2 No. 2548 Nov. 14. 2016 12:48°M Plen of Correction—Immediate Jeopardy November 9, 2016 stale: pep. OF PUBL: DIBNOY Ue PHI: 43 |ngicagioN Comective Action “SR FRSrieLD olsT- ie Tssue dentified Person Responsible Monitoring/Evidence of | Compliance | 1. On November 9, 2016 J, Nursing Director 1 & during the CDPH survey of Surgery, a. The surgcon in questio1 effective a. All surgeries during it was identified that one Chief of Surgery 11/09/16 voluntarily took a leave of which any portion of the surgeon performed high and/or OB Chief absence for 10 days during which time the procedure was risk and/or lengthy cases (when OB \ ‘Medical Executive Committee will convene performed after 1700 after hours without an cases), Chief of to discuss appropriate corrective action. The will be reviewed by the assistant despite existing Staff, CNO, Medical Executive Committee is scheduled Surgical Steering policy. COO, CEO. to meet 11/16/16. Hospital obtained a Committee biweekly or 2. 1 OR on call team 2. Nursing Director backup surgeon| cover from more frequently as covers emergency of Surzery, 11/09/16 at ea 0/16 at 1300. needed for 90 days after surgeries and C-sections CNO, COO, An additional Surgeor Jwas secured 11/9/16. Surgery between Spm-7am. CEO on 11/09/16 to cover from 11/10/16 at 1300 Committee will make 3. No plan to enforce: 3. Nursing Director until | '16 at 1800. An additional ‘final recommendation to existing policy and of Surgery, Surgeot is secured to cover 11/11/16 Medical Executive Chief of Surgery at 1800 I 11/14/16 at 1600. Surgeon Committee regarding 4, andjor OB Chief = secured to cover an 11/14/16 at ‘on-going monitoring (when OB i ‘until 11/21/16 at 1700. On 11/21/16 cases), Chief of at 1700, our regular scheduled General 5. No plan on how to Staff, CNO, ‘Surgeon| will resume his 10 day cali develop asecondOR | C©O0,CEO schedule. ‘permanent monitoring team. 4. Chief of Surgery program. 6. No plan on how to and/or OB Chief b. Implement policy that defines the types of b. All post hour cases will incorporate/include OB with surgery. No plan on how to have a second surgeon assistant available. (when OB ceases), Chief of Staff, Nursing Director of Surgery, CNO procedures considered to be high risk (see item 4 below) and/or lengthy in which a surgeon must utilize the services of an assistant and define when the assistant can be a PA rather than a physician ‘be forwarded to the Medical Staff Quality Review Committee. 2. ._Will develop OB/OR.P No, 2548 Now. 14. 2016 12:40PM AT pero PUBL and/or OB Chief (when OB cases), Chief of 6. Nursing Director of Surgery, CNO, Chief of Surgery, Chief of Staff 7. Nursing Director of Surgery, NO, COO, CEO 8, Nursing Director of Surgery, Chief of Surgery and/or OB Chief (when OB cases), Chief of Stal, CNO, C00, CEO A revision to policy #12-3038 was made to reflect the surgical after hours guidelines. OR Director to enforce the policy and escalate when necessary to the CNO, then to the Chief of Service, then to the Chief of Staff, and the CEO if necessary. . Surgeries that will require a second surgical assistant are: * Abdominal trauma iavolving blood loss and/or organ damage Bowel Resection Abdominal Aottic Aneurysms Open Thoracotomy Abdominal Perineal Resection Nephrectomy Splenectomy Gastric Bypass Open ‘Whipple Rue-N-Y Nissan Fundoplication 2. a. Follow our internal disaster list to ensure that coverage is available when needed, b, OB emergency team will be developed and implemented to serve as a second OR team for OB surgical cases (training and recruitment las already begun and will be ‘Competency Assessment tool. OB nurses will complete the ‘OB/OR Competency Assessment Tool upon completion of training and annually thereafter. All surgeries performed after 1700 will be reviewed by the Surgical Steering Committee biweekly or more frequently as needed for 90 days after 11/9/16, Surgery Committee will ‘make final recommendation to MEC. MEC will then take final action, All post hour cases will be forwarded to the Medical Stai¥ Quality Review Committee. ‘The éeily surgery schedule will be reviewed by the Director of Surgery the day prior to scheduled surgeries. . Any request for post hous surgeries will be_ iTALES pep oF PUBL PHI2L3 i completed within 120 days) through (I) The’ escalated to the Chief of 2 & CERTIFICATION cross training of OB nurses to provide Service, then to Chief of = BeGobist oFrice surgical support (IT) Recruiting CRNA staff Staff and the CEO if S necessary. < ©. All surgeries performed reviewed by Surgical progress) to support the team. ‘The team Steering Committee will be available on-site after 1700 Monday biweekly or more through Friday and on Saturdays, Sundays frequently as needed for and holidays. 90 days after 11/9/16 ¢. Recruit CRNA with an assigned Surgery Committee will anesthesiologist as a supervising physician. make final 4. Limit surgical cases performed during off recommendation to hours as described in item 1 above to help MEC. MEC will thea assure appropriate coverage for OB take final action. services, 4. All post hour cases will 3. OR Director to enforce the policy and be forwarded to the escalate when necessary to the CNO, then Medical Staif Quality then to the Chief of Review Committee. CEO ifnecessary. 4 4 policy (0 & srentiate levels of surgical risk t ‘Level I (Immediate Surgery) aie hours, will be = 1. Bleeding Emergencies escalated to the Chief of = 2. Immediate lifesaving, limb and organ saving Service, then to Chief of ra surgical intervention, Staff and the CEO if is necessary. = Level If (Surgery within 2 hours) b._All surgeries during = 3p. No. 2548 Nov. 14. 2016 12:49PM ied hernia, perforated viseus, diffuse peritonitis, soft tissue infection accompanied ‘with sepsis. 2. Administration of antibiotics upon diagnosis. Level II (Surgery within 4-6 hours) 1. Soft tissue infection (abscess) not accompanied with sepsis, 2. Administration of antibiotics upon diagnosis. Level IV Gurgery within 24 hours) 1. Ortho (hip), abscess not accompanied with sepsis. 2. Surgery scheduled in advance, intervention should occur during normal surgery hows. a. Policy revision process to approve ‘Surgical Risk Assessment P Surgical Committee approv. by Medical Executive Committee approval, followed by Board of Directors approval. Completion date 110/16, ency team will be devetoped and implemented to serve as a second OR team for OB surgical cases (training and recruitment has already begun and will be surgical support (II) Recruiting CRNA staff GID) Development of an anesthesiologist ‘which any portion of the procedure was performed after 1700 will be reviewed by the Surgical Steering Committee biweekly or mote frequently 2s, needed for 90 days after LIA/16. Surgery Committee will make final recommendation to Medical Executive Committee regarding on-going monitoring frequency. Medical Executive Committee will then implement permanent monitoring program, c. The tevision to policy #12-3038 will be reviewed/approved by Medical Imaging Committee, Surgery Committee, Medical Executive Committee s. a__Ongoing monitoring ofPp No. 2548 Nov. 14. 2016 12:49PM call list, (TV) Recruiting a surgical PA (V) Recruiting a surgical tech (currently in Prozres) to support the team. The team . OB emergency team will be developed and implemented to serve as a second OR team for OB surgical cases (training and recruitment has already begun and will be completed by 120 days) through (I) The cross training of OB nurses to provide surgical support (II) Recruiting CRNA staff (IID Development of an anesthesiologist call list, (IV) Recruiting a surgical PA (currently in progress) to support the team assistant surgeon (for emergency cases and/or cases requiting a second surgeon). ‘The hospital is presently recruiting an additional surgeon. "a. When the operating room team/room is available on-site after 1700 Monday | > the OB surgical team will be done through competency evaluation after initial training and ongoing annual competency evaluation thereafter. The OB Committee and Surgery Committee will review monthly all OB surgical cases performed after hours and report to the Medical Exceutive Committee and Board of Directors, . Ongoing monitoring of the OB surgical team will be done through initial and ongoing annual competency. by the hospital Safety Officer. . The surgeon on call list is continuously monitored by the Medical Staff officeNo. 2548 Li BAKER! TIFICATION GA Sbist Fri committed, the Emergency Department will ‘be immediately notified with instructions to transfer all surgical cases until OR capacity i sblished, When OR capacily is re- ed, a notification will be sent out via phone call and email, Both sets of notifications will be made by both phone call and email from the Director of Surgery or designee to the House Supervisor and to the ER Charge Nurse. b. Per the medical staff rules, if surgeon is called for consultation in the emergency department, the surgeon must be at the patient's bedside within 30 minutes, but no Jonger than 60 minutes. If the surgeon is unavailable and no back up surgeon is available within that allotted time frame, the Emergency Department will transfer all surgical cases until OR capacity/surgeon becomes available. The Emergency Department charge nurse will notify the ‘House Supervisor via phone call and email that of such an occurrence. ¢. We will provide surgeon back up coverage utilizing local surgeons and locum surgeons as necessary. b. ‘and reported to the NO. An emnail will be sent to the CEO, COO & CNO by the House ‘Supervisor informing them of any incident ‘when OR has reached ‘maximum capacity and is unable to established, an email will be sent by the House Supervisor to the CEO, COO & CNO to notify them that the OR ‘Noncompliance of ‘Medical Staff rules will be reported to the Service Committee, Peer Review ‘Conunittee and MEC. OR Director will add “Surgical Patient ‘Transfer due to OR at Nov. 14 2016 12:50PM8 P No. 2548 Now. 14.2016 12:50PM 2016NOY th py ya: 1 ena oo Full Capacity” to the OR Monthly PI. The PI will be reviewed at Service Committee(s) and Governing Board.