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.
|ST FRANCIS HOSPITAL||5959 PARK AVE MEMPHIS, TN 38119||Aug. 25, 2016|
|VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING||Tag No: A0144|
|Intakes: TN 256
Based on policy review, medical record review and interview, the facility failed to ensure care was provided in a safe manner, related to allergy assessment and treatment, for 1 of 3 (Patient #2) sampled patients.
The findings included:
1. The facility's "Latex Allergy" policy documented, "...All patients admitted to [stated facility]and its services will be assessed for a history of latex allergy. Individuals with known sensitivity to latex or individuals at high risk to develop latex sensitivity should be treated as if they have a known allergy...Employees providing direct patient care are responsible for obtaining latex free supplies for those patients identified to be at great risk for developing latex sensitivity and/or those patients with a known latex sensitivity..."
2. Medical record review for Patient #2 revealed a Patient Demographics screen, dated 5/17/16. Latex is listed on the allergy screen with a statement that documented, "...patient denies having a reaction/entered due to multiple environmental allergies per latex screening..."
Patient #2's operative report documented the date of surgery as 5/23/16. Documentation in the pre-operative narrative at 6:14 AM on 5/23/16, stated that the allergy band was "on". A Pre-Anesthesia & Sedation Assessment and Plan, dated 5/23/16, documented, "Allergies: ...latex..." An anesthesia intra-operative note, dated 5/23/16, documented, "...Allergies...latex..." The operative report on 5/23/16 documented, "...A foley catheter was placed..."
Patient #2's Discharge Summary documented, "...the patient was noted to have what appeared to be a contact dermatitis...presumably secondary to Latex allergy from a Latex foley that had been placed for bladder drainage after cystotomy repair..."
3. During an interview with the Quality Director on 8/1/16 at 12:00 PM in the administration office, the Director verified that the foley catheter placed during surgery was a latex foley catheter.
4. During an interview with the Customer Relations representative on 8/1/16 at 11:20 AM in the administration office, the representative verified that the operating room did not have Patient #2's procedure listed as a latex allergy case.