HospitalInspections.org

Based on observation, records reviewed and interview the Hospital failed to ensure a comprehensive plan of correction after a wrong site procedure in the Outpatient Department.

1.) According to the Hospital's policy titled "Universal Protocol for Invasive Procedures" the clinician performing the procedure will conduct a Time-Out pause immediately prior to the start of the procedure.

The Surveyor observed a Botox injection for Patient # 6 at 9:50 A.M. on 1/18/2021. Physician #1 obtained verbal consent from the activated Health Care Proxy. While discussing what would happen during the procedure with Patient #6, Physician #1 marked the sites according to the Hospital's policy. Physician #1 then left the treatment room saying that she was going to obtain the medication she would use for the procedure. When Physician #1 returned to the treatment area she began the invasive procedure without performing the Time-Out as required by the Hospital's policy.

The Surveyor interviewed the Clinic Director at 10:30 A.M. on 1/18/2021. When asked about training for Physician #1 the Clinic Director said that Physician #1 had not been included in the Time-Out training. The Clinic Director said that because the wrong site incident had involved a Pediatric patient that all of the Time-Out training was done with the Pediatric practitioners. The Clinic Director said only clinic staff at this location received Time-Out training even though at least four other Hospital sites performed the same invasive procedure.

The Surveyor reviewed the follow-up training and monitoring data which supported the Clinic Director's statements.