HospitalInspections.org

Based on document review and interview, the facility failed to ensure that persons participating in surgical procedures were qualified to do so. Seven of seven persons (including one minor, age 15 years old) verbally identified as medical assistants (MA) were assisting surgeons in the hospital's operating room (OR) during surgical procedures. These individuals were performing duties of a surgical technologist, but were not qualified to perform these duties.
The hospital had no documentation that these persons had been onboarded through hospital processes (human resources, employee health and staff education). Additionally, Staff A (surgeon) did not demonstrate a level of understanding and concern for this practice.


Please see findings in tag A-0339.

Based on document review and interview, the Governing Body failed to ensure that persons participating in surgical procedures were qualified to do so. Specifically, 7 of 7 persons (including one minor, age 15 years old) verbally identified as medical assistants (MA) and listed as visitors in medical records (MR) were assisting surgeons in the hospital's operating room (OR) during surgical procedures. These individuals were performing duties of a surgical technologist, but were not qualified to perform these duties. Additionally, the hospital lacked a job description for MAs. The hospital also lacked documentation that these MAs were onboarded through hospital processes. The hospital lacked health related information e.g., health assessment, vaccination status, background information and reference check information for these MAs. There was no documentation that these persons participated in orientation or completed hospital required competencies. These failures may have placed patients at risk for harm.

Findings include:

-- Review of 6 intraoperative reports for orthopedic surgeries performed by Staff A (dated 6/20/2023, indicated a "Visitor" (Visitor/MA #1, a 15-year-old) was present in the OR for all procedures and assisted in 3 surgical procedures.

There was no documentation that Visitor/MA #1 was qualified to assist in surgical procedures. Visitor/MA #1 was not onboarded through hospital processes.

-- During interview of Staff A, Surgeon on 6/28/2023 at 8:30 am, he/she/they indicated this 15-year-old MA's vaccination records had been provided to the OR registered nurse (RN) manager and the OR educator. The Visitor/MA had watched videos provided by the OR educator, observed OR staff scrub in, and returned demonstration of scrubbing in. The Visitor/MA had participated in 5-10 cases and helped position patients on and off the table as well as hold retractors (a surgical instrument used to separate the edges of a surgical incision/wound or to hold away certain organs and tissues so that body parts underneath may be accessed during surgical operations). Staff A indicated the age of Visitor/MA #1 was not relevant as he/she/they do research and are employed as a MA in a private practice. Staff A indicated other surgeons within the hospital are bringing in MAs to assist with surgeries.

-- During interview of Staff B, RN on 6/28/2023 at 9:00 am, Staff B recalled being scrubbed into one case with Visitor/MA #1 where he/she/they held retractors for the surgeon and positioned the patient. After that case was completed, Visitor/MA #1 scrubbed into another case.

-- Review of 4 of 8 intraoperative reports for orthopedic surgeries performed by Staff C, dated 6/28/2023, indicated MAs provided care during the surgical procedures. There was no documentation that these MAs were qualified to assist with surgical procedures.

-- Per interview of Staff F, Director of Peri-Operative Surgical Services on 6/27/2023 at 3:50 pm, 6/29/2023 at 1:00 pm, and 6/30/2023 at 1:50 pm, . Staff F was made aware of an unauthorized minor (Visitor/MA #1) present in the OR after it occurred. Staff F spoke with HR and was told that the individual was not approved to be in the OR. Staff F indicated another surgeon, Staff C, had been bringing in MAs since at least 2014. Those MAs hold retractors but are typically not in the room when positioning of patients occur. There are no annual competencies for the MAs and Staff F had no concerns regarding the use of the MAs in the OR.

-- During interview of the Staff D, Director of Medical Surgical Nursing & Nursing Quality, and Staff E, Director of Quality Management and Regulatory Affairs on 6/30/2023 at 9:45, they acknowledged the above findings.