HospitalInspections.org

Based on review of medical staff member credential files and staff interviews; the facility failed to provide National Practitioner Data Bank (NPDB) search verification information for 2 of 9 medical staff (Staff "G"and Staff -"I"). This deficient practice had the potential to affect patients treated by Staff G and I at the facility. Facility census was 3 at the time of survey.

Findings are:

A. A review of Physician Credential files for Staff G (on 2/28/19 at 10:40am), with Director of Nursing (DON) and HIS (Health Information Systems) Manager, revealed the Last NPDB verification on file was for 2010. Staff G had been reappointed in 2017. Interview with HIS manager (on 2/28/19 at 11:10am) revealed that no NPDB search was available for the physician credential file since the last verification in 2010.

B. A review of Staff I, the NPDB verification search was incomplete and not available in the credential file for re-appointment process completed in September 2017.

C. Review of the facility Governing Bylaws of the Medical Staff of the facility revealed that the Procedure for Appointment and Reappointment required on a form in detailed information 2 references with extensive experience in observing and working with the applicant and information as to whether the applicant's membership status and/ or clinical privileges have ever been revoked, suspended, reduced, or not renewed in local, at any other hospital or institution, and as to whether his membership in state or national medical societies, or his license to practice any profession in any jurisdiction, has ever been suspended or terminated. This applicant shall also state whether the applicant narcotic license has ever been suspended or revoked or information concerning an applicant.

D. The NPDB is a summary of reports including any medical malpractice, state licensure actions, exclusion or debarment actions, government administrative actions and clinical privileges actions. This information can be used to formulate a decision based on competency and history of the medical provider. This information is to be used to determine recommendations for appointments and re-appointments and directed to the Medical staff and then ultimately the Governing Board of the Hospital.