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Based on patient's medical records, staff interviews, medical staff meeting minutes, quality improvement meeting minutes, on-call anesthesiologist schedules, medical staff rules and bylaws and a tour, it was determined that the Governing Body failed to address a problem of inadequate patient care staffing and failed to take corrective actions to provide anesthesia back up for after hours emergency surgical cases for 1(# 3) of 3 cases on 2/24/2010. The governing body's failure to address the problem of inadequate staff resulted in an immediate jeopardy situation of potential harm.

Findings were:

Cross refer to A-1000 as ir relates to Anesthesia Service responsibilities
Cross refer to A-1001 as it relates to Anesthesia Service Organization and Staffing

Review of the medical staff meeting minutes dated 2/8/10, indicated that the the anesthesia after hour on-call was discussed and the medical staff was aware that something needed to be in place in the event that additional help was needed for after hours emergency surgical cases. The minutes revealed that administration - Chief Executive Officer, Chief of Staff and the Chief Nursing Officer were in attendance.

Review of the Quality Improvement meeting minutes on 2/3/10 noted that the anesthesiologist (credential file #2) indicated that the issue about after hours anesthesia was mentioned and that the anesthesiologist informed the committee that the issues were being reviewed.

The failure of the governing body to provide adequate numbers of staff to meet the needs of patients where patients were subject to be left without appropriate anesthesia coverage resulted in an immediate jeopardy situation related to staff shortages.

Based on patient's medical records, staff interviews, medical staff meeting minutes, quality improvement meeting minutes, on-call anesthesiologist schedules, medical staff rules and bylaws and a tour, it was determined that the facility failed to provide adequate anesthesia coverage throughout the patient's surgery for 1 of 3 (#3) patients on 2/24/2010. The facility's failure to address the problem of inadequate staff resulted in an immediate jeopardy situation for potential patient harm.

Findings were:

Cross refer to A-1001 as it relates to qualified anesthesiologists to ensure that the appropriate staff was present to administer and monitor the needs of the patients.

Review of patient #3's medical record revealed that the patient was admitted to the facility for right shoulder pain on 2/24/2010. The patient signed a consent for routine procedures and treatments the day before surgery for the patient's right shoulder arthroscopy with rotator cuff repair procedure. The patient received a history and physical by a qualified medical professional. The patient also signed a consent for anesthesia services the day of surgery. The medical record revealed that a pre-anesthetic assessment was completed by a a qualified medical professional anesthesiologist (credential file #2), which indicated that the patient was an appropriate candidate for the planned anesthetic. A peri-operative report was completed by a registered nurse (personnel file #5).

Review of patient #3's medical record revealed on the anesthesia record that the anesthesiologist started the patient's anesthesia at 4:59 pm on 2/24/2010 and that the patient was in the operating room at 5:00 p.m. The record revealed that the procedure began at 5:29 p.m. During the procedure, the anesthesiologist documented that he/she left the operating room at 6:10 p.m. on 2/24/2010 to attend to an emergent surgery. At the time, the patient was stable and remained stable until he/she returned. No return time was documented as to when the anesthesiologist returned to patient #3. The anesthesia record noted that the patient's surgery ended at 7:23 p.m. and that the patient was taken to PACU (recovery room) at 7:33 p.m. The record lacked documentation of the patient's ventilation status on the anesthesia record from 6:00 pm. until 7:00 pm. The record noted that the patient was under general anesthesia during the procedure. The anesthesiologist documented on the record at 7:00 p.m. and 7:30 pm. and that the patient was taken to recovery room at 7:33 p.m. where the patient remained stable. The anesthesiologist completed his/her post -anesthetic assessment and documented that the patient was ok to be discharged from the recovery room at 7:37 p.m. However, further review of the medical record revealed in the physician's notes the patient was awakened in the operating room and was taken to the recovery room stable without complications. The physician documented that because of the patient's interscalene block, the patient's oxygen saturations were in the low 90's to upper 80's and it was felt because of the late hour it was best to keep the patient over night for proper oxygenation. The patient was discharged the next morning (2/25/2010) in stable condition when the block had worn off and his/her saturation was back to normal. The patient was discharged with instructions to use an abduction pillow for his/her arm and wound care dressing changes with a prescription for pain medications (OxyContin and Lortab).

During interview #3 (credential file # 2) on 3/10/10 at 2:50 p.m. in the computer room, the anesthesiologist (the anesthesiologist who administered anesthesia to patients #2 and #3) stated that he/she had administered anesthesia to patient #3 on 2/24/2010 in the operating room and that the patient was stable during his/her care. The anesthesiologist explained that he/she had left patient #3 in the operating room because another patient (#2) needed an emergency cesarean section (c-section) immediately and he/she needed to be there. The anesthesiologist stated an additional recovery room nurse was brought into the operating room for patient #3 and helped to monitor the patient, while the anesthesiologist left to attend patient # 2 for an emergency c-section. The anesthesiologist stated that he/she was the only anesthesiologist on-call and that he/she had no assistant. The anesthesiologist explained that the need for additional help for after hours anesthesia had been discussed in the medical staff meetings.

During interview # 4 on 3/10/10 at 3:00 p.m. in the computer room, the physician (who performed surgery on the patient) stated that the anesthesiologist left the operating room of patient #3 on 2/24/2010 because of another patient who needed an emergency c-section in the operating room next door. The physician also stated that he/she had helped to monitor patient #3, however, he/she was not a qualified anesthesiologist to administer general anesthesia. The physician explained that the patient was stable during the time that the anesthesiologist left the patient for the emergency surgery in the next room. The physician stated that an additional staff recovery room nurse, who was trained to recover patients, was in the room along with the scrub nurse.

Review of the medical staff meeting minutes dated 2/8/10, indicated that the the anesthesia after hour on-call was discussed and the medical staff was aware that something needed to be in place in the event that additional help was needed after hours. The minutes revealed that administration - Chief Executive Officer, Chief of Staff and the Chief Nursing Officer were in attendance.

Review of the Quality Improvement meeting minutes on 2/3/10 noted that the anesthesiologist (credential file #2) indicated that the issue about after hours anesthesia was mentioned and that the anesthesiologist informed the committee that the issues were being reviewed.

On 3/10/2010, the facility submitted a plan to HFRD stating the following:

Plan for Ensuring Anesthesia Availability for Emergency Surgical Cases Arising After Hours Effective immediately (3/10/10): if an elective case has continued after normal operating hours, a second anesthesia provider will remain in the facility to attend to any emergency case that may arise. After the elective case is complete, the anesthesia provider not "on-call" for the night may leave the facility. The "on-call" anesthesia provider will continue to be available for emergency surgical cases.

The facility identified a potential problem with anesthesia coverage on 2/08/2010,16 days prior to the incident occurring on 2/24/2010, however, failed to take any action
.
Tour of the facility on 3/10/10 at 3:00 p.m. with the Director of Surgical Services, revealed in operating rooms #1 and #2 that the areas were clean and unobstructed. The rooms had a small glass window on the doors that viewed both operating rooms. The clean room was between these two operating rooms (patient #2 and #3 were in these rooms).

Based on patient's medical records, staff interviews, medical staff meeting minutes, quality improvement meeting minutes, on-call anesthesiologist schedules, medical staff rules and bylaws and a tour, it was determined that the facility failed to provide adequate anesthesia coverage throughout the patient's surgery for patient #3 on 2/24/2010.

Based on patient's medical records, staff interviews, medical staff meeting minutes, quality improvement meeting minutes, on-call anesthesiologist schedules, medical staff rules and bylaws and a tour, it was determined that the facility failed to provide adequate anesthesia coverage throughout the patient's surgery for 1 of 3 (#3) patients on 2/24/2010. The facility's failure to ensure that the appropriate staff was present to administer and monitor the needs of the patient staff resulted in an immediate jeopardy situation for potential patient harm.

Findings were:

Review of patient #3's medical record revealed that the patient was admitted to the facility for right shoulder pain on 2/24/2010. The patient signed a consent for routine procedures and treatments the day before surgery for the patient's right shoulder arthroscopy with rotator cuff repair procedure. The patient received a history and physical by a qualified medical professional. The patient also signed a consent for anesthesia services the day of surgery. The medical record revealed that a pre-anesthetic assessment was completed by a a qualified medical professional anesthesiologist (credential file #2), which indicated that the patient was an appropriate candidate for the planned anesthetic. A peri-operative report was completed by a registered nurse (personal file #5).

Review of patient #3's medical record revealed on the anesthesia record that the anesthesiologist started the patient's anesthesia at 4:59 pm on 2/24/2010 and that the patient was in the operating room at 5:00 p.m. The record revealed that the procedure began at 5:29 p.m. During the procedure, the anesthesiologist documented that he/she left the operating room at 6:10 p.m. on 2/24/2010 to attend to an emergent surgery. At the time, the patient was stable and remained stable until he/she returned. No return time was documented as to when the anesthesiologist returned to patient #3. The anesthesia record noted that the patient's surgery ended at 7:23 p.m. and that the patient was taken to PACU (recovery room) at 7:33 p.m. The record lacked documentation of the patient's ventilation status on the anesthesia record from 6:00 pm. until 7:00 pm. The record noted that the patient was under general anesthesia during the procedure. The anesthesiologist documented on the record at 7:00 p.m. and 7:30 pm. and that the patient was taken to recovery room at 7:33 p.m. where the patient remained stable. The anesthesiologist completed his/her post -anesthetic assessment and documented that the patient was ok to be discharged from the recovery room at 7:37 p.m. However, further review of the medical record revealed in the physician's notes the patient was awakened in the operating room and was taken to the recovery room stable without complications. The physician documented that because of the patient's interscalene block, the patient's oxygen saturations were in the low 90's to upper 80's and it was felt because of the late hour it was best to keep the patient over night for proper oxygenation. The patient was discharged the next morning (2/25/2010) in stable condition when the block had worn off and his/her saturation was back to normal. The patient was discharged with instructions to use an abduction pillow for his/her arm and wound care dressing changes with a prescription for pain medications (OxyContin and Lortab).

During interview #3 (credential file # 2) on 3/10/10 at 2:50 p.m. in the computer room, the anesthesiologist (the anesthesiologist who administered anesthesia to patients #2 and #3) stated that he/she had administered anesthesia to patient #3 in the operating room and that the patient was stable during his/her care. The anesthesiologist explained that he/she had left patient #3 in the operating room because another patient (#2) needed an emergency cesarean section (c-section) immediately and he/she needed to be there. The anesthesiologist stated an additional recovery room nurse was brought into the operating room for patient #3 and helped to monitor the patient, while the anesthesiologist left to attend patient # 2 for an emergency c-section. The anesthesiologist stated that he/she was the only anesthesiologist on-call and that he/she had no assistant. The anesthesiologist explained that the need for additional help for after hours anesthesia had been discussed in the medical staff meetings.

During interview # 4 on 3/10/10 at 3:00 p.m. in the computer room, the physician (who performed surgery on the patient) stated that the anesthesiologist left the operating room because of another patient who needed an emergency c-section in the operating room next door. The physician also stated that he/she had helped to monitor patient #3, however, he/she was not a qualified anesthesiologist to administer general anesthesia. The physician explained that the patient was stable during the time that the anesthesiologist left the patient for the emergency surgery in the next room. The physician stated that an additional staff recovery room nurse, who was trained to recover patients, was in the room along with the scrub nurse.

During interview #9 on 3/10/10 at 3:00 p.m. in the computer room, the Director of Surgical Services stated that the facility does not use nurse anesthetists and that only credential anesthesiologists are used.

During interview #5 on 3/10/10 at 3:30 pm. in the operating room, the nurse who was the circulating nurse, stated that another nurse was called into the operating room and assisted with the patient because the anesthesiologist had to leave to care for another patient. The nurse stated that he/she nor the other nurse were under the supervision of a qualified anesthesiologist.

Review of personnel file #5 lacked evidence that the registered nurse who was in the operating room with the patient, was qualified to administer anesthesia to the patient or was under supervision of a qualified anesthesiologist.

Review of the medical staff meeting minutes dated 2/8/10, indicated that the anesthesia after hour on-call was discussed and the medical staff was aware that something needed to be in place in the event that additional help was needed after hours. The minutes revealed that administration - Chief Executive Officer, Chief of Staff and the Chief Nursing Officer were in attendance.

Review of the Quality Improvement meeting minutes on 2/3/10 noted that the anesthesiologist (credential file #2) indicated that the issue about after hours anesthesia was mentioned and that the anesthesiologist informed the committee that the issues were being reviewed.

On 3/10/2010, the facility submitted a plan to HFRD stating the following:

Plan for Ensuring Anesthesia Availability for Emergency Surgical Cases Arising After Hours Effective immediately (3/10/10): if an elective case has continued after normal operating hours, a second anesthesia provider will remain in the facility to attend to any emergency case that may arise. After the elective case is complete, the anesthesia provider not "on-call" for the night may leave the facility. The "on-call" anesthesia provider will continue to be available for emergency surgical cases.

The facility identified a potential problem with anesthesia coverage on 2/08/2010,16 days prior to the incident occurring on 2/24/2010, however, failed to take any action
.
Tour of the facility on 3/10/10 at 3:00 p.m. with the Director of Surgical Services, revealed in operating rooms #and #2 that the areas were clean and unobstructed. The rooms had a small glass window on the doors that viewed both operating rooms. The clean room was between these two operating rooms (patient #2 and #3 were in these rooms).

Based on patient's medical records, staff interviews, medical staff meeting minutes, quality improvement meeting minutes, on-call anesthesiologist schedules, medical staff rules and bylaws and a tour, it was determined that the facility failed to provide adequate anesthesia coverage throughout the patient's surgery for patient #3 on 2/24/2010.