HospitalInspections.org

Based on a review of credential files (CR) and staff interview(s) it was determined that a facility physician conducted a procedure he/she was not privileged by the facility to complete for one credential file reviewed. (CR1).

Findings include:

Review of facility's Credentialing, Privileging and Peer Review Policy last approved July 28, 2016 revealed "...Article 4 Clinical Privileges...(a) appointment or reappointment will not confer any clinical privileges or right to practice at the Hospital. Only those clinical privileges granted by the Board may be exercised..."

1) Review of CR1 revealed that CR1 applied for reappointment and was approved effective June 1, 2016, through June 1, 2018, but did not request nor have privileges to inplant pacemkaers at this facility.

2) A Review of pacemaker insertions inplanted by CR1 since reappointment to this facility effective June 1, 2016, revealed that CR1 inplanted two pacemakers without privileges, MR1 on March 24, 2017 and MR2 on October 6, 2016

During interview on April 20, 2017 at approximately 9:00 PM EMP2 confirmed the above findings and revealed "...[CR1] did not check the box requesting privileges at this facility...he did not have privileges, that is correct..."

Based on a review of medical records (MR) and facility documentation, and staff interview(s) (EMP), it was determined that the facility failed to complete a consultation report for one of 24 medical records reviewed (MR1).

Findings include:

Review of facility Medical Staff Rules and Regulations approved June of 2015 revealed "...(b) Consultations must normally be provided by the end of the next calendar day, unless urgent circumstances require that the consultation be completed sooner. If an urgent consultation is needed, the physician requesting the consultation will call the consulting physician directly...Section 4.3. Contents of Consultation Reports: (a) Each consultation report will be completed in a timely manner and will contain an opinion and recommnedations by the consultant that reflect when appropruate, an actual examination of the patient and the patient's medical record. A statement such as "I concur" will not constitute an acceptable consultation report. The consultation report will be made a part of the patient's medical record. ..."

1) Review of MR1 Physician orders dated March 24, 2017 at 0945 revealed "Consult Dr [CR2]..."

2) Further review of MR1 revealed that on March 24, 2017 at approximately 1:00 PM the patient was taken to surgery for pacemaker insertion and there was no documentation in the medical record that indicated a consult was completed by the consult physician nor any other physician prior to the surgical event.


3) Review of Consultation Form dated March 24, 2017 revealed documentation under "Report Of Consultation," "I did not see the patient" dated March 31, 2017 and signed by CR2.


During interview on April 20, 2017, at approximately 1:15 PM EMP1 confirmed the above findings and revealed "...That's right [doctor] did not see the patient he was gone for the weekend after 12 noon..."