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Based on interview and record review, the facility failed to enforce its bylaws for five of five practitioners whose credentials files were reviewed (MD 1, MD 2, MD 3, MD 4 & MD 5). MD 1, MD 2, MD 3, MD 4 & MD 5 had no request for clinical privileges on file. The failure to delineate clinical privileges for each practitioner had the potential to allow practitioners to perform activities and procedures for which they were not qualified.

Findings:

MD 5's credentials file was reviewed on 1/5/12 at 2:25 p.m. and indicated that MD 5's application for appointment to the medical staff was reviewed and approved by the Privileges & Credentialing Committee on 11/23/11, approved by the Medical Executive Committee on 11/29/11, by the Quality Improvement Committee on 11/30/11 and the Board of Directors on 12/8/11. There was no documentation of the privileges requested by MD 5 and whether these privileges had been granted or denied by the governing body (Board of Directors).

MD 2's credentials file was reviewed and indicated that her application for appointment to the medical staff was reviewed and approved by the Privileges & Credentialing Committee on 12/6/11, approved by the Medical Executive Committee on 12/7/11, by the Quality Improvement Committee on 12/8/11 and the Board of Directors on 12/8/11. There was no documentation of the privileges requested by MD 2 and whether these privileges had been granted or denied by the governing body.

MD 3's credentials file was reviewed and indicated that her application for appointment to the medical staff was reviewed and approved by the Privileges & Credentialing Committee on 11/29/11, approved by the Medical Executive Committee on 11/29/11, by the Quality Improvement Committee on 11/30/11 and the Board of Directors on 12/8/11. There was no documentation of the privileges requested by MD 3 and whether these privileges had been granted or denied by the governing body.

MD 1 & MD 4's credentials file were also reviewed and did not have any documentation of the privileges requested until it was brought to the facility's attention by the surveyor.

On 1/5/12 at 3:15 p.m., MD 5's credentials file was reviewed with the Director of the Geriatric Psychiatric unit. When asked if he could show the surveyor which privileges had been granted to MD 5, he said " I'm not seeing it either and it's an important part."

On 1/5/12 at 3:35 p.m., the Assistant Director of the Psychiatric unit presented a form titled "Physician Request for Privileges" to the surveyor. She said "(Name of Administrative Staff 1) says it should be in all the credentials files, it's part of the medical staff bylaws."

During an interview on 1/6/12, Administrative Staff 1 stated the facility thought that having the physicians sign the medical staff bylaws at the time of appointment/reappointment "covered the request for privileges". She said the facility would update all the credentials files to include a Physician Request for Privileges form. She presented Physician 5's request for privileges form dated 1/6/12 which indicated he requested and was granted "Consult Only" privileges. MD 5's speciality was listed as radiology. Administrative Staff 1 stated MD 5 was the facility's supervising radiologist. When asked what specific procedures or activities MD 5 was privileged for, she responded "I don't know." She acknowledged there was no delineation of privileges for the supervising radiologist.

A review of the facility's medical staff bylaws indicated the following:

Article V
Clinical Privileges

Section 1- Exercise of Privileges

Every Medical Staff Member providing direct clinical services at this Hospital is entitled to exercise only those Privileges specifically granted to him by the Governing Body. Said Privileges must be within the scope of the license authorizing the Medical Staff Members to practice in California and consistent with any restrictions thereon. Regardless of the Privileges granted, each Medical Staff Member must obtain consultation when necessary for the safety of his patients or when requested by these Bylaws, the Rules and Regulations and other policies and procedures of the Medical Staff or the Hospital.

Section 2 - Delineation of Clinical Privileges

A. Application . Clinical Privileges may be granted only upon formal request on forms provided by the Hospital with subsequent processing and approval. Every application for Medical Staff appointment and reappointment must contain a request for the specific Clinical Privileges desired by the applicant. A request by a Medical Staff Member for a modification of Privileges must be supported by documentation of training and/or experience supportive of the request.

Based on interview and record review, the facility failed to ensure that the consulting radiologist (MD 5) was supervising it's radiology services. There was no job description to indicate the duties of the supervising radiologist and no documentation that he was coming to the facility to observe the provision of radiology services. The deficient practices limited the facility's ability to provide radiology services in accordance with acceptable standards of practice.

Findings:

On 1/5/12, the surveyor requested to review the facility's contract with the supervising radiologist. The facility presented a contract titled "Agreement for X-ray & EKG Services." The services provided included "professional reads of radiological exams" and "written report same day service." The contract did not include any documentation of the scope and nature of the services provided by the supervising radiologist.

During an interview on 1/5/12 at 2:55 p.m., the Assistant Director of the Psychiatric unit was asked to describe how the consulting radiologist provides oversight to the radiology department. She said "He comes onsite once in a while but its nothing formal. We're working on that." She said there was no documentation of the consulting radiologist's visits to the facility.

MD 5's credentials file was reviewed on 1/5/12. There was no job description to indicate the duties of the supervising radiologist.

During an interview on 1/6/12, Administrative Staff 1 acknowledged there was no documentation of the supervising radiologist's visits to the facility and no job description to indicate the supervising radiologist's job duties.

Based on observation, interview and record review, the facility failed to ensure that staff peformed infection control practices to prevent and control infections when a staff member did not do proper handwashing with soap and water; and the staff member touched her eyeglasses and face while serving food and continued to handle plates of food without sanitizing or washing her hands. This practice had the potential for cross-contamination.

Findings:

In an observation on 1/5/12 at 11:55 AM, a staff member was observed serving food in the kitchen. While plating the food, she touched her eyeglasses and face three times and continued to handle plates of food. When it was brought to her attention that she kept touching her eyeglasses, she went to the sink and washed her hands with water for approximately 3 seconds.

In an interview on 1/5/12 at 12:00 PM, the staff member was asked how she should wash her hands, she said, "Wash hands for three seconds."

In an interview on 1/5/12 at 12:01 PM, the Nutritional Services Supervisor said she also observed that the staff member did not wash her hands properly using soap and water for 10-15 seconds.

The facility's policy and procedure titled Nutritional Services Department Washing Hands indicated, "Wash hands: after touching hair, face or body... Follow proper handwashing procedures...Wet hands and forearms with warm, running water at least 100?F and apply soap. Scrub lathered hands and forearms, under fingernails, between fingers for at least 10-15 seconds. Rinse thoroughly under warm running water for 5-10 seconds. Dry hands thoroughly with single-use paper towels."








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