HospitalInspections.org

Based on document review and interview, the hospital did not ensure that physicians conducted periodic reviews of midlevel provider's medical records, in 2 of 2 employee files reviewed (Staff A and Staff B). This could lead to untoward outcomes for patients.

Findings include:

-- Per review of hospital's Policy and Procedure (P&P) titled "Nurse Practioner Practice Standards," last reviewed in 2022, collaboration/supervision will be accomplished by medical record reviews to be conducted for each non-physician as follows:
1) Chart reviews will be performed at least quarterly for each practitioner.
2) Minimum of five charts to be included in each quarterly review.
3) Results of chart review to be conveyed via discussion between the non-physician practitioner and the supervising physician conducting the review.
4) Results of the review to be documented and signed by both the reviewing/supervising physician and non-physician practitioner. This documentation will be maintained in the practitioner's quality file in the office of Medical Staff Affairs along with the current Practice Agreement or scope.

It is the responsibility of each nurse practitioner to ensure that these reviews are completed and documented and that the up-to-date documentation resides in their individual quality file.

-- Review of the personnel /credentials files for Staff A, NP and Staff B, NP, revealed both lacked documentation that periodic medical record reviews were conducted by a physician.

-- Per interview of Staff A on 10/4/2023 at 3:45 pm, physicians have not been conducting quarterly medical record reviews to evaluate his/her/their documentation of patient care and treatment.

-- During interview of Staff C, Physician, on 10/5/2023 at 1:35 pm, he/she/they acknowledged there are no quarterly medical record reviews of nurse practitioners documentation of care.

--Per interview of Staff D, Chief Nursing Officer, on 10/5/2023 at 3:30 pm, physicians complete periodic medical record reviews in the outpatient setting but there are no periodic medical record reviews conducted in the inpatient setting.

-- During interview of Staff E, Medical Director on 10/5/2023 at 3:30 pm, he/she/they acknowledged the above findings.