HospitalInspections.org

Based on bylaws review, policy review, record review, and staff interview, the Critical Access Hospital's (CAH's) governing board failed to ensure granting of privileges followed the bylaws for 1 of 1 locum tenens provider's file reviewed (Provider #1). Failure to follow the bylaws when granting privileges placed the CAH's patients at risk of receiving services from unqualified providers.

Findings include:

Review of the governing board's "Amended and Restated Bylaws of Sanford Health Network North" occurred on 08/31/22 at 08:00 a.m. These bylaws, dated 01/01/19, stated,
". . . III. Board of Directors
Section 3.1 Authority and Responsibility. . . . The authority delegated to the Board of Directors includes, but is not limited to, the following:
d. Credentialing and granting privileges to medical staff members and other health care professionals providing services at the Hospitals . . ."

Review of the "Medical Staff Bylaws of Sanford Mayville Medical Staff" occurred on 08/30/22 at 4:10 p.m. These bylaws, effective 08/22/19, stated,
". . . 2.D. Non-Applicant Practitioners
2.D.1. Qualifications:
The Non-Applicant Practitioners shall consist of . . . Advanced Practice Practitioners who are not appointed to the Medical Staff . . . but are granted clinical privileges to fulfill an important patient care, treatment and service need.
(a) Practitioners are required to meet the same qualifications as applicant for appointment . . .
(b) Practitioners may serve as locum tenens . . ."

Review of the policy "Sanford Policy Enterprise Credentialing" occurred on 08/31/22 at 10:20 a.m. This policy stated,
". . . 4. Clinical Privileges . . .
4.B. Temporary Clinical Privileges . . .
(a) Temporary Privileges for a Completed Initial Application Awaiting Board Approval. Temporary privileges for an Applicant for initial appointment may be granted by the Administrative Executive, upon recommendation of the Chief of Staff . . .
(5) temporary privileges for a Medical Staff Applicant will be granted for a maximum period of 120 consecutive days. . . ."

Review of providers' 2021-2022 credentialing files occurred on 08/31/22 and indicated the following:
- Provider #1 (an advanced practice practitioner): granted temporary privileges on 10/27/21 for 120 days (until 02/24/22). The record lacked evidence of granted privileges after 02/24/22.

Review of the CAH's 2022 emergency room patient log occurred on 08/31/22. The log indicated Provider #1 treated fourteen patients at the CAH on July 29-31, 2022.

Upon request on 08/31/22, the CAH failed to provide evidence medical staff recommended and the governing body approved appointment/privileges for Provider #1 after 02/24/22.

During interview on 08/31/22 at 3:25 p.m., an administrative staff member (#9) confirmed Provider #1 provided care for CAH patients without appointment/privileges in July 2022.

Based on review of policy, professional literature, and temperature/humidity records, observation, 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 4 surgical areas (Operating Room (OR) used for procedures requiring general anesthesia and Endoscopy Scope Storage Room). Failure to ensure the temperature and humidity of the OR and Endoscopy Scope Storage Room are within the recommended ranges may result in the growth of bacteria and an increase in patient infections.

Findings include:

Review of the policy titled "Humidity and Temperature levels, Surgery - [Facility Name]" occurred on 09/01/22. This policy, dated 05/12/22, stated, ". . . To ensure adequate temperature and humidity is maintained in critical spaces . . . Endoscopy Scope Storage Room [Humidity] Max 60% (percent). . . [Temperature] N/A . . . Operating Room [Humidity] 30-60% . . . [Temperature] 68-75 degrees [Fahrenheit (F)] . . . "

An article from the "Association of Perioperative Registered Nurses (AORN)" found at https://doi.org/10.1002/aorn.13563, dated 11/30/21, stated, ". . . Temperature or relative humidity variations that fall outside the recommended parameters for the perioperative environment can have serious implications for patient safety . . . Some pathogenic microbes can thrive in prolonged elevated humidity. Supplies and equipment in perioperative environments exposed to variations in temperature and humidity may become sources of infection or undergo alterations in function, putting patients at increased risk of harm. . . ."

During observation of the OR and Endoscopy Scope Storage area on 08/30/22 at 2:15 p.m., with an administrative nurse (#12) and sterile processing staff (#2), a thermometer and hygrometer (gauge used to measure the amount of humidity (moisture) in the air) located in the OR identified a temperature of 68 degrees F and humidity of 47%. The Endoscopy Scope storage room thermometer and hygrometer identified a temperature of 67 degrees F and humidity of 58%.

Reviewed on 09/01/22, the temperature and humidity logs for the OR for the months of May - August 2022 showed the following unacceptable temperature and humidity readings:
* 05/07/22 Temperature 67.5 F
* 05/09/22 Temperature 65.5 F
* 05/23/22 Humidity 28%
* 08/24/22 Temperature 55 F Humidity 67%
* 08/25/22 Temperature 54.5 F Humidity 75%
* 08/26/22 Humidity 63%
* 08/30/22 Temperature 66 F

Reviewed on 09/01/22, the temperature and humidity logs for the Endoscopy Scope Storage Room for the months of May - August 2022 showed the following unacceptable humidity readings:
* 05/19/22 Humidity 71%
* 05/24/22 Humidity 63%
* 08/23/22 Humidity 65%
* 08/24/22 Humidity 69%
* 08/25/22 Humidity 77%
* 08/29/22 Humidity 65%

During interview on 08/30/22 at 2:45 p.m., an administrative nurse (#12) stated the CAH staff had reported concerns regarding the temperature and humidity of the OR/Endoscopy Scope Storage Room to the maintenance department all summer, and it correlated with "the boiler being on or off."

During interview on 09/01/22 at 9:00 a.m., the infection preventionist (#13) agreed the CAH failed to maintain the temperature and humidity levels within the parameters set forth in their policies for the OR/Endoscopy Scope Storage Room, and that may place patients at increased risk for infections.