HospitalInspections.org

I. Based on record reviews, staff interviews and a review of the Medical Staff By-Laws, Rules and Regulations, the Governing Body failed to follow the bylaws during the physician reappointment process. The CAH (Critical Access Hospital) reported a total of 931 acute care patient admissions during the most recent fiscal year. Findings include:

A. A review of the log of surgical procedures performed for the past year, as compared with the surgeons' privilege list, revealed the privilege list failed to reflect actual hospital practice. High risk procedures such as splenectomy (removal of the spleen), thyroidectomy (removal of the thyroid gland) and neck dissection (unspecified) were listed as approved.

B. In the Medical Staff By-Laws page 14, Section 5, Reappointment/Renewal Process, it states, "The Medical Staff and Board may also consider whether the practitioner has actually exercised all of the requested privileges with sufficient frequency since the time of last appointment or reappointment to indicate current proficiency."

C. A review of the surgery log for 2011 - 2012 did not include any of the above mentioned procedures.

D. An interview conducted with the Director of Nursing on 6/21/12 at 3:00 PM confirmed none of the high risk procedures had been performed in the hospital within the past year.

II. Based on staff interviews and a review of the physician's reappointment privilege list, the Governing Body allowed a practitioner to perform procedures without privileges to do so.
Findings include:

A. An interview with Radiology Manager on 6/22/12 at 12:30 PM revealed Physician 9 provides his own interpretation of patients' radiologic images, without the benefit of an over read by a Radiologist.

B. Review of the list of approved privileges in the physician's reappointment file, dating back to 2005, lacked privileges to interpret radiologic images. In addition, there was a lack of continuing education for this physician to maintain proficiency in this specialty and the hospital failed to develop any quality monitoring of this physician's performance to ensure patient quality of care.

C. An interview conducted with the Administrator on 6/22/12 confirmed the physician did not have privileges for this function and also confirmed the hospital failed to developed a quality monitor to ensure proficiency.

Record review and staff interviews revealed the CAH (Critical Access Hospital) failed to ensure documentation for 1 of 5 Swing Bed Patients (Patient 32) was accurate pertaining to the admission History and Physical. The Hospital is licensed for 20 beds and had a census of 3 acute care inpatients and 5 skilled care patients. Findings include:

A. Review of Patient 32's medical record on 6/27/12 at 3:00 PM revealed Patient 32 was admitted to the CAH on a Swing Bed status on 3/12/12 with pertinent diagnoses of ORIF for a right distal fractured femur, morbid obesity with an admission weight of 447.3 pounds. Review of Madonna's admission history and physical dated 2/10/12 revealed the ORIF was surgically performed at Bryan/LGH West by Dr. [name of doctor] on 2/8/12. On 2/12/12 Patient 32 was transferred to Madonna Rehabilitation Hospital. On 3/6/12 was transferred to Bryan LGH East for a I and D of surgical wound. Patient 32 was then transferred from Bryan /LGH East on 3/12/12 to the CAH for extended rehabilitation with physical and occupation therapy and a final goal of returning home.

B. Review of the admission history and physical dated 3/12/12 indicated Patient 32, dictated by the Physican Assistant at the CAH, indicated the patient had the surgical ORIF to the right distal fractured femur at St. Elizabeth Regional Medical Center. Telephone interview with the Director of Nursing on 7/3/21 at 11:00 AM revealed: "with the electronic medical record system, the physicians should also be checking the reports, but doesn't always get done."