HospitalInspections.org

Based on interview and medical record review, it was determined that 1 of 3 sampled physicians did not have privileges to perform surgical services. Specifically, endoscopic carpal tunnel surgeries were performed without a delineation of services from the governing body. (Patient identifier: 4)

Findings include:

1. A review of the surgical procedures from 6/1/2021 to 8/9/2021 was reviewed. Patient 4 had an endoscopic carpal tunnel release of the left arm performed by physician 1 on 6/30/2021. Additionally, the right arm was surgically repaired by physician 1 on 7/9/2021.

2. A review of the delineation of surgical procedures for physician 1 was completed on 8/10/2021. Physician 1 did not have a delineation to perform endoscopic carpal tunnel release.

3. An interview was conducted with the administrator of the hospital. The surveyor asked the administrator why physician 1 was performing carpal tunnel surgeries when carpal tunnel surgery was not delineated on his approved surgery list. The administrator stated, "The carpal tunnel surgery should have been on the list of delineated procedures but we neglected to add it to the list".