Advanced Dallas Hospitals and Clinics

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 10135 Based on interview and record review, the facility failed to ensure quality data that was collected was kept to show how they were analyzing and developing their performance improvements from February 2025-April 2025. This deficient practice had the likelihood to cause harm to all patients. Findings include: Review of the facility’s Quality dashboard revealed performance improvements listed with numbers and percentages listed for February -March 2025. During an interview on 04/14/2025 after 1:31 p.m.,Staff #2 (Chief nursing officer) revealed there were medical record and surgery audits being performed by staff. A request was made to see the data she had obtained so far, and Staff #2 (Chief nursing officer) said they had just started auditing about 2 weeks ago. When asked when staff were supposed to provide the information to her from the audits, she did not give a definitive answer. Staff #2 (Chief nursing officer) said the 1st quarter ended 03/31/2025. Staff #2 (Chief nursing officer) said their next department meeting was 04/22/2025 and that she would have staff provide the information quarterly. Review of the facility’s undated policy named “Quality Management Plan Chapter/Department Quality Improvement Policy Number Q101” revealed some of the following: “...V. FRAMEWORK FOR QUALITY MANAGEMENT... ..C. Data Collection collection of data helps the organization evaluate outcomes or determine the performance of functions or processes. When the data collection is systemic and used to: a) establish a performance baseline; b) describe process performance or stability; c) describe the dimensions of performance relevant to functions, processes and outcomes; d) identify areas for more focused data collection; and e) sustain improvement...””

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 10135 Based on interview and record review, the facility failed to develop and maintain an ongoing data drive quality program. The facility failed to ensure: A. Sentinel events involving deaths were thoroughly analyzed and performance improvements were identified (Patient #1). B. Data collection was kept to show how they were developing their performance improvements. C. There was a system in place to identify and develop internal performance improvements. D. The Quality Director had sufficient time to oversee the quality department. This deficient practice had the likelihood to cause harm to all patients. Findings include: Sentinel event Review of the record of Patient #1 revealed she was a 63 -year- old female who presented to the facility on 03/15/2024 for a right shoulder arthroscopic rotator cuff repair. Nurse notes dated 03/15/2024 at 1:14 p.m., revealed Patient #1 had diagnoses of hypertension and diabetes. According to a general nurses note dated 03/15/2024 at 1:15 p.m. Physician #12 and Staff #4 (Registered nurse/RN) were at Patient #1’s bedside performing a nerve block. Another general note dated 03/15/2024 revealed the procedure time- out was at 1:13 p.m. and started a 1:15 p.m. According to documentation Physician #12 and Staff #4 (RN) was at Patient #1’s bedside. Staff #4 (RN) was assisting Physician #12 with a supraclavicular nerve block of the brachial plexus. A sedative medication was administered prior to the procedure by Physician #12 and there was documentation to refer to see the anesthesia sheet. The ultrasound was at the bedside and the nerve stimulator was applied to Patient #1. Staff #4 (RN) aspirated nerve block needle and injected 25 milliliters of Bupivacaine 0.5% 150 milligrams/30 milliliters as instructed by Physician #12. Staff #4 (Registered nurse/RN documented that the aspirations were clear and that the ultrasound was not used per guidance of Physician #12. Patient #1 tolerated the procedure well and there were no adverse reactions. The procedure ended at 1:41 p.m. Review of Physician #12’s untimed intraoperative note for the nerve block revealed Patient #1 was given Bupivacaine 0.5 % (amount was left blank) and Lidocaine 2% 1cc. There was no documentation of who administered the medication. Review of Physician #12’s untimed post operative note revealed Patient #1 was given Bupivacaine 0.5 % 20cc and Decadron 10 milligrams. Prior to the injection Patient #1 received Midazolam 1 milligrams, Decadron 4 milligrams, Zofran 8 milligrams, and Toradol 30 milligrams. There was a discrepancy in what medications and the dosage that was administered during the procedure. Review of the personnel file on Staff #4 (RN) revealed there was no documentation of competencies or training on administration of anesthetic during nerve blocks. According to a general nursing note dated 03/15/2024 revealed Patient #1 was taken to the operating room at 1:42 p.m. At 1:55 p.m. sedatives and paralytics were administered by the anesthesiologist (Physician #12). At 2:12 p.m. Physician #12 asked the surgeon (Physician #11) to pause the draping of Patient #1 and said the monitor was not reading the ETCO2. The ETCO2 line was checked, and it was connected properly. The nurse noticed that there were no EKG and oxygen saturation readings. Patient #1’s radial pulse was checked and there was no pulse. A code blue was called. At 3:30 p.m. Patient #1 was transferred to another hospital for a higher-level of care. Physician #12 wrote a post anesthesia note dated 03/15/2025 and documented what occurred. Physician #12 documented that after Patient #1 was transferred out he went back to the operating room with the intention of retrieving the vital sign, ventilation and gas information but the cleaning crew had turned off the machine and monitors and the information was lost. Physician #12 documented that his immediate thoughts at the loss of the ETCO2, since the ventilation system was intact and the ET tube in place was a pulmonary embolus or a massive heart event. Patient #1 did not have signs of anaphylaxis or malignant hyperthermia. Physician #11 wrote a post procedure note dated 03/15/2025 and documented that prior to beginning surgery anesthesia report loss of end tidal CO2. Patient #1 was transition back to the supine position and CPR initiated. Successfully resuscitated and once 911 personal arrived Patient #1 was transported in critical condition to local intensive care unit. Review of the Patient #1’s record revealed inaccurate documentation and the inability to retrieve vital sign, ventilation and gas information before Patient #1 coded. There was no documentation of the nurse’s training for regional anesthesia adminstration while assisting with nerve blocks. During an interview on 01/27/2025 after 10:12 a.m., Staff #4 (RN) confirmed she assisted with the nerve block and injected the Bupivacaine as instructed. Staff #4 (RN) said Physician #12 refused to use the ultrasound and because it was taking so long, she called another nurse into the room just to watch. Staff #4 (RN) said that when there was positive aspiration, she did not give any of the medication, but when there was negative aspiration, she administered some of the medication. Staff #4 (RN) said it took 45 minutes to get the block. After the procedure Patient #1 was taken immediately to the operating room. Staff #4 confirmed she had not had any facility training with administering medications during nerve blocks, but she was under the direct supervision of the physician. During an interview on 01/27/2025 after 10:12 a.m., Staff #4 (RN) said that since the incident occurred and there had not been any practices changed in the operating room. She takes it open herself to not assist with a physician nerve block again who does use an ultrasound. Staff #4 (RN) said she had not been interviewed about the incident and she thought the anesthesia group did an investigation on the incident. During an interview on 01/27/2025 after 1:30 p.m., with Staff #7 (Operating room manager) revealed he was in the room when Patient #1 coded and assisted with the code. Staff #7 revealed that Patient #1 was transferred out to another hospital and ultimately died. Staff #7 said the chart was peer reviewed and went to Quality at Corporate. There were no identified concerns and no changes in their system. During an interview on 01/27/2025 after 2:04 p.m. with Staff #1 (Chief operating officer) revealed there were no system failures with the incident. One of the physician’s that use to work there reviewed the chart 2-3 days after the incident. It was sent to corporate, and she did not get any feedback. Quality minutes/ Performance improvements (PI’s)/Oversight Review of the Quality meetings for 06/11/2024 and 12/24/2024 revealed no documentation of the Code or Death on Patient #1. Review of the Dashboard revealed the following PIs were being looked at from January 2024 to December 2024. Ventilation weaning -( 0 was documented for the entire year). Hospital acquired ventilator associated pneumonia rate (0 was documented for the entire year). Days to Wean (0 was documented for the entire year). Decannulation (0 was documented for the entire year). Units of fresh frozen plasma Units of platelets Number of incident reports related to peri op services Number of procedures performed Consents prior to procedure Employee injuries Blood transfusions, Blood transfusion reactions Hand hygiene ER CT compliance Incident reports related to Radiology Mortality rate Total number of expirations Total number of discharges Organ donation compliance Patient Falls Patient Falls with injuries Infections Patient Satifaction Readmssions within 30 days Total inpatient volumes Total outpatient volumes Patient Adverse Events (communication with doctors and nurses), responsiveness of hospital staff to patient needs, hospital cleanliness and quietness, communication about medicines, and discharge information and patients’ understanding of care when leaving the hospital) During an interview on 01/27/2025 after 2:40 p.m., with Staff #3 (Chief nursing officer) revealed there was no formal documentation there and they did not keep any documentation of what’s reported to quality. Their quality meetings with Corporate were held quarterly. Staff #3 (Chief nursing officer) said that corporate had access to their information and current performance improvements (PI’s). The facility did not come up with internal PI’s, corporate determined their PI’s. During an interview on 01/28/2025 after 12:16 p.m., with Staff #3 (Chief nursing officer) revealed she over Quality, Risk management, Patient safety and infection control. Deaths or codes were reported out daily. Staff #3 (Chief nursing officer) said she immediately starting looking at the patient charts, finalize information, shared the information with corporate, chief operating officer, and then to the medical director. Staff #3 (Chief nursing officer) said she had just started working at the facility 04/2024 and was not there when the incident on Patient #1 occurred. Staff #3 (Chief nursing officer) said that the codes were supposed to go through quality. This incident would have been discussed in the June 11/2024 meeting, but it was pushed to end of August or September 2024. The last quality meeting in December 2024, but the incident not been discussed then. Staff #3 confirmed the information was not discussed in the Quality meetings. Staff #3(Chief nursing officer) said the facility had huddle meetings daily, but no documentation was kept. Staff #3 (Chief nursing officer) said she read off what everyone reported to her to corporate during the meetings, but that information was not kept. During an interview on 01/28/2025 after 12:54 p.m., Staff #8 (Corporate quality manager) confirmed some Quality meetings were not done because of staff turnover. Their 1st quarter was January-March (meeting date 2/52024), 2nd quarter April - June (meeting 6/11/2024), 3rd quarter July-September (meeting deferred because of staff turnover), and 4th quarters October- December (meeting 12/12/2024). During an interview on 01/28/2025 after 4:00 p.m., Staff #3 (Chief nursing officer) revealed that the facility did not have an Intensive care unit. The PI related to ventilator weaning was not an appropriate PI for this facility. Review of a facility’s policy named “SUBJECT:SENTINEL EVENT” dated 03/15/2019 revealed the following: “ ...POLICY Unexpected events or occurrences involving death or permanent harm or severe temporary harm (i.e.,sentinel events), shall be reported to the Performance Improvement Department immediately upon identification. Any sentinel event requires immediate action to examine, in-depth, the event do determine why the incident occurred and how to reduce the likelihood of recurrence..” Review of the facility’s undated “Quality Management Plan Chapter/Department: Quality Improvement Policy Number :QI01” revealed the following: ...IV. Quality Objectives: The objective of the Quality Management Program is to maintain and/or improve activities of the medical staff and hospital department/services by assessing processes that affect patient care and documenting and monitoring corrective and preventive action plans implemented ... ...Functions of Leadership The leadership of Advanced Diagnostics Healthcare System has the responsibility to take steps to promote safe, effective improvement of patient care and organization-wide functions. This includes planning, directing, implementing, coordinating services and improving services in a collaborative and interdisciplinary manner through: ...5) Allocating adequate resources for assessment and improvement of the organizations governance, managerial, clinical and support processes through: a)the assignment and training of personnel a well as providing adequate time for personnel to participate in quality improvement activities; ...”

“ORGANIZATION OF NURSING SERVICES CFR(s): 482.23(a) The hospital must have a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care. The director of the nursing service must be a licensed registered nurse. He or she is responsible for the operation of the service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital. This Standard is not met as evidenced by: 10135 Based on interview and record review, the facility failed to ensure nursing services was well organized. The Chief nursing officer was over Quality, Risk management, Patient safety and infection control and did not have a delineation of all her responsibilities regarding patient care. This deficient practice had the likelihood to affect all patients. Findings include: During an interview on 01/28/2025 after 12:16 p.m., with Staff #3 (Chief nursing officer) revealed she was also over Quality, Risk management, Patient safety and infection control. Review of the personnel file on Staff #3 (Chief nursing officer) revealed she had a signed job description for Director of Quality, Infection Control, Employee Health and education. The job description did not give a detailed outline of all of the Director of Infection responsibilities or the qualifications required. Review of the personnel file on Staff #3 (Chief nursing officer) revealed there was no job descriptions or delineation that outlined all her responsibilities for the Chief Nursing Officer, Director of Patient Safety or Risk Manager. During an interview on 01/28/2025 after 1:28 p.m. Staff #1(Chief operating officer) confirmed the missing documentation in the personnel files. During an interview on 01/28/2025 after 3:24 p.m., Staff #10 (Human resource director) said she did not have job decriptions on staff #3 for Risk Manager, Patient Safety or Chief nursing officer. She had just gotten the Chief nursing officer job description signed today (01/28/2025).”

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 10135 Based on interview and record review, the facility failed to ensure accurate and complete on 4 of 12 sampled patients (Patient #’s 1, 9, 10 and 11). The facility failed to ensure: A. Medication administration was documented accurately (Patient #1). B. Surgery charts were accurate. complete and legible (Patient #1, #10 and 11) C. Foley catheter removal were accurately documented (Patient #9). This deficient practice had the likelihood to cause harm to all patients. Findings include: Patient #1 Review of the record of Patient #1 revealed she was a 63 -year- old female who presented to the facility on 03/15/2024 for a right shoulder arthroscopic rotator cuff repair. Nurse notes dated 03/15/2024 at 1:14 p.m., revealed Patient #1 had diagnoses of hypertension and diabetes. According to a general nurses note dated 03/15/2024 at 1:15 p.m. Physician #12 and Staff #4 (Registered nurse/RN) were at Patient #1’s bedside performing a nerve block. MEDICATION ADMINISTRATION According to documentation Physician #12 and Staff #4 (RN) was at Patient #1’s bedside. Staff #4 (RN) was assisting Physician #12 with a supraclavicular nerve block of the brachial plexus. A sedative medication was administered prior to the procedure by Physician #12 and there was documentation to refer to see the anesthesia sheet. The ultrasound was at the bedside and the nerve stimulator was applied to Patient #1. Staff #4 (RN) aspirated nerve block needle and injected 25 milliliters of Bupivicaine 0.5% 150 milligrams/30 milliliters as instructed by Physician #12. Staff #4 (Registered nurse/RN documented that the aspirations were clear and that the ultrasound was not used per guidance of Physician #12. Patient #1 tolerated the procedure well and there were no adverse reactions. The procedure ended at 1:41 p.m. Review of Physician #12’s untimed intraoperative note for the nerve block revealed Patient #1 was given Bupivicaine 0.5 % (amount was left blank) and Lidocaine 2% 1cc. There was no documentation of who administered the medication. Review of Physician #12’s untimed post operative note revealed Patient #1 was given Bupivicaine 0.5 % 20 cc and Decadron 10 milligrams. Prior to the injection Patient #1 received Midazolam 1 milligrams, Decadron 4 milligrams, Zofran 8 milligrams, and Toradol 30 milligrams. There was a discrepancy in what medications and the dosage that was administered during the procedure. HISTORY AND PHYSICAL Review of the history and physical on the chart was dated 01/17/2024. The surgeon completed an updated history and physical on 03/15/2024. Which had documentation that the “H& P has been Reviewed and there are No Changes” There was a category on the form for significant medical history which listed HTN, DM, OSA and other. The marked through the category indicating Patient #1 had none of the diagnoses. The surgeon signed and dated the form but did not time to indicate it was done prior to the procedures. ANESTHESIA ASSESSMENT The anesthesiologist completed an initial assessment and reassessment on Patient #1 on 03/15/2024 but failed to time the forms to indicate they occurred prior to the procedure. Review of the procedure intraoperative anesthesia notes had documentation throughout the form that was not legible. The form was signed and dated but it was not timed. INTRAOPERATIVE NOTES Review of Physician #12’s intraoperative notes for the nerve block procedure revealed the time was 12 which was incorrect. The time out section was blank, amount of Bupivicaine given was left blank. Who injected the Bupivicaine was not included. The time the notes were completed was left blank. There was no documentation of vital signs on the form during the procedure. Review of the surgical procedure intraoperative anesthesia notes revealed documentation throughout the form that was not legible. The form was signed and dated but it was not timed. During an interview on 01/27/2025 after 12:59 p.m., Staff #3 (Chief Nursing Officer) confirmed the missing and illegible documentation in the record. Patient #9 FOLEY CATHETER CARE Review of a history and physical on Patient #9 dated 01/22/2025 revealed he was a 39-year old male who presented to the hospital for a lumbar fusion. Patient #9 was in severe intractable pain post operatively so he was admitted to the hospital for pain management and recommendations. According to the post anesthesia care unit notes dated 01/22/2025 at 4:54 p.m. revealed Patient #9 had an indwelling Foley catheter. Review of physician orders dated 01/22/2025 at 5:53 p.m. Patient #9 was to be admitted to the Medical surgical unit. 01/22/2025 at 6:27 p.m., Patient #9 had a physician’s order for an Indwelling Foley catheter. Review of physician orders dated 01/23/2025 at 3:09 p.m. revealed the Foley catheter was to be removed. Review of nurses notes dated 01/24/2025 at 6:44 a.m. there was documentation that there was noted hematuria in the catheter bag. “Patient had an indwelling catheter. Reported concern to the surgeon and the hospitalist. Hospitalist ordered a 3 way irrigation. Unable to find equipment for the procedure. ER charge nurse aware. Nurse emptied the catheter, Output was 2000 unit, changed the bag and continued to monitor urine output. Urine color was dark amber and Nurse emptied it the second time. Urine color is clearer. ..” Another physician’s order was written to remove the Foley catheter on 01/24/2025 at 8:53 a.m. Review of physical therapy notes dated 01/24/2025 at 9:20 a.m. revealed the Foley catheter was removed this morning. Review of physician’s orders dated 01/26/2025 at 5:53 p.m. Patient #9 was to be discharged home. During an interview on 01/28/2020 after 4:00 p.m. with Staff #3(Chief nursing officer) and Staff #9 (House supervisor) revealed they could not find documentation of where nursing documented the Foley catheter was discontinued or status of Patient #9 voiding capabilities before discharge. Staff #3 (Chief nursing officer) revealed they were having problems with their documentation since changing to their new charting system. Staff #9 (House supervisor) said that they needed a place in the new charting system to document their assessment on Foley catheters. Patient #10 Review of an “Emergency Nursing Triage” dated 01/27/2025 revealed Patient #10 was a 37 -year- old male who presented to the emergency department at 11:44 a.m., with chief complaints of a perianal abscess. According to an Emergency Physician record dated 01/27/2025 Patient #10 had a perianal abscess. Patient #10 had a general surgery consult and was being taken to the operating room today. The emergency department (ED) history and physical was dated 01/27/2025 and timed 12:50 p.m. Review of a “Pre-Operative Check List” dated 01/27/2025 at 3:37 p.m., revealed Patient #10 was having an excision of an external hemorrhoid. There was a stamp on the ED history and physical that it had been reviewed and there were no changes, but the surgeon failed to time to indicate it was reviewed prior to surgery. Review of an anesthesia consent revealed Patient #10 was going to receive general anesthesia. The anesthesia provider signed the consent, but failed to date and time the consent. Review of a “ANESTHESIA PRE-OP ASSESSMENT” dated 01/27/2025 revealed the physician signed the initial evaluation and reassessment but did not time the form. The intra-operative “ANESTHESIA FORM” had an area that read”Preanesthesia notes and patient reassessed immediately prior to induction of anesthesia.” There was a box for the anesthesia staff to check, but it was left blank. The category was signed but it was not timed. Review of the “POST ANESTHESIA EVALUATION” revealed the sections asking if patient able to participate in the evaluation, hydration status, post procedure nausea and or emesis, anesthesia complications was not addressed. The form was signed and dated, but not signed. Review of “POST OP ANESTHESIA PHYSICIAN ORDERS” revealed an order for the pain medication Hydrocodone 5/325 milligrams tablet. There was no notation of the frequency and how many tablets to administer. Patient #11 Review of a “Pre-operative Check List” dated 01/27/2025 at 10:10 a.m., revealed Patient #11 was a 39-year-old male who was presenting for a umbilical hernia repair. Review of a “ANESTHESIA PRE-OP ASSESSMENT” dated 01/27/2025 revealed the physician signed the initial evaluation and reassessment but did not time the form. The intra-operative “ANESTHESIA FORM” had a area that read”Preanesthesia notes and patient reassessed immediately prior to induction of anesthesia.” There was a box for the anesthesia staff to check, but it was left blank. The category was signed but it was not dated or timed. The free-handed notes written at the bottom of the form were not legible. Patient #11 was taken to the operating room on 01/27/2025 at 11:40 a.m. The surgery started at 12:13 p.m. and stopped at 12:35 p.m. Patient #11 signed the procedure consent at 9:30 a.m. and the surgeon signed the consent at 12:00 p.m.,after Patient #11 was in the operating room. The “POST ANESTHESIA EVALUATION” had a section to assess if Patient #11 had post procedure nausea and /or emesis and it was not addressed. The surgeon’s “IMMEDIATE POST-OP NOTE” was not timed. Review of “POST OP ANESTHESIA PHYSICIAN ORDERS” revealed an order for the pain medication Hydromorphone where the dosage was written in over the original dosage on the form and it was not legible. The physician orders were not timed. Review of the “HISTORY/PHYSICAL EXAMINATION” there was documentation in pre- op diagnosis of “Large” The physician signed that Patient #11 was an acceptable candidate for the surgery, but he failed to document if the patient had changes or not after the examination. The form was not timed to indicate it was completed prior to the surgical procedure. Review of a facility’s policy named “Title: Medical Record Content” and reviewed on 11/23/2021 revealed: “...STANDARD: The Hospital maintains a complete, timely, accurate, verifiable and accessible medical record that thoroughly documents the care provided each individual who receives treatment and services”....”

“OPERATING ROOM SUPERVISION CFR(s): 482.51(a)(1) The operating rooms must be supervised by an experienced registered nurse or a doctor of medicine or osteopathy. This Standard is not met as evidenced by: 10135 Based on interview and review, the facility failed to ensure there was a qualified operating room manager in place. Staff # 7 (Operating room manager) did not have the credentials that the facility’s job description required for the position he held since 2022. This deficient practice had the likelihood to cause harm to all patients receiving surgery. Findings include: Review of the personnel file on Staff #7(Operating room manager) revealed he had a signed job description and read: The Operating Room Manager has 24/7 responsibility for managing, supervising, and providing leadership for the Perioperative department staff and other nursing units. The manager is responsible for ensuring a positive environment for physician/staff relations ... QUALIFICATIONS (Education, Experience and Certifications) Education: Graduate of a school in professional nursing (Associate degree) is required/Bachelor’s degree is preferred. Certification, Licensure: Current state license to practice nursing is required. American Heart Association BLS, ACLS and PALS is required. Education, Knowledge, Training: 3 years’ experience in nursing is required. Previous management experience is preferred preferably in a hospital setting. The job description was signed off by Staff #7(Operating room manager) on 10/5/2022. Review of the personnel file revealed that Staff #7(Operating room manager) did not have a professional nursing degree, 3 years of nursing experience, ACLS certification, or a PAL’S certification. Review of the personnel file on Staff #7(Operating room manager) revealed he was a Certified Surgical Technologist (CST) also. There was no signed job description for a Certified Surgical Technologist on file. During an interview on 01/27/2025 after 1:30 p.m., Staff #7(Operating room manager) said he had been the operating room manager for 4 years. During an interview on 01/28/2025 after 1:28 p.m. Staff #1(Chief operating officer) confirmed the documentation in the personnel files. During an interview on 01/28/2025 after 3:24 p.m., Staff #10 (Human resource director) said she did not have job description on staff #7 for the CST position and that he signed one today (01/28/2025). During an interview on 01/30/2025 after 11:00 a.m., Staff #1 (Chief operating officer) said Staff #7 (Operating manager) had been in his position for 4 years. They were told that this was acceptable from someone. A request was made by the surveyor to provide documentation that that given to her showing it was acceptable, and none was provided.”

“ORGANIZATION OF ANESTHESIA SERVICES CFR(s): 482.52(a), (c) The organization of anesthesia services must be appropriate to the scope of the services offered. Anesthesia must be administered only by: (1) A qualified anesthesiologist; (2) A doctor of medicine or osteopathy (other than an anesthesiologist); (3) A dentist, oral surgeon, or podiatrist who is qualified to administer anesthesia under State law; (4) A certified registered nurse anesthetist (CRNA), as defined in §410.69(b) of this chapter, who, unless exempted in accordance with paragraph (c) of this section, is under the supervision of the operating practitioner or of an anesthesiologist who is immediately available if needed; or (5) An anesthesiologist’s assistant, as defined in Sec. 410.69(b) of this chapter, who is under the supervision of an anesthesiologist who is immediately available if needed. State Exemption (1) A hospital may be exempted from the requirement for MD/DO supervision of CRNAs as described in paragraph (a)(4) of this section, if the State in which the hospital is located submits a letter to CMS signed by the Governor, following consultation with the State’s Boards of Medicine and Nursing, requesting exemption from MD/DO supervision of CRNAs. The letter from the Governor must attest that he or she has consulted with State Boards of Medicine and Nursing about issues related to access to and the quality of anesthesia services in the State and has concluded that it is in the best interests of the State’s citizens to opt-out of the current MD/DO supervision requirement, and that the opt-out is consistent with State law. (2) The request for exemption and recognition of State laws, and the withdrawal of the request may be submitted at any time, and are effective upon submission. This Standard is not met as evidenced by: 10135 Based on interview and record review, the facility failed to ensure anesthesia services was appropriate to the scope of services offered. The facility failed to ensure nursing staff had competencies in providing regional anesthetic agents and assisting with insertions of nerve blocks in 1 of 12 charts reviewed (Patient #1). This deficient practice had the likelihood to cause harm to all patients receiving nerve blocks. Findings include: Review of the record of Patient #1 revealed she was a 63 -year- old female who presented to the facility on 03/15/2024 for a right shoulder arthroscopic rotator cuff repair. Nurse notes dated 03/15/2024 at 1:14 p.m., revealed Patient #1 had diagnoses of hypertension and diabetes. According to a general nurses note dated 03/15/2024 at 1:15 p.m. Physician #12 and Staff #4 (Registered nurse/RN) were at Patient #1’s bedside performing a nerve block. Another general note dated 03/15/2024 revealed the procedure time- out was at 1:13 p.m. and the procedure started a 1:15 p.m. According to documentation Physician #12 and Staff #4 (RN) was at Patient #1’s bedside. Staff #4 (RN) was assisting Physician #12 with a supraclavicular nerve block of the brachial plexus. A sedative medication was administered prior to the procedure by Physician #12 and there was documentation to refer to see the anesthesia sheet. The ultrasound was at the bedside and the nerve stimulator was applied to Patient #1. Staff #4 (RN) aspirated nerve block needle and injected 25 milliliters of Bupivicaine 0.5% 150 milligrams/30 milliliters as instructed by Physician #12. Staff #4 (Registered nurse/RN documented that the aspirations were clear and that the ultrasound was not used per guidance of Physician #12. Patient #1 tolerated the procedure well and there were no adverse reactions. The procedure ended at 1:41 p.m. Review of Physician #12’s untimed intraoperative note for the nerve block revealed Patient #1 was given Bupivicaine 0.5 % (amount was left blank) and Lidocaine 2% 1 cc. There was no documentation of who administered the medication. Review of Physician #12’s untimed post operative note revealed Patient #1 was given Bupivicaine 0.5 % 20 cc and Decadron 10 milligrams. Prior to the injection Patient #1 received Midazolam 1 milligrams, Decadron 4 milligrams, Zofran 8 milligrams, and Toradol 30 milligrams. There was a discrepancy in what medications and the dosage that was administered during the procedure. Review of the personnel file on Staff #4 (RN) revealed there was no documentation of competencies or training on administration of regional anesthetic agents during nerve blocks. During an interview on 01/27/2025 after 10:12 a.m., Staff #4 (RN) confirmed she assisted with the nerve block and injected the Bupivicaine as instructed. Staff #4 (RN) said Physician #12 refused to use the ultrasound and because it was taking so long she called another nurse into the room just to watch. Staff #4 (RN) said that when there was positive aspiration she did not give any of the medication, but when there was negative aspiration she administered some of the medication. Staff #4 (RN) said it took 45 minutes to get the block. After the procedure Patient #1 was taken immediately to the operating room. Staff #4 confirmed she had not had any formal facility training with administering medications during nerve blocks, but she was under the direct supervision of the physician. During an interview on 01/27/2025 after 1:30 p.m., Staff #7(Operating room manager) said he had been the operating room manager for 4 years. The nurses were not supposed to push the anesthesia agent and should let the physicians know up front. During an interview on 01/27/2025 after 12:59 p.m., Staff #3 (Chief nursing officer) revealed there was no training for Staff #4 (RN) in regard to assisting and administering regional anesthesia during nerve blocks.”