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Based on record review and staff interview, the Governing Body failed to ensure members of the medical staff were appointed after considering the recommendations of the medical staff. The Governing Body failed to ensure the medical staff bylaws were followed for appointment of medical staff members as evidence by:
1) Failing to grant temporary privileges in accordance with Medical Staff Bylaws for 3 (SF7Physician, SF8APRN, SF9APRN) of 6 (SF6MD, SF7Physician, SF8APRN, SF9APRN, SF10APRN, SF11APRN) credentialing files reviewed, and;
2) Failing to ensure the process for appointment to the medical staff was followed for physicians granted temporary privileges pending appointment to the medical staff. This resulted in the privileges terminated for 1 (SF7Physician) of 6 (SF6MD, SF7Physician, SF8APRN, SF9APRN, SF10APRN, SF11APRN) credentialing files reviewed.

Findings:

Review of the Medical Staff Bylaws, revised date of 07/08/15 revealed in part the following:
Article VII Clinical Responsibilities
B. Authority to Grant Temporary Responsibilities/Conditions
The Administrator/CEO, with the written concurrence of the chairman of the department where the Responsibilities will be exercised and of the chairman of the Medical Executive Committee (MEC), may grant Temporary Responsibilities under the circumstances noted below. In all cases, Temporary Responsibilities shall be granted for a specific period of time, not to exceed one hundred twenty (120) days....
3. Pending Appointment to the Medical Staff. In addition to the general requirements noted in above, the applicant's professional degree must be verified (e.g. M.D., D.O. [Medical Doctor, Doctor Osteopathy]) as well as his current license, current DEA (Drug Enforcement Agency) registration, and specialty claimed, at least two (2) references relating positively to his professional and ethical status, and documentation of the current requisite amount of professional liability insurance coverage. Except pursuant to appropriate Board action, under no circumstances shall Temporary Responsibilities be extended under this paragraph for more than a total of 120 days.

1) Failing to grant temporary privileges in accordance with Medical Staff Bylaws:

SF7Physician
Review of the Current Medical Staff roster revealed SF7Physician was board certified in Family Medicine and was the collaborating physician for the Nurse Practitioners.

Review of the credentialing file for SF7Physician revealed a Temporary Privileges Form dated 03/24/15 where temporary privileges were requested for medical examination & treatment, and medical history & physical (H&P) examination while the medical staff application was being processed. Review of the form revealed SF1ADM (Administrator) signed the form on 05/27/15 (during the last survey). Further review of the credentialing file revealed no documented evidence of 2 references as required in the Medical Staff Bylaws. Review of the entire credentialing file revealed no documented evidence of written concurrence by the chairman of the department and the chairman of the MEC (Medical Director at this facility) for granting temporary privileges while the application was being processed.


SF8APRN
Review of the credentialing file for SF8APRN revealed a Temporary Privileges Form dated 05/22/15 where temporary privileges were requested for medical examination & treatment, and H&P examination, general psychiatry, psychopharmacology, adolescent psychiatry, and addictive medicine. The form revealed the privileges were requested while the medical staff application was being processed. Review of the form revealed SF1ADM signed the form on 06/02/15. Further review of the credentialing file revealed no documented evidence of 2 references as required in the Medical Staff Bylaws. Review of the entire credentialing file revealed no documented evidence of written concurrence by the chairman of the department and the chairman of the MEC (Medical Director) for granting temporary privileges while the application was being processed.


SF9APRN
Review of the credentialing file for SF9APRN revealed a Temporary Privileges Form dated 04/13/15 where temporary privileges were requested for general psychiatry, psychopharmacology, adolescent psychiatry, and addictive medicine. The form revealed the privileges were requested while the medical staff application was being processed. Review of the form revealed the signature line for the Chief Executive Officer only included the date - 05/27/15. Further review of the credentialing file revealed only one reference. Review of the entire credentialing file revealed no documented evidence of written concurrence by the chairman of the department and the chairman of the MEC (Medical Director) for granting temporary privileges while the application was being processed.


In an interview on 07/30/15 at 4:40 p.m. SF1ADM and SF3Director RM/PI (Risk Management/Performance Improvement) reviewed the credentialing files of SF7Physician, SF8APRN, and SF9APRN and confirmed the bylaws had not been followed for granting temporary privileges. S1ADM stated he signed what SF5Consultant RHIA (Registered Health Information Administrator) handed him and he thought the Medical Director (SF6MD) had signed a form approving temporary privileges. SF1ADM confirmed the Medical Staff Bylaws required concurrence with the MEC and the applicant was to have 2 references. SF3Director RM/PI reviewed the credentialing files and confirmed SF7Physician and SF8APRN had no references and SF9APRN had only one.


2) Failing to ensure the process for appointment to the medical staff was followed for physicians granted temporary privileges pending appointment to the medical staff. This resulted in the privileges terminated for 1 (SF7Physician) of 6 (SF6MD, SF7Physician, SF8APRN, SF9APRN, SF10APRN, SF11APRN) credentialing files reviewed:

SF7Physician
Review of the Current Medical Staff roster revealed SF7Physician was board certified in Family Medicine and was the collaborating physician for the Nurse Practitioners.

Review of the credentialing file for SF7Physician revealed a Temporary Privileges Form dated 03/24/15 (128 days) where temporary privileges were requested for medical examination & treatment, and medical history & physical (H&P) examination while the medical staff application was being processed. Review of the form revealed SF1ADM (Administrator) signed the form on 05/27/15 (during the last survey).

In an interview on 07/30/15 at 4:40 p.m. SF1ADM was asked why the credentialing for SF7Physician had not moved through the process by now since the application date was 03/24/15. SF1ADM stated because SF5Consultant RHIA was only at the hospital 2 days a week and she was responsible for the credentialing files. SF1ADM confirmed the temporary privileges for SF7Physician had expired and confirmed the process should have been completed within 120 days. SF1ADM confirmed SF7Physician had been on staff at the hospital since March 2015. He also confirmed that the APRNs doing the H&Ps now did not have a collaborating physician that had privileges at the hospital.

Based on observation and interview, the hospital failed to ensure patients received care in a safe setting as evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for patients admitted for acute inpatient psychiatric services by failing to ensure the patients' environment was free of ligature risks and safety hazards. Findings:

In an observation on 07/30/15 at 11:15 a.m. of the Adult Acute Unit (East) with SF2DON (Director of Nursing), the doors to the patients' rooms and the bathroom doors were observed to have door hinges set apart widely enough to allow for potential ligature. SF2DON confirmed patients are allowed to close the door to their rooms and confirmed the bathroom doors posed a ligature risk. SF2DON stated there were 22 beds (11) rooms on this unit and confirmed the door hinges were the same in all the patient rooms.

The sinks in all the patient rooms were observed to have flanged handles that could be used as ligature points. SF2DON confirmed the observations. SF2DON stated the bathrooms were going to be renovated and the bathtubs would be removed and replaced with stand-up showers. SF2DON indicated anti-ligature fixtures would be used. SF2DON stated the renovation would start in September or October.

In an interview on 07/30/15 at 12:00 p.m. SF1ADM (Administrator) stated the renovations were in the permit stage and all hardware will be replaced.

Review of the EOC (Environment of Care) Proactive Risk Assessment dated 06/25/15 revealed the flanged sink handles and the door hinges on the patient room doors and the bathroom doors were identified as a medium risk. The mitigation of the risk was documented as, "Inspected during daily room safety checks and monthly inspections. Patients monitored Q (every) 15 minutes. Staff educated on room safety and suicide risk annually, during orientation, and as needed." Review of the form revealed the sink handles and door hinges were to be replaced during the 4th quarter of 2015.

Review of the hospital policy titled Precautions Levels and Record revealed Suicide/Self-Harm Precautions indicated the patient would be monitored at least every 15 minutes.

Review of the Nurse Staffing Form completed by SF2DON on 07/30/15 at 1:30 p.m., revealed no patients on the Adult Acute Unit were on 1:1 observation in the past 2 weeks. SF2DON indicated they rarely have patients on 1:1 observation.

On 07/30/15 at 4:50 p.m. SF3Director RM/PI (Risk Management/Performance Improvement) confirmed 5 current patients on the Adult Acute Unit were currently on suicidal precautions (RF1, RF2, RF3, RF4, and RF5).

In an interview on 7/30/15 at 4:40 p.m. S1ADM confirmed all suicidal patients are not placed on 1:1 observation.