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Based upon record review and interview, the hospital failed to ensure the delineation of clinical privileges for the mid-level practitioners (Staff T, U, V) requested was approved by the Medical Staff and Governing Board. This deficient practice had the potential to affect outpatient, inpatient, and emergency room patients. Findings:

1) Review of the credential file for Staff T, an Advanced Practice Registered Nurse (APRN), revealed the clinical privileges were requested on 06/18/21. Review of the core privileges revealed of the 45 procedures only 4 were identified. Of the Special Non-Core Procedures, Staff T requested "Provide care to critical care patients" and "Insertion and removal of chest tubes". There failed to be documented evidence the clinical privileges requested were approved by the Medical Staff. The dates and signatures for the Medical Staff and Governing Board approval was blank.

2) Review of the credential file for Staff U, a Certified Physician Assistant (PA-C) revealed he provided care to the Emergency Department patients. Review of the clinical privileges request dated 10/22/21 revealed there failed to be documentation they were approved by the Medical Staff. The dates and signatures for Medical Staff and Governing Board approval was blank.

3) Review of the credential file for Staff V, PA-C, revealed an extensive list of requested clinical privileges. There failed to be documented evidence the Medical Staff and Governing Board approved the privileges.

Interview with Staff W on 02/22/23 at 11:10 a.m. revealed the hospital was in the process of converting the credential files from paper to an electronic system. When asked about the Medical Staff and Governing Board approval of the requested clinical privileges for Staff T, U, and V, Staff W stated the medical staff appointments were approved by the medical staff and was found in the meeting minutes. There was documentation in the meeting minutes of the appointment approvals; however, there was no evidence the actual clinical privileges were identified and approved by the Medical Staff and Governing Board.