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Based on interview and record review, the Governing Body failed to ensure that contract services were fully integrated into the Quality Assessment & Performance Improvement (QAPI) program.

Quality data for the contracted services of lithotripsy and dialysis was not reviewed and analyzed for the year of 2013.

Findings include:

Record review on 02-13-14 of facility list of contracted services revealed ( ) dialysis service utilized through 3rd quarter of 2013 and a current contract for ( ) lithotripsy service.

Lithotripsy:

Interview on 02-13-14 at 9:45 a.m. with Chief Medical Officer (CMO) / Staff ID # 4 he stated that lithotripsy QA reports were reviewed quarterly at the Department of Surgery meeting and then forwarded to the Medical Executive Committee (MEC) for review.

Record review on 02-13-14 of facility QA data for contracted lithotripsy services revealed that QA reports were submitted to the facility by the contracted vendor on June 6, 2013; July 18, 2013; and October 17, 2013.

Record review on 02-13-14 of facility Department of Surgery meeting minutes revealed the last time that lithotripsy QA data was reported and discussed was 12-04-2012. CMO/ID # 4 was unable to locate other documentation that lithotripsy QA data was discussed.

Dialysis:

Interview on 02-13-14 at 9:45 a.m. with Chief Medical Officer (CMO) / Staff ID # 4 he stated that dialysis QA reports were reviewed by the Medical Executive Committee (MEC).

Record review on 02-13-14 of facility QA data for contracted dialysis service revealed that QA reports were submitted to the facility by the contracted vendor for the first and third quarters of 2013.

Record review on 02-13-14 of the MEC meeting minutes for 2013 revealed the last documented time that dialysis QA data was discussed was 09-10-2012.

Interview on 02-13-14 at 11 a.m. with the Chief Nursing Officer (CNO)/ ID # 1 she stated
the facility changed their contracted dialysis service provider beginning 4th quarter 2013. Although the CNO said she " was sure the dialysis data had been presented; " she was unable to locate documentation that dialysis QA was presented to MEC in 2013.

Review of facility " Performance Improvement Plan, " undated, read: " ...Authority and Accountability :The ultimate authority for quality patient care and services provided by our licensed independent practitioners along with other professional and support staff rests with the Board of Trustees ... "

Based on observation, interview and record review, the facility's registered nurses failed to follow physician's order for an abdominal binder for 1 of 57 sampled patients: Patient #10
Findings;
On 02/11/2014 at 10:23 a.m. Patient # 10 was observed on unit 2W in his room. The patient was alert and oriented to person, place and time.

Interview with the patient at this time revealed his abdomen is tight, red, painful and sore that the physician prescribed an abdominal binder for his stomach. The patient stated " The doctor told me the binder is to keep these rupture inside. I asked for it yesterday but no one knows about it. I guess they forgot." The patient said he was discharged for home early in the a.m. but he had not received his abdominal binder.
The patient then lifted his gown and exposed his abdomen to the Surveyor and the nurses present in the room. Observation of the patient's abdomen at that time revealed it appeared swollen and red in color.

Interview on 02/11/2014 at 10:32 a.m. with the Registered Nurse (#16) who was assigned to the patient revealed the patient was discharged for home; she had called central supply for the binder but had not received it.

Review of the patient's clinical record (History and Physical) dated 02/06/2014 revealed, the patient was admitted to the facility on 02/06/2014 with admitting chief complaint of abdominal pain and distension. The physician's assessment of the patient indicated that the patient had ileus versus obstruction, ventral hernia.
Review of the patient's clinical record revealed a physician's order dated 02/07/2014 for " abdominal binder. "
Review of a physician's progress noted dated 02/08/2014 revealed the following entry: " Complex of ventral Hernia. Arrange abdominal binder. "
Review of the patient 's clinical record (nurses progress notes) dated 02/07/2014 - 02/11/2014 revealed no evidence of an abdominal binder applied to the patient's abdomen as prescribed by the patient's physician.

Based on observation, record review and interview, the facility failed to ensure contract nurses document verbal orders when it is given by the physician in 1 of 57 sampled patients.

Findings;
On 02/13/2014 at 8:50 a.m. Patient #57 was observed in the hemodialysis suite of the facility receiving hemodialysis treatment.
Review of the patient's clinical record located in the chairside computer revealed no documentation of a physician's prescription for hemodialysis treatment on the patient.
Interview on 02/13/2014 at 8:51 a.m. with the registered nurse ( #50) who was assigned to the patient revealed Contract Nurse ( #17) had taken a verbal telephone order from the patient 's nephrologist but she had not entered the information in the computer.
The Contract Registered Nurse # 50 then informed the surveyor that she would enter the information in the computer since the nurse who took the verbal telephone order was busy and did not enter the information in the computer.

The Surveyor asked the registered Nurse if she was present when the order was given and where was she going to get the information to enter in the computer. Contract Nurse #57 said she was not present when the verbal order was given.

Registered Nurse # 50 then presented a laboratory report to the Surveyor. On the laboratory report was documented the following entry: " 3k, 2.5 Uf 2L.
There was no date, or time on the laboratory when the order was obtained. It was not signed by the person who obtained the order

Based on record review and interview, the facility failed to execute informed consent forms for procedures and treatment and ensure two persons verified blood prior to initiation of blood transfusion in 3 of 57 patients ' charts reviewed : #s 6, 26, and 27 .
Findings:
Patient #6
Record review on 2/11/14 of Patient #6's surgical consent form revealed he had an appendectomy performed on 2/9/14. Section 9 with blank lines to list risks and hazards was highlighted, but not filled out. Pages 3 to 10 were boxes to check for Risks and Hazards, but none of them were checked and initialed.
Interview on 2/11/14 at 10:55 a.m. with the Director of Perioperative Services, RN (Registered Nurse) #44, she was shown the consent form and stated the risks and hazards should have been listed and checked.
Interview on 2/11/14 at 1:25 p.m. with Preoperative Charge Nurse, RN #14, she said that 50% of the time the physicians have the consents signed in their offices. If the patient comes to the hospital without a signed consent, then the nursing staff is responsible for filling out the consent. The patient is asked if the physician has discussed the risks and hazards. If they say no, then the physician is called to discuss them with the patient.
Record review of the facility's Policy and Procedure for Informed Consent dated 6/1/82 and revised/reviewed on 2/1/12 revealed " Each patient has the right to be informed of his/her medical condition, the risks, benefits, and alternatives of proposed medical service or treatment, and to consent to or decline any medical service or treatment ...The nurse ' s role is to:
1. Ensure that the informed consent form is filled out completely by verifying the following: ...The informed consent form lists the risks and hazards associated with that procedure/treatment in section 9 of the form and/or the applicable box is checked on the appropriate panel ...of the Informed Consent form. "


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BLOOD VERIFICATION
Review of the facility's current Policy and Procedure on Blood Transfusion, # PC/PS051, revised 10/09/2012 directed staff as follows: " Obtain and verify blood. Blood must be verified by two licensed people (One of which must be a RN). The blood bank armband number must match the number that is on the unit of blood. Any discrepancy noted on identifying information will be reported to the blood bank immediately, and no blood product will be transfused until the matter is resolved. Complete all information on the request form, including blood unit number, and expiration date, patient ' s name, medical record number, current vital signs, religion, blood group and type etc. "
Patient # 26
Review on 02/12/2014 of patient # 26's clinical record revealed documentation which indicated that the patient was transfused with a unit of Packed Red Blood Cells on 02/05/14.

Review of the patient's clinical record (Issue and Transfusion Record) revealed documentation which indicated that the Pre Transfusion checklist was incomplete. Instruction on the Issue and Transfusion Record directs staff to " Completed with another Licensed Nurse. "
Review of the Patient ' s Pre-Transfusion Checklist revealed it was signed by one Licensed Nurse.
There was no pre transfusion temperature, pulse, respiration documented on the record. The Post Transfusion section on the form which addresses who discontinued the blood was blank.

Patient # 27
Review on 02/12/2014 of patient # 27's clinical record (Issue and Transfusion Record) revealed documentation which indicated that the patient was transfused with a unit of Packed Red Blood Cells on 01/31/14.

Review of the patient's clinical record (Issue and Transfusion Record) revealed documentation which indicated that the Pre Transfusion checklist was incomplete. Instruction on the Issue and Transfusion Record directs staff to " Completed with another Licensed Nurse. "
Review of the Patient ' s Pre-Transfusion Checklist revealed it was signed by one Licensed Nurse.

Based on observation, interview and record review the facility failed to maintain the kitchen free of dust, grease, and build up of discolored grease on kitchen equipment. Citing one (1) of two (2) kitchens (#1).

Findings:

Observations on 2/11/2014 at 11:10 am in kitchen (#1) at the main campus revealed the following information:

The Steam Kettle, Convection oven, and Tilt skillet was discolored with heavy buildup of grease. There was food splatter and buildup of crumbs on the bars and base of the skillet.

Observation in the Dry storage room revealed a build up of dust on plastic containers with bread. There was dust and discolored areas on the lower food storage shelf that contained coffee and coffee creamers.

Observation in the Dishwashing area revealed heavy build up of dust and grease on soap and paper towel dispenser. The hand washing sink was greasy. There was grease, dust and crumb like substance on stainless steel shelf where clean dishwashing towels were stored.
A container of cantelopes in the refrigerator was not dated.

During an interview with the Dietary Director he stated will be inserviced in following the cleaning procedure for the kitchen. He stated some of the kitchen equipment are old and need replacement.

Review of the policy/procedure for the kitchen revealed various sections and equipment in the kitchen is on a monthly cleaning schedule and some areas are on a quarterly cleaning schedule.

Based on observation, interview and record review:
-Failed to ensure expired supplies in the emergency room and the Cath lab were removed from stock
-facility's registered nurses failed to wash/clean contaminated hands after direct contact with patients, , contaminated hemodialysis equipment and cleaning of blood, failed to clean medication vial prior to withdrawing medication in 11 of 57 sampled patients #s 9, 11, 17, 18, 21, 22, 23, 27, 50, 51, 55
Findings:.

Observation 2/11/14 at 9:40 a.m. during intial tour revealed the following:
-A suture cart in the emergency room contained a box (3 dozen) of 5.0 Sofsilk sutures with an expiration date of 01/2013.
-Inside a cabinet in the cardiac cath lab an Angiocath catheter (6 french) expired January 2014.

Review of the facility's Policy and Procedure on Hand Hygiene: Healthcare personnel hand washing and hand antisepsis # PC/PS131 directed staff as follows: "Hand Hygiene is the single most important procedure for preventing healthcare associated (HAI) infections ' Hands must be washed thoroughly with soap and water if visibly soiled. . Hands may be disinfected by using soap and water or alcohol -based hand sanitizers if hands are not visibly soiled: Before and after patient contact. After contact with a source of microorganisms,body fluids and moist substances, mucous membranes, non - intact skin, inanimate objects that are likely to be contaminated. "

Patient #9
On 02/11/2014 at 9:45 a.m. Contracted Registered Nurse (#18) was observed on hemodialysis suite of the facility. The registered nurse was providing hemodialysis treatment to patient # 9. The Registered Nurse reset the panel on the patient's hemodialysis machine, removed her contaminated gloves and held them in her right hand while she entered information in the patient ' s clinical record located at the bedside of the patient. Contracted Registered Nurse (#18) did not clean/ wash her contaminated hands after she had touched the patient's contaminated hemodialysis machine and removed her contaminated gloves.
During an interview on 02/11/2014 at 9:49 a.m. with Contracted Registered Nurse (#18), the Surveyor notified her that she the Surveyor observed that she the Contracted registered Nurse did not wash/ clean her contaminated hands after touching the contaminated machine. She stated " Thank you. "

Patient #9
On 02/11/2014 at 2:00 p.m. Contracted Registered Nurse (#18) was observed on the facility's hemodialysis suite. The Contracted Registered Nurse was observed terminally cleaning hemodialysis machine which was previously used by Patient (#9) for hemodialysis treatment. Observation revealed after the Registered Nurse had cleaned the contaminated hemodialysis machine, she removed her contaminated gloves, threw them in the garbage and then proceeded to enter information in the patient's clinical record located at the nurses ' station. Contracted Registered Nurse (#18) did not clean/ wash her hands after she had terminally cleaned the contaminated hemodialysis machine and removed her contaminated gloves.

During an interview on 02/11/2014 at 2:02 p.m. with Contracted Registered Nurse (#18) , the Surveyor notified her that she did not wash/ clean her contaminated hands after cleaning the contaminated machine. She stated " I thought I did "

BLOOD ON FLOOR
Patient #51
On 02/11/2014 at 9:57 a.m., 10:02 a.m. and 10:15 a.m. droplets of blood were observed on the treatment floor of the hemodialysis suite adjacent to the nurses ' station.
The Surveyor notified the Contracted Registered Nurse (#17) at 10:15 a.m. that droplets of blood were on the floor of the treatment room near the nurses ' station.
Contracted Registered Nurse (#17) retrieved wipes from the packet of wipes and wiped the blood from the flooring. The registered Nurse was not wearing gloves while cleaning blood from the floor. She also held her pen in her hand while cleaning the blood.
After cleaning the blood from the flooring the nurse then returned to the bedside of Patient (#51) and entered information in the patient's clinical record. Contracted Registered Nurse (#17) did not clean/ wash her contaminated hands after cleaning the blood from the treatment floor.

During an interview on 02/11/2014 at 10:17 a.m. with Contracted Registered Nurse (#17), the Surveyor notified her that she was not wearing gloves and that she the nurse had not washed/ cleaned her hands after cleaning blood from the floor. She stated " OK "


Patient #11
On 02/11/2014 at 11:00 a.m., during tour of unit 2 W, revealed three physicians were observed entering the room of patient (#11). The physicians were wearing their laboratory coats. The physicians donned pairs of gloves and entered the patient's room. After finished with the patient, the physicians removed their gloves, discarded them in the garbage bin. Two of the three physicians cleaned their hands with alcohol while one of the three physicians discarded his gloves and walked from the room without cleaning /washing his hands.
Observation of a sign posted on the patient's door revealed the occupant of the room was on contact isolation.

Interview on 02/11/2014 with the RN# 53 on tour with the Surveyor revealed the patient was on contact isolation for Clostridium Defficile

Review of the Center for Disease Control article Rationale for Hand Hygiene Recommendations after Caring for a Patient with Clostridium difficile Infection Fall 2011 update documented : " alcohol does not kill C difficile spores. In addition several studies have found that handwashing with soup and water or with antimicrobial soap and water, to be more effective at removing Cdificile spores than alcohol based hand hygiene products from the hands of volunteers inoculated with known number of C difficile spores."

Wound Care
Patient #27
On 02/12/14 at 9:50 a.m. Physical Therapist (#55) was observed in the patient ' s room providing wound care to Patient # (27) who had a wound on his right foot and three wound on his left foot. During the procedure the Physical Therapist cleaned her hands, applied clean gloves and removed the patient's soiled dressing from the wounds on the patient's left foot. After removing the dirty dressings, Physical Therapist (#55) removed a pair of clean gloves from a box of gloves and proceeded to clean the patient's wound using 4X4 swabs soaked with Normal Saline. The Physical Therapist did not clean/ wash her hands after removing the soiled dressing from the patients wound.

During an interview on 02/12/2014 at 9:55 a.m., post wound care, The Surveyor notified the Physical Therapist that she did not wash/clean her hands after removing the soiled dressing of the patient during wound care. The Physical Therapist said she agreed that she had failed to wash her hands after removing the soiled dressing.

Patient #50
On 02/13/2013 at 9:13 a., Patient (#50) was observed in the hemodialysis suite receiving hemodialysis treatment. Observation revealed the patient's physician (#56) washed his hands, examined the patient's lung field with his personal stethoscope, examined and touched the patient's abdomen and feet. After completing examination of the patient, (Physician #56) returned the stethoscope to his neck, picked up the patient's chart and proceeded to the chart room where he began charting on the patient. The Physician did not wash/ clean his contaminated hands or stethoscope after he examined the patient.

During an interview on 02/13/14 at 9:14 a.m. with Physician (#56), The Surveyor notified him that he did not wash/ clean his hands after he examined the patient. The Physician stated " I washed my hands before examining the patient. The Surveyor informed him that he did not wash/ clean his hands after examining the patient. The physician stated " I think I can do better. "


CENTRAL VENOUS CATHETER CARE
Patient #50
ON 02/13/2014 at 8:47 a.m., Contracted Registered Nurse (#17) was observed in the hemodialysis suite cleaning the central venous catheter limbs of Patient (#50). The Contract Registered Nurse Manager retrieved gloves from a box of gloves on the wall and threw the gloves on the patient's contaminated chart ( folder). The registered nurse needed an extra pairs of gloves which she placed on the patient's contaminated chart sitting on the bedside table. The Registered Nurse donned a pair of the gloves that she retrieved from off the patient 's chart and wiped the limbs of the central venous catheter with small alcohol wipes. The Contract Registered Nurse did not clean the full length of the catheter limb. She then accessed the patient's central venous catheter and initiated treatment on the patient using the potentially contaminated gloves.

Review of the facility's current Policy and Procedure on Vascular Access Devices: Insertion Access, Care and Maintenance # PC/ PS069 direct staff as follows: " Sterile gloves and mask will be worn when changing all central catheter dressings. All end caps will be scrubbed with 70% alcohol for 15 seconds prior to accessing any vascular access device, including peripheral (short) sites, as well as central lines."



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Patient #55

Observation on 2/13/14 at 1:30 p.m. revealed Patient #55 was being admitted to unit 3 West. He had a urinary drainage bag that was hooked on the bed frame, but lying on the floor.

Interview at this time with RN #58, she said that when the bed was in a low position, the bag would rest on the floor. She said the staff should put the urinary drainage bag in the patient's plastic wash basin. RN #58 went to get the patient's wash basin, but then decided to raise the bed until the bag was off the floor.

During an interview on 2/14/14 at 10:00 a.m. with the Director of Perioperative Services, RN #44, she was asked for a Policy and Procedure for hanging a urinary drainage bag. She presented a Policy and Procedure for Foley Catheter Removal Protocol (no date) saying she did not have one specifically for the urinary drainage bag.

Record review on 2/14/14 of the facility's Procedure for Foley Catheter Removal Protocol revealed it did not address anything about the urinary drainage bag.



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Observation on the Intensive Care Unit on 2/11/2014 at 10 :55 am in room # 7 revealed Patient (# 22) was receiving hemodialysis treatment. Staff (#59) Registered Nurse providing hemodialysis treatment for the patient was at her bedside and was not wearing an impervious gown. The staff was wearing a cloth lab gown.

Observation on the Intensive Care Unit on 2/12/2014 at 9:45 am revealed room # 5 had a sign on the entrance to the room indicating the patient (#21) in the room was on Contact Isolation. Observation at that time revealed Staff (#38) was at the patient's bedside providing care and was not wearing a gown.
Review of the patient's clinical record revealed she was on contact isolation for Methicillin-resistant Staphylococcus Aureus (MRSA) of wound.

Observation on 2/12/2014 at 9:55 am on the Intensive Care Unit revealed posted sign on room 8 that the patient (#23) in the room was on contact isolation. Observation at that time revealed a Registered Nurse and Patient Care Attendant was in the room providing care to the patient including turning and repositioning the patient and handling the patient's bed linen. Neither of the two staff were wearing gowns.
Review of the patient's clinical record revealed she was on contact isolation for MRSA of the urine.
Review of the posted isolation signs revealed instructions as follows:
"To prevent the spread of infection anyone entering this room MUST:
Perform hand hygiene before entering and upon leaving room.
Gloves and Gown. Dedicated equipment. Patient's visitor to perform hand hygiene, wear gloves and gown upon entering room".

Review of Infection Control Policy and procedure dated 8/1/2013 gave there following information:

"Contact Precautions interrupt transmission of infection transmitted by direct contact with contaminated items or persons. Contact precautions may be used for multiple drug-resistant bacteria and other nosocomial pathogens.
Wear clean non-sterile gloves when contact with patient or his environment will occur.
Remove gloves before leaving the patient's environment. Wash hands after removing gloves or use alcohol hand sanitizer until hand washing is feasible.

Wear a clean non sterile gown when entering the room if it is anticipated that clothing will have substantial contact with the patient, environmental surfaces or items in the patient's room, or if the patient is incontinent or have diarrhea, an ileostomy, a colostomy, or wound drainage not contained by a dressing. Remove the gown before leaving the patient's environment".

Observation in the Laboratory on 2/12/2014 at 10:40 am revealed Staff (#60) was observed handling paper files with ungloved hands. The Staff donned gloves and took a unit of blood from the refrigerator after replacing the blood she proceeded to use the same gloved hands to handle the paper files. After removing her gloves the staff did not immediately wash her hands.

Review of infection control policy/procedure for the Laboratory dated June .2013 documented the following information:
Universal precautions will be utilized by all laboratory employees. The hospital hand washing procedure will be followed.

All personnel should remove gloves before using the phone or keyboards unless the keyboard has been designated as dirty.
All specimens will be regarded as potentially infectious, regardless of the source patient diagnosis. Gloves will be worn for handling all specimens".

Observation on 2/12/2014 on Unit 2 South revealed the following information:
At 11:10 am Staff (#37) Registered Nurse was preparing medication for intravenous(IV) administration at the nurses station and did not clean the area prior to preparing the medication.

At 11:25 am Staff (#36) prepared medication at the nurses station for IV administration without cleaning the area prior to preparing the medication. The staff failed to clean the hub of the medication vial prior to inserting the needle to withdraw the medication.

During an interview on 2/12/2014 at 11:40 am with Staff (#36) regarding not cleaning the hub of the medication vial prior to entering she stated she did not know she had to clean prior to entry since it was a new vial.

Further observation on Unit 2 South revealed there was no clean dedicated area provided for the staff to prepare medication.

During an interview on 2/12/2014 at 2:10 pm with the Unit Director she stated the facility will ensure there were dedicated medication preparation areas on the unit.

Based on observation, record review, and interview, the facility failed to ensure policy and procedures were developed for training of staff for Robotic Arm procedures and that 2 of 2 ( #41 and #42 ) Certified Surgical Technicians (CST) were checked for skills and competency as First Assistants for equipment/instrumentation for Robotic Arm procedures.

Findings include:

Observation on 2/11/14 at 1:45 p.m. with Director of Perioperative Services, RN #44, of the surgical suite revealed a daVinci Robotic Arm was available for use.

Interview at this time with the Director of Perioperative Services, RN #44, she said two CSTs (#41 and #42) would scrub as First Assistants under the direction of the surgeon during Robotic Arm surgeries. She said when the facility first acquired the Robotic Arm, staff were sent for training by the manufacturer. She said none of the original CSTs were still working at the facility. She said they were working to cross train all of the staff on the use of the Robotic Arm. RN #44 was asked if the facility had a Policy and Procedure for CSTs performing as First Assistants for Robotic Arm surgeries or for any staff working with the Robotic Arm. She said they did not have any Policy and Procedure for that.

Record review on 2/14/14 of the personnel and training files for CSTs #41 and #42 revealed they had no skills/competency check list for First Assistant for Robotic arm surgeries.

Record review of Inservice Documentation Records for daVinci Robotic Surgery presented by the Manufacturer's Representatives dated 2/8/12 and 9/5/12 revealed neither CSTs #41 or #42 were present.

Interview on 2/14/14 at 9:40 a.m. with CST #41, she said she received her training on the Robotic Arm from the two people who used to work it before they left. She said she received verbal training; no manual training was provided.

Interview at this time with RN #57, she said she was the original RN who went to San Francisco to train for the Robotic Arm. She said that was two years ago. She said she has trained three other RNs in the procedure. She said she trained them verbally and by demonstration. She said the manufacturer had an on-line training service with a certification for proof of training. She said the manufacturer left a training manual.

Interview at this time with the Director of Perioperative services, RN #44, she was asked if any staff had taken the on-line training and she said she did not think any staff had taken the course. She said Robotics was being put into the 2014 Competency/Skills checks.

Record review of the Manufacturer's Training manual revealed it had one printed diagram and instrumentation sheet for Hysterectomy and detailed sheets on parts of the Robotic arm and instrumentation. There was no training information.

Based on interview and record review the facility failed to ensure anesthesia services were under the direction of one individual for 2 of 2 operative services (hospital and Ambulatory Surgical Center, ASC).

Findings include:

Interview on 2/12/14 at 10:00 a.m. with the Director of Perioperative Services, RN #44, she was asked who was the Director of Anesthesia Services. She said Dr. #24 was the Director for the Hospital and Dr. #58 was the Director for the ASC. She said Anesthesia Group #1 provided services for the hospital and Dr. #24 worked for them. She said Anesthesia Group #2 provided services for the ASC and Dr. #58 worked for them. She said the two surgical areas had operated that way since the hospital bought the ASC in 2006.

Interview on 2/12/14 at 11:20 a.m. with Dr. #24, he was asked what services he directed for the hospital. He said he was over labor and delivery, endoscopy, any radiological procedures requiring anesthesia and the hospital surgery department. He said the ASC had a separate anesthesia service that he was not in charge of. He said Dr. #58 was in charge of the ASC.

Interview on 2/12/14 at 2:30 p.m. with CEO, Staff #6, she said the facility had identified that the Anesthesia Service needed to be under the direction of one person and had already initiated a proposal.

Record review on 2/14/14 of the facility's proposal from vendors capable of providing professional anesthesia services for administration and oversight of the Anesthesia Department revealed the following time line:
Request Proposal - 3/3/14
Due Date - 12 p.m. on 3/24/14
Evaluation period - 3/24/14 - 3/31/14
Award contract - 4/1/14
Service Start date - 5/12/14

Record review on 2/14/14 of the facility's Medical Staff By Laws dated 11/18/13 revealed current Departments and Sections included the Department of Surgery which included surgical subspecialties and Anesthesiology. Each Department was to have a chairman who would be responsible for the overall supervision of the clinical work within his department. The Surgical Care Improvement Committee would be comprised of at least one active Medical Staff member from Obstetrics & Gynecology, three active Medical Staff members from the department of Surgery, including at least one anesthesiologist. There was nothing addressing the Anesthesia Department being under the direction of one individual.

Based on record review and interview the hospital failed to ensure that 4 of 4 endoscopy records reviewed contained an appropriate post - anesthesia evaluation. (The anesthesia evaluations were being done as the patients were coming out of the procedure room)
(ID# 's 13, 52. 53, and 54)

Findings :

Record review revealed patient ( ID's 13, 52, 53 and 54 ) had endoscopy procedures.

The medical records were as follows:

Patient ID# 13 had an endoscopy procedure on 2/11/14. The Anesthesia Record reflected the procedure ended at 10:18 a.m. The post-anesthesia evaluation was documented at 10:19 a.m.

Patient ID# 52 had an endoscopy procedure on 2/12/14. The Anesthesia Record reflected the procedure ended at 9:16 a.m. The post-anesthesia evaluation was documented at 9:19 a.m.

Patient ID# 53 had an endoscopy procedure on 2/13/14. The Anesthesia Record reflected the procedure ended at 12:04 p.m. The post-anesthesia evaluation was documented at 12:07 p.m.

Patient ID# 54 had an endoscopy procedure on 2/13/14. The Anesthesia Record reflected the procedure ended at 8:02 a.m. The post-anesthesia evaluation was documented at 8:06 a.m.

Interview with the Director of Anesthesiology ( # 24) acknowledged 02/13/14 at 1:30 p.m. post-anesthesia evaluations are written immediately after the procedure. The Anesthesia Director further stated that patients are checked for proper anesthesia evaluation while in the recovery room but this is not always documented.

Record review of a policy titled "Official Procedure Anesthesiology Service" (dated January 2014) stated "Standard V: Patients who have received anesthesia are evaluated by the anesthesiologist after recovery from anesthesia, and prior to discharge."




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