HospitalInspections.org
Bringing transparency to federal inspections
BAYLOR SCOTT & WHITE MEDICAL CENTER GARLAND
OPERATING ROOM POLICIES
Tag No.: A0951
Based on review of documentation, and an interview with the Chief Nursing Officer/Chief Operation Officer, the facility failed to maintain a safe standard of medical and patient care; patient # 1 sustained burns to the neck, ear, and shoulder during a surgical procedure on 07/31/12 at the facility.
Findings were:
Review of Skin Prep policy and procedure, revised 2011 stated, " To provide guidelines for preparation of operative sites. Purpose prepare operative sites prior to all surgical procedures and render the operative site as free as possible from bacteria. Gentle preps should be done for all neck surgeries or suspicious lesions. Allow drying time for prep before draping. "
Review of Electrosurgical Safety, revised 2011 state, " purpose is to ensure safe functioning of the electrosurgical unit and to provide a safe exit for electrical current. Vi. When using flammable liquids directly on skin, allow time for evaporation before activation."
Review of facility documentation root cause and analysis 08/14/12 stated, " The choraprep may have not dried completely before the incision was made with the cauther. A large foam neck pillow was used to help support the head. Adequate padding behind the head was required to allow the head not to hang free. Patient was induced under anesthesia and when that was done patient was given 100% oxygen."
Review of operative Report 08/01/12 stated, " Patient #1 was brought to the operation suite due to a significant cervical stenosis and fusion, patient # 1 had to have adequate padding behind the head to allow the head not to hang free, an incision was made and cautery was used to go through the fat, in the first seconds of cauterization patient # 1 was noted to have some burning sweet smell and then noted smoke. "
In an in-person interview with the Chief Nursing Officer/Chief Operating Officer on the morning of 10/02/12 at the facility it was confirmed that patient # 1 sustained burns to the neck, ear, and shoulder during the surgical procedure on 07/31/12 at the facility.