HospitalInspections.org

Based upon review of the Quality Assurance/Performance Improvement program and data, and staff interview, the hospital failed to ensure a mechanism was established to evaluate the quality of each contracted service. Findings:

Review of the Quality Assurance/Performance Improvement Program and associated data revealed there failed to be documented evidence contracted services were evaluated through the program. Interview with the Director of Quality RN S10 on 04/18/12 at 10:50 AM confirmed contracted services were not evaluated through the QA program.

Based upon staff interview and review of contracted services, the hospital failed to ensure a list of all contracted services was maintained and included the scope and nature of the service. Findings:

On 04/18/12 at 10:50 AM, interview with Registered Nurse (RN) S10 revealed when the list of contracted services was requested, RN S10 responded the hospital did not maintain a list of any contracted services.

Based upon review of 1 of 8 physician credential files (S2), Medical Staff Bylaws, and staff interview, the Medical Staff failed to ensure the Bylaws were followed as evidenced by failure to ensure the Temporary Privileges for physician S2 were granted for 120 days as indicated in the Medical Staff Bylaws. Findings:

Review of the Medical Staff Bylaws revealed under Article VII, Clinical Privileges, Section 2, Temporary Privileges "2.3 Temporary privileges granted to any practitioner will be at the discretion of the President of the Medical Staff. Temporary privileges are granted for 120 days and will occur only two times within the calendar year."

Review of the credential file of physician S2 revealed the physician applied for Temporary privileges in May 2011. The Chairman of the Board indicated he signed the privileges on 03/15/12, the President of the Medical Staff signed the privileges; however, failed to document the date it was signed, and the Secretary of the Governing Board signed and dated the form on 09/19/11.

Interview on 04/17/12 at 2:30 PM with the Medical Staff Coordinator confirmed the Medical Staff bylaws were not followed related to the Temporary privileges granted to physician S2.

There failed to be evidence the Medical Staff followed their Bylaws and ensured physician S2's Temporary privileges were granted for 120 days.