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Based on observation, document review, and staff interview, the Critical Access Hospital (CAH) staff failed to ensure outdated supplies and medications in the Pharmacy and the crash cart on the medical surgical unit were not available for patient use. The CAH had a census of 11 in-patients with a daily average of 11 in-patients.

Failure to remove outdated medications and/or supplies for patient care areas could potentially result in patients receiving outdated and/or ineffective medications.

Findings include:

1. Observation, during the initial tour of the Pharmacy accompanied by the Pharmacist on 1/11/11 at 3:00 PM, revealed 6 of 6 bags of Intralipid 20% expired as of 9/10.

a. During the initial tour on 1/11/11 at 3:00 PM, the Pharmacist acknowledged the medication had expired and stated they did not have any more of the Intralipid and that he/she needed to take the expired Intralipid out of circulation.

b. A review of the Intralipid leaflet stated in part, "...Intralipid is an intravenous nutrient for people whose body may require intravenous nutrition...due to illness or after surgery...Storage...The expiry date of Intralipid is on the label of the pack. Intralipid should not be used if the expiry date has passed ...."

2. Observation on 01/10/11 at 2:47 PM, revealed the following outdated medications and supplies available for patient use in the crash cart located on the Medical/Surgical Unit: 14 -.9% NaCl (sodium chloride) 3 cc syringes, 13 expired on 01/01/2011 and 1 expired on 07/01/2010 and 8-.9% NaCl 10 cc syringes, 4 expired 11/2010 and 4 expired 12/2010.
a. On 01/11/11, a review of the CAH policy titled Crash Cart Security dated 10/2009 showed it stated in part, the cart contents will be checked for outdates by the evening nurse on the first of each month.
Review of the Crash Cart and Defibrillator Checklist on 01/11/11, for September-December 2010 and January 2011 verified staff failed to check the crash cart contents in September and October 2010. The checklist verifies staff checked the crash cart contents on 11/01/10, 12/04/10, and 01/02/11.
b. During an interview on 01/10/11 at 2:47 PM, Staff A, medical surgical registered nurse, said the night nurses check the crash cart. Staff A did not know why the night nurse did not remove the expired NaCl.
During and interview on 1/11/11 at 3:00 PM, the Pharmacist said the nurses check the crash cart for outdates and pharmacy restocks the crash cart after a medication has been used or when an expired medication needs replaced.
c. Review of the undated "Pharmacy Policy for Storage, Handling, Dispensing, and Administering Medications" showed it stated in part, "...all outdated or recalled medication will be quarantined in the pharmacy with the label 'OUTDATED DRUGS, NOT FOR PATIENT USE'....No outdated or recalled medication will be dispensed or administered...Pharmacy will conduct monthly checks for outdates...."

II. Based on observation, staff interviews and document review, the Critical Access Hospital (CAH) staff failed to ensure outdated nutritional supplements in the kitchenette on the medical surgical unit were not available for patient use. The CAH had a census of 11 in-patients with a daily average census of 11 in-patients.

Failure to remove outdated nutritional supplements for patient care areas could potentially result in patients receiving outdated, ineffective, and/or spoiled nutritional supplements potentially resulting in longer hospital stays related to gastrointestinal upset, nausea, vomiting, and/or diarrhea.

Findings include:

1. During the initial tour of the medical surgical unit accompanied by Staff B, Registered Nurse (RN) on 1/10/11 at 11:45 AM, the kitchenette refrigerator contained 10 cans of 1.0 Cal, a nutritional supplement, with an expiration date of 1/1/11 and 2 cans of of 1.0 Cal with and expiration date of 9/1/10. The freezer held 2 cartons of "Nutritious Juice-Resource", a nutritional supplement, with an expiration date of 11/13/10. The refrigerator freezer had 2 cartons of "Nutritious Juice-Resource", a nutritional supplement, with an expiration date of 11/13/10.

a. During the initial tour on 1/10/11 at 11:45 AM, Staff B acknowledged the expired nutritional supplements and stated the nurses were responsible to monitor for outdated items in the kitchenette refrigerator.

b. During an interview on 1/10/11 at 12:10 PM, Staff K, Licensed Practical Nurse (LPN) confirmed the expired supplements were available for patient use if a physician ordered them. Staff K, removed the nutritional supplements and took the supplements to the kitchen for disposal.

During an interview on 1/11/11 at 2:30 PM, Staff L, Consulting Dietitian, stated the pharmacist supplied the supplements. Staff L stated the Physicians order the supplement at least monthly for in-patients.

c. Review of the CAH policy titled, "Patient Refrigerator", dated 2/2010, showed it stated in part, "...To insure that there are no outdated food products in Patient Refrigerator...All food products in refrigerator will have expiration dates and will be discarded when outdated...Certified Nurse Aides will check refrigerator daily for outdates...."

III. Based on observation, documentation review, and staff interview, the Pharmacist failed to maintain evidence of current testing and certification of the Laminar Flow Hoods in the pharmacy and outpatient surgery area. The CAH had a census of 11 in-patients with a daily average of 11 in-patients.

Failure to ensure the required testing and certification of the Laminar Hoods was completed could potentially lead to a malfunction of the equipment and contamination patient medications.

Findings include:

1. Observation, during the initial tour of the pharmacy, with the Pharmacist on 1/11/11 at 3:00 PM, revealed a Laminar Flow Hood with a testing and certification tag that showed the next recertification was due by 11/7/10.

a. During the initial tour on 1/11/11 at 3:00 PM, the Pharmacist acknowledged the testing and certification for the Laminar Hood was past due and stated he/she called the company to set up an appointment. The Pharmacist stated, January 26, 2011 was the next available appointment.

b. Review of the pharmacy's Laminar Hood log revealed "A Biological Safety Cabinet" test report, dated 5/7/10. The report stated in part, "...Testing and Certification: The purpose of field testing this equipment is to assess whether it is functioning as designed in compliance with the specifications..."

2. Observation, during the initial tour of the outpatient clinic, accompanied by Staff G, RN, Surgery/outpatient services manager, on 1/11/11 at 10:00 AM, revealed a tag on the Laminar Hood that showed the next testing and certification check was due by 11/7/10. Staff G, acknowledged the Laminar Hood certification was overdue.

a. Review of the clinic's Laminar Hood "Biological Safety Cabinet" test report dated 5/7/10 showed the report stated in part, "...Testing and Certification: The purpose of field testing this equipment is to assess whether it is functioning as designed in compliance with the specifications..."

b. Review of CAH policy titled, "Compounding Aseptic Isolator Use" dated 7/8/10 showed the policy stated in part, "...The pharmacist is responsible for...seeing that equipment is in proper working condition..."

3. During a phone interview on 1/12/11 at 4:20 PM, a Laminar Hood manufacturer representative stated the Iowa Pharmacy regulation USP 797 required the completion of the Laminar Hood certification every 6 months.

Based on document review, and staff interview, the Critical Access Hospital (CAH) staff failed to ensure physician notification, date of physician notification, and/or the time of physician notification for 13 of 29 medication errors reviewed (Patients # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13). The CAH reported a census of 11 inpatients.

Failure to date/time and/or notify the physician of medication errors could potentially result in life threatening conditions, or other related health conditions that could lead to serious harm.

Findings include:

1. Review of the medication error reports and patient medical records from October thru December 2010 revealed staff failed to date/time and/or notify each patient ' s physician of medication errors for Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13 .

a. Review of the Pharmacy policy/procedure titled "Medication Errors Procedure", dated 12/26/10, stated in part. "When a medication error is found, the patient's physician will immediately be notified. . . the nurse in charge of the patient is responsible for contacting the physician as soon as possible...."

b. Review of the "Medication Error Reporting" form, dated 4/10, showed in the following in part. "Physician notified? yes//No Date/time Physician notified...."

c. Review of the medication error reports from October through December 2010 revealed 7 of 29 medication error reports lacked documented evidence that showed staff notified the patients physicians when the errors occurred, in accordance with CAH policy for Patients #4, 5, 6, 7, 9, 10 and 13.

Review of the medication error reports from October through December 2010 revealed 10 of 29 medication errors reports lacked the date of physician notification of the medication errors for Patients #2, 4, 5, 6, 7, 8, 9, 10, 11 and 13.

d. During an interview on 1/12/11 at 11:15 AM, Staff E, Quality Coordinator acknowledged the lack of documentation of date/time and/or physician notification of the medication errors for Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13. Staff E stated, the nurses received education in the use of the medication error form, "I see we still need to improve."

I. Based on observation, document review, and staff interview, the CAH staff failed to ensure that all employees followed the manufacturer's instructions for use of the hospital approved disinfection product Cidex OPA when cleaning snd disinfecting patient care equipment for the Radiology and Surgery departments. The Radiology manager reported completing approximately 10 pelvis ultrasounds monthly. The Surgery/Outpatient Services Manager reported completing 30-40 scope procedures monthly.

Failure to use disinfection products as directed by the manufacturer potentially puts patients at risk for exposure to infections and blood borne pathogens.
Findings include:

1. Observation on 01/11/11 at 10:15 AM, during the tour of the Radiology department, with Staff D, Radiology Manager, showed staff used Cidex OPA disinfectant to disinfect the Ultrasound trans-vaginal probes. An opened bottle of Cidex Solution Test Strips with an expiration date of 10/10 contained 1 of 15 strips remaining and an additional bottle of unopened test strips was available for use. Observation showed the staff failed to date the bottle of test strips when opened. Staff D verified there were no additional test strips in the Radiology Department available for use.

a. The product insert for Cidex Solution Test Strips, provided by Staff D on 01/11/11, revealed in part, " Cidex Solution Test Strips are a semi-quantitative chemical indicators for use in determining whether the concentration of glutaraldehyde, the active ingredient in CIDEX Activated Dialdehyde Solution, is above or below the minimum effective concentration established for CIDEX Activated Dialdehyde Solution " . The Cidex Solution Test Strip label stated in part, " The shelf life (expiration date) for the unopened Cidex Solution Test Strips is stamped on the immediate container label. When opening the bottle for the first time, record the date opened in the space provided on the label. Precautions: Do not use any remaining strips 90 days after opening the bottle. "
b. Review of the (undated) Pelvic Ultrasound Log On 1/12/11, showed staff used the last test strip on 01/11/11. The first expired Cidex Solution Test Strips used on 11/11/10 and the Pelvic Ultrasound log showed staff used the expired Cidex Solution Teststrips for 14 procedures .
c. During an interview on 01/12/11 at 10:15 AM, Staff E, Quality Assurance Registered Nurse verified the CAH administrative staff failed to develop and implement policies and procedures that delineated the proper use of the Cidex Solution Test Strips in the Radiology Ultrasound Department.
d. During an interview on 01/13/11 at 10:23 AM, Staff F, Ultrasound technician, verified that she/he was unaware that the Cidex Solution Test Strips were expired, and the need to record the date the bottle was opened on the bottle of test strips.
2. An observation on 01/10/11 at 3:15 PM, during the tour of the Surgery department, with Staff G, Surgery/Outpatient Services Manager, showed staff used Cidex OPA disinfectant, to disinfect the surgical equipment and endoscopy scopes in the department.
a. The decontamination room contained an opened bottle of Cidex Solution Test Strips with an expiration date of 04/11 that still contained 15 of 15 strips. The opened bottle of Cidex test strips lacked the date opened.
b. The endoscopy room contained an opened bottle of Cidex Solution Test Strips with an expiration date of 04/11 that contained 14 of 15 strips. The opened bottle of test strips lacked the date opened. Staff G verified there were no additional test strips in the Surgery Department available for use.
c. Additional observation showed staff failed to maintain records that showed staff had tested the disinfecting solution for efficacy using the Cidex Solution Test Strips. At the time of the observations, Staff G verified the Cidex Solution Test Strips lacked the date the bottles were first opened and the Surgery Department lacked a system for recording the effectiveness of solution before each use.

d. The Cidex Solution Test Strips insert, provided by Staff G on 01/10/11, revealed in part, "Cidex Solution Test Strips are a semi-quantitative chemical indicators for use in determining whether the concentration of glutaraldehyde, the active ingredient in CIDEX Activated Dialdehyde Solution, is above or below the minimum effective concentration established for CIDEX Activated Dialdehyde Solution. "The Cidex Solution Test Strip label stated, "The shelf life (expiration date) for the unopened Cidex Solution Test Strips is stamped on the immediate container label. When opening the bottle for the first time, record the date opened in the space provided on the label. Precautions: Do not use any remaining strips 90 days after opening the bottle. It is recommended that the activated solution be tested daily before each usage with the test strips in order to guard against dilution, which may lower the glutaraldehyde level of the solution below its minimum effective concentration."
e. Review of the policy "Use of Cidex Test Strips" revised on 01/26/06 on 01/10/11, showed it stated in part .... " After initial testing, positive and negative control checks will be preformed as needed. "
During an interview on 01/11/11 at 9:45 AM, Staff H, the Sterile Processing Technician, stated the staff did not keep records for the use of the Cidex Solution Test Strips and she/he failed to write the date first opened on the container.

Based on review of open/closed medical records, documents, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the patient and/or the patient's representatives signed a "Conditions of Admission" consent at admit for 3 of 7 (Patients #14, 15, and 16) in-patient medical records and 8 of 15 (Patients #17, 18, 19, 20, 21, 22, 23, and 24) closed inpatient medical records.

The CAH administrative staff reported a census of 11 in-patients and a daily average of 11 in-patients.

Informed consent means the CAH staff gave the patient or patient's representative the information, explanations, consequences, and options needed in order to consent to a procedure or treatment prior to the patient signing a consent form. Failure to provide the patient with the information needed to make an informed decision could potentially result in the patient receiving a treatment or procedure which the patient did not want or agree to receive.

Findings include:

1. Review of the medical records for Patient #14, 15 and 16 showed the patients received treatment while the patients were inpatients at the CAH. The medical records for Patient #14, 15 and 16 lacked a dated and signed "Conditions of Admission" consent form at admit.

a. Review of Patient #14's medical record on 1/10/11, showed Patient #14 had an admission date of 1/3/11. The patient's open medical record lacked a dated and signed "Conditions of Admission" consent form.

b. Review of Patient #15' medical record on 1/10/11, showed Patient #15 had an admission date of 1/7/11. The patient's open medical record lacked a dated and signed "Conditions of Admission" consent form.

c. Review of Patient #16' medical record on 1/10/11, showed Patient #16 had an admission date of 1/6/11. The patient's open medical record lacked a dated and signed "Conditions of Admission" consent form.

d. During an interview on 1/10/11 at 12:40 PM, Staff B, a Registered Nurse (RN), acknowledged the open medical records for Patient 14, 15 and 16 lacked a dated and signed "Conditions of Admission" consent form. Staff B stated he/she thought admission office personnel helped the patient fill out this form during the admission process.

2. Review of Patients #17, 18, 19, 20, 21, 22, 23, and 24 closed medical records with Staff I, RN, on 1/13/11 at 11:15 AM, showed the medical records lacked a dated and signed "Conditions of Admission" consent form during their hospital stay.

a. Review of Patient #17's closed medical record on 1/13/11, showed Patient #17 had an admission date of 11/2/10 and discharge date of 11/6/10. The patient's closed medical record lacked a dated and signed "Conditions of Admission" consent form.

b. Review of Patient #18's closed medical record on 1/13/11, showed Patient #18 had an admission date of 12/2/10 and discharge date of 12/15/10. The patient's closed medical record lacked a dated and signed "Conditions of Admission" consent form.

c. Review of Patient #19's closed medical record on 1/13/11, showed Patient #19 had an admission date of 11/27/10 and discharge date of 11/29/10. The patient's closed medical record lacked a dated and signed "Conditions of Admission" consent form.

d. Review of Patient #20's closed medical record on 1/13/11, showed Patient #20 had an admission date of 11/27/10 and discharge date of 12/2/10. The patient's closed medical record lacked a dated and signed "Conditions of Admission" consent form.

e. Review of Patient #21's closed medical record on 1/13/11, showed Patient #21 had an admission date of 11/28/10 and discharge date of 12/1/10. The patient's closed medical record lacked a dated and signed "Conditions of Admission" consent form.

f. Review of Patient #22's closed medical record on 1/13/11, showed Patient #22 had an admission date of 11/27/10 and discharge date of 11/29/10. The patient's closed medical record lacked a dated and signed "Conditions of Admission" consent form.

g. Review of Patient #23's closed medical record on 1/13/11, showed Patient #23 had an admission date of 12/13/10 and discharge date of 12/16/10. The patient's closed medical record lacked a dated and signed "Conditions of Admission" consent form.

h. Review of Patient #24's closed medical record on 1/13/11, showed Patient #24 had an admission date of 11/27/10 and discharge date of 11/30/10. The patient's closed medical record lacked a dated and signed "Conditions of Admission" consent form.

i. During an interview on 1/13/11 at 11:15 AM, Staff I, RN, acknowledged the closed medical records for Patients #17, 18, 19, 20, 21, 22, 23, and 24 lacked a dated and signed "Conditions of Admission" consent form obtained during their hospital stay. Staff I stated there was some confusion, the nurses thought the admission office had the patient sign the form and the admission office thought the nurses was doing it. Due to this confusion, some of the consent forms lacked a signature.

3. Review of the CAH policy titled, "Informed Consent" showed it stated in part, "...to provide all patients with informed consent...responsibility: Nursing...."

Based on review of medical records, documents and staff interviews the Critical Access Hospital (CAH) failed to ensure all verbal orders in the patients' medical records were accurately dated and timed when authenticated by the physician for 5 of 7 open records (Patients #14, 15, 16, 25, and 26) and 9 of 15 closed medical records, (Patients #17, 18, 19, 20, 21, 22, 23, 28, and 29). The hospital identified a census of 11 patients.

Failure of the medical staff to document the date and time they authenticated a verbal order could potentially interrupt continuity of care and transferability of changes in procedures or treatments and/or jeopardize patient safety and quality of care.

Findings include:

1. Review of the open medical records for Patients #14, 15, 16, 25, and 26 showed the patients' medical records included physician verbal orders during their inpatient stay. The staff failed to ensure physicians accurately dated and timed all of their verbal orders in the patients' medical records at the time the physician authenticated the order.

a. Review of Patient #14's medical record on 1/10/11, showed Patient #14 had an admission date of 1/3/11. Patient #14's medical record showed 4 of 4 physician authenticated verbal orders lacked a date and time of the authentication by the physician.

b. Review of Patient #15's medical record on 1/10/11, showed Patient #15 had an admission date of 1/7/11. Patient #15's medical record showed 4 of 4 physician authenticated verbal orders lacked a date and time of the authentication by the physician.

c. Review of Patient #16's medical record on 1/10/11, showed Patient #16 had an admission date of 1/6/11. Patient #16's medical record showed 1 of 1 authenticated physician verbal order lacked a date and time of the authentication by the physician.

d. Review of Patient #25's medical record on 1/10/11, showed Patient #25 had an admission date of 1/5/11. Patient #25's medical record showed 5 of 5 authenticated physician verbal orders lacked a date and time of the authentication by the physician.

e. Review of Patient #26's medical record on 1/10/11, showed Patient #26 had an admission date of 1/9/11. Patient #26's medical record showed 1 of 1 authenticated physician verbal order lacked a date and time of the authentication by the physician.

f. During an interview on 1/11/11 at 9:15 AM, Staff J, Registered Nurse, acknowledged the verbal orders lacked the date and time the medical staff members authenticated the verbal orders. Staff J further stated he/she was not sure when the medical staff members signed the verbal orders.

2. Review of the closed medical records with Staff I, RN on 1/13/11 at 11:15 AM for Patients #17, 18, 19, 20, 21, 22, 23, 28, and 29 showed the patients received Physician verbal orders while being treated as inpatients at the CAH. The medical staff staff failed to ensure all verbal orders in the patient's medical record were accurately dated and timed when authenticated by the medical staff member.

a. A review of the CAH medical record for Patient #17 on 1/13/11, showed Patient #17 had an admission date of 11/2/10 and discharge date of 11/6/10. Patient #17's medical record showed 2 of 2 physician verbal orders authenticated by the physician lacked a date and time of the authentication.

b. Review of Patient #18's medical record on 1/13/11, showed Patient #17 had an admission date of 12/12/10 and discharge date of 12/15/10. Patient #17's medical record showed 2 of 2 physician verbal orders authenticated by the physician lacked a date and time of the authentication.

c. Review of Patient #19's medical record on 1/13/11, showed Patient #19 had an admission date of 11/22/10 and discharge date of 11/29/10. Patient #19's medical record showed 2 of 2 physician verbal orders authenticated by the physician lacked a date and time of the authentication.

d. Review of Patient #20's medical record on 1/13/11, showed Patient #20 had an admission date of 11/27/10 and discharge date of 12/2/10. Patient #20's medical record showed 3 of 3 physician verbal orders authenticated by the physician lacked a date and time of the authentication.

e. Review of Patient #21's medical record on 1/13/11, showed Patient #21 had an admission date of 11/28/10 and discharge date of 12/1/10. Patient #21's medical record showed 1 of 1 physician verbal order authenticated by the physician lacked a date and time of the authentication.

f. Review of Patient #22's medical record on 1/13/11, showed Patient #22 had an admission date of 11/27/10 and discharge date of 11/29/10. Patient #22's medical record showed 1 of 1 physician verbal order authenticated by the physician lacked a date and time of the authentication.

g. Review of Patient #23's medical record on 1/13/11, showed Patient #23 had an admission date of 12/13/10 and discharge date of 12/16/10. Patient #23's medical record showed 1 of 1 physician verbal order authenticated by the physician lacked a date and time of the authentication.

h. Review of Patient #28's medical record on 1/13/11, showed Patient #28 had an admission date of 11/30/10 and discharge date of 12/4/10. Patient #28's medical record showed 5 of 5 physician verbal orders authenticated by the physician lacked a date and time of the authentication.

i. Review of Patient #29's medical record on 1/13/11, showed Patient #29 had an admission date of 12/2/10 and discharge date of 12/6/10. Patient #29's medical record showed 1 of 1 physician verbal order authenticated by the physician lacked a date and time of the authentication.

j. During the review of the closed medical records on 1/13/11 at 11:15 AM, Staff I, RN acknowledged the patient's closed medical record showed physicians authenticated their verbal orders but failed to add the date and time of their authentication.

3. Review of the CAH policy titled, "Qualitative Analysis" stated in part, "...verbal and phone orders shall be taken be [by] authorized personnel and authenticated within 24 hours by Medical Staff member...."

Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to verify the credentials and grant privileges for 1 of 1 non-employee Registered Nurse surgical assistant, brought to the hospital by a surgeon, prior to assisting that surgeon in surgery. The CAH administrative staff reported a census of 11.

Failure to verify credentials and grant privileges for surgical assistants could potentially put CAH patients at an increased risk for medical errors and/or substandard patient care during surgery.

Findings include:

1. Review of the credential files revealed a non-hospital Staff N, Registered Nurse a surgical assistant, brought in by Physician Q, to assist in a surgery performed on a CAH patient, lacked a credential file verifying that Staff N had the appropriate credentials and qualifications to perform the services he/she provided.

a. Review of the Medical Staff Bylaws dated 10/26/10 showed the CAH ' s medical staff failed to include a process for verifying credentials and qualifications of non-employee staff brought to the CAH by members of the medical staff to assist in surgery.

b. During an interview on 1/12/11 at 2:30 PM, Staff M, Director of Health Information, confirmed the CAH lacked a credentialing process for Staff N. Staff M stated, "We did not realize [Staff N] would have to be credentialed."

Based on review of policies/procedures, document review, and staff interview, the Critical Access Hospital (CAH) staff failed to ensure an appropriate entity evaluated the quality and appropriateness of the diagnosis and treatment furnished by doctors of the CAH for 16 of 16 consulting Radiologist physicians (Practitioners A, B, C, D, E, F, G, H, I, and J). The CAH had a census of 11 patients.

Failure to ensure an external entity evaluated the quality and appropriateness of the diagnosis and treatment furnished by doctors at the CAH could potentially result in medical staff members misdiagnosing patients and/or providing inappropriate or substandard patient care.

Findings included:

1. Review of Physician credential files revealed the CAH staff failed to include Practitioners A, B, C, D, E, F, G, H, I, and J) in the external peer review process (the evaluation of the quality and appropriateness of the diagnosis and treatment furnished by doctors at the CAH).

a. Review of CAH policy/procedure titled "Quality Assessment/Performance Improvement (QA/PI) Peer Review" dated reviewed 11/18/10, revealed the following in part, " ...[Network Hospital] will participate in our peer review process by conducting an annual review of a random sample of medical records, which include records of each member of our active medical staff...as well as speciality staff...."

Review of the CAH Network agreement dated 10/26/06 stated in part, "...[Network Hospital] shall assist the hospital in reviewing the quality and appropriateness of the diagnoses and treatment furnished by hospital;s physicians and other practitioners on an annual basis for purposes of assisting hospital in carrying out the requirements of its quality plan....B. Peer Review. TRMC's participation in HOSPITAL'S Peer Review process shall consist of an annual review of a random sample of medical records of each member of HOSPITAL'S Active medical staff...."

b. During an interview on 1/12/11 at 2:30 PM Staff M, Director of Health Information reported the network hospital staff completed an external peer review for the physicians on staff, and the consulting radiologist group conducted their own peer review, within the group, then sent their results to the CAH.

During a phone interview on 1/13/11 at 9:23 AM, the contact person for the consulting Radiologist acknowledged the radiologist reviewed their own peers medical records. This contact person confirmed consulting radiologist lacked an external peer review for the quality and appropriateness of the diagnosis and treatment furnished by these Radiologist.