HospitalInspections.org

Based on observation of the Emergency Department and Radiology, and interview, it was determined the facility failed to maintain the building physical structure, safety, environment, and equipment in a state of good repair. The failed practice promoted the spread of fire and/or placed the patients at risk of fire. The failed practice had the likelihood to affect all patients, staff and visitors in the event of a fire. Findings follow:

A. Observation of the Emergency Department on 05/06/24 showed the following:
1) Fire wall penetrations in corridor leading to the Emergency Department on 05/06/24 at 2:47 PM.
2) Fire wall penetrations in administration corridor leading to Radiology on 05/06/24.

B. The findings in A were verified with the Maintenance Supervisor on 05/06/24 at 2:55 PM.


Based on observation of the Operating Room, and interview, it was determined the facility failed to maintain the building physical structure, safety, environment, and equipment in a state of good repair. The failed practice promoted the spread of infection. The failed practice had the likelihood to affect all patients, staff and visitors. Findings follow:

A. Observation of the Emergency Department on 04/15/24 showed there was an elevated portion of unsealed concrete on the floor adjacent to the operating table in Operating Room 1.

B. The findings in A were verified with the Maintenance Supervisor on 05/06/2024 at 2:55 PM.

Based on observation, review of policies and procedures and interview, it was determined the facility failed to create and review policies and procedures on a biennial basis for:
1) Yearly door checks
2) Ceiling tile checks
3) fire wall penetrations

By not creating and reviewing the policies and procedures biennially, the facility had the likelihood to not be able to identify hazardous conditions and take steps to minimize the risks to patients and patient care staff. The failed practice had the likelihood to affect all patients admitted to the facility. Findings follow:

A. Review of the facility's policy and procedures on 05/06/2024 showed that the facility failed to create and maintain a policy and procedure for annually checking fire doors. Documentation for annually checking fire doors was requested and none was provided.

B. Review of the facility's policy and procedures on 05/06/24 showed that the facility failed to create and maintain a policy and procedure for conducting ceiling tile checks. Documentation for ceiling tile checks was requested and none was provided.

C. Review of the facility's policy and procedures on 05/06/24 showed that the facility failed to create and maintain a policy and procedure for fire wall penetration checks. Documentation for fire wall penetration checks was requested but none was provided.

D. The findings of A through C were confirmed in an interview with the Maintenance Supervisor on 05/06/2024 at 3:00 PM.

Based on review of Medical Staff Bylaws, Physician Credential files and interview, it was determined the Governing Body failed to ensure one (#2) of two (#2 and # 6) physicians credentialed to perform robotic surgery had evidence they met the qualifications and requirements to be granted privileges. By not assuring the physician met the qualifications and requirements to utilize the robotic system, the facility could not assure the safety and efficacy of the surgeries performed. The failed practice had the likelihood to affect all patients who received robotic procedures from Physician #2. Findings follow:

A. Record review of the facility's Medical Staff Bylaws (Reviewed/Revised 01/2024) showed a physician must have documented current competence, as demonstrated by background, experience and demonstrated ability.
B. Review of Physician #2's Credential file showed they requested additional privileges of Robotic Surgery. The Privilege Request states criteria for this privilege are:
1) Clinical Privileges for the open operation that will be performed robotically.
2) Documentation of satisfactory completion of the FDA (Food and Drug Administration) mandated training course in the safe use of the robotic surgical system, which must be of at least eight hours duration and must include three hours of personal time on the system during the training.
3) Documentation of having observed at least three robotic operations performed by an experienced surgeon and been proctored during the performance of two robotic procedures.
4) There was no evidence in Physician #2's credential file that confirms the criteria above were fulfilled. The Board of Directors approved the reappointment of this physician on 7/26/22 without the above-mentioned evidence the physician was competent.
C. During an interview on 05/15/2024 at 10:36 AM, The Chief Operating Officer and the Medical Staff Coordinator both verified the findings at B.


Based on review of Medical Staff Bylaws, Physician Credential files and interview, it was determined the Governing Body failed to adhere to their Medical Staff Bylaws in that they failed to recredential one (#5) of six (#1-#6) physicians after their last appointment expired, within two years, per their Bylaws. Failure by the Governing Body to re-credential a physician did not assure the Governing Body reviewed the physician's credentialing information (i.e. licensure, performance, any changes to requested privileges, etc) to decide to allow the physician to continue to work in the facility and assure that member of staff has given quality care to the patients of the facility. The failed practice had the likelihood to affect all patients who received services from Physician #5. Findings follow:

A. Record review of the facility's Medical Staff Bylaws (Reviewed/Revised 01/2024) showed a physician must be recredentialed every two years.
B. Review of Physician #5's Credential file showed the last completed credentialed period was from August 1, 2020, to July 31, 2022.
C. During an interview on 05/15/2024 at 10:36 AM, The Chief Operating Officer and the Medical Staff Coordinator both verified the findings at B.

Based on observation, policy and procedure, Association of Perioperative Registered Nurse (AORN) guidelines review, and interview, it was determined the infection prevention and control program failed to create and implement policies and procedures to maintain compliance with (AORN) standards for aseptic or sterile surveillance and practices for Peripheral Nerve Blocks. The failed practice placed the patients at risk of infection and had the likelihood to affect all patients undergoing a peripheral nerve block. Findings follow:

A. Review of AORN guidelines showed the workflow for Peripheral Nerve Block were to prep, drape injection site, use sterile technique to palpate anatomic landmarks and confirm using ultrasound or nerve stimulator.
B. A policy was requested on 5/15/24 at 10:30 AM. There was no evidence of a policy for the workflow for a peripheral nerve block provided.
C. Observation on 5/14/24 at 9:30 AM, showed Certified Registered Nurse Anesthetist (CRNA) did not use a drape or sterile gloves to perform a Peripheral Nerve Block to a surgical patient.
D. In an interview with the Anesthesia Director via telephone on 5/15/24 at 2:30 PM, he stated that the hospital does adhere to AORN standards, they do not have a policy for Peripheral Nerve Blocks, and the hospital will create and implement a new policy to adhere to AORN standards.