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NORTHEASTERN VERMONT REGIONAL HOSPITAL 1315 HOSPITAL DRIVE SAINT JOHNSBURY, VT 05819 Dec. 2, 2014
VIOLATION: EVALUATIONS - PRE-OP & POST-OP Tag No: C0322
Based on record review and confirmed through staff interview the facility failed to assure that assessments were conducted to evaluate for appropriate anesthesia recovery, prior to discharge, for 5 of 8 patients reviewed. (Patients #4, #5, #6, #7 and #8). Findings include:

1. Per 12/1/14 record review, Patient #4 was administered general anesthesia for a surgical procedure on 10/22/14. His/her medical record did not include evidence that a post anesthesia follow up assessment was completed to assure proper anesthesia recovery prior to discharge home that same day.

2. Per 12/2/14 medical record review, Patient #5 had a surgical a surgical procedure on 10/20/14 and was administered general anesthesia. There was no evidence that the patient received a post anesthesia follow up assessment to determine anesthesia recovery prior to discharge home that day.

3. Per 12/2/14 review Patient #6's record did not include a post anesthesia follow up assessment. There was no evidence that the patient, who received general anesthesia while undergoing a surgical procedure on 9/6/14, was assessed by a qualified practitioner for appropriate recovery from the anesthesia prior to his/her discharge home the following day, on 9/7/14.

4. Per 12/2/14 record review there was no evidence that a post anesthesia follow up assessment had been conducted, to evaluate for proper anesthesia recovery, on Patient #7, who underwent a surgical procedure on 11/24/14, under general anesthesia, prior to his/her discharge home on that same date.

5. Per 12/2/14 review, Patient #8 received MAC (Monitored Anesthesia Care) during a surgical procedure on 11/10/14. There is no evidence that a post anesthesia assessment was conducted by a qualified practitioner to determine anesthesia recovery prior to the patient's discharge home the same day.

On 12/2/14 at 10:35 AM, CRNA #1 (Certified Registered Nurse Anesthetist #1) reported that patients who are seen for same day surgeries are assessed at the time of "hand off" to the recovery room but are not always seen again prior to discharge as the CRNA staff often "move on to the next patient" [scheduled for a procedure requiring anesthesia]. On 12/2/14, CRNA #2 reported that prior to the survey, there was not a process in place to perform post anesthesia recovery evaluations, prior to discharge, on patient's having same day surgeries. S/he confirmed that patients have been discharged prior to having a post anesthesia recovery assessment as the staff are scheduled for other procedures requiring anesthesia and not available at the time of the patient's discharge.
VIOLATION: PATIENT CARE POLICIES Tag No: C0271
Based on record review and staff interview the facility failed to assure that health care services are furnished in accordance with written policies related to meeting requirements for credentialing for 1 of 5 medical staff files that were reviewed. Findings include:

Per 12/2/14 review, the NVRH (Northeastern Vermont Regional Hospital) Medical Staff Policy, Credentialing Process Policy (revision 5/9/13) lists requirements for medical staff credentials to include "...current certifications for BLS (Basic Life Support), ACLS (Advanced Cardiovascular Life Support)...(as required for the requested area of practice)..." On 12/1/14, the Chair of the Anesthesia department confirmed that all anesthesia staff are required to have ACLS certification. Likewise, on the afternoon of 12/2/14, the Medical Staff Coordinator confirmed that CRNAs (Certified Registered Nurse Anesthetists) are required to have ACLS certification; BLS certification is not required if the staff member has ACLS certification.

Per 12/2/14 review of credentialing files, CRNA #1's ACLS and BLS certification had expired in October 2014; CRNA #1 is an active adjunct staff member whose privileges include administering general and regional anesthesia and emergency medications, providing post anesthesia care and CPR (Cardio-Pulmonary Resuscitation) management.

On 12/2/14, the Medical Staff Coordinator confirmed that CRNA #1's certification for ACLS had expired in October 2014.
VIOLATION: PATIENT CARE POLICIES Tag No: C0272
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and staff interview the facility failed to assure that all policies directing the care and services for patients were reviewed on an annual basis. Findings include:

Per record review, on the afternoon of 12/2/14, the following established policies, identified by staff as the policies currently governing the practice of Anesthesia services, had not been reviewed on an annual basis:

The Discharge DSU (Day Surgery Unit) Policy and Discharge criteria for DSU policy were each last reviewed on 4/26/12; and the policy titled Surgeon Presence Requirement, which directed that the administration of anesthesia shall not begin unless the operating practitioner is in the operating suite, was last reviewed on 5/14/12.

Although there were a few policies, including the Moderate Sedation Analgesia policy and the policy for Anesthesia Department Neuraxial Pain Management that were last reviewed in June of 2013, the remainder of the Anesthesia department policies reviewed, a total of 53, which included Admission policies, the policy for Pre-Anesthesia Equipment Checklist and [DIAGNOSES REDACTED], all identified their date of last review as April or May of 2012, a period of greater than 2 years.

The Vice President of Quality confirmed, during interview on the afternoon of 12/2/14, that there was no evidence the aforementioned policies had been reviewed on an annual basis.