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Based on interview and record review, medical practioners providing the care or service failed to promptly authenticate the verbal orders that were given.

Findings:

On 4/5/16 at 11:00am, open medical records were reviewed. The review found 2 of the 4 medical records reviewed contained verbal orders that were not promptly authenticated by the medical provider who provided the service or care.

Specifically, 1 medical record contained a verbal order dated 4/2/16 and 1 medical record contained 8 telephone orders from 3/30/16 to 4/2/16 that were not authenticated by the medical providers that gave the orders.

Interview with the Medical Records Supervisor on 4/7/16 at 10:30am verified that non-emergent verbal/telephone orders are discouraged but need to be authenticated promptly when used.

Based on medical record review and document review, the hospital failed to secure a properly executed informed consent for anesthesia services.

Findings:

On 4/5/15 at 11:30am, open medical records were reviewed. The review found 3 of 4 open medical records did not contain a properly executed informed consent for anesthesia services by the anesthesia provider who conducted the informed consent discussion with the patient. All the individuals involved in the consent process, the patient, witness and provider did not sign, date and time the consent all at the same time.

Specifically, 1 record contained an anesthesia consent that was not dated, signed or timed by the anesthesia provider. The patient had surgery on 4/4/16. 1 record contained an anesthesia consent that was not timed by the anesthesia provider. 1 record contained an ansethesia consent that was signed, dated and timed by the patient and the nurse witness on 4/4/16 at 10:58am, but lacked a signature, date or time by the anesthesia provider. The patient went to surgery on 4/5/16. Re-review of the medical record on 4/6/16 revealed that the anesthesia consent had been signed, dated and timed (4/4/16 at 10:58) by the anesthesia provider.

Policy # 2000 (reviewed 10/15), was reviewed on 4/5/16. The policy sets forth the requirements and responsibilites for obtaining and documenting informed consent. The hospital failed to ensure that the responsible physician provided the patient with sufficient information to provide informed consent at the time the consent was signed by the patient and the nurse witness. This is not consistent with hospital policy.

Based on interview, and document review, the facility did not maintain Relative Humidity (RH) levels of 35% or greater in anesthetizing locations.

Findings:

Operating Room Humidity logs from January to April of 2016. The logs indicated that humidity levels in the operating rooms were below the required 35% RH on several days throughout this 4 month period.

For Example, on 1/20/16, the Relative Humidity in OR#1 at 12:00 AM was 17.8% and remained below 35% through 1/22/16 at 6:00AM.On 1/29/16, the Relative Humidity in OR#10 at 7:00PM was 9.4% and remained below 35% through 1/31/16 at 6:00PM.On 3/12/16, the Relative Humidity in OR#3 at 7:00PM was 27.3% and remained below 35% through 3/16/16 at 1:00PM.On 4/3/16, the Relative Humidity in OR#6 at 7:00AM was 27.3% and remained below 35% through 4/5/16 at 10:00AM.

Plant Operations staff was interviewed on 4/7/16 at 12:00PM and stated that the boiler operators acknowledge the low RH alarms, but they do not take any action.


Operating Room staff was interviewed at 12:30 PM on 4/7/16 and stated that they do not monitor low RH, they only monitor for RH over 60%.

When asked for the policy regarding RH, the hospital staff provided a policy titled: Installing, Maintaining, Appropriate Temperature & Pressure Relationships, Effective Date: 9/15.

This policy does not address the Relative Humidity percentage that is to be maintained in anesthetizing locations.

This finding was confirmed by the Director of Facilities Operations, and the Manager of Plant operations.

Based on observation the facility did not maintain a proper environment for the storage of clean and sterile supplies.

Finding #1:

During the facility tour on 4/5/2016 at 1:00 PM, it was observed that the receiving area is being used for clean and sterile supply storage. Several cardboard shipping containers are also being stored in this area.

A smaller room adjacent to the receiving area is also being used to store clean and sterile supplies. The room also contains a table, chairs, a coffee pot, a microwave, a small refrigerator, and personal belongings including a jacket and handbag.

The Association for the Advancement of Medical Instrumentation, Standard 79, states that external shipping containers should not be used in clean storage areas for infection control purposes. This standard further states that clean or sterile items should be handled separately from foodstuffs, waste material, soiled laundry, and other potential sources of contamination.

This finding was confirmed with the Manager of Plant Operations and the Distribution/Supply Chain Manager at the time of observation.

Finding #2:


34937

Based on observation, this standard is not met by:

On 04/07/16 at 0840 a physician was observed leaving a contact isolation room in the Intensive Care Unit. The physician did not perform hand hygiene with either soap and water, or an alcohol based hand sanitizer.

According to the policy "Hand Hygiene/Artificial Nails" (effective date 10/30/15) under the sub title PROCEDURES 1. General Hand-Washing/Hand Antisepsis Indiciations:
a. Before and after touching a patient.
b. Before and after wearing gloves.
The physician failed to perform hand hygiene after leaving the contact isolation room, making contact with the patient and removing his gloves.