HospitalInspections.org

Based upon review of 3 of 4 Physician Credential Files (S4, S5, S6), Medical Staff Bylaws, and staff interviews, the hospital failed to ensure the Medical Staff Bylaws were followed related to the appointment/re-appointment process as evidenced by: 1) failing to approve clinical privileges for physicians S5 and S6 during the reappointment process, and 2) failing to conduct professional reference checks, past and present Health Care affiliations, and a query from the National Practitioner Data Bank for physician S4. Findings:

Review of credential files for physicians S5 and S6 revealed the physicians were reappointed to the Medical Staff in July 2009. According to S5 and S6 Reappointment Applications, #9 on the applications identified "...Please complete this Clinical Privilege Form and the application for physician clinical privileges which is attached, for additional clinical privileges must be accompanied by information demonstrating current clinical competence." There failed to evidence the Clinical Privileges Forms were attached to the reappointment application for physicians S5 and S6.

On 10/05/10, 2:15 PM, interview with S9, who was responsible for physician credentialing, revealed during the reappointment process, the physician was to complete the Reappointment Application and attach the Clinical Privileges Form to the application.

Review of physician S4's credential file revealed the physician applied for Medical Staff membership in July 2010 and was approved by the Medical Director and a Governing Body representative in August 2010. Further review of physician S4's credential file revealed 1 of the 3 peer reference checks failed to be completed, past and present Hospital/Health Care entities failed to be verified, and the National Practitioner Data Bank query failed to be completed.

Review of the Medical Staff Bylaws revealed Article VI, Section 4 - Submission of Application "...The Hospital shall query National Practitioner Data Bank...". "B. Specific Information Required: (f) all past and present Hospital and other health care entity affiliations; (k) professional references: References [three (3)] from persons other than family or affiliated by marriage who must have personal knowledge of the applicant's recent professional performance, his ethical character, current competence, and his ability to work cooperatively with others; [NOTE: Specific written substantive comments will be obtained either through letters or completion of a Hospital request form.]."

Based upon review of 1 of 6 medical records (#2), hospital polices and procedures, observations made during the environmental tour on 10/04/10, 11:20 AM, and staff interviews, the hospital failed to ensure the Registered Nurse evaluated the nursing care of each patient as evidenced by: 1) failing to evaluate patient #2's respiratory status after identifying the patient was short of breath and 2) failing to follow the respiratory policy and procedure related to Aerosol Drug Administration and Oxygen use. Findings:

During the environmental tour on 10/04/10, 11:20 AM, inspection of patient #2's room revealed located at the patient's bedside was an Oxygen concentrator with a sterile water humidifier and nasal cannula tubing. The tubing was coiled in a circle and lying on top of the concentrator. A "CompMist" machine was located on the patient's bedside table and the attached tubing and medication chamber with associated mask was located on top of the patient's bed. There failed to be documentation on the oxygen equipment the date of implementation or when the container of sterile water was opened.

Review of patient #2's medical record revealed according to the physician's admission orders, the patient was to receive "Oxygen at 2 Liters/minute via nasal cannula PRN (as needed) for shortness of breath". Review of the 3PM to 11PM 8 hour nursing shift notes revealed the nurse identified by check mark the patient was "short of breath"; however, there failed to be documentation by the Registered Nurse oxygen was initiated per physician orders. Review of the nursing notes from 09/21/10 to 10/04/10 revealed there failed to be evidence the Registered Nurse documented an assessment of the patient's respiratory status and the interventions implemented, such as Oxygen therapy, for the patient's complaint of shortness of breath.

Review of Respiratory Policy 5.28B, Pulse Oximetry and Oxygen Use, A. Nasal cannula, #8. "Monitor the liter flow to ensure the physician's order is followed and the flow has not been changed/increased..", #9. "When not in use, the nasal cannula should be coiled and placed in a plastic bag for storage to prevent contamination". VI, A. "Humidity is added to oxygen in the form of sterile/distilled water. #1. When the bottle of sterile/distilled water is opened, the Nurse must write the date and time the bottle was opened on the label of the bottle", and IX. J. "The Nurse must document the following information when oxygen has been initiated: 1. Date and time that the oxygen was administered. #2. Type of oxygen therapy and the liter flow. #3. Patient tolerance of procedure."

There failed to be evidence the Registered Nurse (RN) followed hospital policy and procedure related to oxygen use and document the date and time when PRN (as needed) oxygen was initiated for patient #2, the type of oxygen therapy (nasal cannula, mask) and the liter of flow, and the patient's tolerance of the administration of the oxygen. There also failed to be documented evidence the RN documented on the sterile water container the date and time the bottle was opened.

Further review of the medical record revealed the physician also ordered "Albuterol Hand Held Nebulizer QID (four times a day)" Review of the Respiratory Therapy policy 5.28C, Aerosol Drug Administration, IV. Protocol: A. Hand Held Nebulizer 2. "The Respiratory Therapist will administer the first dose and then nursing staff will take over. After 24-48 hours of utilizing a nebulizer, the Respiratory Therapist will assess the patient for the ability to use a metered dose inhaler...". Interview with the Respiratory Therapist S11 on 10/05/10 at 9:35 AM revealed she was to be consulted on every patient who received Aerosol Drugs; however, the nursing staff had not notified her that patient #2 was on Hand Held Nebulizer treatments.

Based upon review of the personnel file of the Infection Control Officer, S2, and staff interview, the hospital failed to ensure the designated infection control officer was qualified by education, training, experience or certification. Findings:

Interview with the hospital administrator on 10/05/10, 10:00 AM, revealed the Director of Nursing S2 was designated as the infection control officer. Interview with S2 on 10/05/10, 10:30 AM, revealed she had a master's degree in nursing; however, she stated she did not have any training, experience, education or certification related to infection control.

Based upon review of 1 of 6 medical records (#5) and staff interviews, the hospital failed to ensure Psychiatrist S5 identified in the Psychiatric Evaluation a description of patient #5's assets on which to base treatment modalities. Findings:

Review of the medical record for patient #5 revealed the patient was admitted to the hospital on 08/27/10. Review of the Psychiatric Evaluation dated 08/28/10 revealed Psychiatrist S5 failed to describe the patient's personal assets/strengths that would be useful in therapeutic treatment modalities.