HospitalInspections.org

Based on review of credentialing files and staff interview the medical staff failed to evaluate the performance of credentialed staff during the credentialing process. This occurred in three of three (EE, FF and GG) dental assistant, whose credential files, were reviewed.

Findings:

The credentialing process for the allied health practitioners, dental assistant, included a skills checklist, written competency exam and a review of privileges requested by the medical staff.

Review of the credential files for Staff EE, FF and GG did not contain the above information.

This was confirmed by Staff D and CC on 02/27/14 at 1:20.

Based on review of the hospital ' s surgery log, physician credential files and staff interview the hospital failed to provide specific privileges for each practitioner credentialed by the hospital. This occurred in two of two (Staff HH and II) physician credential files reviewed.

Findings:

A letter submitted by the hospital on September 27, 2013, to remove the Immediate Jeopardy, documented, " ...In response to the recent findings as of 8:00 am Friday September 27th, 2013 all Surgical Services has been stopped and all surgeries/procedures have been cancelled ... " , signed by the CEO, COO and Board of trustee, President ... "

Review of the hospital ' s surgery log, documented that Endoscopy/Colonoscopy procedures were performed from October 6, 2013 through December 5, 2013 by both Staff HH and II.

Documentation in the physician credential files stipulated if a physician wanted to be privileged to perform Gastrointestinal Endoscopic procedures, an additional form had to be requested.

Review of Staff HH credential files documented " General Surgery Core Privileges " and " Family Medicine Privileges " were requested and granted. The credential file did not contain documentation Staff HH had requested and been privileged to perform Gastrointestinal Endoscopic procedures.

Review of Staff II credential files documented " General Surgery Core Privileges " were requested and granted. The credential file did not contain documentation Staff II had requested and had been privileged to perform Gastrointestinal Endoscopic procedures.

This was confirmed by Staff D in the afternoon of 02/28/14.