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TROY COMMUNITY HOSPITAL
No Description Available
Tag No.: C0321
Based on review of facility documents, observation and interview of staff (EMP) it was determined the facility failed to ensure all staff who provided services in the operating room were granted privileges (CF8 and CF9) for 169 surgical procedures performed since February 3, 2016.
Findings include:
Review of "Troy Community Hospital Medical Staff Bylaws," last reviewed June 29, 2016, revealed "... Article 2: Purposes and Responsibilities 2.1 Purposes The purposes of the Staff are: A. Be the formal organizational structure through which: 1. The benefits of membership on the Staff may be obtained by individual and practitioners, and 2. The obligations of Staff membership may be fulfilled. B. Serve as the primary means for accountability to the board for the appropriateness of the professional performance and ethical conduct of its members and to strive toward assuring that the pattern of patient care in the Hospital is consistently maintained at a high level of quality and efficiency. ... 2.2 Responsibilities The responsibilities of the Staff, to be fulfilled through the actions of its Officers, Services, and Committees, include: 2.2-1 Account for the quality and appropriateness of patient care rendered by all practitioners authorized to practice in the Hospital through the following measures: A. A credentials process, including mechanisms for appointment and reappointment, and the matching of clinical privileges to be exercised or for specified services to be preformed [sic], with the verified credentials and current demonstrated performance of the applicant or Staff member; ... 2.2-2 Recommend to the Board action with respect to appointments, reappointments, staff category, service assignments, clinical privileges, and corrective action. Article 3: Staff Membership 3.1 Nature of Staff Membership Membership on the Staff of Troy Community Hospital is a privilege which shall be extended only to professionally competent physicians, podiatrists, and dentist who continuously meet the qualifications, standards and requirements set forth in these Bylaws. Appointment to and membership on the Staff shall confer on the Staff member only such clinical privileges as prerogatives as have been granted by the Board in accordance with these Bylaws, and shall include Staff category and Service assignments. 3.2 Basic Qualifications [sic] for Membership 3.2-1 Basic Qualifications Only dentist, podiatrists, and physicians licensed to practice in the Commonwealth of Pennsylvania who: A. Document their experience, background, training, demonstrated ability, and upon request their physical and/or mental health status, with sufficient adequacy to demonstrate to the Staff and the Board that any patient treated by them will receive care of the generally professionally recognized level of quality and efficiency ... 3.2-2 Allied Health Professionals A. Health Professional Affiliates are individuals who are duly licensed persons qualified to render direct medical care under the supervision of a member of the Medical Staff and who are capable of effectively communicating with patients, the Medial [sic] Staff and hospital personnel. Such affiliates may include, but shall not be limited to, clinical nurse specialist, clinical pharmacologists, clinical psychologists, CRNA'S [certified registered nurse anesthetist], nurse clinicians, nurse practitioners and physician assistants. B. Where appropriate, the Medical Executive Committee may establish particular qualifications required of members of a specific category of Health Professional Affiliates, provided that such qualifications are not founded upon an arbitrary or discriminatory basis and are in conformance with applicable law. The training, experience and demonstrated current competence of specific professional personnel shall be sufficient to permit their performance of the following functions: The exercise of judgment within their areas of competence, provided that a member of the Medical Staff shall have ultimate responsibility for patient care ..."
Observation at 11:30 AM on August 10, 2016, revealed CF8 performed the surgical technician duties during MR6's surgery.
Interview with EMP2 at 11:30 AM on August 10, 2016, revealed CF8 was not a hospital employee. CF8 accompanied and assisted CF1 with surgeries at Troy Community Hospital. EMP2 revealed CF9, who was not a hospital employee, also came to the hospital and assisted OTH1 with surgeries.
Review of the facility surgical log revealed:
On February 3, 2016, CF8 assisted CF1 with two myringotomies (incision of the eardrum) with insertion of tubes (BMT), one BMT with adenoidectomy (removal of the adenoids), and three sinus surgeries using the Fiagon navigation system.
On February 10, 2016, CF8 assisted CF1 with one myringotomy, one tonsillectomy (removal of the tonsils) and adenoidectomy (T and A), two tonsillectomies and one closed reduction of a nose fracture.
On February 17, 2016, CF8 assisted CF1 with three BMTs, two BMTs with adenoidectomy, and one sinus surgery using the Fiagon navigation system.
On February 24, 2016, CF8 assisted CF1 with one BMT with adenoidectomy, three T and As, one BMT, one canaloplasty (revision of ear canal) and one cerumenectomy (removal of ear wax).
On March 2, 2016, CF8 assisted CF1 with one removal of ear tube, on tonsillectomy, and one complex sinus surgery.
On March 9, 2016, CF8 assisted CF1 with one BMT, one tonsillectomy, two tympanomastoidectomy (eardrum and mastoid bone surgery), and one sinus surgery.
On March 23, 2016, CF8 assisted CF1 with one adenoidectomy, one BMT, two complex sinus surgeries and one septoplasty (revision of the septum).
On March 30, 2016, CF8 assisted CF1 with one mastoid debridement, one BMT, two tympanoplasties (revision of ear drum) and one complex sinus surgery.
On April 6, 2016, CF8 assisted CF1 with one myringotomy with tube removal, one lip surgery, one T and A, one tonsillectomy, one tympanoplasty and one image guided sinus surgery.
On April 13, 2016, CF8 assisted CF1 with three BMTs and one tympanoplasty.
On April 20, 2016, CF8 assisted CF1 with one skin lesion removal, one complex sinus surgery and one vocal cord surgery.
On April 27, 2016, CF8 assisted CF1 with one BMT, two tonsillectomies, one septoplasty, and one image guided sinus surgery.
On May 4, 2016, CF8 assisted CF1 with two BMTs, two T and As, one nasal irrigation, one image guided sinus surgery and one tympanoplasty.
On May 11, 2016, CF8 assisted CF1 with two BMTs, one T and A with sinus surgery, one septoplasty with sinus surgery, and one T and A with right ear tube.
On May 18, 2016, CF8 assisted CF1 with one thyroid surgery, one T and A and one sinus surgery.
On May 25, 2016, CF8 assisted CF1 with one BMT, one septoplasty, one tonsillectomy and one sinus surgery.
On June 1, 2016, CF8 assisted CF1 with two BMTs, one tympanoplasty and one thyroid surgery.
On June 8, 2016, CF8 assisted CF1 with one BMT and adenoidectomy, one tonsillectomy, one T and A and one nasal surgery.
On June 15, 2016, CF8 assisted CF1 with one T and A, two septoplasties, one tympanoplasty and one vocal cord surgery.
On June 22, 2016, CF8 assisted CF1 with three ear drum surgeries, one BMT, one sinus surgery, one thyroid surgery and one T and A.
On June 29, 2016, CF8 assisted CF1 with two BMTs, one BMT with adenoidectomy, one T and A, one ear drum surgery and one image guided sinus surgery.
On July 6, 2016, CF8 assisted CF1 with two BMTs, one T and A and one vocal cord surgery.
On July 13, 2016, CF8 assisted CF1 with three T and As, two BMTs and one throat surgery.
On July 20, 2016, CF8 assisted CF1 with one tympanomastoidectomy with tube and one cochlear ear surgery.
On August 3, 2016, CF8 assisted CF1 with two BMTs, three T and As, one adenoidectomy and one tympanoplasty.
On August 10, 2016, CF8 assisted CF21 with one BMT, one laryngoscopy (exam of throat), one tympanoplasty and one image guided sinus surgery.
On February 12, 2016, CF9 assisted OTH1 with one bunionectomy (removal of bunion), one tendon repair and one plantar fasciotomy (incision of plantar tissue).
On February 26, 2016, CF9 assisted OTH1 with one bunionectomy, one bone spur removal and one excision of a fibroma (benign tumor).
On March 11, 2015, CF9 assisted OTH1 with two bunionectomies.
On March 25, 2015, CF9 assisted OTH1 with three bunionectomies.
On April 8, 2016, CF9 assisted OTH1 with two bone spur removals and one plantar fasciotomy.
On April 22, 2016, CF9 assisted OTH1 with two bunion surgeries, one plantar wart removal and one excision of a lesion.
On May 6, 2016, CF9 assisted OTH1 with one bunion surgery, one hammer toe repair and one plantar wart removal.
On May 13, 2016, CF9 assisted OTH1 with one hardware removal, one bunionectomy and one hammer toe repair.
On June 3, 2016, CF9 assisted OTH1 with two bunionectomies and one toe amputation.
On June 10, 2016, CF9 assisted OTH1 with one hardware removal, one removal of bone fragments and one tendon repair.
On June 24, 2016, CF9 assisted OTH1 with two bunionectomies and two toe amputations.
On July 8, 2016, CF9 assisted OTH1 with one hammertoe repair, one toe amputation and one removal of hardware.
On July 22, 2016, CF9 assisted OTH1 with two bunionectomies and one plantar fasciotomy.
On July 29, 2016, CF9 assisted OTH1 with one bunionectomy and one toe surgery.
Interview with EMP2 at approximately 9:00 AM on August 11, 2016, confirmed CF8 and CF9 assisted with the above listed surgical procedures at this hospital.
Review on August 11, 2016, of CF8 revealed they were not a hospital employee. Review of CF8 revealed a "Troy Community Hospital Orientation" packet with documentation of CF8's review of operating room policies and competency evaluation performed by the operating room supervisor. Further review of CF8 revealed no privilege letter that granted CF8 permission to assist in the hospital operating room.
Review on August 11, 2016, of CF9 revealed they were not a hospital employee. Review of CF9 revealed a "Troy Community Hospital Orientation" packet with documentation of CF9's review of operating room policies and competency evaluation performed by the operating room supervisor. Further review of CF9 revealed no privilege letter that granted CF9 permission to assist in the hospital operating room.
Interview with EMP2 at approximately 9:00 AM on August 11, 2016, confirmed CF8 and CF9 were not hospital employees. EMP2 confirmed they performed competency reviews of operating room procedures on CF8 and CF9.
Interview of EMP6 at approximately 10:30 AM on August 11, 2016, confirmed the hospial did not have credential files for CF8 and CF9. EMP6 also confirmed CF8 and CF9 were not given privileges to provide services in the hospital's operating room.