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Based on interview, record review, bylaws and policy review the facility failed to provide evidence that the medical staff is organized and accountable through the processes of peer review to the governing body for the quality of the medical care provided to it patients and in 1 of 11 sampled patients (SP) #6.

The findings:

Review of the medical records showed that (sampled patient) SP#6 presented to the hospital on 5/18/17 with complaint of chest pain, shortness of breath, and dizziness. Pt was diagnosed for aortic stenosis.

On 5/26/17, the Operative report of Physician C showed SP #6 underwent heart surgery.

It is noted on 5/31/17 Discharge Summary that the patient was critically ill with a poor prognosis. The patient to transfer to another hospital. Pt on ventilator assistant and acute respiratory failure.

Interview on 10/5/17 at 11:01 am with the Chief Medical Officer (CMO) stated on the case of SP#6. This is a complex and challenging case. There is some bleeding issues, which is inherent in this surgery. There is no ECMO (extra corporeal membrane oxygenation) services here. There is no corrective plan for this specific case and she recalls she reviewed the case.

Review of SP #6 History and Physical 05/31/2017 at 23:40 PM, from the receiving hospital showed that the patient was admitted for severe symptomatic anemia and was found to have severe aortic stenosis. He is now S/P SVAR (status/post aortic valve replacement) on 05/26/2017 at [the named transferring hospital]. The procedure was complicated by significant cross-cramp time of 6 hours, significant amount of blood loss, and difficulty sizing the prosthetic aortic valve due to oversizing of the valve on imaging leading to aortic root dilation. The note further showed that the patient was transferred to the [named receiving hospital] for VA (ventilation assistance) ECMO support.

Interview on 10/4/17 at 11:21 am, with the Assistant General Counsel stated that anything that would be presented to the GB (governing Body) by the MEC (Medical Executive Committee) is part of the peer review. Credential files parts of them is also part of peer review. Peer review is protected and we cannot turn over peer review. It is statutory privilege. Patient records can be provided, however specific actions of physicians I cannot give that information to the agency.

Interview on 10/5/17 at 12:37 pm with the Assistant General Counsel via telephone and with the Director of Risk Management stated, "I cannot admit or deny that anyone has gone for peer review by statutes." He further stated that the facility could not provide such request to the surveyor.

Interview on 10/4/17 at 3:28 pm , the Assistant General Counsel said that upon advice of counsel the hospital cannot provide any information that could be subject to peer review privilege nor able to confirm or deny whether a particular review of a particular case, nor a practitioner based on privilege, such as peer review.

Review of the Medical Executive Committee Agenda, and minutes for 2/14/2017 showed that it was redacted and the peer review process could not be identified.


Review of the Policy and Procedure: "Peer Review Policy", Revised Date: July 2010-Reviewed Date: July 2012 states that the peer review process is designed to perform ongoing review and evaluation of activities that contribute to the preservation and improvement of the quality, performance, effectiveness and efficiency of patient care.


Review of the Peer Review Policy, Revised Date: July 2010-Reviewed Date: July 2012 .
I. Scope of the policy applies to all appointed members of the Medical Staff in accordance to the By Laws and Rules and Regulations.
IV. Under A. Procedure for Peer Review Identification showed that for potential quality of care issues identified, the identifying individual should notify the Quality Management Department. The following peer review criteria should be used as guide and not an exclusion list to initiate review for referral to the appropriate Peer Review Committee and maybe modified periodically to maintain the quality, performance, effective, and efficiency of patient care such as:
d. post procedural complications/injuries
h. unexpected transfer to a higher level of care

The facility failed to provide evidence that the case of SP#6 was referred for peer review nor went through the peer review process.


The " Bylaws Of The Medical Staff" revised May 19, 2010, showed under 6.4 the investigation/ Peer Review Process, and under 6.4.5.4 states that the peer review procedures outlined in these Bylaws shall be followed.
Under 7.10.4. External Reporting Requirements states the hospital shall submit a report regarding a final Adverse Action to the appropriate state professional licensure board (i.e., the state agency that issued the individual's license to practice) and all other agencies as required by all applicable Federal and/or State law(s).

The policy and the bylaws do not address procedures for recording of agendas and minutes, which do not contain confidential material, for review by the Division of Health Quality Assurance of the agency.