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Based on interview and document review , the hospital failed to comply with Public Health Law Section 2824, which sets forth the requirements for surgical techonologists who practice in a general hospital that provides surgical services.

Findings:

The personnel file of Staff K, a surgical techonologist, was reviewed on 2/16/17 at 2pm. The file lacked any evidence that this surgical techonologist had completed the mandatory annual fifteen hours of continuing education to remain qualified to practice as a surgical techonologist.

Upon interview with the Director of Surgical Services on 2/17/17 at 10:30am, this finding was verified.

Based on observation, medical record review and document review, the hospital failed to maintain high standards of medical practice and patient care, in accordance with their established protocols governing surgical care. Specifically, the procedures established for surgical attire in the operating room, the handling and documentation of medications used for anesthesia and the authentication of telephone orders by the surgeons and anesthesiologists were not followed.

Findings:

A tracer case was observed on 2/15/17 at 1:00pm. The Anesthesiologist involved in the procedure wore a head covering with elastic trim and a surgical mask. This attire did not provide complete coverage of all facial hair.

Facility policy for the Operating Room, titled "Surgical Attire" effective 2/9/17 regarding surgical caps, masks and shoes states, "All head and facial hair need to be contained within a disposable product."

On 2/15/17 at 11:00am, staff were observed cleaning an Operating Room in between cases. The surveyor was accompanied by the Director of Surgical Services. During this observation the anesthesia cart was found to be unlocked. The top drawer contained several filled syringes, many of them labeled as narcotics. The labels indicated the name of the drug but were not dated or timed, nor did they indicate who drew up the medications. Upon discovery, the Director of Surgical Services took possession of these syringes.

The facility policy and procedure manual for Anesthesiology revised Nov. 2016 section 7.4.1 "Labeling of Syringes" states, "All medications drawn by anesthesia personnel should be immediately labeled with: 1. Drug name 2. Drug Concentration 3. Time and date drawn." Section 7.4.3 "Narcotics" states, "3. Narcotics are to kept under lock and key or on person at all times."

During medical record review, 5 open and 6 closed records, including the index case were reviewed.

The intra-operative Anesthesia Record for 11 of 11 of the medical records reviewed, the listed drugs administered did not consistently indicate the unit of measure for the drug (i.e. mg, mcg).

The facility policy and procedure manual for Anesthesiology revised Nov. 2016 section 10.4 "Recording the Anesthetic" states, "Intraoperative anesthesia records shall document all pertinent events that occur during the induction, maintenance, and emergence for anesthesia. These pertinent events shall include, but not limited to the following: 3. Dosage and duration of all anesthetic agents; 4. Dosage and duration of all other drugs and intravenous fluids."

The Anesthesia pre-operative orders for 2 of 6 closed medical records reviewed (Patient #8 and Patient #10), included telephone orders signed by nursing staff, but the telephone orders were not authenticated by a physician within 24 hrs. Physician orders in 1 of 6 closed medical records reviewed (Patient # 7), contained a telephone order signed by nursing staff but not verified by a physician within 24 hrs.

Facility Medical Staff Rules and Regulations Section 5.2: states, "Verbal orders (this includes telephone orders) shall be authorized within 24 hours."

The Director of Surgical Services and the Nurse Manager of Surgical Services confirmed these medical record findings on 2/16/17 at 1:30pm.