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Based on interview and record review, it was determined the hospital did not have a complete operating room (OR) registry which included all 10 required regulatory elements.
Findings include:
On 8/30/16 at 10:45 AM, the OR manager was interviewed regarding the hospital OR Registry. The OR manager stated when the hospital converted to an Electronic Medical Record (EMR), the manual registry book was discontinued and the new electronic OR registry was implemented. The manual OR registry book was reviewed and no concerns were noted.
The OR manager was unable to provide the current OR registry information for the past month which was implemented when the facility initiated the new EMR. The OR manager required EMR support help to retrieve the new form titled 'Case Selection Form'. Review of the new EMR OR registry revealed the documentation was missing 6 of the 10 required regulatory elements. The missing requirements were; the total time of operation, any surgery assistants, nursing personnel including scrub and circulating RN's, type of anesthesia and who administered it, pre and post op diagnosis and age of the patient.

Based on interview and record review it was determined that the Critical Access Hospital (CAH) did not ensure that certified registered nurse anesthetists (CRNAs) were under the supervision of the operating practitioner.

Findings include:

On 8/30/16 at 1:16 PM, an interview was conducted with the Operating Room Coordinator (ORC). The ORC stated the facility contracted CRNAs to administer anesthesia. The ORC stated when CRNAs were administering anesthesia it was not required for them to have supervision by the operating practitioner.

On 8/30/16 at 1:23 PM, a telephone interview was conducted with CRNA 1. CRNA 1 stated CRNAs did not require supervision when administering anesthesia.

On 8/30/16 at 1:56 PM, a second telephone interview was conducted with CRNA 1. CRNA 1 stated he had talked with a board member from the Utah Association of Nurse Anesthetists who informed him that according to the Utah Nurse Practice Act CRNAs could administer anesthesia without supervision. CRNA 1 also stated the board member informed him that to bill a medicare patient the operating practitioner had to agree to to have the CRNA perform the anesthesia. CRNA 1 further stated CRNA supervision was, "Related to Medicare billing only."

Multiple requests were made for the facility policy regarding CRNA supervision, however a policy was never provided to the survey team.





30334

On 8/31/16 at 10:00 AM, a follow up telephone interview was conducted with the facility Administrator. The Administrator stated that as far as he knew, the facility did not have a policy or protocol in place that addressed the supervision of CRNAs by the operating practitioner. The Administrator stated that he would have to consult with the Nurse Administrator.

Based on interview and record review, it was determined the hospital did not have a complete operating room (OR) registry which included all 10 required regulatory elements.
Findings include:
On 8/30/16 at 10:45 AM, the OR manager was interviewed regarding the hospital OR Registry. The OR manager stated when the hospital converted to an Electronic Medical Record (EMR), the manual registry book was discontinued and the new electronic OR registry was implemented. The manual OR registry book was reviewed and no concerns were noted.
The OR manager was unable to provide the current OR registry information for the past month which was implemented when the facility initiated the new EMR. The OR manager required EMR support help to retrieve the new form titled 'Case Selection Form'. Review of the new EMR OR registry revealed the documentation was missing 6 of the 10 required regulatory elements. The missing requirements were; the total time of operation, any surgery assistants, nursing personnel including scrub and circulating RN's, type of anesthesia and who administered it, pre and post op diagnosis and age of the patient.

Based on interview and record review it was determined that the Critical Access Hospital (CAH) did not ensure that certified registered nurse anesthetists (CRNAs) were under the supervision of the operating practitioner.

Findings include:

On 8/30/16 at 1:16 PM, an interview was conducted with the Operating Room Coordinator (ORC). The ORC stated the facility contracted CRNAs to administer anesthesia. The ORC stated when CRNAs were administering anesthesia it was not required for them to have supervision by the operating practitioner.

On 8/30/16 at 1:23 PM, a telephone interview was conducted with CRNA 1. CRNA 1 stated CRNAs did not require supervision when administering anesthesia.

On 8/30/16 at 1:56 PM, a second telephone interview was conducted with CRNA 1. CRNA 1 stated he had talked with a board member from the Utah Association of Nurse Anesthetists who informed him that according to the Utah Nurse Practice Act CRNAs could administer anesthesia without supervision. CRNA 1 also stated the board member informed him that to bill a medicare patient the operating practitioner had to agree to to have the CRNA perform the anesthesia. CRNA 1 further stated CRNA supervision was, "Related to Medicare billing only."

Multiple requests were made for the facility policy regarding CRNA supervision, however a policy was never provided to the survey team.





30334

On 8/31/16 at 10:00 AM, a follow up telephone interview was conducted with the facility Administrator. The Administrator stated that as far as he knew, the facility did not have a policy or protocol in place that addressed the supervision of CRNAs by the operating practitioner. The Administrator stated that he would have to consult with the Nurse Administrator.