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Based on observation, interview and record review, the facility failed to maintain the physical environment and ensure appropriate measures were taken to ensure the safety of the patients, staff and visitors as evidenced by the following:

1) The facility did not ensure fire drills were conducted. This practice placed patients, visitors and staff at risk in the event of a fire. (Cross Refer to tag A714.)

2) The facility failed to secure three nitrous oxide gas cylinders even after the facility received a deficiency from the local fire authority 01/31/11. (Cross Refer to tag A715.)

3) The facility failed to ensure 17 of 17 fire extinguishers located throughout the facility were inspected, 2 of 2 emergency generators were not regularly tested, the dietary dishmachine wash/rinse cycle was below safe temperatures, the ED (Emergency Department) closet/floor was soiled and required cleaning, equipment stored in the closet had expired inspection stickers and was available for patient use. (Cross Refer to tag A724.)

4) The facility failed to ensure periodic inspections of the radiology equipment were performed in that the last physicist radiation protection survey and inspection was conducted on 07/09/08. (Cross Refer to tag A537.)

Based on interview and record review, the hospital's medical staff failed to periodically conduct appraisals of it's members in violation of the medical staff bylaws for 1 of 1 Radiologist (Personnel #38). Personnel #38's provisional privileges were not appraised at the end of the provisional period.

Findings included:

Review of Personnel #38's credentialing file reflected, Personnel #38 was appointed as provisional staff on 05/13/09. No further documentation was found in the credentialing file and/or in the medical staff minutes that indicated an appraisal was done at the end of the one year provisional period.

The above findings were confirmed by Personnel #2 on 09/14/11 at 02:30 PM.

The Medical Staff Bylaws approved by the Governing Body on 06/11/11 reflected, "All initial appointments and initial granting of clinical privileges shall be provisional and shall be for one year....at the successful completion of the provisional period the Practitioner's status will be reviewed for advancement to the requested category..."

Based on review of records and interview, the Medical Staff "Rules and Regulations" included conflicting times the patient's medical history and physical were to be completed. Times were noted "within 24 hours...or 48 hours after an admission."

Findings included:

The hospital's own Medical Staff "Rules and Regulations" approved 06/07/11 by the Medical Staff Committee and 06/09/11 by the Governing Board included that "A complete history and physical examination...of all inpatients within 24 hours...a physical examination and medical history must be done no more than seven (7) days before or 48 hours after an admission for each patient by an osteopathic physician or allopathic physician or, for patients admitted only for oral/maxillofacial surgery, by an oral/maxillofacial surgeon who has been granted such privileges by the Medical Staff in accordance with Texas State law."

The Medical Staff's "Rules and Regulations" included conflicting information as to when the medical history and physical examination was to be completed.

During an interview at approximately 04:00 PM on 09/14/11, the Administrator (Personnel #3) reviewed the Medical Staff's Rules and Regulations with the surveyor and agreed that some of the information was conflicting when compared to the "State" information that included timeframe for the completion of the patient's medical history and physical examination as 24 hours.

Based on interview and record review, the hospital failed to ensure 1 of 1 Registered Nurse (RN-Personnel #35) evaluated effectively the nursing care for 1 of 2 patients (Patient #30) who was administered blood products. RN #35 failed to obtain vital signs within the first 15 minutes of administering a blood transfusion.

Findings included::

During review of Patient #30's medical record, Patient #30 received a blood transfusion on 08/25/2011 with a start time of 00:50. RN #35 failed to obtain vital signs within the first 15 minutes of administering blood products to Patient #30. (This was the most critical time for a blood transfusion reaction.)

The staff members who obtained Patient #30's temperature, pulse, respirations, blood pressure, and oxygen saturation levels failed to sign their names on the "Frequent Vital Signs" form for 8 of 14 entries as noted below:
Time Temp Pulse Resp B/P SpO2 Signature
1. 0044 99.1 82 20 149/61 100 none
2. 0110 100.2 79 20 143/63 98 none
3. 0125 98.3 77 20 141/51 99 none
4. 0140 99.8 81 20 131/50 98 none
5. 0155 99.5 76 20 135/50 98 none
6. 0210 99.0 77 20 132/50 99 none
7. 0240 99.4 85 20 132/52 98 none
8. 0310 99.0 79 19 140/52 100 none
9. 0325 99.3 76 20 142/54 98 1st signature

The hospital's policy "Department: Emergency Department, Subject: Standard of Care- Administration of Blood " revealed, " Standard: Obtain and document vital signs 15 minutes after transfusion begins, then 30 minutes, 1 hour and 1 hour post transfusion. "

The hospital's policy "Department: Medical Records, Subject: Content of Medical Record " revealed, "Medical Record content should be sufficiently detailed and organized to enable: A. The responsible practitioner to provide effective continuing care to the patient, to determine later what the patient's condition was at a specific time, and to review the diagnostic procedures performed and the patient's response to treatment."

Based on observation, interview and record review, the hospital failed to ensure 1 of 1 LVN (License Vocational Nurse-Personnel #15) was competent to administer Flagyl 500 mg (milligrams) Q8 (every eight) hours IV (Intravenous) medication for 1 of 1 patient (Patient #28).

Findings included:

During a medication pass observation on 09/14/11 at 10:05 AM, the surveyor observed Personnel #15 administer Flagyl 500 milligrams per Intravenous Piggy Back (IVPB) at the bedside to (Patient #28).

The short stay record for (Patient #28) dated 09/14/11 reflected, "Patient was admitted with abdominal pain, nausea, vomiting, dehydration..."

The physician's orders dated 09/14/11 untimed reflected, "Flagyl 500 milligrams Q8 hours IV (Intravenous)."

Review of Personnel #15's employee personnel record did not reflect documentation indicating competency and/or verification for IV therapy was completed.

In an interview with Personnel #15 on 09/14/11 during the medication pass at 10:05 AM, Personnel #15 stated she had been trained by the hospital staff to perform IV therapy.

In an interview with Personnel #1 on 09/14/11 at approximately 10:35 AM, Personnel #1 confirmed, there was no documentation verifying IV competencies had been completed for Personnel #15.

The education program and competency verification, competency requirements with a revision date of 04/13/11 reflected, "1. The Education Department will present or coordinate the following annually: a. IV Therapy and IV medication administration to verify competency for all LVN's and RN's..."

The hospital policy and procedure entitled, "Nursing Organizational Plan" with a revision date of 03/01/10 reflected, "Licensed Vocational Nurse...are supervised by a RN and may perform all aspects of patient care and charting as specified by hospital and Texas regulations...LVN's who have not previously been certified for IV therapy will need to pass the IV therapy medication administration test..."

The Texas Board of Nurse Examiners Position Statement 15.3 entitled, "LVN's (Licensed Vocational Nurse) Engaging in Intravenous Therapy, Venipuncture, or PICC Lines" reflected, "The basic educational curriculum for LVN does not mandate teaching of principles and techniques of insertion for peripheral intravenous catheters, or the administration of fluids and medications via the intravenous route...as such, basic competency in management of intravenous lines/intravenous therapy is not a given for any specific LVN license...applicable nursing standards...LVN practice is guided by the Nursing Practice Act (NPA) and Board Rules, rule 217.11, Standards of Nursing Practice, is the rule most often applied to nursing practice issues. Two standards applicable in all practice scenarios included: 217.11(1)(B) implement measures to promote a safe environment for clients and others, and 217.11(1)(T) accept only those assignments that take into consideration client safety and that commensurate with the nurse's educational preparation, experience, knowledge, and physical and emotional ability..."

Based on interview and record review the facility failed to ensure ED (Emergency Department) medical record entries were complete, dated, timed and/or signed for 6 of 6 patient's (Patient #12, #16, #17, #18, #19 and #20).

Findings included:

1) Patient #12's ED medical record reflected the following:

The ED nursing record reflected no date Patient #12 was seen.
The physician order form reflected, no date the orders were written.
The radiology report dated 07/31/11 reflected, no date and time the physician signed the report.
The discharge instructions reflected, no date the patient, witness and/or physician signed the document.

2) Patient #16's ED medical record reflected the following:

The ED nursing record reflected no date when the patient was seen and no date was documented when discharged.
The physician order form reflected, no physician signature, date and/or time.

3) Patient #17"s ED medical record reflected the following:

The ED nursing record reflected, no date seen and/or discharged.
The physician's order form reflected, no time the physician wrote the orders, and no date/time and nurse signature.
The patient rights document reflected, no witness signature, date and/or time.

4) Patient #18's ED medical record reflected the following:

The ED nursing record reflected, no RN (Registered Nurse) signature and/or date seen.

5) Patient #19's ED medical record reflected the following:

The ED physician record reflected no time was documented when Patient #19 was seen.
The ED nursing record reflected, no date seen or discharged.
The physician order form reflected, no time the physician signed the orders, no nurse signature, date and time.

6) Patient #20's ED medical record reflected the following:

The ED nursing record reflected, no date Patient #20 was seen.
The physician's orders (verbal orders) were not dated and timed when signed by the physician.

On 09/14/11 at 4:00 PM, Personnel #1 was interviewed. Personnel #1 verified the above entries were not dated, timed and/or signed.

The Performance Improvement Quarterly Report dated 07/27/11 reflected, "not timing charts, no dates, missing signatures..."

The facility policy entitled, "Medical Records" with a revision date of 03/01/10 reflected, "all orders shall be dated, timed and signed...progress notes...dated, timed and signed...ancillary reports...signed and dated.."

Based on observation, interview and record review, the facility failed to have records with sufficient detail to follow the flow of drugs (Atropine Abboject) for 1 of 2 drug storage areas (the locked medication cart) in the Emergency Department (ED), in that, A) there was no record of when the drugs had last been stocked into the ED medication cart by the pharmacy, and B) no record of when or to whom the drugs had been dispensed to.

Findings included:

On a tour of the hospital ED at 10:30 AM on 09/15/11 with Personnel #42, the surveyor observed during a random check of drugs and drug records in the locked ED medication cart, drawer #2, designated to contain 2 Atropine Abboject (one-time use, 10 milliliter boxed dose each), did not contain these 2 medications, and had no record they had been dispensed.

In an interview at 10:30 AM on 09/15/11 with Personnel #42, she verified the number of boxes of Atropine Abboject that was supposed be in drawer #2, according to the PAR levels noted on the top of the medication cart, was 2 boxes and none were found in the locked drawer. When asked how the nurses in the ED documented they had removed medication doses from the locked medication cart, Personnel #42 said they did not keep records of what had been removed from the cart, and only document removal of "narcotic drugs" from their locked storage cabinet. When asked how Personnel #42 knew which ED patient had received the Atropine Abboject, Personnel #42 said she did not know, but she would check patient charts seen in the ED the last 2 to 4 days, to see which patients may have received the medication. When asked how she knew the drugs had not been used for someone other than the ED patients, she said she would not know. Personnel #42 was asked how the locked medication cart was filled. She stated the pharmacy technicians check the medication drawers at least once a day, to replace drugs that had been used. Personnel #42 verified each medication drawer was individually locked with a disposable plastic lock, and required a new lock each time one of the drugs was used, indicating a need to replace a drug.

On 09/15/11 at 3:10 PM Personnel #32 was asked A), how the facility tracked the flow of medications from the pharmacy to the ED. Personnel #32 stated the ED medications were 'non-profile,' and were followed by keeping drugs stocked according to their established par levels. Personnel #32 stated the pharmacy technicians were responsible for stocking the medication cart with the designated number of each medications' par level. He stated he did not know what had happened, but the technicians could have missed that the medication was gone, and did not replace it. Personnel #32 was asked B), if he knew which ED patients these 2 doses of Atropine Abboject were dispensed to. He said an ED physician had remembered ordering this medication for Patient #33, who had presented with chest pain and a heart rate less than 40 bpm (beats per minute). Personnel #32 confirmed he did not know who had received the 2nd dose (one-time use box) of Atropine.

Review of the ED medical record for Patient #33, verified Patient #33 had been ordered
Atropine 0.4 mg (milligram) intravenously (IV), prn (as needed) for heart rate less than 40 bpm. The documentation reflected, Patient #33 received a one-time dose of Atropine at 10:26 AM on 09/12/11.

The facility policy entitled "Medications in the Emergency Department" with a revision date of 04/13/11, noted the following:
-"Purpose: Establish criteria to store medications in the Emergency Department."
-"All medications will be stocked in the Emergency Department per par levels established between the Emergency Department and the Pharmacy."
-"Medication cabinets will be stocked by Pharmacy: Pharmacy will periodically check for outdates."

The policy did not require records of sufficient detail to follow the flow of drugs from entry (from pharmacy to ED), through dispensation (from ED to dispensation to a patient), and did not demonstrate management of this drug storage area (the medication cart) in the ED.

On 09/15/11 at 4:10 PM Personnel #1, #32, and #42 were interviewed. Personnel #1, #32 and #42 agreed the system used for tracking non-narcotic medications in the ED, did not record A), the flow of drugs from the pharmacy to the ED, and B) from the ED to dispensation to ED patients.

Based on interview and record review, the facility failed to ensure periodic inspections of the radiology equipment were performed.

The Findings included:

Review of the radiology department documentation on the morning of 9/14/11 reflected the last medical physicist radiation protection survey and inspection was conducted on 7/9/08.

The above findings were confirmed in an interview with Personnel #23 and Personnel #3 on 9/14/11 at 10:15 AM.

The facility policy entitled "Calibration & Preventative Maintenance of Equipment" with an approved date of 3/4/10 reflected, "Medical Physicist will perform survey of all equipment on a yearly basis." 25 Texas Administrative Code ?289.227(o) Equipment Performance Evaluation stated "For radiographic, fluoroscopic and CT x-ray systems, the tests listed in paragraphs (5)-(7) of this subsection shall be performed by or under the supervision of a licensed medical physicist, at the frequency listed in the following table. Type of Machine/Frequency: CT, 1 year; Fluoroscopy, 1 year; all other Radiographic, 2 years." The facility radiology department equipment included CT and Fluoroscopy x-ray systems.

Based on interview and record review, the facility failed to ensure only staff designated as qualified may use the radiologic equipment and administer procedures as a facility ultrasonographer. The medical staff failed to ensure the ultrasonographer (Personnel #26) was qualified and had the required license and certification.

Findings included:

Review of Personnel #26's personnel file reflected, no documentation of licensure and/or certification.

The facility Position Description entitled "Ultrasonographer Position Control: 582-007-8007" found in the file reflected, "Position Requirements, Licenses and Certifications: State license, ARDMS (American Registry for Diagnostic Medical Sonography), and current Basic Life Support required."

The above findings were confirmed in an interview with Personnel #23 on 9/14/11 at 2:45 PM. Personnel #23 stated she called the ultrasonographer Personnel #26 who verified they did not have a state license or ARDMS registration."

Based on observation, interview and record review, the facility failed to ensure fire drills were conducted from 11/12/10 to 06/07/11. This practice placed patients, personnel and guests at risk in the event of a fire.

Findings included:

Review of documentation provided by the facility reflected, no fire drills were conducted from 11/12/10 until 06/07/11.

The above findings were confirmed in an interview with Personnel #18 on 09/14/11 at 03:00 PM.

The facility policy #SC.01 entitled "Safety Committee" with a Revised Date of 03/01/10 reflected, "Safety Committee Responsibilities: The Safety Committee will review and critique the following safety programs and all other issues related to hospital safety ....reviews monthly fire drills."

Based on observation, interview and record review, the facility failed to ensure three nitrous oxide gas cylinders were secured. The facility further failed to correct a deficiency noted in the Fire Safety Survey Report completed by the local fire authority dated 01/31/11. The report indicated nitrous oxide cylinders were not tied down to prevent tipping.

Findings included:

A tour of the outdoor oxygen and nitrous oxide storage area was conducted on the afternoon of 09/14/11 in the company of Personnel #18. The surveyor observed three nitrous oxide gas cylinders loose and not secured in any way.

The above findings were confirmed in an interview with Personnel #18 on 09/14/11 at 03:30 PM.

Review of the Fire Safety Survey Report for General & Special Hospitals dated 01/31/11 completed by the local fire authority showed in the Oxygen and Nitrous Oxide Storage section, in response to line "(d) Are cylinders stored to prevent tipping?" the "No" column was marked with an "X." In the comments section, the local fire authority noted "Tie down cylinders."

The facility policy #VII G entitled "Surgery Safety Standards" with an approved date of 09/06/11 reflected, "All cylinders are securely attached to portable units, chained to the wall, or placed in special holders..."

Based on observation, interview and record review, the facility failed to maintain supplies and equipment to ensure an acceptable level of safety and quality was provided. The facility failed to properly maintain, 17 of 17 fire extinguishers located throughout the hospital, 2 of 2 emergency generators, the hot water supply to the dish washing machine both wash and/or rinse cycles, clean 1 of 1 storage closet and/or equipment contained in the closet, and failed to remove expired supplies from patient care areas (Radiology, ED Trauma Room #2, #4 and the Labor and Delivery Operating Room).

Findings included:

1) A tour of the facility was conducted with Personnel #18 and Personnel #3 from 09/13/11 to 09/15/11. The inspection tags for 17 of 17 fire extinguishers were due for inspection by the fire equipment contractor on May 2011. The locations of the fire extinguishers observed were: education room, dining room, kitchen, hall near day surgery, hall near endoscopy lab, hall near radiology, emergency room, hall near patient room 107, hall near nursing station, hall near pharmacy, hall near patient room 206, hall near back door leading to patio, hall near patient room 306, hall near patient room 403, hall near the engineering shop, hall in surgery, and medical record storage.

The above findings were confirmed in an interview with Personnel #18 and Personnel #3 on 09/15/11 at 09:30 AM.

1) A fire equipment inspection report dated 11/18/10 reflected "Fire Extinguishers Due Date 05/20/11." The facility policy entitled "Fire Alarm/Safety" with an approved date of 09/06/11 reflected "II. Procedures: The procedures to be followed for proper maintenance of the fire protection equipment are presented on daily, weekly, monthly and annual basis as follows: ...5. Annual. All fire extinguishers inspected by certified fire extinguishers Company."

2) On the afternoon of 09/14/11 a review of the emergency generator operating log indicated maintenance and testing of the facility's 90 KW emergency generator was not performed from 10/04/10 until 08/01/11. The maintenance and testing for the facility's 300 KW emergency generator was not performed from 10/04/10 until 04/17/11.

The above findings were confirmed in an interview with Personnel #18 and Personnel #3 on 09/14/11 at 03:15 PM.

The facility policy entitled "Testing Emergency Generator" with an approved date of 09/06/11 reflected, "Monthly full load test: This test is to be done every 3rd Friday of the month. Weekly: Parcel (sic) Load Test; Testing to be done every 1st, 2nd, and 4th Friday of the month."

The facility policy entitled "Emergency Generator Maintenance and Testing Procedure" reflected "M. Records-Fill out weekly record and file."

3) On the morning of 09/13/11, the "Food Service Department Dishmachine Temperature Record" for September 2011 reflected, 8 of 60 recorded wash and final temperatures were below 120 degrees for the following dates:

The 09/02/11 lunch wash temperature was 115 degrees.
The 09/05/11 breakfast wash temperature was 115 degrees.
The 09/06/11 breakfast wash temperature was 100 degrees and the breakfast final temperature was 110 degrees.
The 09/08/11 lunch wash temperature was 100 degrees and the lunch final temperature was 110 degrees.
The 09/11/11 lunch wash temperature was 110 degrees and dinner wash temperature was 110 degrees.

The facility policy #8001 entitled "Food and Nutrition Services Infection Control" with a revised date of April 2011 reflected "Dishwasher temperature control: In...hospital, a chemical sanitizer is used. Chemical Sanitizer Wash; 120 degrees or above, Final Rinse; 120 degrees or above..."

In an interview with Personnel #11 on 09/13/11 at 11:00 AM, Personnel #11 verified the above findings and stated the temperatures below 120 degrees were reported to the maintenance department.

4) On 09/15/11 at 9:35 AM a tour of the Emergency Department was conducted with Personnel #42. The closet in Room #4 was observed to have a soiled floor, with a definite contrast between the floor of room #4 which was clean and the soiled closet floor. Several dead crickets were observed and the floor had not been recently swept or mopped. Inside the closet was patient equipment available for patient use: a SonoSite ultrasound machine with a biomed inspection sticker dated October 2009, 2 soiled standing fans, and 3 soiled table fans sitting on the soiled floor.

The above findings were verified in an interview with Personnel #42 on 09/15/11 at 9:35 AM.

The facility policy entitled "Infection Control Plan," dated 07/26/11, reflected, "The Infection Control Officer will be responsible for the following functions: to coordinate the Environmental Rounds Committee for environmental surveillance of the hospital and grounds inspection to assure a sanitary environment, life-safety issues are in compliance, infection control standards and employee health issues are addressed."

The facility policy #SC.01 entitled "Safety Committee" with a revised date of 03/01/10 stated that "The Safety Committee is responsible for maintaining and developing an active interest in hospital safety review and act upon applicable safety issues, and report appropriate results of monitoring and actions/recommendations to the Governing Board, QAI, Administration and department directors at least quarterly."

5) During a tour of the facility on 09/14/11 at 09:15 AM and 09/15/11 at 10:30 AM, the following expired supplies were found in patient care areas available for patient use.

1. In the Labor & Delivery OR, Penrose Drains, 1 expired January 2010, 2 expired February 2010, 2 expired February 2008; Blade Shield expired July 2010; Vacuum Assist Delivery Cup, 2 expired July 2008; Urine catheter expired September 2009; Ambu Laryngeal Mask #2 expired February 2008.
The above findings were confirmed in an interview with Personnel #35 on 09/14/11 at 09:15 AM.
2. In a supply cart in Radiology, 18 gauge, 1-1/4" intravenous catheters, 2 expired June 2010, and 2 expired June 2011.

The above finding was confirmed in an interview with Personnel #23 on 09/14/11 at 10:00 AM.

3. In the Activase Kit in the cabinet in ED Trauma Room #2, 20 gauge angiocath needles, 2 expired November 2008.
The above findings were confirmed in an interview with Personnel #42 on 09/15/11 at 10:30 AM.
4. In a cabinet in ED Room #4, specimen swab, 1 expired 12/31/10; Liquid fixative, 4 expired March 2010; Culture swabs, 2 expired February 2011.
The above findings were confirmed in an interview with Personnel #42 on 09/15/11 at 10:30 AM.
The facility policy #09.03 entitled "Expiration Dates" with an approved date of 2/28/07 reflected, "Expiration dates of drugs and devices shall be checked during routine medication area inspections and all drugs and devices scheduled to expire during the next month shall be removed from stock..."

Based on interview and record review, the infection control officer Personnel #4 did not maintain a log of incidents related to infections and communicable diseases. The information provided as the infection control log did not include details of treatment provided, what type of isolation the patient was placed in, if needed, and had no determination of whether the identified infection was community or hospital acquired.

Findings included:

On 09/13/11 at approximately 01:00 PM an interview was conducted with Personnel #4. Personnel #4 was asked to provide the surveyor the hospital's infection control log. Personnel #4 said she did not actually have a log, but did have some information on several sheets of paper. Personnel #4 provided a list of laboratory positive cultures with the dates, for patients identified by medical record numbers only. No other information was included, such as treatment, isolation precautions, or determination of whether the infection had been determined to be community or hospital acquired by the infection control officer. Personnel #4 was asked if she had received any infection control training, on how to collect data on infections, and how to maintain an infection control log. She said "no."

Review of the personnel file for Personnel #4 contained no documentation of infection control training. The "Infection Control Nurse Job Description," signed by Personnel #4 on 07/15/11, located in this personnel file, required skills and specifications to include, "knowledge of techniques for data collection...collecting data on infections from hospital departments and maintaining records for each case."

Based on interview and record review the hospital failed to ensure the patient's surgical informed consent document was properly executed and/or completed prior to surgery for 5 of 5 patients (Patient #4, #5, #6, #7, and #8).

Findings included:

1) Patient #4's medical, surgical and diagnostic procedure consent dated 08/31/11 timed at 12:50 PM reflected, under the section, "Just as there may be hazards..." the following was written in the section, "Allergic Reaction, Bleeding, Infection, Perforation, Aspiration," Further review of the risks and hazards section, the following was revealed, two blank boxes which failed to be marked by the nurse or physician reflected, "No specific risks and hazards listed above, See list A Procedures:" and "Risks & Hazards explained by physician." The surgeon failed to time the consent form and the Anesthesiologist/CRNA failed to sign, date, and time the informed consent form.

2) Patient #5's medical, surgical and diagnostic procedure consent dated 09/02/11 reflected, the nurse failed to sign, date and time the consent form.

3) Patient #6's medical, surgical and diagnostic procedure consent dated 05/18/11 reflected, the Anesthesiologist failed to sign, date, and time the informed consent form.

4) Patient #7's medical, surgical and diagnostic procedure consent dated 08/28/11 reflected in the section, "Just as there may be risks and hazards..." the following was written in this section, "Allergic Reaction, Bleeding, Infection, Perforation." Further review of the Risks and Hazards section, the following was revealed, two blank boxes which failed to be marked by nurse or physician stated, "No specific risks and hazards listed above, See list A Procedures: " and "Risks & hazards explained by physician." The Surgeon failed to time the consent and the Anesthesiologist/CRNA failed to sign, date and/or time the consent.

5)Patient #8's medical, surgical and diagnostic procedure consent dated 08/18/11 reflected in the section, "Just as there may be risks and hazards..." the following was written in this section, "Allergic Reaction, Bleeding, Infection, Recurrence." Further review of the Risks and Hazards section, the following was revealed, two blank boxes which failed to be marked by the nurse or physician reflected, "No specific risks and hazards listed above, See list A Procedures:" and "Risks & hazards explained by physician." The surgeon and Anesthesiologist/CRNA failed to time the informed consent form.

The above was confirmed in an interview with Personnel #3 and Personnel #35 on 09/15/11, at 2:45 PM.

The policy and procedure entitled, "Department Operating Room" with an approved date of 09/06/11 reflected, "Subject: Admission and Care of Patients in the Pre-Operative Area, reflected on page 2 of 3, "Responsible Persons: RN, General Comments: 2. Incomplete results to prior tests and consents...can be verified at this time and physicians alerted for any discrepancies." Further review of the policy reflected on page 2 and 3, "Person: RN, Action: 5. Verify that consent forms are completed properly."

Based on review of patient surgical records and interview, the hospital failed to ensure the post-anesthesia follow-up report was written prior to transferring the patient from the post-anesthesia care unit. The medical records of 5 of 5 patients (Patient #4, #5, #6, #7 and #8) were missing evaluations for recovery from anesthesia, level of activity, respiration, blood pressure, level of consciousness, and/or the patient's oxygen saturation level. The hospital failed to follow it's own policies and procedures.

Findings included:

The review of the surgical medical records revealed the following:

The "Pre and Post Anesthesia Summary" for Patient #4 dated 09/02/11 did not include the evaluation for recovery from anesthesia, level of activity, respirations, blood pressure, level of consciousness, and oxygen saturation level in either the section "recovery room and/or the post-op note."

The "Pre and Post Anesthesia Summary" for Patient #5 dated 09/02/11 did not include the evaluation for recovery from anesthesia, level of activity, respirations, blood pressure, level of consciousness, and oxygen saturation level in either the section "recovery room" and/or the "post-op note."

The "Pre and Post Anesthesia Summary" for Patient #6 dated 05/18/11 did not include respirations, blood pressure, level of consciousness, and oxygen saturation level in either the section "recovery room" and/or the "post-op note."

The "Pre and Post Anesthesia Summary" for Patient #7 dated 08/29/11 did not include the evaluation for recovery from anesthesia, level of activity, respirations, blood pressure, level of consciousness, and oxygen saturation level in either the section "recovery room" and/or the "post-op note."

The "Pre and Post Anesthesia Summary" for Patient #8 dated 08/19/11 did not include the evaluation for recovery from anesthesia, level of activity, respirations, blood pressure, level of consciousness, and patient's oxygen saturation level in the section "recovery room" and/or the "post-op note." Patient #8 had a general anesthetic.

The hospital's policy #III E "Department: Surgery Room, Subject: Preoperative and Postoperative Anesthesia Evaluations" reflected, "Purpose: To provide instructions regarding necessary pre and postoperative anesthesia evaluations to assure patient safety and to be in compliance with hospital and AOA standards...post anesthesia evaluation will be performed by the anesthesiologist or anesthetist not more than 24 hours after anesthetic and will include the following: a. any post operative abnormalities or complication and patient responses to same, b. Blood pressure and pulse, c. Presence or absence of swallowing reflex, d. Any degree of cyanosis, e. General condition of patient-level of consciousness, f. Any plans for follow-up and observations...Responsible Persons: Anesthesiologist, Anesthetist. "

The hospital's policy #III F "Department: Surgery Room, Subject: Intraoperative Anesthesia Record" reflected, "The intraoperative anesthesia record will include the continuous recording of the patient's status noting the following information regarding the patient's response to anesthesia: a. Blood pressure, b. Cardiac rate/rhythm, c. Respiration rate, d. Sa02 levels, e. Effects of medication, agents and interventions including untoward outcomes, f. Conditions at end of procedure and transfer to next level of care..."Responsible Person: Anesthesiologist, CRNA."

The hospital's policy # III G "Department: Surgery Room, Subject: Immediate Post Anesthesia Care (PACU) " reflected, "Purpose: To outline the care that will be given in the immediate post anesthesia period...Each patient shall have post operative abnormalities, complications blood pressure and pulse, cardiopulmonary, presence or absence of swallowing reflex, level of consciousness, any degree of cyanosis and general condition of the patient, as well as any plans for follow up care..."

The hospital's policy "Department: Medical Records/ Anesthesia, Subject: Immediate Post Anesthesia Care" reflected, " I. Objective: To assess post-op condition and detect post-op complications...III. Procedure: D. Each patient shall have a post-anesthetic evaluation performed by the Anesthesiologist or Anesthetist who administered the anesthesia not more than 24 hours after the anesthetic."

This was confirmed in an interview with staff member #3 on 09/15/2011 at 02:55 PM.

Based on interview and record review, the Governing Body failed to assume legal responsibility for the operations of the hospital in that 5 of 6 credentialing files (Personnel #8, #47, #48, #50, and #51) was not approved by the members of the Governing Body.

Findings included:

Review of Personnel #8, #47, #48, #50, and #51's credentialing files did not include an approval letter of credentialing by the Governing Body and the information was not provided to the surveyor upon request during the survey.

The hospital's "Governing Board" meeting minutes from 05/12/11 through 09/12/11 did not include an approval of the credentialing of Personnel #8, #47, #48, #50, and #51.

This was confirmed in an interview with Personnel #2, #3, #45, #46 on 09/15/11 at 04:35 PM.

The "Governing Board Bylaws" dated 06/09/11 reflected, "Evaluation of Performance...monitoring of credentialing, appointment, and re-appointment of medical staff..."