The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

TERRE HAUTE REGIONAL HOSPITAL 3901 S SEVENTH ST TERRE HAUTE, IN 47802 May 16, 2012
VIOLATION: LICENSURE OF PERSONNEL Tag No: A0023
Based on document review and interview, the hospital failed to be in compliance with Indiana Law IC 25-36.1-2-3, "Surgical technology".

Findings included:

Findings included:

1. Review of IC 25-36.1-2-3, "Surgical Technology" on 5-16-12 indicates the surgical technologist may conduct the following:
a. Preparing the operating room for surgical procedures by: ensuring that surgical equipment is functioning properly and safely and preparing sterile supplies, instruments, and equipment using sterile technique.
b. Anticipating the needs of the surgical team based on knowledge of human anatomy and pathophysiology related to the surgical patient and the patient's surgical procedure.
c. Performing tasks in an operating room setting in the sterile field including the following: passing supplies, equipment , or instruments, suctioning or sponging an operative site, preparing and cutting suture material, transferring and irrigating with fluids, transferring, without administering, drugs within the sterile field, handling specimens, holding retractors, assisting in counting sponges, needles, supplies, and instruments with an operating room circulator as allowed.

2. Review of job descriptions for CSTs on 5-16-12 lacked documentation of placing pins, screws, or k-wires as part of the job description.

3. Review of personnel files on 5-16-12 for B#6, B#7, and B#9 lacked documentation of training and/or competencies to place pins, screws, or k-wires.

4. Interview with B#6 on 5-16-12 at 1010 hours indicated he/she is a CST, has been employed 9 years. He/she indicated he/she places pins, screws,and k-wires into bone under the direct supervision of the physician while the surgeon is holding the bone and/or plate and directing the CST where to place the pin, screw, or k-wire.

5. Interview with B#7 on 5-16-12 at 1015 hours indicated he/she is a CST, has been employed 5 years. He/she indicated he/she places pins, screws,and k-wires into bone under the direct supervision of the physician while the surgeon is holding the bone and/or plate and directing the CST where to place the pin, screw, or k-wire.

6. Interview with B#9 on 5-16-12 at 1028 hours indicated he/she is a CST, has been employed 3 years. He/she indicated he/she places pins, screws,and k-wires into bone under the direct supervision of the physician while the surgeon is holding the bone and/or plate and directing the CST where to place the pin, screw, or k-wire.
VIOLATION: CONTRACTED SERVICES Tag No: A0084
Based on document review and interview, the governing body failed to ensure services performed under a contract are provided in a safe and effective manner for 1 of 1 contracts reviewed for an RN Surgical Assistant (B#10).

Findings included:

1. Review of the hospital contract with CC #1 on 5-16-12, effective 11-1-07, indicated the following:
a. CC#1 will use an RN Surgical Assistant who is fully qualified and credentialed by the Hospital to provide such services and who are certified, licensed, or registered to perform such services.
b. Provide Hospital with any documents required in support of each Assistant's credentials, training, or malpractice.
c. Surgical Assistants will comply with Hospital's annual employment requirements to include annual criteria-based performance evaluation on each Assistant and annual skills/competency skill assessment.
d. CC#1 shall maintain malpractice insurance.
e. Will provide proof of Varicella titer.

2. Review of the medical record for P#2 on 5-16-12 indicated that B#10 is an RN 1st Assistant.

3. 2. Review of B#10's personnel file, an contracted employee of CC#1, on 5-16-12 lacked evidence of a job description or privileges, first assistant training or certification, malpractice insurance, skills/competency assessment, performance evaluation, or Varicella titer.

4. Interview with B#10 on 5-16-12 at 1035 hours indicated he/she is an RN 1st Assist who is contracted with the hospital to harvest veins and assist with major vascular and cardiac cases; B#10 indicated he/she is currently credentialed and privileged at the hospital.

5. Interview with B#4 on 5-16 12 at 1145 hours confirmed the personnel file of B#10 does not contain documentation of privileges, first assistant training or certification, malpractice insurance, skills/competency assessment, performance evaluation, or Varicella titer as required by contract.
VIOLATION: MEDICAL STAFF BYLAWS Tag No: A0353
Based on document review and interview, the medical staff failed to follow their approved Bylaws/Rules and Regulations related to 1 of 1 (B#10) contracted RN First Assistant.

Findings included:

1. Review of the medical staff rules and regulations on 5-16-12 indicated the following on page 32: Surgical Assistants - Privileges must be approved by the Department of Surgery with final approval being granted by the Board of Trustees; must have sterile techniques reviewed by the OR Nursing Supervisor and documentation of this must be placed in the applicant's credentials file.

2. Review of the personnel file of B#10, RN First Assistant, on 5-16-12 lacked documentation that sterile techniques were reviewed by the OR Nursing Supervisor, that the privileges were approved by the Department of Surgery and that final approval of privileges was granted by the Board of Trustees.

3. Review of the medical record for P#2 on 5-16-12 indicated that B#10 is an RN 1st Assistant.

4. Interview with B#10 on 5-16-12 at 1035 hours indicated he/she is an RN 1st Assist who is contracted with the hospital to harvest veins and assist with major vascular and cardiac cases; B#10 indicated he/she is currently credentialed and privileged at the hospital.

5. Interview with B#4 on 5-16-12 at 1145 hours confirmed the personnel file of B#10 did not contain documentation that privileges were approved by the Department of Surgery and final approval of the privileges was granted by the Board of Trustees; B#4 confirmed the personnel file did not contain documentation that sterile techniques were reviewed by the OR Nursing Supervisor.