HospitalInspections.org

Based on record review the facility failed to ensure a physician's application that is was in compliance with facility policies for 1 of 5 physicians ( #5) to determine privileges to be granted. Failure to review the appropriate documentation of a completed application for credentialing and privileging as required by the facility places patients/clients at risk of not receiving necessary professional services.

Findings:

Review of Physician #5's personnel file revealed that this physician had failed to complete their Credentialing file with the facility as the personnel file revealed no:
1. professional references
2. Health Status statement, Delineation, and checklists
3. Certification and authorization
4. CME's, and copy of current license

Review of the facility's By-Laws, policy and procedures revealed that Practitioners wishing to provide services at The Centers are required to complete a Credentialing and Privileging Packet ( referred to as the "packet" in the remainder of this Policy) and submit it with required attachments to the Department of Human Resources as required by medical staff Bylaws page 1, dated 08/01/09

Further review revealed that physician #5 had not submitted the required attachments as of 03/18/10.

Based on record review and staff interviews the facility failed for 1 of 20, ( #6,), records reviewed to have physician's orders signed by the prescribing physician. Failure to ensure complete medical records places patients at risk for not receiving appropriate care and services.

Findings:

1. Review of the medical record for patient #6 revealed a form Appendix A titled Verification Of Need For Unscheduled Service dated 02/28/10 for Bio-Psycho- Social Evaluation that was not signed by a physician.

2. Interview with the Director of Nursing (DON) on 03/18/10 at 9:00 AM revealed that the physician is to sign orders within 24 hours of prescribing.

Based on record review and staff interview the facility failed for 2 of 20, (#1 and #8), records reviewed to have telephone physician orders signed by the physician. Failure to ensure complete medical records places patients at risk for not receiving appropriate care and services.

Findings:

1. Medical record review revealed that patient #1 had a telephone order (TO) written by nursing services from the physician, dated 03/12/10, for a Private room/several precautions. Further review revealed that the physician as of 03/18/10 had not signed this telephone physician order


2. Review of the medial record for patient #8 revealed admission TO orders dated 03/10/10 for Trazodone 50 milligrams (mg) for 1 day, for insomnia that was not signed by the physician as of 03/18/10. Additionally a TO written by nursing services from the physician assistant (PA) on 03/14/10 at 4:20 PM for Accuchecks-fasting in the morning (AM) with sliding scale of regular insulin; Metformin 500 mg 2 times a day; and Lidoderm 5% patch- may apply 3 patches daily which were not signed by the physician assistant (PA) as of 03/18/10.

3. Interview with the Director of Nursing on 03/18/10 at 9:00 AM revealed that the physician is to sign the telephone orders within 24 hours of prescribing that order.

4. Review of the Pharmacy Services Policy and Procedure Manual revealed policy #600, "Medication Orders," with an effective date of April 2008. Further review of this policy revealed, "II. Telephone Orders." According to this section, "Telephone or verbal orders are signed by the prescriber within 24 hours are part of the clinical record."