HospitalInspections.org

Based on medical record reviews, interviews and review of the Operating Room Technicians (ORT) job description the facility failed to ensure the ORT position criteria was the same for the hospital staff and the credentialed staff. This affected Medical Record (MR) # 1, 2, and 3 and had the potential to affect all surgery patients who had credentialed ORT's in the operating room (OR). A review of 1 staff ORT personnel file and 3 credentialed ORT files revealed 1 of 4 did not have the qualification for an ORT position.

The findings include:

The ORT job description: Minimum Requirements- Graduate from an accredited Surgical Technician Training Program or Graduate from a Licensed Practical Nursing Program approved by the Alabama Board of Nursing and one (1) year of surgical scrub experience required. Work experience may NOT substitute for minimum education requirement.

Review of EI # 5's ORT credentialing file revealed EI # 5 was not qualified for the ORT position. EI # 5 was not a graduate from an accredited Surgical Technician Training Program or a graduate from a Licensed Practical Nursing Program.

A review of the 11/8/11 surgery schedule revealed the following patients had surgery on 11/8/11:

1. MR# 1 was admitted to the facility on 11/8/11 for Lumbar Laminectomy Fusion.

2. MR# 2 was admitted to the facility on 11/8/11 for Decompression Lumbar Laminectomy.

3. MR# 3 admitted to the facility on 11/8/11 for Extreme Lateral Interbody Fusion Posterior Lumbar Interbody with Instrumentation.

During an interview on 5/15/12 at 1:25 PM, with Employee Identifier (EI) # 7, Director of Surgical Services, the director stated that EI # 5 was not a credentialed ORT on 11/8/11.

EI # 5 was in the OR for the surgeries of MR # 1, MR # 2, and MR # 3 on 11/8/11. EI # 5 was not credentialed until 20 days later, on 11/28/11. EI # 5 did not have the training and education described in the ORT job description.

Based on interview, review of the 2012 Quality Plan, and review of facility Root Cause Analysis form the facility failed to fully investigate a 4/12/2012 anonymous concern related to the qualifications of a credentialed Operating Room Technician (ORT). This affected 1 of 3 facility grievances reviewed and had the potential to affect all patients with concerns and grievances filed with the facility.

The findings include:

Quality Plan 2012
Purpose and Scope: ... Measures include those related to functions, structure, processes and outcomes of care, safety and services as identified by regulatory and accrediting bodies and the organizational strategic plans.
Principles: 7. The principles of data and information management will be utilized. These include: Studying and understanding the complex processes that contribute to services provided.
Goals: 5. Establish and maintain a systematic approach to the identification/correction of potential safety risks: management of actual events/ near misses and proactive intervention to prevent reoccurrence as defined by the Patient Safety plan. Infrastructure: ... establish and maintain effective mechanisms to continuously monitor care delivery processes at all levels of the organization. This will include the following forums: System Level- Quality & Missions Committee- Key Functions- Approve credentialing, associated privileges, and related matters including review and approval of medical staff bylaws and rules and regulations.

The facility form "A Framework for a Root Cause Analysis and Action Plan In Response to a Sentinel Event" documented, "A root cause is typically a finding that is related to a process or system that has a potential for redesign to reduce risk ... Each finding that is a root cause should be considered for an action and addressed in the action plan ... What happened ...Why did that happen? What systems and processes underlie those proximate factors ... Human Resources ... To what degree are staff properly qualified and currently competent for their responsibilities?

The investigation related to the 4/12/12 grievance related to the qualifications of a credentialed Operating Room Technician (ORT) was requested on 5/15/12.

On 5/15/12 at 10:17 AM, the Vice President of Patient Care Services (CNO), Employee Identifier (EI) # 1, was interviewed. EI # 1 verified there were handwritten notes and a summary of the events but did not have it written down in a formal Root Cause format.

The facility did not document the investigation of the grievance related to the qualifications of a credentialed ORT.

Based on review of 3 credentialing files for Operating Room Tech (ORT), credentialing files for 5 Dental Assistants (DA), review of the ORT job description, and interviews the medical staff failed to ensure one credentialed ORT had training as an ORT and the DA credentialed staff had criteria for credentialing. This had the potential to affect all patients who received surgery and all dental surgery patients.

The findings include:

The ORT job description: Minimum Requirements- Graduate from an accredited Surgical Technician Training Program or Graduate from a Licensed Practical Nursing Program approved by the Alabama Board of Nursing and one (1) year of surgical scrub experience required. Work experience may NOT substitute for minimum education requirement.

Review of EI # 5's ORT credentialing file revealed EI # 5 was not qualified for the ORT position. EI # 5 was not a graduate from an accredited Surgical Technician Training Program or a graduate from a Licensed Practical Nursing Program.

During an interview on 5/15/12 at 1:25 PM, with Employee Identifier (EI) # 7, Director of Surgical Services, stated that EI # 5, credentialed ORT, was in the OR on 11/8/11 until 5/15/12 with EI# 4, surgeon.

During an interview on 5/15/12 at 1:40 PM, with EI # 6, Credentialing staff, revealed there was no job description for staff DA.

The Director of Surgical Services EI # 7 was interviewed on 5/15/12 at 1:45 PM and verified there was no DA criteria or job description in the DA credentialing files.

A review of the 5 DA credentialing files revealed there was no credentialing criteria listed. The medical staff had not set up the basic DA qualifications for credentialing.

Based on interviews, review of credentialing files revealed the specific criteria for Dental Assistants (DA) was not available. This had the potential to affect the credentialing of all DAs available for patient care.

The findings include:

During an interview on 5/15/12 at 1:40 PM, with EI # 6, Credentialing staff, revealed there was no job description for staff DA.

The Director of Surgical Services EI # 7 was interviewed on 5/15/12 at 1:45 PM and verified there was no DA criteria or job description in the DA credentialing files.

A review of the 5 DA credentialing files revealed there were no credentialing criteria listed. The medical staff had not set up the basic DA qualifications for credentialing.

Based on review of credentialing files for Operating Room Tech (ORT) and Dental Assistants (DA) and interview the facility failed to ensure the privileges granted was documented in the credentialing file of 6 (Employee Identifier # 8, # 9, # 10, # 11, # 12, and # 13) of 9 credentials files reviewed.

The findings include:

A review of the credentialing files of Employee Identifier (EI) # 8 DA, EI #9 ORT, EI # 10 ORT, EI # 11 ORT, EI # 12 DA, and EI # 13 DA revealed there was no documentation of the privileges granted. The credentialing files of EI # 8, EI # 9, EI # 10, EI # 11, EI # 12, and EI # 13 revealed the credentials had been reviewed and signed by the Credentials Committee but had failed to document what privileges had been granted.

EI # 1, the Vice President of Patient Care Services, was interviewed on 5/16/12 at 1:09 PM, and verified there was no documentation of what privileges had been granted for EI # 8, EI # 9, EI # 10, EI # 11, EI # 12, and EI # 13.