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Based on interview, grievance report documentation reviewed for 5 of 6 patients/patient representatives (Patient #s 38, 39, 41, 43 and 44) that submitted a grievance to the hospital, review of policies and procedures, and review of other documentation, it was determined that the hospital failed to provide each patient/patient representative with a written notice regarding the grievance that contained all of the elements required by hospital policy and this regulation.

Findings included:

1. Review of a policy and procedure titled "Patient Complaint Resolution," Policy #: 100.38, last revision 09/2009, reflected the following internal requirements: "Grievance Management...5. Grievances will be managed within a reasonable time period determined by the complexity of the grievance, and the investigation and decision-making required...6. When a final decision has been reached, a written response will be provided to the patient/designated representative. The written response will include: a) Name of the Hospital contact person b) Steps taken on behalf of the patient to investigate the grievance c) Results of the grievance process d) Completion date"

2. Grievance report documentation for Patient 38 was reviewed. The documentation reflected the "Date of Occurrence" was 07/01/2013 and the "Date Complaint Received" was 07/08/2013. The "Case Narrative" notes dated 07/08/2013 at 1013 reflected a metal clip was inadvertently left behind in the patient's left breast during a surgical procedure.

An interview was conducted with I1 on 10/22/2013 at 1715. He/she stated that no written notice had been provided to the patient in relation to the grievance, as required by hospital policy and this regulation.

3. Grievance report documentation for Patient 39 was reviewed. The documentation reflected the "Date of Occurrence" was 03/25/2013 and the "Date Complaint Received" was 04/29/2013. The grievance "Initial Complaint Description" dated 04/30/2013 reflected the patient submitted an "Inappropriate touch allegation" regarding a therapist. Additionally, the patient complained that he/she received the wrong medication, and that "a...young [man/lady]...who was 'nastier than hell' told the patient, 'You need to respect me'." The report reflected "I [I1, Patient Relations] told patient we would investigate [his/her] inappropriate touch allegation and other complaints and respond within two weeks to 30 days."
An interview was conducted with I1 on 10/22/2013 at 1715. During the interview, the grievance report and a written response from the hospital dated 05/24/2013, submitted to the patient in response to the grievance, was reviewed. The letter reflected "This letter is in response to the concerns you raised on 04/30/2013...regarding the behavior of a [male/female] therapist..." The letter lacked the steps taken on behalf of the patient to investigate the grievance, and the completion date. The written response lacked documentation addressing Patient 39's complaint of the "young [man/lady]...who was 'nastier than hell," or the complaint that he/she received the wrong medication. I1 stated those parts of the Patient 39's complaint got dropped and were never investigated. I1 acknowledged the letter failed to include all of the elements required by this regulation.

4. Grievance report documentation for Patient 43 was reviewed. The documentation reflected the "Date of Occurrence" and the "Date Complaint Received" were both 05/08/2013. The "Case Narrative" notes reflected Patient 43 complained that an ED physician hit him/her on the back as the physician walked the patient down the hall toward the ED waiting room.

An interview was conducted with I1 on 10/22/2013 at 1715. During the interview, the grievance report and a written response dated 06/06/2013 submitted to the patient in response to the grievance were reviewed. The written response lacked documentation of the grievance completion date. This was reviewed with I1 during the interview.

5. Grievance report documentation for Patient 44 was reviewed. The documentation reflected the "Date of Occurrence" was 05/28/2013 and the "Date Complaint Received" was 05/29/2013. The grievance "Initial Complaint Description" notes reflected "05/29/2013...[Patient 44] tells me one of [his/her] nurses was 'verbally abusive' [at][him/her] and 'looked like [he/she] would get physically abusive'..."

An interview was conducted with I1 on 10/22/2013 at 1715. During the interview, the grievance report and a written response dated 06/27/2013, submitted to the patient in response to the grievance were reviewed. The written response lacked documentation of the steps taken on behalf of the patient to investigate the grievance and the date of completion. This was reviewed with I1, and he/she acknowledged during the interview that the written response lacked all of the elements required by this regulation.

6. Grievance report documentation for Patient 41 was reviewed. The documentation reflected the "Date of Occurrence" was 12/29/2012 and the "Date Complaint Received" was 01/21/2013. The "Initial Complaint Description" dated 01/21/2013 reflected the patient submitted a complaint that he/she was left alone in the bathroom, sustained a fall, and his/her diet was not monitored correctly while he/she was in the hospital.

An interview was conducted with I1 on 10/22/2013 at 1715. During the interview, the grievance report and a written response dated 01/28/2013 submitted to the patient, in response to the grievance were reviewed. The written response lacked documentation of the grievance completion date. This was reviewed with I1 during the interview.

Based on observations made in the ED of the hospital on 10/22/2013 at 0940, staff interviews at that time, and hospital documentation, it was determined that the hospital failed to maintain the supplies within the resuscitation cart that would ensure the delivery of emergency services in accordance with medical staff directives and according to acceptable standards of care in a safe setting.

Findings included:

1. A Legacy Health System policy titled "Code Blue (Cardiac/Respiratory Arrest): Staff Response, Code Cart Maintenance/Exchange, and Emergency Equipment/Drug Supplies for Areas Without Code Carts," revised 03/2010 reflected on page 3 of 11, "CODE CART MAINTENANCE AND EXCHANGE 1. The integrity of the code cart will be checked by department personnel at least daily for: a. Numbered lock in place[,] b. Code Cart expiration date...[,] c. Proper functioning of defibrillator through daily test discharge[,] d. Verification of the exterior contents of the cart[,] e. Operation of all equipment to ensure proper functioning[.] 2. Records of cart integrity and equipment functioning will be kept on the unit for a minimum of one year." The policy further states on page 4 of 11, "3. The responsibility of checking the Emergency equipment will be designated by the unit management. a. Emergency equipment shall be checked daily when patient care unit is open for completeness and replenished after each use. b. All equipment will be operated daily when patient care unit is open to ensure proper functioning. c. An equipment list shall be used on all units and initiated when the contents are verified and equipment is checked."

2. During a tour of the ED on 10/22/2013 at 0940 with the ED manager it was discovered that the ED staff neglected to conduct and document checking the integrity of the code cart per policy on the following days:

05/04/2013, 05/09/2013, 05/13/2013, 05/20/2013, 05/25/2013, 05/26/2013, 06/25/2013, 06/30/2013, 07/01/2013, 07/10/2013, 07/11/2013, 07/15/2013, 07/18/2013, 07/20/2013, 07/23/2013, 07/24/2013, 7/27/2013, 08/01/2013, 08/06/2013, 08/13/2013, 08/23/2013, 08/29/ 2013, 09/18/2013, 09/22/2013, 09/25/2013, 10/06/2013, 10/12/2013 and 10/13/2013.

The finding were discussed and confirmed with the ED Manager, I16, on 10/22/2013 at 1000 and with the Hospital Nurse Executive, I23, on 10/22/2013 at 1510.

Based on interview, grievance documentation reviewed for 2 of 2 patients who submitted a complaint of physical or verbal abuse, and review of policies and procedures and other documentation, it was determined the hospital failed to fully implement a policy and procedure to ensure each patients right to be free from all forms of abuse as required by this regulation. The hospital failed to ensure allegations of abuse were investigated timely and thoroughly, and to ensure patients were protected during the investigation.

Findings included:

1. Grievance report documentation for Patient 43 was reviewed. The documentation reflected the "Date of Occurrence" and the "Date Complaint Received" were both 05/08/2013. The grievance "Initial Complaint Description" notes reflected "05/08/2013...Patient presents to hospital front lobby requesting to speak with patient relations to 'file a complaint'...[He/she] said that ED physician came in and told [him/her], 'You're okay'...and as doctor 'walked [him/her]' down the ED hall toward the ED waiting room, 'kept hitting' [him/her] on the back with [his/her] 'open hand so [he/she] wouldn't leave any bruises' as 'hard as [he/she] could,' then 'stopped hitting' [him/her] as [he/she] got to the door exiting to the waiting area,' because their would be witnesses. Patient said physician 'didn't tap lightly; forcibly hit me on the back several times'..."

An interview was conducted with I1, Patient Relations, on 10/22/2013 at 1715. He/she reviewed the grievance documentation for Patient 43 and acknowledged during the interview that he/she received the grievance from Patient 43 on 05/08/2013. I1 was asked if the grievance was an allegation of physical abuse and he/she stated "Yes."

Review of grievance "Case Narrative" notes dated 06/04/2013 at 2124 reflected the ED physician was interviewed by hospital staff on 06/04/2013 and he/she stated during the interview that there were witnesses ("nurses") present at the time of the incident involving Patient 43. However, the documentation reflected the witnesses were not interviewed as part of the investigation. I1 was asked why the witnesses were not included in the investigation and he/she stated, "I don't have an answer for that." I1 was asked what was done to provide protection of patients during the investigation involving the ED physician, or for any allegation of physical abuse he/she may receive. I1 stated "Aside from getting in touch with their (the alleged perpetrator's) immediate supervisor, there's nothing else." I1 acknowledged during the interview that he/she did not forward the grievance involving Patient 43, to anyone until 05/20/2013, 12 days after he/she received it. Therefore, appropriate actions were not taken to ensure a timely and thorough investigation or to provide protection of patients until an investigation was completed.

The procedure titled "Investigatory Administrative Leave," Procedure #: 500.95, origination date 10/2013 reflected "A. When Employee Relations is notified of a patient-related safety allegation or concern or any other concern that may affect the safety of the workplace (such as a serious allegation of harassment, etc.) it will immediately launch an investigation. B. Employee Relations Consultant (ER), in consultation with applicable manager/director/leader, will review the allegation or concern to determine whether to remove the subject employee from the workplace for the duration of the investigation...An allegation/concern of inappropriate contact (physical or verbal) with a patient that is not on its face consistent with applicable treatment/care requires immediately placing the subject employee on an investigatory administrative leave...F. At the conclusion of the investigation, the ER Consultant and applicable leader will determine if and when to return the subject employee from Administrative Leave."

An interview was conducted with I5, Accreditation and Clinical Compliance, on 10/23/2013 at 0950. He/she was asked if the hospital had a policy or procedure for protecting patients from abuse during an investigation of an allegation of patient abuse prior to the "Investigatory Administrative Leave," Procedure #: 500.95, origination date 10/2013. He/she stated "No, this has been a learning for us."

An interview was conducted with I4, Manager of Care Management, on 10/23/2013 at 1120. I4 stated he/she was the direct supervisor of RN case managers and social workers at the hospital. I4 was provided the "Investigatory Administrative Leave" Procedure #: 500.95, origination date 10/2013, and he/she stated "That's a brand new policy." I4 stated he/she had not been trained to the new policy and had not reviewed it yet. Although I4 was a manager and according to the "Investigatory Administrative Leave" policy, may have responsibilities surrounding an allegation of abuse, he/she had not reviewed the policy and had not been trained to it.

An interview was conducted with I2, Clinical Risk Manager Quality and Safety, on 10/23/2013 at 1300. I2 stated he/she was the only risk manager for the hospital. I2 stated he/she was involved in investigations related to allegations of sexual abuse of patients. I2 stated if he/she received a complaint of abuse that did not involve a patient injury, he/she would "hand it off" to I1, Patient Relations. I2 was asked if he/she had received any training regarding a process for protecting patients during an investigation of an abuse allegation. I2 stated there had been discussions at team meetings "over the past few months," but he/she had not received any training to the process. He/she was provided the "Investigatory Administrative Leave" Procedure #: 500.95, origination date 10/2013. I2 stated he/she had not seen the policy before. He/she was asked for documentation of any training he/she had received related to protection of patients during an investigation of an allegation of abuse. I2 stated he/she had no documented evidence of training. Although I2 stated he/she was involved in investigations of patient abuse, he/she had not seen the new "Investigatory Administrative Leave" procedure, and stated during the interview he/she had no evidence of training related to protecting patients during an abuse investigation.

An interview was conducted with I3, Employee Relations Manager, on 10/23/2013 at 1345. I3 was shown the "Investigatory Administrative Leave" Procedure #: 500.95, origination date 10/20I3. I3 acknowledged during the interview, that employee relations staff would be involved in the process of placing an employee on an investigatory leave during an investigation of abuse as outlined in the procedure. He/she stated the employee relations team were involved in reviewing aspects of the policy during their team meetings. He/she provided meeting minutes for 10/15/2013 which reflected the policy was still in a draft form. The meeting minutes reflected "Team went over draft of Investigatory Administrative Leave procedure..." I3 stated the employee relations staff did not receive the final version of the policy until yesterday (10/22/2013). I4 stated he/she did not have any documentation that training had been conducted for the employee relations staff on a process to protect patients while investigating an allegation of abuse.

2. Grievance report documentation for Patient 44 was reviewed. The documentation reflected the "Date of Occurrence" was 05/28/2013 and the "Date Complaint Received" was 05/29/2013. The grievance "Initial Complaint Description" notes reflected "05/29/2013...Phone call from patient inside hospital, requesting I [I1, Patient Relations] come speak to [him/her] about concerns...[he/she] tells me that one of [his/her] nurses was 'verbally abusive' [at][him/her] and 'looked like [he/she] would get physically abusive.'" The grievance "Case Narrative" notes reflected "05/29/2013...Met with [Patient 44]...[He/she] says that [Nurse I9] came in to give [him/her] an antibiotic, which patient acknowledged [he/she] refused, because [he/she] wanted [his/her] stomach to settle first. [Patient 44] says that at this point, [Nurse I9] started 'ranting and raving' and 'screaming at the top of [his/her] lungs' telling the patient, 'You have no respect for staff or anyone else,' and 'called me an asshole and a dick', then tried to take patient's Coke mug from [him/her]. "[Patient 44] says that [Nurse I9] 'got louder' and [Patient 44] says that [he/she] then 'started to get mad' and 'told [Nurse I9] to leave' but [Nurse I9] wouldn't. [Patient 44] states that [Nurse I9] then went to the sink and then came back to [Patient 44] and 'got in [Patient 44's] face' and 'looked like [he/she] could hit [Patient 44]..." The documentation reflected Patient 44 stated he/she felt very vulnerable and "in danger" due to this interaction. The documentation further reflected that a CNA encouraged Patient 44 to report the incident to patient relations.

An interview was conducted with I2, Clinical Risk Manager, on 10/23/2013 at 1300. He/she reviewed the grievance report documentation for Patient 44. He/she acknowledged during the interview that the patient's complaint was an allegation of verbal abuse.

Grievance "Case Narrative" notes reflected I1 met with Nurse 19's unit manager on 05/31/2013 (2 days after the grievance was received) and discussed the incident involving Patient 44's grievance.

Grievance "Case Narrative" notes from I2, submitted to I1, and Nurse I9's manager dated 06/03/2013 at 0809 (5 days after the grievance was received) reflected "...I wonder if this is the same [Nurse I9] [Patient 45] complained about. If it is, [Nurse I9]'s trend of perceived interactions is starting to worry me."

Grievance "Case Narrative" notes dated 06/03/2013 at 0816, from Nurse I9's manager submitted to I1 and I2 reflected "It is indeed. It worries me too. I will meet with [Nurse I9] for corrective action."

Grievance "Case Narrative" notes dated 06/03/2013 at 1602, from Nurse I9's manager submitted to I1 and I2 reflected "[male/female name] confirmed that [Nurse I9] did say the patient was a 'dick' and although [he/she] did not witness the interaction, [he/she] did deal with the fall out and heard about it from [Nurse I9]...I have an appointment to meet with [Nurse I9] next Monday..."

An investigation of the allegation of verbal abuse of Patient 44 was requested from I3, Employee Relations, on 10/23/2013. An untitled form designed to "Coach or counsel an employee" dated 06/06/2013 was received and reviewed. Documentation on the form reflected that the complaint submitted by Patient 44 was discussed with Nurse I9 and Nurse I9's charge nurse on 06/06/2013 (8 days after the complaint was received). Documentation on the form reflected "[male/female name] was in charge that night and states the patient was combative and using racial slurs. Supports [Nurse I9's] account and said [he/she] changed assignments to support [Nurse I9]..."

None of the documentation reviewed reflected that a timely investigation was conducted or that patients were protected from further abuse during the course of the investigation.

Based on the review of documentation in 4 patient records of patients who received transfusions of blood or blood products (Patient record #s 18, 19, 20, and 21), policy review and the review of blood bank documentation, it was determined the hospital failed to ensure documentation of all of the elements required by the hospital's policy in 2 of the 4 records (Patient record #s 18 and 19).

1. Patient record 18 was reviewed and reflected the patient received two units of blood on 09/25/2013 which was started at 1203. Vital signs were taken at noon and lacked the temperature of the patient. A second unit of blood was started at 1352 without a full set of vital signs being completed.

Legacy Health Policy titled, "Blood and Blood Product Administration and Monitoring" Procedure #: 915.4282, last reviewed 10/2011 states, "Obtain a full set of vital signs within one hour prior to starting the transfusion."

2. Patient record 19 was reviewed and reflected the patient received two units of blood on 09/24/2013. The first unit of blood was hung at 1045 and was completed at 1233. At 1246 a set of vital signs were completed that lacked the patient's temperature. The second unit of blood did not have a documented start time and did not have a second signature to verify the blood with the primary nurse.

The hospital failed to "Obtain a full set of vital signs within one hour prior to starting the transfusion," as per their policy and procedure. The hospital also failed to follow the Legacy Health Policy titled "Blood and Blood Product Administration and Monitoring" Procedure #: 915.4282, last reviewed 10/2011, Section 4a which states, "Transfusionist and witness must complete 'Time Out' to verify that the patient and blood product identification match."

Based on review of 10 medical records of surgical patients, and review of medical staff rules and regulations, it was determined that 2 of 10 records (Records P36 and P37) lacked evidence that a medical history and physical examination were completed not more than 30 days before or 24 hours after admission or registration and placed in the patients medical record within 24 hours after admission or registration.

Findings included:

Patient P37 was admitted to the hospital on 08/15/2013. The H&P scanned into the chart lacked date, time, and signature of the provider. The update on the day of surgery referred to the H&P, stating, "No interval change in preoperative H&P since last internist note." Without the date and time on the original H&P there was no way to determine if it was completed during the time frame required in this regulation and/or according to Legacy Good Samaritan Hospital and Medical Center Medical Staff Rules and Regulations, adopted 09/16/2010.

Patient P36 was admitted to the hospital on 08/19/2013. The H&P on the chart was dated 06/24/2013. The H&P update dated 08/19/2013, noted, "I've reviewed the medical record, independently verified the findings documented in my prior note on 6/24/2013, and verified that there have been no interval changes since then." The H&P on the chart did not meet the requirements outlined in this regulation and/or according to Legacy Good Samaritan Hospital and Medical Center Medical Staff Rules and Regulations, which require a medical history and physical examination to be "documented greater than 24 hours (but no greater than 30 days) before admission or an invasive procedure."

A team of State Fire Marshals conducted an onsite Fire & Life Safety Survey as part of the Validation survey.

Based on observations, interviews of hospital staff, policy and procedure review, and documentation review, the State Fire Marshals determined that the hospital failed to ensure that the physical environment was constructed, arranged, and maintained to ensure the safety of patients.

Findings included:

The hospital staff failed to respond appropriately to two fire drills. In addition, fire drills and training were not conducted as required and the hospital failed to design, implement, monitor and evaluate their fire drill policy and procedure. Due to changes to the fire alarm system at the hospital, the fire doors failed to close properly throughout the entire hospital during a fire drill conducted on 10/23/2013 at 1945. The cumulative effect of these systemic problems resulted in an Immediate Jeopardy situation and a significant threat to the health and safety of patients and staff.

Findings include:

Refer to the detailed findings listed at K tags:

A. Based on staff interview, review of policies and procedures and other documentation, it was determined that the hospital failed to ensure a system for identifying and controlling infections of patients was fully developed and enforced as required by this regulation. Policies and procedures were not fully implemented for disinfecting devices (transvaginal probes) used during patient care procedures (ultrasound examinations) in accordance with hospital policy.

Findings included:

A tour of the Imaging Department was conducted on 10/22/2013 at 0930. During the tour, an interview was conducted with I8, the Imaging Supervisor. He/she stated that transvaginal probes were used (during ultrasound examinations) and disinfected in 5 of the examination rooms within the Imaging Department. I8 stated the disinfectant used to disinfect the probes was Cidex, and he/she stated it was to be changed every 14 days. I8 provided a log used to record when the disinfectant for the probes was changed. Documentation on the log reflected the disinfectant was not changed every 14 days as expected. The following were examples:

Examination room 1: Review of the Cidex OPA (disinfectant) log records reflected the disinfectant was changed on 04/14/2013. The next documentation reflecting the disinfectant was changed was not until 05/05/2013 (21 days later); and then 05/20/2013 (15 days later).

Examination room 2: Review of the Cidex OPA log records reflected the disinfectant was changed on 03/25/2012. The next documentation reflecting the disinfectant was changed was not until 04/09/2012 (15 days later); and then 04/30/2012 (21 days later).

Examination room 4: Review of the Cidex OPA log records reflected the disinfectant was changed on 08/03/2012. The next documentation reflecting the disinfectant was changed was not until 08/19/2012 (16 days later); and then 09/13/2012 (25 days later).

Examination room 5: Review of the Cidex OPA log records reflected the disinfectant was changed on 04/14/2013. The next documentation reflecting the disinfectant was changed was not until 05/05/2013 (21 days later); and then 05/20/2013 (15 days later).

These findings were reviewed with I8 on 10/22/2013 at 1030.

A document titled "Cidex Procedure:" (undated) was posted in Room 4 on 10/22/2013 at 1115. The document was reviewed and reflected "...Cidex is replaced every 14 days"

During the Imaging Department tour on 10/22/2013 at 1030, I7, the Manager of Imaging stated that the hospital planned to implement a different process for disinfecting the probes because there were too many components for the staff to monitor/track when using the Cidex disinfectant.

A policy and procedure titled "High-Level Disinfection: Procedure for Use and Quality Control of Semi-Critical Medical Devices," Procedure #: 600.38 last revised 12/2012 was reviewed. The policy reflected that Cidex OPA (used for disinfecting the transvaginal probes) expired 14 days after opening the container.


B. Based on a tour of the facility, interview with the Operating Room Manager, and review of documentation and policy and procedures, it was determined that the facility failed to fully develop and implement infection control policies and procedures for monitoring temperature and humidity as required by this regulation.

Findings included:

On 10/22/2013, this surveyor requested the Temperature and Humidity logs, as well as policies and procedures for monitoring temperature and humidity. The Operating Room Nurse Manager brought in a hygrometer log book and a copy of a Policy titled, "Legacy Salmon Creek Environmental Condition Waiver Revision #1 Draft August 2013 "Temperature and Humidity in the Perioperative Environment." He/she explained that the hospital had recently completed a survey by JCAHO and today adopted the new policy for temperature and humidity. Attached to the policy were meeting minutes showing that the Legacy Health SCIP/SSI Team had discussed the humidity algorithm at the meeting on 10/22/2013 at 1000. The hygrometer log showed humidity had been monitored inconsistently throughout the year and the days that the ORs were closed were unclear. Documentation of temperature commenced on 09/10/2013.

On 10/23/2013, during a discussion with the State Fire Marshall, it was determined that the outpatient unit housed another log titled, "Humidity Readings," and contained a second policy titled "Humidity," #14.11, origination date 09/09/2013.

With two policies in place, and an absence of documentation as to which policy the staff had been trained to follow the hospital failed to design, implement, monitor and evaluate one comprehensive policy and procedure related to the control of temperature and humidity in the Operating Room. In addition the hospital failed to properly document temperature and humidity regularly in all appropriate locations.


C. Based on interview, review of policies and procedures, and review of documentation of 6 of 11 (Credentialing Records #s 1, 2, 4, 8, 10, and 11) credentialing records of medical staff granted privileges, it was determined that the hospital failed to ensure a system was in place to monitor TB testing of contracted physicians in accordance with hospital policy.

Findings included:

1. Review of the policy and procedure manual revealed Policy #: 600.36, "Tuberculosis Screening and Immunity Requirements," last review date 11/12/2012. The policy regarding Tuberculosis Screening Requirements for Non-Employees states "Baseline TB screening is a condition of service of Legacy Health." An interview with I6, System Manager of Infection Prevention/Control, on 10/24/2013 at 1330 confirmed this policy applied to contracted physicians.

2. Review of credentialing records for Provider # 1, a contracted physician, revealed that privileges were granted initially on 06/15/2000. The provider's file lacked documentation that reflected TB testing had been conducted.

Review of credentialing records for Provider # 2, a contracted physician, revealed that privileges were granted initially on 11/04/1991. The provider's file lacked documentation that reflected TB testing had been conducted.

Review of credentialing records for Provider # 4, a contracted physician, revealed that privileges were granted initially on 12/18/2008. The provider's file lacked documentation that reflected TB testing had been conducted.

Review of credentialing records for Provider # 8, a contracted physician, revealed that privileges were granted initially on 10/16/2008. The provider's file lacked documentation that reflected TB testing had been conducted.

Review of credentialing records for Provider # 10, a contracted physician, revealed that privileges were granted initially on 01/08/1999. The provider's file lacked documentation that reflected TB testing had been conducted.

Review of credentialing records for Provider # 11, a contracted physician, revealed that privileges were granted initially on 07/12/1988. The provider's file lacked documentation that reflected TB testing had been conducted.

These findings were reviewed with I20, Medical Staff Coordinator and I21, Credentialing Specialist.






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