QA Investigation Results

Pennsylvania Department of Health
ASPLUNDH SURGICAL CENTER
Health Inspection Results
ASPLUNDH SURGICAL CENTER
Health Inspection Results For:


There are  11 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:

This report is the result of a State licensure survey conducted on March 22, 2022 at Asplundh Surgical 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:




555.32 (a) LICENSURE
Administration of Anesthesia

Name - Component - 00
Anesthesia Services

555.32 Administration of anesthesia

(a) Anesthetics shall be administered by anesthesiologists and certified registered nurse anesthetist and dentist anesthetists as defined in 551.3 (relating to definitions).


Observations:

Based on review of facility policies, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure conscious sedation was administered by the physician or a CRNA (certified registered nurse anesthetist) provider in five of ten medical records reviewed (MR1 through MR5).

Findings include:

Review on March 22, 2022 of facility policy "Moderate Sedation (Conscious Sedation), 113.06," revised November, 2021, revealed "Purpose...This policy specifically addresses the administration of moderate sedation by non-anesthesia staff. Roles and Responsibilities of the administator/monitoring practitioner. The Registered Nurse... administering the ordered medications... are known as the administering/monitoring practitioner."

Review of MR1 on March 22, 2022 revealed patient underwent a procedure on March 22, 2022 at 8:35 AM. Further review revealed RN (EMP3) administered "Fentanyl 50mcg and Midazolam (Versed) 1mg into MRI intravenous catheter at 8:19 AM."

Review of MR2 on March 22, 2022 revealed patient underwent a procedure on March 7, 2022 at 10:13 AM. Further review revealed RN (EMP4) administered "Fentanyl 50mcg and Midazolam (Versed) 1mg into MR2 intravenous catheter at 9:50 AM, and administered Fentanyl 25mcg and Midazolam (Versed) 0.5mg at 9:59 AM."

Review of MR3 on March 22, 2022 revealed patient underwent a procedure on March 7, 2022 at 11:52 AM. Further review revealed RN (EMP4) administered "Fentanyl 50mcg and Midazolam (Versed) 1mg into MR3 intravenous catheter at 11:13 AM, and administered Fentanyl 25mcg and Midazolam (Versed) 0.5mg at 11:23 AM."

Review of MR4 on March 22, 2022 revealed patient underwent a procedure on March 3, 2022 at 9:51 AM. Further review revealed RN (EMP3) administered "Fentanyl 25mcg and Midazolam (Versed) 0.5mg at 9:34 AM."

Review of MR5 on March 22, 2022 revealed patient underwent a procedure on February 28, 2022 at 10:09 AM. Further review revealed RN (EMP4) administered Fentanyl 50mcg and Midazolam (Versed) 1mg at 9:49 AM, and administered Fentanyl 25 mcg and Midazolam (Versed) 0.5mg at 9:56 AM.

Interview on March 22, 2022, with EMP2 at approximately 2:30 PM confirmed the nurses that administered conscious sedation in medical records one through five were administered by Registered Nurses. Further interview confirmed the facility does not contract or have a Certified Registered Nurse Anesthetist on staff.











Plan of Correction:

Services requiring moderate sedation were stopped immediately, as of the time of the survey. Since that time, the organization has been trying to determine whether there is a safe and reasonable path forward for these services at this site. This is under review. Our interim plan is to not use this site for any services requiring moderate sedation. This plan of correction will be updated once a final plan is determined.


569.35 (7) LICENSURE
General Safety Precautions

Name - Component - 00
569.35 General Safety Precautions
The following safety precautions shall be met:
(7) Only nonflammable agents may be present in a surgical suite.

Observations:

Based on a review of facility policy, documents, medical records (MR) and interview with staff (EMP) it was determined the facility was using flammable agents in the operating room (OR), without an exception from the Department of Health (the "Department") in 10 of 10 records (MR1 through MR10).

Findings include:

A review on March 22, 2022 of facility policy "Prepping and Draping" revision June, 2021, revealed "III. Procedure: 2. Use of Alcohol based skin preparations...Chloraprep...must be prepackaged... make sure solution does not soak into patient' s hair... Solution contains alcohol and gives off flammable vapor. Use of electro cautery...other sources of ignition will not be used until all safety measures.... established. Confirmation of appropriate safety measures have been met... verbalized during the "time out process."

A review of manufacture instructions of alcohol-based preoperative skin preparation solution package insert for Chloraprep revealed "Warnings. ...Flammable."

A review on March 22, 2022, of the Department data base revealed no documentation the Department had granted the facility an exception for the use of flammable agents in the operating room.

A review on March 22, 2022 of MR1, revealed a scheduled procedure for port placement on March 22, 2022 at 8:35 AM. Further review revealed an alcohol-based preoperative skin preparation solution was used to prepare the operative site before the procedure.

A review on March 22, 2022 of MR2, revealed a scheduled procedure for port placement on March 7, 2022 at 10:13 AM. Further review revealed an alcohol-based preoperative skin preparation solution was used to prepare the operative site before the procedure.

A review on March 22, 2022 of MR3, revealed a scheduled procedure for port placement on March 7, 2022 at 11:52 AM. Further review revealed an alcohol-based preoperative skin preparation solution was used to prepare the operative site before the procedure.

A review on March 22, 2022 of MR4, revealed a scheduled procedure for port placement on March 3, 2022 at 9:51 AM. Further review revealed an alcohol-based preoperative skin preparation solution was used to prepare the operative site before the procedure.

A review on March 22, 2022 of MR5, revealed a scheduled procedure for port placement on February 28, 2022 at 10:09 AM. Further review revealed an alcohol-based preoperative skin preparation solution was used to prepare the operative site before the procedure.

A review on March 22, 2022 of MR6, revealed a scheduled procedure for port removal on March 3, 2022 at 8:49 AM. Further review revealed an alcohol-based preoperative skin preparation solution was used to prepare the operative site before the procedure.

A review on March 22, 2022 of MR7, revealed a scheduled procedure for port removal on March 7, 2022 at 8:31 AM. Further review revealed an alcohol-based preoperative skin preparation solution was used to prepare the operative site before the procedure.

A review on March 22, 2022 of MR8, revealed a scheduled procedure for port removal on February 28, 2022 at 12:57 PM. Further review revealed an alcohol-based preoperative skin preparation solution was used to prepare the operative site before the procedure.

review on March 22, 2022 of MR9, revealed a scheduled procedure for port removal on February 28, 2022 at 1:52 AM. Further review revealed an alcohol-based preoperative skin preparation solution was used to prepare the operative site before the procedure.

A review on March 22, 2022 of MR10, revealed a scheduled procedure for port removal on February 23, 2022 at 9:52 AM. Further review revealed an alcohol-based preoperative skin preparation solution was used to prepare the operative site before the procedure.

An interview with MR2 conducted on March 22, at 2:30 PM confirmed the facility routinely used alcohol-based preoperative skin preparation solution to prepare the operative site before procedures. EMP2 further confirmed the facility did not have an exception granted by the Department to use flammable agents in the operating room.















Plan of Correction:

The use of chloraprep was immediately discontinued. Staff were educated that they are not to use chloraprep. No procedures are being done at this site at this time, so no medical record reviews are being conducted. Once procedures are restarted, we will monitor the use of the agent that is used for patient preparation.
All of this was reported to the patient safety committee and the Board. All corrective actions were complete as of 6/23/22.