HospitalInspections.org

Based on interview and record review, it was determined the hospital failed to have an effective governing body that was responsible for the conduct of the hospital. Specifically, the governing body failed to provide surveyors with requested information in a timely manner or provide patient medical records in their entirety.

Findings include:

1. On 6/19/19, at 10:08 AM, the survey team asked for the following information for 22 of their licensed care providers: their date of hire, license verification, and evidence of training and skills including life support certification.

Multiple requests were made from 10:45 AM to 12:20 PM for any information regarding the requested personnel information. At 12:20 PM, the survey team asked to have the hospital's nurse educator come in and look up the personnel education needed, which he had said on the survey entrance date (6/17/19) he could help the survey team with when needed.

On 6/19/19 at approximately 12:30 PM, the hospital's nurse educator met with the survey team and began pulling up the life support certification for the personnel whose files he had access to. Note: This was approximately two and a half hours after the survey team initially requested the information.

On 6/19/19 at 12:37 PM, an email was received with the life support certification expiration dates, if applicable, for the 22 licensed care providers. Survey staff had not received dates of hire or licensure verification.

On 6/19/19 12:54 PM, an interview was conducted with the Geographic Manager (GM). The GM stated there were hospital staff who had access to personnel files, but that "we have been instructed to go through our ask HR (human resources)" and that, "they manage all of our employee records." The GM further stated they had ran into two issues getting the survey team the requested information timely; one that some of the names were listed incorrectly and two, "we have another survey going on and so our resources are stretched."

On 6/19/19 at 1:00 PM, the GM called an HR representative at another hospital and had her read off the hire dates over the telephone for the requested licensed care providers. Note: This was approximately three hours after the initial request had been made.

On 6/19/19 at approximately 1:30 PM, the survey team received licensure verification for 15 of the 22 requested personnel.

On 6/19/19 at 1:37 PM, survey staff began looking up staff licensure through the Utah Division of Occupational and Professional Licensing website to expedite the process. Note: This was three hours and 29 minutes after the survey team initially requested the information.

2. On 6/18/19, surveyors had to depend on the hospital's nursing staff to participate in medical record review under their own log-ins to find pertinent documentation due to the limited view of the patient electronic medical record that had been provided to surveyors. The GM stated they thought the surveyor access provided included access to all pertinent patient information, but that they now realized this was not the case.

Failure to provide requested information in a timely manner impeded the survey process and made review of some areas of compliance difficult or impossible to complete.

Based on interview and record review it was determined that the Hospital did not ensure that certified registered nurse anesthetists (CRNAs) were under the supervision of the operating practitioner or an anesthesiologist who was immediately available.

Findings include:

On 6/18/19 at 10:40 AM, during an observation of an orthopedic surgical procedure in an operating room, an interview was conducted with the operating physician (OP). The OP stated he thought it was the hospital's medical director (MD) of surgical services who supervised the CRNAs. The OP stated that was one of the questions he had asked when he began working at the hospital. The OP stated he had asked who supervised the CRNA's because, "I am not".

On 6/18/19 at 12:47 PM, an interview was conducted with the geographic manager (GM), surgical services manager (SSM), and clinical operations manager (COM). The SSM stated that the hospital's CRNAs were under the supervision of the hospital's MD of surgical services. The SSM stated the MD of surgical services was, "on call" and "available by phone" if needed by the CRNAs. The GM and COM confirmed this was the hospital's process.

On 6/18/19 at 1:35 PM, an interview was conducted with CRNA 1 at the request of the COM and GM. CRNA 1 stated, "We consider the operating physician that we work with as our supervising physician."