HospitalInspections.org

Based on a review of Medical Staff reappointment documentation and staff interview,( as compared with the Medical Staff By-Laws, Rules and Regulations), the Critical Access Hospital(CAH) failed to follow the Medical Staff By- Laws, Rules and Regulations in the reappointment process for the Active and Courtesy Staff.
This failure on the part of the CAH to obtain sufficient data to evaluate the physicians individual performance and competence, has the potential to affect all patients receiving surgical services in this facility.

The Medical Staff consisted of 4 active physicians, 5 mid-level practitioners, 2 consulting surgeons

The facility reported 366 acute inpatient admissions for the most recent annual program evaluation.

Findings Include:

1. The Medical Staff By-Laws, Rules and Regulations specified (page 9) Article V Clinical Privileges Section 2e "Competence"
stated, "Possess demonstrated current competence, including current knowledge, judgment, and technique, in his or her specialty area ."

Under this same section, k. Observation: "Perform a sufficient number of procedures, manage a sufficient number of cases, and have sufficient patient care contact with the hospital to permit the ...Medical Staff to assess current competency for all requested privileges..."
Under Section V. Reappointment/Renewal Process, c. 'The executive Committee and Board may also consider whether the practitioner has actually exercised all of the requested privileges with sufficient frequency since the time of last appointment or reappointment to indicate current proficiency.'

2. A review of 2 of 2 current Active Medical Staff member's (AC, F) files revealed both had privileges to perform Circumcisions.
Circumcision is a procedure during which the foreskin, at the head of the penis is removed. This is most often performed on newborn infant males)

Neither file contained any information on the number of circumcisions performed or the outcomes. Interview with the Director of Quality on 5/24/16 at 10:30 A.M. revealed that the number of procedures performed, or clinical outcomes had not been documented. In addition, during this same interview, it was determined that Physician C had discontinued obstetric services in 2010., but still retained privileges for this specialty.
Both clinicians also had privileges to treat 'psychiatric disorders without consultation'.

Neither physician had treated any patients with psychiatric disorders, within the past 2 years, however, neither had evidence of specialized training regarding the use of restraint and seclusion, required for treatment of physicist patients.

3. A review of Physician D,and E( General Surgeons and Courtesy staff members) revealed they received surgical privileges to perform Thyriodectomy
a butterfly shaped gland in the front of the neck which controls and regulates hormone production), Lung resection
(removal of part of the lung, used for breathing)
Aortic bypass (removing or reattaching a portion of the aorta which is a responsible for moving blood around the body) and Colon Resection.
( A Colon Resection is a surgical procedure in which a part of the large or small intestine is removed. )


During this same interview, the Quality Assurance Manager confirmed none of the above mentioned procedures had been performed in the facility for at least 5 years
Therefore, their competence to perform these procedures, in this facility, had not been established.

Based on medical record review and staff interview; the CAH (Critical Care Hospital) failed to ensure that a physician examined the patient immediately before surgery to evaluate the risk of the planned procedure for 7 of the 13 surgical medical records (5, 25, 26, 27, 28, 29 & 30) reviewed. This failed practice had the potential to affect all surgical patients of the CAH. The average number of surgical procedures performed at the CAH on a monthly basis is 20.

Findings are:

A. Review of Patient 5's medical record on 5/26/15 at 9:25 AM revealed the patient had a left total knee arthroplasty (the surgical reconstruction or replacement of a joint) on 1/14/16. Review of the Pre-operative Evaluation by [the] Physician revealed a physician signature that lacked the date and time evidence ensuring the examination was completed immediately before surgery.
- Review of Patient 25's medical record on 5/25/16 at 10:20 AM revealed the patient had bilateral myringotomy (a surgical procedure in which a tiny incision is created in the eardrum (tympanic membrane) to relieve pressure) and tube placement on 5/24/16. Review of the Pre-operative Evaluation by [the] Physician revealed a physician signature that lacked the date and time evidence ensuring the examination was completed immediately before surgery.
-Review of Patient 26's medical record on 5/25/16 at 10:30 AM revealed the patient had bilateral myringotomy with tube placement and adenoidectomy (surgical removal of the adenoids for reasons which include impaired breathing through the nose, chronic infections, or recurrent earaches) on 5/24/16. Review of the Pre-operative Evaluation by [the] Physician revealed a physician signature that lacked the date and time evidence ensuring the examination was completed immediately before surgery.
-Review of Patient 27's medical record on 5/25/16 at 10:45 AM revealed the patient had a laparoscopic cholecystectomy (surgery to remove gallbladder) on 4/7/16. Review of the entire medical record revealed that the record lacked evidence of an examination of the patient by a physician immediately before surgery to evaluate the risk of the procedure to be done.
-Review of Patient 28's medical record on 5/25/16 at 11:10 AM revealed the patient had a septoplasty (a surgical procedure to correct a deviated nasal septum) on 3/17/16. Review of the Pre-operative Evaluation by [the] Physician revealed a physician signature that lacked the date and time evidence ensuring the examination was completed immediately before surgery.
-Review of Patient's 29's medical record on 5/25/16 at 11:25 AM revealed the patient had laparoscopic appendectomy (surgical removal of the appendix) on 2/25/15. Review of the Anesthesia Record revealed the Proc. (procedure) start time as 1634 (4:34 PM) and the Proc. stop time as 1706 (5:06 PM).Review of the Pre-operative Evaluation by [the] Physician revealed evidence that the physician examined the patient for the risk of the procedure on 2/25/16 at 1709 (5:09 PM), three minutes after the procedure was completed.
-Review of Patient 30's medical record on 5/25/16 at 11:45 AM revealed the patient had an excision (the surgical removal of a foreign body or of tissue) and debridement (the surgical removal of dead tissue or cellular debris from the surface of a wound) of a recurrent ganglion cyst (a tumor or swelling on top of a joint or the covering of a tendon) on left wrist on 4/21/16. Review of the Pre-operative Evaluation by [the] Physician revealed a physician signature and date that lacked the time evidence ensuring the examination was completed immediately before surgery.
B. Interview with the Chief Nursing Officer on 5/27/16 at 11:00 AM confirmed the above medical records were missing the evidence that the physician examined the patients immediately before surgery to evaluate the risk of the procedure to be performed.