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.


Based on medical record review and interviews, the Hospital failed to ensure that their corrective action plan related to a retained sponge was implemented. In addition, the Hospital failed to report to the Department of Public Health that the retained sponge was not related to care provided at the Hospital, as well as to Hospital #2 where Patient #1 was transferred for tertiary care services and to the Visiting Nurse Association where Patient #1 had received home based wound care.

Findings include:

1) The Emergency Department (ED) Report dated 9/28/11 indicated that Patient #1, who was 8 months pregnant, presented to the ED with shortness of breath and intermittent lower abdominal pains. The ED physician transferred Patient #1 to the Labor and Delivery Unit for evalution.

The Labor Progress Chart dated 9/29/11 indicated Patient #1's oxygen saturation levels dropped and at 2:30 A.M. Patient #1 was moved to the Operating Room for an emergency cesarean section.

2) The Intraoperative Record dated 9/29/11 indicated that a sponge/sharps count was not performed based on the emergent need for surgery. Review of the Hospital policy indicated that this was an accepted practice, but that in lieu of a complete instrument count, an x-ray had to be obtained to assure that no retained foreign objects remained.

The Radiology Report dated 9/29/11 indicated that there were no unidentified foreign/metallic bodies identified at the surgical site.

3) Patient #1 was transferred to Hospital #2, a Tertiary Care Center Intensive Care Unit for continued care related to cardiac complications. At Hospital #2, the surgical wound dehisced [the bursting open of an incisional line].

4) The OB/GYN physician who followed Patient #1 after discharge from Hospital #2, (Physician #2), was interviewed on 1/9/12 at 10:00 A.M. Physician #2 said that when he first saw Patient #1 in his office, Patient #1's surgical wound was almost healed and there was no evidence of infection. Physician #2 said there was a small opening centrally located on the incision site that would not close. Physician #1 said wound cultures were negative for infection. Physician #2 said Patient #1 allowed him to surgically explore the area to determine the cause of delayed healing.

The operative report dated [DATE] indicated that a chronic sinus wound tract [canal like space that encapsulated the sponge] was excised and sent to pathology. The Report indicated that the Pathologist opened the sinus wound tract and found an intact wound packing paper gauze. Physician #2 said he reported the finding to Risk Management.

There was no radiopague strip noted on the sponge which Hospital #1 uses for surgical cases. Hospital #1 determined the retained sponge was not theirs. Hospital #1 did not inform Hospital #2 of the retained sponge so that an investigation could occur at their Facility.

5) Patient #1 was discharged to home with Visiting Nurse Services for wound care. The sponge could have been placed by the Visiting Nurse Service, but Hospital #1 did not notify them of the retained surgical sponge.

4) Review of Hospital #1's investigation/action plan dated 12/15/11 indicated that opportunities for improvement were identified. The action plan indicated that physicians were required to document in the operative note why the surgical team did not perform a formal 2-person sponge/sharp count and why a post-operative x-ray was obtained. The action plan also indicated that Hospital #1 was responsible for notifying Hospital #2 and the visiting nurse service about the retained sponge.

5) The Director of Quality/Risk was interviewed on 1/9/12 at 8:20 A.M. The Quality Director said the action plan had not been implemented.

Despite efforts made by the Surveyor during the onsite survey process to identify the source of the sponge and when or where it may have been placed, the identification of the source of the retained sponge was not able to be determined.