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Based on observation, interview, and document review the facility failed to ensure the Certified Registered Nurse Anesthetists (CRNAs) are supervised as required by the New York State Board of Nursing as described in the New York State Department of .Health Dear Administrator Letter dated 2/1/1980.

Findings:

A surgical procedure was observed during the survey at 10:00 a.m. on 5/21/13. The CAH did not have an anesthesiologist in the hospital. The CRNA was observed administering anesthesia

The New York State Education Board of Nursing requires that CRNAs must be supervised by an educated, trained, and/or experienced appropriate to the level of anesthesia administered, and in accordance with physicians scope of practice and privileges.

The facility's policy and procedure "Nurse Anesthesia Services Organization and Direction with effective date of 12/26/2005 states the scope of practice fo the CRNA encompasses the professional functions, privileges and responsibilities associated with nurse anesthesia practice. These are performed in collaboration with and under the supervision of qualified and authorized professional physician.

The operating surgeon must co-sign the pre-anesthesia evaluation that includes the planned choice of anesthesia.
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Review of credentials files on 5/22/13 revealed that there was no agreement/privileges that the operating physician was responsible for the supervision of CRNAs.

The CRNA on interview on 5/21/13 at 10:30 a.m. confirmed the operating physician was responsible for supervision. There was no documentation to support the practice.

Based on observation, interview and document review during an onsite survey, the facility failed to ensure that equipment and supplies commonly used in life saving procedures was monitored daily for operational capability and was adequately disinfected in compliance with infection prevention practices.

Findings:

During a tour of the Operating Room area on 5/21/13 at 10:30 a.m., review of the crash cart/defibrillator log demonstrated that the checks had been completed on 5/2/13 and 5/16/13. Surgical procedures were being conducted on the day of this onsite visit, 5/21/13.

Laryngoscope blades located in a drawer of the airway cart were not wrapped and lacked evidence that any cleaning and high level disinfection of the blades had been performed, in accordance with infection prevention standards.

During a tour of the Patient Care area on 5/21/13 at 3:00 p.m., upon direct questioning, a staff nurse indicated that the crash cart/defibrillator are required to be checked every 24 hrs. Review of the crash cart/defibrillator log demonstrated that the checks had been completed on 5/13/13 and 5/18/13.

The Patient Care Unit Nursing policies, "Crash Cart" and "Defribillator" were reviewed to verify the 24hr. check requirement. Based on observation and interview during the tour of the Operating Room area and the Patient Care Unit on 5/21/13, this requirement is not being met.

Based on observation and interview during an onsite survey, the housekeeping and preventive maintenance programs failed to ensure proper ventilation in patient care areas.

Findings:

On 5/21/13 at 2:30 p.m., during a tour of the facility with the Maintenance Supervisor, it was noted that the exhaust fan for the janitors closet located in the northwest hallway was not operable. This was confirmed with the Maintenance Supervisor at the time.

Based on interview, observation, and document review, the Governing Body does not provide oversight to ensure facility policies are administered to provide quality health care in a safe environment.

Findings:

The facility failed to follow their policy "Nurse Anesthesia Services Organization and Direction" with effective date of 12/26/2005. The policy states that the operating physician will co-sign the preanesthesia evaluation. There was no documented evidence in 4 out 4 medical records reviewed that the operating physician co-signed the preanesthesia evaluation.

There was no documented evidence in the medical record that the functions of the CRNA were in collaboration with, and under the supervision of a qualified and authorized physician.

Review of credentials files on 5/22/13 revealed that there was no agreement/privileges that the operating physician was responsible for the supervision of CRNAs.

A surgical procedure was observed during the survey at 10:00 a.m. on 5/21/13. The CAH did not have an anesthesiologist present in the hospital. The CRNA was observed administering anesthesia.

The CRNA stated on 5/21/13 at 10:30 a.m. that the operating physician supervises the CRNAs. No documented evidence was provided to support the statement or practice.

Based on interview and review of policies it was noted the facility did not have the required documentation that all policy and procedure manuals were reviewed annually by a group of professional personnel and reviewed as necessary by the CAH.

Specifically, there was no documented evidence that the Anesthesia Policy and Procedures were reviewed on an annual basis. For example, "Nurse Anesthesia Services Organization and Direction" effective date 12/26/2005 was last reviewed/revised 2/20/2007.

Interview on 5/21/13 at 2:00 p.m. with the Director of Clinical Operations confirmed the required annual review had not been completed.

Based on observation, staff interview and document review the facility failed to 1) grant privileges to the operating physician for supervision of the CRNAs 2) follow their Universal Protocol for site marking.

# 1.

Findings:

Document review determined that the governing body did not have credentialing privileges in place for the supervision of the CRNAs by the operating physician.

A surgical procedure was observed at 10:00 a.m.during the survey on 5/21/13. The CAH did not have an anesthesiologist present in the hospital. The CRNA was observed administering anesthesia.

Credentials files for the surgeons did not contain the physicians' scope of practice and privileges to supervise the CRNAs.


Based on interview, observation, and document review the facility failed to follow their Universal Protocol for site marking.

# 2.

Findings:

In the Pre-op and Pre anesthesia care unit (PACU) a patient was awaiting cataract surgery. The patient's surgical site was marked with an" X". On interview with the Registered Nurse (RN) in Pre-op/PACU on 5/21/13 at 9:30 a.m. stated that she marks the eye with an "X", and the surgeon will verify the site.

On 5/21/13 at 10:00 a.m. a patient was observed through pre-op and surgery. A direct observation was made of the RN marking the surgical site with an "X". The surgeon did not mark the site with his/or her initials per facility policy "Universal Protocol Policy" dated 2013.

Based on interview, observation, and document review the facility failed to examine each patient before surgery to evaluate the risk of anesthesia, and before discharge for proper anesthesia recovery.

Findings:

During the survey a surgical procedure was observed at 10:00 a.m.on 5/21/13. The CRNA performed a pre-anesthesia evaluation. The patient signed consent for "monitored anesthesia care" (MAC). The patient was discharged after surgery without a post-anesthesia evaluation.

During the survey 3 out of 4 medical records reviewed did not contain a pre-anesthesia evaluation prior to surgery and no post-op anesthesia evaluation prior to discharge.

This was confirmed on interview with the CRNA on 5/21/13 at 10:30 a.m. He stated he does not always complete a post-op anesthesia evaluation prior to discharge of PACU patient. He stated the patient received conscious sedation.

Based on observation, and document review the facility failed to specify anesthesia privileges for each practitioner who administers anesthesia, or who supervises the adminsitration of anesthesia by another practitioner.

Findings:

During the survey 2 out of 2 credentials files for the surgeons did not contain privileges for the supervision of CRNAs.

A surgical procedure was observed on 5/21/13 at 10:00 a.m. The facility did not have an anesthesiologist present in the hospital. The CRNA was observed administering anesthesia. The surgery was performed by a surgeon without privileges to supervise the CRNA.