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Certified registered nurse anesthetists (CRNAs) in California are pushing back after two hospitals in Modesto were hit with "Immediate Jeopardy" violations in part for CRNAs reportedly operating beyond their scope of practice.

CRNAs argued that California state policy allows them to operate without physician oversight, including ordering and administering anesthesia drugs independently.

But the California Department of Public Health (CDPH), operating on behalf of the Centers for Medicare & Medicaid Services (CMS), has maintained that CRNAs at Stanislaus Surgical Hospital and Doctors Medical Center cannot order medications or develop a treatment plan without physician oversight.

The California Association of Nurse Anesthesiology (CANA) has challenged the CDPH's findings, noting that a 2009 decision by the state to opt out of a CMS rule requiring physician supervision of CRNAs governs their current practice capabilities.

The Modesto Bee has reported that have been canceled or rescheduled as both hospitals suspended CRNA practice in response to the citations.

Stanislaus Surgical Hospital was hit with two Immediate Jeopardy citations -- one in August 2023 and another in January 2024.

Acting on behalf of federal regulators, the CDPH said a CRNA changed a doctor's order for general anesthesia for a surgery to higher-risk spinal anesthesia and sedation, according to the Bee. After surgery, that patient became unresponsive and had to be transferred to another hospital.

Overall, several patients had negative health outcomes following care provided by CRNAs and required transfer to a higher level of care.

The CDPH also said that hospital policy was that physicians oversee anesthesia -- and there were other issues, including problems with infection prevention and control, and sterilization processes.

In February, in response to the Immediate Jeopardy citation, Stanislaus Surgical Hospital suspended CRNA practice at the facility, .

In late May, Doctors Medical Center was hit with an Immediate Jeopardy notice, in part due to the use of CRNAs to sedate and monitor surgical patients.

The statement of deficiencies and plan of correction form, known as CMS-2567, has not been posted publicly and the Bee noted it likely will be months before documents are available.

The CDPH said it could not share documents for investigations that are ongoing.

The Bee reported that CRNA practice has been put on hold at Doctors Medical Center and that the hospital will revise its credentialing process for CRNAs.

CANA spokesperson Kaitlin Perry said in a statement to MedPage Today that there is "no debate about scope of practice, particularly in California, as CRNAs have practiced anesthesia care independently for decades."

CANA is calling on the CDPH to conduct an investigation into the citations at the hospitals and the resulting surgery cancellations (due to CRNA departures) in an "already underserved region," Perry said.

Not surprisingly, the California Society of Anesthesiologists (CSA) took a different viewpoint.

"We have long been an advocate for physician-led anesthesia care," CSA spokesperson Alison MacLeod told MedPage Today. Recent reporting on the surveys at Modesto hospitals "puts a very important spotlight on how hospitals and healthcare facilities are choosing to staff," she noted.

MacLeod added that "nurse anesthetists fill an essential role," and "we need more, just like we need more anesthesiologists." However, physician-level care shouldn't only be available to some patients, she said, adding that "we don't want to have any facilities trying to stretch resources in ways where there is not physician involvement."

Neither Stanislaus Surgical Hospital nor Doctors Medical Center responded to a request for comment.

Cheryl Clark contributed reporting to this story.

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