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Based on interview and record review, the facility's Medical Staff failed to conduct complete reappraisals for two (2) of seven practitioners (Medical Doctor 1 [MD 1] and MDA 2). MD 1 and MDA 2 did not have a peer (person equal in qualifications and abilities) reference letter for their most recent reappointment period (MD 1 for the period spanning 3/1/2022 to 2/29/2024 and MDA 2 from 2/1/2023 to 1/31/2024).

This deficient practice resulted in MD 1 and MDA 2 providing medical care to patients in the facility without having their proper qualifications and current clinical competencies corroborated by peers.

Findings:

On 12/13/2023 at 5:10 p.m., during a concurrent interview with Director of Medical Staff Administration (DMSA) and record review of seven medical staff (practitioners) credential files with the DMSA and the Director of Quality and Risk Management (QM), the files of MD 1 and MDA 2 were noted to be lacking documentation of the practitioners' appraisal by peers for the current reappointment period (MD 1 from 3/1/2022 to 2/29/2024 and MDA from 2/1/2023 to 1/31/2024). The DMSA verified and stated no peer reference letters could be located from these two physicians' files (MD 1 and MDA 2) for their most recent reappointment cycle and confirmed that reappointment of members to the Hospital Medical Staff requires a minimum of one peer reference.

A review of the facility's Medical Staff Bylaws, approved by the Community Board on 9/19/2019, indicated under Section 1.2, "The purpose of the Medical Staff shall be [ ...] to assure a high level of professional performance of all Practitioners authorized to practice in the Hospital through an ongoing review and evaluation of each Practitioner's performance in the Hospital." Section 4.6.1 of the Bylaws indicated, "Each Medical Staff member shall submit to the Medical Staff Office the completed application for reappointment to the Medical Staff and a completed privilege sheet for renewal or modification of clinical privileges. The application form shall include all information necessary to update and evaluate the qualifications of the applicant, including without limitation, the matters set for the in Section 4.5.1, as well as other relevant matters." Section 4.5.1 of the Bylaws, under Application for Initial Appointment and Reappointment, indicated, "The [application] form shall require detailed information which shall be verified by the Medical Staff and include, but not be limited to, information concerning: [ ...] peer references familiar with the applicant's professional competence and ethical character."

Based on observation, interview, and record review, the facility's perioperative staff (RN 3) failed to ensure one (1) of thirty (30) sampled patients (Patient 2) was secured while on the operating table) with the three-point straps (arm strap, a chest strap, and safety belt across the mid-thigh) in accordance with the facility's policy and procedure for positioning patient.

This deficient practice resulted in Patient 2 sliding off the operating table during surgery and delayed completion of Patient 2's surgery. Patient 2 required to have a computed tomography (CT, a diagnostic imaging procedure that combines images taken from the body) to check for injuries and returned back to the OR a second time to complete Patient 2's surgery.

Findings:

During a review of Patient 2's History and Physical (H&P), dated 10/9/23, indicated Patient 2's past medical history included a diagnosis of pandiverticulosis (outpouching of the lining of the colon) in the colon. The patient was referred for surgical intervention (requiring surgery) for a laparoscopic cholecystectomy (surgery to remove the gallbladder).

During an interview, on 12/11/23 at 2:30 p.m. Registered Nurse 1 (RN 1) stated this year there was a case where a patient (Patient 2) slipped off the operating table while the surgeon was performing a laparoscopic cholecystectomy. RN 1 stated, "At that time, the policy indicated that three straps (safety securing devices designed to secure patients to the operating table) should be in place for any patient placed in the Trendelenburg (position the operating table placing a patient with the head was down and feet were up) position during surgery. The patient (Patient 2) did not have on the third strap." RN 1 stated after the incident all staff in the operating room (OR) received education on proper positioning and reiterated that three-point straps were required when patients were placed in the Trendelenburg position.

During an interview on 12/11/23 at 2:38 p.m. the Director of the Operating Room 1 (DOR 1) , stated after Patient 2 was put into a steep Trendelenburg position, Patient 2 slid off the operating room table. DOR 1 stated Patient 2's surgery was stopped, and Patient 2 was transferred to a CT scan to ensure Patient 2 did not sustain injury. DOR 1 stated the CT scan results were normal. DOR 1 stated that Patient 2 was brought back into the operating room to complete the surgery.

During a concurrent interview and record review of Patient 2's Surgical Documents, on 12/12/23 at 11:25 a.m., the Interim Director of Perioperative Services (IDPS), Patient 2's Surgical Documents, dated 10/9/23, were reviewed. The surgical documents indicated, "Arm Strap, Ulnar Pad(s), bath blanket, blanket under head and shoulders, and one wrapped around head, left arm tucked and padded with ulnar (forearm) pads. The surgical document indicated Patient 2's right arm was on the arm board and secured with an arm strap. Patient 2's had safety belt across the mid-thigh and the position was verified by the medical doctor (MD) and anesthesiologist (MDA 2, MD administering and monitoring patient's sedation). IDPS stated RN 3 did not apply all three safety straps . IDPS stated the foot board and the chest strap were not placed. IDPS stated when Patient 2 was placed in a Trendelenburg position, a minimum of three straps must be applied according to the facility policy and procedure.

During a review of the facility's policy and procedure (P&P) titled "Positioning the Patient," dated 2/23/23, indicated the following:
The perioperative staff will implement safe practices for the positioning of patients undergoing operative and other invasive procedures. The Safe Positioning Practices included:

a. A minimum of two-point restraints must be used for all patient positioning.

b. A minimum of three-point restraints (straps) must be used for the following patient positions: Reverse Trendelenburg (position the operating table placing a patient with the head was up and feet were down) , Trendelenburg, and Lateral Side Up (patient lies on their left or right side with the operative side up).

c. The surgeon and the surgical team will apply additional positioning aids as needed.

Based on observation, interview, and record review, the facility failed to establish a safe process to secure a patient on the operating table, requiring repositioning to a reverse Trendelenburg (position for the operating table place, a patient with the head up and feet down) for one (1) of the thirty (30) sampled patients (Patient 1). Patient 1 was placed in the reverse Trendelenburg position of the OR table during a surgery.

This deficient practice resulted in Patient 1 falling off the operating table during surgery and sustaining a liver laceration (cut to the liver) and had the potential to put other patients requiring reverse Trendelenburg at risk for falling while on the operating table.

Findings:

During a review of Patient 1's History and Physical (H&P),dated 9/8/2021, indicated, Patient 1 medical history included cerebrovascular accident (CVA, loss of blood flow to part of the brain) with left-sided deficit (a common after-effect of stroke that causes weakness on one side of the body), hypertension (high blood pressure), and gallstones (harden deposits that form in the gallbladder). Patient 1 was sent into the emergency department by Patient 1's primary care doctor for persistent right upper quadrant abdominal (stomach) pain for two days.

During a concurrent interview and record review of Patient 1's Operative Report, on 12/12/2023 at 10 a.m., the Manager of Patient Safety Officer (PSO) reviewed and verified Patient 1's Operative Report, dated 9/9/2021 indicated the surgery had started and incisions were made on Patient 1's upper left part of the abdomen, and supra umbilicus (above the bellybutton). The operative report indicated, "At this time, the patient's arms became loose, and her upper body sided off the OR table, followed by her lower body. She was extubated (the tube that provides oxygen was accidentally removed), and her IV (tube that goes in the vein to administer medication and fluid) was dislodged." The PSO stated, "The patient (Patient 1) sustains a liver laceration (deep cut) as a result of the fall."

A record review of Patient 1's Anesthesia Physician Note, dated 9/16/2021, indicated, "The patient (Patient 1) was positioned in reverse Trendelenburg and left tilt of the bed (operating table). A few minutes later, (name of the surgeon [MD 1]) requested additional reverse Trendelenburg. A few minutes later he (MD 1) requested that the bed height be increased. As the table was rising the upper half of the patient suddenly and quickly fell off the bed to the left. The upper part of her body hit the ground, and the ETT (endotracheal tube, to provide a passageway to deliver oxygen to the patient) and IV were pulled out. Her (Patient 1) legs and hips were still on the OR bed."

During an interview on 12/14/2023 at 3:55 p.m., the Interim Director of Perioperative Services (IDPS) stated that in 2021, there was no other process in place regarding securing the patient when placed in reverse Trendelenburg during surgery. IDPS confirmed that the facility's positioning policy and procedure in 2021 indicated the circulating Registered Nurse (RN) was responsible for securing the patient during surgery. IDPS stated the patient's positioning during surgery requires a collaborative team effort to maintain safety and prevent injuries. IDPS confirmed that the facility's policy and procedure for patient positioning in the operating room were revised in 6/2022 to indicate that the perioperative staff are responsible for ensuring the patient is secure during surgery.

A review of the facility's policy and procedure (P&P) titled, "Patient Positioning: Operative," dated 10/24/2018, the P&P indicated, " It is the policy of the facility to optimize patient positioning during surgical procedures while providing optimum exposure and access to the operative site, sustain circulatory and respiratory function, support musculoskeletal and neurological structures, preserve skin integrity, and prevent injury and complications while maintaining patient dignity, comfort, and safety.
The P&P indicate the circulating RN performed the following:

1. Preoperative assessment for positioning the patient to include:
a. Type of procedure,
b. Patient age, height, weight, and body mass index (BMI, measurement of body fat),
c. Skin condition,
d. Nutritional status,
e. Neuropathies (nerve damage leads to pain, weakness, numbness or tingling),
f. Preexisting disease conditions,
g. Physical limitations,
h. Presence of implanted devices or prosthetics,
i. Presence of catheters drains and/or orthopedic immobilizers.

2. Identifies risk factors that can increase skin, respiratory, nerve or cardiovascular compromise related to positioning.

3. Determines the correct position and positioning devices for the patient based on the procedure to be performed, patient assessment, surgeon's preference(s), and injury prevention..."

A review of the facility's P&P titled, "Patient Positioning: Operative," reviewed date 6/2022 and effective date 2/23/2023, indicated "The perioperative staff (surgical team [nurses and surgeons]) will implement safe practices for the positioning of patients undergoing operative and other invasive procedures." The P&P indicates that safe positioning practices include the following:

a. A minimum of three-point restraints (straps) must be used for the following patient positions: Reverse Trendelenburg, Trendelenburg (position the operating table placing a patient with the head was down and feet were up), Lateral Side up.

b. The surgeon and the surgical team will apply additional positioning aids as needed.