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Based on records reviewed and interviews Quality Assessment & Performance Improvement (QAPI) activities failed for one patient (Patient #1) of ten sampled patients to implement preventive actions and mechanisms that included opportunities for improvement and learning for all Surgeons credentialed and privileged to provide spine surgery and all Surgeons credentialed and privileged to provide surgery requiring internal (in the body) site marking, to Hospital patients in the Action Plan after Patient #1's adverse patient event.

Findings included:

The Operative Note, dated 8/28/18 for Patient #1, indicated Surgeon #1 operated on the incorrect level (area) of Patient #1's spine (back).

The document titled Action Plan, dated 9/2018, indicated an action item regarding surgical site verification for Surgeon #1. The Action Plan indicated no indication the Hospital implemented the action item regarding site verification for the five Surgeons credentialed and privileged to provide spine surgery to Hospital patients.

The Surveyor interviewed the Vice President for Surgical Services at 11:00 A.M. The Vice President for Surgical Services said the Hospital included in the Action Plan Surgeon #1 and did not include the other Surgeons who provided like spine surgery and all Surgeons credentialed and privileged to provide surgery requiring internal (in the body) site marking, to Hospital patients in the Action plan regarding site verification.

Based on records reviewed and interviews, Surgical Services failed to ensure organization of Surgical Services in documentation supporting the Hospital's scope of Surgical Services.

Findings included:

The document titled Scope of Service Operating Room, dated 2018, indicated the mission, values, goals, scopes of services and procedures provided to Hospital patients by operating room nursing staff.

The Hospital provided no documentation to indicate the Hospital's Surgical Service Scope of Services provided to Hospital patients by the Hospital. The Hospital provided no documentation to indicate the Medical Staff approved a Surgical Services Scope of Service.

The Surveyor interviewed the Vice President for Surgical Services at 9:50 A.M. on 9/28/18. The Vice President for Surgical Services said that the document titled Scope of Service Operating Room, dated 2018, was a nursing developed document approved by the Chief Nursing Officer. The Vice President for Surgical Services said that the Medical Staff did not approve the Scope of Service Operating Room document.

Based on records reviewed and interviews the Surgical Services failed for one patient (Patient #1) of ten sampled patients to ensure the verification of the correct surgical site was governed by Hospital policy designed to assure high standards of medical practice and patient care.

Findings included:

The Operative Note, dated 8/28/18 for Patient #1, indicated Surgeon #1 operated on the incorrect level (area) of Patient #1's spine (back).

The Hospital Policy titled Verification of Patient, Procedure & Operative Site, Side, dated 10/31/17, indicated spine surgery required a two-part marking process (marking the surgical site): 1.) The Surgeon marked the patient's skin at the level (area) of the surgery preoperatively and 2.) During the surgery, the Surgeon confirmed the level or surgery with an x-ray. The Verification of Patient, Procedure & Operative Site, Side Policy indicated additional consideration for spine surgery included that the Surgeon may use the following:

-Meet with a radiologist prior to surgery to review x-rays and develop a plan,

-Request a radiology technologist in the Operating Room to assist with X-rays,

-Request a radiology review during the surgery to site verification,

-Request a radiologist presence in the Operating Room for site verification.

The Verification of Patient, Procedure & Operative Site, Side Policy did not indicate a policy or guideline for internal (inside the body, at the spine site) site marking. The Verification of Patient, Procedure & Operative Site, Side Policy did not indicate a second "time-out" verification procedure with a qualified provider for the internal site verification. The Verification of Patient, Procedure & Operative Site, Side Policy did not indicate an alternative internal (in the body) site markings.

The Surveyor interviewed the Vice President for Surgical Services at 11:00 A.M. on 9/26/18. The Vice President for Surgical Services said Surgeon #1 changed Surgeon #1's method of internal site verification to verify the correct site with x-ray before the actual surgery on the spine. The Vice President for Surgical Services said that the Hospital Verification of Patient, Procedure & Operative Site, Side Policy was not updated for clarification for internal site verification. The Vice President for Surgical Services said the Hospital expected to implement the updates to the Verification of Patient, Procedure & Operative Site, Side Policy within the next three months. The Surveyor interviewed the Vice President for Surgical Services at 8:30 A.M. on 9/28/18. The Vice President for Surgical Services said that Hospital did not have Methylene Blue (solution to mark an internal site) available for surgical site markings.

The Surveyor interviewed Surgeon #1 at 10:45 on 9/27/18. Surgeon #1 said that if the Hospital had Methylene Blue available this error would not have occurred.

The document titled Action Plan, dated 9/2018, indicated Surgeon #1 did not follow Hospital Verification of Patient, Procedure & Operative Site, Side Policy.