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Based on interview and record review, the hospital failed to ensure one of one sampled physician (MD 1) followed the hospital's Medical Staff Department of Surgery Rules and Regulations when performing the surgical procedure for one of six sampled patients (Patient 1). The failure posed the potential to result in an unsafe environment for the patients the hospital.

Findings:

Review of the hospital's Medical Staff Department of Surgery Rules and Regulations dated February 2015 showed the surgeon shall be in the hospital prior to and during the induction of anesthesia and in the operating room immediately following the induction of anesthesia and continuously until the conclusion of the case.

On 9/13/24 at 1434 hours, an interview and concurrent review of Patients 1 and 2's medical records was conducted with the Charge Nurse.

* Patient 1's medical record showed Patient 1 had a surgical procedure on 8/27/24. The surgical procedure was for the hernia repair ventral and performed by MD 1. The Surgery Case Details showed MD 1's "Time In" was at 0922 hours and "Time Out" was at 1046 hours. The procedure was started at 0924 hours and ended at 1051 hours.

* Patient 2's medical record showed Patient 2 had a surgical procedure on 8/27/24. The surgical procedure was for the excision axillary mass and performed by MD 1. The Surgery Case Details showed MD 1's "Time In" was at 1027 hours and "Time Out" was at 1243 hours. The procedure was started at 1029 hours and ended at 1043 hours.

During the concurrent interview with the Charge Nurse, the Charge Nurse confirmed Patients 1 and 2's medical records showed on 8/27/24 from 1027 hours to 1046 hours, MD 1 was in both Patients 1 and 2's ORs.

On 9/17/24 at 1006 hours, RN 2 was interviewed for documenting the physician's OR Time In/Out. RN 2 stated she was an OR circulating nurse (a RN who works in the operating room to ensure the patient safety and comfort during surgery). The OR circulating nurse was responsible to document the time when the surgeon came in and left the OR. RN 2 recorded the time when the surgeon walked into the OR, the time when the Time Out (a brief pause in the surgical procedure to confirm the correct patient, procedure, and site before the surgical incision initiated) was conducted, and the time when the surgeon left the room. RN 2 would write those times on the room white board and then transferred those data into the patient's medical record. RN 2 stated all OR circulating nurses were required and responsible to record the Time In/Out accurately.

On 9/18/24 at 1205 hours, MD 1 was interviewed regarding to the recorded Time In/Time Out for Patients 1 and 2's surgical procedures on 8/27/24. MD 1 confirmed on 8/27/24, MD 1 performed the surgical procedures for both patients. MD 1 reviewed both medical records and stated on 8/27/24, MD 1 first performed the procedure for Patient 1 and MD 1 left the OR to have the assisting PA continue finishing the rest. MD 1 went to the Patient 2's OR and performed Patient 2's procedure. MD 1 read the hospital's Medical Staff Department of Surgery Rules and Regulations that showed the surgeon shall be in the operating room continuously until the conclusion of the case. MD 1 confirmed he did not follow the Rules and Regulations.

Based on record review and interview, the hospital failed to maintain the high standards of care for the patients receiving the surgical services as evidenced by:

1. The hospital failed to ensure the hospital's P&Ps and Standardized Procedure were reviewed as per the hospital's P&P.

2. The hospital failed to the physician's order was obtained to discharge one of six sampled patients (Patient 5) as per the hospital's P&P.

These failures had the potential to result in an unsafe patient care environment.

Findings:

1. Review of the hospital's P&P titled Policy & Procedures Development, Approval and Review Process dated September 2020 showed it is the policy of the hospital that a consistent method of documenting, approving, and reviewing policy and procedures will be used. All policies and procedures will be reviewed at least every three years by the CNO and others as assigned.

On 9/18/24 at 1454 hours, the hospital's P&Ps were reviewed with the CNO/DON and Chief Quality and Patient Safety Officer. The following was identified:

* The hospital's P&P titled Policy & Procedures Development, Approval and Review Process of the Nursing Manual showed the last reviewed date was September 2020.

* The hospital's P&P titled Anesthesia Awareness, Intraoperative of the Nursing Manual showed the last reviewed date was September 2020.

* The hospital's P&P titled General Anesthesia Induction Out Side Of the Surgical Suite of the Surgical Services Manual had the last reviewed date was March 2021.

* The hospital's P&P titled Discharging Patients After Outpatient Surgery of the Surgical Services Manual showed the last reviewed date was March 2021.

* The hospital's P&P titled Discharge Criteria for the Surgical Services department showed the last reviewed date was November 2017.

* The hospital's P&P titled Standards of Practice/Standards of Care of the Surgical Services department showed the last reviewed date was November 2017.

* The hospital's Standardized Procedure titled Discharge from PACU of the Nursing department showed the effective date was June 2008.

During the concurrent interview, the CNO/DON and Chief Quality and Patient Safety Officer confirmed the above findings and stated those were the current and active P&Ps for patient care units including the hospital's P&P for Policy & Procedures Development, Approval and Review Process with the last reviewed date of September 2020.

2. Review of the hospital's P&P titled Standard Procedures: Discharging Outpatients from the Hospital dated September 2023 showed the physician must write an order to discharge the patient "per criteria" before the standardized procedure can be implemented.

On 9/17/24 at 1046 hours, an interview and concurrent review of Patient 5's medical record was conducted with Quality Manager 1.

Patient 5's medical record showed on 9/13/24, Patient 5 came to the hospital for a laparoscopic cholecystectomy (a minimally invasive surgical procedure used for the removal of a gallbladder). The patient was under general anesthesia. Patient 5's medical record showed the patient was admitted to the PACU on 9/13/24 at 1312 hours, moved to the Women's Center at 1427 hours, and discharged home at 1630 hours.

Review of the Post-Anesthesia and Discharge Orders showed the physician's initial on 9/13/24 at 1317 hours. The box of "Once discharge criteria met, may discharge patient to:...POR... ICU...Med/Surg...Women's Center" were left blank.

During the concurrent interview, Quality Manager 1 stated the Women's Center was used as an extension recovery unit for the outpatient surgery. Quality Manager 1 confirmed there was no documented evidence the RN had obtained a physician's order to discharge the patient as per the hospital's P&P.

Based on interview and record review, the hospital failed to ensure the log for the patients seen for surgical procedure was completed. This failure had the potential to negatively affect the patients in the hospital.

Findings:

On 9/17/24, the surgical schedules for 8/27, 9/13, 9/10, and 9/17/24 were requested. Review of the these surgical schedules showed the OR number, scheduled procedured, duration of the procedures, patient names, patient sex and age, case numbers, medical record numbers, visit numbers, visit types, types of anesthesia, and names of the surgeons.

On 9/17/24 at 1006 hours, the Surgery Scheduler was interviewed. The Surgical Scheduler stated she received the surgery schedule requested from the individual physician clinic/office. She entered it into the Sunrise system (the hospital computer system) to generate the surgical schedules for the staff to use. The Surgery Scheduler stated the surgery schedules would be the final one once it was made. The Surgery Scheduler was not told to update or revise when adding the cases, canceling the cases, or delay the cases. The Surgery Scheduler stated the hospital was utilizing Sunrise system which was difficult to use.

On 9/17/24 at 1613 hours, the Chief Quality and Patient Safety Officer was interviewed. The Chief Quality and Patient Safety Officer stated she was aware of the requirement for the OR register, but the hospital failed to have it. Therefore, the hospital could not show the following information:

* Inclusive or total time of the operation.
* Name of any assistants.
* Name of nursing personnel (scrub and circulating).
* Name of the person administering anesthesia.
* Pre and post-op diagnoses.