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Based on interviews and record reviews, the facility's medical staff failed to assume responsibility for implementing and monitoring the facility's medical staff services. The facility's medical staff failed to provide oversight for the quality health care provided to patients by the hospital. The facility did not meet the conditions for coverage for medical staff and management by failing to:


1. Ensure one of the three sampled physicians (MD 2), who was the cardiologist on-call for Patient 1 on 12/8/24, documented Patient 1s assessment in the medical record.'
This deficient practice of omitting documentation may result in a lack of crucial information for safe discharge, potential miscommunication among healthcare providers, and compromised patient safety. (Refer to A-360.)


2. Ensure one of the three sampled physician credential records (MD 1) had the approved clinical privileges (authorization to a medical staff member to provide medical services granted by a governing authority or according to medical staff bylaws [define the structure and responsibilities of these member organizations]) on file.

This deficient practice has the potential to impact patient care and lead to unsafe practices. Without the correct privileges documented, physicians may be allowed to perform procedures or make decisions outside their expertise, increasing the risk of medical errors and misdiagnoses, compromising the quality of care provided, and compromising patient safety. (Refer to A-341.)


The cumulative effect of these systemic practices resulted in the facility's inability to ensure the medical staff had oversight and accountability for the quality of medical care provided to patients by the hospital.

Based on the interview and record review, the facility failed to ensure one of the three sampled physician credential records (MD 1) had the approved clinical privileges (authorization to a medical staff member to provide medical services granted by a governing authority or according to medical staff bylaws [define the structure and responsibilities of these member organizations]) on file.
This deficient practice has the potential to impact patient care and lead to unsafe practices. Without the correct privileges documented, physicians may be allowed to perform procedures or make decisions outside their expertise, increasing the risk of medical errors and misdiagnoses, compromising the quality of care provided, and compromising patient safety.

Findings:

During a concurrent interview and record review on 5/2/24 at 9:55 a.m. with the Manager of Medical Staff (MMS), MD 1's "Delineation of Privileges (the practice of listing specific granted to provide medical and other patient care procedures and services that a provider is allowed to perform within an organization)," provisional appointment (the employment of a person to a vacant position for a specify period of time) dated 7/31/23 through 7/31/25 was reviewed. The Delineation of Privileges form indicated that MD 1 was approved for the following: "Anesthesiology core: A core privilege is granted to physicians who are qualified by training to render patients insensible (lacking sensory perception or ability to react) to pain and stress during surgical, obstetrical (relating to childbirth and the processes associated with it), radiological (a branch of medicine that uses imaging technology to diagnose and treat disease), and certain medical procedures using general anesthesia (medicine that is administered by an anesthesiologist, to eliminate all sensations, accompanied by total loss of consciousness as well as loss of the ability to maintain a functional airway).

Category Core privileges include conscious (sedation that the patient stay awake and aware without feeling discomfort) and deep sedation (induced depression of consciousness during which patients cannot be easily aroused but respond purposefully) for anesthesiologists (a physician who evaluates, monitors, and supervises patient care before, during, and after surgery, delivering anesthesia). The Delineation of Privileges form also indicated MD 1 is on proctor (an objective evaluation of a provider's clinical competence by someone serving as a proctor who represents and is responsible to the medical staff) for the following:
Proctor: Pediatric Anesthesia, Ages < 12 Years
Proctor, Level I: Healthy greater than or equal to 2 years. of age; complex and critically ill greater than or equal to 6 years of age."
MMS stated, "MD 4 is overseeing MD 1. MD 4 will cosign MD 1's note (the physician's note)."

During a concurrent interview and record review on 5/2/24 at 12:21 p.m. with the physician anesthesiologist (MD 1), Patient 1's "Anesthesia Post Procedure Handoff Report (the transfer of information, responsibility, and authority from one provider to another in health care)," dated 12/8/23, was reviewed. The report indicated that on 12/8/23, Patient 1, who was a 7-month-old pediatric patient with a medical history of Tetralogy of Fallot (a congenital heart condition that affects normal blood flow through the heart), was administered general anesthesia by MD 1. MD1 confirmed that on 12/8/23, he was the physician anesthesiologist for Patient 1. The Anesthesia Post-Procedure Handoff Report was not co-signed by MD 4.

During a concurrent interview and record review on 5/2/24 at 1:07 p.m. with the MMS, the Anesthesiology Service Privilege Delineation Form" was reviewed. MMS stated MD1 "has a recommendation for pediatric level 3 privilege, but we recorded as level 1; it is a recording error on our part; we had marked the wrong privilege." MMS stated Level 1 privileging may care for healthy less than or equal to 2 years of age, complex and critically ill older than or equal to 6 years of age. For privilaging at level 3, the physician can care for infants and children of all ages that are healthy, complex and critically ill. MMS stated MD 1 is recommended for level 3 privileges, but he must complete the requirements for proctoring. MMS stated the requirement is to complete five (5) general anesthesia cases and two (2) pediatric anesthesia cases. MMS stated that MD 1 completed the 5 cases but did not complete the 2 cases. MMS stated, "The 2 cases had to be specific cases, to the age group, healthy, complex, and critically ill infants and children of all ages."

During a concurrent interview and record review on 5/2/24 at 2:20 p.m. with the Accreditation Specialist (ACS), the ACS stated MD 1 had completed all 7 cases as required by level 3 privileges. The facility was able to locate the two (2) cases completed, titled "Anesthesiology Pediatric Anesthesia Proctoring Form," dated 8/30/23 and 8/31/23. The ACS confirmed the two forms were in MD 4 possession; the two forms were not in the medical credential files kept by the Medical Staff Administration.

During an interview on 5/2/24 at 4:17 p.m. with the Chief Medical of Anesthesiology (MD) 5, the MD 5 stated that the anesthesiologist in proctorship may perform procedures and does not require the signature of the attending physician for their physician's note.

During a review of the facility's "Medical Staff Bylaws," dated 2023, the Medical Staff Bylaws indicated, under section Clinical Privileges, "The Governing Body may grant clinical privileges upon the recommendation of the Medical Staff Executive Committee, the Credentials Committee, and the Service Chief(s) (or Designee(s) in which the practitioner holds appointment. These privileges generally shall be for two years to coincide with the appointment term for the medical staff. Privileges for each Medical Staff member shall be kept on file by Medical Staff Administration and available to the Medical Center by intranet access."

Based on interview and record review, the facility failed to ensure one of the three sampled physician (MD 2), who was the cardiologist on-call for Patient 1, documented Patient 1's assessment in the medical record.

This deficient practice of omitting documentation may result in a lack of crucial information for safe discharge, and potential miscommunication among healthcare providers, and compromised patient safety.

Findings:

During a review of Patient 1's "Progress Notes," dated 12/7/24, the "Progress Notes" indicated that Patient 1 "is 7 months old and is being seen in a cardiology (a branch of medicine that specializes in diagnosing and treating diseases of the heart, blood vessels, and circulatory system) clinic after hospital follow-up. History includes T21 (Down syndrome, trisomy 21 is a genetic condition caused by an extra chromosome [a structure found inside the cell]), right cerebellar hypoplasia (condition in which the part of the brain that coordinates movement-is smaller than usual or not completely developed), atrioventricular septal defect (AVSD, a heart defect in which there are holes between the chambers of the right and left sides of the heart, and the valves that control the flow of blood between these chambers may not be formed correctly). Will need a CT (computed tomography, a procedure that uses a computer linked to an x-ray machine to make a series of detailed pictures of areas inside the body) or MRI (A procedure that uses radio waves, a powerful magnet, and a computer to make a series of detailed pictures of areas inside the body) the MRI is scheduled for tomorrow morning. Otherwise, no changes. No change in respiratory status (how well a patient is breathing); no diaphoresis (excessive sweating due to a secondary condition); energy level unchanged ...mom checks saturations (measurement of how much oxygen the blood is carrying as a percentage of the maximum it could carry) at home daily. Saturations remain in the low 80's on 1 L 02 (one liter of oxygen), decrease off supplemental 02 (oxygen) ...noisy breathing and needs a lot of suctioning, but is consistent with baseline (an initial measurement of a condition that is taken at an early time point and used for comparison over time to look for changes) ..."

During a review of Patient 1's "MR (Magnetic resonance angiography, a powerful magnetic field, radio waves and a computer to specifically evaluate the body's blood vessels) WO (without) + W (with) contrast (drugs administered to patients to enhance the ability to see blood vessels and organs)," dated 12/8/23, by MD 6, the MR report indicated, "Reason for Exam: 6 month old female patient with history of Tetralogy Fallot (a combination of four heart changes present at birth. There is a hole in the heart) and Blalock shunt (a small, soft tube that lets blood in the body be redirected). Evaluate for pulmonary artery (blood vessels that carry oxygen-poor blood from the right side of your heart to your lungs) anatomy (the identification and description of the structures of living things) and intracardiac (situated or occurring within or introduced or involving entry into the heart) anatomy. The study was performed on a (name of the scanner) MRI scanner at (name of the facility), under uneventful general anesthesia (medicine that is administered by an anesthesiologist, to eliminate all sensations, accompanied by total loss of consciousness as well as loss of the ability to maintain a functional airway). with controlled ventilation (a mode of ventilation in which the respirator delivers the preset volume or pressure regardless of the patient's own inspiratory efforts) ..."


During a concurrent interview and record review on 5/2/24 at 4:26 p.m. with the Anesthesiologist Resident (MD 3), Patient 1's "Anesthesia Post Procedure Evaluation," dated 12/8/23, was reviewed. The anesthesia post-procedure evaluation indicated, "Arrived in PACU with frank upper airway obstruction (occlusion or narrowing of the airways leading to compromise in ventilation), mild retractions (a sign that someone is working hard to breathe), placed on an HFNC (high-flow nasal cannula, an oxygen supply system capable of delivering up to 100% humidified and heated oxygen at a flow rate of up to 60 liters per minute). Weaned down to baseline 2LNC (two liters [unit of volume measurement]) nasal cannula [a device that gives additional oxygen through the nose] with SpO2 (a measurement of how much oxygen the blood is carrying as a percentage of the maximum it could carry): 70-80% as assessed by the peds cardiology hospitalist." MD 3 stated although her notes on 12/8/23 indicated that the cardiologist assessed the patient (Patient 1) the cardiologist "did not put in a note."

During an interview on 5/2/24 at 3:00 p.m. with the Chief Medical of Anesthesiologist (MD) 5, MD 5 stated after the cardiologist examine the patient (Patient 1) there should be documentation of the assessment.


During a review of the facility's Medical Staff Bylaws dated 2023, the Medical Staff Bylaws indicated, "To supervise and ensure compliance with these Bylaws, Rules and Regulations, Medical Staff Policies, and Medical Center policies to carry out its responsibilities for patient safety and the professional work performed in the Hospital, pursuant to the authority delegated by the Governing Body."