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Tag No.: C0241
Based on review of the facility's Medical Staff Bylaws and Credential Manual, credential files (CF), and staff interview (EMP), it was determined the facility failed to ensure physician requests for reappointment privileges reflected the physician's ability for one of two credential files reviewed (CF1).
Findings include:
Review on January 3, 2013, of the facility's "Medical Staff Bylaws," last approved May 12, 2011, and effective July 1, 2011, revealed "Preamble ... All licensed practitioners are credentialed and privileged by the medical staff. ... The hospital's Board of Directors, which has the ultimate authority and responsibility for the oversight and delivery of health care rendered by licensed practitioners privileged through the medical staff process or any equivalent process, delegates the responsibility to the members of the medical staff and its leaders to organize and conduct its affairs consistent with the mission of the hospital, applicable laws, regulations and accreditation standards and in the best interest of the communities served by the hospital and the members of the staff. 1. Name ... 3. Responsibilities - Medical Staff ... 3.1.7.2 Credentials evaluations, including mechanisms for appointment and reappointment and matching the clinical privileges to be exercised or of specified services to be performed with the verified credentials and current demonstrated performance of the applicant, staff member, or allied health professional. ..."
Review on January 3, 2013, of the facility's "Credentials Manual," last approved May 12, 2011, and effective July 1, 2011, revealed "1. Establishment of a Credentials Function: 1.1 The Medical Executive committee will establish a medical staff credentialing and privileging function in accordance with the Medical Staff Bylaws ...1.3 Responsibilities of the Medical Executive Committee (the Committee): 1.3.1 Investigate and consider each application for appointment or reappointment to the Staff and each request for clinical privileges. ... 1.4 ... The granting of clinical privileges is an entirely independent action. Privileges are granted based on an individual's specific request and the ability of that individual to demonstrate he/she is clinically competent to engage in that particular activity. ... 2. General policies: ... 2.1.3 Each applicant to the Medical Staff or Allied Health Professional Staff will complete and sign an application for appointment; privileges or duties will not be granted without a completed application. ..."
Review of CF1 on January 3, 2013, revealed this physician requested reappointment of orthopedic privileges on March 8, 2011. The orthopedic privileges included the treatment of upper extremity impacted and displaced fractures and dislocation of the anatomical neck. Further review of CF1 revealed the physician requested privileges were reviewed and granted by CF1's Department Chair.
Interview with EMP1, EMP2, EMP3 and EMP4 on January 3, 2013, at approximately 4:15 PM revealed CF1 does not treat patients with fractures of the neck. Further interview confirmed CF1's privileges to treat upper extremity impacted and displaced fractures and dislocations of the anatomical neck should not be checked as requested privileges for CF1 and should not have been approved for CF1.
Tag No.: C2404
Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to provide on call physician services for four of 10 medical records reviewed (MR1, MR2, MR6 and MR10).
Findings include:
Review on January 3, 2013, of the facility's "Emergency Medical Screening and Transfer Policy," reviewed on November 15, 2011, and November 18, 2012, with no revisions, revealed "Purpose: To establish actions to comply with State and Federal laws and regulations governing the provision of emergency medical services and the transfer of patients ... Definitions: ... Dedicated Emergency Department ("DED") ... Patient Screenings and Treatment ... On-Call List The Hospital will maintain an on-call list of physicians on its Medical Staff in a manner that best meets the needs of the Hospital's patients. The list of on-call physicians will be as specified on the Hospital's 'Daily Call Sheet' issued for the Admissions Department. Physician group names are not acceptable for identifying the on-call physician. Individual physician names are to be identified on the list. The purpose of the on-call list is to ensure that the DED is prospectively aware of which physicians, including specialists, are available to provide treatment necessary to stabilize individuals with emergency medical conditions. Physicians including specialists, are not required to be on-call at all times. Physicians are expected to participate in reasonable call and to respond within a reasonable time period. ..."
Review on January 3, 2013, of the facility provided memorandum dated January 11, 2012, identified by EMP1, EMP2, EMP5 and EMP6 as the "Orthopedic ED Coverage Protocols (for ED only)" revealed "In an effort to provide a consistent process for the CCMH [Charles Cole Memorial Hospital] Emergency Department relative to orthopedic after hour coverage refer to the following: On even calendar days, [name of covering orthopedic surgeon] should be called first; if [name of covering orthopedic surgeon] does not respond within 30-minutes then [name of covering orthopedic surgeon] should be called. On odd calendar days, [name of covering orthopedic surgeon] should be called first; if [name of covering orthopedic surgeon] does not respond within 30-minutes then [name of covering orthopedic surgeon] should be called. If either one of the two orthopedic surgeons are out of town then the other should be called. The Office Manager for [name of orthopedic group] is responsible for notifying the ED when one or both surgeons are out of town. ..."
1) Review on January 3, 2013, of the facility's Daily Call Sheet for December 6, 2011, revealed orthopedic coverage was available by contacting the hospital operator. Further review revealed December 6, 2011, was an even day, and CF1 was the covering orthopedic surgeon.
Review of MR2 on January 3, 2013, revealed the patient presented to the emergency department (ED) on December 6, 2011, following a fall and was diagnosed with a C2 cervical fracture of the neck. Further review of MR2 revealed nursing documentation indicating there was no orthopedic coverage. The patient was transferred to another facility. Continued review of MR2 revealed no nursing or physician documentation that attempts were made to notify the covering orthopedic surgeon regarding MR2's C2 cervical fracture of the neck.
Interview with EMP1 and EMP2 on January 3, 2013, at approximately 3:00 PM confirmed orthopedic coverage was available by contacting the hospital operator on for December 6, 2011, and CF1 was the covering orthopedic surgeon. EMP1 and EMP2 confirmed MR2 presented to the ED on December 6, 2011, following a fall and was diagnosed with a C2 cervical fracture of the neck. EMP2 confirmed MR2's medical record contained nursing documentation there was no orthopedic coverage, and the patient was transferred to another facility. EMP2 confirmed there was no documentation that attempts were made to notify the covering orthopedic surgeon regarding MR2's C2 cervical fracture of the neck.
2) Review on January 3, 2013, of the facility's Daily Call Sheet for December 30, 2011, revealed orthopedic coverage was available by contacting the hospital operator. Further review revealed December 30, 2011, was an even day, and CF1 was the covering orthopedic surgeon.
Review of MR1 on January 3, 2013, revealed this patient presented to the ED on December 30, 2011, following a fall and was diagnosed with a fractured right ankle. Further review of MR1 revealed nursing documentation indicating there was no orthopedic coverage. The patient was transferred to another facility. Continued review of MR1 revealed no nursing or physician documentation that attempts were made to notify the covering orthopedic surgeon regarding MR1's fractured right ankle.
Interview with EMP1 and EMP2 on January 3, 2013, at approximately 3:10 PM confirmed orthopedic coverage was available by contacting the hospital operator for December 30, 2011, and CF1 was the covering orthopedic surgeon. EMP1 and EMP2 confirmed MR1 presented to the ED on December 30, 2011, following a fall and was diagnosed with a fractured right ankle. EMP2 confirmed MR1's medical record contained nursing documentation there was no orthopedic coverage, and this patient was transferred to another facility. EMP2 confirmed there was no documentation that attempts were made to notify the covering orthopedic surgeon regarding MR1's fractured right ankle.
3) Review on January 3, 2013, of the facility's Daily Call Sheet for April 17, 2012, revealed orthopedic coverage was available by contacting the hospital operator. Further review revealed April 17, 2012, was an odd day, and CF2 was the covering orthopedic surgeon.
Review of MR6 on January 3, 2013, revealed the patient presented to the ED on April 17, 2012, following a fall and was diagnosed with a fractured left arm. Further review of MR6 revealed nursing documentation indicating there was no orthopedic coverage. The patient was transferred to another facility. Continued review of MR6 revealed no nursing or physician documentation that attempts were made to notify the covering orthopedic surgeon regarding MR6's fractured left arm.
Interview with EMP1 and EMP2 on January 3, 2013, at approximately 3:15 PM confirmed orthopedic coverage was available by contacting the hospital operator on April 17, 2012, and CF2 was the covering orthopedic surgeon. EMP1 and EMP2 confirmed MR6 presented to the ED on April 6, 2012, following a fall and was diagnosed with a fractured left arm. EMP2 confirmed MR6's medical record contained nursing documentation there was no orthopedic coverage, and the patient was transferred to another facility. EMP2 confirmed there was no documentation that attempts were made to notify the covering orthopedic surgeon regarding MR6's fractured left arm.
4) Review on January 3, 2013, of the facility's Daily Call Sheet for May 31, 2012, revealed orthopedic coverage was available by contacting the hospital operator. Further review revealed May 31, 2012, was an odd day, and CF2 was the covering orthopedic surgeon.
Review of MR10 on January 3, 2013, revealed this patient presented to the ED on May 31, 2012, following a fall and was diagnosed with a fractured right hip. Further review of MR10 revealed nursing documentation indicating there was no orthopedic coverage. The patient was transferred to another facility. Continued review of MR10 revealed no nursing or physician documentation that attempts were made to notify the covering orthopedic surgeon regarding MR10's fractured right hip.
Interview with EMP1 and EMP2 on January 3, 2013, at approximately 3:20 PM confirmed orthopedic coverage was available by contacting the hospital operator on May 31, 2012, and CF2 was the covering orthopedic surgeon. EMP1 and EMP2 confirmed MR10 presented to the ED on May 31, 2012, following a fall and was diagnosed with a fractured right hip. EMP2 confirmed MR10's medical record contained nursing documentation there was no orthopedic coverage, and the patient was transferred to another facility. EMP2 confirmed there was no documentation that attempts were made to notify the covering orthopedic surgeon regarding MR10's fractured right hip.