HospitalInspections.org

Based on record review and interview, it was determined that the facility failed to follow their policy and procedure related to physician credentials for moderate sedation and physician privileges for Propofol administration.

Findings Were:

Facility policy entitled "Moderate Sedation ...Effective Date: Dec 2003," reviewed on 11/30/11, stated the following:

- On page 2 of 11: "4. Qualified Personnel ...Physicians must be credentialed for moderate sedation to order and/or administer moderate sedation as they must demonstrate a working knowledge of resuscitation equipment, monitoring equipment, commonly utilized medications and their dosages and risks, be able to interpret the clinical findings, and be able to rescue a patient from the next level of sedation. Physicians will maintain credentials to order/administer moderate sedation and will be encouraged to maintain ACLS provider status."

- On page 7 of 11: "Agents Used for Moderate Sedation...Physicians and nurses who do not have privileges in anesthesiology should not administer drugs classified as anesthetic agents, including but not limited to Propofol ..."

The facility's Medical Bylaws were reviewed on 11/30/11. The Medical Bylaws entitled "Lubbock Heart Hospital, L.L.C. Bylaws of the Medical Staff" stated under "Article V Determination of Clinical Privileges" section "5.1 Exercise of Privileges" stated "Every Medical Staff member of Affiliate providing direct Clinical services at the Hospital shall, in connection with such practice and except as otherwise provided in Sections 5.6 and 5.7 be entitled to exercise only those clinical privileges or specified services specifically granted to him/her by the Governing Body."

Provider #2's (physician) credential file was reviewed on 11/30/11. No evidence could be found by the surveyor, or provided to the surveyor by the facility's staff, regarding Provider #2's credentials for moderate sedation, or privileges for anesthesia.

The following patient medical records, reviewed on 11/29/11 and 11/30/11, had an invasive cardiac procedure performed by Provider #2:

- Patient #1: An intra-operative note by Provider #2 stated that during a procedure on 2/11/11 the patient received "conscious sedation." A medication record from this procedure indicated that a total of 5 mg of Versed were ordered by Provider #2 and administered to the patient by a nurse between 2:39PM and 3:44PM. Additionally, this record indicated that 30 mg of Propofol (as a drip at the rate of 20 mcg/kg/min) was ordered by Provider #2 and administered by Provider #2 between 2:35PM and 3:35PM.

- Patient #2: An intra-operative note by Provider #2 stated that during a procedure on 1/23/11 the patient received "conscious sedation." A medication record from this procedure indicated that a total of 4 mg of Versed were ordered by Provider #2 and administered to the patient by a nurse between 9:06AM and 9:36AM.

- Patient #3: An intra-operative note by Provider #2 stated that during a procedure on 9/19/11 the patient received "conscious sedation." A medication record from this procedure indicated that a total of 24 mg of Versed were ordered by Provider #2 and administered to the patient by a nurse between 1:46PM and 3:10PM.

- Patient #4: An intra-operative note by Provider #2 stated that during a procedure on 10/13/11 the patient received "conscious sedation." A medication record from this procedure indicated that a total of 20 mg of Versed were ordered by Provider #2 and administered to the patient by a nurse between 3:14PM and 4:13PM.

- Patient #5: An intra-operative note by Provider #2 stated that during a procedure on 9/711 the patient received "conscious sedation " A medication record from this procedure indicated that a total of 17 mg of Versed were ordered by Provider #2 and administered to the patient by a nurse between 7:26AM and 8:13AM.

- Patient #6: An intra-operative note by Provider #2 stated that during a procedure on 6/1/11 the patient received "conscious sedation." A medication record from this procedure indicated that a total of 10 mg of Versed were ordered by Provider #2 and administered to the patient by a nurse between 8:52AM and 8:58AM.

- Patient #7: An intra-operative note by Provider #2 stated that during a procedure on 6/1/11 the patient received "conscious sedation." A medication record from this procedure indicated that a total of 5 mg of Versed were ordered by Provider #2 and administered to the patient by a nurse between 11:35AM and 11:44AM.

The above findings were confirmed by the Staff #4 (Chief Nursing Officer) during an interview on 11/30/11.