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Based on document review and interview, the hospital failed to ensure that Contracted Staff #8 adhered to the scope of practice for a Surgical Technologist in accordance with the Health and Safety Code Chapter 259.

Refer to A0945

Based on document review and interview, the hospital's Medical Staff failed to ensure that Contract Staff #8 had the proper credentials to perform Surgical Assistant (SA) tasks during a surgical procedure. Also, the hospital's Medical Staff Failed to follow their bylaws and the policy titled "Allied Health Credentials".

A review of the credentialing file for Contract Staff #8, Medical Executive Committee meeting minutes, and Governing Body meeting minutes was conducted with Staff #11 on 7/01/2025. In the Credentialing file, was the delineation of privileges for Contract Staff #8. The delineation of privileges revealed:

"Baptist Beaumont

Delineation of Privileges

Provider: Contract Staff #8 C.S.T
.
ID: AHP584

Department: Physician's Employee-Licensed/Certified

Status: Current

Category: Allied Health Professionals

Privileges

I. General Statement
This listing of functions for this category of physician's employee is not all inclusive and may be changed from time to time through addition or deletion. This category of physician's employee may work Skilled care Unit only under the direct supervision of the physician employer. (Direct supervision is defined as "in the presence of the physician employer".)
II. Medical Records
May access the medical records- Approved 12/15/2015 Start 12/13/2024 End Date 12/12/25.
III. Patient Contact- Approved 12/15/2015 Start 12/13/2024 End Date12/12/25.
May visit patient- Approved 12/15/2015 Start 12/13/2024 End Date12/12/25.
May relay general information- Approved 12/15/2015 Start 12/13/2024 End Date12/12/25.
IV. Orders
V. Other- Approved 12/15/2015 Start 12/13/2024 End Date12/12/25
Assist the physician employer in surgery (as approved by the physician Annual Renewal: Demonstrate current competence and evidence of the provision of surgical assisting services for at least 48 cases within the past appointment period. Attached log sheet. Assist the physician employer in treatments and procedures (as approved by the physician).
Please list: open or endoscopic vein harvest"

A review 07/09/2025 at 1:05 PM of the Delineation of Privileges form, Contract Staff #8 was listed as a CST (Certified Surgical Technologist). Contract Staff #8 did not have the proper certificatation to work as a Surgical Assistant.


A review on 07/09/2025 at 1:05 PM of "Baptist Hospital of Southeast Texas, INC Medical Staff Bylaws and Rules and Regulations MS.01.08.001" last reviewed on 12/09/2024 stated:
" ...Definition

ALLIED HEALTH PROFESSIONAL or AHP means an individual, other than a Physician, Dentist, or Podiatrist, not in a recognized training program within or affiliated with the Hospital, who may or may not exercise independent judgment within the scope of his/her lawful professional practice and who is legally qualified to render direct or indirect medical, surgical, dental, podiatric, or health care under the supervision of a Staff member who has been accorded Privileges to provide such care in the Hospital. Allied Health Professionals shall be divided into two categories: (rev. 12/2024)

(a) Privileged Allied Health Professionals (Advanced Practice Professionals) shall consist of Physician Assistants, Advanced Practice Registered Nurses (i.e. nurse practitioners, clinical nurse specialists and CRNA), Certified Anesthesiologist Assistants, Psychologists and Clinical Pharmacists. (rev. 12/24)
(b) Non-Privileged Health Professionals shall consist of Registered Nurses, Licensed Vocational Nurses, Medical Assistants, Certified Podiatric Assistants, Dental Assistants, Surgical Assistants, Surgical Technicians, Ophthalmic Assistants, Audiologists, Prosthetists, Orthotists, Histotechs and neurological monitoring technicians ...

2.2 RESPONSIBILITIES OF THE MEDICAL STAFF ...

To implement and conduct the following specific activities in order to supervise the quality and efficiency of patient care provided by all Practitioners authorized to practice in the Hospital:
(1) review and evaluation of the quality of patient care through an appropriate patient care quality assessment plan;
(2) on-going monitoring of selected patient care practices through defined mechanisms and Staff organization components;
(3) credentials evaluation of Practitioners practicing or seeking the privilege to practice in the Hospital and for defining privileges for Practitioners and Specified Services for Allied Health Professionals; ...
...(b) To make recommendations to the Board regarding Staff and AHP appointments, Staff category and section assignments, AHP section assignments, Clinical Privileges and Specified Services for Allied Health Professionals; ...
...(g) To seek compliance with these Bylaws, the Rules and Regulations of the Staff and other Hospital policies by Practitioners and Allied Health Professionals at the Hospital; ...

...4.10 ALLIED HEALTH PROFESSIONALS
Allied Health Professionals shall not be eligible for Medical Staff membership nor shall these professionals be assigned to a specific Staff category. Allied Health Professionals shall be divided into two categories: Privileged Allied Health Professionals (Advanced Practice Professionals) and Non-Privileged Health Professionals. Both categories shall act as an adjunct to the Medical Staff in accordance with these Bylaws and should comply with the responsibilities of membership as they are applicable to the AHP/APP. The qualifications and procedures for obtaining AHP affiliation and authorization to provide services/clinical privileges in the Hospital are outlined in the Allied Health Professional's Credentials Policy and Procedure Manual ..."

A review on 07/09/2025 at 1:05 PM of the Hospitals Policy Manual title "Allied Health Credentials AH.01.01.001" reviewed by the Credentials Committee & MEC (Medical Executive Committee) with a last revision date of 12/4/2024 stated:
" ...2. Procedure for Appointment

2.1 Application. A person desiring membership on the Allied Health Professional Staff, or a medical staff member who desires to utilize an Allied Health Professional, shall submit an application in writing, on a form or forms provided by the Hospital.
2.2 Required Information. It is the applicant's responsibility to provide all documentation necessary to complete an application. No application will be deemed completed without the following: ...

Copies of certificates or letters confirming completion of training programs (if applicable) or other educational curricula ..."


In interview on 07/01/2025 with Staff 11 it was confirmed that contract Staff #8 had only a CST certification.


The hospital failed to ensure that Contract Staff #8 had the appropriate certification, training and education to act as a Surgical Assistant.

Based on document review and interview, the hospital failed to ensure that Contracted Staff #8 adhered to the scope of practice for a Surgical Technologist in accordance with the Health and Safety Code Chapter 259.

Findings:

A review of Contract Staff's #8 credentialing file, Medical Executive Committee meeting minutes, and Governing Body meeting minutes occurred on 7/1/2025 after 1:30 PM with Staff #11. The Medical Executive Committee and Governing Board approved Contract Staff #8 to perform surgical assistant duties. The Medical Staff failed to ensure that contract Staff #8 had the appropriate certification to perform surgical first assistant duties. Contract staff #8 was a certified surgical technologist (CST) and not a certified surgical first assistant (CSFA). The scope of practice for a CST and a CSFA require a different set of skills to be performed during a surgical procedure. These two scopes of practice have two different sets of skills to be performed during a surgical procedure.


According to The Health and Safety Code Chapter 259 the scope of practice for a CST was as follows:
"Sec. 259.001. DEFINITIONS. In this chapter:
(1) "Department" means the Department of State Health Services.
(2) "Surgical technologist" means a person who practices surgical technology.
(3) "Surgical technology" means intraoperative surgical patient care as follows:
(A) preparing the operating room for surgical procedures by ensuring that surgical equipment is functioning properly and safely;
(B) preparing the operating room and the sterile field for surgical procedures by preparing sterile supplies, instruments, and equipment using sterile technique;
(C) anticipating the needs of the surgical team based on knowledge of human anatomy and pathophysiology and how they relate to the surgical patient and the patient's surgical procedure;
(D) as directed in an operating room setting, performing the following tasks at the sterile field:
(i) passing supplies, equipment, or instruments;
(ii) sponging or suctioning an operative site;
(iii) preparing and cutting suture material;
(iv) transferring and pouring irrigation fluids;
(v) transferring but not administering drugs within the sterile field;
(vi) handling specimens;
(vii) holding retractors and other instruments;
(viii) applying electrocautery to clamps on bleeders;
(ix) connecting drains to suction apparatus;
(x) applying dressings to closed wounds; and
(xi) assisting in counting sponges, needles, supplies, and instruments with the registered nurse circulator;
(E) cleaning and preparing instruments for sterilization on completion of the surgery; and
(F) assisting the surgical team with cleaning of the operating room on completion of the surgery."

This law states what duties a surgical technologist can perform prior to, during, and after a surgical procedure.


According to the Association of Surgical Technologists (AST) and NBSTSA (National Board of Surgical Technologists and Surgical Assisting), the credentials and education requirements for a Surgical First Assistant are:

"Education
Surgical assistants graduate from surgical assisting programs accredited through ARC/STSA" (Accreditation Review Council on Education in Surgical technology and Surgical Assisting)

"Credentials
Certification is conferred by the National Board of Surgical Technology and Surgical
Assisting (NBSTSA). Initial certification as a Certified First Assistant (CSFA) is based upon satisfactory performance on the national certifying examination following completion of an accredited program in surgical assisting or another pathway acceptable to the NBSTSA. CSFAs maintain their certification by earning 75 hours of approved continuing education in a four-year period or by successfully retaking the certifying examination at the conclusion of the four-year period."

Role of the Surgical Assistant (SA)/First Assist (FA)/Certified Surgical First Assist (CSFA)
The following description of the surgical assistant has been approved by the American
College of Surgeons and Association of Surgical Technologists:

1. Positioning the patient
A. The surgeon shall convey the exact position that will give the best
exposure for the surgical procedure. The surgical assistant will carry out
this order. Consideration will be given to the patient's comfort and safety.
B. Points of pressure shall be padded: elbows, heels, knees, eyes, face, and
axillary region.
C. Circulation shall not be impaired. (A tourniquet may be required for some
procedures.)
D. Nerve damage shall be guarded against.
E. The temperature of the patient should be discussed with the anesthesia
personnel and methods employed to maintain the desired temperature
range.
F. The surgical assistant shall be familiar with common positions related to
the surgical procedure and will be able to use the equipment necessary to
provide the position. Competencies will include the following:
(1) Fracture tables
(2) Head stabilizers
(3) Body stabilizers
(4) C-arm extensions
(5) Any other equipment needed
G. Upon completion of the procedure, the patient shall be evaluated for any
possible damage from positioning which will include assessment of the
skin. The abnormal condition shall be reported to the surgeon and
treatment and documentation shall be carried out.
2. Providing visualization of the operative site by the following:
A. Appropriate placement and securing of retractors with or without padding
B. Packing with sponges
C. Digital manipulation of tissue
D. Suctioning, irrigating, or sponging
E. Manipulation of suture materials (e.g., loops, tags, running sutures)
F. Proper use of body mechanics to prevent obstruction of the surgeon's view
3. Utilizing appropriate techniques to assist with hemostasis
A. Permanent
(1) Clamping and/or cauterizing vessels or tissue
(2) Tying and/or ligating clamped vessels or tissue
(3) Applying hemostatic clips
(4) Placing local hemostatic agents
B. Temporary
(1) Applying tourniquets and demonstrating awareness of the
indications/contraindications for use with knowledge of side effects of extended use
(2) Applying vessel loops
(3) Applying noncrushing clamps
(4) Applying direct digital pressure
4. Participating in volume replacement or autotransfusion techniques as appropriate
5. Utilizing appropriate techniques to assist with closure of body planes
A. Utilizing running or interrupted sutures with absorbable or nonabsorbable
material of wound layers, including muscle and fascia.
B. Utilizing subcuticular closure technique with or without adhesive skin
closure strips
C. Closing skin with method per surgeon's directive (suture, staples, etc
D. Postoperative subcutaneous injection of local anesthetic per surgeon's
directive
6. Selecting and applying appropriate wound dressings, including the following:
A. Liquid or spray occlusive materials
B. Absorbent material affixed with tape or circumferential wrapping.
C. Immobilizing dressing (soft or rigid)
7. Providing assistance in securing drainage systems to tissue."


An interview was conducted on 6/30/2025 after 2:30 PM with Contract Staff #8. Contract Staff #8 was asked what part of the surgical procedure he performed. He stated that he performed as a surgical first assistant in cardiovascular (operating procedures dealing with the heart and blood vessels of the human body) procedures only. He stated that he had a certification of training in the Vasoview Endovascular Harvesting System (VEHS). The VEHS is a medical device system used to harvest blood vessels endoscopically, most commonly the Saphenous vein from the leg or the radial artery from the arm, for use in coronary artery bypass (CABG) surgery (surgery that replaces vessels of the heart). The VEHS is a minimally invasive surgical tool set that enables the removal of blood vessels through a small incision using an endoscopic tissue dissector and cautery tools to minimize trauma, reduce wound complications, and improve recovery time. Contract staff #8 was asked if he made the incisions (cuts into human tissue) and if he sutured (sewing material for human tissue) the incisions closed. Contract Staff #8 stated, "I do make the incisions and suture them closed".


A review of the operating room log revealed Contract Staff #8 was documented as the FA and performed FA duties in 6 (Patient 7, 8, 9, 10, 11, and 12) out of 6 patients having a CABG performed in the operating room (OR).
An interview was conducted with Contract Staff #8 on 07/08/2025 after 1:00 PM. Contract staff #8 confirmed he performed FA duties in 6 (Patient #7, 8, 9, 10, 11, and 12) of 6 patients reviewed.

According to the AST, a CST must not manipulate (alter living tissue during a surgical procedure) unless they have completed a recognized first assistant program and earned CSFA certification. This would include making incisions, suturing, or taking a vein for grafting.

A review of the credential file for Contract Staff # 8 confirmed he had a current certification for a CST. There was no certification for a SA/FA/CSFA. Contract Staff #8 was working outside his scope of practice as a CST.


During a review of the scope of practice for a CST and a SA/FA/CSFA on 07/01/2025 after 2 PM with Staff #1, 2, 3, 4, and 5 it was confirmed that the scope of practice required different training and certification.