Timpanogos Regional Hospital

Based on interview, it was determined that the hospital did not ensure that surgical care was achieved and maintained at a high standard of patient care. Specifically, the hospital did not use protective equipment such as lead shields to protect patients from excess exposure to radiation during x-ray in the operating suite.

Findings include:

A routine interview was conducted with the director of surgical services (DSS) on 4/4/17 at 10:13 AM. She was asked how they protect patients during x-ray in the OR, in which she replied that they do not use protection and there was no policy requiring them to do so. Their policy was requested.

The hospital's policy titled Reducing Radiological Exposure in the Practice Setting was reviewed. The policy was a protocol to assist the perioperative nurse in reducing radiation exposure in the practice setting. The policy read, Ionizing radiation can damage living tissue and may produce long-term effects. Because of the effects of ionizing radiation exposure on tissue, patients and personnel should be protected from unsafe levels of radiation that are not medically indicated. Under the heading Protocol number 2 read, During medically indicated radiological procedures, the patient should be protected from unnecessary radiation exposure. The bulleted section of number 8 read, Leaded shields should be used, when possible, to protect the patient's ovaries, or testes (ie, gonads) during x-ray studies. Protective shielding should be placed between the patient and the source of radiation.... Leaded shields should be used when possible, to protect the thyroid during x-ray studies of the upper extremities, trunk and head.

On 4/5/17 at 9:47 AM the DSS informed the surveyors that she stand corrected that per AORN (The Association of periOperative Registered Nurses) and hospital Policy they were to use patient protection during x-ray. She stated that she spoke with her staff and that currently their practice was to use lead shields only on pregnant women.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, it was determined that the facility did not ensure that all patients' medical records contained a comprehensive medical history performed no more than 30 days prior to surgery for 3 of 11 sampled patients. Patient identifiers: 3, 4, and 10.

Findings include:

1. Patient 3, a [AGE]-year-old female, was admitted to the facility on [DATE] for a lumbar fusion.

A review of patient 3's medical record was completed on 4/6/17.

Patient 3's History and Physical (H&P) form was dated 2/8/17 and had the following stamp No changes since the H&P. The stamped area was signed by patient 3's surgeon and dated 3/15/17. Patient 3's H&P was completed 36 days prior to her scheduled surgery. This was six days over the allotted time for an H&P to be completed prior to surgery.

On 4/5/17 at 2:42 PM, an interview was conducted with the hospital Risk and Quality Manager (RQM). The RQM confirmed patient 3's H&P was completed over the required 30 days prior to surgery.

2. Patient 10, a [AGE]-year-old male, was admitted to the facility on [DATE], for a tonsillectomy.

A review of patient 10's medical record was completed on 4/6/17.

The only H&P form found in patient 10's medical record was an undated Physician Written History and Physical or Update Note form. The form did not contain either a history or complete physical.

On 4/5/17 at 1:59 PM, an interview was conducted with the Surgical Services Manager (SSM). The SSM confirmed an H&P was not in patient 10's medical record and that it should have been in his medical record prior to surgery.

3. Patient 4, an [AGE]-year-old female, was admitted [DATE]

A review of patient 4's medical record was completed on 4/6/17. There was no evidence of a H&P in the medical chart.

On 4/6/17 at 11:57 AM, an interview was conducted with the RQM. The RQM stated she did not have any documentation to show patient 4's surgeon reviewed her H&P prior to surgery. The RQM confirmed there should have been some documentation to show patient 4's H&P was reviewed prior to surgery.