Observations:
Based on review of facility documents, credential files (CF), personnel files (PF) and staff interview (EMP), it was determined the facility failed to ensure staff completed mandatory annual education regarding the use of surgical skin preparations that contain combustible agents for 7 of 10 credential files reviewed (CF4, CF5, CF6, CF7, CF8, CF9, and CF10) and 3 of 10 personnel files reviewed (PF5, PF9, and PF10).
Findings include:
Review on February 25, 2025, of the facility's granted Exception Request, dated May 15, 2020, for the use of surgical skin preparations what contain combustible agents revealed "Conditions of the Exception included ... The facility shall institute annual mandatory education provided to all staff, including the physician staff, involved in the use of surgical skin preparations that contain combustible agents. The content of the education provided and documentation of same will be reviewed by the Department during survey activity ..."
Interview with EMP1 and EMP2 on February 25, 2025, revealed CF4, CF5, CF6. CF7, CF8, CF9, CR10, PF5, PF9 and PF10 were staff involved in the use of surgical skin preparations that contained combustible agents.
Review of staff files revealed CF4, CF5, CF6, CF7, CF8, CF9, CR10, PF5, PF9 and PF10 on February 25, 2025, revealed no documentation staff completed the mandatory annual education regarding the use of surgical skin preparations as indicated in the granted Exception Request.
Interview with EMP1 and EMP2 on February 25, 2025, confirmed the above findings.
| | Plan of Correction - To be completed: 03/10/2025
1. Used our Corner Stone online educational tool to assign our staff members that are involved with the use of ChloroPrep education that included an article and a quiz. This education will be sent out with our other yearly mandatory education. New hires will be assigned this at time of hire.
2. Took the information from Corner Stone and emailed it to the surgeons. Surgeons instructed to email back stating they read the material and understand if and if they don't understand or have questions to reach out to get their questions answered. This will be done every year. Newly credentialed surgeons will receive this information in person and email.
3. For our anesthesia providers, doctors and CRNA's the article is printed out and available, they are to read the article and sign off they have read and understand the article.
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