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SELECT SPECIALTY HOSPITAL - OKLAHOMA CITY, INC
INFECTION PREVENTION CONTROL ABX STEWARDSHIP
Tag No.: A0747
Based on observation, record review and interview, the hospital failed to ensure COVID-19 infection control protocols were followed for one (Pt #5) of ten patients. This failed practice had the likelihood to place all patients, staff, visitors, and communities-at-large at increased risk of contracting the COVID-19 virus. (See Tag 0749)
CONTENT OF RECORD: DISCHARGE SUMMARY
Tag No.: A0468
Based on record review and interview, the hospital failed to ensure the physician completed the discharge summary
for one (Pt #4) of 10 patients.
Findings:
A document titled "Appendix A" stated in part "All records must document final diagnosis with completion of medical records within 30 days following discharge."
A review of the clinical record documented Patient #4 was admitted on 05/29/20 and discharged 07/02/20. The clinical record showed no discharge summary as of 08/06/20 (34 days after discharge).
On 08/06/19 at 1:30 pm, Staff F stated the discharge summary for Patient #4 was not in the EMR.
INFECTION CONTROL PROGRAM
Tag No.: A0749
Based on observation, record review and interview, the hospital failed to ensure COVID-19 infection control protocols were followed for one (Pt #5) of ten patients. This failed practice had the likelihood to place all patients, staff, visitors, and communities-at-large at increased risk of contracting the COVID-19 virus.
Review of a policy titled "Cardiac Arrest Management" (located on every crash cart observed throughout the hospital) documented the code team was to use N-95 masks.
Review of a document titled "PPE and Room Guidance During Universal Mask Use" documented the requirement for staff during a Code/Intubation to don N-95 masks.
On 08/04/20 at 10:28 AM - 10:40 am, Surveyor #1 observed during a code blue, staff was observed not wearing N95 masks or respirators. One staff member was observed wearing goggles on top of the head not covering his or er eyes. Three staff were observed wearing surgical masks during intubation. Four staff were observed with unfastened gowns. Staff was observed performing chest compressions, intubation, and oral suctioning prior to intubation.
On 08/04/20 at 1:00 PM, Staff B stated he had not donned a N-95 mask prior to intubating Pt #5.
On 08/04/20 at 10:58 AM Staff D stated:
1. All crash carts have a laminated sheet of "Cardiac Arrest Management" attached and all staff have been trained on this document.
2. All staff participating in a code are to wear N-95 masks.
3. N-95 masks are in the bottom drawer of the crash cart and the charge nurse should pass the N-95 masks out to code members.
4. All infection control protocols related to a code were not followed for Pt #5.
7 of 7 observed crash carts had signage stating "Code Team: PPE: N-95 (or other espirator ifN-95 not available), fluid resistant gown, eye protection, gloves"