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Based on record review, interviews, and policy/procedure review, the hospital failed to ensure surgical services were consistent with needs and resources for one of 10 patients reviewed (Patient #1). The census was 73.

Findings include:

On 02/12/24 at 9:57 A.M. an interview with Staff A revealed Patient #1 had been seen at the provider's offsite Emergency Department (ED) on 12/21/23.

On 02/12/24 at 12:22 P.M. a review Patient #1's medical record revealed she reported to the ED staff on 12/21/23 of potentially being exposed to COVID-19 a couple weeks back and reported she had similar signs and symptoms, but felt she had recovered from the signs and symptoms. Further review revealed it was recommended that Patient #1 have surgery after a computed tomography (CT) concluded a thick-walled gall bladder with stones, fluid, and suspected acute cholecystitis. Further review revealed Patient #1 did test positive for COVID-19 in the ED on 12/21/23, and the case was discussed with a general surgical resident at this hospital at 7:30 A.M. The resident at this hospital agreed to accept Patient #1 for surgical intervention and an order was written to transfer Patient #1 to this hospital. On 12/21/23 at 9:45 A.M. the anesthesia department at this hospital refused to do the surgery because the patient tested positive for COVID-19, and she was referred to another hospital system for surgery. An interview with Staff E during the medical record review confirmed the findings, and reported the surgery should not have been refused because the patient had COVID.

On 02/12/24 at 2:39 P.M. an interview with Staff F revealed there was an increased risk of performing surgery on a patient that had tested positive for COVID, but the anesthesia staff explained this risk to every COVID positive patient and the staff did the surgery as scheduled based on the surgeon's discretion. Further interview with Staff F after a review of Patient #1's medical record revealed the operation should not have been "refused" and this was the first time he had heard about this situation.

On 02/13/24 at 8:10 A.M. an interview with Staff G revealed it was the responsibility of the surgeon to determine if a surgical procedure was to be conducted or not after he/she had discussed the risks/benefits with the anesthesia staff. Staff G stated the role of the anesthesia staff was to collaborate with the surgeon, but the surgeon made the final determination/decision to do the surgery or not.

On 02/13/24 at 8:45 A.M. a review of the Peri-Operative COVID-19 Planning protocol, revised 10/22, revealed it recommends that the health care organizations perform surgeries (including urgent surgeries) and other procedures on COVID-19 positive patients following the same guidelines for active Tuberculosis patients. The protocol defines specific parameters for doing surgery on those patients and recommends delaying elective surgeries for COVID-19 patients.

On 02/13/24 at 9:01 A.M. a review of the Scheduling Policies for Peri-Operative Services, effective 11/09/22, revealed the policy defines urgent and emergent surgeries, and an interview with Staff H during the review revealed Patient #1's gall bladder surgery would have been an urgent surgery.

This deficiency represents non-compliance investigated under Substantial Allegation OH00149740.