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Based on interview and record review, in 1 of 1 credentialing file reviewed, the facility failed to follow Medical Staff Services policy titled: Practitioner Health and Wellness. Once receiving notification of physician condition, there was no written request to investigate submitted to Peer Review Committee.

Findings include:

Chief nursing officer (ID# 51) and Director of Medical Staff Services (ID# 83) on 1/2/2016 at 12:41 stated that there is no documentation in February or March meeting minutes for peer review, medical executive committee, or Board of Trustee meeting regarding reported condition physician (ID# 54), nor is there a written request to investigate.



Record review of credentialing file for physician (ID# 54) revealed a letter dated 2/20/2015 from health care provider (ID# 84) regarding the medical condition of physician (ID#54). This letter expressed presenting symptoms, treatment and medical studies conducted. In the conclusion of this letter, it is stated that physician (ID#54) does not currently demonstrate disabling symptoms of Parkinson's disease and should be able to continue functioning in his practice.

Record review of facility policy for the department of medical staff services titled: Practitioner Health and Wellness (no date on policy) revealed the following information:
Policy:
1. Any individual who has clinical privileges must maintain physical and mental health status sufficient to carry out those privileges in a safe manner.
2. Reports or concerns about impairment must be investigated and acted upon in a timely manner and in accordance with state and federal law, including, but not limited to, the Americans with Disabilities Act (ADA).

Definition:
b. Physical illness or condition, including but limited to those illnesses or conditions that would adversely affect cognitive, motor, or perceptive skills, including deterioration through the aging process.

Procedure:
Self reporting-Application process
1. During the application process, all applicants must report information about their ability to perform the clinical privileges they are requesting. Each medical staff member or other individual with clinical privileges is responsible for reporting any change in his/her abilities that might possibly affect the quality of patient care rendered by him/her as related to the performance of his/her clinical privileges and/or medical staff duties. Such reports should be made immediately upon the individual becoming aware of the change.
2. A written report must be given to the Chief Executive officer, the Chief of Staff, the Chairperson of the individual's medical staff department, and/or the chairperson of the credentials committee. The recipient of this letter shall submit it, along with a written request to investigate, to the Peer Review Committee.

Based on interview and record review, the facility failed to report 1 of 2 preventable adverse events (PAE) to the Texas Health Care Safety Network (TxHSN) and to complete a root cause analysis (RCA) for 1 of 3 adverse events reviewed.

Findings include:

Interview with Chief Nursing Officer ( ID# 51) on 11/1/2016 at 2:20 PM revealed that adverse event (wrong surgical procedure) performed 3/11/15, involving patient (ID# 3) was not reported to the state as required and that it should have been.

Interview with Chief Nursing Officer (ID# 51) on 11/2/2016 at 9:35 AM revealed that in regard to adverse advent (wrong surgical procedure) that occurred with patient (ID# 3) on 3/11/2015, there was no incident report generated when the facility was notified. There was no documentation of a root cause analysis (RCA) performed regarding the event. There was an investigation performed, but no documentation to review that shows the investigation process.




Record review of Texas Department of State Health Services Facility-Specific Healthcare Safety Report of preventable adverse events reported from January 2015-July 2015 for Conroe Regional Medical Center reveled the following information.

Preventable Adverse Events (PAEs)
Events related to patient care: Total Number of 1
Patient death or severe harm associated with a fall in the healthcare facility that caused a broken bone.

Record review of the Texas Department of State Health Services 3 Tier Phase -In Implementation for Preventable Adverse Events (PAE) revealed the following information:
First Tier PAE Reporting Beginning January 1, 2015
1. Surgeries or invasive procedures involving a surgery on the wrong patient, wrong procedure.
10. Patient death or severe harm associated with a fall in a healthcare facility resulting in fracture, dislocation, intracranial injury, crushing injury, burn or other injury.




Record review of facility policy titled Event Reporting: Patient and Non-Patient dated 01/2012 revealed the following information:
Purpose:
-To provide a record of events and documentation of the facts
-To provide a base for further investigation with a focus on a patient safety and environmental safety processes and systems, and the corrective measures needed to prevent recurrence and sustain improvement
-To collect data for statistical analysis
-To fulfill regulatory requirements for reporting events
-to alert Risk Management to potential claim situations

Policy:
-Adverse events, errors, unexpected events, variances, incidents, and near misses involving patients will promptly reported online in the Meditech Risk Management Patient Notification System even if the event seems insignificant at the time.
-Event reports are intended to provide a record of the event and document the facts
- Event reporting is an important part of the Hospital-wide focus on safety and performance improvement.
- Event reporting is a system of notification to Hospital leadership of actual or potential risks and patient safety issues/concerns.
-Events reports should be completed during the shift the event occurs or is discovered to have occurred.

Supervisor, Manager and Director Review responsibilities:

2. Service leaders are responsible for prompt (within 72 hours) initial review of all information entered by the employee and for conducting an investigation to determine root cause and follow-up to ensure resolution of identified issues/concerns.
4. Results of investigations should be shared with the staff with a focus on process and systems design and redesign and outcome, and the corrective measures needed to prevent recurrence and sustain improvement.