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Based on review of Governing Body Bylaws, physician credentialing files, and administrative interview, the facility failed to reappoint each physician as evidenced by the lack of written application by each physician to request reappointment and delineation of privileges. Findings:

Review of the credentialing file for Drs. S1, S2, and S3 revealed lack of documented evidence of a written request for reappointment to the medical staff at the end of the term established by the Governing Body.

Review of the Governing Body Bylaws (amended 02/09/08) Article VIII. MEDICAL STAFF; section 2 revealed the board shall review recommendations from the Medical Staff concerning reappointments and clinical privileges and make final approval of each. The Board also requires that each practitioner applying for medical staff membership and/or clinical privileges, sign an agreement to abide by the hospital bylaws and by the medical staff bylaws, rules and regulations.

Interview with S7 medical records staff on 2/16/2011 at 1:00 PM revealed the hospital had not required the physicians to submit an application for reappointment. S7 stated the Medical Staff approved each reappointment at one of their meetings without reviewing any recommendations or applications as evidenced by lack of a signed written application by each physician to request reappointment and delineation of privileges.

Interview with S4 Administrator on 2/16/11 at 2:00 PM confirmed Dr.S1, Dr.S2, and Dr. S3 had not submitted a written application for reappointment with delineation of privileges. S5 also confirmed proposed recommendations for review had not been submitted to the Governing Body from the Medical Staff.

Based on review of Governing Body meeting minutes from 1/2010 to 1/2011 and interview with S4 Administrator, the Governing Body failed to evaluate contracted services to ensure the services were provided in a safe and effective manner. This was evidenced by the failure to evaluate contracted services for lab, radiology, emergency department physicians, linens and waste management. Findings:

Review of Governing Body meeting minutes from 1/2010 to 1/2011 failed to reveal documentation that the governing body addressed any service provided to the hospital under contract. In an interview on 2/16/2011 at 2:30 PM, S4 Administrator stated she could not provide documented evidence that the Governing Body had evaluated contracted services since 2009.

Based on review of Medical Staff Bylaws, physician credentialing files, and administrative interview, the Medical Staff failed to make recommendations for reappointment for each physician as evidenced by lack of a written application for reappointment with delineation of privileges. Findings:

Review of the credentialing file for Dr. S1, DR. S2, and Dr. S3 revealed lack of documented evidence of a written request for reappointment to the medical staff at the end of the term established by the Governing Body.

Review of the Medical Staff Bylaws (approved 6/3/10) "Section 3. Terms of Appointment Subsection 1. Appointments shall be made by the governing Board after recommendations of the Medical Staff and shall be for the period of one year. Section 4. Procedure for Appointment: Subsection 1. Application for membership on the the Medical Staff be presented in writing on the prescribed form and shall state the qualifications and references of the applicant and shall also signify his agreement to abide by the Bylaws, Rules and Regulations of the Hospital. The application for membership on the Medical Staff shall be presented to the Administrator of the hospital who shall transmit it to the Secretary of the medical Staff". Under Subsection 3 the bylaws included "all proposed recommendations for new and reappointment's shall be submitted by the Credentials Committee to the Medical Staff for approval at a regular Medical Staff meeting".

Interview with S7 medical records staff on 2/16/2011 at 1:00 PM revealed the hospital had not required the physicians to submit an application for reappointment for Medical Staff to present for recommendation to the Governing Body. S7 stated the Medical Staff approved each reappointment at one of their meetings without reviewing any recommendations or applications as evidenced by lack a signed agreement agreeing to the bylaws, rules and regulations for the intended term of appointed membership.

Based on review of 3 of 3 open medical records of patients of Dr. S2 in a total sample of 18, review of Medical Staff Rules and Regulations (reviewed and approved 6/2010) and interviews, the hospital failed to ensure all orders were authenticated by the ordering physician. This was evidenced by the use of Dr. S2's "Standing Orders" which were preprinted, pre-signed by Dr. S2 and contained inaccurate information. Findings:

Review of the medical records of patients #1, #2, and #3 (patients of Dr. S2) revealed a form under physician orders in each of the 3 medical records that was titled, "(Dr. S2's) Standing Orders". Further review revealed the form was copied and contained a copied signature in the designated area for physician signature and had not been authenticated, dated or timed by Dr. S2. Continued review of the form revealed "as needed" orders for treatment of elevated temperature, nausea, vomiting, diarrhea, cough, minor lacerations, dyspnea, bladder distention, seizure activity, and sliding scale insulin. Additionally, the form also contained the following statement, "These above standing orders apply to adult patients only. All req____(blank area that did not copy) regarding pediatric patients should be referred to (Dr. S2) or ( name of a Family Nurse Practitioner who had not worked in the area for the past year)".

In an interview on 2/15/2011 at 2:00 PM S5 DON confirmed the nursing staff used the standing orders form for Dr. S2's patients. S5 also confirmed the form was copied, (including Dr. S2's signature) but the physician does not authenticate the copied signature. S5 DON also confirmed the form contained incomplete and inaccurate instructions about who to contact for pediatric patients.

Review of medical Staff Rules and Regulations (reviewed 6/2010) revealed that each practitioner must authenticate any documentation in the medical record for which he/she is responsible. An interview with S4 Administrator on 2/16/2011 at 4:30 PM confirmed the copied, pre-signed standing orders form should not be used and that the form was incomplete and contained inaccurate information.

Based on review of pharmacy quality data and interview with S9 Pharmacist, the hospital failed to ensure adverse drug reactions were reported to the pharmacist who is responsible for supervising and coordinating all activities of pharmaceutical services. Findings:

Review of pharmacy data submitted to quality council each month failed to reveal S9 Pharmacist was tracking adverse drug reactions. In an interview on 2/08/2011 at 12:15 PM S9 stated she was not informed when an adverse drug reaction occured and does not receive a copy of the report of the occurrence.

A. Based on observation and interview the hospital failed to ensure the safety and well being of patients by not maintaining the physical environment. Findings:

Observations on 2/08/2011 from 9:45 AM to 11:00 AM revealed the following:

Emergency Department;
1. Two environmental services staff were cleaning the ED (emergency department). Both employees had service carts containing mop buckets that had a thick build-up of dirt on the rims and in all crevices of the buckets.

2. There was a thick build-up of dust on the portable x-ray machine outside the ED.

3. The wheels and bottom of the 2 large oxygen cylinders and a portable oxygen tank had a thick build-up of dirt and grime.

4. Sterile packaged items were stored on glass shelving in cabinets in the ED trauma room. All shelving had a thick film of dust.

5. The papoose board (used to restrain children during procedures) was stored directly on the floor beside the pediatric crash cart and the straps were soiled.

6. The table that housed lab supplies and sterile water for inhalation treatments was dirty.

7. The cover was missing from a fluorescent light in the room.

8. All metal blinds had a thick build-up of dust and grime.

9. There was dirt and grime around the hopper in the treatment room.

10. All corners in and behind the doors in the treatment room and the trauma room had a thick build-up of dust and grime.

Radiology Department:
1. The white straps on the CT (computed tomography) table were very soiled.

2. There was thick dust under the x-ray table and on all areas of the room.


B. Based on observation and interview the hospital failed to ensure the safety and well-being of patients by having out-of-date medical supplies immediately available for patient use. Findings:

CT Department
On 2/15/2011 at 10:30 AM observation of the CT department revealed there were 5 (18G) Angiocaths (used to establish IV access for contrast) which expired in 3/08, 5 (18G) Angiocaths which expired in 9/08 and 34 (18G) Angiocaths which expired in 10/09.

Further observation revealed there were 3 Fleets Prep Kits which expired 3/07, 2 Fleets kits which expired in 9/07 and 1 Fleets kit which expired i2/08. An interview at that time with S8 radiology tech confirmed the items were out-of-date and immediately available for patient use.

Rural Helath Clinic-A
On 2/16/2011 at 12:45 PM observation of the supply room in the clinic revealed the following:

1. There were 11 (24G) angiocaths that expired 11/2010.

2. There were 3 packages of 4-0 silk suture that expired in 9/2007 and 14 packages of 3-0 silk sutures which expired 1/2011.

3. There was 1 bottle of Iodoform gauze which expired 11/2010.