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HOSPITAL PAVIA SANTURCE
MEDICAL STAFF CREDENTIALING
Tag No.: A0341
Based on the review of ten medical staff credentials files, it was determined that the facility failed to evalaute Credentials Files (C.F) to ensure that the medical staff have updated Cardiopulmonary Resuscitation (CPR), Malpractice, Influenza Vaccine, Health Certificate, Medical Appointment and Criminal Record for 6 out of 10 (C.F #3, #4, #7, #8, #9 and #10).
Findings include:
1. During the review of medical staff credential files with the Faculty Assistant (employee #8) on 07/24/2024 at 8:30 AM the following was found:
a. C.F # 3, #4 and #9 of the medical staff criminal records were expired since 2023.
b. C.F #8 and #9 of the medical staff medical appointments were expired since 2023.
c. C.F #4, #7, #8, #9 and #10 of the medical staff health certificate were expired since 2023.
d. C.F # 8 of the medical staff malpractice was expired since 2023.
e. C.F #9 and #10 of the medical staff cardiopulmonary resuscitation were expired since 2023.