Pennsylvania Department of Health
SURGERY CENTER OF BUCKS COUNTY
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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SURGERY CENTER OF BUCKS COUNTY - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

This report is the result of a State licensure survey conducted on December 20, 2023, at the Surgery Center of Bucks County. It was determined the facility was not in compliance with the requirements of the Pennsylvania Department of Health's Rules and Regulations for Ambulatory Care Facilities, Annex A, Title 28, Part IV, Subparts A and F, Chapters 551-573, November 1999.

Plan of Correction:

555.11 (a) LICENSURE MEDICAL ORDERS - Written:

555.11 Medical orders
Written orders

(a) Medication or treatment shall be administered by authorized persons to administer drugs and medications only upon written and signed orders of a practitioner acting within the scope
of the practitioner's license.

Observations:

Based on review of facility policies and procedures, review of medical records (MR) and interview with staff (EMP), it was determined the facility failed to ensure treatment was provided only upon a written and signed order of a practitioner acting within the scope of the practitioner's license for 1 of 10 medical records reviewed (MR6).

Findings include:

Review on December 20, 2023, of facility policy "Standing Orders" revised August 16, 2023, revealed "...Standing orders are written documents containing medical directives for the provision of patient care ... Standing orders are to be considered a starting point in witting orders and should be individualized to the needs of the patient ... Orders for drugs and biologicals must be documented and signed by the practioner ...follow a standardized format for the prescriber to select desired orders (checkbox or circle) ..."

1.Review on December 20, 2023, of MR6 nursing documentation "Patient Medication Record Cataract" dated October 10, 2023, revealed 2 strengths of the medication neosynephrine (2.5% and 10%) were preprinted on the medication administration record (MAR). Further review revealed the medication "Neosynephrine 10%" was adminstered at 7:55 AM, 8:00 AM, and 8:05 AM. Continued review of MR3 physician documentation "Standing Physician Treatment/Order Sheet" revealed no documention the physician selected the strength of the medication to be adminstered to the patient. The physician signed the Standing Order Sheet October 10, 2023, at 8:22 AM

Interview on December 20, 2023, at approximately 1:30 PM with EMP3 confirmed the strength of the medication adminstered to the patient was not ordered by the physcian at the time the medication was adminstered.

Plan of Correction - To be completed: 02/09/2024

All physicians and nursing staff will be re-educated on the revised medical order physician treatment/preprinted order sets that will no longer include an as needed order for a medication on the preprinted order set. After assessment of the patient by the surgeon, an as need medication order will be written if necessary.

The Administrator, Director of Nursing and Infection Control Nurse will audit 10 patient charts daily for 2 weeks to ensure 100% compliance. Results of the audits will be reported to the Safety Committee as well as the Medical Advisory and Governing Boards.

Ongoing performance will be monitored by including a medication order to the monthly chart audit. Fifteen charts are audited monthly. Identified non-compliance will be reported to the Medical Director for discussion with the provider.

Results will be reported by the Administrator to the Patient Safety and Quality Improvement, Risk Management, Medical Advisory and Governing Board committees. The Medical Director and Administrator are responsible for this plan of correction and will be presented to the Medical Advisory and Governing Boards.

555.13 LICENSURE Administration of Drugs:

555.13 Administration of drugs

Drugs shall be administered only upon the proper order of a practitioner acting within the scope of the practitioner's license and authorized according to medical staff bylaws, rules and regulations. Drugs shall be administered directly by a practitioner qualified according to medical staff bylaws, rules and regulations or by a professional nurse or by a licensed practical nurse with pharmacy training. Physician assistants and certified registered nurse practitioners shall be permitted to administer drugs within their authorized scope of practice. Further policies on the administration of drugs shall be established by the medical staff in conjunction with pharmaceutical services or personnel.

Observations:

Based on the review of facility policy, review of medical records (MR), and interview with facility staff (EMP), it was determined that the facility failed to ensure that drugs were properly administered as per physician order for 1 of 10 medical records reviewed. (MR4)

Findings include:

Review on December 20, 2023, of facility policy "Medication Administration" revised June 2023, revealed "Medications will be adminstered to patients by a properly licensed nurse on the written ordered of a physician ..."

Review on December 20, 2023, of MR3, revealed the patient presented to the surgery center on November 6, 2023, for a surgical procedure. Review of physician orders dated Novemer 6, 2023, revealed "Diamox 500 mg, 1 tab (if not allergic to sulfa)." Further review of nursing documention "Patient Medication Record Cataract Surgery" dated November 6, 2023, revealed "Diamox not given CKD (chronic kidney disease)Stage III"

Interview on December 20, 2023, at approximately 1:00 PM with EMP2 confirmed the physician ordered for the administration of the medication and confirmed the medication was not administered to the patient. EMP2 confirmed the medication was not ordered based on an article posted in the facility regarding the administration of diamox to patients with kidney disease.

Plan of Correction - To be completed: 02/09/2024

The patient will be evaluated in PACU by the surgeon to identify whether a medication listed in the medical orders should be administered or withheld according to the patient's medical history. The surgeon will sign, date and time the medical orders for postoperative care. Staff will be re-educated on waiting until the surgeon has confirmed and has signed the orders stating to continue or withhold the postoperative orders listed.

Ongoing performance will be monitored by including a medication order to the monthly chart audit. Fifteen charts are audited monthly. Identified non-compliance will be reported to the Medical Director for discussion with the provider.

The Administrator, Director of Nursing and Infection Control Nurse will audit 10 patient charts daily for 2 weeks to ensure 100% compliance. Results of the audits will be reported to the Safety Committee as well as the Medical Advisory and Governing Boards.

Results will be reported by the Administrator to the Patient Safety and Quality Improvement, Risk Management, Medical Advisory and Governing Board committees. The Medical Director and Administrator are responsible for this plan of correction and will be presented to the Medical Advisory and Governing Boards.

561.15 LICENSURE Locked Storage:

561.15 Locked Storage

Special locked storage space shall be provided to meet requirements for storage of controlled substances, alcohol and other prescribed drugs as set forth in Chapter 25 (relating to controlled substances, drugs, devices and cosmetics) and 49 Pa Code 27.16 (4) and 27.17 (relating to construction requirements and security for Schedule II controlled substances).

Observations:

Based on observation, review of facility policies and procedures and interview with staff (EMP), it was determined the facility failed to ensure medications were properly stored.

Findings include:

A request was made on December 20, 2023, at 1:15 PM to EMP2 for the policy and procedure regarding controlled substances in the operating room's anesthesia cart. None provided.

A tour on December 20, 2023, at 1:03 PM, of operating room number two (2) revealed, the anesthesia cart was unattended, and no anesthesia was actively being used. Further observation revealed an unsecured box on top of the anesthesia cart. The box contained the following medications: 14 fentanyl 100 mcg/2 ml vials, one (1) propofol (Diprivan) 200 mg vial, and 10 midazolam (Versed) 2 mg/2 ml vials.

Interview on December 20, 2023 at 1:06 PM with EMP2, confirmed the following medications: 14 fentanyl 100 mcg/2 ml vials, one (1) propofol (Diprivan) 200 mg vial, and 10 midazolam (Versed) 2 mg/2 ml vials were unattended and unsecured on the anesthesia cart located in operating room number two (2).

Plan of Correction - To be completed: 02/02/2024

All anesthesia providers have been contacted via email, will additionally be confirmed by sign-off sheet of the importance of the handling of controlled substances, and received a copy of the Controlled Substance Loss/Waste Policy. All controlled substances are to remain locked in the cart whenever there is no anesthesia physician and/or certified registered nurse anesthetist physically present.

The Director of Nursing and Infection Control Nurse will conduct random audits of OR when no clinicians are present to ensure that controlled substances/medication are not left unattended for four weeks. Identified non-compliance will be reported to the Medical Director for immediate discussion with the provider. Results of the audits will be reported to the Safety Committee, Risk Management Quality Committee as well as the Medical Advisory and Governing Boards.

Ongoing performance will be monitored by quarterly random rounding by the Infection Control Nurse. Results will be reported by the Administrator to the Patient Safety and Quality Improvement, Risk Management, Medical Advisory and Governing Board committees. The Medical Director and Administrator are responsible for this plan of correction and will be presented to the Medical Advisory and Governing Boards.

563.5 LICENSURE Storage of Medical Records:

563.5 Storage of Medical Records

Medical records shall be stored to provide protection from loss, damage
or unauthorized access.

Observations:

Based on observation and interview with staff (EMP), it was determined the facility failed to ensure medical records were stored to provide protection from damage.

Findings include:

Observation on December 20, 2023, at 9:45 AM of a locked conference room located in the office section of the facility revealed 8 cardboard boxes that contained patient medical records. Further observation revealed the boxes were stored in this non-sprinklered room.

A request was made on December 20, 2023, at 10:00 AM for a policy related to the storage of medical records. None provided.

Interview with EMP1 on December 20, 2023, at 10:00 AM confirmed there were 8 boxes that contained patient medical records stored in this room , and confirmed the room was not sprinklered. Further interview with EMP1 confirmed these medical records would not be protected from damage.

Plan of Correction - To be completed: 02/02/2024

Patient records will be stored at the Center in locked cabinets. Patient records from the previous year will be prepared for transfer and sent to the offsite storage facility. Until pick up of the records within 48 hours, the boxed records will be maintained on pallets off the floor in a storage room with a sprinkler located within the facility and locked until pickup. The facility purchased a waterproof tarp to protect against any damage.

The entry door from the outside into the facility where the storage area is located is locked and can only be opened from the inside by Wills Eye personnel. The door has a ring security camera with display monitors in the Business Office. No unauthorized access is permitted.

The policy and procedure has been updated to reflect the storage of medical records waiting for transport to the offsite storage facility. All staff will receive a copy of the updated policy that will be confirmed with a sign-off sheet.

Administrator will report this to the Safety, Medical Advisory and Governing Board committees. The Medical Director and Administrator are responsible for this plan of correction and will be presented to the Medical Advisory and Governing Boards.

567.41 LICENSURE MAINTENANCE SERVICE - Principle:

567.41 Principle

The ASF shall be equipped, operated and maintained to sustain its
safe and sanitary characteristics and to minimize health hazards in the ASF
for the protection of patients and employes.

Observations:

Based on observation, review of facility policies and procedures and interview with staff (EMP), it was determined the facility failed to maintain a safe and sanitary environment.
Findings include:
A tour on December 20, 2023, at 12:59 PM, of operating room number one (1) revealed, on the wall on the same side as the operating door an area of what appeared to be a reddish brown dried liquid. The pattern of the reddish brown liquid appeared to be in a spray or splashing pattern. This pattern of reddish brown was also noted on the adjacent wall.
Review on December 20, 2023, of facility policy and procedure, "Infection Control-House Keeping" reviewed June 2023 revealed, "...It will be the responsibility of the entire facility staff to maintain a clean and safe environment for staff and patients ...D... terminal cleaning of the OR [operating room] and recovery areas nightly..."
Review on December 20, 2023, of facility policy and procedure, " Infection Control-House Keeping Services" reviewed June 2023 revealed, " ...GENERAL CLEANING ... 3. Walls will wet wiped with a disinfectant weekly ...Remove spots and splashed from walls..."
Interview on December 20, 2023, at 1:01 PM with EMP2 confirmed the reddish brown dried liquid on the wall of operating room one (1) Further interview with EMP2 confirmed it should have been cleaned off.
_____________________________________________________________________
Based on observation, review of facility policies and procedures and interview with staff (EMP), it was determined the facility failed to maintain a safe and sanitary environment.
Findings include:
A tour on December 20, 2023, at 1:03 PM, of operating room number two (2) revealed, on the wall to the left of the operating room door an area of what appeared to be a reddish brown dried liquid. The pattern of the reddish brown liquid appeared to be in a spray or splashing pattern.
Review on December 20, 2023, of facility policy and procedure, "Infection Control-House Keeping" reviewed June 2023 revealed, " ...It will be the responsibility of the entire facility staff to maintain a clean and safe environment for staff and patients ...D... terminal cleaning of the OR [operating room] and recovery areas nightly..."
Review on December 20, 2023, of facility policy and procedure, "Infection Control-House Keeping Services" reviewed June 2023 revealed, " ...GENERAL CLEANING... 3. Walls will wet wiped with a disinfectant weekly ...Remove spots and splashed from walls..."
Interview on December 20, 2023, at 1:04 PM with EMP2 confirmed the reddish brown dried liquid on the wall of operating room two (2) Further interview with EMP2 confirmed it should have been cleaned off.

Plan of Correction - To be completed: 02/02/2024

Operating Rooms #1 and #2 were terminally cleaned and freshly painted. All staff will receive of the Infection Control-House Keeping Services Policy. The Cleaning Service has been alerted and stressed the importance of notifying the Administrator of staining that cannot be removed.

Ongoing performance will be maintained by a log of terminal and weekly cleaning. Routine inspections will be done by the Infection Control Nurse to ensure cleaning is properly completed and maintained. In the absence of the Infection Control Nurse, the Administrator and/or the Director of Nursing will sign-off on the weekly inspections. Staff and Cleaning Service will be reminded to report any issues upon occurrence to the Administrator.

Results will be reported by the Administrator, Director of Nursing, Infection Control, Medical Advisory and Governing Board committees. The Medical Director and Administrator are responsible for this plan of correction and will be presented to the Medical Advisory and Governing Boards.

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