HospitalInspections.org

Based on interview and record review, the facility failed to require specific criteria for privileges (unique training and skills) for physicians making a "special privilege request." The bylaws must include criteria for determining the privileges granted to individual practitioners and a procedure for applying criteria for physicians requesting privileges. This failed practice could keep crucial information regarding physician competency from the governing body which has the potential to cause harm to patients. The findings are:

A. Record review of the facility Bylaws indicated the following: the anesthesia privileges were " Core privileges " and were accompanied by criteria which includes completion of Anesthesia Postgraduate training. However other departments, such as Orthopedics listed many privileges as an individual privilege request. While some of the privileges were in " core " as based on criteria such as " completion of post graduate training in Orthopedic surgery " , there were many individual requests that were contained outside of the core. These individual requests were not accompanied by any criteria at all. Physicians would simply request them and they would be granted based on no criteria at all.

B. On 04/01/15 at 2:00 pm, during interview, the Medical Staff Office Supervisor confirmed that the medical staff were using a "core privileging" system. Core privileging implies there are common criteria for all privileges (the core). "Special request" privileges are privileges for procedures that are beyond the "core" privileges. These individually-delineated privileges contained no specified criteria.

C. Record review of facility's Medical Staff Bylaws, Rules, and Regulations last revised and adopted on 09/2013 regarding special request privileges for physicians indicated no criteria specified for the special privileges.

Based on observation and interview, the facility failed to prepare drugs and biologicals in accordance with accepted standards of practice for sterile technique, specifically USP-797 (United States Pharmacopoeia). This deficient practice exposed all medications prepared in this room to potential contamination and patients that take these medications may be at risk associated to contaminated medications. This deficient practice has the potential to harm all patients who rely on this service/practice. The findings are:

A. This standard requires that medications be prepared according to accepted standards of practice for sterile techinique. One of these standards is the U.S. Pharmacopoeia for a hospital pharmacy. Specific reference is made to USP-797, a code that requires certain environmental standards for rooms in which there is compounding of sterile products. USP-797 is a regulation that is designed both to reduce infections transmitted to patients through pharmaceutical products prepared in the pharmacy and to better protect staff working in pharmacies in the course of their exposure to pharmaceuticals.

B. On 03/31/15 at 1:00 pm, during observation of the mixing room at the main pharmacy, there were no sealed ceiling tiles, nor was there sealed-seamless flooring in evidence as required by USP-797. The floor was dirty along the edge of the cove base (molding) where the floor meets the wall, and the floor along that edge cannot be cleaned without the removal of the cove base.

C. On 03/31/15 at 1:15 pm, during interview, the Director of Pharmacy confirmed that none of the ceiling tiles in the mixing room in the main pharmacy were sealed and that the flooring seams were not sealed. The Director of Pharmacy stated that there was a plan to renovate the room to USP-797 standards, but that the plan was at least two years away.

Based on record review and interview, the hospital failed to ensure that written notification was provided to the patient and practitioner no later than 2 days after the Utilization Review committee decided that the continued stay was not medically necessary. This failed practice could delay the appeal of all patients who appeal this decision. The findings are:

A. Record review of the hospital's "Utilization Management Plan" revised on 02/13/15 revealed no policy or procedure to inform the patient and practitioner in writing within 2 days of the decision that the continued stay was not medically necessary.

B. On 03/31/15 at 11:00 am, during interview, the Director of Case Management confirmed that there was no time frame in the plan to provide written notification to the patient and practitioner. When asked, she stated that Case Management Staff verbally inform the doctor and patient of the decision, but she was not sure of the time frame. She further stated that the patient was only given the notice for the right to appeal form if the patent disagree with the decision.

Based on record review and interview, the facility's Director of Anesthesiology (DOA) failed to endorse the Anesthesia Services Policies for the facility for deep sedation (anesthesia only), and communicate them to the Emergency Department (ED) for 6 (P #2, 3, 4, 5,6, and 7) of 6 (P #2, 3, 4, 5,6, and 7) patients that received ketamine (an anesthetic) and other sedation for procedures in the emergency room. None were compliant with the requirements of the anesthesia department to document an American Society of Anesthesiologists (ASA) risk score (The risk score measures the patient's respiratory, cardiac and neuro status). This deficient practice has the potential to harm patients through the improper application of medications required for deep sedation and the patient becoming overly sedated and not waking up. The findings are:
A. Record review of the medical records for patients (#2 through 7) did not document an American Society of Anesthesiologists (ASA) risk score or indicate an airway assessment was completed post-anesthesia recovery documentation.

B. On 04/02/15 at 1:00 pm, during interview, the Nurse Manager of the ED confirmed the following:
1. The privilege to perform deep sedation was included in the Emergency Medicine core privileges of the facility, but this individual privilege did not require approval by the Director of Anesthesia Services.
2. The ED did not have a deep sedation policy and did not implement the deep sedation protocol from Anesthesia Services.
3. The ED did have a conscious sedation policy. Conscious sedation is less complete sedation that can be performed by Nurses. This policy does not address the administration of ketamine or Propofol (medications for anesthesia), used for deep sedation or Anesthesia Services.
C. Record review of the hospital's policy entitled Procedural Sedation, revised on 12/16/14, indicated the administration of ketamine and Propofol for procedures as being monitored anesthesia care. Monitored anesthesia care is most demanding, highest level of sedation and must be performed by specially trained physician or nurse practitioner.
1. The policy further states that "only persons privileged in administering general anesthesia or deep sedation will administer Propofol for moderate sedation/analgesia."
2.. The only "deep sedation policy" was a monitored anesthesia care policy that applied ONLY to anesthesia or those specially trained physicians and nurses.
3. Conscious sedation is a nursing procedure and does not include anesthetics such as ketamine or Propofol.

D. Record review of the privileges for the ED physicians revealed that none of the ED physicians were privileged for deep sedation.