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Based on observation, interview, and record review, the hospital was found to be out of compliance with the Condition of Participation related to the Physical Environment (42 CFR 482.41) related to lack of compliance with Life Safety Code requirements. These findings have the potential to affect all patients in the hospital. Findings included:

The hospital was found out of compliance with the Condition of Participation related to the Physical Environment (42 CFR 482.41) as evidenced by deficiencies issued as a result of a Life Safety Code inspection. Findings include:

Please refer to Life Safety Code inspection tags: K0029, K0050, K0052 and K0144, for additional information.

Based on observation, record review, policy review, and interview, the hospital failed to ensure the outpatient surgical services department informed each patient of the patient's rights prior to receiving outpatient surgical services for 2 of 2 patients (P1, P2) in the sample.

Findings include:

P1 did not receive the Patient Bill of Rights prior to receiving outpatient services.

When interviewed on 9/7/11 at 7:00 a.m., P1 could not recall receiving the Bill of Rights information. On record review it was noted that there was no information as to if the patient had receive the Bill of Rights.

P2 did not receive the Patient Bill of Rights prior to receiving outpatient services.

When interviewed on 9/8/11 at 11:45 a.m., P2 stated no information had been given concerning patient rights. On record review it was noted that there was no information as to if the patient had received the Bill of Rights.

The facility's policy on the Patients' Bill of Rights was requested and presented. The policy dated 4/15/11, read in part: "It is the policy of the Austin Medical Center to comply with the Patient Bill of Rights, Minnesota Statute 144.651. A copy of the Bill of Rights is available in each patient admission packet. Patient Bill of Rights brochure and posters are located in each outpatient waiting area." However, during the tour of the outpatient services department on 9/7/11 at 7:00 a.m. there had been only one of the two registration desks with brochures of the Bill of Rights available for patients. Also, there were no posters of the Bill of Rights located in the patient waiting area.

The Director of Surgical Services interviewed on 9/7/11 at 7:00 a.m. indicated that the Bill of Rights should have been given when the patient comes in the door. There were brochures observed on the desk area. The Director of Surgical Services also indicated the patient may have been given the Bill of Rights when seen in the physician's office prior to surgery; however, there was no information in the medical record to indicate this. The Director of Surgical Services further indicated the registration desk employee does not hand out or explain the Bill of Rights to the patients. This was confirmed by registration employee-A on 9/7/11 at 7:10 a.m. Registered nurse (RN)-A who admitted P1, was interviewed on 9/7/11 at 7:15 a.m., and RN-A confirmed she does not hand out the Bill of Rights to patients nor does RN-A explain the Bill of Rights to the patients.

Based on observation, interview and policy review, the hospital failed to maintain a sanitary environment in the kitchen to prevent food borne illness. This had the potential to affect any patients receiving their meals from the dining room.

Findings include:

Cutting boards were worn and stored with moisture between the boards. Also the utensil drawers were soiled.

During the kitchen tour on 9/6/11, at 2:00 p.m. with the dietary supervisor it was noted that the four green colored cutting boards were observed to be stacked together and placed behind the faucet of a sink for storage. Upon closer observation, the boards were found to be wet and to have worn and multiple grooved surfaces. The moisture on the contact surface of the cutting boards along with the close proximity prevented air circulation and increased the risk of microbial growth. The dietary supervisor (DS) verified that the boards were wet and worn. The facility policy for food safety standards and requirements indicated that cutting boards were to be stored vertically for proper draining and quick drying. The DS indicated that the green cutting boards were to be used for washed raw fruits and vegetables.

Also observed during the kitchen tour, three drawers were soiled with debris on the outside and inside of the drawers where the sanitized utensils were placed. The insides of the drawers had debris that was sticky. The dietary supervisor stated that the drawers were to be cleaned and sanitized on the weekends. The supervisor verified that it appeared that the drawers may not have been cleaned according to the schedule. The drawers are constructed of metal and are to be wiped out with a sanitizing solution according to the dietary supervisor.

Based on observation, interview, and policy review, the hospital failed to ensure safe procedures during surgery were followed for 1 of 3 patients (P2) surgical procedures reviewed in the sample related to the use of the cautery to prevent the risk of burns to the patient and staff.

Findings include: The surgeon did not consistently holster the cautery instrument (an electric device that can burn or cause ignite a fire) during the surgery nor did the scrub techs cue the physician to holster the cautery instrument.

During observation of P2's surgery on 9/8/11 at 2:00 p.m. for a laparoscopic cholecystectomy (gall bladder removal) and repair of an umbilical hernia the following was observed: Dura prep (pre-operative alcohol based skin prep) was used to prep the abdomen. No pooling or wet drapes were observed. The dry time for the alcohol skin prep was observed to be over three minutes before draping occurred. During the umbilical hernia procedure electro-cauterization was utilized. The sheath or holster for the cautery pencil was clipped to the drape on the left side of the patient where the second scrub nurse stood. The surgeon stood on the right side of the patient. The cautery pencil was used several times by the physician and each time it was placed on the drape over the lower abdomen and not in the holster. The longest interval when not it use was for ten minutes. Neither surgeon-A nor scrub technicians-A and B placed the cautery in the holster when not in use.

The Director of Surgical Services when interviewed on 9/8/11 at 3:50 p.m., indicated when not in use the cautery pencil should always be holstered.
Review of the hospital's policy and procedure related to Electro-surgery/Cautery use, the policy indicated during the surgical procedure the cautery pencil is to be placed in the cautery holster when not in use.

Review was conducted of the cautery Covidien user's guide (manufacturer's direction) provided by the facility. Located on pages 2-4 under the heading of Fire/Explosion Hazard states, "Fire Hazard. Do not place active instruments near or in contact with flammable materials (such as gauze or surgical drapes). Electrosurgical instruments that are activated or hot from use can cause a fire. When not in use, place electrosurgical instruments in a safety holster or safely away from patients, the surgical team, and flammable materials. "

Based on review of the organizational chart of outpatient services and interview, the hospital failed to ensure that there was one single person responsible for the 11 outpatient services. This had the potential to affect any patients receiving outpatient services.

Findings include:

On 9/7/11, at 3:30 p.m. the locations of the outpatient services were reviewed and the hospital organizational chart indicated they had 5 outpatient off-sites and approximately 6 different outpatient services which included endoscopy, infusion therapy, urgent care, sleep clinic and the specialty outreach clinic with numerous disciplines.

The facility's organizational chart dated 3/10/2011 was reviewed. The organizational chart indicated that there had been no single person designated who would direct the overall operation of the outpatient services.

On 9/8/2011, at 3:54 p.m., the Vice President of Operations was interviewed and stated that the outpatient services are assigned to various "service lines" that best match the services provided. The duties had been disseminated throughout the system.