HospitalInspections.org

Based on bylaws review, record review, and staff interview, the Critical Access Hospital's (CAH's) governing body failed to ensure the appointment/reappointment for 2 of 8 provider (#1 and #2) credentialing files reviewed followed the medical staff bylaws. Failure to reappoint providers every two years and approve delineated privileges limited the governing body's ability to ensure the CAH's patients received treatment/services from qualified practitioners.

Findings include:

Review of the "West River Regional Medical Center Bylaws of the Medical Staff" occurred on 05/28/24 at 12:00 p.m. These bylaws, approved 12/18/19, stated,
". . . Article III: Medical Staff Membership
3.1 . . . Membership on the medical staff of the hospital is a privilege that shall be extended only to professionally competent physicians . . . who continuously meet the qualifications, standards and requirements set forth in these bylaws. . . .
3.3.2 . . . Reappointments shall be for a period of not more than two medical staff years. . . .
3.3.6 Appointment to the medical staff shall confer on the appointee only such clinical privileges as have been granted by the governing body, in accordance with these bylaws. . . ."

Review of the governing body's bylaws, titled "Bylaws West River Health Services Hettinger, North Dakota," occurred on 05/28/24 at 2:35 p.m. These bylaws, approved 10/23/20, stated,
" . . . Article V - Board of Directors . . .
Section 6 Responsibilities. Responsibilities of the Board include: . . . maintain a qualified medical staff . . .
Article XI - Medical Staff
Section 1 . . .
a. The Board of Directors shall organize the physicians and appropriate other persons granted practice privileges in the hospital into a medical staff under medical staff bylaws approved by the Chairman and the Board of Directors. The Board of Directors shall consider recommendations of the medical staff and appoint to the medical staff . . . physicians and others who meet the qualifications for membership as set forth in the bylaws of the medical staff. . . .
c. . . . Re-appointments shall be for a period of not more than two medical staff years. . . .
Section 2 . . .
c. The medical staff shall make recommendations to the Chairman and the Board of Directors concerning: (1) appointments, re-appointments . . . (2) granting of clinical privileges . . ."

Reviewed on 05/30/24, the CAH's current credentialing records indicated the following:
- Provider #1: the governing body last approved reappointment and privileges on 01/27/21, three years and four months ago.
- Provider #2: the governing body approved the most current reappointment and privileges on 08/23/23, two years and three months after the previous appointment of 05/26/21.

During an interview on the morning of 05/30/24, an administrative staff member (#2) confirmed the most current reappointments for Providers #1 and #2 exceeded two years from the past appointments; and Provider #1 provided cardiac consulting services and Provider #2 provided pathology consulting services during the periods listed above.

Based on review of personnel files, review of facility policy, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff, including medical staff, and, as applicable, personnel providing contracted services in the CAH, received patient-centered, trauma informed competency-based training and education regarding the use of restraints and seclusion in 2023 for 5 of 7 personnel files (Staff Member #3, #4, #6, #8, and #9) reviewed. Failure to ensure staff received the required annual education limited the CAH's ability to ensure staff were knowledgeable regarding the use of restraints and seclusion.

Findings include:

Review of the facility policy titled "Use of Restraints" occurred on 05/30/24. This policy, dated 02/07/20, stated, ". . . Staff education/competency: All staff will have ongoing skills labs and training in the appropriate use of alternative strategies, identification of potential risk behaviors, correct application and removal of restraints . . . Use of Restraints: Strategies to meet emergent patient needs. Education begin at time of orientation. . . ."

Review of seven randomly selected personnel files occurred on the afternoon of 05/30/24. Staff Member #3, #4, #6, #8, and #9's files failed to include evidence of completed education regarding the use of restraints and seclusion in 2023.

During an interview on 05/30/24 at 10:00 a.m., a human resources staff member (#10) confirmed Staff Members #3, #4, #6, #8, and #9 failed to complete the required annual education addressing the use of restraints and seclusion for 2023.