Texas Ambulatory Surgical Center

Clinic is Closed

• The facility did not have a RN employed at the facility. The doctor said that he performs all RN duties and he thought that because he cannot perform procedures because he has no hospital admitting privileges that it would be okay for him to perform all of the registered nursing activities that are required. The physician does not have a registered nursing license.
• An operating room assistant was present during all the procedures and stated there has not been a registered nurse there in her 4 years of employment. She assists him with all procedures.
• The facility was using expired medications and supplies. Included in these supplies were some as old as 12 years.
• Facility failed to establish policies and procedures overseeing and evaluating the clinical activities of certified registered nurse anesthetists. There was no policy to verify qualifications of certified registered nurse anesthetists. No policy for oversight in anesthesia services.
• Failed to ensure facility implement and enforce a policy to ensure compliance with health and safety code relating to informed consent. Patients informed consent did not accurately reflect which staff and physicians performed their procedures.
• Failed to properly train staff. No Documentation of nurses license or CPR training.
• Failed to accurately document patient records. Patient records were missing pre-anesthesia evaluations by individuals qualified to administer anesthesia.
• Unlicensed, unqualified, untrained staff providing patient care. Investigation found non-qualified staff performing pre-anesthesia evaluations (incorrectly and incompletely).
• Failure to comply with building standards. One out of four restrooms had working call systems for emergencies.