HospitalInspections.org

Based on physician credential review, Medical Staff Bylaws review and interview, it was determined the Medical Staff failed to reappraise the privileges for one of one (Physician #1) physician whose privileges were expired. The failed practice did not ensure the physician was practicing with the approval of the Medical Staff and had the potential to affect all patients treated by that physician. The findings follow:

A. Review of the Physician #1 credential file on December 07, 2011, revealed a letter dated February 18, 2010 that stated, "Your appointment will end on November 01, 2011." There was no evidence the physician's privileges were reviewed or renewed after November 01, 2011.
B. The findings were confirmed in an interview with the Administrative Assistant/Medical Staff Coordinator on December 07, 2011 at 1430.