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Based on interview and record review, the critical access hospital did not ensure a current roster listing each practitioner's specific surgical privileges were available in the surgical suite and in the area where surgical scheduling occurred for 13 of 13 medical doctors (MD-A, MD-B, MD-C, MD-D, MD-E, MD-F, MD-G, MD-H, MD-I, MD-J, MD-K, MD-L and MD-M) who currently have surgical privileges at the Critical Access Hospital.

Findings include:

A current roster listing each practitioner's specific surgical privileges was not available in the surgical suite nor in the area where scheduling of surgical procedures occurred.

During a tour of the surgical suite and the ambulatory specialty services on 5/28/2014 at 10:30 a.m., the registered nurse (RN)-A acting manager of surgical services and the ambulatory specialty services clinic verified MD-A, MD-B, MD-C, MD-D, MD-E, MD-F, MD-G, MD-H, MD-I, MD-J, MD-K, MD-L and MD-M had surgical privileges at the critical access hospital (CAH). RN-A stated scheduling of patients for surgical procedures occurred in the ambulatory specialty services clinic.

RN-A was interviewed at 11:00 a.m. on 5/28/2014 and stated a current roster listing each practitioner's specific surgical privileges was not available in the surgical suite nor in the ambulatory specialty services clinic.