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Based on records reviewed for one patient (Patient #13), in a toal of 37 records reviewed, the Hospital failed to ensure that a History and Physical Examination (H & P) was completed and documented by a qualified member of the Medical Staff. Findings included:

Review of the Medical Staff Bylaws Article 18, dated 6/14/06, indicated that a History and Physical must be completed in the medical record of any patient admitted to the Hospital or undergoing a procedure for which moderate sedation, deep sedation, or general anesthesia was planned. The H & P must be completed by one or more members of the Medical Staff, House Staff or a Professional Staff Member, authorized to perform a H & P examination.

Review of Patient #13's History and Physical, dated 12/20/19 at 12:00 P.M. indicated a Registered Nurse, who was not a member of the Hospital's Professional Staff, electronically entered data into the History and Physical section of the electronic record and wrote the plan for Patient #13's upcoming surgery.

During review of Patient #13's electronic medical record with the Nursing Director for Clinical Informatics indicated that one day later on 12/31/19 at 5:21 P.M., the Attending Surgeon reviewed the Registered Nurses data under the History and Physical.

Based on records reviewed and interviews the Hospital failed for one of two patients (Patient #24) of in a total sample of 37, who had a postpartum hemorrhage, to administer blood in accordance with Hospital policy. Findings included:

The Hospital policies titled "Blood and Blood Product Administration and Suspected Transfusion Reaction," dated 5/10/19, and Hospital policy titled, "Blood Products and Blood Transfusions in the Operating Room," dated 3/26/18, indicated two transfusionists (persons) reviewed and verified the blood transfusion information. The Hospital policy titled, "Blood Products and Blood Transfusions in the Operating Room," indicated transfusionists were Registered Nurses or Physicians.

The History and Physical Examination, dated 11/5/19 at 5:27 P.M., indicated Patient #24 was admitted to Labor & Delivery for a Cesarean section.

The Operative Report, dated 11/6/19 at 1:49 P.M. indicated Patient #24 received two blood transfusions for uterine bleeding.

Medical record review indicated there was no documentation that two transfusionists reviewed and verified blood transfusion information prior to administering blood to Patient #24, in accordance with Hospital policy.

Based on observations, record review and interviews it was determined the Hospital failed to ensure that it met the requirements for fire safety in accordance with Chapter 19 of the National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 Edition related to Life Safety from Fire and Maintenance of the Physical Plant. Findings include:

1. The facility failed to ensure that hospital environment was maintained in such a manner that the safety and well being of patients was assured by ensuring that automatic doors release when smoke detectors activate: smoke detectors were provided in required spaces; egress routes were free from locked doors; facility failed to ensure compliance with sections of the 2011 edition of NFPA 72 "National Fire Alarm and Signaling Code"; and facility failed to ensure that smoke barrier doors are maintained and equipped as required, in accordance with the National Fire Protection Agency requirements for Health facilities.

See A-709

2. The facility failed to failed to comply with the various sections of NFPA 72 related to fire safety protections within the facility. These deficient practices could affect all patients, as well as an undetermined amount of staff and visitors in the event of an actual emergency situation where fire was to threaten these locations

Please see A0710 below and the Life Safety Code 2567 survey findings regarding evidence of non-compliance with NFPA 101 Life Safety Code Standard requirements.

Based on observations and interviews, the facility failed to ensure that the hospital environment was maintained in such a manner that the safety and well being of patients was assured by ensuring that automatic doors were released when smoke detectors activated: smoke detectors were provided in required spaces; egress routes were free from locked doors; facility failed to ensure compliance with sections of the 2011 edition of NFPA 72 "National Fire Alarm and Signaling Code"; and the facility failed to ensure that smoke barrier doors are maintained and equipped as required, in accordance with the National Fire Protection Agency requirements for Health facilities. Findings include:

1) The facility failed to ensure that hospital environment was maintained in such a manner that the safety and well being of patients was assured by ensuring that doors held open by magnetic devices released with the activation of a smoke detecting device and smoke detecting devices were provided in spaces that required them in accordance with the National Fire Protection Agency requirements for Health facilities.

During the morning and afternoon hours of 01/06/20 and 01/07/20 while surveying the hospital, the following items were observed regarding doors and hold open devices:

The smoke barrier door on the 3rd floor level, West Unit, located between the Medication Room and the Clean Utility Room was held open by a magnetic device tied into the fire alarm system. There is no smoke detector provided on either side of this doorway for door release as required.
The surveyor observed that the depth of the wall section above the door on each side is less than 24", requiring at a minimum one smoke detector for door release.

The 2nd floor level Auditorium doors are part of the 2-hour fire separation and were held open by magnetic devices tied into the fire alarm system. The surveyor observed that the depth of the wall section above the doors on the Auditorium side is approximately 12' in height. There is no smoke detector located on this side of the doorway as required.

This deficient practice could affect all patients, as well as an undetermined amount of staff and visitors in the event of the doors not releasing and closing during an emergency situation.

As a result of the lack of a smoke detector and the doors being held open by a magnetic devices, the facility failed to comply with section 17.7.5.6.5.1 for proper smoke detection devices.

The findings were confirmed by the Hospital's Administrative Leadership Team during the exit interview process.

2) The facility failed to ensure that egress routes are free from locked doors.

During the morning hours of 01/07/20 at 9:15 A.M., while touring the 3rd floor S5 (Respiratory) area, deadbolt locking devices were observed on four of the examination room doors.

This deficient practice can prevent instant patient removal in the event of an actual emergency situation where the exiting the room is required.

As a result, the facility failed to comply with section 7.2.1.5.1 requiring doors to be opened readily from the egress side.

The findings were confirmed by the Hospital's Administrative Leadership Team during the exit interview process.

3) The facility failed to ensure compliance with sections of the 2011 edition of NFPA 25 "Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems."

While conducting the facility tour during the afternoon hours of 01/07/20 at 2:30 P.M., observations revealed the existence of a damaged sprinkler head positioned in the ceiling near room #424 of the area identified as "Usen West". The damaged head is of the concealed type with a drop down deflector which rides on guide rails when activated. At time of observation, the sprinkler head was found to be missing its cover and the deflector guide rails were bent and misaligned.

As a result of the finding, the facility failed to ensure compliance with Section 5.2.1.1.2 of NFPA 25 which requires damaged sprinkler heads to be replaced.

The findings were confirmed by the Hospital's Administrative Leadership Team during the exit interview process.

4) The facility failed to ensure that smoke barrier doors are maintained and equipped as required.

During the afternoon hours of 01/06/20 and 01/07/20 while touring the hospital, it was observed that smoke barrier doors are not properly maintained or equipped. The following items (but not limited to) were observed regarding smoke barrier doors:

a) On 1/6/2020 at 10:40 A.M., the surveyor observed that the pair of smoke barrier doors on the 6th floor corridor located at S3 have an approximate 1/4" gap between the two door leaves which would allow smoke to seep in between the doors from one area to the next.

b) On 1/6/2020 at 3:15 P.M., the surveyor observed the smoke barrier door on the 3rd floor West Unit located between the Medication Room and the Utility Room does not close as required. The door appears to be out of adjustment preventing full closure as required.

c) On 1/6/2020 at 4:15 P.M., the surveyor observed the smoke barrier door on the 3rd floor East Unit located between the X-Ray Control Room and Exam Room 1 was found to be wedged in the open position. This door wedge was immediately removed by hospital staff.

d) On 1/7/2020 at 2:20 P.M., the surveyor observed the second floor smoke barrier door which separates SC-2A from SC-2 G is deficient as follows.

1) It is equipped with a non-rated vision panel.

2) It was being held open by a releasing device which requires manual activation to close the door. As section 7.2.1.8.2 requires, smoke barrier doors shall only be allowed to be held in the open position by use of an automatic releasing device that is actuated by the fire alarm system.

As a result, the facility failed to comply with requirements that state smoke barrier doors are to self close and be smoke tight which would allow smoke to seep in between the doors from one area to the next.

The findings were confirmed by the Hospital's Administrative Leadership Team during the exit interview process.

Based on observations and interviews, the facility failed to failed to comply with the various sections of NFPA ( National Fire Protection Agency):
NFPA 101, the 2012 edition of the Life Safety Code
NFPA 12, the 2010 edition of the "Standards for the installation of Sprinkler Systems'"
NFPA 25, the 2011 edition of the "Standards for Inspections, testing and Maintenance of Water-Based Fire Protection Systems,"
NFPA 72, the 2010 edition of the "National fire Alarm and Signaling Code," and
NFPA 99, the 2012 edition of the "Health Care Facilities Code."

These deficient practices could affect all patients, as well as an undetermined amount of staff and visitors in the event of an actual emergency situation where fire was to threaten these locations. Findings include:

1. The facility failed to ensure all required areas were protected by the automatic sprinkler system and failed to ensure areas had proper fire rated separation as required.

During the morning and afternoon hours of 01/06/20 and 01/07/20, the following items were observed regarding the installation of the automatic sprinkler system:

a. On 1/6/20, at 11:00 A.M., the IT Room located on floor 6 East is not protected throughout by an automatic sprinkler system. The floor/ceiling IT server/cable management rack is located in the middle of the room. The sprinkler head within this room is located on the front side of this rack, as a result, the rack is obstructing sprinkler protection on the rear side.

b. On 1/7/20, at 3:30 P.M., while viewing the newly created Medical Gas Storage Room, the surveyor observed that the original lay in ceiling tile system had been removed. However, the sprinkler heads protecting this location were left at the original ceiling height. As a result, the sprinkler heads are now approximately four feet (4') below the concrete deck above.

c. On 1/7/20, at 1:30 P.M., while viewing the Electrical closet on the 2nd floor level identified by door #12015A, it was observed to be non-sprinklered. In addition, the room was observed to not have a 2-hour separation as required if non-sprinklered.

d. On 1/6/20, at 2:10 P.M., while conducting the facility tour during the afternoon hours of 1/06/20 observations revealed the presence of a quick response sprinkler head approximately fifty inches (50") apart from a standard response sprinkler head in room #470 on the fourth floor of the "Usen Building".

In addition to these sprinkler heads being to close to each other, regulations prohibit the installation of quick response and standard response sprinkler heads within the same compartmented space. To ensure compliance with NFPA 13 regulations, the standard head sprinkler located approximately 50" from the quick response head must be removed. The surveyor observed that all other sprinkler heads within the observed compartmented space (room #470) are of the quick response type

The findings were confirmed by the Hospital's Administrative Leadership Team during the exit interview process.


2. The facility did not comply with Chapter 19 Section 19.7.8 of the 2012 edition of NFPA 101 " Life Safety Code ".

Section 19.7.8 " Portable Space Heating Devices " states the following. Portable space heating-devices shall be prohibited in all health care occupancies, unless both of the following criteria are met:
(1) Such devices are used only in non-sleeping staff and employee areas.
(2) The heating elements of such devices do not exceed 212 degrees F (100 degrees C).

While conducting the facility tour on 01/06/20, the surveyors observed the existence of a portable electric space heaters with heating elements capable of exceeding 212 degrees F (100 degrees C) at the following locations:

a. On 1/6/20, at 10:40 A.M., at the sixth floor level MGH Outpatient Checkout / Reception desk.

b. On 1/6/20, at 2:10 P.M., the third floor level outpatient Dietary and Psychiatric office spaces at: office # 13 B, Social Service(s) Workers, office # 12 B, office # 11 B, and the Care Coordinator Office #4 ( opposite office #17) which also utilized an extension cord to supplement power to the space heater.

The finding was confirmed by the facility's head electrician and reviewed with the Director of Facilities, Engineering and other Hospital Administrative staff during the exit conference.

3. The facility failed to ensure that the electrical wiring is in accordance with NFPA 99, (Health Care Facilities Code) 2012 edition.

While conducting the facility tour during the afternoon hours on 1/6/20, the surveyor observed an extension cord being utilized to supplement power to a non-conforming quartz type portable electric space heater and a cell phone charger on the third floor level, outpatient Dietary and Psychiatric office spaces, at the Care Coordinator Office #4 (opposite office #17).

The facility's head electrician, who also noted this, immediately removed the space heater and placed in a locked closet.

4. The facility failed to ensure that all stairwells are protected with the required fire resistance rating.

NFPA Section 19.3. requires any vertical opening to be enclosed or protected and where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating.

During the morning hours of 01/06/20 while reviewing the hospital floor plans and construction documents, it was observed that the stairwells in the building are identified as having a 2-hour fire resistance rating. During the the tour, the 7th floor level of "Stairwell L" was observed to be equipped with an approximate 6' door leading into the penthouse area. Although this door is no longer used, a 2" hole was observed in the door where the previous door latching assembly was located. The door was sealed from the inside (within the penthouse) with 2-layers of 5/8" gypsum which did not provide a 2 hour fire resistance rating. This enclosure is not accurate with the hospital plans listing the separation as 2-hours.

This deficient practice could affect all patients, as well as an undetermined amount of patients, staff and visitors in the event of an actual emergency. This stairwell door would not offer the degree of safety as indicated to prevent fire from compromising this stairwell.

As a result, the hospital failed to comply with providing a 2-hour fire separation as the plans indicate.


5. The facility failed to ensure compliance with specific requirements of the 2012 edition of NFPA 101 Life Safety Code which states doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke and shall be constructed of materials such as
(1) 1-3/4 in. (44 mm) thick, solid-bonded core wood or material that resists fire for a minimum of 20 minutes
The requirements do not apply to doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.

During the morning and afternoon hours of 01/06/20 at 11:00 A.M., the following items were observed:

a.) On the "South" Building's sixth floor level MGH pediatric area:
1.) The Nursing Director's Office was held open by a floor wedge,
2.) Exam Room #9 had a 1/2 inch unsealed gap between the door face and door stop along the header.

b). On the third floor level, identified as outpatient Dietary and Psychiatric office spaces, Office # 10 B utilized a floor wedge to hold the door open.

c.) On the Usen Building's third floor level occupied unit, the two (2) Interview Room's corridor doors each were equipped with the total hinge, and no door stops along the header, the hinge side and latch side jam.
Facility staff stated that it is a way to access room in the event of a hostile patient. Neither one of the frames are equipped with door stops rendering the doors less than smoke resistant.

d.) On 1/6/2020 at 11:40 A.M. , the surveyor observed the set of double doors leading into the 6th floor NICU to have an approximate 1/4" gap between the two door leaves.

e.) On 1/6/2020 at 4:14 P.M., the surveyor observed that all of the patient room doors on the 3rd floor West Unit were obstructed. These room doors were unable to close and latch as a soiled linen cart and/or trash container were preventing the doors from closing. The rooms are designed with an approximate 10 inch wall on the latching side of the door so that when these obstructing carts and /or containers are placed in this wall location, they prohibit the doors from closing.

The finding was confirmed by the facility's head electrician and reviewed with the Director of Facilities, Engineering and other Hospital Administrative staff during the exit conference.

6. The facility failed to ensure that smoke compartments were maintained as smoke tight as required.

NFPA states any required smoke barrier shall have a minimum 1/2-hour fire resistance rating, be continuous from outside to an outside wall from a floor to a floor, or from a some barrier to a smoke barrier or any combination thereof and smoke barriers shall be continuous through all concealed spaces including interstitial spaces.

During morning and afternoon hours of 01/07/20 the following deficiencies but not limited to were observed regarding smoke barrier walls:

a. On 1/7/2020 at 9:00 A.M., the surveyor checked the 3rd floor level smoke barrier wall by S8 for structural integrity during the facility tour. An electronic smoke damper was observed directly above smoke barrier door #33,000. Upon closer examination, the smoke damper was observed to be located in the middle (between studs) of the actual wall, and not on one side as it should be. As a result of the placement of this damper, the wall was observed as having an approximate 8" x 8" non-sealed penetration. With the location of this smoke damper, it would not be possible to be smoke tight as there are moving components of the mechanism.

b. On 1/7/2020 at 11:00 A.M., the surveyor checked for structural integrity, the smoke barrier wall on the 2nd floor level between S6 and S7 during the facility tour. Numerous non-sealed penetrations were observed throughout this wall, these include voids around conduits, piping, wiring, and electrical components.

c. On 1/7/2020 at 10:50 A.M. to 11:10 A.M., , the surveyor checked the smoke barrier wall separating smoke compartment SC-2G from smoke compartment SC-2A for structural integrity during the facility tour. Numerous non-sealed penetrations as well as missing pieces of rated wallboard were noted throughout this barrier. These include the following areas.
a) Above the cross-corridor smoke barrier door leading into Suite #9.
b) Above the layed in ceiling tiles of the office area located adjacent to the corridor that leads to Suite #9.
c) Above the layed in ceiling tiles of the "Usen CDC staff breakroom".

As result, the facility failed to ensure compliance requiring smoke barrier walls to be tight from outside wall to outside wall.

Based on observation, record review and interview, the Hospital failed to ensure its infection prevention and control program employed adequate methods of controlling the potential spread of infections within the Hospital by failure of its staff [Hemodialysis Nurse #1, Anesthesia Technician #1, Physician #4, Registered Nurse (RN) #8 and #9 and Patient Care Technician (PCT) #1] to follow policy and procedures for infection control practice. Findings included:

The Hospital standard precaution policy, with an effective date of 7/8/2018, indicated the following:

A. Hand hygiene must be performed before donning and after glove removal and

B. Wear a mask and eye protection or a face shield to protect mucous membranes during procedures and patient care activities that are likely to generate splashes or sprays of blood, body fluid secretions and excretions.


1. Observation of the dialysis unit on 1/6/2020 at 11:50 A.M., revealed a 2 bed unit with portable reverse osmosis (RO) equipment for each bed as well as a hemodialysis machine (HD). Stored next to station 1 was an extra RO machine and hemodialysis machine within 2 feet of the HD machine delivering dialysis to the patient in bed at station 1. This was within the splash zone or area of contamination, should blood splatter occur from the dialysis machine and bloodlines that were in was use. There was no barrier between the clean machine and dirty or contaminated area where the patient was receiving treatment increasing the risk of cross contamination of the clean equipment which could be used on another patient.

The surveyor observed Hemodialysis Nurse HD #1 during care of the dialysis patient on 1/6/2020 at 11:30 A.M. During two glove changes, HD RN#1 failed to perform hand hygiene after glove removal.

2. During an observation in Operating Room (OR) 6 on 1/7/2020 at 11:20 A.M., the surveyor observed that the electrocautery metal cart was severely rusted on the bottom on all sides of the cart. An intravenous (IV) pole used by anesthesia to hang IV fluids was observed to have a very rusted base with peeling paint. Rust can indicate the presence of bacteria known as enterobacter. Equipment with peeling paint and rust cannot be properly cleaned and disinfected as the surface is not intact and such equipment should be removed from the surgical environment and repaired or disposed of.

3. During an observation of the cleanup and turnover of OR 6, at 11:20 A.M., the surveyor observed the anesthesia technician (AT) while he cleaned and disinfected the anesthesia equipment. The AT failed to wear his mask-shield combination correctly, wearing the mask portion below his nose the entire time. The AT also failed to remove the dirty chux on top of the Omnicell (where a used laryngoscope had been placed and medications from the previous case had been prepared) and failed to clean and disinfect the top of the Omnicell until surveyor inquiry.

4. During an endoscopy in procedure room #9, on 1/8/2020 at 8:50 A.M., the Surveyor observed that the surgeon (Physician #4), and the Registered Nurse (RN #8), who was performing surgical technician duties, failed to wear their mask-shield combinations correctly. Both wore the mask portion below their nose.

After the observation, during an interview on 1/8/2020 at 10:00 A.M., the endoscopy Nurse Manager said that staff should wear all PPE (personal protective gear) correctly and that the mask should be worn over the nose. The Nurse Manager said that a mask is required for the endoscopy procedure.

5. During observations in the endoscopy suite on 1/8/2020 at 8:45 A.M., the Surveyor observed RN #9 prepare intravenous medication for moderate sedation in procedure room #9 for Patient #28.

RN #9 inserted a sterile needle into a vial of Demerol (narcotic pain reliever) 100 milligrams (mgs) per milliliter (ml) without cleansing the rubber septum of the vial with an alcohol pad first. He then inserted a sterile needle into a vial of Versed (antianxiety agent) 10 mg/ml without cleansing the rubber septum of the vial with an alcohol pad first.

CDC ( Centers for Disease Control) safe injection practices state that the rubber septum of an injectable vial of medication must be cleansed with alcohol each every time it is entered whether it is the first or subsequent time to prevent cross contamination of the injectable medication.

6. On 1/6/2020 at 11:35 A.M., the surveyor observed a staff member identified as a Patient Care Technician (PCT #1) entered a room without a face mask on. The door to the room was labeled as " droplet precautions" indicating that all who entered the room needed to wear a face mask. A box of face masks was observed outside the room. PCT #1 said she did not know the patient was on (droplet ) precautions.

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Based on records reviewed and interviews, the Hospital failed to delineate surgical privileges, ensure competencies and routinely review privileging for three of three Surgical Technologist/First Surgical Assistants (CSTFA #1, #2 and 3#) and for two of two Registered Nurse (RN) First Assistants (RNFA #1 and #2) as required. Furthermore, the Certified Surgical Technologist Assistants were practicing outside of their State defined scope of practice by suturing and dissecting tissue.

Findings include:

According to the State Regulations at 130.860: Surgical Technology Definitions, a surgical technologist is any person who provides surgical technology services who is not licensed or registered under M.G.L. c. 112, para. 2, 16, 74 or 74A or who is not an intern, fellow, or medical officer who conducts or assists with the performance of surgery. The surgical technology scope of practice is defined as:

(1) collaboration with an operating room circulator prior to a surgical procedure to carry out the plan of care by preparing the operating room, gathering and preparing sterile supplies, instruments and equipment, preparing and maintaining the sterile field using sterile and aseptic technique and ensuring that surgical equipment is functioning properly and safely;

(2) Intraoperative anticipation and response to the needs of a surgeon and other team members by monitoring the sterile field and providing the required instruments or supplies;

(3) Performance of tasks at the sterile field, as directed in an operating room setting, including:

(a) Passing supplies, equipment or instruments;

(b) Sponging or suctioning an operative site;

(c) Preparing and cutting suture material;

(d) Transferring and irrigating with fluids;

(e) Transferring, but not administering, drugs within the sterile field;

(f) Handling specimens;

(g) Holding retractors; and

(h) Assisting in counting sponges, needles, supplies and instruments with an operating room circulator.

The State Regulations do not provide for surgical technologists to operate as first assistants to perform surgical tasks such as placement of suture ligatures and /or ties, closure of all wound layers as per the surgeon's directive, dissecting tissue with surgical instruments, use of electrocautery to cut tissue, insertion of drainage tubes and use and application of surgical instruments needed for hemostasis.

Review of the hospital policy titled "Credentialing/Role of the Surgical First Assistant, dated 10/13/2016, indicated that RNFA and CSTFA would be credentialed through Operating room (OR) Nursing Administration. Part of that process would include clinical competency in the OR setting, or Nurse Manager's discretion.

1. Review of RNFA #1 and #2 credentialing file indicated they were approved for "active staff category" to provide the following duties as a delineation of privileges: provide hemostasis: passing instrumentation; apply dressing; suture and suture removal; performing secondary portions of surgical procedures; retraction; cutting of tissue; splint, brace and cast application and positioning of patient.

Review of RNFA #1 and #2 credentialing file indicated no competencies in either personnel files to establish what each RNFA was competent to do. For example: what type of tissue could each RNFA competently dissect: could they open a chest, dissect out breast tissue, open leg for vein removal, dissect an open abdomen for colon cancer- each involving different dissection skills.

Review of RNFA #1 and #2 credentialing file indicated privileges were granted by the supervising physician, OR nurse manger, Director of Perioperative Services (also a nurse) and the Chair of Surgical Services, a physician.

Review of RNFA #1 credentialing file indicated privileges were granted for RNFA #1 on 11/3/2010 and not renewed or reviewed since.

Review of RNFA #2 credentialing file indicated privileges were granted for RNFA #2 on 11/3/2010 and not reviewed or renewed since.

2. Review of the personnel file for CSTFA #1 indicated she was reviewed and renewed as of 1/6/2020 with the last review of credentialing done on 6/30/2006, 14 years prior. Her delineation of privileges were: to provide hemostasis: passing instrumentation; apply dressing; suture and suture removal; performing secondary portions (not defined) of surgical procedures; retraction; cutting of tissue; splint, brace and cast application and positioning of patient but also included the handling of medications (passing in medications from the back table) and working under a microscope. There was a performance evaluation in the record done on 12/19/2019 by the supervising physician but no documentation of any competencies for the tasks she was given privileges to do.

3. Review of the personnel file for CSTFA #2 indicated she was granted the same privileges as above on 6/30/2006 but has not been reviewed or renewed since. The personnel file for CSTFA #2 indicated no competencies or performance evaluation.

4. Review of the personnel file for CSTFA #3 indicated he had the same privileges as listed above. There was no supervising physician listed in his file and no competencies were found.

5. During an interview on 1/8/2020 at 11:00 A.M., the Chief Nursing Officer said the hospital goes by what the RNFA and CSTFA certification course says each first assistant can do for their competencies. They do not give the RNFA or CSTFA a delineation of privileges like they do for surgeons or other practitioners. When the surveyors said this staff was performing surgery like those "other practitioners'' and should be held accountable, the CNO said they would have to review their process.

During interview with the Associate Chief Nursing Officer for Perioperative Services on 1/8/20 at approximately 11:30 A.M., the Associate Chief Nursing Officer said she not was qualified to evaluate the Certified Surgical Technologists/Surgical First Assistant performance of surgery.

6. Review of the personnel files did not contain details on what each practitioner was competent to do upon completion of the certified surgical tecnologist first assistant program. The files only contained course completion certificates.

7. Review of the Medical Staff Bylaws, Article II, dated and reviewed on December 2019, indicated that the Certified Surgical Technologists/Surgical First Assistants were not approved to be surgical practitioners in the Hospital.