Nursing Investigation Results -

Pennsylvania Department of Health
AMBULATORY SURGERY CENTER AT ST MARY, LLC, THE
Patient Care Inspection Results

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AMBULATORY SURGERY CENTER AT ST MARY, LLC, THE
Inspection Results For:

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AMBULATORY SURGERY CENTER AT ST MARY, LLC, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


This report is the result of a full State Licensure survey conducted on February 4, 2020, at Ambulatory Surgery Center at St. Mary. It was determined the facility was not in compliance with the requirements of the Pennsylvania Department of Health's Rules and Regulations for Ambulatory Care Facilities, Annex A, Title 28, Part IV, Subparts A and F, Chapters 551-573, November 1999.


 Plan of Correction:


Initial comments:


This report is the result of a State Licensure survey conducted on February 4, 2020, at Ambulatory Surgery Center at St. Mary. It was determined the facility was in compliance with the requirements of 35 P.S. 448.809 (b).



 Plan of Correction:


551.3 LICENSURE DEFINITIONS:State only Deficiency.
551.3 Definitions

Observations:


Based on a review of medical records (MR), and interview with facility staff (EMP), it was determined this Class C Ambulatory Surgical Facility failed to adhere to the definition of the facility to treat patients in one of one medical records reviewed (MR1)

Findings include:

State Regulation "551.3. Definitions. The following words and terms, when used in this subpart, have the following meanings, unless the context clearly indicates otherwise: ASF-Ambulatory surgical facility- (i) A facility or portion thereof not located upon the premises of a hospital which provides specialty or multispecialty outpatient surgical treatment. (ii) This does not include individual or group practice offices of private physicians or dentists, unless the offices have a distinct part used solely for outpatient surgical treatment on a regular and organized basis. For the purposes of this provision, outpatient surgical treatment means treatment to patients who do not require hospitalization, but who require constant medical supervision following the surgical procedure performed. Act-The Health Care Facilities Act (35 P. S. 448.101-448.904). Ambulatory surgery-Surgery which is performed: (i) On an outpatient basis in a facility which is not located in a hospital. (ii) On patients who do not require hospitalization but who do require constant medical supervision following the surgical procedure performed and whose total length of stay does not exceed the standards in this subpart."
Review on February 4, 2020, of "Bylaws of the Medical Staff of The Ambulatory Surgery Center at St. Mary", dated March 28, 2019, revealed "Whereas The Ambulatory Surgery Center at St. Mary is organized to provide ambulatory surgical and other related services consistent with the "Rules and Regulations for Ambulatory Surgical Facilities" (Commonwealth of Pennsylvania) ... and to provide the community it serves with a comprehensive program of ambulatory care that is safe ... and to operate a surgical center that is designed for the safe, efficient and effective management of medical and surgical procedures appropriate for an ambulatory setting ..."
Review on February 4, 2020, of policy "Procedure Selection", dated December 2019, revealed "Purpose: the purpose of this policy is to describe, in general terms, procedures that may be carried out at the Center. Policy: Procedures that may be scheduled at the Center include those that: ... g. Are not emergency or life threatening in nature ..."
Review on February 4, 2020, of MR1 revealed the patient had a procedure on December 12, 2019, at 08:00 AM at the facility. Further review of MR1's "Progress Note" revealed "Pt [patient] s/p [status post] tonsillectomy this AM. [Patient] was d/c'd [discharged] and then had bleeding. [Patient return[ed] and attempts were made to control bleeding at the bedside unsuccessfully. [Patient] will be taken to the OR for control." Further review of MR1's Anesthesia record revealed the patient was taken back to the OR for "Control of Tonsil Bleeding" at 2:00 PM. Review of MR1's "Operative Report" revealed "Procedure Performed: Control of Postoperative Tonsillectomy Hemorrhage ... Description of Procedure: ... [Patient had previously undergone tonsillectomy this morning and returned with the postoperative bleeding. It could not be controlled in the preoperative area, so [the patient] was taken to the operating room."

Interview with EMP1 on February 4, 2020, at approximately 10:45 AM confirmed the patient had a procedure on December 12, 2019, in the morning, went home, called the facility to report a complication, came back to the facility in the early afternoon, was seen by the surgeon for evaluation, and returned to the OR to control bleeding. EMP1 further confirmed the Ambulatory Surgical Facility is not an Emergency Surgical Facility.













 Plan of Correction - To be completed: 03/20/2020

Advised by DOH that violation is based on 551.21 (d)(4) defining this procedure as emergent. As such, The ASC at St. Mary has updated policy "Patient Discharge Criteria" #305 to reinforce procedure for patients needing treatment after discharge. All medical staff and employees will be educated via dissemination of this policy; topic discussed and documented at Patient Safety Committee, Owner's Meeting, and Board of Manager's Meeting. Executive Director and Director of Nursing will not permit treatment of discharged patients and will ensure the implementation of this plan of correction.

Any and all requests for a patient to return to the Center for treatment post-discharge or otherwise are presented to the Director of Nursing or Executive Director for review. In all cases, the DON and/or ED will redirect patient to surgeon or ER. Any patient who presents to an ER or returns to an OR after discharge is captured by our event log and PSRS reporting process - these are reviewed in detail quarterly at Patient Safety Committee. Staff and medical director are educated on these protocols.

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