HospitalInspections.org

Based on policy and procedure review, hand hygiene data review, and staff interviews, the hospital failed to collect performance assessment data in the frequency identified for 1 of 3 indicators reviewed. (hand hygiene)

The findings include:

Review of policy "Quality Assessment Performance Improvement Plan", reviewed/revised date 10/01/2015, revealed "...I. Purpose: The (hospital name) Performance Improvement Plan serves as a guide for the systematic integration and coordination of performance improvement initiatives throughout the hospital....The primary goal for improving performance is the provide safe, timely, efficient, effective, equitable, and patient centered care. This is achieved by assuring the organization designs processes well and systematically monitors, analyzes and improves performance and outcomes.... VII. Indicator Measurement: Indicators (projects), selected by the leaders using Performance Improvement Team Rankings, monitor high volume, high-risk, problem prone procedures and processes that may place patients at risk....Department and product line measures are organized around core organization and patient functions and include both structure and process stability....Leaders integrate data from multiple sources to evaluate organization and departmental performance including data from the following sources:....Infection control data....IX. Governance, Authority and Accountability....A decentralized approach for quality improvement is used with accountability for quality improvement and patient safety residing with department leaders....The leader's role includes the following functions: measurement and analysis of data... ."

Review of Hand Hygiene data presented by the Infection Prevention Specialist (IPS) on 05/12/2016 revealed monthly data submission for 2015 and first quarter 2016. Review revealed the following number of monthly audits submitted in 2015 was: 6 in January, 10 in February, 10 in March, 6 in April, 16 in May, 21 in June, 19 in July, 16 in August, 7 in September, 6 in October, 32 in November, 16 in December. For 2016, the observational audits submitted were: 5 in January, 16 in February, 20 in March.

Staff interview on 05/12/2016 with the IPS revealed the hospital collects data on a hand hygiene indicator to assess staff compliance with sanitizing their hands. Interview revealed the audits were to be done by trained "secret shoppers". Each of six (6) department leaders were to ensure completion of a minimum of 5 audits per month and submit the results to the IPS. This would yield a total of 30 observations per month. Interview revealed sufficient audits were not being returned. Review of the data and interview revealed that 30 or more observation audits had been received only once in the 15 month time period (November 2015). The IPS stated email reminders had been sent to leaders and the issue had been discussed in Safety Committee, but there had not been sustained improvement. Further interview revealed that as of 05/12/2016 no audits had been returned for April 2016.

Based on policy and procedure review, hand hygiene data review, committee meeting minute review, and staff interview, the hospital failed to continue to implement new interventions to improve and sustain performance for 1 of 3 quality indicators reviewed. (hand hygiene)

The findings include:

Review of policy "Quality Assessment Performance Improvement Plan", reviewed/revised date 10/01/2015, revealed "...I. Purpose: The (hospital name) Performance Improvement Plan serves as a guide for the systematic integration and coordination of performance improvement initiatives throughout the hospital....The primary goal for improving performance is the provide safe, timely....and patient centered care. This is achieved by assuring the organization....systematically monitors, analyzes and improves performance and outcomes.... VII. Indicator Measurement: Indicators (projects), selected by the leaders using Performance Improvement Team Rankings, monitor high volume, high-risk, problem prone procedures and processes that may place patients at risk....Department and product line measures are organized around core organization and patient functions and include both structure and process stability....Leaders integrate data from multiple sources to evaluate organization and departmental performance including data from the following sources:....Infection control data....IX. Governance, Authority and Accountability....A decentralized approach for quality improvement is used with accountability for quality improvement and patient safety residing with department leaders....The leader's role includes the following functions: measurement and analysis of data, implementing improvement strategies, sustaining improvement... ."

Review of Hand Hygiene data measuring staff compliance with sanitizing their hands revealed monthly data from January 2015 through March 2016. Review revealed the monthly percentage compliance was: January 2015 100%, February 80%, March 50%, April 83%, May 100%. June 33%, July 47%, August 56%, September 86%, October 50%, November 59%, December 50%, January 2016 40%, February 0%, March 10%. Review of the data form revealed staff education sessions (lunch and learns) were offered in July 2015 and in August "...Hand washing signs place (sic) in every patient room....labels placed at doorway for isolation & (and) 'soap & water only'. ..." Review of the data form did not reveal any new interventions after August 2015.

Review of Safety Committee meeting minutes, dated 01/21/2016, revealed "...Hand hygiene 66% compliance Goal is 95%....Accepted as information. ..." Review did not reveal any recommended actions to improve hand hygiene compliance.

Review of Safety Committee meeting minutes, dated 04/28/2016, revealed "...Hand Hygiene 66% compliance. Goal is 95%....Accepted as information. ..." Review did not reveal any recommended actions to improve hand hygiene compliance.

Staff interview with the Infection Prevention Specialist (IPS) on 05/12/2016 revealed the issues with hand hygiene compliance continue. Interview revealed compliance increased to 86% in September 2015, but did not sustain. Interview revealed the compliance issue was reported to leadership but did not reveal additional actions taken after August 2015.

Staff interview on 05/12/2016 at 1630 with Administrative Staff (AS) #8 revealed although hand hygiene data had been reported to the Safety Committee, it had not been brought forward to the Quality Committee. If it had been brought to Quality, interview revealed, two consecutive months of low compliance would lead to action. Interview revealed current hand hygiene compliance data was a concern and did not meet the organization's goals.

Based on hospital policy review, Infection Control Plan, open medical record review, observation, and staff interviews, the hospital staff failed to ensure oversight of established guidelines for surveillance of hand hygiene as outlined in the Infection Control Plan and per policy for 4 of 4 patients (Pt. #4, 9, 10, 24) and failed to ensure storage of patient care equipment in a clean area.
The findings include:
A. Policy review on 05/12/2016 revealed "Hand Washing/Hand Hygiene" review/revised 04/2013. Review revealed "Purpose: Hand washing/hand hygiene is the...most important measure in preventing the transmission of infectious agents...Policy: Hand hygiene is...a critical component of patient safety in the hospital...2...Decontaminate hands not visibly soiled with alcohol hand rub or alternately with antimicrobial soap and water: a. when entering a patient's room...g. after contact, with inanimate objects...h. after removing gloves, i. when leaving the patient's room.
Policy review on 05/12/2016 revealed "Infection Control Guidelines for All Staff" reviewed/ revised 04/2013. Review revealed Purpose: To protect patients, visitors and staff from infectious agents. Policy: It is the policy of (named hospital) that staff members perform their duties....Barriers....will be maintained through adherence to the Infection Control policies...D. Patient Contact 1. Routine...b. Hand hygiene and barrier precautions will be adhered to. 2. Hand Hygiene a. Hands are decontaminated...before and after contact with any patients...d. Hands are decontaminated after removal of gloves..."
Policy review on 05/12/2016 revealed "General Infection Control Issues" reviewed/revised 04/2013. Review revealed "Purpose: To protect patients, visitors, and staff from infectious agents...All employees will adhere to hospital...and Personal Protective Equipment (PPE)...Hand Hygiene is....important procedure in preventing the spread of hospital acquired infections....Hands should be decontaminated before each patient contact, after contact with... inanimate objects in the immediate vicinity of the patient...Gloves should be removed immediately... and not worn to answer phones, transport patients, handle charts, etc. Hands should be decontaminated after removing gloves."
Policy review on 05/12/2016 revealed "Isolation for Suspected/Confirmed Infectious Diseases" reviewed/revised 04/2013. Review revealed "Purpose:...2. To prevent the transmission of infection...Policy:...health care workers will follow isolation precautions for patients in...Contact...Isolation...Procedure: 1. Isolation Categories. a. Standard Precautions - Use Standard Precautions for the care of all patients. Use barrier precautions (gloves...) when anticipating an exposure to...or contaminated items/equipment...3. Personal Protective Equipment (PPE) Requirements...c. When exiting room, PPE will be removed...(3) Wash hands..."
Review on 05/12/2016 of the hospital's "Infection Control Plan Program (ICPP)" reviewed/revised 10/2015 revealed, "Purpose: The purpose of the Infection Prevention Plan is to reduce risks of... infections (HAIs)...The plan does the following:...2. Describes hospital's strategies to minimize, reduce, or eliminate...risks and strategies will be evaluated...Types of Surveillance...Hand Hygiene, Surveillance rounds...Assess the overall success or failure of...processes for preventing and controlling infection...Recording and Reporting Infections and Surveillance:...Surveillance Rounds - Rounds of various areas to monitor selected quality control issues, procedural implementation, and staff knowledge of process..."
1. Medical record review on 05/11/2016 for Patient #4 revealed a hospital admission on 04/08/2016 with a diagnosis including Polymicrobial (multiple organisms) Diabetic Foot Ulcers and MRSA (Methicillin-resistant Staphylococcus aureus (bacterium resistant to many antibiotics)). Review revealed the patient was a direct admission from an acute hospital and admitted on Contact Precautions (used for patients with infections (gown and gloves required with either gel or soap and water use following removal of gloves)). Infectious Disease was consulted prior to admission and continued to follow the patient. Review revealed the patient developed C. Diff (bacteria) associated diarrhea on 04/29/2016. Enteric Precautions (used for patient's with bacteria in the intestines (soap and water only are used following removal of gloves)) was initiated.
Observation during the unit tour on 05/11/2016 at 1450 revealed Staff #6 donning gloves and gown to enter Patient #4's room. Observation revealed hand hygiene was not performed prior to donning gloves.
Interview on 05/10/2016 at 1450 with Staff #3 revealed, "She did not perform hand hygiene prior to putting on the gloves." Interview revealed Staff #6 did not follow the hospital Hand Hygiene policy.
Interview on 05/10/2016 at 1540 with the hospital's Infection Prevention Specialist (IPS) revealed, "They know what they're supposed to do but I can't be everywhere and it's up the managers to make sure they comply. That's why we have the problems we do, there's no accountability." Interview revealed hand hygiene compliance was a problem area for the hospital in 2015 and continues to date.
2. Open medical record review on 05/12/2016 for Patient #9 revealed a hospital admission on 04/22/2016 with a diagnosis including CVA (cardio vascular disease) with right-sided hemiparesis (weakness. Interview revealed Patient #9 was admitted for "aggressive physical therapy (PT)." PT was consulted 04/22/2015 at 0700 and evaluated the patient at 1245 the same day. Further review revealed "4-5 days/week" of therapy was recommended.
Observation on 05/10/2016 at 1145 during tour of the PT department revealed Staff #1 and #2 assisting the patient with therapy on the stationary bike. The patient was unable to sit on the bike, modifications were made so that the wheelchair was used during therapy. Observation revealed Staff #1 did not have gloves on and was observed assisting the patient with foot placement on the bike pedals. When the patient finished, he remained in the wheelchair while Staff #1 obtained gloves and wiped the bike down. Observation revealed Staff #1 did not perform hand hygiene prior to donning gloves. When Staff #1 finished cleaning the dirty equipment, gloves were removed, there was no hand hygiene performed, and Staff #1 returned to assist the the patient out of the wheelchair. Observation revealed the stationary bike had foam wrapped grips and seat for patients capable of sitting on the bike for therapy.
Interview on 05/10/2016 at 1150 with Staff #3 revealed staff are expected to wear gloves during the provision of patient therapies and hand hygiene should be performed prior to donning gloves and following removal. Interview revealed, "She (Staff #1) doesn't have gloves on while she's doing that (assisting with foot placement)." Interview revealed Staff #1 did not wash her hands following patient care, prior to donning gloves. Interview revealed after Staff #1 cleaned the stationary bike, she did not perform hand hygiene, "Please tell me she washed her hands when she took her gloves off. I didn't hear any water or see her wash her hands." Interview revealed staff are expected to perform hand hygiene before donning gloves, wear gloves during patient care, and perform hand hygiene following removal of gloves." Interview revealed the foam wrapped bike grips and seat was an Infection Control concern that would be discussed with the hospital's Infection Prevention Specialist (IPS) and hospital administrative staff for further review and evaluation of risks.
Interview on 05/12/2016 at 0910 with the hospital's IPS revealed, she was not aware the stationary bike grips were wrapped in foam or that the seat was made of a foam material. Interview revealed, "My assumption was that the seat was vinyl." Interview revealed, "Foam is porous and cannot be cleaned." Interview revealed the IPS walks through the PT area daily on her way to her office but she does not conduct Infection Control (IC) surveillance in the two designated PT rooms or of the equipment. Interview revealed, "It's their (Department Head) responsibility to ensure I am made of aware of any concerns or issues." Interview revealed the IPS does not perform surveillance of all patient care areas in the hospital.
3. Medical record review on 05/10/2016 for Patient #10 revealed a hospital admission of 04/19/2016 for Respiratory Failure (RF) with a noted history of a tracheotomy (incision in the windpipe to help with breathing). Record review revealed the patient tested positive for Methicillin-resistant Staphylococcus Aureus (MRSA: bacteria) on 04/19/2016 at 1458 but the order for Contact Precautions was not written until 05/08/2016 at 1458.
Observation during unit tour on 05/10/2016 at 1200 revealed Contract Staff #7 was outside of Patient #10's room, donning a gown and gloves. Observation revealed a sign on the door that read "Contact Precautions". Contract Staff #7 entered the patient's room, handled the nurse call light and returned it to the patient's side. Observation revealed Contract Staff #7 did not perform hand hygiene following contact with an "inanimate object" following removal of gloves as outlined in hospital policy. Observation revealed Contract Staff #7 walked directly into the nursing office picked up a clipboard, and returned it to the counter. Contract Staff #7 came back out into the hall, got the ladder, and proceeded down the hall.
Interview on 05/10/2016 at 1200 with Staff #3 revealed, "He's (Contract Staff #7) working on the call bell system, he's not one of our regular staff members." Interview revealed (Contract Staff #7) "didn't clean his hands after he took his gloves off and went straight into the office." Interview revealed Contract Staff #7 did not follow the hospital's hand hygiene and Isolation Precaution policies.
Interview on 05/12/2016 at 0910 with the IPS revealed she does not provide Infection Control (IC) or Isolation Precaution education to contracted staff. Interview revealed the IPS could not verify that contracted staff receive training on IC practices and precautions. Interview revealed the IPS did not know whether (Contract Staff #1) was trained or competent in hand hygiene. Interview revealed the IPS does not perform surveillance of contracted staff's hand hygiene practices or application of PPE (gown and gloves). Interview revealed, "I don't have anything to do with contracts. It's up to the contractor to educate them."
Continued interview with the IPS revealed she was not aware Patient #10 was on contact precautions or that she tested positive for MRSA on 04/19/2016 at 1458. Interview revealed Patient #10's name was not on the laboratory's (lab) generated precautions list and that she had not been made aware of the need for precautions. Interview revealed, "I receive a printed list from the lab (laboratory) of all patients who are placed on precautions" but she could not explain why Patient #10's name was not on the list. Interview revealed, "The lab makes the initial notification of the need for precautions to all staff, the list is updated, and prints directly to my office." Interview revealed if a patient is on precautions, for any reason, and their name is not on the precautions list generated by the lab, the IPS consults the nurse or physician to ascertain why and when precautions were initiated. Interview revealed nursing staff "can initiate isolation precautions" but there should be a physician's order "within 24 hours" of initiation. Interview revealed other measures that are in place to ensure she is aware of patients who have been placed on precautions are "record reviews within 3 days of admission, unit rounds 3-4 times a day, communication." Inteview revealed if a patient is placed on precaution and the IPS is not aware, there's signage on the door and isolation carts (carts set up with gowns, gloves, masks, etc. (PPE)) outside the room" she would see during her rounds and would investigate further as needed.
4. Medical record review on 05/12/2016 for Patient #24 revealed an admission date of 04/16/2016 with a diagnosis including Endocarditis (inflammation of the heart), End Stage Renal (kidney) Disease (ESRD) with transplant failure, and Foot Ulcer with Gangrene (deterioration). Review revealed Patient #24 was placed on Contact Precautions on 04/15/2016 prior to transfer and admission due to a documented history of MRSA. Review revealed Patient #24 tested positive for MRSA on 05/12/2016 while at (named hospital) with Contact Precautions continued per hospital policy.
Observation on 05/11/2016 at 1118 revealed Staff #9 standing in Patient #24 without PPE. Observation revealed contact isolation sign with instructions and isolation cart with required PPE outside patient's room. Further observation revealed Staff #9 exited Patient #24's room and entered another patient's room (436) without performing hand hygiene between patients. Observation revealed Staff #9 failed to perform hand hygiene after exiting and entering patient's rooms per policy.
Interview on 05/11/2016 with Staff #9 at 1119 revealed Staff #9 was in Patient #24 room to get menu selection. Further interview revealed ancillary staff can enter into patients room while on isolation if contact is not made with patient or objects. Interview revealed Staff exited Patient #24 room and entered anoter patient's room (436) without performing hand hygiene per policy.
Interview on 05/11/2016 with Staff #10 at 1120 regarding staff entering patient's room while on isolation without donning gloves and PPE revealed the parameter (restrictive area) is just inside the doorway entrance. Further interview revealed there is not a policy specifying parameters and no markings to guide staff as to how far to enter a patient's room who is on isolation precautions. Interview revealed hand hygiene was not performed is to be performed before entering and exiting patient room per policy.
B. Observation during tour of the Physical Therapy department on 05/10/2016 at 1130 revealed clean patient care equipment was stored in the shower of the bathroom. Observation revealed the equipment included stationary bike pedal adapters, crutches, and gait belts. Observation revealed a container sitting in the floor beside the toilet with gait belts inside.
Interview on 05/10/2016 at 1130 with Staff #3 revealed the clean medical equipment has been stored in the bathroom "ever since we've been here. We are limited on space and just don't have anywhere else to store it." Interview revealed the toilet was actively being used and that clean equipment should not be stored in the bathroom. Interview revealed, "It didn't even dawn on me until you asked. We will have to find another place for it (clean equipment)." Interview revealed the hospital's IPS "has never said anything about it."
Interview on 05/10/2016 at 1530 with the hospital's IPS revealed she was not aware clean equipment was stored in a bathroom that is used. Interview revealed, "I didn't know they were storing clean equipment in there (bathroom)." Interview revealed the IPS does not make rounds in the actual PT rooms where the equipment is maintained. Interview revealed the IPS walks through the PT area daily on her way to her office but she does not conduct surveillance in the two designated PT rooms or of the equipment. Interview revealed, "The expectation is that the manager would make rounds and report any areas of concern to me and it is not acceptable practice to store clean equipment in a bathroom that is being used." Interview revealed the IPS does not perform surveillance of all patient care areas in the hospital.

Based on policy and procedure review, medical record review and staff interview the hospital failed to ensure timely notification to the organ procurement organization after death for 2 of 4 sampled patients (#6 and #20).

The findings include:

Review of policy "Organ, Tissue, Eye Donation: including Donation After Circulatory Death (DCD)", "Effective: March 9, 2016", revealed "... B. (Hospital name) through the medical and nursing staffs, will identify possible candidates for organ, tissue and eye donation and use the services of (OPO-Organ Procurement Organization name), the local, Federally-designated OPO...II. Procedure A. The Nursing Clinical Supervisor/Charge Nurse or designee will identify potential organ, tissue and eye donors based on the program's criteria 1. On all deaths, the "Authorization for Release of Body" form 2. A call will be placed to (OPO name) to report all deaths and imminent deaths, regardless of age, in a timely manner 3. It is the responsibility of the Nursing Clinical Supervisor/Charge Nurse or designee to see that the call is placed within the designated time periods (a On cardiac deaths, the call to (OPO name) should be made within one hour of the death... ."

1. Medical record review revealed Patient #6 "Date of Death 12/04/2015 Time of Death 1920... ." Further record review revealed a call was initiated to OPO on 12/05/2015 at 0245, (7 hours and 25 minutes later).

Interview on 05/12/2016 at 1520 with Staff #11 revealed the expectation of the staff is to follow the policy for organ procurement and notify the OPO in a timely manner. Further interview revealed timely manner is one hour. Interview revealed staff did not follow policy and notify OPO one hour after patient expired (died).

2. Medical record review revealed Patient #20 "Date of Death 01/25/2016 Time of Death 1747... ." Record review revealed a call was initiated to OPO on 01/25/2016 at 1515. Further record reveled on "Authorization For Release of Body" form states ... "- Early referral (return call at time of cardiac death): ...". Medical record review revealed early referral call was made (2 hours and 17 minutes) prior to Patient #20's death. Further record review revealed no other documented calls made to OPO for Patient #20.

Interview on 05/12/2016 at 1520 with Staff #11 revealed the expectation of the staff is to follow the policy for organ procurement and notify the OPO in a timely manner. Further interview revealed timely manner is one hour. Interview revealed staff did not follow policy and notify OPO one hour after patients expired (died).

Based on policy and procedure review, medical staff bylaws review, medical record review and credentialing file review the hospital failed to ensure a Nurse Practitioner (NP #13) had privileges to perform a surgical procedure performed at the bedside for 1 of 1 patients who had surgical procedures performed (#23).

The findings include:

Review of policy "Professional Credential and Licensure" reviewed/revised June 1, 2013 revealed, "...PURPOSE: To ensure that all staff are competent to perform his/her responsibilities POLICY: It is the policy of (hospital name) to verify the credentials and licensure of all staff...A) There will be verification of the credentials and licensure of all staff, consultants, students, and volunteers, when applicable. Such verification shall be documented in the personnel file of each staff member. Verification will be done at time of employment and periodically according to licensing authorities and professional associations."

Review of "MEDICAL STAFF BYLAWS OF (HOSPITAL NAME) 2012" revealed,
"... PROCEDURE FOR APPOINTMENT a) Application Process and Credentialing Guidelines...b) Basic Responsibilities for Applicants and Appointees:...Each applicant or appointee shall:...(11) abide by all Bylaws, Policies, and Rules and Regulations of the Medical Staff and Hospital as they exist from time to time during the term of appointment;...(19) authorize the release of all information necessary for an evaluation of the individual's qualifications for initial or continued appointment, reappointment, and/or clinical privileges;...d) Medical Executive Committee Credentialing Procedure (1) The Medical Executive Committee shall examine evidence of the applicant's...qualifications...whether the applicant has established and satisfied all of the necessary qualifications for appointment and for the clinical privileges requested....(e Medical Executive Committee Recommendation...recommendation for appointment is favorable, the Medical Committee shall make a written report and recommendations to respect to applicant....All recommendations to appoint,...must specifically recommend the clinical privileges to be granted....CLINICAL PRIVILEGES...Each individual who has been appointed to the Medical Staff shall be entitled to exercise only those clinical privileges specifically granted by the Board (or its designated committee)."

Medical record review on 05/12/2016 revealed, Patient #23 was admitted to the hospital on 02/25/2016 at 1455 with the chief complaint of respiratory failure (condition that effects oxygen in the lungs). The H&P (History and Physical) revealed a 63 year old with a history of paraplegic due to a motor vehicle accident in 2001. Continued, review revealed, Patient
#23 was awake and alert and responding to healthcare provider kindly. Further review of the H&P revealed, an unstageable ulceration (open sore with skin loss including soft tissue and blood vessels with bone exposure) to the right buttock and a stage 2 ulceration (blister or sore with the loss of the top layer of skin) to the bottom of the right buttock. Medical record review of "Consent For Operation/Procedure" revealed on 05/04/2016 Patient #23 signed and approved the following procedure "APPLICATION OF DECELLULARIZED HUMAN DERMIS TO THE SACRAL ULCER WOUND BED to be performed by" (Staff #13). The consent was signed and dated 05/04/2016 at 0930. (The procedure is the transplant of skin taken from other humans to be placed on the open sore of Patient #23's body). Further review revealed, on the "Operative Report/Proc. Note"...the procedure was performed by Staff #13 after prepping, draping and numbing the selected area. Continued review revealed two pieces of the human skin was placed over the sacral wound of Patient
#23 and sutured in place with 4-0 Vicryl sutures (synthetic braided material used for closing open wounds). Medical record review of "ALLOGRAFT TRACKING FORM" revealed,...on 05/06/2016 sacral pressure ulcer (wound) was sutured in place by Staff#13.

Credentialing file review on 05/12/2016 revealed a written recommendation for Staff #13 stating "...Upon recommendation...at its 08/06/2015 meeting, the Board of Directors of (hospital name) approved your reappointment...Primary Appointment...From: 08/31/2015 To: 08/31/2017...". Further review of "Delineation of Approved Privileges" form revealed, PA/NP (Physician Assistant- medical licensed professional that help doctors) Privileges were granted for Staff #13. Continued review of credentialing file of "...REQUEST FOR PRIVILEGES" for "Physician Assistant/Nurse Practitioner" form revealed, "...Physician Assistant/Nurse Practitioner may be granted clinical privileges to conduct the following professional core services:...Perform...normal growth and development, and long-term management of disease....Perform or assist in performing...,therapeutic and diagnostic procedures delegated by the supervising physician...Please request additional privileges desired by marking the appropriate "Requested" box for each procedure." Further review of request for privileges form revealed, under "Procedure/Specific Skills" list "...Wound Suture" was not marked requesting privileges. Review of credentialing file did not reveal further documentation of privileges for Staff #13.

Interview on 05/12/2016 with Administrative Staff (AS #12) at 1250 revealed "I thought" Staff #13 had privileges. Interview revealed AS #12 confirmed the requested box for wound suture was not marked. Further interview revealed Staff #13 performed a bedside procedure without privileges.

Interview on 05/12/2016 with Staff #14 at 1645 revealed Staff #13 did not have privileges to perform bedside privileges. Interview revealed Staff #14 confirmed the requested box for wound suture was not marked. Further interview revealed Staff #13 performed a bedside procedure without privileges.