• Failed to acquire proper informed consent for 100% of the charts reviewed. The physician did not discuss the comparative risks, benefits, and alternatives to having a procedure in an ambulatory surgery center versus a hospital. This disclosure is required by law.
  • The staff failed to ensure that the patient was properly assessed according to discharge protocol before discharge for 100% of the charts reviewed.
  • Two of the physicians performing procedures at this facility did not have a background check from the national clearinghouse as required. The National Practitioner Data Bank is a workforce tool that prevents practitioners from moving state to state without disclosure or discovery of previous damaging performance.
  • In 100% of the charts reviewed, the patients who received local anesthesia did not have a physical on file.
  • The surgeon failed to properly identify the patient before surgery in 100% of the charts reviewed.
  • There was no post-operative surgical report dictated in 100% of the charts reviewed.
  • There was no registered nurse on the quality assurance committee as required by regulation.
  • There was no written policy regarding the preservation of medical records.
  • Medical records were not accurate and complete. There was no date or authentication on entries.
  • The facility had no committee for infection prevention, control, and investigation at the facility.
  • There was no policy that prohibited unauthorized personnel in the surgical area.
  • Employees did not have infection control training or education.
  • There was no emergency call system in the operating room and in the recovery area.
  • The staff failed to monitor the temperature and humidity levels in the surgical suite. There was no policy regarding the monitoring of the temperature and humidity and there was no inspection of the ventilation system.
  • The facility failed to establish a workable plan with the nearest fire department in case of an emergency.
  • There were no automatic sprinklers in the building. There were no automated or manual fire alarms.
  • No quarterly fire drills were conducted.
  • There was no emergency call bell in the patient restroom.
  • The facility was not in compliance with construction guidelines for ambulatory surgical facilities.
  • The facility failed to have emergency equipment available for resuscitation purposes for procedures using local anesthesia.
    • No cut down trays
    • Oxygen tanks were empty
  • Staff failed to administer Rhogam to an Rh negative patient. There was also no documentation that the patient had refused the injection.
  • The staff failed to notify a patient within seven days of a serious event because they had no patient safety officer.
Report 2012 Report 2013 Report 2018
DISCLAIMER: All of the inspection reports on this site were acquired through public records request to state departments of health and public records online.