HospitalInspections.org

Based on a review of facility documents, credential files, and staff interviews (EMP), it was determined the facility failed to ensure an appointed and credentialed physician performed a procedure.

Findings include:

A review of the facility's "Credentialing and Privileging Policy", which was "Approved by all Medical Executive Committees as of December 21, 2020", revealed under Article 4, Clinical Privileges: "... Appointment or reappointment will not confer any clinical privileges or right to practice at the Hospital. Individuals may only exercise those clinical privileges that have been granted by the Board, subject to the terms of this Policy. ..."

A review of MR1 revealed that MR1's father inserted a nasogastric tube in MR1. As documented in MR1: " ... Patient family was visually agitated at the failed attempts. The patients father, who is a physician, immediately said he would place it. [EMP12] handed the father the NG tube to place. Patient allowed father to insert NG tube. Two more attempts through the right nare were tried. Patient started to cough both times. Patient's father pulled out the tube from the patients nose. Another break was given to the patient. Father had attempted one last time through the right nare. Tube had output of green bile. ..."

During interview on April 1, 2021, at approximately 1:45 PM, EMP2 confirmed that an non-credentialed individual, who was not a hospital staff member, inserted a nasogastric tube in a patient.