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Based on record review and interview, the facility failed to ensure the medical staff is organized under written by-laws that are approved by the governing body for one staff B.


The findings:

Review of the copy of the of the facility "Rules And Regulations For The Medical Staff of [both named] Hospitals", state the duties of the house physician employed by the hospital will be to assist in conducting the professional work of the institution by writing histories, doing and recording physician examinations.

Review of the facility's Medical Staff Bylaws, dated 04/14, showed that appointments and reappointments to the medical staff shall be made by the Governing Body. All practitioners that provide services at the hospital, whether employed by the hospital or some other entity, are evaluated individually to determine their ability to provide medical services at the hospital. The Medical Staff Bylaws also stated that during the application process, an application for appointment shall be delivered to the Chief Executive Officer or designee who shall verify its accuracy and completeness. Upon completion, the Chief Executive Officer of designee shall forward the application to the Credentials Committee for investigation and review. Upon completion of its investigation, the Credentials Committee shall present its report to the Medical Executive Committee of the Medical Staff Committee for its recommendation. Upon completion, the decision of the Medical Executive Committee shall be forwarded to the Governing Body for final action.



On 03/12/2015 at 4:30 pm during an interview with the Chief Executive Officer (CEO) who is the CEO for both hospitals stated that we are a multi-hospital system. She also stated that we have had a unified medical staff since 7 to 8 years ago.

On 03/13/15 at 12:17 PM, Staff L, a Medical Doctor, (who was named by the CEO as the supervising physician for staff A) stated that there are currently no House Physicians. He stated that House Physicians were used in the past. However, since the initiation of the Residency Program, there has been no need for House Physicians because the Residents do the H&Ps. He stated that he used a House Physician (Staff B), in the past, to complete Admission H&Ps. He stated that he had a verbal contract with the House physician. He stated that he knew Staff B because they went to the same medical school and that they were classmates. He stated that he knew that Staff B had a license/registration as a House Physician from the state. He stated that Staff B had a brother who was a psych tech. However, he never used Staff B's brother as a House Physician. The medical doctor also stated that he used Staff B only at Southern Winds Hospital. He stated that the facility was aware that Staff B was working as a house physician because in order for Staff B to be a house physician, he had to have a sponsoring institution. He stated that he had not used a House Physician in the past year.

Review of staff B personnel record on 03/12/2015 showed that he was hired as a House Physician, at Southern Winds Hospital, to perform history and physicals. The personnel records also have a copy of the staff B current house physician license/registration. However, there was no contract, application or .

The facility could not provide evidence of a contract, application or appointment/credentialing on file. The facility could not show evidence that staff B was no longer working as a House Physician.

Based on record review and interview, the facility failed to ensure the progress notes were completed, and the history and physical were co-signed by the Attending Physician, in (2) two Sampled Patients (#1and #2 ) of 5 sampled patients.

The findings :

Review the copy of the facility "Rules And Regulations For The Medical Staff of [both named] Hospital" dated 04/18/2014, showed on page 7 in section: Required Physician Visits- A physician is required to visit a patient within 24 hours of their admission to the hospital and daily thereafter. The Rules and Regulation for the Medical Staff, dated 09/30/12, showed that progress notes shall be written daily. The Rules and Regulation for the Medical Staff also showed that progress notes shall be written daily and that the history and physical must be signed by the Attending Physicians.

Review the copy of the facility "Rules And Regulations For The Medical Staff of [both named] Hospital" dated 04/18/2014, showed on page 7 in section: Required Physician Visits- 2. A physician is required to visit a patient within 24 hours of their admission to the hospital and daily thereafter. The Rules and Regulation for the Medical Staff also showed that progress notes shall be written daily and that the history and physical must be signed by the Attending Physicians.

Review of SP#1 medical record showed that the patient was admitted to the facility on 01/22/15. The History and Physical on 01/23/15 was completed by a Resident Physician and signed by the Attending Physician. The medical record showed that there was no daily physician progress notes completed for 01/25/15.

On 03/12/15 at 3:50 PM, the Assistant Vice President of Clinical Operations stated that there were no notes found for SP#1 for 01/25/15.

Review of SP#2 medical record showed that the patient was admitted to the facility on 03/01/15. The History and Physical on 03/02/15 was completed by a Resident Physician. However, the H&P was not signed by the Attending Physician. The patient was discharged on 03/02/15.

On 03/12/15 at 3:50 PM, the Assistant Vice President of Clinical Operations stated that the H&P had not been signed yet and that this would be reviewed with the physician.


On 03/13/15 at 12:17 PM, Staff L, Medical Doctor, stated that Resident physician can do history and physicals and progress notes for patients. However, the Attending Physician must co-sign within 24 to 48 hours. He stated that this was written in the facility's bylaws as well as rules and regulations.

On 03/12/15 at 1:53 PM, Staff X, Resident Physician, stated that the Resident Physicians does the admission H&P. She stated that the Attending Physician reviews the residents ' documentation and signs off within 24 to 48 hours.