HospitalInspections.org

Based on record review of physician credential files, review of Medical Staff Bylaws and Rules and Regulations, staff interviews, facility policy and procedures and physician interview, the Critical Access Hospital (CAH) failed to:
Part I: Ensure surgical privileges were granted only to physicians with demonstrated clinical competency to independently perform the surgical procedures for 1 of the 5 files reviewed (Physician A).
Part II: Ensure the CAH followed their policy for the timely investigation and resolution of 1 of 2 patient (Patient 9) grievances reviewed.
This failure has the potential to effect physician credentialing and all patients with concerns or grievances.

Finding are:

PART I
A. Record review of the undated facility document titled "Medical Staff Bylaws" states in Article VI titled "Clinical Privileges" that Privileges to practice at the Hospital are granted by the Board of Directors following the recommendations of the Medical Staff. The document states that "A practitioner may exercise only those clinical privileges specifically granted in accordance with these Bylaws." Under Section 6.2 "Qualifications", the document states that each member and applicant for membership and clinical privileges shall "Process and maintain demonstrated clinical competence, including current knowledge, judgment, and technique, in his or her specialty area and for all privileges held or applied for."

B. Review of Physician A's credential file on 2/28/17 revealed the Physician is an active member of the medical staff and is a family practice physician. The Physician completed a list of privileges requested when up for reappointment on 2/5/16. The privileges included multiple general surgical procedures such as thyroidectomy (removal of thyroid gland), simple and radical mastectomy, surgery of the diaphragm, gastrectomy (removal of stomach), splenectomy (removal of spleen), small bowel resection. Orthopedic privileges requested included major limb amputation, fracture repair using metal screw, nail, pin. Oral Surgery privileges requested included open and closed repair of fractures of the jaw. The file contained no records to ensure the facility that Physician A was competent or experienced to perform these complex surgical specialty procedures. The Medical Staff approved the reappointment and privileges on 6/8/16 and the Board of Directors approved the appointment and requested privileges on 6/27/16.

C. Telephone interview with Physician A on 3/7/17 at 9:00 AM confirmed the Physician was unable to perform surgeries independently and that the only surgery the Physician regularly performs at the facility is related to obstetrical surgeries such as Cesarean Sections.


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PART II
A. An interview with the Registered Nurse - Quality Director (RN Q) on 2/28/17 at 2:20 PM revealed that the CAH received a written letter of concern/grievance from Patient 9 the second week of February 2017. The RN Q stated the the record had been reviewed by RN Q and following the chart review was sent to (another CAH in their network) for peer review. RN Q stated, "I have not yet showed the letter to the physicians, I am going to talk to them when it comes back. I will take it to Medical Staff meeting then." "I did write a letter to (Patient 9) to apologize that for the concerns." RN Q stated, "(Patient 9) had called the CEO (Chief Executive Officer) a week after Christmas and was told to write a letter." RN Q provided a copy of the undated letter that was sent to (Patient 9).

RN Q stated, "I process the grievances and complaints, I am not sure I get them all. We had discussed this (my receipt of grievances) at Medical Staff meeting two weeks ago and a change in policy that they will come to the interim CEO and then to me."

B. A review of the 3 page grievant letter dated 2/3/17 from Patient 9, summarized the grievance as, "I wish for no one to ever have to go through what I had to. (The CAH) and (Physician A) put me at risk because they would not ship me to (A hospital of higher level of care-Hospital B) to a specialist. I was in (The CAH) for six days, during which I only saw a doctor once a day even when we requested to see one in the afternoon."... "(Family and Patient 9) assumed that (Physician A) was keeping in touch with (Physician B that provided surgery on the patient on 12/13/16 at Hospital B), which Physician A was not." "My (family) had to call (Physician C-CAH physician) at home, on (Physician C's) day off, to get moved to (Hospital B)." Patient 9 indicated that on admission to Hospital B on 12/26/17, Physician B was not aware that (Patient 9) had not recovered as (Physician B) had never heard again from (The CAH). Patient 9 stated on 12/27/16 that (gender) was taken to surgery, then stayed 5 additional days for IV antibiotics at Hospital B.

C. Review of Patient 9's medical record for the hospital stay from 12/21/16-12/26/17 revealed on the transfer sheet sent to Hospital B that the patient diagnosis was "SBO (small bowel obstruction- when the small bowel can not adequately move food and fluid through the bowels), pelvic infection after hysterectomy."

D. Review of the Patient Grievance Process policy and procedure with an effective date of 06-2014 included:
-It is the policy of the (CAH) to provide a system whereby patients and/or their significant others or representatives, can voice concerns about the quality of care and services received at (the CAH) and receive a timely response without fear of discrimination or reprisal.
-Written complaints are always considered a grievance. This is to include faxes or emails. A) Patients or their representatives who wish to file a formal grievance will be provided with the Patient Grievance Form to record their grievance. This form will then be forwarded to the CEO, Acting Administrator or the DON.
-All efforts will be made to effectively and expeditiously resolve the patient's grievance. On grievances addressing potential harm to a patient, grievances will be addressed immediately. However a response shall be sent within 7 days of receipt of the grievance to the grievant. If the hospital is still working to resolve the grievance after the 7 days, the hospital must inform the patient or representative of when to expect a determination.
-When the grievance process is complete, the grievant will be sent a written notice of its decision along with the finding facts and an explanation ot the resolution or disposition of the grievance. Content will also include name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance and date of completion.
-The right to appeal the determination within 30 days of its notice.

Based on staff interview, review of medical records, review of Medical Staff Rules and Regulations, grievances and review of policy and procedures the Critical Access Hospital (CAH) failed to follow their policy related to Progress Notes in of 1 of 10 patient (Patient 9) records reviewed. This failure has the potential to effect all patients.

Findings are:

A. Review of Patient 9's medical record revealed the Discharge Summary from (the attending physician-Physician A) dated 12/26/16 revealed, "(Patient 9) actually was seen earlier this morning by (Physician C-CAH physician). I (Physician A) was busy with another patient." "(Patient 9) had talked with (Physician C) earlier about further evaluation and (Physician C) had placed a call to the on call physician for (Physician B that provided surgery on the patient on 12/13/16 at Hospital B-a hospital of a higher level of care) who is (Physician D). (Physician D) was in surgery when (Physician C) had called and did eventually call back early afternoon."

B. A review of the 3 page grievance letter dated 2/3/17 from Patient 9, summarized the grievance as, "My (family) had to call (Physician C-CAH physician) at home, on (Physician C's) day off, to get moved to (Hospital B)."

C. A review of Patient 9's medical record revealed a lacked of a Progress Note from (Physician C) from the 12/26/16 hospital visit.

D. A telephone interview with Physician C on 3/7/17 between 9:00 AM and 9:30 AM revealed:
-When asked how Physician C was contacted on 12/26/16 regarding Patient 9, "(Patient 9's family) called my house and talked to my (spouse) and asked if I would stop and see (gender). (My spouse) told me. When I stopped into the hospital I stopped to see (gender)."
-When asked if examined Patient 9, Physician C replied, "I did."
-When asked if any notes were made about the visit with Patient 9, Physician C replied, "I did not."
-When asked if Physician C could tell the surveyors why there were no notes made, Physician C replied, "I considered it more of a courtesy call, especially after I talked with (Physician A) and I felt like (gender) care was appropriate and anything I would have recommended was already being done."

E. A review of the undated policy and procedure named MEDICAL RECORD CONTENT revealed:
-Policy: "It is the policy of (the CAH) that all medical records shall contain sufficient information to identify the patient, support the diagnosis, to justify the treatment and document the results accurately."
-Procedures: "Clinical observations are made daily in the progress notes by the physician. Other persons making observations, report on designated forms. The progress notes give a pertinent chronological report of the patient's course in the hospital and reflect any change in condition and the results of treatment."

F. A review of the undated Medical Staff Rules and Regulations revealed under MEDICAL RECORDS:
-4.9 Progress Notes- "Pertinent progress notes shall be recorded at the time of observation, sufficient to permit continuity of care and transferability. Whenever possible, the patient's clinical problems shall be identified in the progress notes and correlated with specific orders as well as the results of tests and treatment. Progress notes shall be recorded at least daily and more often as appropriate for critically ill patients and patients where there is difficulty in diagnosis or management of the clinical problem."