HospitalInspections.org

Based on medical record and document review, the medical staff did not enforce their bylaws related to the supervision of Physician Assistants (PA) in 4 of 21 medical records. (Patients # 2, 12,13,15).


Review of facility bylaws on 5/13/15 revealed supervision of PA ' s is as follows:
2.2 RESPONSIBILITIES
To effectuate the purposes enumerated above, it is the obligation and responsibility of the organized Staff:
(d) to develop, administer, comply with and recommend amendments to these Bylaws, rules and regulations, policies, and the supporting manuals of the Staff and its various components;...

Review of policy # MSO -H - 003 titled Health Professional Affiliate revised 5/24/14 on 3/13/15 revealed 2. Physicians Assistants a. Supervision of Physician Assistants, iii The PA may conduct patient care without the physical presence of the supervising physician. The supervising physician must authenticate by his or her signature 100% of records of care provided by the PA.

Review of Patient #2 on 5/12/15 revealed preoperative orders for 4/28/15 that were signed by the PA on 4/14/15 and not co-signed by the physician.

Review of Patient # 12 on 5/13/15 revealed the PA wrote orders on 1/7/15 that were not co-signed by the physician.

Review of Patient # 13 on 5/13/15 revealed the PA gave a verbal order for Ativan on 2/14/15, which was not signed by the PA or the physician. Additional orders were written by the PA, which were not co-signed by the physician.

Review of Patient # 15 on 5/13/15 revealed the progress notes and orders written by the PA on 2/4/15 and 2/5/15 were not co-signed by the physician.

Interview with Staff #1 on 5/15/15 at 1 PM verified these findings.

Based on medical record review, document review and interview, the operator does not ensure all components of the surgical site marking and documentation of "time outs" are correctly documented in accordance with the New York State Surgical Invasive Protocol (NYSIPP) and facility policy in 7 of 21 patients. (Patient #2, 12, 14, 15, 19, 20, 21 ). Failure to follow facility policy could potentially place patients at risk of injury.

Findings include:


Review of Policy #: P-8-01a, titled Surgical and Invasive Procedure Protocol (Prevention of Wrong Site/Wrong Procedure/Wrong Patient Surgical/Invasive Procedure-Time Out) revised 2/08 on 5/13/15 revealed that I.) Must Include: 1.) Entire procedure, exact site, level, digit, and side/laterality(including spelling out " Left, " " Right, " and " Bilateral " - abbreviations). In addition, the physician performing the procedure must initial the site when laterality is involved.

Review of Patient #2 on 5/12/15 revealed the patient was having a left hip resurfacing on 4/28/15. The area to document the surgical site marking was blank. During the " time-out ", the correct site was identified, but it is unclear if the surgical site was marked.

Review of Patient # 12 on 5/13/15 revealed the use of a circled " R " rather than using " right " in the operative note.

Review of Patient # 14 on 5/15/1 5 revealed the surgical site (right carpel tunnel) was initialed by the patient on 2/27/15, but the record does not indicate the physician initialed the operative site. A " time out " was performed and documentation shows verification of site, but it does not document site location or presence of markings.

Review of Patient # 15 on 5/13/15 revealed the use of a circled " L " rather than using " left " in the operative note. Additionally, documentation revealed the surgical site (left total hip replacement) was initialed by the patient on 2/3/15, but the record does not indicate the physician initialed the operative site. A " time out " was performed and documentation shows verification of site, but it does not document site location or presence of markings.

Review of Patient # 19 on 5/15/1 5 revealed the surgical site (right shoulder) was initialed by the patient on 2/27/15, but the record does not indicate the physician initialed the operative site. A " time out " was performed and documentation shows verification of site, but it does not document site location or presence of markings. Additionally, physician documentation revealed the use of a circled " R " rather than using " right " in the operative note.

Review of Patient # 20 on 5/15/1 5 revealed the surgical site (left shoulder replacement) was initialed by the patient on 2/27/15, but the record does not indicate the physician initialed the operative site. A " time out " was performed and documentation shows verification of site, but it does not document site location or presence of markings. Additionally, physician documentation revealed the use of a circled " L " rather than using " left " in the operative note.

Review of Patient # 21 on 5/15/15 revealed the surgical site (Right total knee replacement) was initialed by the patient on 2/27/15, but the record does not indicate the physician initialed the operative site. A " time out " was performed and documentation shows verification of site, but it does not document site location or presence of markings. Additionally, physician documentation revealed the use of a circled " R " rather than using " Right " in the operative note.

Interview with Staff #1 on 5/15/15 verified these findings.