HospitalInspections.org

Based on record review and interviews, the hospital failed to:

(1) conduct periodic appraisals of its medical staff (refer to A340),

(2) examine the credentials of all eligible candidates for medical staff membership and make recommendations to the governing body on the appointment of the candidates (refer to A341), (3) be well organized and accountable to the governing body for the quality of the medical services provided to the patients (refer to A347),

(4) enforce bylaws to carry out its responsibilities (refer to A353), and

(5) include criteria for determining the privileges to be granted to individual practitioners and a procedure for applying the criteria to individuals requesting privileges (refer to A363). The cumulative effect of these systemic deficient practices resulted in noncompliance with the Condition of Participation for Medical Staff. These deficient practices have the potential to place patients at risk for not receiving safe and effective care.

Based on interviews and record review, the medical staff failed to periodically appraise the qualifications of all practitioners granted membership on the medical staff. This deficient practice has the potential to affect patient care and treatment due to lack of evidence of qualifications and competencies specific to the members' area of expertise. The findings are:

A. On 02/28/17 at 9:05 am, during an interview, the Chief Nursing Officer (CNO) stated that appraisals of medical staff members were not conducted.

B. On 02/28/17 at 3:00 pm, during an interview, the Executive Assistant / Medical Staff Services clerk stated that she is not currently keeping track of appraisals.

C. Review of medical staff records confirmed that there were no appraisals on file for 13 of 13 records.

Based on interviews and record review the hospital failed to examine the credentials of all eligible candidates for medical staff membership and make recommendations to the governing body on the appointment of the candidates. This deficient practice has the potential to fail to identify the lack of eligibility for the scope of practice requested by candidates practicing at the hospital. The findings are:

A. On 02/28/17 at 9:05 am, during an interview, the Chief Nursing Officer (CNO) stated that at this time there is no mechanism in place to identify specialties in credentialing and that each eligible candidate has identical privilege delineation (Delineation of privileges refers to the process by which clinical privileges are requested, recommended, and granted). The CNO further stated that eligible candidates are typically "over credentialed, beyond what the hospital can provide."

B. On 02/28/17 at 3:00 pm, during an interview, The Executive Assistant / Medical Staff Services clerk stated that eligible candidates can pick what privileges they want on a check-off list. The Executive Assistant / Medical Staff Services clerk further stated that eligible candidates will "write in" what they would like expanded to their privileges.

C. Review of medical staff records revealed that 13 of 13 records had identical privilege delineation documents. The records further revealed handwritten expanded privileges by the eligible candidates.

Based on interviews and record reviews the medical staff failed to be well organized and accountable to the governing body for the quality of the medical services provided to the patients. This deficient practice has the potential to affect patient care and safety due to lack of oversight by the governing body. The findings are:

A. On 02/28/17 at 9:05 am, during an interview, the Chief Nursing Officer (CNO) stated during this interview that there has been a lack of accountability regarding credentialing. The Chief Executive Officer (CEO) stated that Medical Executive Committee (MEC) minutes had not been completed for the previous year [2016].

B. On 02/28/17 at 3:00 pm, during an interview, the Executive Assistant / Medical Staff Services clerk stated that the previous CEO did not pay much attention to credentialing and did not manage the process.

C. Review of MEC minutes revealed that no minutes were documented for 2016.

Based on interviews the medical staff failed to enforce bylaws to carry out its responsibilities. This deficient practice has the potential to affect patient care and safety due to lack of oversight. The findings are:

A. On 02/28/17 at 9:05 am, during an interview, the Chief Executive Officer (CEO) stated that oversight from the governing body was lacking and it was assumed that medical staff services were following up on credentialing. The Chief Nursing Officer (CNO) also stated that the bylaws needed to be revised and enforced as this was not currently done.

B. On 02/28/17 at 3:00 pm, during an interview, the Executive Assistant / Medical Staff Services clerk stated that the previous CEO did not pay much attention to credentialing and did not manage the process. The Executive Assistant / Medical Staff Services clerk also stated that she is not currently keeping track of appraisals.

C. Review of hospital bylaws revealed that periodic appraisals were to be conducted prior to the the reappointment of medical staff.

Based on interviews and record review the medical staff bylaws failed to include criteria for determining the privileges to be granted to individual practitioners and a procedure for applying the criteria to individuals requesting privileges. This deficient practice has the potential to affect patient care and safety due to lack of oversight of medical staff by the governing body. The findings are:

A. On 02/28/17 at 9:05 am, during an interview, the CNO (Chief Nursing Officer) stated that at this time there is no mechanism in place to identify specialties in credentialing. At this time, each practitioner has identical privilege delineation (Delineation of privileges refers to the process by which clinical privileges are requested, recommended, and granted). The CNO further stated that all practitioners are "over credentialed, beyond what the hospital can provide."

B. On 02/28/17 at 3:00 pm, during an interview, the Executive Assistant / Medical Staff Services clerk stated that members are able to pick what privileges they want on a check-off list. The Executive Assistant / Medical Staff Services clerk further stated that individual practitioners will "write in" what they would like to expanded to their privileges.

C. Review of medical staff members' records revealed that 13 of 13 records had identical privilege delineation documents. The charts further revealed handwritten expanded privileges by the individual practitioners.