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Based on observation, review of the manufacturer's instructions, and staff interview, the Critical Access Hospital (CAH) failed to provide safety equipment to prevent backflow of contaminated water into 1 of 1 food preparation sink (main kitchen) used to wash ready-to-eat foods in the kitchen and failed to correctly disinfect 2 of 2 ice machines (cafeteria and nursing unit). The lack of an air gap or a safety device has the potential to cause contaminated water to back up into the sink and can affect all patients who eat food prepared from this sink. Failure to sanitize ice machines can result in patients ingesting contaminated water.

Findings include:

Review of the instruction manual for the "Cubelet Icemaker/Dispenser" occurred on 06/19/13. This manual, dated 2012, stated, ". . . Cleaning and Sanitizing Instructions. [name of company] recommends cleaning and sanitizing this unit at least twice a year. More frequent cleaning and sanitizing, however, may be required in some existing water conditions. . . . recommended cleaner, [name of company] "Scale Away" or "LIME-A-WAY" [name of company] . . . Pour . . . Scrub . . . soak for about 10 minutes. . . . Make ice using the solution until the icemaker stops making ice. . . . Sanitizing Solution. . . . sodium hydrochloride solution (chlorine bleach) with . . . warm water . . ."

- Observation of the main kitchen occurred on 06/19/13 at 1:00 p.m. with two dietary staff members (#1 and #2) and showed the food preparation sink lacked an air gap on the drainpipe below the sink. The dietary staff members (#1 and #2) stated staff used the sink to prepare vegetables and fruits.


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- Observation with an environmental service staff member (#3) on the afternoon of 06/19/13, showed two ice machines, one located in the CAH cafeteria (available to patients, visitors, and staff) and one located on the medical/surgical wing of the CAH used for patient hydration. The staff member (#3) stated every three months he removes all the ice from the machines and cleans the inside, the spill tray, and the filters with water.

The facility failed to provide evidence staff disinfected the ice machines at least twice a year.

Based on observation, review of policy and procedure, and staff interview, the Critical Access Hospital (CAH) failed to store drugs and biologicals in a secure manner to prevent access by unauthorized personnel in 4 of 7 medication storage areas (Emergency Room [ER], Surgery Center, Medication Room, and Radiology Department) and in 1 of 1 offsite clinic, and failed to label multi-use vials with the open date and dispose of them within 28 days in 1 of 1 Surgery Center. Failure of the CAH to adequately secure and restrict access of drugs and biologicals created an opportunity for unsafe and unauthorized use of medications. Failure to date multi-use vials with the date opened and dispose of appropriately may result in the use of expired medications.

Findings include:

Review of the policy "Security" occurred on 06/19/13. This policy, dated December 2012, stated, ". . . 1. There shall be a secure storage of all medications within the hospital . . . C. For each patient care area drugs are secure. 1. A locked night cabinet of drugs is available in the Med/Surg [Medical/Surgical] Unit . . . 3. Pharmacy determines and replenishes floor stock supply of all drug storage areas. . . ."

Review of the policy "Beyond Use Dating - Multiple Dose Vials - Single Dose Vials - Compounded Sterile Products" occurred on 06/19/13. This policy, dated December 2012, stated, ". . . 2. Multiple-dose containers (e.g. [example given], vials) are formulated for removal of portions on multiple occasions because they contain antimicrobial preservatives. The beyond-use date after initially entering or opening (e.g., needle punctured) multiple-dose containers is 28 days, unless otherwise specified by the manufacturer. . . ."

- Observation of the Surgery Center occurred on 06/18/13 at 1:00 p.m. with an administrative nurse (#4) and identified the following unsecured medications:
* OR (operating room) #1 - a bottle of Sevoflurane and Suprane (both inhaled and used for the induction and maintenance of general anesthesia) in an unlocked anesthesia cart; 15 vials of xylocaine/lidocaine (an anti-arrhythmic and anesthetic), 9 vials of bupivacaine (Sensorcaine) (a local anaesthetic), and 1 syringe of lidocaine jelly all in an unlocked cupboard
* OR #2 - a bottle of Sevoflurane and Suprane in an unlocked anesthesia cart; one bottle of injectable lidocaine (opened and undated) and one bottle of injectable midazolam (a sedative) (opened and undated) in an unlocked cupboard
* Storage Room #1 - two bottles of dexamethasone sodium phosphate (an anti-inflammatory medication) (one bottle opened and undated), six vials of Sensorcaine, six vials of bupivacaine, one vial of Marcaine (all three local anesthetics), and five bottles of lidocaine (one bottle opened and dated 05/17/13 - (expired 06/14/13)) all stored in an unlocked tool box/medication cart in the unlocked storage room
* Storage Room #2 - 36 vials of Dantrium (muscle relaxant), five vials of Lasix (a diuretic), two vials of calcium chloride (used in cardiac resuscitation), one bottle of dextrose (glucose/sugar), four bottles of sodium bicarbonate (used to make blood and urine less acidic), and five vials of thorazine (anti-psychotic medication) all in portable boxes locked with a blue breakaway lock but stored in an unlocked tool box/medication cart and in the unlocked storage room
* Recovery Room - 17 vials of rocuronium bromide (a muscle relaxant used in moderate anesthesia), five vials of succinycholine (used to induce muscle relaxation and short-term paralysis), one bottle of phenylephrine hydrochloride ophthalmic solution (used to constrict the blood vessels of the eyes), one bottle of tropicamide ophthalmic solution (dilates the pupils), one bottle of apraclonidine ophthalmic solution (used to reduce the pressure in the eye), one vial of methylergonovine maleate (used to prevent and control postpartum hemorrhage), and one vial of insulin (all of the preceding medications in the Recovery Room located in an unsecured refrigerator).

During an interview on 06/18/13 at 2:30 p.m., an administrative nurse (#4) stated the staff member in charge of central supply and processing, housekeeping, and maintenance staff have access to the locked areas of the surgery center/operating rooms.

During an interview on 06/19/13 at 10:35 a.m., an administrative nurse (#10) stated she expected staff to date multi-use bottles after opening and dispose of the bottle after 28 days.

- Observation of the ER with an administrative nurse (#7) on 06/19/13 at 9:30 a.m. showed eight carpuject syringes of injectable lorazepam (anti-anxiety medication) in an unlocked medication fridge in the supple area connecting the two ERs. The nurse (#7) stated housekeeping and maintenance staff know the code to the key pad to access the locked ER doors.



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- Observation of the CAH radiology department occurred on the afternoon of 06/19/13 with the radiology manager (#5) and showed the following unsecured medications:
* Portable emergency kits with plastic locks located in the general radiology room, the nuclear medicine room, and the computed tomograpy (CT) room. Each kit contained atropine (antiarrhythmic), epinephrine (bronchodilator), and diphenhydramine hydrochloride (antihistamine).
* Numerous vials of ioversol injection (iodine used for CT scans) located in a warmer in the CT room.

The radiology manager (#5) stated radiology staff do not lock the back door to the radiology department at night and staff do not lock the doors to the general radiology room and CT room (located inside the radiology department). The manager (#5) stated housekeeping and maintenance staff may access the department after hours.

- Observation of the CAH medication room occurred on 06/17/13 at 4:00 p.m. and showed no door to the room. A refrigerator (unlocked) in the medication room contained numerous medications which included lorazepam (antianxiety), insulin, diltizem (antianginal), Integrilin (a platelet drug), Hepatitis B vaccine, tuberculin purified protein (TB vaccine), famotidine (antiulcerative drug), and Phenadoz (antihistamine).

During an interview on 06/19/13 at 7:30 a.m., the CAH pharmacist (#6) stated he would expect all medications secured when unattended.


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- Observation of the Scranton Clinic, on 06/17/13 at 4:30 p.m. with the clinic manager (#8), showed an unlocked cupboard in a patient examination room. The cupboard contained aspirin, liquid Advil, lidocaine, an EpiPen (used for a severe allergic reaction), and albuteral (inhaled asthma medicine). An unsecured portable kit with a plastic breakaway lock, located on top of a cart, contained Lipitor (for high cholesterol), Prilosec (for reflux), sublingual nitroglycerin and Nitropaste (for chest pain), and Lovenox (a blood thinner).

A nurse (#9) stated upon entering the examination room this morning, the cupboard and the door to the examination room was unlocked.

Based on observation, review of professional literature, review of temperature and humidity logs, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff followed acceptable surgical standards of practice regarding the temperature and humidity of 2 of 2 Operating Rooms (OR) (OR #1 and obstetrical OR) used for procedures requiring general anesthesia. Failure to document, monitor, and ensure the temperature and humidity of the OR are within the recommended ranges may result in the growth of bacteria and an increase in patient infections.

Findings include:

An article from the Association of Perioperative Registered Nurses (AORN), updated 06/30/09, stated, ". . . The recommended temperature range in an operating room is between 68 [degrees] F [Fahrenheit] and 73 [degrees] F . . . The recommended humidity range in an operating room is between 30% [percent] to 60%. Both the temperature and humidity should be monitored and recorded daily using a log or electronic documentation of the heating, ventilation, and air conditioning (HVAC) system . . . The potential risk of microbial growth increases in areas where sterile supplies are stored when the humidity is too high. . . ."

Observation of OR #1 occurred on 06/18/13 at 1:30 p.m. with an administrative nurse (#4). A thermometer and hygrometer (gauge used to measure the amount of humidity (moisture) in the air) located in the OR identified a temperature of 72 degrees F and humidity of 70%. Review of humidity readings documented for the month of June 2013 identified the following percentages: June 4th - 66%, June 5th - 66%, June 6th - 67%, June 7th - 68%, June 8th - 70%, June 11th - 70%, June 14th - 72%, June 17th - 68%, and June 18th - 70%.

Observation of the OR used for Caesarian sections located on the obstetrics unit occurred on 06/18/13 at 2:15 p.m. with an administrative nurse (#4). A thermometer located in the OR identified a temperature of 70 degrees F and the room lacked a hygrometer to measure the humidity of the OR. The nurse (#4) stated the facility failed to monitor and keep a log of the temperature and humidity of the OR.

Based on record review, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to monitor and document the effectiveness of medications administered to patients on a pro re nata (PRN) basis for 3 of 7 closed inpatient (Patient #15, #16, and #19) and 1 of 1 closed observation patient (Patient #14) records reviewed who received various PRN medications throughout their hospital stays. Failure to evaluate the patient's response to PRN medications limited the nursing staff's ability to assess whether the medication achieved the desired effect, or if the patient experienced any side effects or adverse reactions from the medication.

Findings include:

Review of the policy "Pain Management" occurred on 06/19/13. This policy dated 08/18/04, stated, "PURPOSE: 1. To address the right of all patients to have their pain assessed and controlled . . . 2. To provided [sic] guidelines for assessment, interventions, and evaluation of patient outcomes related to pain management . . . ROLE RESPONSIBILITIES: . . . 3. Ongoing pain assessment will be performed to evaluate the changing nature of pain as well as the effectiveness of treatments for pain. Pain is the fifth vital sign. Pain ratings will be obtained before and after interventions, and as needed. . . ."

During interview on 06/19/13 at 10:30 a.m. an administrative nursing staff member (#10) stated she expected nursing staff to assess and document the effectiveness of all PRN medications within 30 minutes to one hour after administration.

Review of Patient #14, #15, #16, and #19 medical records occurred on June 18-19, 2013.

- Review of Patient #19's closed emergency room (ER) and inpatient (IP) record identified the CAH admitted the patient on 02/10/13 with diagnoses of weakness, falls, and dementia. Patient #19's admission orders included, "Avoid benzodiazepines" and Haldol (an antipsychotic medication) 1 milligram (mg) intravenous (IV) every hour PRN for "severe agitation."

Review of Patient #19's Medication Administration Record (MAR), dated February 10-14, 2013, showed nursing staff administered PRN Haldol on 02/10/13 at 8:30 p.m., 02/11/13 at 11:45 p.m., 02/12/13 at 4:15 a.m., 1:40 p.m., and 4:00 p.m., 02/13/13 at 12:00 p.m. and 5:45 p.m., and 02/14/13 at 8:30 a.m. and 3:00 p.m. Patient #19's record showed nursing staff failed to document the effectiveness of the above PRN doses of Haldol administered on February 10 at 8:30 p.m., February 11 at 11:45 p.m., February 13 at 5:45 p.m., and February 14 at 8:30 a.m.)

Patient #19's Daily Documentation Nurse's Notes included the following:
*02/10/13 from 7 p.m.-7 a.m. ". . . Pt [patient] sleeping until [8:30 p.m.]. Up and agitated. Very confused. Taken to BR [bathroom]. Haldol given. Given [oral] meds [medications] but pt spit them in the garbage. Urine very odorous. Started on IV Cipro. Awake again [10:30 p.m.] Continues to try to get out of bed. Bed alarm on. Haldol repeated at [11:45 p.m.]. Slept. Yells [at] [times]. This AM saying she has to go to the bathroom. Gets to the bathroom then turns around. Taken to another bathroom. Wanting to go home." Patient #19 received PRN IV Haldol at 8:30 p.m. and the CAH nursing staff failed to evaluate and document Patient #19's response to this dose of medication prior to repeating the medication at 11:45 p.m.
*02/11/13 from 7 p.m.-7 a.m. ". . . wanders in hall throughout evening after several attempt [with] HS [bedtime] med pt does not take Seroquel as ordered. Resting in bed at [9:00 p.m.] [with] eyes closed, [11:30 p.m.] resting, eyes closed. [2:30 a.m.] awakes, ambs [ambulates] hall [with] CNA [certified nursing aide] is easily redirected though not ready to rest for the noc [night] . . ." Patient #19 received PRN Haldol at 11:45 p.m. and the record identified the patient as "awake" at 2:30 a.m. (2 hours and 45 minutes later). The record lacked evidence the CAH nursing staff evaluated the effectiveness of the Haldol.
*02/13/13 from 7 a.m.-7 p.m. ". . . Very confused. Haldol given [12:00 p.m.] for agitation. Attempted to get pt to lay or sit. 1:1 until [2:00 p.m.] Pt sitting in room [and] walking per self in room . . . Haldol repeated [5:45 p.m.] for agitation. Continues to be agitated walking in room."
*02/13/13 from 7 p.m.-7 a.m. ". . . Remeron tablet [without] difficulty, rested for a few hours . . . [Up] walking around in room ad lib [per self], out ambulating in halls [with] staff assisted back to bed [at] [12:15 a.m.], rested comfortably. . ." Patient #19 received PRN IV Haldol at 5:45 p.m. The record lacked evidence nursing staff evaluated the effectiveness of this dose of medication.
*02/14/13 from 7 a.m.- 3 p.m. ". . . Meds per MAR . . . [up] in rm [room] early [sic] this day, ambulates halls [with] SBA [stand-by assist] of one staff, [at] end of hall becomes set on going outside, much difficulties in redirecting to rm, many attempts by different staff members. Haldol given . . . Pt returns to rm [and] rests [after] waking up takes AM [morning] medication [without] difficulty. 11:30 a.m. awake . . ." Patient #19 received PRN Haldol at 8:30 a.m. and the record identified the nursing staff evaluated and documented the effectiveness of the medication (3 hours later) at 11:30 a.m.

Patient #19's record lacked documentation of the effectiveness of PRN Haldol on four separate occasions (February 10 at 8:30 p.m., February 11 at 11:45 p.m., February 13 at 5:45 p.m., and February 14 at 8:30 a.m.).

- Review of Patient #15's closed ER, IP, and surgical record identified the CAH admitted the patient on 04/20/13 with a diagnosis of abdominal pain. Patient #15's admission orders included PRN orders for IV Demerol (an opioid pain medication) for pain control and PRN IV Reglan (an antemetic medication) for nausea/vomiting.

Patient #15's MAR, dated 04/20/13, showed nursing staff administered PRN Demerol at 2:00 p.m. and 9:00 p.m. and Reglan at 2:15 p.m. and 8:45 p.m. Review of Patient #15's record lacked documentation of the effectiveness of these PRN medications.

Patient #15's Daily Documentation Nurse's Notes" included the following:
*04/20/13 from 7 a.m.-3 p.m. ". . . [2:00 p.m.] Pains come [and] go 4-5/10 [numerical pain scale. Zero indicates no pain and ten indicates severe pain]. IV Demerol 25 slow then try to sit up. Got nauseated [at] [2:15 p.m.] Reglan 5 mg slow. BS [bowel sounds] faint. [2:30 p.m.] stood up at edge of bed, did go - not dizzy."
*04/20/13 from 3 p.m.-5 p.m. ". . . Assist to bathroom by 2 [and] unable to void but feels she got sensation. She became pale [and] lightheaded during walk to bathroom [approximately] 12 feet but regained momentum [after] seated. Unable to void . . ."
*04/20/13 from 5:00 p.m.-11:00 p.m. ". . . assist to bathroom to void at [7:30 p.m.]. She did not become dizzy or lightheaded [at] this time. Alert. NPO [. . . ] [and] ice chips. Medicated for pain [with] Demerol [and] prophylactic with Reglan. Up to void again [9:00 p.m.] but this time felt weak [and] dizzy again . . ."

The above nurse notes, as well as all subsequent nurse notes, lacked evidence the CAH nursing staff monitored and documented the effectiveness of all PRN doses of Demerol and Reglan administered to Patient #15.

- Review of Patient #14's closed observation record identified the CAH admitted the patient on 04/18/13 with a diagnosis of mononucleosis. Patient #14's MAR, dated 04/18/13, identified nursing staff administered PRN IV Toradol (a non-steriodal anti-inflammatory drug used to treat short-term pain) at 8:10 a.m. and PRN Tylenol at 11:00 a.m.

Patient #14's Daily Documentation Nurse's Notes, dated 04/18/13 from 7 a.m.-2:05 p.m., stated, "Patient discharged. Refer to discharge summary," and failed to evaluate and assess the effectiveness of the two PRN medications administered prior to discharge.

- Review of Patient #16's closed IP record identified the CAH admitted the patient on 04/24/13 with diagnoses of pneumonia and dehydration. Patient #16's MAR showed nursing staff administered PRN Tylenol on 04/24/13 at 9:30 p.m.

Patient #16's Daily Documentation Nurse's Notes" included the following:
*04/24/13- 7 p.m.-7 a.m. ". . . Tylenol given at [9:30 p.m.] for [elevated] temp [temperature]. Diaphoretic [at] [10:30 p.m.] - Clean linen. Does get 'winded' [and] wheezy [with] activity. . . Sleeping well at [12:01 a.m.] . . . [2:30 a.m.] temp [decreased] . . ." Nursing staff failed to assess and evaluate the effectiveness of the Tylenol until midnight after administering the medication to Patient #16 for an elevated fever at 9:30 p.m. (2 hours and 30 minutes).

Based on record review, review of medical staff rules and regulations, and policy and procedure review, the Critical Access Hospital (CAH) failed to ensure completion of written discharge instructions for 2 of 7 closed inpatient records (Patient #18 and #24) reviewed. Failure to provide written discharge instructions limited Patient #18 and #24 abilities' to follow the providers follow up care instructions.

Findings include:

Review of the CAH's Medical Staff Rules and Regulations occurred on 06/19/13. These Rules and Regulations, approved on 03/28/12, stated ". . . Section 3: General Conduct of Care . . . 5. The practitioner's orders must be written clearly, legibly and completely. Orders, which are illegible or improperly written, will not be carried out until rewritten or understood by the nurse. The use of 'Renew,' 'Repeat,' and 'Continue' orders are not acceptable . . . ."

Review of the policy "Content and Security of the Medical Record" occurred on 06/19/13. This policy, dated January 1990 and revised October 2012, stated, "POLICY: A medical record is created and maintained for each patient who is receiving care . . . The content of the medical record will contain sufficient information to identify the patient, support the diagnosis, justify treatment, document the course and results and promote continuity of care between health care providers . . . The following information is included in a hospital medical record: . . . Discharge instructions to the patient . . . "

- Record review identified the physician admitted Patient #24 at 32 4/7 weeks gestation with a diagnosis of "leaking membranes" on 03/02/13 and discharged the patient home on 03/05/13. Patient #24's written physician discharge orders stated, "D/C [discontinue] IV [intravenous]. Discharge. Cont [continue] Prenatal Vits, Fish Oil, [and] Vit [vitamin] D3. No smoking or heavy lifting. No return for work- Note given. Appt [appointment] in [name of city] on 03/21/13. The physician failed to specify the dosage and frequency of the above medications.

Patient #24's written "Discharge Medication Instructions" form completed by the CAH nursing staff and given to the patient at the time of discharge, stated "Prenatal Plus 1 tab daily, Vitamin D3 200 unit daily, Fish Oil 500 mg [milligram] 2 cap [capsule] twice a day with meals." Patient #24's medical record lacked evidence the nurse contacted and clarified the above medication dosages and frequency as written on the discharge medication form.

- Record review identified the physician admitted Patient #18 to the CAH on 05/02/13 at 9:45 a.m. with diagnosis of abdominal pain and possible pancreatitis and discharged the patient home on the evening of the same day. Patient #18's written physician discharge orders included an oral medication (Prilosec 20 mg twice daily), a low residue bland diet, and the need for an "upper endoscopy and colonoscopy next week."

Patient #18's written "Discharge Education" and "Discharge Medication Instruction" forms, completed by CAH nursing staff and given to the patient at the time of discharge, included information and instruction on how to take the Prilosec and the need for the patient to follow a low residue bland diet. Review of both discharge forms failed to inform Patient #18 about how to schedule additional testing (upper endoscopy and colonoscopy) as ordered by the medical provider.

Based on record review and staff interview, the Critical Access Hospital (CAH) failed to ensure 1 of 6 closed emergency room (ER) records (Patient #24) contained reports of treatments and other pertinent information necessary to monitor the patient's progress. Failure to document the results of the obstetrical examination limited the CAH's ability to ensure the quality and continuity of patient care.

Findings include:

Review of Patient #24's medical record occurred on June 18-19, 2013. Patient #24, a 32 4/7 week pregnant female, presented to the ER on 03/02/13 at 1:40 p.m. with complaints of "cramping, [and] Braxton-Hicks [contractions], fetal pressure on bottom." The ER nurse's documentation identified the fetus with "gd [good] movement. FHT's [fetal heart tones] strong. [name of on-call doctor] notified. Taken to Clinic. [1:50 p.m.] exam done by [name of on-call provider] [and] US [ultrasound]/ States has had clear liq [liquid] mucous drainage last couple wks [weeks] [with] bending or lifting. Admitted to OB [obstetric] rm [room] via w/c [wheelchair]."

Patient #24's Emergency Room Physician Orders, included a verbal order, dated 03/2/13 at 2:00 p.m., stated, ". . . To clinic for exam."

Patient #24's medical record failed to include documentation the ER physician completed an examination of Patient #24 in the ER.

During the exit conference on 06/19/13 at 3:00 p.m., an administrative nurse (#10) stated Patient #24's ER physician saw Patient #24 in the ER and then decided to further exam Patient #24 using his own ultrasound equipment in the clinic. This administrative nurse (#10) confirmed the physician failed to document this information in Patient #24's medical record.

Based on credentialing file review, policy review, and staff interview, the Critical Access Hospital (CAH) failed to evaluate the quality and appropriateness of the diagnosis and treatment furnished by 1 of 1 certified registered nurse anesthetist (CRNA) (#1) reviewed providing services to the CAH's patients. Failure to evaluate the quality and appropriateness of the treatment furnished has the potential to affect patient outcomes involving surgical procedures requiring anesthesia services.

Findings include:

Review of the policy "WEST RIVER HEALTH SERVICES' MEDICAL STAFF POLICIES" occurred on 06/19/13. The policy, effective 03/28/12, stated,
". . . Peer Review: Evaluation of medical staff members by individuals from the same or a related discipline with similar qualifications. . . . If needed a contract may be obtained to perform outside peer review by an organization or individual physician as appropriate.
Ongoing: Continuously, or on a regular basis.
The medical staff of West River Regional Medical Center conducts ongoing peer review as part of its quality improvement activities . . .
Results of peer review performed in these committees are provided to the individuals involved . . . These statistics are then documented in physician profiles and analyzed by the credentials committee at the time of reappointment. . . .
External peer review may be utilized . . ."

Review of the "Quality Improvement/Risk Management Plan - 2013" occurred on 06/18/13. The plan, approved by the governing body on 02/27/13, stated,
". . . GOALS, To establish, maintain, support, and document evidence of an on-going Quality Improvement/Risk Management program that shall apply to all . . . practitioners involved in the delivery of patient care. It shall include effective mechanisms for reviewing and evaluating patient care, enhancing clinical performance . . .
OBJECTIVES . . . Monitor and evaluate the quality of patient care and the clinical performance/competency of all individuals with clinical privileges . . .
Assess/Act . . . When the findings of the assessment process are relevant to an individual's performance the Medical Staff is responsible for determining their use in peer review in accordance with the Medical Staff Bylaws . . ."

Review of the Medical Staff Bylaws occurred on 06/17/13. The bylaws, approved by the Board of Directors on 03/28/12, stated regarding the reappointment process,
". . . Basis for Recommendations: Each recommendation concerning the reappointment of a staff member and the clinical privileges to be granted upon reappointment shall be based upon peer evaluation of such member's professional ability and clinical judgment in the treatment of patients . . . Procedure for Appointment to the Allied Health Professional Staff: . . . The applicant shall agree to abide by the Medical Staff Bylaws/Rules and Regulations . . ."

Review of the credentialing file of CRNA #1 occurred on the morning of 06/19/13. The file lacked documentation the facility evaluated the quality and appropriateness of the diagnosis and treatment provided by CRNA #1.

On 06/19/13 at 3:10 p.m., an administrative quality assurance member (#11) confirmed the hospital has not completed peer review for CRNA #1 by a physician qualified to administer anesthesia. The staff member stated the CAH does not have the quality and appropriateness of the treatment provided by any of the nurse anesthetists evaluated by a physician with experience in anesthesiology.