HospitalInspections.org

The hospital reported an average daily census of 3.3 patients with a current census of three patients, two acute and one swing bed patients. Based on Medical Staff Credentialing file review and staff interview the hospital Governing Body failed to ensure medical staff had a complete reappointment file for four of eight Medical Staff Credentialing files reviewed (Medical Staff E, F, G, and H). This deficient practice had the potential to affect quality patient care.

Finding include:

- The hospital's Medical Staff Bylaws, Rules and Regulations reviewed on 7/10/14 at 9:10am directed, "...Reappointments and appointments shall be for a period of two medical staff years...The credentials file shall consist of...applications for renewal...National Practitioner Data Bank queries..."

- Medical Staff E's credentialing file reviewed on 7/9/14 at 1:00pm revealed a reappointment date of 7/9/14. The credential file failed to include a National Practitioner Data Bank report (a federal background check for health care providers). The Governing Body failed to ensure practitioner E, an active staff physician, had a complete reappointment file.

- Certified Registered Nurse Anesthetist Staff F's credentialing file reviewed on 7/9/14 at 1:00pm revealed a reappointment date of 10/7/13. The credential file failed to include a National Practitioner Data Bank report. The Governing Body failed to ensure practitioner F had a complete reappointment file.


- Medical Staff G's credentialing file reviewed on 7/9/14 at 1:00pm revealed a reappointment date of 7/9/14. The credential file failed to include an application and a National Practitioner Data Bank report. The Governing Body failed to ensure practitioner G, listed as the hospital's consulting pathologist, had a complete reappointment file.

- Medical Staff H's credentialing file reviewed on 7/9/14 at 1:00pm revealed a reappointment date of 7/9/14. The credential file failed to include a National Practitioner Data Bank report. The Governing Body failed to ensure practitioner H, a consulting dentist, had a complete reappointment file.


Medical Records staff C interviewed on 7/9/14 at 2:15pm acknowledged Medical Staff E, F, G, and H failed to have a complete reappointment file when the Governing Body reappointed them to the Medical Staff.

The hospital reported an average daily census of 3.3 patients with a current census of three patients, two acute and one swing bed patients. Based on medical record review, Medical Staff Rules and Regulations, and staff interview the hospital failed to ensure the providers complete a history and physical within twenty-four hours after admission for two of ten sampled inpatients (#'s 10 and 11). This deficient practice had the potential to affect the patient's planned course.

Findings include:

- The hospital's Medical Staff Rules and Regulations reviewed on 5/27/14 at 4:00pm directed, "...A complete history and physical examination shall be written or dictated within twenty-four hours after admission of the patient..."

- Patient #10's closed medical record reviewed on 7/9/14 revealed an admission date of 5/29/14 and discharged on 6/2/14 with diagnoses of diabetes. Patient#10's history and physical indicated a completion date of 6/18/14 (20 days after admission).

- Patient #11's medical record reviewed on 7/8/14 revealed an admission date of 7/5/14 with a diagnosis of anxiety. Patient #11's medical record lacked a history and physical (three days after admission).

- Review of Medical Records quality assurance study between 5/28/14 to 7/8/14 on 7/9/14 at 1:00pm revealed the hospital had 24 admissions requiring a history and physical within 24 hours. The study revealed 18 admissions lacked a history and physical within 24 hours of admission.

Medical Records staff C interviewed on 7/9/14 at 1:00pm acknowledged hospital Medical Staff failed to complete the required history and physical within twenty-four hours after admission for patients #10 and #11 and their quality assurance study revealed Medical Staff were less than 50% compliant with completion of a history and physical within 24 hours.

The hospital reported an average daily census of 3.3 patients with a current census of three patients, two acute and one swing bed patients. Based on observation, staff interview and document review, the hospital's infection control officer failed to develop an active infection control system ensuring hospital personnel followed basic infection control practices during one of one blood draw observation of laboratory personnel. This deficient practice places patients at risk for hospital-acquired infections.

Findings include:


- The hospital's policy for hand hygiene reviewed on 7/10/14 at 8:00am directed, "...hand hygiene after touching blood, body fluids, secretions, excretions, and contaminated items, regardless of whether or not gloves are worn...It is necessary to perform hand hygiene immediately after gloves are removed, between patient contact, when otherwise indicated to avoid transfer of microorganisms to other patients or environment..."

- The hospital's policy for cleaning of patient care equipment, reviewed on 7/10/14 at 8:00am directed, "...All medical equipment used for patient care must be cleaned and disinfected using a disinfectant or wipe before use on another patient..."


- Laboratory staff D, observed on 7/8/14 at 11:00am performed a blood draw on patient #17. Staff D entered patient #17's room performed hand hygiene, applied gloves, laid a lab tray on an empty bed frame, then removed their gloves and left the room without performing hand hygiene. Staff D reentered patient #17's room without performing hand hygiene, applied gloves, moved the lab tray to patient #17's bedside table, and placed blood draw supplies and biohazard bag on patient #17's bed. Staff D obtained blood from two sites and placed the tubes in the biohazard bag. Staff D removed their gloves, performed hand hygiene, removed the lab tray that sat directly on patient #17's bedside table and the biohazard bag that sat on patient #17's bed and left patient #17's room without disinfecting the lab tray and the biohazard bag.

Staff D interviewed on 7/8/14/14 at 11:45am, acknowledged they should perform hand hygiene when entering patient rooms, leaving patient rooms, after glove removal, and should disinfect patient care equipment after use.