HospitalInspections.org

Based on review of medical records, review of agreements, review of credential files, review of the Medical Staff Bylaws and staff interview, the CAH (Critical Access Hospital) failed to have an agreement for credentialing for 2 of 2 teleradiology physicians (Physicians L and M) reviewed. There were 19 physicians on the teleradiology physician list. On the first day of survey patient census was 4 acute inpatients, 5 skilled inpatients and 1 observation patient.

Findings are:

A. Interview with the Imaging Services Manager on 1/7/13 from 1:00 PM to 2:30 PM revealed the following:
- CAH contracts with a group of radiologists from Omaha, NE, who provides Radiology Services at the CAH;
- During the hours of 11:00 PM to 7:00 AM another group of radiologist provides interpretations via teleradiology (referred to as the teleradiology group).

Review of Medical Record 28 revealed Physician L provided a preliminary report for a CT (computed tomography) of the head on 12/20/12. Review of Medical Record 29 revealed Physician M provided a preliminary report for a CT of the abdominal and pelvic region on 1/3/13. Both of these reports had a header with the teleradiology group's logo.

B. Review of the credential files for Physician L and M revealed a document on Saunders Medical Center letter head dated 8/18/11 with the following documentation:
"We, the Saunders Medical Center Medical Staff Executive Committee, hereby recommend that the following providers from [name of the teleradiology group] be permitted to provide preliminary reports to Saunders Medical Services pursuant to a Credentialing Acknowledgement executed by [name of teleradiology group] and Saunders Medical Center". Both Physician L and M were on the list. The credential files also contained the following:
- Evidence of current Nebraska physician licenses;
- Evidence of current malpractice insurance;
- Evidence of inquiry to the National Practitioner Data Bank;
- Request for Diagnostic Radiology Privileges with teleradiology group's logo at top of privilege list; and
- Board's (teleradiology group's) recommendation for approval of requested privileges

C. Review of a Service Agreement with the teleradiology group revealed the service agreement was between the radiology group from Omaha and the teleradiology group and not an agreement with Saunders Medical Center. Review of a Service Agreement dated 7/1/92 revealed an agreement between Saunders County Community Hospital and the radiology group in Omaha to provide "...exclusive medical responsibility for the Department of Radiology...."

D. Medical Staff Bylaws approved by the CAH's governing body on 3/24/03 revealed the following under Article IX Medical Staff Appointment and Privileging Procedures, Section 7 - Simplified Application Procedures for Minimal Contact: "In some situations, the CEO [Chief Executive Officer] (with the advice of the Chief of Staff) may authorize simplified application and approval procedures for practitioners who will have minimal contact with the Hospital." The Medical Staff Bylaws contained no information concerning credentialing and privileging of telemedicine physicians.

Based on review of credential files, review of the Medical Staff Bylaws and staff interviews, the CAH's (Critical Access Hospital's) governing body failed to follow the Medical Staff Bylaws to ensure that physicians were trained and qualified for the additional surgical privileges requested and granted by the governing body for 3 of 14 physicians/practitioners (Physicians B, C and E) reviewed (Refer to C-0241 examples A, B, C, D and H) and for the reappointment and continuation of privileges for 7 of 14 physicians/practitioners (Physicians B, C, E, F, G, H and J) reviewed (Refer to C-0241 examples A, E, F and H).

This deficient practice resulted in the potential for physicians to perform surgical procedures at the CAH they were not trained and competent to perform and for physicians to continue to provide services at the CAH without evidence of continued competency, sufficient contact with patients at the CAH and timely completion of medical records.

The roster of Medical Staff provided by the CAH listed 4 Active Staff, 75 Consulting Staff (physicians and practitioners) and 4 Emergency Department Staff. On the first day of survey patient census was 4 acute inpatients, 5 skilled inpatients and 1 observation patient.

Findings are:

A. Review of credential files revealed Physicians B, C and E were granted additional surgical procedures without evidence of training and competence for the requested additional privileges (Refer to C-0241 examples B, C and D).

B. Review of credential files revealed Physicians B, C, E, F, G, H and J were reappointed and granted continued privileges without evidence of competence, sufficient contact with patients at the CAH, timely completion of medical records and compliance with medical staff rules and regulations and applicable CAH policies (Refer to C-241 examples E, F and H).

C. Interview with CEO (Chief Executive Officer), Director of Clinical Services, and Health Information Management Manager/Medical Staff Credentialing on 1/10/13 from 9:50 AM to 11:06 AM revealed the CAH could provide no additional documentation concerning the reappointment and adding of privileges for Physicians B, C, E, F, G, H and J that was available at the time of reappointment and/or adding of privileges.

Based on review of the Medical Staff Bylaws, review of governing body meeting minutes, review of credential files and staff interview, the governing body of the CAH (Critical Access Hospital) failed to follow the Medical Staff Bylaws in regards to:
- Granting of new surgical privileges for 3 of 14 physician/practitioner reviewed (Physicians B, C and E);
- Reappointment and continued privileges for 7 of 14 physicians reviewed (Physicians B, C, E, F, G, H and J); and
- Appointment for 1 of 14 physicians/practitioners to the right Medical Staff Category (Practitioner N).

The roster of Medical Staff provided by the CAH listed 4 Active Staff, 75 Consulting Staff (physicians and practitioners) and 4 Emergency Department Staff. On the first day of survey patient census was 4 acute inpatients, 5 skilled inpatients and 1 observation patient.

Findings are:

A. Review of the Medical Staff Bylaws approved by the governing body on 3/24/03 under Article VIII - Independent Clinical Privileges Section 2 - Qualifications revealed the following concerning qualifications for Independent Clinical Privileges:
"The following constitute qualifications for the exercise of independent clinical privileges at the Hospital. Each member and applicant for membership and clinical privileges, shall:...
b. Competence: Possess and maintain demonstrated clinical competence, including current knowledge, judgment, and technique, in his or her specialty area and for all privileges held or applied for....
c. Sufficient Contact/Review of Competence: Demonstrate that he or she will have sufficient patient care contact at the Hospital to permit the Medical Staff to continually assess competency for all requested privileges....
o. Records. Complete all required records in a thorough, professional and timely fashion....
s. Compliance with Rules. Abide by the terms, conditions, and procedures of these bylaws, the Medical Staff rules and regulations, applicable Medical Staff and Hospital policies, and the governing documents of the Hospital....
t. Documentation. Document each of the foregoing qualifications to the satisfaction of the Board and the Medical Staff...."

B. Review of the credential file for Physician B revealed a document dated 12/13/12 with the following documentation:
"We the Saunders Medical Center Medical Staff Executive Committee, hereby recommend to the Saunders Medical Center Governing Board, the approval of [Physician B's name] request for additional surgical privileges to perform:
Cervical Biopsy (not with colposcope), Diagnostic D&C [dilation and curettage] - with/without polypectomy, Hymenectomy, Hysterectomy; Abdominal, Vaginal, Hysterosalpingography, I&D [incision and drainage] of Bartholin cyst or perineal abscess, I &D of pelvic abscess, Labiaplasty, Use of Laparoscope: for diagnostic laparoscopy or operative laparoscopy, Marsupialization of Bartholin cyst, Operation for treatment of carcinoma of the vulva, vagina, endometrium, ovary or cervix, Operations for treatment of benign pelvic disease; D&C with conization, laparotomy, abdominal hysterectomy, vaginal hysterectomy...salpingectomy, oophorectomy, trachelectomy, Ovarian cystectomy, Repair of rectocele, enterocele, cystocele, and Vulvar biopsy (small punch-Keyes)." This document included signatures of the Chief of Staff, Vice Chief of Staff and 1 other physician. Further review of the credential file revealed Physician B was originally appointed to the medical staff by the governing body in 2006 and revealed no information about competency for these additional requested privileges.

Review of the governing body meeting minutes dated 12/17/12 (unapproved) revealed these additional surgical privileges were approved with no indication of any further discussion.

C. Review of the credential file for Physician C revealed a document dated 2/17/11 with the following documentation:
"We, the Saunders Medical Center Medical Staff, hereby recommend that [Physician C's name] request for approval of additional clinical privileges to perform lumbar puncture under fluoroscopy and myelography." This document included signatures of the Chief of Staff, Vice Chief of Staff and 2 other physicians. Further review of the credential file revealed Physician C was originally appointed to the medical staff by the governing body in 2006 and revealed no information about competency for these additional requested privileges.

Review of the governing body meeting minutes dated 2/17/11 revealed these additional surgical privileges were approved with no indication of any further discussion.

D. Review of the credential file for Physician E revealed a document dated 2/17/11 with the following documentation:
"We, the Saunders Medical Center Medical Staff, hereby recommend to the Saunders Medical Center Governing Board that [Physician E's name] request for approval of additional clinical privileges to perform breast biopsies and aspiration of breast and soft tissue cysts." This document included signature of the Chief of Staff, Vice Chief of Staff and 2 other physicians. Further review of the credential file revealed Physician E was originally appointed to the medical staff by the governing body in 2002 and revealed no information about competency for these additional requested privileges.

Review of the governing body meeting minutes dated 2/17/11 revealed these additional surgical privileges were approved with no indication of any further discussion.

E. Review of the credential files for the Active Medical Staff Physicians G and H (last reappointment by governing body dated 12/19/11) and Physician F (last reappointment by governing body dated 7/23/12 revealed no information concerning: Competence (possess and maintain demonstrated clinical competence, including current knowledge, judgment, and technique, in his or her specialty are and for all privileges held or applied for); Sufficient Contact/Review of Competence (number of patients attended since last appointment); Records (Complete all required records in a thorough, professional and timely fashion); and, Compliance with Rules (Attendance at medical staff meetings).

Review of the governing body meeting minutes dated 7/23/12 revealed Physician F was reappointed with no indications of further discussion.

F. Review of the credential files for Consulting Staff Physicians B and C (last reappointment by governing body dated 12/17/12) and Physician E (last reappointment by governing body dated 7/23/12) and Emergency Department Staff Physician J (last reappointment by governing body dated 1/24/11)revealed no information concerning Competence (possess and maintain demonstrated clinical competence, including current knowledge, judgment, and technique, in his or her specialty are and for all privileges held or applied for); Sufficient Contact/Review of Competence (Demonstrate that he or she will have sufficient patient care contact at the Hospital to permit the Medical Staff to continually assess competency for all requested privileges); Records (Complete all required records in a thorough, professional and timely faction); and, Compliance with Rules (Medical Staff rules and regulations and applicable Hospital policies).

Review of the governing body meeting minutes dated 7/23/12 and 12/17/12 (unapproved) revealed Physicians B, C and E were reappointed with no indications of further discussion.

G. Review of the credential file for Practitioner N (Psychologist) revealed a document dated 11/28/12 regarding appointment to the medical staff with the following documentation "I am pleased to inform you that on November 26th, 2012, the Governing Board of Saunders Medical Center approved moving your status from provisional consulting medical staff membership to full consulting medical staff membership at Saunders Medical Center for the period of May, 2012 through May, 2014.

Review of the Medical Staff Bylaws approved by the governing body on 3/24/03 under Article VII - Medical Staff Categories Sections 3 - Consulting Staff and Section 4 - Affiliate Staff revealed the following:
"The Consulting Staff consists of physicians who are recognized specialists willing to serve in a consulting capacity, but who do not serve as primary care physicians at the Hospital and who do not request admitting or co-admitting privileges."
"The Affiliate Staff consists of all nonphysician practitioners who are qualified to hold independent clinical privileges at the Hospital pursuant to Article VIII....This category will generally include dentists, podiatrists, psychologists, and chiropractors."

Nonphysician Practitioner N (psychologist) was appointed to a category of the Medical Staff that could only be "physicians".

H. Interview with CEO (Chief Executive Officer), Director of Clinical Services, and Health Information Management Manager/Medical Staff Credentialing on 1/10/13 from 9:50 AM to 11:06 AM revealed the CAH could provide no additional documentation concerning the reappointment and adding of privileges for Physicians B, C, E, F, G, H, J and Nonphysician Practitioner N (psychologist).