HospitalInspections.org

Based on review of the hospital policy and procedure for the use of restraints and staff interview the facility failed to ensure their policy and procedure addressed physician and other licensed independent practitioner training requirements and failed to ensure medical staff were provided training on the hospital policy for the use of restraints. The hospital census on the day of entrance was 9. Findings are:

Review of the hospital policy and procedure titled "Use of Restraints" last reviewed on 10/2011 revealed it did not contain any direction related to physician training on the use of restraints in the facility.

On 8/1/12 at 3:50 PM an interview was completed with the Director of Nursing (DON) regarding the restraint policy and procedure. She stated that they do not provide training on the restraint policy to their physicians. She added that the only training they provide is to the nursing staff.

Based on review of physician credential files, review of the Medical Staff Bylaws, review of the credentialing verification agreement and staff interview, the hospital failed to query the NPDB (National Practitioner Data Bank) for 9 of 10 physician credential files reviewed (Physicians A, B, C, D, E, F, G, H and I) and failed to include demonstrated clinical activity for the reappointment of 1 of 9 physician credential files reviewed (Physician C). The hospital census on the day of entrance was 9. The hospital's Medical Staff included 85 physicians.

The NPDB is an electronic repository of all payments made on behalf of physicians in connection with medical liability settlements or judgments as well as adverse peer review actions against licenses, clinical privileges, and professional society memberships of physicians and other health care practitioners. Findings are:

A. Review of the credential files for Physicians A, B, C, D, E, F, G, H and I revealed no information related to querying the NPDB. Interview with the Business, Human Resources and Credentialing Manager on 8/1/12 from 2:00 PM - 2:45 PM while reviewing the credential files revealed the following:
- Confirmed the lack of information concerning the National Practitioner Data Bank in Physician A's and B's credential files;
- Indicated that they had needed this information during the Accrediting Organization survey; and
- Would call the credential verification organization the hospital had an agreement with to get more information.

B. Review of the Memorandum of Understanding with the credentialing verification organization which was signed by both parties in December 2007 revealed the credential verification organization would query the NPDB for the hospital if the credentialing organization was registered by the hospital as an authorized agent. Interview with the Business, Human Resources and Credentialing Manager on 8/1/12 at 3:20 PM confirmed that neither the hospital nor the credential organization as an authorized agent had queried the NPDB.

C. Review of the credential file for Physician C revealed a Request for Reappointment for Internal Medicine and signed by the Medical Director on 3/7/12 and the Board Chair on 3/8/12. Review of the entire credential file revealed no information on clinical activity in the Hospital during the past 2 years. The only information concerning clinical activity was dated April and May of 2010. Interview with the Business, Human Resources and Credentialing Manager on 8/1/12 at 3:20 PM confirmed the lack of information concerning clinical activity after reviewing the file.

D. Review of the Medical Staff Bylaws with a last revised date of 5/4/12 revealed the following criteria for reappointment to the medical staff "...demonstrate clinical activity in the Hospital during the past 2 years".

Based on staff interview and review of the listing on physicians on the hospital's medical staff and review of the Professional Services Agreement for radiology, the hospital failed to have a full-time, part-time or consulting radiologist that was on the hospital medical staff supervise the radiology services at the hospital. The hospital census on the day of entrance was 9. The hospital Medical Staff included 85 physicians. Findings are:

A. During review of the contracted radiology services provided at the hospital on 7/30/12 from 11:40 AM to 12:15 PM, the Radiology Manager stated that Physician J was Medical Director of the contracted Radiology services. Review of the listing of physicians on the hospital medical staff revealed Physician J had not been granted privileges at this hospital.

B. Review of the Professional Services Agreement for radiology services signed by both parties on 4/28/08 revealed the following responsibility of the Contractor:
"Provide all professional, technical and administrative staff and personnel necessary to perform the Services, including licensed technicians and supervising Board certified Physicians."

The contract also included the following under number 9:
"No Medical Staff Appointment by Virtue of Agreement. None of Contractor's physicians shall be entitled to appointment or reappointment or any clinical privileges at Hospital, by virtue of this Agreement. Notwithstanding the foregoing, Contractor's physicians are required to obtain active Medical Staff membership at Hospital prior to the time they provide any service under this Agreement. Contractor agrees to comply with and assist Hospital in observing Medicare certification standards."

Based on review of the hospital's identified list of committees and staff interview, the facility failed to develop a Utilization Review (UR) Committee even though the facility is performing its own UR functions. The hospital census on the day of entrance was 9. Findings are:

Review of the list of hospital committees provided by the Administration failed to find a UR committee identified.

An interview with the UR Registered Nurse (RN) Coordinator on 7/30/12 at 1:50 PM confirmed she was responsible for the UR functions of the hospital. She also confirmed that all of the UR functions are done internally and she is the only one performing any of the UR functions. She revealed the hospital does not have patients with extended stays and does not have outlier cases because of the type of specialty hospital they have in place. The UR RN said they do not have a UR Committee. If they have issues or changes that are needed she takes it to the Quality Improvement Committee or has the Director of Nursing (DON) take it to the Board or the Medical Staff Meeting. They have not had an occasion to need a physician to review a case for an extended stay. She said she may have to contact the insurance company to get approval for 1 extra day for pain management, but they do not have patients that develop complications that require long stays. Their hospital is not set up to handle patients that develop secondary medical problems such as cardiac complications, stroke, etc. When a patient has medical complications requiring intensive care or telemetry they have to transfer them to another facility that can manage those needs.

On 8/2/12 at 12:00 noon an interview was completed with both the DON and the UR RN regarding the lack of a UR Committee that has at least 2 physicians. Again they confirmed they do not have such a committee and will need to discuss this requirement with the Board and Administration to decide how they will handle this issue.