Initial Comments:
This report is the result of a State licensure survey conducted on January 18, 2024, at Eye Surgery Center. 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:
553.25 (1-6) LICENSURE
Discharge Criteria
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553.25 Discharge Criteria
A patient may only be discharged from an ASF if the following physical status criteria are met:
(1) Vital signs. Blood pressure, heart rate, temperature and respiratory rate are within the normal range for the patient's age or at preoperative levels for that patient.
(2) Activity. The patient has regained preoperative mobility without assistance or syncope, or function at his usual level considering limitations imposed by the surgical procedure.
(3) Mental status. The patient is awake, alert or functions at his preoperative mental status.
(4) Pain. The patient's pain can be effectively controlled with medication.
(5) Bleeding. Bleeding is controlled and consistent with that expected from the surgical procedure.
(6) Nausea/vomiting. Minimal nausea or vomiting is controlled and consistent with that expected from the surgical procedure.
Observations:
Based on review of facility policy, medical records (MR), and staff interview (EMP), the facility failed to ensure that patients met the required discharge criteria prior to discharge for 7 out of 10 medical records reviewed (MR1, MR2, MR3, MR4, MR6, MR9, MR10).
Findings include:
A review of facility policy "Discharge Policy" (last revised 6/22/10) revealed "All patients who receive anesthesia care shall receive appropriate post anesthesia management. A PACU or an area that provides equivalent post anesthesia care, shall be available to receive patients after surgery and anesthesia. A verbal report is given by the OR Registered nurse to the PACU Registered Nurse. Procedure: 1. Vital signs will be assessed and recorded upon arrival in PACU, and the patient's condition shall be evaluated continually while in the PACU ... 3. Patients will be judged ready for discharge based on the following criteria: ... Vital signs documented to include temperature, pulse, respiration ..."
Review of MR1 on January 8, 2024, revealed the patients temperature was not assessed prior to discharge from the facility.
Review of MR2 on January 8, 2024, revealed the patients temperature was not assessed prior to discharge from the facility.
Review of MR3 on January 8, 2024, revealed the patients temperature was not assessed prior to discharge from the facility.
Review of MR4 on January 8, 2024, revealed the patients temperature was not assessed prior to discharge from the facility.
Review of MR6 on January 8, 2024, revealed the patients temperature was not assessed prior to discharge from the facility.
Review of MR9 on January 8, 2024, revealed the patients temperature was not assessed prior to discharge from the facility.
Review of MR10 on January 8, 2024, revealed the patients ' temperature was not assessed prior to discharge from the facility.
Interview with EMP1 on January 18, 2024, confirmed the medical records did not contain documentation that the patients were assessed for temperature prior to discharge.
Plan of Correction:Staff was re-educated on 1/29 to the policy.
Starting 2/1 DON will audit 10 charts per day for 30 days for complianc.
If after 30 audit does not result in 100% compliance, audit will continue for another 30 days and continue until 100% compliance is met
555.33 (d)(3) LICENSURE
Anesthesia Policies and Procedures
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555.33 Anesthesia policies and procedures
(d) Anesthesia procedures shall provide at least the following:
(3) Prior to beginning the administration of anesthesia, the anesthetist shall check equipment to be used in administration of anesthetic agents. An anesthetic gas machine in anesthetising areas shall have a pin-index system.
Observations:
Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure the anesthesia equipment was checked by the anesthesia provider prior to anesthesia being administered for 7out of 10 medical records reviewed (MR1, MR2, MR4, MR5, MR6, MR9, MR10).
Findings include:
Review on January 18, 2024, of facility policy "Anesthesia - Equipment and Drugs" last revised, March 21, 2008, revealed no documentation regarding the person administering anesthesia should check the equipment prior to anesthesia being administered per regulation.
Interview with EMP1 on January 18, 2024, confirmed the above findings.
A review of MR1 on January 8, 2024, revealed no documentation the person administering anesthesia checked the equipment prior to anesthesia being administered.
A review of MR2 on January 8, 2024, revealed no documentation the person administering anesthesia checked the equipment prior to anesthesia being administered.
A review of MR4 on January 8, 2024, revealed no documentation the person administering anesthesia checked the equipment prior to anesthesia being administered.
A review of MR5 on January 8, 2024, revealed no documentation the person administering anesthesia checked the equipment prior to anesthesia being administered.
A review of MR6 on January 8, 2024, revealed no documentation the person administering anesthesia checked the equipment prior to anesthesia being administered.
A review of MR9 on January 8, 2024, revealed no documentation the person administering anesthesia checked the equipment prior to anesthesia being administered.
A review of MR10 on January 8, 2024, revealed no documentation the person administering anesthesia checked the equipment prior to anesthesia being administered.
Interview with EMP2 on January 18, 2024, confirmed there was no documentation the person administering anesthesia checked the anesthesia equipment prior to anesthesia being administered for the above MR.
Plan of Correction:Anesthesia staff was re-educated on 1/22 that documentation of equipment check prior to surgery is required.
In addition a new check box was added to the EHR for compliance.
Starting 2/1 DON will audit 10 charts per day for 30 days for compliance.
If after 30 audit does not result in 100% compliance, audit will continue for another 30 days and continue until 100% compliance is met
567.41 LICENSURE
MAINTENANCE SERVICE - Principle
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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 review of the Pennsylvania Code for Labor and Industry, observation, and interview with staff (EMP), it was determined the facility failed to ensure the autoclave used for sterilization of surgical supplies was inspected.
Findings include:
Review on January 18, 2024, of the Pennsylvania Code for Labor and Industry, 34 3a. revealed 3a.168. Autoclaves and quick opening vessels.
(a) An inspector shall inspect autoclaves and quick opening vessels with close examination of all moving parts, locking devices, pins, and interlocking devices, in accordance with ANSI/NB 23.
(b) An autoclave and quick opening vessel must have interlocking systems to prevent charging the vessel until all openings and locking devices are fully in place.
(c) A pressure-relieving device must be sized in accordance with the data plate for pressure. The capacity must be based on the pressure and pipe size or the total BTU valve of the boiler.
(d) Inspection of autoclaves and quick opening vessels shall be performed in accordance with 3a.111(8) (relating to field inspections).
Observation on January 18, 2024, of the facility's sterilization area revealed two autoclaves including one Reman Eagle 3000 and one Amsco 400. The autoclaves are used for sterilization of surgical supplies.
A request was made on January 18, 2024, for documentation of the current boiler/pressure vessel inspections. No documentation was provided.
Interview with EMP2 on January 18, 2024, confirmed there was no documentation of current boiler/pressures vessel inspections for the autoclaves.
Plan of Correction:Administrator contacted Dept of Labor and Industry to schedule inspection.
Inspection is scheduled for 1/31/2024.
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