HospitalInspections.org

Based on review of 1 of 1 surgical patient records, and interview, the surgery department was not integrated into a hospital wide QAPI program.

A review of patient #1 records for 6/23/2010 shows a laparoscopic cholecystectomy was delayed for 1 hour and 15 minutes because a irrigation suction tip was not in the sterile instrument pack. This was not discovered until after the patient had been anesthetized.

Documentation from the CRNA flow sheet shows that the patient was in the surgery suite at 0910 AM the physician was in the surgery suite at 0925. Further documentation from the CRNA reads " Awaiting surgical instrument to begin. 1030 Surgery start. 1130 Magnet off"

Upon review of the circulating nurses notes the patient entered the surgery suite at 0910- and left the surgery suite at 1140.
The patient remained anesthetized while a hospital employee drove to a neighboring town and borrowed the needed irrigation suction tip from the local hospital there and return with it. A surgery which normally takes less than 1 hour took 2 hours and 20 minutes.

Employee #1 stated, "I don't have anything" when this surveyor asked to see their QAPI for Surgery. The Governing Body nor the Medical Staff was made aware of the delay of this surgery. There was no risk management involved nor was there an investigation as to how the instrument tray for a laparoscopic cholecystectomy was incomplete. The Quality Assessment Process Improvement committee had not met to discuss the risk to the patient or to discuss any method for identifying future problems before a patient is anesthetized in the surgery suite.

This surveyor questioned employee #1 as to who recovered the patient from surgery? She state "Well, I do" When asked where do you recover the patient? She stated "Well, if there isn't another surgery, I recover them in the surgery suite or I take them, and a crash cart, to their room and recover them there". No policy or procedure for this was found in the policy & procedure manual. There was no documentation for Surgical Quality Assessment Process Improvement review.

Based on 1 of 1 record review and interview the patient and/or her representative was not given accurate information regarding the circumstances of the delay in the surgery.

The patient's record shows she consented to a laparoscopic cholecystectomy, she was aware a Certified Registered Nurse Anesthetist (CRNA) providing the anesthesia, she was made aware of "certain complications" with the use of any anesthesia however, the patients record also shows a 1 hour and 15 minute delay in the start time of the surgery after the patient was anesthetized.

An interview with the patient confirms she was unaware of any delay and was told by her family that the delay occurred. When her family asked the staff what the delay was, the family reported to this surveyor, they were told "the room was not clean yet" They were not told the missing surgical instrument was the reason for the delay. The patients representative was not given the information required to make a decision to proceed or to stop the delayed surgical procedure.

`Based on interview and record review 3 of 4 employees who worked in surgery had incomplete employee files.
1 of 4 employees working in surgery had no job description, no competencies or annual job performance evaluation.
1 of 4 had no orientation, no job description no competencies and no application for employment identified with the facility. The employment application was from another facility the DON worked closely with.
1 of 4 positions did not have current credentialing.

In an interview with employee #1 when questioned about her lack of a personnel record, her remarks were "I don't have a file the Fed's have it". No employment documentation or inservice education was found.

In an interview on 7/1/2010 with employee #5, the Scrub Tech revealed he had been employed 2 months and had not received employee orientation, although he knew what he was hired for he had not seen a job description nor had he completed job competencies.

Review of the personnel file for employee #1, who functioned as the circulating nurse, did not have a job description, and the facility policy and procedure competency statement titled: CIRCULATOR ROLE COMPETENCY TOOL. was not found for employee #1.

Review of the personnel file for employee #5 did not have a job description or orientation. The facility policy and procedure competency titled: SCRUB ROLE COMPETENCY TOOL, OR, was also not found for employee #5. Employee #5 had no employment application for the facility he was working in. His personnel record had an employment application for a sister hospital in it.

Review of employee #4, revealed the CRNA was credentialed on 6/7/2007. The last annual performance review titled "Annual Performance Review for Contracted Allied Healthcare Professionals" was 8/1/08.