Federal officials ordered York Hospital to take corrective action last year because two doctors who were not licensed in Maine participated in surgeries there.

A report by the federal Centers for Medicare and Medicaid Services described two incidents that occurred last year. In March, a vascular surgeon who was on call for the hospital but not licensed in Maine operated on a patient. In August, the father of a patient was allowed to participate in her cesarean section birth.

The CMS investigated the March incident after someone filed a complaint. The report contains little information but says the hospital did not immediately conduct a review of what happened.

Jody Merrill, a hospital spokeswoman, said in an email that the surgeon involved was licensed in New Hampshire and was minutes away from York Hospital.

“This was an emergency situation during which a licensed surgeon was in close proximity to the hospital and performed a lifesaving procedure for our patient,” she said.

After CMS investigated, the hospital submitted a plan that included training staff on the need for all doctors to have Maine licenses even in emergency situations.

The hospital reported the August incident to CMS, which was detailed extensively in the report.

A woman had gone to the hospital to deliver her child, through cesarean. Her father, a doctor, accompanied her and expressed interest in “scrubbing in” – participating in the surgical team and the patient consented. Some hospital staff expressed concerns, but the attending surgeon said she was aware of the father’s interest and had received permission from the hospital’s chief executive on a similar request two years earlier.

“In hindsight, I did not revisit the situation,” the surgeon told federal officials. “In my mind the father had a medical license and he did the same as a student would do … I’m 100 percent responsible … I allowed him to scrub … I didn’t really think about it.”

The anesthesiologist involved also took responsibility. “In retrospect, I should have been concerned as I am the last gatekeeper,” he said, according to the report.

One of the nurses told federal officials that there was confusion in the operating room about what to do. “It was unclear if (the father) had privileges,” the nurse said.

The hospital CEO was notified that the father would be “scrubbing in” but assumed that meant observing, not participating.

The deficiencies were first reported by the Bangor Daily News.

In a statement provided to the Press Herald, the hospital acknowledged that it was not in compliance with federal regulations but also defended the actions of its staff.

“Based on our respect for CMS as well as our pledge to excellent patient care and full transparency, York Hospital recently self-reported to CMS about an instance which questions our compliance with their regulations. During this instance, our esteemed clinical staff made the safety and wishes of our patients their top priority,” the statement read. “There was absolutely no harm to the patients. To maintain our patients’ privacy, we are unable to provide further details about this case. Although, this instance was not in CMS compliance, York Hospital gave preference to our patient’s wellbeing and ensured positive outcomes for them and their families.”

The statement also said the hospital is taking steps to ensure that a similar incident doesn’t happen in the future, including better communication among physicians and administrators.

York Hospital is a full-service 80-bed facility that serves primarily southern York County. It’s affiliated with Massachusetts General Hospital.

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