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Based on review of the Network Hospital Agreement, documentation, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure designated staff of the Network Hospital met at least annually with the CAH Quality Assurance (QA) representatives to provide oversight or assistance to the CAH's quality staff as stated in the Network Agreement. The CAH staff reported a current census of 5 in-patients.

Failure to ensure the CAH Network Hospital Quality Assurance Program review takes place at least annually, in accordance with the agreement, could potentially result in the CAH's quality staffs failure to identify and act on patient care related issues and potentially cause adverse patient outcomes.

Findings include:

1. Review of the Network Agreement, dated November 1, 2010, revealed the following in part. ". . .The parties agree that [Network Hospital], through participating members of its medical staff or other personnel designate by [Network Hospital], shall meet with the CAH's QA representatives no less than on an annual basis to provide objective oversight and assistance to the CAH in reviewing the quality and appropriateness of the diagnosis and treatment furnished by CAH's doctors of medicine or osteopathy and to assist the CAH to implement its QA Plan, to review findings under the CAH's QA Plan, and to propose improvement plans and/or recommend corrective actions."

2. Review of Critical Access Hospital Committee Meeting minutes dated March 9, 2010 revealed in part, ". . . The Quality Oversight Review was done by the Manager of Lean Network Operations from [Network Hospital] (attached). The report was accepted by consensus of those present. . . ."

Review of the attached document titled, "Annual Network Review of Quality Assurance" dated December 30, 2009 revealed in part, "This document serves as the Network Annual QA review and outlines findings and resulting recommendations from on-going and annual review of the performance improvement/quality assurance processes at Crawford County Memorial Hospital. . . ."

3. During an interview on 8/4/11 at 11:30 AM, Staff O, Director of Nursing, acknowledged the lack of documented evidence of an annual review of the CAH's QA program by the Network Hospital staff since December 30, 2009 and last reported to the CAH's QA representatives on March 9, 2010 as stated in the Network Agreement.

Based on observation, review of policy and procedures, and staff interview, the CAH (Critical Access Hospital) Radiology administrative staff failed to ensure ultrasound staff tested the disinfecting solution in 1 of 1 disinfecting bottle prior to each use. Additionally, Ultrasound Staff failed to record open and discard dates on the test strips in accordance with the manufacturer's recommendations. The Radiology Director identified an average of 16 ultrasound procedures using the transvaginal probe per month.

Failure to test the disinfecting solutions prior to each use and appropriately label the test strips could potentially result in the disinfecting solution lacking sufficient strength of the active ingredient to kill all microorganisms, potentially puts patients at risk for exposure to infectious microorganisms.

Findings include:

1. Observations, during a tour of the Radiology Department (Ultrasound), on 8/02/11 at 1:30 PM, revealed 1 of 1 disinfecting bottle contained Cidex OPA Solution and 1 package of Cidex OPA Solution test strips. Observation showed staff failed to document the date opened and expiration date in accordance with the manufacturer ' s recommendations.

2. Review of the "Cidex OPA High-Level Disinfection Log," revealed Staff F, Sonographer, failed to test the Cidex OPA Solution prior to each use in accordance with the manufacturer's recommendations.

3. During an interview, at the time of the tour on 8/02/11 at 1:30 PM, Staff F reported that he/she failed to record the open and expiration dates on the CIDEX OPA Solution test strips.

4. Review of the manufacturer's directions for CIDEX OPA Solution Test Strips revealed in part ... " It is recommended that CIDEX OPA Solution be tested before each usage with the CIDEX OPA Solution test strips in order to guard against dilution, which may lower the ortho-phthalaaldehyde level of the solution ....When opening the bottle for the first time, record the date opened in the space provide on the label. Precautions: Do not use any remaining strips 90 days after opening the bottle ... "

Review of CAH policy/procedure on 8/03/11 titled, "CIDEX OPA Solution Test Strips", reviewed on 8/10, revealed in part ... "Intended use: The CIDEX OPA Solution Test Strips are chemical indicators for use in determining whether the concentration of ortho-phthaladehyde, the active ingredient in CIDEX OPA Solution, is above or below the minimum effective concentration established for CIDEX OPA Solution ....It is recommended that CIDEX OPA Solution be tested before each usage with the CIDEX OPA Solution test strips in order to guard against dilution, which may lower the ortho-phthaladehyde level of the solution ....When opening the bottle for the first time, record the date opened I the space provided on the immediate container label. "




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Based on observation, policy review and staff interviews, the Critical Access Hospital (CAH) dietary staff failed to maintain a sanitary kitchen environment. The Dietary Manager reported the dietary staff provided approximately 10 patient meals daily.

Failure to maintain the kitchen environment in a sanitary manner could potentially result in the contamination of the patient's food.

Findings include:

1. Observation during the kitchen environment tour on 8/1/11 at 1:15 PM, revealed the following:

a. One of 1 large, 2 of 2 medium white and one of one medium green plastic cutting boards showed multiple surface cuts and a worn unsanitizable surface.

b. Seven of 7 large and 7 of 10 medium rubber spatulas showed multiples cracks and broken surface areas.

c. The large Hobart mixer had a golden brown greasy substance directly underneath the area where mixer attachments are placed. The mixer also had a dried golden brown substance under the mixer head and the splash guard contained white dried food debris. During an interview at the time of the observation, Staff A, Dietary Manager, reported staff were trained to clean the mixer after each use and relayed she would have someone clean it.

2. Review of the CAH policy titled "Food Preparation," with a review date of 6/11, revealed in part "... B. 2. Kitchen equipment is kept in good repair and is replaced as needed to ensure safe and efficient food preparation."

Review of the CAH policy titled "Cleaning Procedures," with a review date of 4/10, revealed in part "... Mixer - after each use: ... Thoroughly scrub mixer all over".

3. Observation on 8/1/11 at 1:55 PM showed Staff B, maintenance, entered the kitchen without a hair restraint. Staff A reported Staff B was in the kitchen to complete work on the garbage disposals. Observation showed Staff B was in the area of the 3-compartment sink and food prep counters. During an interview at the time of the observation, Staff A reported she did not require non-foodservice persons to wear hair restraints in the kitchen and stated, "I guess I have never done that."

Observation on 8/2/11 at 7:45 AM showed Staff B entered the kitchen without a hair restraint and walked through the food preparation area as staff prepared for breakfast service. Staff A reported she planned to have non-foodservice people wear a hair restraint and provided one to Staff B. Staff A said she would develop a policy to address the issue.

Review of the CAH policy titled "Dress Code", with a review date of 4/10, revealed in part "... 1. Hair Restraints - All dietary staff in food prep area must wear hairnets".

Review of the CAH policy titled "Infection Control", with a revision date of 6/11, revealed in part "Policy: Dietary Department will maintain strict sanitary conditions to eliminate food contamination and prevent growth of organisms ... B. 4. Hair is kept clean and hair restraint used when in the kitchen by all dietary employees."

Based on review of the Critical Access Hospital (CAH) policies, medical record and staff interviews the CAH nursing staff failed to ensure they received a written Physician order for the wound treatment performed on 1 of 1 inpatient admitted for wound treatment, Patient #11.

Failure to ensure the patient had a physician written order for treatment performed could potentially result in an inadequate care of the patient's wound and potentially delay healing.

Findings include:

1. Review of the CAH policies:
a. "Physician Orders" revision date 10/09 revealed in part, "...Medications shall be administered only upon the order of a member of the hospital medical staff..."
b. "Pressure Ulcers--Care of" revision date 7/08 revealed in part, "...treatments to be ordered by physician..."
c. "Uniform Medication Administration Policy" revision date 12/04 revealed in part, "...the nurse verifies the physician's order after the transcription..."
d. "Medical Staff bylaws" amended 12/15/08 revealed in part, "...General Conduct of care...all orders for treatment or testing for both inpatient or outpatients visits, shall be in writing..."

2. Review of Patient #11's medical record revealed an Emergency Room (ER) visit on 7/31/2001 for a left lateral foot ulcer.
Patient #11's ER evaluation by the ER Physician revealed in part, "...Skin: on the sole of his left foot, patient has a 4 cm [centimeter] diameter x [by] 2 cm deep wound with fruity smelling, purulent drainage and surrounding erythema to the mid foot. The foot is tender and warm to the mid foot and the erythema involves the 3rd, 4th, and 5th toes...
To be admitted for Intravenous (IV) Antibiotic (ATB)...
Impression 1) Cellulites, left foot severe...2) Type 2 diabetes mellitus, moderate control...
Plan:...Unasyn and oral Tetracycline...recheck lab studies in the morning, await wound cultures..."

Review of Patient #11's nursing notes revealed:
7/31/11 at 23:58 (11:58 PM) noted by Staff P, Registered Nurse (RN) "Open lesion, measurements: 7 cm x 2.6 cm, Location: lateral side of sole of left foot towards toes. Open to air, Dressing applied after appl [applying] Silvadene cream. Redness around edge of open wound"
8/1/11 at 7:50 AM noted by Staff K, RN, "Edges not approximated, wound appears infected, foul odor. Large amount blackish brown drainage seeping through dressing Redness to left foot Area outlined in Red from admission...
[Patient] agrees to shower this morning and rinse out the sore prior dressing being changed..."
8/1/11 at 11:50 AM, noted by Staff K, RN, "Large amount. Dressing changed, Wound rinsed, covered with Kerlix secured with."

Review of Patient #11's admission orders lacked a Physician order for treatment to the left lateral foot ulcer.
Review of Patient #11's Medication Administration Record (MAR) dated 7/31/11 and 8/1/11 lacked a Physician order for treatment to the left foot ulcer.

3. Review of an incident reporting form dated 7/31/11 and 8/1/11 revealed in part, "...Order not obtained by physician prior to dressing changes being performed by nursing staff...
Patient [#11] admitted to medical unit close to 2200 [11:00 PM] in evening...
Neither the ER or Primary Physician ordered dressing changes...Nurse verified comment to apply Silvadene to wound when no order was found by physician...
Two nurses performed dressing changes with no evidence of physician order..."

4. During an interview on 8/1/11 at 2:45 PM Staff K, Registered Nurse (RN) confirmed the dressing change and Silvadene ointment treatment performed on Patient #11. Staff K reviewed Patient #11's medical record and acknowledged the medical record lacked a physician order for the treatment.

During an interview on 8/1/11 at 3:00 PM, Staff L, RN-Utilization Review Nurse, reviewed Patient #11's medical record and acknowledged the medical record lacked a physician order for the treatment.

During a follow up interview on 8/2/11 at 8:30 AM, Staff N stated, the staff communication breakdown happened when the ER nurse told the unit nurse the Physician wanted the treatment of Silvadene to continue. Neither nurse nor the Physician wrote the order. Staff N stated, the nursing staff filled out a variance report to report the error.

Based on observation, review of policy and procedures, and staff interview the CAH (Critical Access Hospital) Laboratory administrative staff failed to secure confidential patient information in 1 of 1 Laboratory. The CAH identified a census of 5 patients.

Failure to secure confidential patient information could potentially result in identity theft for the patients.

Findings include:

1. Observation on 8/02/11 at 2:34 PM, with Staff E, Medical Laboratory Technician, revealed a 12-drawer unlocked file cabinet that contained approximately 1500 files and a culture logbook with approximately 1500 entries of confidential patient information. Staff E verified housekeeping staff cleaned the office at the close of business, when Laboratory staff was not present. Housekeeping need access to confidential patient information to perform their job duties.

2. Review of the policy on 8/03/11 titled, " Security & Protection of the Medical Record in Paper Form " , revision date 3/10, reveals in part ...Policy: To prevent unauthorized access to patient medical records. The CAH administrative staff failed to develop and implement a policy/procedure to address only authorized staffs have access to the confidential patient medical records.

3. During an interview on 8/02/11 at 4: PM, Staff C, Housekeeper, verified he/she cleans the Health Information office when no Laboratory staff is present.

I. Based on review of policies, patient medical records, and staff interviews, the Critical Access Hospital (CAH) surgical staff failed to ensure a qualified practitioner evaluated each patient for proper anesthesia recovery prior to discharge for 2 of 2 surgery patient open records reviewed, (Patient's #17, #18) and 3 of 5 closed surgical records (Patients #13, 15, 16). The ambulatory surgery department staff reported approximately 100 surgical procedures performed per month.

Failure to provide a proper anesthesia recovery assessment by a qualified practitioner could potentially harm patients if complications, related to the use of anesthesia, occur after surgery and the patient has returned home.

Findings include:

1. Review of the CAH documents:
a. Policy, "Post Anesthesia Visit", revision date 9/05, revealed in part, "...The anesthetist will make a post anesthesia visit and will document the presence or absence of anesthesia related complications...The post anesthesia will be documented and will describe the presence or absence of anesthesia related complications..."
b. "Medical Staff Bylaws", amended 12/15/2008, revealed in part, "...Anesthesia: The post-anesthesia follow-up report must be written on all inpatients and outpatients prior to discharge from surgery and anesthesia services..."

2. Review of Medical records for Patients #17, 18, 13, 15, 16 revealed the following:

a. Patient #17, open medical record revealed an admission on 8/1/2011 with acute gallstone pancreatitis and to have a surgeon consult for cholecystectomy on 8/2/2011.
Review of Patient #17's Pre-Anesthesia Summary form revealed the anesthesia exam performed on 8/2/11, but lacked a time when the Anesthesiologist performed the pre-anesthesia exam. The Anesthesia Record dated 8/2/11 revealed anesthesia start time at 12:05 PM and stop time 2:20 PM.
Review of Patient #17's Post anesthesia Visit Summary (lacked date, time or signature) revealed the anesthesiologist failed to document a post-anesthesia exam following the surgery.

During an interview on 8/3/11 at 3:50 PM, Staff O, Director of Nursing (DON), reviewed Patient #17's medical record and acknowledged the lack of a date for the per-anesthesia exam and lacked a post anesthesia exam recorded. Staff O stated the surgery staff manager will review the records for any further information that may have been dictated and not printed at this time.

b. Patient #18's open medical record revealed an admission on 7/31/2011 with acute appendicitis with plan for an Appendectomy surgery. The Anesthesia Record dated 8/1/11 revealed anesthesia start time at 3:25 AM and stop time 4:20 AM.
Review of Patient #18's Post anesthesia Visit Summary (lacked date, time or signature) revealed the anesthesiologist failed to document a post-anesthesia exam following the surgery.

During an interview on 8/3/11 at 3:50 PM, Staff O, DON, reviewed Patient #18's medical record and acknowledged the lack of a post anesthesia exam recorded. Staff O stated the surgery staff manager will review the records for any further information that may have been dictated and not printed at this time.

c. Review of Patient #13 closed medical record revealed an admission to Emergency Room (ER) on 3/8/11 with acute appendicitis and was taken to surgery. The Anesthesia Record dated 3/8/11 revealed anesthesia start time at 1:30 PM and stop time 2:45 PM.
Review of Patient #13's Post anesthesia Visit Summary (lacked date, time or signature) revealed the anesthesiologist failed to document a post-anesthesia exam following the surgery.

During an interview on 8/3/11 at 3:50 PM, Staff O, DON, reviewed Patient #13's medical record and acknowledged the lack of a post anesthesia exam recorded. Staff O stated the surgery staff manager will review the records for any further information that may have been dictated and not printed at this time.

d. Review of Patient #15's closed medical record revealed an admission to Emergency Room (ER) on 7/25/11 with acute cholecystitis, then admitted to the acute unit for pain control and hydration. Review of the consultants report, dated 7/25/11, confirmed the acute cholecystitis and plan for surgery.
The Anesthesia Record dated 7/27/11 revealed anesthesia start time at 10:15 AM and stop time 1:05 PM.
Review of Patient #15's Post anesthesia Visit Summary (lacked date, time or signature) revealed the anesthesiologist failed to document a post-anesthesia exam following the surgery.

During an interview on 8/3/11 at 3:50 PM, Staff O, DON, reviewed Patient #15's medical record and acknowledged the lack of a post anesthesia exam recorded. Staff O stated the surgery staff manager will review the records for any further information that may have been dictated and not printed at this time.

e. Review of Patient #16's closed medical record revealed an admission on 7/19/11 for a total vaginal hysterectomy and bilateral salpingo-oophorectomies surgery.
The Anesthesia Record dated 7/19/11 revealed anesthesia start time at 3:05 PM and stop time 4:05 PM.
Review of Patient #16's Post anesthesia Visit Summary (lacked date, time or signature) revealed the anesthesiologist failed to document a post-anesthesia exam following the surgery.

During an interview on 8/3/11 at 3:50 PM, Staff O, DON, reviewed Patient #16's medical record and acknowledged the lack of a post anesthesia exam recorded. Staff O stated the surgery staff manager will review the records for any further information that may have been dictated and not printed at this time.

3. During an interview on 8/4/11 at 7:50 AM, Staff O, DON, stated the surgery manager reviewed the above medical records and could not find any additional information. Staff O stated the surgery manager will visit with the Anesthesiologist today to remind them of the importance of timing entries and documenting their post anesthesia exam.


II. Based on review of policies, patient medical records, and staff interviews, the Critical Access Hospital (CAH) surgical staff failed to ensure a qualified practitioner assessed the patient's condition immediately prior to surgery for 2 of 5 surgical patients closed records reviewed, (Patient's #12, 15). The ambulatory surgery department staff reported approximately 100 surgical procedures performed per month.

Failure to provide a proper pre-operative assessment by a qualified practitioner could potentially harm patients if complications, related to conditions not identified prior to surgery occur during surgery or occur after surgery and the patient has returned home.

Findings include:

1. Review of the CAH documents:
a. "Medical Staff Bylaws", amended 12/15/2008, revealed in part, "...the pre-operative diagnosis, history and physical...must be recorded on the patient's medical record prior to any surgical procedure...comprehensive note regarding the patient's condition prior to the induction of anesthesia and the start of surgery..."
b. "Surgery Procedure" revision date 12/08 revealed in part, "...the surgeon will make a note prior to surgery that the patient is able to have the proposed operation and that the heart and lungs are o.k...."

2. Review of Medical Records for Patients #12 and 15 revealed:
a. Patient #12 an admission date of 7/29/11 for arthroscopy of the right knee. Review of the history and physical revealed an exam date of 7/27/11.
Review of progress note for per-operative evaluation revealed a check mark next to words Heart and Lungs but lacked documentation of the patient's condition. The progress note, also lacked a date, time and signature of the person who checked the heart and lung area on the form.
Review of the Anesthesia Record dated 7/29/11 revealed anesthesia stated at 8:10 AM and finished at 8:55 AM.
Review of the Physician post operative note dated 7/29/11 at 8:30 AM, lacked a Physician exam of the patient's condition after the surgery.

During an interview on 8/3/11 at 3:50 PM, Staff O, DON, reviewed Patient #12's medical record and acknowledged the lack of documented evidence of a Physician pre-surgical exam dated, timed and signed. Staff O stated the surgery staff manager will review the records for any further information that may have been dictated and not printed at this time.


b. Patient #15's closed medical record revealed an admission to Emergency Room (ER) on 7/25/11 with acute cholecystitis, then admitted to the acute unit for pain control and hydration. Review of the consultants report, dated 7/25/11, confirmed the acute cholecystitis and plan for surgery.
The Anesthesia Record dated 7/27/11 revealed anesthesia start time at 10:15 AM and stop time 1:05 PM.
Patient #15's medical record lacked documentation of a physician exam immediately prior to surgery on 7/27/11.

During an interview on 8/3/11 at 3:50 PM, Staff O, DON, reviewed Patient #15's medical record and acknowledged the lack of documented evidence of a physician exam immediately prior to surgery on 7/27/11.
Staff O stated the surgery staff manager will review the records for any further information that may have been dictated and not printed at this time.

3. During an interview on 8/4/11 at 7:50 AM, Staff O, DON, stated the surgery manager reviewed the above medical records and could not find any additional information. Staff O stated the CAH administrative staff will visit with the Physicians to remind them of the importance of documenting their pre operative exam.

III. Based on review of Medical Staff Bylaws, patient medical records, and staff interviews, the Critical Access Hospital (CAH) surgical staff failed to ensure a qualified practitioner assessed the patient's condition after surgery for 1 of 5 surgical patients closed records reviewed, (Patient's #12). The ambulatory surgery department staff reported approximately 100 surgical procedures performed per month.

Failure to provide a proper post recovery assessment by a qualified practitioner could potentially harm patients if complications occur after surgery and the patient has returned home.

Findings include:

1. Review of the "Medical Staff Bylaws", amended 12/15/2008, revealed in part, "...an operative report or note should be written or dictated immediately after surgery and should reflect the actual condition of the individual patient..."

2. Review of Patient #12's medical record revealed an admission date of 7/29/11 for arthroscopy of the right knee. Review of the history and physical revealed an exam date of 7/27/11.
Review of the Physician post operative note dated 7/29/11 at 8:30 AM, lacked a Physician exam of the patient's condition after the surgery.

During an interview on 8/3/11 at 3:50 PM, Staff O, DON, reviewed Patient #12's medical record and acknowledged the lack of documented evidence of a Physician post-surgical exam. Staff O stated the surgery staff manager will review the records for any further information that may have been dictated and not printed at this time.

3. During an interview on 8/4/11 at 7:50 AM, Staff O, DON, stated the surgery manager reviewed the above medical records and could not find any additional information. Staff O stated the CAH administrative staff will visit with the Physicians to remind them of the importance of documenting their post operative exam.

Based on review of the Quality Improvement Plan, Quality and Utilization Review Committee Meeting minutes, Board of Trustees Meeting minutes, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the Quality Committee met at least quarterly to review Quality Assessment Performance Improvement (QAPI) activities and to provide oversight of the QAPI program. The CAH administrative staff reported a current census of 5 in-patients.

Failure to monitor and evaluate all patient care services for quality of care could potentially expose patients to inappropriate and/or substantial care.

Findings include:

1. Review of the "Quality Assessment Performance Improvement Program", dated revised 7/10, stated in writing in part. ". . . Crawford County Memorial Hospital has in place an ongoing hospital-wide quality assessment and performance improvement program that continually monitors, evaluates and works to improve the processes of healthcare and delivery of services. The program works to bring about improvement in the quality of care by a patient centered approach to healthcare delivery, quality improvement and integration of care. . . The Quality Committee meets at least quarterly to review QAPI activities and to provide oversight of QAPI program. . . The Board of Trustees has the overall responsibility for the QAPI Program. . . ."

2. Review of the "Quality Committee Meeting" minutes from February 2, 2010 through August 2011 revealed the last documented Quality Committee Meeting was October 26, 2010.

Documentation lacked evidence of Quality Committee Meeting at least quarterly as stated in the Quality Assessment Performance Improvement Program.

3. Review of the Board of Trustees Meeting minutes from January 18, 2011 to July 25, 2011 lacked documentation of quality information presented to the Board of Trustees.

4. During an interview on 8/4/11 at 10:05 AM, Staff O, the Director of Nursing, and Staff Q, The Quality Manager acknowledged the lack of Quality Committee Meetings at least quarterly as stated in the Quality Assessment Performance Improvement Program with the last documented Quality Committee Meeting on October 26, 2010 and the lack of documentation of quality information presented to the Board of Trustees since November 2010.

Based on review of policies/procedures, documentation, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure that an appropriate entity completed a review of the quality and appropriateness of the diagnosis and treatment furnished, for all practitioners during the credentialing process, that provided care and services to the CAH patients for 7 of 7 applicable practitioners reviewed. (Practitioners F, I, J, N, U, V, W) The CAH administrative staff reported a current census of 5 in-patients.

Failure to ensure an appropriate 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 include:

1. Review of documentation for the credentialing period of 2/1/2011 - 2/28/2013, revealed the CAH quality staff failed to include external peer review results during the credentialing process for all practitioners that provided care and services to the CAH patients (Practitioner V):

Practitioner V re-credentialed on 1/11/2011 by the Medical Staff and on 1/24/2011 by the Governing Body revealed the lack of documentation of external review results available at the time Practitioner V re-credentialed.

The CAH administrative staff identified the practitioners provided services to the number of patients the previous 12 months as follows:
- Practitioner V - 16 out-patients

Review of documentation for the credentialing period of 4/1/2011 - 4/30/2013, revealed the CAH quality staff failed to include external peer review results during the credentialing process for all practitioners that provided care and services to the CAH patients (Practitioner U):

Practitioner U re-credentialed on 3/8/2011 by the Medical Staff and on 3/28/2011 by the Governing Body revealed the lack of documentation of external review results available at the time Practitioner U re-credentialed.

The CAH administrative staff identified the practitioners provided services to the number of patients the previous 12 months as follows:
- Practitioner U - 13 out-patients

Review of documentation for the credentialing period of 6/1/2011 - 6/30/2013, revealed the CAH quality staff failed to include external peer review results during the credentialing process for all practitioners that provided care and services to the CAH patients (Practitioners F, J, N, W):

Practitioner F, J, N, W re-credentialed on 6/14/2011 by the Medical Staff and on 6/27/2011 by the Governing Body and Practitioners J, N, W re-credentialed on 5/10/2011 by the Medical Staff and on 5/23/2011 by the Governing Body revealed the lack of documentation of external review results by an approved entity available at the time Practitioners F, J, N, W re-credentialed.

The CAH administrative staff identified the practitioners provided services to the number of patients the previous 12 months as follows:
- Practitioner F - 186 in-patients and 3,091 out-patients
- Practitioner J - 1,652 out-patients
- Practitioner N - 390 out-patients
- Practitioner W - 14 out-patients

Review of documentation for the past credentialing period of 8/1/2011 - 8/31/2013, revealed the CAH quality staff failed to include external peer review results during the credentialing process for all practitioners that provided care and services to the CAH patients (Practitioner I):

Practitioner I re-credentialed on 7/12/2011 by the Medical Staff and on 7/25/2011 by the Governing Body revealed the lack of documentation of external review results available at the time Practitioner I re-credentialed.

The CAH administrative staff identified the practitioners provided services to the number of patients the previous 12 months as follows:
- Practitioner I - 4 in-patients and 131 out-patients

2. Review of the CAH policy/procedure titled "Medical Staff Peer Review", dated revised 7/10, stated in writing in part, "All members of the Medical Staff will participate in Peer Review activities. . . ."

Review of the CAH Network agreement dated November 1, 2010 revealed the following in part, ". . .The parties agree that [Network Hospital], through participating members of its medical staff or other personnel designate by [Network Hospital], shall meet with the CAH's QA representatives no less than on an annual basis to provide objective oversight and assistance to the CAH in reviewing the quality and appropriateness of the diagnosis and treatment furnished by CAH's doctors of medicine or osteopathy and to assist the CAH to implement its QA Plan, to review findings under the CAH's QA Plan, and to propose improvement plans and/or recommend corrective actions."

3. During an interview on 8/4/11 at 10:05 AM, Staff Staff O, the Director of Nursing, and Staff Q, The Quality Manager acknowledged the lack of documented evidence that showed an evaluation of the quality and appropriateness of the diagnosis and treatment they furnished to CAH patients had occurred by an approved entity at the time Practitioners F, I, J, N, U, V, W re-credentialed. Staff O confirmed Practitioners F, I, J, N, U, V, W had provided services to patients of the CAH during the last credentialing period.

Therefore, the medical staff and governing body lacked information from the external peer review process, including the quality and appropriateness of the diagnosis and treatment furnished by doctors at the CAH, in the physician's credential files at the time of reappointment for 7 of 7 physicians.