HospitalInspections.org

Based on record review and staff interview it has been determined that the hospital failed to implement the facility's Core Privilege Requirement for 4 of 5 sample employee Midwives (ID A, B, C and D ).

Findings are as follows:

Review of the "Midwifery Privileges Eligibility Criteria" under "Core Privileges Requirements" states:

"Certification in ACLS (advanced cardiac life support) and Neonatal Resuscitation (NRP)"

1. Review of the credentialing file for employee ID A lacked evidence of ACLS and NRP certification in accordance with the Core Privilege requirement.

2. Review of the credentialing file for employee B, lacked evidence of ACLS certification in accordance with the Core Privilege requirement.

3. Review of the credentialing file for employee C, lacked evidence of ACLS certification in accordance with the Core Privilege requirement.

4. Review of the credentialing file for employee D, lacked evidence of ACLS certification in accordance with the Core Privilege requirement.


When interviewed on 3/14/16 at approximately 10 AM, the Risk Manager was unable to produce evidence that the required certifications had been completed.

Based on surveyor observation, staff interview and review of hospital policies, it has been determined that the hospital failed to implement the policy entitled "Universal Protocol (Procedure Verification)" for 2 of 3 sample patients relative to "Time Out" (ID #s 17 and 19).

Findings are as follows:

A review of the hospital policy entitled " "Universal Protocol (Procedure Verification)" under "Time Out" states:

"The purpose of the Time Out is to conduct a final verification of the correct patient, procedure(s), site(s), side(s), / level(s) and as applicable, implants or special equipment. The Time Out must be conducted by the practitioner performing the procedure, immediately prior to incision/puncture and with all members of the procedural team participating. The Time Out will be documented on the Universal Protocol Checklist. "

Under "Procedure" section "Time Out" item #4:

"The Time Out confirms the following:
Patient identity, using at least two patient identifiers (name and date of birth)..."

1. During a surveyor observation on 3/9/16 at approximately 9:00 AM, of a colon resection for patient ID #17, the surveyor observed the surgeon pause to do what appeared to be the initiation of a "Time Out", prior to making the surgical incision. The surveyor heard what was believed to be the patient's name. However, the surgeon stopped due to the need to move an overhead light. Once the light was moved the surgeon then proceeded to make the incision. The surveyor did not hear the surgeon resume or complete the Time Out per hospital policy as it relates to verifying the procedure or patient's date of birth, before beginning surgery.

The Executive Director of Professional Practice and the Clinical Director of perioperative services were both with the surveyor at the time of the procedure. When the surveyor turned towards them, they both acknowldeged that a Time Out was not completed in accordance with hospital policy.

2. On 3/11/16 at approximately 10 AM, the surveyor observed the same surgeon begin an umbilical hernia repair on patient ID #19. Prior to beginning the surgery, the surveyor heard the surgeon pause and say something, two words were all that was heard, and then proceed to make his surgical incision. The Executive Director of Professional Practice was with the surveyor at this time, and told the surveyor she heard the surgeon state the procedure, but that was all she heard.

When interviewed on 3/11/16 at approximately 10:30 AM, the surgical technician and First Circulator who were present for the case, revealed the surgeon did do a time out, but the the patient's date of birth was not confirmed, in accordance with hospital policy.