digestion. The signs and symptoms include abdominal pain and vomiting. In mechanical obstruction is the cause of about 5 to fifteen percent of cases with severe abdominal pain of sudden onset requiring admission to the hospital).

During a review of the Emergency Department Physician Notes dated August 15, 2017 at 3:50 PM and written by the Emergency Department Physician (ED MD 2) indicated: ..."Care was transitioned to the Obstetrics and Gynecology (a physician that delivers babies and specializes in treating diseases of the female reproductive organs) (OBGYN MD 1) at 1:00 PM. At 3:30 PM her heart rate had increased to 180's. Her blood pressure had dropped in the high 60's. Her pulse was palpable but rapid. There was approximately one liter of nasogastric tube (insertion of a plastic tube through the nose, past the throat and down the stomach) output which was dark in color and tested positive for hemacult (abnormal bleeding is occurring in the digestive tract). The OBGYN MD 1 was contacted from the emergency department and updated her about the patient's condition, expressing that the patient was critically ill and would require intensive care unit care. The OBGYN MD 1 stated she was currently at another hospital . The OBGYN MD 1 arrived at this hospital's emergency department at around 5:00 PM as well as Physician (MD 1) . The MD 1 called the (On Call Surgeon MD1) to request emergent surgical consultation for possible ischemic bowel (narrowing of the arteries that supply blood and oxygen to the intestines. As the narrowing worsens, the arteries become unable to supply enough oxygen to meet demand. This can cause abdominal pain and damage to the intestines). The ED MD 2 went off shift at 6:00 PM. At that time patient had not yet been taken to the operating room."

During a review of the Nursing progress notes dated August 15, 2017 at 7:15 PM written by the Intensive Care Unit Registered Nurse (ICU RN 1) indicated: "Received patient from the emergency department. Patient 1 was oriented but drowsy. Patient 1 was cool and clammy. Lung sounds were clear. Patient 1 was complaining of pain to lower back and abdomen was distended. Unable to get blood pressure reading. One was in the 70's. Patient was still complaining of pain.."

During a review of the Nursing Progress Note dated August 15, 2017 at 10:35 PM written by the Intensive Care Unit Registered Nurse (ICU RN 2) indicated: "The On Call Surgeon MD 1 was at the bedside, spoke with Patient one's family and discussed surgery to be done..."

During a review of the operative report dated August 18, 2017 at 7:25 PM, written by the On Call Surgeon MD 1 indicated: "Preoperative diagnosis was septic schock (a condition in which the blood pressure falls dangerously and it may occur in patients with serious infections) with small bowel obstruction and the post operative diagnosis were Septic shock with small bowel obstruction, severe ischemia with patchy necrosis of the entire small bowel (restriction of blood supply to the organ and the death of most of the cells in the organ), from just below the ligament of Treitz (a bad smooth muscle extending from the junction of the duodenum and jejunum) to just above the ileocecal valve (a sphincter muscle valve that separates the small intestine and the large intestine), and small bowel obstruction, due to a knuckle of distal ileum (final section of the small intestine) stuck within the superior aspect of the closure of the cesarean section which she had seven days ago..."

During a review of the final autopsy report (a post mortem exam to discover the cause of death) dated August 23, 2017 at 10:30 AM, indicated: "Cause of Death were complications of diffuse small bowel ischemic necrosis (damage to part of the intestine. It is due to a decrease in the blood supply to the area), including acute myocardial infarction
(a heart attack happened when the blood vessels that supply blood to the heart (coronary arteries) are blocked and leaded to heart failure) and multi-organ failure (a progressive dysfunction of two or more organ systems in a critically ill patient)."

During an interview with the Surgeon (S 2) on January 4, 2018 at 2:24 PM, he stated that the Emergency Department Physician Assistant (ER PA 1) should have recommended a (KUB) Kidneys, Ureters, and Bladder (x-ray of the abdomen, providing information about abdominal organs).


During an interview with the On Call Surgeon MD 1 on January 4, 2018 at 3:36 PM, the Emergency Department Physician Assistant (ED PA 2) that saw the patient in the emergency department told me that Patient 1 was stable.


During an interview with the On Call Surgeon MD 1 on January 4, 2018 at 3:37 PM, the On Call Surgeon MD 1 stated, whoever closed the caesarean section is at fault. The Emergency Department Physician Assistant ( ER PA 1) should have called the Obstetrics and Gynecology because patient 1 was a post op caesarean section for seven days.
which is a common complication of a status post C-section.

During an interview with the Physician (MD 1) on January 5, 2017 at 9:34 AM, the MD 1 stated he saw her in the emergency department and her abdomen was distended and was tachycardia (high pulse rate). The Emergency Department Physician Assistant (ER PA 1) should have ordered a KUB (KUB) Kidneys, Ureters, and Bladder (x-ray of the abdomen, providing information about abdominal organs) and Cat scan (x-ray tests that produce cross-sectional images of the body using x-rays and a computer).


During an interview with the Emergency Department Physician (ER MD 1) on January 5, 2018 at 9:59 AM, the ER MD 1 stated he trusted the Emergency Department Physician Assistant (ER PA 1) assessment of Patient 1 and also stated he cannot be everywhere at the same time.


During an interview with the Emergency Department Physician (ED MD 2) on January 5, 2018 at 10:52 AM, the ED MD 2 stated he spoke with the Obstetrics and Gynecology (OBGYN MD1) and I told her the patient was unstable. We should have seen the patient sooner and called a second surgeon and placed Patient on a monitor (monitors the patients heart rate blood pressure, and heart electrical wave activity) sooner. The ED MD 2 also stated they had limited number of monitors and that's why patient was in the emergency department hallway.


During an interview with the Obstetrics and Gynecology (OBGYN MD 2) on January 5, 2018 at 11:38 AM, the OBGYN MD 2 stated that the facility should enforce two surgeons because they only had one surgeon on call.


During an interview with the Chief of Surgery (COS) on January 5, 2018 at 2:45 PM, stated that the physicians should've called any available surgeon and followed the chain of command because she was never notified regarding patient 1. I would have called another available surgeon.


During an interview with the President of Medical Staff (POMS) on January 8, 2018 at 10:29 AM, stated that next time the physicians will have better communication among them and have other opportunities for improvement for example,the time frame for which the consultants should see the patient.


A review of the facility's "Medical Staff Rules and Regulations" dated March 22, 2017 indicated: ..."In the event that the Emergency Department physician requests an in person consultation, the consultant on-call should attend to the patient in the Emergency Department and perform an appropriate consultation. The timeframe of the in-person consultation shall be dependent upon the urgency of the patient's medical condition. In the event that the on-call physician cannot respond because of situations beyond his or her control, the alternate covering physician will be contacted..."
VIOLATION: GOVERNING BODY Tag No: A0043
The facility failed to ensure the Condition of Participation: CFR 482.12 Governing Body was met by failing to ensure:

1. Patient 1 did not receive proper diagnosis and treatment. This failure resulted in the delay in surgery for Patient 1. ( Refer to A-0951, A-0049, A- , A-0358 and A-0286)


2. One of two autoclave machines (used to sterilize surgical instruments) had a large amount of dark brown staining within the chamber. This failure had the potential for the spread of infection in a universe of 167 patients. (Refer to A-0951)

3. The temperature in the sterile supplies and suture room (a room where the operating room department kept surgical instruments and stitches used to hold the edges of a surgical incision) located in the operating room department temperature was out of range (82.2 Fahrenheit). This failure had the potential for the spread of infection in a universe of 167 patients. (Refer to A-0951)

4. The humidity levels were out of range in the four operating rooms (where the surgeon performs surgeries) and the two caesarean section rooms (rooms where the surgeon performs a surgical procedure in which one or more incisions are made through a mothers abdomen and uterus to deliver a baby). The temperature level was out of range in caesarean section room number two. This failure had the potential for the spread of infection in a universe of 167 patients. (Refer to A-0951)

5. The facility failed to provide an updated policy on humidity and temperatures normal range levels for the sterile processing department and operating room areas that were based on Association of Preoperative Registered Nurses(AORN). This failure had the potential for the spread of infection in a universe of 167 patients. (Refer to A-0951)

6. Documentation of the humidity levels were out of range in the sterile processing and distribution department ( they sterilize, prepare, pack, and store the surgical instruments), and operating rooms were out of range. This failure had the potential for the spread of infection in a universe of 167 patients. (Refer to A-0951)

7. The facility failed to provide evidence of tuberculin skin test (a test to determine the presence of infection with (TB) tuberculosis (a bacterial infection of the lungs) annual screening for 1 of eleven sampled medical staff. This failure had the potential to spread undetected TB infection to a universe of 167 patients in the facility. (Refer to A-0347)

The cumulative effect of these systemic practices resulted in the failure of the facility to deliver care in compliance with the Condition of Participation: Governing Body.
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, and record review, the Governing Body failed to ensure Patient 1 received a proper diagnosis and treatment. This failure resulted in the delay in surgery for Patient 1.

Findings:


a). During a review of the medical record for Patient 1 on January 3, 2018 at 1:56 PM the admission record indicated Patient 1 was admitted on [DATE] and discharged on [DATE] with a diagnosis of acute urinary tract infection (an infection of the urinary tract).

During a review of the Nursing assessment dated [DATE] at 5:53 PM, indicated: "Patient 1 complained of vomiting and low abdominal pain for two days. Patient is a seven day post partum (the period following birth).


During a review of the Emergency Department Physician Notes dated August 14, 2017 at 6:03 PM and written by the Emergency Department Physician Assistant (ER PA 1) indicated: "The twenty-eight year old female presented with vomiting x 2 days. Patient 1 claimed approximately ten episodes and denied diarrhea (loose stools) or dysuria (painful or difficult urinating). Patient 1 was post partum (the period following birth) x 7 days.


During the review of the medical record for Patient 1 was conducted with the Quality Coordinator Registered Nurse (QCRN) on January 8, 2018 at 8:40 AM indicated there was no documentation that the Emergency Department Physician (ER MD 1) saw the patient on August 14, 2017.


During a concurrent interview with the QCRN confirmed that there was no documentation that the ER MD 1 saw patient on August 14, 2017.


b). During a review of the medical record for Patient 1 on January 3, 2018 at 1:57 PM the admission record indicated Patient 1 was admitted on [DATE] with a diagnosis of small bowel obstruction (a mechanical or functional obstruction of the intestines which prevents the normal movement of the products of the digestion. The signs and symptoms include abdominal pain and vomiting. In mechanical obstruction is the cause of about 5 to fifteen percent of cases with severe abdominal pain of sudden onset requiring admission to hospital) and passed away on August 17, 2017.


During a review of the Emergency Department Physician Notes dated August 15, 2017 at 9:50 AM and written by the Emergency Department Physician Assistant (ED PA 2) indicated: "Twenty-eight year old female complained of lower back pain and abdomen pain for two days. Patient 1 reported her back pain was in the center, and denied injury. Pain was worse with movement and touch. Abdomen pain in the left lower quadrant that began at 01:00 this AM. History of a caesarean section that was done eight days ago and also had history of previous caesarean sections (a surgical procedure in which one or more incisions are made through a mothers abdomen and uterus to deliver a baby). Patient 1 reported that this pain was different. Patient 1 was seen in the emergency department yesterday (August 14, 2017) with the same issue. Patient also reported heavy vaginal bleeding..."


During a review of the CT of the abdomen and pelvis without a contrast (x-ray tests that produce cross-sectional images of the body using x-rays and a computer) dated August 15, 2017 at 10:50 AM indicated: "Distal small bowel obstruction (a mechanical or functional obstruction of the intestines which prevents the normal movement of the products of the digestion. The signs and symptoms include abdominal pain and vomiting. In mechanical obstruction is the cause of about 5 to fifteen percent of cases with severe abdominal pain of sudden onset requiring admission to the hospital).

During a review of the Emergency Department Physician Notes dated August 15, 2017 at 3:50 PM and written by the Emergency Department Physician (ED MD 2) indicated: ..."Care was transitioned to the Obstetrics and Gynecology (a physician that delivers babies and specializes in treating diseases of the female reproductive organs) (OBGYN MD 1) at 1:00 PM. At 3:30 PM her heart rate had increased to 180's. Her blood pressure had dropped in the high 60's. Her pulse was palpable but rapid. There was approximately one liter of nasogastric tube (insertion of a plastic tube through the nose, past the throat and down the stomach) output which was dark in color and tested positive for hemacult (abnormal bleeding is occurring in the digestive tract). The OBGYN MD 1 was contacted from the emergency department and updated her about the patient's condition, expressing that the patient was critically ill and would require intensive care unit care. The OBGYN MD 1 stated she was currently at another hospital . The OBGYN MD 1 arrived at this hospital's emergency department at around 5:00 PM as well as Physician (MD 1) . The MD 1 called the (On Call Surgeon MD 1) to request emergent surgical consultation for possible ischemic bowel (narrowing of the arteries that supply blood and oxygen to the intestines. As the narrowing worsens, the arteries become unable to supply enough oxygen to meet demand. This can cause abdominal pain and damage to the intestines). The ED MD 2 went off shift at 6:00 PM. At that time patient had not yet been taken to the operating room."

During a review of the Nursing progress notes dated August 15, 2017 at 7:15 PM written by the Intensive Care Unit Registered Nurse (ICU RN 1) indicated: "Received patient from the emergency department. Patient 1 was oriented but drowsy. Patient 1 was cool and clammy. Lung sounds were clear. Patient 1 was complaining of pain to lower back and abdomen was distended. Unable to get blood pressure reading. One was in the 70's. Patient was still complaining of pain.."

During a review of the Nursing Progress Note dated August 15, 2017 at 10:35 PM written by the Intensive Care Unit Registered Nurse (ICU RN 2) indicated: "The On Call Surgeon MD 1 was at the bedside, spoke with Patient one's family and discussed surgery to be done..."

During a review of the operative report dated August 18, 2017 at 7:25 PM, written by the On Call Surgeon MD 1 indicated: "Preoperative diagnosis was septic schock (a condition in which the blood pressure falls dangerously and it may occur in patients with serious infections) with small bowel obstruction and the post operative diagnosis were Septic shock with small bowel obstruction, severe ischemia with patchy necrosis of the entire small bowel (restriction of blood supply to the organ and the death of most of the cells in the organ), from just below the ligament of Treitz (a bad smooth muscle extending from the junction of the duodenum and jejunum) to just above the ileocecal valve (a sphincter muscle valve that separates the small intestine and the large intestine), and small bowel obstruction, due to a knuckle of distal ileum (final section of the small intestine) stuck within the superior aspect of the closure of the cesarean section which she had seven days ago..."

During a review of the final autopsy report (a post mortem exam to discover the cause of death) dated August 23, 2017 at 10:30 AM, indicated: "Cause of Death were complications of diffuse small bowel ischemic necrosis (damage to part of the intestine. It is due to a decrease in the blood supply to the area), including acute myocardial infarction
(a heart attack happened when the blood vessels that supply blood to the heart (coronary arteries) are blocked and leaded to heart failure) and multi-organ failure (a progressive dysfunction of two or more organ systems in a critically ill patient)."

During an interview with the Surgeon (S 2) on January 4, 2018 at 2:24 PM, he stated that the Emergency Department Physician Assistant (ER PA 1) should have recommended a (KUB) Kidneys, Ureters, and Bladder (x-ray of the abdomen, providing information about abdominal organs).


During an interview with the On Call Surgeon MD 1 on January 4, 2018 at 3:36 PM, the Emergency Department Physician Assistant (ED PA 2) that saw the patient in the emergency department told me that Patient 1 was stable.


During an interview with the On Call Surgeon MD 1 on January 4, 2018 at 3:37 PM, the On Call Surgeon MD 1 stated, whoever closed the caesarean section is at fault. The Emergency Department Physician Assistant ( ER PA 1) should have called the Obstetrics and Gynecology because patient 1 was a post op caesarean section for seven days.
which is a common complication of a status post C-section.

During an interview with the Physician (MD 1) on January 5, 2017 at 9:34 AM, the MD 1 stated he saw her in the emergency department and her abdomen was distended and was tachycardia (high pulse rate). The Emergency Department Physician Assistant (ER PA 1) should have ordered a KUB (KUB) Kidneys, Ureters, and Bladder (x-ray of the abdomen, providing information about abdominal organs) and Cat scan (x-ray tests that produce cross-sectional images of the body using x-rays and a computer).


During an interview with the Emergency Department Physician (ER MD 1) on January 5, 2018 at 9:59 AM, the ER MD 1 stated he trusted the Emergency Department Physician Assistant (ER PA 1) assessment of Patient 1 and also stated he cannot be everywhere at the same time.


During an interview with the Emergency Department Physician (ED MD 2) on January 5, 2018 at 10:52 AM, the ED MD 2 stated he spoke with the Obstetrics and Gynecology (OBGYN MD 1) and I told her the patient was unstable. We should have seen the patient sooner and called a second surgeon and placed Patient on a monitor (monitors the patients heart rate blood pressure, and heart electrical wave activity) sooner. The ED MD 2 also stated they had limited number of monitors and that's why patient was in the emergency department hallway.


During an interview with the Obstetrics and Gynecology (OBGYN MD 2) on January 5, 2018 at 11:38 AM, the OBGYN MD 2 stated that the facility should enforce two surgeons because they only had one surgeon on call.


During an interview with the Chief of Surgery (COS) on January 5, 2018 at 2:45 PM, stated that the physicians should've called any available surgeon and followed the chain of command because she was never notified regarding patient 1. I would have called another available surgeon.


During an interview with the President of Medical Staff (POMS) on January 8, 2018 at 10:29 AM, stated that next time the physicians will have better communication among them and have other opportunities for improvement for example,the time frame for which the consultants should see the patient.


A review of the facility's "Medical Staff Rules and Regulations" dated March 22, 2017 indicated: ..."In the event that the Emergency Department physician requests an in person consultation, the consultant on-call should attend to the patient in the Emergency Department and perform an appropriate consultation. The timeframe of the in-person consultation shall be dependent upon the urgency of the patient's medical condition. In the event that the on-call physician cannot respond because of situations beyond his or her control, the alternate covering physician will be contacted..."
VIOLATION: QAPI Tag No: A0263
The facility failed to ensure the Condition of Participation: CFR 482.21 Quality Assessment and Performance Improvement was met by failing to ensure:

1. Patient 1 did not recieve proper diagnosis and treatment. This failure resulted in the delay in surgery for Patient 1. ( Refer to A-0951, A-0049, A- , A-0358 and A-0286)

2. One of two autoclave machines (used to sterilize surgical instruments) had a large amount of dark brown staining within the chamber. This failure had the potential for the spread of infection in a universe of 167 patients. (Refer to A-0951)

3. The temperature in the sterile supplies and suture room (a room where the operating room department kept surgical instruments and stitches used to hold the edges of a surgical incision) located in the operating room department temperature was out of range (82.2 Fahrenheit). This failure had the potential for the spread of infection in a universe of 167 patients. (Refer to A-0951)

4. The humidity levels were out of range in the four operating rooms (where the surgeon performs surgeries) and the two caesarean section rooms (rooms where the surgeon performs a surgical procedure in which one or more incisions are made through a mothers abdomen and uterus to deliver a baby). The temperature level was out of range in caesarean section room number two.This failure had the potential for the spread of infection in a universe of 167 patients. (Refer to A-0951)

5. The facility failed to provide an updated policy on humidity and temperatures normal range levels for the sterile processing department and operating room areas that were based on Association of Perioperative Registered Nurses(AORN). This failure had the potential for the spread of infection in a universe of 167 patients. (Refer to A-0951)

6. Documentaton of the humidity levels were out of range in the sterile processing and distribution department ( they sterilize, prepare, pack, and store the surgical instruments), and operating rooms were out of range. This failure had the potential for the spread of infection in a universe of 167 patients. (Refer to A-0951)

7. The facility failed to provide evidence of tuberculin skin test (a test to determine the presence of infection with (TB) tuberculosis (a bacterial infection of the lungs) annual screening for one of eleven sampled medical staff. This failure had the potential to spread undetected TB infection to a universe of 167 patients in the facility. (Refer to A-0347)


The cumulative effect of these systemic practices resulted in the failure of the facility to deliver care in compliance with the Condition of Participation: Quality Assessment and Performance Improvement.
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the Medical Staff failed to ensure Patient 1 received proper diagnosis and treatment. This failure resulted in the delay in surgery for Patient 1.


Findings:

a). During a review of the medical record for Patient 1 on January 3, 2018 at 1:56 PM the admission record indicated Patient 1 was admitted on [DATE] and discharged on [DATE] with a diagnosis of acute urinary tract infection (an infection of the urinary tract).

During a review of the Nursing assessment dated [DATE] at 5:53 PM, indicated: "Patient 1 complained of vomiting and low abdominal pain for two days. Patient is a seven day post partum (the period following birth).


During a review of the Emergency Department Physician Notes dated August 14, 2017 at 6:03 PM and written by the Emergency Department Physician Assistant (ER PA 1) indicated: "The twenty-eight year old female presented with vomiting x 2 days. Patient 1 claimed approximately ten episodes and denied diarrhea (loose stools) or dysuria (painful or difficult urinating). Patient 1 was post partum (the period following birth) x 7 days.


During the review of the medical record for Patient 1 was conducted with the Quality Coordinator Registered Nurse (QCRN) on January 8, 2018 at 8:40 AM indicated there was no documentation that the Emergency Department Physician (ER MD 1) saw the patient on August 14, 2017.


During a concurrent interview with the QCRN confirmed that there was no documentation that the ER MD 1 saw patient on August 14, 2017.


b). During a review of the medical record for Patient 1 on January 3, 2018 at 1:57 PM the admission record indicated Patient 1 was admitted on [DATE] with a diagnosis of small bowel obstruction (a mechanical or functional obstruction of the intestines which prevents the normal movement of the products of the digestion. The signs and symptoms include abdominal pain and vomiting. In mechanical obstruction is the cause of about 5 to fifteen percent of cases with severe abdominal pain of sudden onset requiring admission to hospital) and passed away on August 17, 2017.


During a review of the Emergency Department Physician Notes dated August 15, 2017 at 9:50 AM and written by the Emergency Department Physician Assistant (ED PA 2) indicated: "Twenty-eight year old female complained of lower back pain and abdomen pain for two days. Patient 1 reported her back pain was in the center, and denied injury. Pain was worse with movement and touch. Abdomen pain in the left lower quadrant that began at 01:00 this AM. History of a caesarean section that was done eight days ago and also had history of previous caesarean sections (a surgical procedure in which one or more incisions are made through a mothers abdomen and uterus to deliver a baby). Patient 1 reported that this pain was different. Patient 1 was seen in the emergency department yesterday (August 14, 2017) with the same issue. Patient also reported heavy vaginal bleeding..."


During a review of the CT of the abdomen and pelvis without a contrast (x-ray tests that produce cross-sectional images of the body using x-rays and a computer) dated August 15, 2017 at 10:50 AM indicated: "Distal small bowel obstruction (a mechanical or functional obstruction of the intestines which prevents the normal movement of the products of the digestion. The signs and symptoms include abdominal pain and vomiting. In mechanical obstruction is the cause of about 5 to fifteen percent of cases with severe abdominal pain of sudden onset requiring admission to the hospital).

During a review of the Emergency Department Physician Notes dated August 15, 2017 at 3:50 PM and written by the Emergency Department Physician (ED MD 2) indicated: ..."Care was transitioned to the Obstetrics and Gynecology (a physician that delivers babies and specializes in treating diseases of the female reproductive organs) (OBGYN MD 1) at 1:00 PM. At 3:30 PM her heart rate had increased to 180's. Her blood pressure had dropped in the high 60's. Her pulse was palpable but rapid. There was approximately one liter of nasogastric tube (insertion of a plastic tube through the nose, past the throat and down the stomach) output which was dark in color and tested positive for hemacult (abnormal bleeding is occurring in the digestive tract). The OBGYN MD 1 was contacted from the emergency department and updated her about the patient's condition, expressing that the patient was critically ill and would require intensive care unit care. The OBGYN MD 1 stated she was currently at another hospital . The OBGYN MD 1 arrived at this hospital's emergency department at around 5:00 PM as well as Physician (MD 1) . The MD 1 called the (On Call Surgeon MD 1) to request emergent surgical consultation for possible ischemic bowel (narrowing of the arteries that supply blood and oxygen to the intestines. As the narrowing worsens, the arteries become unable to supply enough oxygen to meet demand. This can cause abdominal pain and damage to the intestines). The ED MD 2 went off shift at 6:00 PM. At that time patient had not yet been taken to the operating room."

During a review of the Nursing progress notes dated August 15, 2017 at 7:15 PM written by the Intensive Care Unit Registered Nurse (ICU RN 1) indicated: "Received patient from the emergency department. Patient 1 was oriented but drowsy. Patient 1 was cool and clammy. Lung sounds were clear. Patient 1 was complaining of pain to lower back and abdomen was distended. Unable to get blood pressure reading. One was in the 70's. Patient was still complaining of pain.."

During a review of the Nursing Progress Note dated August 15, 2017 at 10:35 PM written by the Intensive Care Unit Registered Nurse (ICU RN 2) indicated: "The On Call Surgeon MD 1 was at the bedside, spoke with Patient one's family and discussed surgery to be done..."

During a review of the operative report dated August 18, 2017 at 7:25 PM, written by the On Call Surgeon MD 1 indicated: "Preoperative diagnosis was septic schock (a condition in which the blood pressure falls dangerously and it may occur in patients with serious infections) with small bowel obstruction and the post operative diagnosis were Septic shock with small bowel obstruction, severe ischemia with patchy necrosis of the entire small bowel (restriction of blood supply to the organ and the death of most of the cells in the organ), from just below the ligament of Treitz (a bad smooth muscle extending from the junction of the duodenum and jejunum) to just above the ileocecal valve (a sphincter muscle valve that separates the small intestine and the large intestine), and small bowel obstruction, due to a knuckle of distal ileum (final section of the small intestine) stuck within the superior aspect of the closure of the cesarean section which she had seven days ago..."

During a review of the final autopsy report (a post mortem exam to discover the cause of death) dated August 23, 2017 at 10:30 AM, indicated: "Cause of Death were complications of diffuse small bowel ischemic necrosis (damage to part of the intestine. It is due to a decrease in the blood supply to the area), including acute myocardial infarction
(a heart attack happened when the blood vessels that supply blood to the heart (coronary arteries) are blocked and leaded to heart failure) and multi-organ failure (a progressive dysfunction of two or more organ systems in a critically ill patient)."

During an interview with the Surgeon (S 2) on January 4, 2018 at 2:24 PM, he stated that the Emergency Department Physician Assistant (ER PA 1) should have recommended a (KUB) Kidneys, Ureters, and Bladder (x-ray of the abdomen, providing information about abdominal organs).


During an interview with the On Call Surgeon MD 1 on January 4, 2018 at 3:36 PM, the Emergency Department Physician Assistant (ED PA 2) that saw the patient in the emergency department told me that Patient 1 was stable.


During an interview with the On Call Surgeon MD 1 on January 4, 2018 at 3:37 PM, the On Call Surgeon MD 1 stated, whoever closed the caesarean section is at fault. The Emergency Department Physician Assistant ( ER PA 1) should have called the Obstetrics and Gynecology because patient 1 was a post op caesarean section for seven days.
which is a common complication of a status post C-section.

During an interview with the Physician (MD 1) on January 5, 2017 at 9:34 AM, the MD 1 stated he saw her in the emergency department and her abdomen was distended and was tachycardia (high pulse rate). The Emergency Department Physician Assistant (ER PA 1) should have ordered a KUB (KUB) Kidneys, Ureters, and Bladder (x-ray of the abdomen, providing information about abdominal organs) and Cat scan (x-ray tests that produce cross-sectional images of the body using x-rays and a computer).


During an interview with the Emergency Department Physician (ER MD 1) on January 5, 2018 at 9:59 AM, the ER MD 1 stated he trusted the Emergency Department Physician Assistant (ER PA 1) assessment of Patient 1 and also stated he cannot be everywhere at the same time.


During an interview with the Emergency Department Physician (ED MD 2) on January 5, 2018 at 10:52 AM, the ED MD 2 stated he spoke with the Obstetrics and Gynecology (OBGYN MD 1) and I told her the patient was unstable. We should have seen the patient sooner and called a second surgeon and placed Patient on a monitor (monitors the patients heart rate blood pressure, and heart electrical wave activity) sooner. The ED MD 2 also stated they had limited number of monitors and that's why patient was in the emergency department hallway.


During an interview with the Obstetrics and Gynecology (OBGYN MD 2) on January 5, 2018 at 11:38 AM, the OBGYN MD 2 stated that the facility should enforce two surgeons because they only had one surgeon on call.


During an interview with the Chief of Surgery (COS) on January 5, 2018 at 2:45 PM, stated that the physicians should've called any available surgeon and followed the chain of command because she was never notified regarding patient 1. I would have called another available surgeon.


During an interview with the President of Medical Staff (POMS) on January 8, 2018 at 10:29 AM, stated that next time the physicians will have better communication among them and have other opportunities for improvement for example,the time frame for which the consultants should see the patient.


A review of the facility's "Medical Staff Rules and Regulations" dated March 22, 2017 indicated: ..."In the event that the Emergency Department physician requests an in person consultation, the consultant on-call should attend to the patient in the Emergency Department and perform an appropriate consultation. The timeframe of the in-person consultation shall be dependent upon the urgency of the patient's medical condition. In the event that the on-call physician cannot respond because of situations beyond his or her control, the alternate covering physician will be contacted..."
VIOLATION: MEDICAL STAFF ACCOUNTABILITY Tag No: A0347
Based on interview and record review, the facility failed to provide evidence of tuberculin skin test (a test to determine the presence of infection with (TB) tuberculosis (a bacterial infection of the lungs) annual screening for one of eleven sampled medical staff. This failure had the potential to spread undetected TB infection to a universe of 167 patients in the facility.

Findings:

During a review of the personnel file for the Physician (P1) indicated the P1 TB skin test results were documented as being negative on December 30, 2016. No current TB test was documented as being performed annually since December 30, 2016.

During an interview with the Medical Staff Coordinator (MSC) on January 8, 2018 at 11:38 AM, the MSC stated that the physician should have done their TB skin test annually.

A review of the facility's policy and procedure titled, "Tuberculosis Screening and Exposure For Medical Staff and Allied Health Professionals" dated May 2012, included the following: "All physicians and allied health professionals upon appointment, with provide evidence of Tuberculosis screening. Thereafter, evidence of annual TB screening must be provided. It is the responsibility of Medical Staff Administration to ensure that all physicians and allied health professionals upon appointment provide evidence of TB screening that is current within twelve months of the appointment and annually, thereafter..."
VIOLATION: MEDICAL STAFF RESPONSIBILITIES Tag No: A0358
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, and record review, the Medical Staff failed to ensure Patient 1 received proper diagnosis and treatment. This failure resulted in the delay in treatment for Patient 1.


Findings:

a). During a review of the medical record for Patient 1 on January 3, 2018 at 1:56 PM the admission record indicated Patient 1 was admitted on [DATE] and discharged on [DATE] with a diagnosis of acute urinary tract infection (an infection of the urinary tract).

During a review of the Nursing assessment dated [DATE] at 5:53 PM, indicated: "Patient 1 complained of vomiting and low abdominal pain for two days. Patient is a seven day post partum (the period following birth).


During a review of the Emergency Department Physician Notes dated August 14, 2017 at 6:03 PM and written by the Emergency Department Physician Assistant (ER PA 1) indicated: "The twenty-eight year old female presented with vomiting x 2 days. Patient 1 claimed approximately ten episodes and denied diarrhea (loose stools) or dysuria (painful or difficult urinating). Patient 1 was post partum (the period following birth) x 7 days.


During the review of the medical record for Patient 1 was conducted with the Quality Coordinator Registered Nurse (QCRN) on January 8, 2018 at 8:40 AM indicated there was no documentation that the Emergency Department Physician (ER MD 1) saw the patient on August 14, 2017.


During a concurrent interview with the QCRN confirmed that there was no documentation that the ER MD 1 saw patient on August 14, 2017.


b). During a review of the medical record for Patient 1 on January 3, 2018 at 1:57 PM the admission record indicated Patient 1 was admitted on [DATE] with a diagnosis of small bowel obstruction (a mechanical or functional obstruction of the intestines which prevents the normal movement of the products of the digestion. The signs and symptoms include abdominal pain and vomiting. In mechanical obstruction is the cause of about 5 to fifteen percent of cases with severe abdominal pain of sudden onset requiring admission to hospital) and passed away on August 17, 2017.


During a review of the Emergency Department Physician Notes dated August 15, 2017 at 9:50 AM and written by the Emergency Department Physician Assistant (ED PA 2) indicated: "Twenty-eight year old female complained of lower back pain and abdomen pain for two days. Patient 1 reported her back pain was in the center, and denied injury. Pain was worse with movement and touch. Abdomen pain in the left lower quadrant that began at 01:00 this AM. History of a caesarean section that was done eight days ago and also had history of previous caesarean sections (a surgical procedure in which one or more incisions are made through a mothers abdomen and uterus to deliver a baby). Patient 1 reported that this pain was different. Patient 1 was seen in the emergency department yesterday (August 14, 2017) with the same issue. Patient also reported heavy vaginal bleeding..."


During a review of the CT of the abdomen and pelvis without a contrast (x-ray tests that produce cross-sectional images of the body using x-rays and a computer) dated August 15, 2017 at 10:50 AM indicated: "Distal small bowel obstruction (a mechanical or functional obstruction of the intestines which prevents the normal movement of the products of the digestion. The signs and symptoms include abdominal pain and vomiting. In mechanical obstruction is the cause of about 5 to fifteen percent of cases with severe abdominal pain of sudden onset requiring admission to the hospital).

During a review of the Emergency Department Physician Notes dated August 15, 2017 at 3:50 PM and written by the Emergency Department Physician (ED MD 2) indicated: ..."Care was transitioned to the Obstetrics and Gynecology (a physician that delivers babies and specializes in treating diseases of the female reproductive organs) (OBGYN MD 1) at 1:00 PM. At 3:30 PM her heart rate had increased to 180's. Her blood pressure had dropped in the high 60's. Her pulse was palpable but rapid. There was approximately one liter of nasogastric tube (insertion of a plastic tube through the nose, past the throat and down the stomach) output which was dark in color and tested positive for hemacult (abnormal bleeding is occurring in the digestive tract). The OBGYN MD 1 was contacted from the emergency department and updated her about the patient's condition, expressing that the patient was critically ill and would require intensive care unit care. The OBGYN MD 1 stated she was currently at another hospital . The OBGYN MD 1 arrived at this hospital's emergency department at around 5:00 PM as well as Physician (MD 1) . The MD 1 called the (On Call Surgeon MD1) to request emergent surgical consultation for possible ischemic bowel (narrowing of the arteries that supply blood and oxygen to the intestines. As the narrowing worsens, the arteries become unable to supply enough oxygen to meet demand. This can cause abdominal pain and damage to the intestines). The ED MD 2 went off shift at 6:00 PM. At that time patient had not yet been taken to the operating room."

During a review of the Nursing progress notes dated August 15, 2017 at 7:15 PM written by the Intensive Care Unit Registered Nurse (ICU RN 1) indicated: "Received patient from the emergency department. Patient 1 was oriented but drowsy. Patient 1 was cool and clammy. Lung sounds were clear. Patient 1 was complaining of pain to lower back and abdomen was distended. Unable to get blood pressure reading. One was in the 70's. Patient was still complaining of pain.."

During a review of the Nursing Progress Note dated August 15, 2017 at 10:35 PM written by the Intensive Care Unit Registered Nurse (ICU RN 2) indicated: "The On Call Surgeon MD 1 was at the bedside, spoke with Patient one's family and discussed surgery to be done..."

During a review of the operative report dated August 18, 2017 at 7:25 PM, written by the On Call Surgeon MD 1 indicated: "Preoperative diagnosis was septic schock (a condition in which the blood pressure falls dangerously and it may occur in patients with serious infections) with small bowel obstruction and the post operative diagnosis were Septic shock with small bowel obstruction, severe ischemia with patchy necrosis of the entire small bowel (restriction of blood supply to the organ and the death of most of the cells in the organ), from just below the ligament of Treitz (a bad smooth muscle extending from the junction of the duodenum and jejunum) to just above the ileocecal valve (a sphincter muscle valve that separates the small intestine and the large intestine), and small bowel obstruction, due to a knuckle of distal ileum (final section of the small intestine) stuck within the superior aspect of the closure of the cesarean section which she had seven days ago..."

During a review of the final autopsy report (a post mortem exam to discover the cause of death) dated August 23, 2017 at 10:30 AM, indicated: "Cause of Death were complications of diffuse small bowel ischemic necrosis (damage to part of the intestine. It is due to a decrease in the blood supply to the area), including acute myocardial infarction
(a heart attack happened when the blood vessels that supply blood to the heart (coronary arteries) are blocked and leaded to heart failure) and multi-organ failure (a progressive dysfunction of two or more organ systems in a critically ill patient)."

During an interview with the Surgeon (S 2) on January 4, 2018 at 2:24 PM, he stated that the Emergency Department Physician Assistant (ER PA 1) should have recommended a (KUB) Kidneys, Ureters, and Bladder (x-ray of the abdomen, providing information about abdominal organs).


During an interview with the On Call Surgeon MD 1 on January 4, 2018 at 3:36 PM, the Emergency Department Physician Assistant (ED PA 2) that saw the patient in the emergency department told me that Patient 1 was stable.


During an interview with the On Call Surgeon MD 1 on January 4, 2018 at 3:37 PM, the On Call Surgeon MD 1 stated, whoever closed the caesarean section is at fault. The Emergency Department Physician Assistant ( ER PA 1) should have called the Obstetrics and Gynecology because patient 1 was a post op caesarean section for seven days.
which is a common complication of a status post C-section.

During an interview with the Physician (MD 1) on January 5, 2017 at 9:34 AM, the MD 1 stated he saw her in the emergency department and her abdomen was distended and was tachycardia (high pulse rate). The Emergency Department Physician Assistant (ER PA 1) should have ordered a KUB (KUB) Kidneys, Ureters, and Bladder (x-ray of the abdomen, providing information about abdominal organs) and Cat scan (x-ray tests that produce cross-sectional images of the body using x-rays and a computer).


During an interview with the Emergency Department Physician (ER MD 1) on January 5, 2018 at 9:59 AM, the ER MD 1 stated he trusted the Emergency Department Physician Assistant (ER PA 1) assessment of Patient 1 and also stated he cannot be everywhere at the same time.


During an interview with the Emergency Department Physician (ED MD 2) on January 5, 2018 at 10:52 AM, the ED MD 2 stated he spoke with the Obstetrics and Gynecology (OBGYN MD1) and I told her the patient was unstable. We should have seen the patient sooner and called a second surgeon and placed Patient on a monitor (monitors the patients heart rate blood pressure, and heart electrical wave activity) sooner. The ED MD 2 also stated they had limited number of monitors and that's why patient was in the emergency department hallway.


During an interview with the Obstetrics and Gynecology (OBGYN MD 2) on January 5, 2018 at 11:38 AM, the OBGYN MD 2 stated that the facility should enforce two surgeons because they only had one surgeon on call.


During an interview with the Chief of Surgery (COS) on January 5, 2018 at 2:45 PM, stated that the physicians should've called any available surgeon and followed the chain of command because she was never notified regarding patient 1. I would have called another available surgeon.


During an interview with the President of Medical Staff (POMS) on January 8, 2018 at 10:29 AM, stated that next time the physicians will have better communication among them and have other opportunities for improvement for example,the time frame for which the consultants should see the patient.


A review of the facility's "Medical Staff Rules and Regulations" dated March 22, 2017 indicated: ..."In the event that the Emergency Department physician requests an in person consultation, the consultant on-call should attend to the patient in the Emergency Department and perform an appropriate consultation. The timeframe of the in-person consultation shall be dependent upon the urgency of the patient's medical condition. In the event that the on-call physician cannot respond because of situations beyond his or her control, the alternate covering physician will be contacted..."