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Based on staff interview, observation of patient care, and review of hospital policies, it was determined the facility failed to ensure the implementation of procedures to avoid potential transmission of infections and communicable diseases. This directly impacted 1 of 1 patients whose care was observed (#34) and had the potential to impact all staff and patients in the facility. Failure to follow policies and standard precautions had the potential to allow for transmission of infections. Findings include:

1. On 4/15/13 at 4:20 PM an RN was observed on the MED/SURG floor entering a patient's room without first performing hand hygiene. The RN picked up the patient's incentive spirometer - a device placed in the patient's mouth that is used to measure the air inhaled into the lungs - and gave it to the patient to use. The RN then picked socks up off the floor and placed them in a chair. The RN spoke to the patient briefly and then left the room without performing hand hygiene. She was then observed walking to the nurses station where she picked up the telephone at the desk. The RN did not perform hand hygiene.

The same RN was observed administering medications to Patient #34 on 4/17/13 beginning at 9:10 AM. Upon entering Patient #34's room, the RN washed her hands in the sink before using the computer in Patient #34's room to pull up her medication profile. The RN then scanned Patient #34's armband and handled the medication that had been brought into Patient #34's room. She then stated she had to retrieve another medication and left the room, she did not perform hand hygiene after leaving Patient #34's room. She was observed to return to the medication drawer and remove another medication. The RN returned to Patient #34's room and again pulled up the medication profile on the computer. The RN did not perform hand hygiene upon entering the room. The RN exited Patient #34's room again at 9:35 AM and returned to Patient # 34's room with medication cups. The RN opened medications in individual cups, then pulled up Patient #34 medication profile. The RN then scanned Patient # 34's armband and administered medications. The RN did not perform hand hygiene upon entering the room or before handling and giving medications.

The policy "Infection Prevention, Facility Wide," reviewed/revised 3/04/13, stated "Hand hygiene is the single most important control measure in the prevention of the spread of infection." The policy goes on to state hand hygiene must be performed before and after contact with patients and upon entry and exit from patient rooms.

The Clinical Supervisor for MED/SURG and ICU was interviewed on 4/18/13 beginning at 10:00 AM. She confirmed the RN did not follow hospital policy for hand hygiene.

Hand hygiene was not performed.



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2. The Mother/Baby unit and C-Section surgical areas were toured on 4/16/13 from 8:30 AM to 10:30 AM. The OB Manager was present for the tour of the Mother/Baby unit, and an RN was present for the C-Section (Cesarean Section, delivery of a baby through an abdominal incision) surgical area tour. Infection prevention standards were not followed in the Mother/Baby unit and C-Section surgical areas as follows:

a. In the Nursery:

- a hemostat (a surgical instrument used to clamp blood vessels) was found below the mattress on the radiant warmer. The nurse was not able to determine if the hemostat was dirty or clean, although she stated the radiant warmer had been cleaned and set up for a new patient.

-an open, undated liter bottle of sterile water was found on a shelf in a lower cabinet. The OB Manager stated it was a single use item, and should have been discarded,

- a partial-fill 100 cc bag of Normal Saline IV fluid that had needle puncture marks was on a shelf in a lower cabinet. A piece of tape was on the bag with "6/01/13" written in ink, however, the manufacturer's printed expiration date was 5/01/13. The OB Manager confirmed the partial-fill had been punctured, and should not have remained with other IV fluids on the shelf. She stated she did not know why someone would have written the expiration date 1 month after the manufacturer's printed expiration date. She discarded the partial-fill.

b. The "Dirty Utility Room" off the main hallway in the mother/baby unit:

- a 1/3 full gallon container of ultrasound gel was not dated with the open date or expiration date,

- a small refrigerator contained multiple gallon size zip-lock bags with bloody tissue inside. Under the bags was a pool of pink fluid on the floor of the refrigerator. The OB Manager stated the bags contained placentas. She stated the placenta would be sent to pathology for studies if ordered by the physician, and in some cases they would go home with the parents if they requested. She stated the placentas would otherwise remain in that refrigerator for an undetermined period of time then be taken to the hospital lab for disposal.

There was no procedure for staff regarding proper disposal of the tissues after a delivery.

c. A patient refrigerator in the hallway behind the nurses' station was noted to have a discolored door seal from food or other substances.

d. Patient room 226:

- in a closet, a red biohazard bag with undetermined contents,

- tray tables and counter tops had visible dust,

- IV pole had sticky areas, as if from tape adhesive. The OB Manager confirmed the patient room was dusty, and noted the biohazard bag in the closet. She stated the room was "clean" and set up for a potential OB patient, and did not know why the red biohazard bag had something in it. The OB Manager stated she did not conduct surveillance of housekeeping activities and did not know how this was monitored.

e. In the C-Section surgical area, on the Anesthesia Cart:

- "Artificial Tears" ointment, single dose tube, opened and undated,

- "Lubrifresh PM" ointment, single dose tube, opened and undated,

- "Surgilube" large tube, opened and undated,

- paper tape strips hanging from a shelf on the anesthesia cart.

The staff RN confirmed identification of unlabeled/undated items in the C-Section OR.

The facility failed to follow policies and standard precautions.

Based on staff interview, observation, and review of facility policy and procedures, it was determined the facility failed to maintain sanitary and safe food handling practices in the kitchen, visitor, and staff dining areas. The failure to maintain safe food handling practices had the potential to expose hospital patients, staff, and visitors to infection and food borne illness. Findings include:

1. During a tour of the hospital's kitchen on 4/17/13 from 10:30 to 11:50 AM with the Food Service Manager, the following sanitation concerns were noted:

a. The following foods were noted to be undated, inadequately labeled, and/or expired:

i. Refrigerator #1:

- undated containers of grapes and tangerines,
- plastic containers of parmesan cheese and mozzarella cheese, unlabeled and undated,
- plastic container of beef broth, unlabeled and undated,
- five packages of tilapia fillets had expired 4/16/13,
- bulk butter, unwrapped and unlabeled, and undated
- plastic container of sliced carrots, unlabeled and undated,
- plastic container of mango salsa, expired 4/16/13.

ii. Freezer #2:

- plastic bag of opened pepperoni, unlabeled, undated.

iii. Freezer #3:

- plastic bag of blueberries, open, unlabeled and undated,
- plastic bag of blackberries, open, unlabeled and undated,
- plastic bag of mangos, open, unlabeled and undated,
- a box of chocolate chips was unlabeled, open, and undated,
- a box of M&M's was unlabeled, open, and undated.

iv. Dry food storage area:

- a package of panko bread crumbs was unlabeled and undated,
- three packages of opened cookies were unlabeled and undated,
- bulk storage bins of sugar, white flour, and whole wheat flour were unlabeled,
- a box of wine on a metal shelf was leaking from the dispenser spout,
- a zip-lock bag of tortilla strips was unlabeled and undated,
- salt, pepper, and flour containers were unlabeled.

An undated policy, titled "Nutrition Department Infection Control: Food Service Infection Control Practices, Food Storage, Temperature Compliance, Temperature Logs, and Work Area Sanitation Practices," stated "Ready-made or packaged foods after opening will be dated and placed in cold storage. Opened foods will be disposed of after 7 days. Leftovers will be used within 72 hours."

During the tour of the kitchen, the Food Service Manager confirmed the items should have been covered and labeled and/or discarded. He removed and discarded the expired foods at the time of the tour.

b. Personal equipment for the expression of breast milk was noted on a rumpled paper towel on the same shelf with patient eating utensils.

The Food Service Manager stated the equipment belonged to a staff member who had just returned from maternity leave. He confirmed the equipment posed a risk for blood and body fluid contamination with the clean patient eating utensils.

c. Plastic cling wrap had been applied around 3 storage racks that held clean dishes and food items. The plastic wrap was torn and stained with splatter marks. White dishes stored on one rack were dusty and stained. Salt and pepper shakers, with visible residual of contents were noted on a rack with clean items.

The Food Service Manager stated the plastic wrap was placed at the lower portion of the racks to prevent items from falling off the shelves. He stated he did not know when the plastic wrap had been placed, or how often it was to be changed. The Food Service Manager confirmed some items on the clean storage shelves were dusty and stained.

d. The filters over the grill area of food preparation were dusty and greasy. The Food Service Manager stated the filters were steam cleaned by a contracted agency on a quarterly basis. He was unable to provide a schedule for filter cleaning.

e. In the staff and visitor dining room, the Food Service Manager tested salad bar items on the cold food service table. Safe food storage temperatures were not maintained as follows:

- hard boiled eggs, 44 and 52 degrees Fahrenheit on multiple attempts.
- potato salad, 45 degrees Fahrenheit.

The Food Service Manager confirmed the salad bar items were not maintained at safe temperatures.

A policy titled "Nutrition Department Infection Control," undated, stated " ... cold food service tables must maintain foods below 40 degrees F. Periodic internal temperature testing will be accomplished during meal service hours."

On 4/18/13 at 1:45 PM, the Food Service Manager produced a Food Establishment Inspection Report dated 11/21/12. The report indicated the facility's kitchen had been out of compliance with item number 3-501.16 of the Idaho Food Code. The report stated the salad bar refrigeration unit had measured temperatures in the "mid 50's." Instructions on the report recommended the facility contact a refrigeration technician and come back into compliance by 12/01/12.

f. The soda machine spigots and drains had brown build-up.

The Food Service Manager stated the soda machines were cleaned daily with hot water.

The facility did not maintain food sanitation and acceptable hygiene practices in the kitchen.

Based on review of patient medical records, policies, and staff interview, it was determined the facility failed to ensure comprehensive nursing care plans were developed for 2 of 4 patients (#3 and #18) on the Mother/Baby Unit whose records were reviewed. Failure to develop a nursing care plan inclusive of all pertinent nursing needs had the potential to negatively impact the continuity of patient care. Findings include:

A policy, "Medical Record Content," undated, stated "The patient care record will reflect an interdisciplinary process of care including ...nursing process (assessment, planning, implementation, and evaluation.)" Nursing care plans were incomplete and did not include goals, interventions, and monitoring for activity in physiologic status, as follows:

1. Patient #3 was a female infant who experienced distress prior to delivery and was delivered by emergency C-Section on 4/10/13 at 5:31 PM. She required resuscitative efforts to support her breathing. Preparations were made for an emergent transfer to a facility that could support her need for higher level of care.

Patient #3 remained at the facility from her delivery at 5:31 PM on 4/10/13 until 4/11/13 at 5:00 AM, a total of 11.5 hours after her delivery. There was no documentation by nursing after 8:43 PM, more than 8 hours had elapsed without documentation by the nursing staff. Her medical record indicated a total of 7 X-rays had been taken, which described placement of a breathing tube, tube insertions for collapsed lungs and umbilical line placement. Patient #3's medical record did not address her altered respiratory status. There was no nursing care plan with goals and interventions related to this diagnosis, procedures performed, or documentation of Patient #3's response to the interventions performed. There was no indication the mother of Patient #3 had been updated regarding her status.

During an interview on 4/17/13 at 9:30 AM, the OB Nurse Manager reviewed Patient #3's Medical Record and confirmed nursing documentation had not been done.

A nursing care plan for Patient #3 was not initiated, implemented and revised.

2. Patient #18 was a 28 year old female admitted on 4/10/13, and had a C-Section when it was noted her baby was in distress. Her infant was emergently transferred to a NICU (Neonatal Intensive Care Unit) at a hospital in another state for higher level of care. Patient #18's discharge summary, dated 4/13/13, indicated she had a post-partum hemorrhage which resulted in anemia and dizziness. The post-partum assessment for Patient #18, dated 4/10/13 noted she had financial, housing and other personal problems that worried her. In addition, the assessment stated she considered herself a very nervous person that worries much of the time. The assessment identified concerns, but there was no nursing care plan specific to her individual needs of anemia, anxiety related to her critically ill newborn, financial concerns and separation anxiety related to her newborn being transferred to another facility.

The OB Nurse Manager was interviewed on 4/16/13 at 2:10 PM. She reviewed Patient #18's medical record and confirmed the nursing care plan did not contain specific goals and interventions related to her unique individual needs.

Patient #18's care plan was not developed and updated.

Based on record review, policy review, and staff interview, it was determined the hospital failed to ensure informed consent was obtained for 5 of 8 surgical patients' whose records were reviewed. (#18, #23, #30, #34, and #39). This resulted in treatments and procedures performed without a properly executed informed consent.
Findings include:

1. Patient #23 was a 57 year old male admitted to the facility on 11/15/12 for a right nephrectomy- removal of the right kidney. The "Verification of Informed Consent for Anesthesia" documented the type of surgery to be performed as "R nephrecto" and documented an abbreviation of the surgeon's last name. The consent was signed by Patient #23 but was not dated or timed. The anesthesia provider signed the consent on 11/15/12 at 10:00 AM. There was no signature by a witness from the facility.

The Clinical Supervisor of the OR and the Clinical Supervisor for Perioperative Services reviewed the record and were interviewed on 4/18/13 beginning at 12:05 PM. They agreed that the wording of the procedure as "R nephrecto" was unclear, as was the abbreviated version of the surgeon's name. They confirmed that because the wording of the procedure and surgeon on the consent was unclear, informed consent was not properly executed.

2. Patient #30 was a 57 year old male admitted to the hospital on 1/26/13 for an incision and drainage of a lacerations on his left hand. The "Verification of Informed Consent for Anesthesia" documented the type of surgery to be performed as "I + D etc L hand LACS" and documented an abbreviated version of the surgeon's last name. The consent was signed by Patient #30 on 1/26/13 at 4:45 PM. The anesthesia provider signed the consent on 1/26/13 at 4:45 PM. A witness from the hospital also signed the consent on 1/26/13 at 4:45 PM.

The Clinical Supervisor of the OR and the Clinical Supervisor for Perioperative Services reviewed the record and were interviewed together on 4/18/13 beginning at 12:05 PM. They agreed that the wording of the procedure as "I + D etc L hand LACS" was unclear, as was the abbreviated version of the surgeon's name. They confirmed that because the wording for the procedure and the surgeon's name on the consent was unclear, informed consent was not properly executed.

3. Patient #34 was a 44 year old female admitted to the hospital on 4/16/13 for back surgery- lumbar spine level 5 through sacral spine level 1 anterior decompression and fusion with instrumentation. The "Verification of Informed Consent for Anesthesia" documented the type of surgery to be performed as "ALIF." The surgeon was documented only by two initials. Patient #34 signed the consent on 4/16/13 but there was no time documented. The anesthesia provider signed the consent on 4/16/13 at 7:10 AM and an RN signed as a witness on 4/16/13 at 7:28 AM.

The Clinical Supervisor of the OR and the Clinical Supervisor for Perioperative Services reviewed the record and were interviewed together on 4/18/13 beginning at 12:05 PM. They agreed that the wording of the procedure as "ALIF" was unclear, as were the initials of the surgeons name. They confirmed that because the wording on the consent for the procedure and the surgeon's name was unclear, informed consent was not properly executed.

4. Patient #39 was a 33 year old female admitted to the hospital on 11/13/12 for back surgery- cervical spine level 5 through 6 anterior decompression and fusion with instrumentation. The "Verification of Informed Consent for Anesthesia" documented the type of surgery to be performed as "C5-C6 decomp/instrument."

The Clinical Supervisor of the OR and the Clinical Supervisor for Perioperative Services reviewed the record and were interviewed together on 4/18/13 beginning at 12:05 PM. They agreed that the wording of the procedure as "C5-C6 decomp/instrument" was unclear. They agreed that because the wording on the consent was unclear, informed consent was not properly executed.

5. Patient #18 was a 28 year old female admitted to the hospital on 4/10/13. A consent for a Cesarean Section delivery was signed by Patient #18 and her physician on 4/10/13 at 5:00 PM. The section on the consent for a signature of witness, as well as, the date and time was left blank.

On an "Informed Consent for Epidural or Intrathecal for Labor Pain Control and/or Cesarean," Patient #18 signed on 4/10/13 at 11:00 AM, the "Signature of Anesthesia Provider" with date and time was left blank. The section on the consent for a signature of witness, as well as, the date and time was left blank.

During an interview on 4/16/13, the Charge Nurse on the Mother/Baby unit reviewed Patient #18's medical record and confirmed the consent forms had not been completed. She was unable to explain why the forms did not include an anethesia provider and witness signatures with dates and times.

The hospital's "Medical Record Content" policy, undated, stated a properly executed informed consent form must contain the name of the procedure, and the name of the practitioner performing the procedure. The policy also states the consent form must include the date and time consent was obtained. The facility failed to adhere to this policy.

Informed consent was not properly executed.

Based on record review and staff interview, it was determined the hospital failed to ensure records included all nursing notes, documentation of complications, and other pertinent information necessary to monitor patient progress for 2 of 37 patients ( #3, #20) whose records were reviewed. This resulted in an inability to clearly determine the course of patient care. Findings include:

1. Patient #20 was a 76 year old female admitted to the hospital on 11/20/12 for right shoulder surgery. Her medical record contained the following:

- An "ANESTHESIA PAR OPS ORDER," signed by the CRNA on 11/20/12 at 8:30 AM, documented Patient #20 had an allergy to latex.

- The "[hospital name] Admission and Discharge Medication Reconciliation Orders" documented allergies to Indocin and Latex. Indocin is a non-steroidal anti-inflammatory pain medication.

- The "PHYSICIAN POSTOPERATIVE ORDERS," signed by the physician 11/20/12 at 10:00 AM, documented allergies to Indocin and Latex

- A "PRE-OP CLINIC" note, unsigned and undated, stated Patient #20 was allergic to Indocin, Oxycodone, and Vicodin. Oxycodone and Vicodin are narcotic pain medications.

- An H&P, completed by the physician on 11/13/12 at 3:40 PM and signed as reviewed with no changes on 11/20/12 at 7:28 AM, listed Patient #20's allergies as Oxycodone and Vicodin.

The Clinical Supervisor of the OR and the Clinical Supervisor of Perioperative Services reviewed the record and were interviewed together on 4/18/13 beginning at 12:05 PM. They confirmed documentation of Patient #20's allergies was unclear. They agreed unclear documentation of allergies lead to a risk of medication errors and adverse patient outcomes.

Allergies were not clearly documented.

2. Patient #3 was born at the hospital on 4/10/13 at 5:53 PM by emergent C-Section. The "Newborn History and Physical, dated 4/10/13 at 8:11 PM, indicated she required resuscitation at the time of delivery and was transferred to a NICU at a hospital in another state. The record documented her time of discharge as 4/11/13 at 5:30 AM.

a. Documentation pertaining to Patient #3's course of treatment was unclear as follows:

i. On 4/10/13 at 6:30 PM the RN documented Patient #3 had an IV line in her left hand and was receiving a bolus of fluid through it. It was unclear when the IV was placed.

ii. On 4/10/13 at 8:20 PM there was documentation that 7-8 ml of thick, dark green "residual" had been "discarded" from an OG tube. There was no documentation of when the OG tube was placed

iii. The last entry made by hospital nursing staff was on 4/10/13 at 8:46 PM. It stated that the emergency transport team had assumed care of Patient #3. There was no documentation by hospital nursing staff after this time. Patient #3 was discharged 4/11/13 at 5:30 AM - almost nine hours later.

iv. An X-ray, interpreted and signed by the radiologist on 4/10/13 at 6:40 PM, stated Patient #3 had developed bilateral pneumothoraxes - collapsed lungs. There was no documentation by nursing related to the pneumothoraxes or subsequent treatment of pneumothoraxes. There was no order for the chest X-ray.

v. An X-ray, interpreted and signed by the radiologist on 4/10/13 at 8:30 PM, noted the placement of the endotracheal tube after intubation. It also noted pneumothoraxes were still present. There was no order for the chest X-ray.

vi. An X-ray, interpreted and signed by the radiologist on 4/10/13 at 10:11 PM, confirmed the placement of a chest tube in the right side of Patient #3's chest. There was no documentation to indicate a chest tube had been ordered. There was no documentation by nursing staff about the chest tube. There was no order for the chest X-ray.

vii. An X-ray, interpreted and signed by the radiologist on 4/10/13 at 10:20 PM, noted a decrease in the sizes of the pneumothoraxes. There was no documentation by nursing staff related to this. There was no order for the chest X-ray.

viii. An X-ray, interpreted and signed by the radiologist on 4/11/13 at 12:12 AM, noted the placement of a chest tube on the left side of Patient #3's chest and noted an increase in size to the left pneumothorax. There was no documentation to indicate a chest tube had been ordered. There was no documentation by nursing staff about the chest tube. There was no order for the chest X-ray.

ix. An X-ray, interpreted and signed by the radiologist on 4/11/13 at 12:30 AM, noted a decrease in size of the pneumothoraxes. There was no order for the chest X-ray. There was no documentation by nursing staff related to this X-ray.

x. An X-ray, interpreted and signed by the radiologist on 4/10/13 at 4:40 AM, noted a decrease in the pneumothoraxes but also noted an umbilical arterial catheter and an umbilical venous catheter. There was no documentation by nursing staff related to the placement of these lines. There were no orders for these lines in the medical record.

During an interview on 4/16/13 at 9:30 AM, the OB Nurse Manager reviewed Patient #3's record and confirmed there was no documentation by hospital staff after the emergency transport team assumed care of Patient #3. The OB Nurse Manager agreed that documentation should have reflected the care the hospital nursing staff provided until her discharge at 5:30 AM the next day.

b. Patient #3's medical record also contained the following delayed and incomplete documentation:

i. A form labeled "PHYSICIAN ORDERS" contained verbal orders dated 4/10/13 at 6:55 PM. The orders were signed off by an RN on 4/11/13 at 4:35 AM, which was 9 hours and 40 minutes later. There was no physician signature for these orders.

The "PHYSICIAN ORDERS" form also contained a verbal order dated 4/10/13 at 7:45 PM and a late entry verbal order for 4/10/13 at 6:30 PM. Neither of these orders was authenticated by a physician. The late entry order was documented and the verbal orders were noted by the RN at 7:30 AM on 4/11/13, two hours after Patient #3 had been discharged to another hospital.

The hospital policy "Chart Completion for Practitioners," undated, included the expectation that practitioners sign verbal orders within 24 hours.

During an interview on 4/18/13 at 2:30 PM, the Medical Records Supervisor confirmed the verbal orders had not been authenticated by the ordering physician.

Patient #3's medical record was incomplete.

3. Patient #32 was a 53 year old male admitted to the hospital on 12/08/12 at 9:30 PM through the ED for respiratory distress, liver failure and kidney failure. He was admitted to the inpatient unit and placed on comfort care/hospice care and died at 12:45 AM on 12/09/12. His medical record contained the following:

a. An "AUTHORIZATION TO RELEASE BODY" form, unsigned and undated, indicated that Patient #32 was excluded from potentially donating organs and tissues. There was no documentation on the form to indicate why he had been excluded.

b. The "AUTHORIZATION TO RELEASE BODY" documented Patient #32's body had been released to a local mortuary. There was no documentation of the time it was released.

The Clinical Supervisor of the Medical/Surgical Unit reviewed the record and was interviewed on 4/18/13 at 2:55 PM. She confirmed the documentation on the "AUTHORIZATION TO RELEASE BODY" form was incomplete.

Patient #32's medical record was incomplete.

The hospital did not ensure medical records contain authentication of orders and completed documentation.

Based on observation, interview, review of medical records, and review of policies it was determined the facility failed to ensure that, prior to receiving anesthesia, patients were examined to evaluate the potential risks and that a post anesthesia follow up report was completed prior to discharge from anesthesia services. This impacted 1 of 1 patient (#31) whose surgery was observed. Failure to ensure an adequate pre-procedure examination and post-procedure assessment had the potential to result in negative patient outcome. Findings include:

Patient #31 was a 65 year old female admitted to the facility on 4/16/13 for same day surgery on her right shoulder. Her medical record contained an H&P completed by her surgeon on 4/14/13. The surgeon indicated Patient #31 had a history of dyspnea, or shortness of breath, and had undergone a pulmonary function test to determine the cause.

On 4/16/13, beginning at 8:45 AM, Patient #31 was observed in the pre-op area. Two RN's were observed preparing Patient #31 for surgery, which included confirming home medications, and listening to Patient #31's heart and lungs with a stethoscope. At 10:00 AM, the physician was at bedside speaking with Patient #31 and her daughter about the planned procedure and recovery time. He was also observed updating the H&P. He was not observed to listen to Patient #31's heart or lungs.

At 10:10 AM, the CRNA was observed to introduce himself to Patient #31. He asked Patient #31 if she had any prior issues with anesthesia, when she had last had anything by mouth, and about her health history, including a recent diagnosis of dyspnea. Patient #31 stated she no longer had any problems with dyspnea, that it was a result of "deconditioning." Patient #31 also stated she did have a history of high blood pressure. The CRNA reviewed Patient #31's chart and then prepared to administer a nerve block to her right shoulder. After the nerve block was placed, Patient #31 was taken to the OR. The CRNA did not listen to Patient #31's heart and lungs with a stethoscope before she was taken to the OR.

The CRNA was interviewed at 11:05 AM. He stated he did not always assess each patient's heart and lungs prior to surgery. He stated that sometimes the physicians would do this assessment, but the pre-op nurses always assessed a patient's heart and lungs and they would report any abnormal findings to him. He also stated that because Patient #31 had "just had a pulmonary work-up, she was probably ok for anesthesia."

Patient #31's medical record was reviewed. It contained the results of a pulmonary function test, dictated 1/03/13, that indicated Patient # 31 had "normal lung function". The pulmonary function test was performed 102 days prior to Patient #31's surgery. The medical record also contained a "Pre/Post Anesthesia Evaluation," signed by the CRNA on 4/16/13 at 10:00 AM. This document contained information gathered by the CRNA prior to surgery including Patient #31's history of dyspnea and high blood pressure, history of anesthetic complications, medications, and airway assessment. The CRNA checked a box under the "Pulmonary" section labeled "CTAB w/o abnormal finding." The CRNA also checked a box under the "Cardiovascular" section labeled "RRR w/o abnormal findings."

The "Summary of Discharge Instructions: Outpatient Post-Procedure" form, signed by the RN at 6:45 PM on 4/16/13 documented Patient #31 was discharged to home at 6:45 PM on 4/16/13. There was no documentation to indicate Patient #31 had a post-anesthesia evaluation prior to discharge.

Appendix WR of the "Assessment/Reassessment" policy, reviewed/revised 3/12/12 stated "Evaluation of patients must be performed and documented within 48 hours of inpatient or outpatient surgery." The appendix stated the components of assessment include "Anesthesia risk, Anesthesia, Drug and allergy history, Potential anesthetic problems identified, Patient's condition prior to induction of anesthesia, (and) ASA classification as determined by pt. H&P."

The Clinical Supervisor of the OR and the Clinical Supervisor for Perioperative Services reviewed the record and were interviewed on 4/18/13 beginning at 12:05 PM. The Clinical Supervisor for Perioperative Services stated that the checked box labeled "CTAB w/o abnormal findings" meant lungs were clear to auscultation. She confirmed this indicated the CRNA had listened to Patient #31's lungs in pre-op. However, he was not observed to do this. She also stated the box checked "RRR w/o abnormal findings" meant Patient #31 had a regular heart rate and rhythm. She confirmed this also indicated the CRNA had listened to Patient #31's heart in pre-op. However, he was not observed to do this. The Clinical Supervisor for Perioperative Services stated the CRNAs and Anesthesiologists usually do assess patients' heart and lung sounds with a stethoscope prior to surgery. She stated that the pre-op RN always does this assessment and would communicate any findings to the CRNA or Anesthesiologist but the CRNA or Anesthesiologist would still be expected to assess heart and lung sounds prior to surgery. The Clinical Supervisor for Perioperative Services also confirmed there was no documentation on this form to indicate a post-anesthesia evaluation had been performed on Patient #31.

Patient #31 did not receive a pre-anesthesia evaluation or a post anesthesia follow-up.

Based on staff interview and review of quality assurance documents, it was determined the hospital failed to ensure 3 of 6 services (dietary services, infusion services, and therapy services) offered by the CAH were evaluated. This limited the CAH's ability to assess the performance of its patient care services. Findings include:

Quality assurance data was reviewed for 6 patient care services at the CAH for 2012 and 2013. No data was documented for 2 of the services, infusion and therapy services. Daily food temperature data had been collected by the dietary service. However, no analysis of the data was documented and no action that had been taken in response to data had been documented.

The Quality and Patient Safety Manager was interviewed on 4/18/13 beginning at 9:05 AM. She confirmed the lack of involvement with the quality assurance program by the infusion, therapy, and dietary services.

Three CAH services had not been evaluated by the CAH.