Observations:
Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to provide appropriate sterile equipment supplies to ensure good management techniques and prevent delay of care for seven out of seven MR's reviewed (MR1, MR2, MR3, MR4, MR5, MR6 and MR7).
Findings Include:
Review of facility policy "Patient Bill of Rights" last revised October 2017, revealed "The following Statement of The Patient's Rights and Responsibilities is endorsed by the Administration and staff of this facility and applies to all patients ... 13. Right to good hospital management - Patients have the right to expect good management techniques to be implemented within LGH. They may expect every effort will be made to avoid unnecessary delay and, when possible, to avoid undue personal discomfort."
Review of MR1 facility document note entered on February 20, 2024, revealed, "Delay information, Delay Type - Intra-op; Delay Reason - SPD (Sterile Processing Department) did not have instruments sterile for case. The procedure was delayed 270 minutes." Review of MR2 event tracking on February 21, 2024, revealed "Delay information, Delay Type - Intra-op; Delay Reason - 2-Intra-Periop Instruments - Delay. The procedure was delayed for 82 minutes." Review of MR3 event tracking on February 21, 2024, revealed "Delay information, Delay Type - Intra-op; Delay Reason - contamination of instrumentation. The procedure was delayed for 90 minutes." Review of MR4 facility document note entered on February 21, 2024, revealed "Mesh expired x2, no other units avail 1/31/2024 had to break to locate mesh not exp different type with diff type of mesh." Review of MR5 facility document note entered on February 27, 2024, revealed, "Cart Delivery - Case Cart called for case cart at 0930 arrived at 1045, case delayed 75 minutes."
Review of MR6 event tracking entered on February 27, 2024, revealed "Delay information, Delay Type - Intra-op; Delay Reason- 2-Intra Case Cart not available. The procedure was delayed for 40 minutes." Review of MR7 facility document note entered by EMP4 on March 3, 2024, revealed, "Patient brought back to OR and put to sleep for surgery. Surgical tech saw no signs of gross contamination of instruments during initial inspection. Once patient was prepped for surgery, surgical tech was threading cannulas to put together pieces of the set, and a piece of bone came out from inside cannula. Back table and set taken out of OR due to contamination, new supplies brought into room. Second set for case found to have hole in wrapper before placing on sterile field. This event caused a delay in the case while patient already under anesthesia."
Interview with EMP1 on March 11, 2024, confirmed the information above and documents submitted are complete and accurate.
| | Plan of Correction - To be completed: 05/31/2024
Action: Executives responsible for oversight of Plan of Correction to ensure the safety of surgical patients.
Responsible Parties: Chief Operating Officer, Chief Physician Executive, President of the Medical Staff
Completion Date: April 2, 2024
Action: Revised pre-patient arrival time out to include notification of Sterile Processing Department (SPD) supervisor or designee to verify if an instrument defect is present in real-time and in-person to prevent delay of care.
Responsible Party: Senior Director, Perioperative Services
Completion Date: May 31, 2024
Action: Sterile processing leadership corrects any identified instrumentation defects in real-time prior to surgical case start.
Responsible Party: Senior Director, Perioperative Services
Completion Date: May 31, 2024
Action: Established standardized real-time communication process between Operating Room (OR) and Sterile Processing Department to address any needs that occur after the surgical case has started.
Responsible Party: Senior Director, Perioperative Services
Completion Date: May 31, 2024
Action: Educate SPD staff to newly developed standard work for case picking and case cart prep to reduce defects, such as holes, and to reduce incomplete case carts.
Responsible Party: Senior Director, Perioperative Services
Completion Date: May 31, 2024
Action: Implement standardized inventory out-date checks by clinical staff to routinely assess supplies housed in the OR to ensure are available and not expired.
Responsible Party: Senior Director, Perioperative Services
Completion Date: May 31, 2024
Action: Re-educate OR staff on expectations for care, handling and cleaning of instrumentation prior to sending to SPD decontamination room to ensure instruments can be properly cleaned and sterilized.
Responsible Party: Senior Director, Perioperative Services
Completion Date: May 31, 2024
Action: Audit weekly number of case delays due to contamination until at least 95% compliance is maintained for 3 months.
Responsible Party: Senior Director, Perioperative Services
Completion Date: May 31, 2024
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