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Based on observation, document review, and staff interview, the Critical Access Hospital (CAH) staff failed to document the date on 1 of 1 bottle of Cidex OPA Solution Test Strips when opened in accordance with the manufacturer's instructions. (Ultrasound) The CAH ultrasound staff identified using Cidex OPA Solution 15 times per year to disinfect the transvaginal probe.

Failure to document the date staff opened the bottle of Cidex OPA Solution Test Strips could allow staff to use the test strips after the manufacturer's shortened expiration date, potentially resulting in inaccurate test results and inadequate disinfection, which could potentially result in transmission of infectious pathogens to patients.
Findings include:

Observation on 2/9/17 at 10:20 AM, during tour of the ultrasound area with Staff B, Sonographer, revealed 1 opened bottle of Cidex OPA Solution Test Strips were undated when opened.

Review of manufacturer's instructions on the Cidex OPA Solution Test Strips bottle revealed in part, ". . . Do not use after 90 days of opening the bottle. . . . "

Review of CAH policy/procedure titled "Transvaginal Probe Disinfection", dated 12/2015, revealed in part, ". . . After each use of the transvaginal ultrasound probe, it should be washed with hot soapy water according to the manufacturer's recommendation. The probe will then be submersed in the Cidex container attached to the wall in the ultrasound room. . . . "

During an interview on 2/9/17 at 10:20 AM, during tour of the ultrasound area with Staff B, Sonographer, verified the Cidex OPA Solution Test Strips lacked documented evidence of the date the staff opened the bottle to reflect the shortened expiration date, in accordance with the manufacturer's instructions. Staff B acknowledged the staff should date the Cidex OPA Solution Test Strips, in accordance with the manufacturer's instructions.

Based on document review and staff interviews, the Critical Access Hospital (CAH) failed to secure an emergency water agreement with an outside entity to ensure the availability of adequate water in the event of an interruption in the water supply. The administrative staff identified a census of 5 patients at the time of the survey, an average daily census of 5 patients and 99 employees.

Failure to ensure emergency water is available to meet the facility's critical functions during an emergency/crisis situation inhibits the facility's ability to ensure patient safety and quality of care while responding to and recovering from a situation that resulted in disruption of water.

Findings include:

Review of a document titled "Emergency Water Supply Agreement", dated 1/25/01, revealed an agreement with the local fire department to provide water to pressurize the CAH's fire sprinkler system.

Review of a CAH policy titled "Emergency Water Supply Agreement", approved 1/2017, revealed the policy contained details of the agreement with the CAH's local fire department for emergency water to pressurize the CAH's sprinkler system. However, the policy failed to address potable and non-potable water needs for patients, employees and visitors.

During an interview on 2/8/17, at 9:45 AM, Staff C, Chief Engineer, confirmed the agreement with the local city fire department did not include any water needs beyond pressurizing the sprinkler system and reported he did not have an agreement with an outside entity for other emergency water needs, but thought the Disaster Coordinator might.

During an interview on 2/8/17, at 11:20 AM, Staff E, Disaster Coordinator, acknowledged discussions about 5 years ago regarding the CAH needing an emergency water agreement and thought the Chief Engineer and Chief Executive Officer (CEO) had coordinated one but not aware if one had been secured or not.

During an interview on 2/8/17, at 11:30 AM, Staff D, CEO, confirmed the CAH lacked an agreement to supply emergency potable and non-potable water for patients, employees and visitors.

Based on document review and staff interview, the Critical Access Hospital (CAH) failed to ensure the required group of professionals, including a physician and a midlevel provider, annually reviewed all patient care policies for 4 of 23 patient care departments. (Physical Therapy/Occupational Therapy, Speech Therapy, Radiology, and Cardiac Rehabilitation. The CAH staff identified a census of 7 patients at the beginning of the survey.

Failure to ensure the required group of professionals reviewed all patient care policies annually could potentially result in failure to address and develop policies for changing patient care needs to meet current practices that are not addressed in the current CAH policies and/or opportunities to update the policies as needed.

Findings include:

Review of CAH policy titled "Policy, Procedure & Form Approval Process", dated 3/2016, revealed in part, ". . . All policies and procedures will be reviewed at least once per year. . . ."

Review of Critical Access Advisory Committee Meeting Minutes from December 4, 2015 to December 9, 2016 lacked documentation of annual approval of Physical/Occupational Therapy, Speech Therapy, Radiology, and Cardiac Rehabilitation policies.

During an interview on 2/8/2017 at 11:20 AM, Staff A, Administrative Assistant, verified the lack of annual approval of Physical/Occupational Therapy and Radiology policies with the last approval by the required group of professionals December 2015. Staff A also acknowledged the lack of annual approval of Speech Therapy policies.

During an interview on 2/8/2017 at 4:40 PM, Staff A, Administrative Assistant, verified the lack of annual approval of Cardiac Rehabilitation policies with the last approval by the required group of professionals June 2015.

Based on review of Infection Prevention Plan for 2016 and 2017, monthly Infection Control Minutes and Logs for 2016, and staff interviews the Critical Access Hospital (CAH) failed to track and follow surgical site infections, cultures from in-patients and ED (Emergency Department), and analize data from the infection control log. The CAH identified a census of 5 patients at entrance.

Failure to track surgical site infections, ED cultures and analize data from the infection control logs could potentially result in surgical site infections, positive culture results, and trending of hospital infections going undetected, lacking interventions, and infections being passed on to hospital patients and the community.

Findings include:

An interview on 2/8/17 at 3:30 PM, with Staff J, RN Infection Preventionist, revealed a lack of involvement in the surgery department. Staff J revealed she lacked knowledge regarding the daily surgery procedures, and failed to follow surgical patients for possible surgical site infections. Staff J added the surgery department completes follow up phone calls to their patients and stated, I do not receive information regarding those calls. Staff J lacked knowledge of cultures from ED patients that are discharged. Staff J failed to provide an analysis of the information gathered in the Infection Control Logs of 2016. Staff J acknowledged reporting required reportable diseases to QA (Quality Assurance).

Review of the Infection Prevention Plan for 2017 revealed in part...Policy The Infection Control Program in this corporation incorporates the following in a continuing cycle: Surveillance, prevention and control of infections throughout the organization: Develop alternative techniques to address the real and potential exposures: Select and implement the best techniques to minimize adverse outcomes: Evaluate and monitor the results and revise techniques as needed. Continuous Quality Improvement & Reporting Structures: B) The link between quality improvement and infection control activities is information gathering and clinical analysis. Both are designed to identify patterns of patient/resident care events that lead to sub-optimal outcomes, thus identifying areas where patient/resident care may need improvement. Assignment of Responsibility B) The responsibility and direct accountability for the surveillance, data gathering, aggregation and analysis is assigned to the Infection Control Nurse.

Review of the monthly Infection Control Minutes/Log for 2016 lacked information related to cultures taken for (inpatients and outpatients), surgical site infections, and Infection Control Log analysis of data gathered.

Review of the Quality Improvement monthly meeting minutes, dated 1-7/2016, 10-12/2016, revealed Staff J, attended all meetings. Quality Improvement minutes for July and December included infection control information related to hand hygiene monitoring and the October meeting contained information related to hospital acquired infections and inpatients with antibiotic therapy. The minutes lacked information related surgical site infections, ED cultures, state required reportable diseases, and analysis of information obtained from the Infection Control Logs.

Based on observations, document review, and staff interviews, the CAH failed to ensure:

Surgery staff used brushes to clean the endoscopes external ports and internal channels. (Refer to C 320 I)

Surgery administrative staff maintained training records for 4 of 4 surgery staff for cleaning and disinfecting of endoscopes. (Refer to C320 I)

Surgery administrative staff developed and implemented a policy and procedure delineating the procedure for cleaning and disinfecting of endoscopes. (Refer to C320 I)

Surgery staff followed AORN (American Operating Room Nurses) Guidelines for Perioperative Practice and manufacturer's guidelines for cleaning and disinfecting endoscopes. (Refer to C320 I)

Surgery staff maintained the correct sterilization procedures when using the autoclave for sterilizing surgical equipment and instruments. (Refer to C-0320 II)

Surgery staff used chemical indicators in peel packs, and correctly place the chemical indicator in a blue wrapped sterile pack that was available for use. (Refer to C-320 II)

Surgery staff correctly assembled the towel pack to ensure accuracy of the biological indicator, and place the pack in the proper location in the autoclave. (Refer to C-320II)

Surgery staff placed the Bowie Dick in the correct location in the autoclave. (Refer to C-320 II)

Surgery administrative staff maintained chemical indicator, biological indicator, and Bowie Dick training records for 4 of 4 surgery staff. (Refer to C-320 II)

CAH policy titled, Infection Control and Sterilization included information regarding use of chemical indicator, biological indicator, and Bowie Dick. (Refer to C-320 II)

Surgery staff followed AORN Guidelines for Perioperative Practice for using chemical indicator, biological indicator, and Bowie Dick. (Refer to C-320 II)

CAH staff tracked, followed and monitored trends in surgical infections. (Refer to C-0320 III and C-0278 )

Infection Preventionist implemented the policy titled, Monitoring of Surgical Infections. (Refer to C-320 II)

The cumulative effect of these systemic failures and deficient practices in infection control resulted in the facility's inability to ensure the safe provision of care to the CAH patients.

State Agency staff notified administrative staff of the IJ at 1:50 PM on 2/9/17.

The CAH took the following actions to remove the immediacy of the IJ:

No surgeries or endoscopes will be performed until each of the items outlined in the plan has been corrected.

No endoscopes will be utilized until the PENTAX representative has instructed staff on proper cleaning and disinfection on 2/13/17 and all endoscopes are reprocessed. Channel Check test strips will be utilized to monitor for cleanliness of the endoscopes. Immediate development of policy and procedure for cleaning and disinfecting of the endoscopes.

Education provided to staff regarding proper placement of the Bowie-Dick in the autoclave. Inservice 2/13/17 provided in regards to general operations of the autoclave.

Immediate education provided to surgery staff on correct placement of Bowie Dick in the autoclave. Immediate development of policy and procedure to reflect education requirements.

All surgical equipment and instruments will be reprocessed utilizing an ATTEST pack (per-made package that contains the biological indicator); the pack will be properly placed. Network hospital staff will retrain the surgery staff on the reprocessing process. Immediate development of policy and procedure to reflect the changes.

Infection Preventionist and surgery staff will monitor surgical site infections. Infection Preventionist will be provided with the weekly surgery schedule and notified of changes, providers and surgeons will be provided with follow-up letters regarding infections within 30 days of the procedure, utilization of logbook for tracking and reporting infections to QC (Quality Control) and medical staff. Immediate development of policy and procedure to reflect the changes.

I. Based on observation, document review, and staff interviews, the CAH failed to ensure staff followed correct procedures when cleaning/disinfecting endoscopes (scopes used for the examination of the upper and lower GI tracts), for 1 of 1 patient (Patient # 17). The CAH administrative staff reported 20-30 scopes performed monthly.

Failure to properly clean and disinfect endoscopes could potentially expose patients to bloodborne pathogens and harmful bacteria, which may result in serious patient injury or death.

Findings include:

Observation on 2/7/17 at 8:35 AM, showed Staff K, Environmental Service Technician in the OR (Operating Room), cleaning a Pentax endoscope using the Scope Buddy (a machine used to deliver detergent or rinse solutions to endoscope channels). Staff K failed to brush all channels, valve ports, and the distal end of the endoscope in accordance with AORN and the manufacturer's recommendation.

During an interview on 2/7/17 at 8:35 AM, Staff K reported she had not used the endoscope brushes since the purchase and the use of the Scope Buddy in August of 2016. Staff K recalled receiving instructions that pre-cleaning with brushes was not required with the Scope Buddy.

Staff F, Pentax Scope representative, also present at the time of the observation and interview, reinforced with Staff K the importance of using brushes on the endoscopes even when using the Scope Buddy to ensure effective disinfection and that use of the Scope Buddy does not eliminate the need to brush cleaning the scope. Staff F provided on-site training to Staff K for brush cleaning the external ports and internal canals of the endoscope.

In a follow up interview on 2/7/17 at 11:30 AM, Staff K acknowledged her failure to use the brushes when cleaning the scopes. Staff K stated, about the time I started using the Scope Buddy I stopped using the brushes because I was instructed that I no longer needed to use the brushes. Prior to using the Scope Buddy, I did use brushes to clean the external ports and the internal canals of the endoscopes.

During an interview on 2/7/17 at 3:00 PM, Staff H, RN Outpatient Clinic/Surgery Manager, reported the facility purchased the Scope Buddy 7/2016 and the surgery department began using the Scope Buddy after inservice training on 8/8/16. However, Staff H lacked training records for 4 of 4 surgery staff that clean and disinfect the endoscopes, and the CAH surgery administrative staff failed to develop and implement a policy and procedure delineating the process for cleaning and disinfecting the endoscopes.

The Scope Buddy inservice sign-in sheet and inservice guide, dated 8/8/17, lacked instructions for the use of brushes in the cleaning/disinfecting process of the scopes. The sign in sheet included 4 of 4 surgical staff. The Inservice guide included in part. 'Follow AORN-endoscope cleaning and disinfection guidelines,' AORN guidelines require cleaning with a brush to ensure effectiver disinfection.

Review of the Pentax Medical Endoscope Leak Testing Log dated 8/16/16 to present, revealed facility staff had cleaned/disinfected 81 endoscopes since they began using the Scope Buddy.

Review of the AORN Guidelines for Perioperative Practice, edition 2017, revealed in part. 'Flexible Endoscopes VI.g. All accessible channels and the distal end of the endoscope should be cleaned with a cleaning brush of the length, width, and material recommended by the endoscope manufacturer. The endoscope valves should be manually actuated while cleaning.'

Review of the Scope Buddy user manual, dated 2015, revealed in part. 'Guidelines-Endoscope Pre-Cleaning: Proper endoscope precleaning is essential to removing microbial burden and bio-debris from the inside and the outside of an endoscope. Precleaning guidelines should always be consulted and followed, and a pre-cleaning process should always be developed and strictly adhered to, to ensure an endoscope is effectively and properly cleaned...Carefully brush all channels and valve ports using the detergent solution and cleaning tools designed for this purpose.'


II. Based on observation, document review, and staff interviews, the CAH failed to ensure staff correctly used the chemical indicator, biological indicator, and Bowie Dick (testing materials used to determine the effectiveness of the sterilization process) in the autoclave (a machine used to sterilize surgical equipment and instruments). The CAH administrative staff reported 4-8 surgical procedures performed monthly.

Failure to use the chemical indicator, biological indicator, and Bowie Dick correctly could potentially result in false positives indicating the sterilization process in the autoclave worked correctly when it did not. Disinfection and sterilization are essential for ensuring that medical and surgical instruments do not transmit infectious pathogens to patients.

Findings include:

A. Observation on 2/7/17 at 8:35 AM, while touring the OR (Operating Room), with Staff H, revealed sterilized wrapped blue packs (containing surgical instruments) and peel packs (clear packaging of sterilized instruments also known as sterilization pouches) available for use in the OR suite. Observation showed the peel packs did not have a chemical indicator inside the package in accordance with the manufacturer's recommendation.

Observation, during the tour of central sterile area, on 2/7/17 at 1:45 PM, with Staff L, RN OR, revealed additional peel packs without chemical indictors inside the packages.

During an interview on 2/7/17 at 1:45 PM, Staff L acknowledge the peel packs did not have the required chemical indicators inside the packages and the reactant strip was found on the outside of the peel pack. Staff L stated chemical indicators are not used in peel packs only in sterile wrapped blue packs. Staff L was asked to open a sterilized wrapped blue pack. Observation showed the chemical indicator was found in the corner instead of the geometric center of the pack as recommended by CDC Guidelines for Disinfection and Sterilization in Health care Facilities and AORN Guidelines for perioperative Practice to ensure effective sterilization.

Review of AORN Guidelines for Perioperative Practice, 2017 edition revealed in part. 'Packaging systems V.b. Chemical indicators should be placed in an area within the package that presents a challenge for air removal and sterilant contact (center of the package). When there is a question concerning the appropriate placement of internal chemical indicators the manufactures should be consulted.'

Review of the CDC Guideline for Disinfection and Sterilization in Health care Facilities, dated 2008, revealed in part. "False-positive biological indicators may occur from improper testing or faulty indicators."

Review of the manufactures instructions for the chemical indicator, dated 3/2013 revealed in part. 'Instructions for use 2. Place a chemical indicator in each pack, peel pack, container system, or tray to be steam sterilized in the area determined to be the least accessible to steam penetration.'

Review of the manufactures instructions for the peel pack, not dated, revealed in part. '3. Sterilization these process indicators ONLY measure temperature and should be used in conjunction with a multi-parameter indicator strip which measures temperature for a specific time, and the presence of steam.'

CAH policy titled, Infection Control and Sterilization, dated 3/2016, lacked direction related to placement of the chemical indicator in the peel pack and the sterile blue wrapped pack.

During an interview on 2/8/17 at 10:00 AM, Staff H indicated the CAH lacked training records for the 4 of 4 surgery staff in the use of the chemical indicators for autoclave found in central sterile.

B. During an interview, while touring the central sterile area, on 2/7/16 at 1:45 PM, Staff Lreported staff wraps the biological indicator in folded surgical towels, and places this pack on the bottom shelf toward the front of the autoclave.

On 2/7/17 at 3:50 PM, Staff H and L, OR RN's, demonstrated wrapping the biological indicator. Two surgical towels were used to wrap the biological indicator, each measured 25 inches x 16.5 inches, the towels were folded widthwise, the stack measured 2.75 inches tall, and contained 8 layers of folded towels above and below the biological indicator.

Review of the CDC Guideline for Disinfection and Sterilization in Health care Facilities, dated 2008, revealed in part. 'The size and composition of the biological indicator test pack should be standardized to create a significant challenge to air removal and sterilant penetration and to obtain reliable results. There is a standard 16-towel pack recommended by AAMI (Association for the Advancement of Medical Instrumentation) for steam sterilization consisting of 16 clean, preconditioned, reusable huck or absorbent surgical towels each of which is approximately 16 inches by 26 inches. Each towel is folded lengthwise into thirds and then folded widthwise in the middle. One or more biological indicators are placed between the eight and ninth towels in the approximate geometric center of the pack. When the towels are folded and placed one on top of another to form a stack (approximately 6 inch height) it should weigh approximately 3 pounds and should have a density of approximately 11.3 pounds per cubic foot...The test pack should be placed flat in an otherwise fully loaded sterilizer chamber, in an area least favorable to sterilization. This area is normally in the front, bottom section of the sterilizer, near the drain.'

Review of the manufactures instructions for the biological indicator, 2/16 revealed in part. 'As a best practice and to provide optimal patient safety, 3M recommends that every sterilization load be monitored with a biological indicator in an appropriate Process Challenge Device i.e. BI challenge test pack. Place a biological indicator in an appropriate test tray or package according to recommended practices. Place the test tray or package in a full load in the most challenging area for the sterilant. This is generally on the bottom shelf, near the door and over the drain.'

Review of the Autoclave Attest (biological indicator test packs) Record, dated 8/16 to 1/17 revealed all biological test packs passed sterilization. However, because of the improper methods used, the facility could not guarantee their sterility.

Review of the CAH policy titled, Infection Control and Sterilization, dated 3/2016 revealed it lacked information related to proper placement of the biological indicator test pack in the autoclave to achieve maximum efficacy and assurance of sterility.

During an interview on 2/8/17 at 10:00 AM, Staff H reported, the CAH lacked records that showed staff had received training in proper wrapping, placement of the biological indicator, and placement in the autoclave for 4 of 4 surgery staff responsible for these tasks.

C. During the tour of the central sterile on 2/7/17 at 1:45 PM, Staff L demonstrated use of the Bowie Dick pack in the autoclave. The Bowie Dick pack was placed on the lower shelf and toward the front of the autoclave, Staff L indicated the drain is located in the center of the autoclave. A Bowie Dick pack is run with the first load of the day, after the autoclave's warm up cycle to test the sterilizer for efficacy of air removal and steam penetration; this is part of the release criteria for using the sterilzer for the day.

Review of the AORN Guidelines for Perioperative Practice, edition 2017, revealed in part. 'A Bowie Dick, air removal test, should be performed each day that the sterilizer is used.'

Review of the manufactures instructions for use of the Bowie Dick pack (S.M.A.R.T pack), dated 2009, revealed in part. 'Place the S.M.A.R.T. pack in a horizontal position on lowest shelf (above drain) of an otherwise empty sterilizer.

A review of the Bowie Dick pack records, dated 8/16 to present revealed no malfunction of the Bowie Dick test. However, because of the improper methods used, the facility could not guarantee sterility.

During an interview on 2/8/17 at 10:00 AM, Staff H, revealed the CAH administrative staff had failed to develop and implement a policy/procedure that delineated correct use of the Bowie Dick pack. Additionally, Staff H reported the CAH lacked records that showed training occurred for 4 of 4 surgical staff responsible for use and monitoring of the Bowie Dick pack used in the autoclave found in central sterile.

III. Based on document review and staff interview, the CAH failed to monitor and follow endoscopy and surgical procedures for infections. The CAH administrative staff reported 20-30 scopes and 4-8 surgical procedures are performed monthly. (Refer to C-0278 for additional information)

Failure to monitor and follow endoscopes and surgical procedures for infections could potentially result in life threatening infections, related to the endoscopies and surgeries, going undetected.

Findings include:

During an interview on 2/8/17 at 3:30 PM, Staff J, RN Infection Preventionist, acknowledged no involvement in surgical infections or followup of surgical patients.

A review of the CAH policy titled, Monitoring of Surgical Infections, dated 9/2009 reads in part...Purpose: To establish guidelines for monitoring post operative patients for infections. Policy: If at any time the patient has signs or symptoms of an infection, an appointment will be made for the patient to see his or her primary physician. The outcome of this appointment and any lab or cultures done will be obtained. This information will be given to the Infection Control Officer. If an infection is found, the Infection Control Officer will be responsible for notifying the surgeon.

Review of the monthly infection control meeting minutes, dated 4/2016 to 1/2017, revealed meeting minutes and infection control logs lacked information related to surgical site infections. The monthly infection control logs, were reported at the monthly infection control meetings, the reports lacked tracking and trending of endoscopes and surgical procedures.

I. Based on observation, policy review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure approval for 1 of 1 manufacturer representative to be present in the procedure room during a procedure. The Surgery Coordinator reported the manufacturer representative had been present in the procedure room twice in the past 2 weeks.

Failure to ensure approval for a manufacturer representative to be present could potentially result in an unauthorized individual assisting with a procedure that could put the patient at risk for surgical complications.

Findings include:

Observation on 2/7/17, at 8:35 AM, revealed Staff F, Pentex Manufacturer Representative, present in the procedure room during a patient procedure.

Review of a CAH policy titled "Observation of Hospital Services by Outside Persons", approved 3/2016, revealed in part "... Any person wishing to observe George C. Grape Community Hospital operations or services must apply through a central process as set out in this Policy. Applications for shadowing/observing shall be submitted in advance to the Medical Staff Office ... Equipment and supply vendors are subject to this Policy ... All requests for observation ... must be submitted in writing by completing the Observation/Shadowing Request form ... The requests will be reviewed and approved or denied by the CEO (Chief Executive Officer) with designated responsibility for the area(s) for which observation is requested ..."

During an interview on 2/9/17, at 10:40 AM, Staff A, Administrative Assistant, acknowledged she did not have a completed and approved "Observation/Shadowing Request" form for Staff F and confirmed there should be one.

During an interview on 2/9/17, at 10:50 AM, Staff H, Surgery Coordinator, confirmed Staff F's presence in the procedure room on 2/7/17 and reported he had been present in the procedure room last Tuesday and again this Tuesday. Staff H acknowledged she did not have any documented evidence to verify the approval of Staff F to be present for procedures.

II. Based on observation, document review and staff interview, the Critical Access Hospital's (CAH) administrative staff failed to ensure the accuracy of surgical staff privileges for 1 of 1 selected urologist (Staff I). The Surgery Coordinator reported the identified urologist performed 26 procedures in 2016.

Failure to ensure the accuracy of current privileges could potentially result in surgery staff allowing a physician to schedule and perform a surgical procedure they are no longer qualified to preform and/or the governing body of the CAH did not authorize a provider to perform.

Findings include:

Review of the closed medical record for Patient #16 revealed the patient had a left radical orchiectomy performed on 11/10/16.

Review of a signed surgical consent for Patient #16 revealed the patient consented to a Left radical orchiectomy on 11/10/16, which listed Staff I, Urologist as the surgeon.

Review of a procedure note dated 11/10/16 revealed Patient #16 had a left radical orchiectomy, performed by Staff I.

Review of Staff I's credential file revealed a privilege list effective 9/1/16 to 8/31/18, approved by the Board of Directors 8/25/16, which failed to identify privileges to perform an orchiectomy.

Review of a CAH policy titled "Provider Reappointment to the Medical Staff", approved 3/2016, revealed in part "... The applicant shall identify ... clinical privileges for which they wish to be considered ... after the Board of Directors has approved the appointment of privileges ... scan their privileges into the appropriate departmental file on the Shared drive if their privileges are to be practiced in the department ..."

Review of the Medical Staff By-Laws, approved 9/2016, revealed in part "... every practitioner providing clinical services ... shall be entitled to exercise only those clinical privileges ... specifically granted to him or her by the Board ...

During an interview on 2/8/17, at 15:50 PM, Staff H, Surgery Coordinator, verified Staff I lacked the delineation of privileges for an orchiectomy, which was performed for Patient #16, on 11/10/16.