HospitalInspections.org

Based on a review of Medical Staff reappointment documentation, and staff interview, as compared with the Medical Staff By-Laws, Rules and Regulations, the Critical Access Hospital (CAH) failed to follow the Medical Staff By- Laws, Rules and Regulations in the reappointment process and failed to establish performance criteria for the Active and Courtesy Staff and failed to grant privileges that matched actual practice.

The Medical Staff consisted of 7 Family Practice Active Staff, 6 mid-level practitioners, 2 General surgeons .

This pattern of practice puts all patients at risk. The CAH reported an acute inpatient census of 5 on the first survey day 11-8-16.

Findings Include:

1. The Medical Staff By-Laws, on page 10, Article VI. Section 2 Qualifications. b
states, "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;"

2. A review of 2 current Active Medical Staff Family Practice physicians and 1 Mid-Level Allied Health member's credential and reappointment files revealed all 3 lacked evidence of quality assurance activities related to the requested privileges. In addition, the practitioners clinical competence, judgement and treatment of patients served in the hospital, was not documented.
Physicians A & C received privileges for obstetric services (treat pregnant mothers and deliver babies), sigmoid (insertion of a long camera tube inside the sigmoid area of the bowel)
Lumbar punctures (Insert a needle between the discs in the back to withdraw spinal fluid for examination),
Central Venous Line(CVL) placement( a permenant portal located under the subclavian collar bone vein for for frequent medication administration).
Mid-level practitioner F held privileges to perform unspecified catheter insertions.( a catheter is any hollow lumen device used to access a vein, bladder, or area of the body to allow drainage)

3. An interview with the Quality Assurance Coordinator, who also oversees the credentialing and reappointment process on 11-10-16 at 9:30 AM confirmed practitioners A & AC had not provided obstetric services in the hospital for at least 4 years and had not performed lumbar punctures, CVL insertion, or sigmoidoscopies during that same timeframe.

In addition, she also confirmed the Midlevel F had not perform any catheter insertions.

Based on the Critical Access Hospital's(CAH) failure to follow the Medical Staff Bylaws, Rules and Regulations in granting clinical privileges, failure to ensure physicians received specified training and provided evidence of proficiency in procedures prior to performing them in the hospital, the Condition of Surgical Services is not met. (See C-0321)

Based on a review of the Medical Staff Rules and Regulations regarding Surgical Privileges as compared with actual practice documented in surgeons' reappointment files, Credentialing Committee meeting minutes and staff interviews, the Critical Access Hospital (CAH) failed to follow the rules specified in those rules and regulations.


This failed practice puts all patients receiving surgical survives at the CAH at risk.

The CAH reported 191 inpatient surgical procedures during the most recent annual program evaluation(2015).

Findings include:

I. 1. The Medical Staff Rules and Regulations, states under 7. Surgical Privileges.

"Applicants and members of the Medical Staff must show evidence of recognized, relevant surgical training to be granted major surgical privileges. Any practitioner desiring an increase in his or her surgical privileges shall submit a specific written request and shall detail the training he or she has taken and his or her experience which qualifies him or her to perform the procedure."

2. A review of the privilege list for surgeons B and D revealed they were granted permission to perform a gastric sleeve procedure in 2014 and again in 2016 without documented evidence of proficiency in the procedure. (A gastric sleeve is a form a weight loss surgery where most of the stomach is removed )

3. In a letter to the Credential Committee of the CAH, dated April 2, 2014 these two surgeons requested the added privilege of gastric sleeve surgery and stated, "...in order to make a smooth transition be more familiar with the sleeve gastrectomy, we plan to have (a local physician named certified as a proctor in the procedure) a proctor for at least the first few cases...Dr. D is also going to attend the course of Current Approaches to Bariatic Surgery,...Chicago, 4-25-14"

Meeting minutes of the Credentials Committee 4-16-14 approved Drs D and B to perform the gastric sleeve procedure, prior to evidence of proctored procedures, or evidence of attendance at formal training, as specified in the letter. In these same meeting minutes it states, "There is no need for additional equipment for this procedure."
A review of the first proctored case, #1-14 revealed that, in fact special equipment was used. A specific type of stapling device.

4. On 11-15-16 at 9:30 AM, the Director of Nursing (DON) submitted evidence of Dr D attendance at a different bariatric sleeve conference held 11-19-14 in Georgia.

On 12-5-14 Drs D and B performed the gastric sleeve procedure with a difference proctor, without the knowledge or consent of the CAH and the salesman of the staple device used in the procedure, was also present in the surgical suite during the surgery. This was also without the knowledge or consent of the CAH administration.

This patient is designated as index case #1-14.

5. On 10-30-15 patient #45 received a gastric sleeve procedure performed by Drs B and D without a proctor, as specified in their letter to the Credentials Committee previously referred to and dated 4-2-2014.


During the time period 4-2-2014 through 11-14-16 Drs B and D failed:
- to submit amended plans for achieving competence to perform the gastric sleeve procedure,
- failed to inform the administration of changes in the proctor and
-to notify the Medical Staff and Administration that a specific type of stapling device was to be used during the surgical procedure
-that a company representative was present during surgery.
-They also failed to submit evidence of formal education, as specified in the written plan. And yet, the Credentials Committee and Governing Body continued to recommend and grant privileges for the gastric sleeve procedure without any evidence of the previously specified proctored procedures or formal training from the time period 2014 through 2016 and reappointed both physicians in 2016 through 2018 without any of the above specified evidence.

In addition, only a single procedure was proctored, not the 'several' indicated in their letter. Furthermore, an additional patient procedure (#45) was performed approximately one year later, which was not proctored, as originally indicated.

Finally, the American Society for Metabolic and Bariatric Surgery (an organization which establishes and oversees best practices and certifies surgeons in Bariatric) recommends a minimum of 10 gastric sleeve procedures, proctored by a physician certified in bariatric procedures(performed over 200 successfully) prior to allowing a physician to perform these without supervision. One procedure per year would not constitute sufficient volume to remain proficient in the procedure, as are the facts in this situation.


II. 1. A review of the reappointment file for Physician H, an Orthopedic surgeon, who was listed as Courtesy staff, had performed 7 unspecified procedures. This was the only evidence listed in the reappointment file. In addition the data also lacked outcomes of the procedures to further assess competence.

2. The Medical staff Rules and Regulations Surgical Privileges states,
"Applicants and members of the Medical Staff must show evidence of recognized, relevant surgical training to be granted major surgical privileges".

3. The Credentials Committee failed to follow the By Laws, Rules and Regulations in evaluating physicians, failed to adequately assess competence based on actual data or collect historic data of physician performance from previous experience failed to ensure physicians had submitted adequate evidence of relevant surgical training prior to granting privileges to perform procedures, as specified in the Medical Staff Rules and Regulations.

Based on a review of Medical Staff reappointment documentation, and staff interview, as compared with the Medical Staff By-Laws, Rules and Regulations, the Critical Access Hospital (CAH) failed to follow the Medical Staff By- Laws, Rules and Regulations in the reappointment process and failed to establish performance criteria for the Active and Courtesy Staff and failed to grant privileges that matched actual practice.

The Medical Staff consisted of 7 Family Practice Active Staff, 6 mid-level practitioners, 2 General surgeons .

This pattern of practice puts all patients at risk. The CAH reported an acute inpatient census of 5 on the first survey day 11-8-16.

Findings Include:

1. The Medical Staff By-Laws, on page 10, Article VI. Section 2 Qualifications. b
states, "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;"

2. A review of 2 current Active Medical Staff Family Practice physicians and 1 Mid-Level Allied Health member's credential and reappointment files revealed all 3 lacked evidence of quality assurance activities related to the requested privileges. In addition, the practitioners clinical competence, judgement and treatment of patients served in the hospital, was not documented.
Physicians A & C received privileges for obstetric services (treat pregnant mothers and deliver babies), sigmoid (insertion of a long camera tube inside the sigmoid area of the bowel)
Lumbar punctures (Insert a needle between the discs in the back to withdraw spinal fluid for examination),
Central Venous Line(CVL) placement( a permenant portal located under the subclavian collar bone vein for for frequent medication administration).
Mid-level practitioner F held privileges to perform unspecified catheter insertions.( a catheter is any hollow lumen device used to access a vein, bladder, or area of the body to allow drainage)

3. An interview with the Quality Assurance Coordinator, who also oversees the credentialing and reappointment process on 11-10-16 at 9:30 AM confirmed practitioners A & AC had not provided obstetric services in the hospital for at least 4 years and had not performed lumbar punctures, CVL insertion, or sigmoidoscopies during that same timeframe.

In addition, she also confirmed the Midlevel F had not perform any catheter insertions.

Based on the Critical Access Hospital's(CAH) failure to follow the Medical Staff Bylaws, Rules and Regulations in granting clinical privileges, failure to ensure physicians received specified training and provided evidence of proficiency in procedures prior to performing them in the hospital, the Condition of Surgical Services is not met. (See C-0321)

Based on a review of the Medical Staff Rules and Regulations regarding Surgical Privileges as compared with actual practice documented in surgeons' reappointment files, Credentialing Committee meeting minutes and staff interviews, the Critical Access Hospital (CAH) failed to follow the rules specified in those rules and regulations.


This failed practice puts all patients receiving surgical survives at the CAH at risk.

The CAH reported 191 inpatient surgical procedures during the most recent annual program evaluation(2015).

Findings include:

I. 1. The Medical Staff Rules and Regulations, states under 7. Surgical Privileges.

"Applicants and members of the Medical Staff must show evidence of recognized, relevant surgical training to be granted major surgical privileges. Any practitioner desiring an increase in his or her surgical privileges shall submit a specific written request and shall detail the training he or she has taken and his or her experience which qualifies him or her to perform the procedure."

2. A review of the privilege list for surgeons B and D revealed they were granted permission to perform a gastric sleeve procedure in 2014 and again in 2016 without documented evidence of proficiency in the procedure. (A gastric sleeve is a form a weight loss surgery where most of the stomach is removed )

3. In a letter to the Credential Committee of the CAH, dated April 2, 2014 these two surgeons requested the added privilege of gastric sleeve surgery and stated, "...in order to make a smooth transition be more familiar with the sleeve gastrectomy, we plan to have (a local physician named certified as a proctor in the procedure) a proctor for at least the first few cases...Dr. D is also going to attend the course of Current Approaches to Bariatic Surgery,...Chicago, 4-25-14"

Meeting minutes of the Credentials Committee 4-16-14 approved Drs D and B to perform the gastric sleeve procedure, prior to evidence of proctored procedures, or evidence of attendance at formal training, as specified in the letter. In these same meeting minutes it states, "There is no need for additional equipment for this procedure."
A review of the first proctored case, #1-14 revealed that, in fact special equipment was used. A specific type of stapling device.

4. On 11-15-16 at 9:30 AM, the Director of Nursing (DON) submitted evidence of Dr D attendance at a different bariatric sleeve conference held 11-19-14 in Georgia.

On 12-5-14 Drs D and B performed the gastric sleeve procedure with a difference proctor, without the knowledge or consent of the CAH and the salesman of the staple device used in the procedure, was also present in the surgical suite during the surgery. This was also without the knowledge or consent of the CAH administration.

This patient is designated as index case #1-14.

5. On 10-30-15 patient #45 received a gastric sleeve procedure performed by Drs B and D without a proctor, as specified in their letter to the Credentials Committee previously referred to and dated 4-2-2014.


During the time period 4-2-2014 through 11-14-16 Drs B and D failed:
- to submit amended plans for achieving competence to perform the gastric sleeve procedure,
- failed to inform the administration of changes in the proctor and
-to notify the Medical Staff and Administration that a specific type of stapling device was to be used during the surgical procedure
-that a company representative was present during surgery.
-They also failed to submit evidence of formal education, as specified in the written plan. And yet, the Credentials Committee and Governing Body continued to recommend and grant privileges for the gastric sleeve procedure without any evidence of the previously specified proctored procedures or formal training from the time period 2014 through 2016 and reappointed both physicians in 2016 through 2018 without any of the above specified evidence.

In addition, only a single procedure was proctored, not the 'several' indicated in their letter. Furthermore, an additional patient procedure (#45) was performed approximately one year later, which was not proctored, as originally indicated.

Finally, the American Society for Metabolic and Bariatric Surgery (an organization which establishes and oversees best practices and certifies surgeons in Bariatric) recommends a minimum of 10 gastric sleeve procedures, proctored by a physician certified in bariatric procedures(performed over 200 successfully) prior to allowing a physician to perform these without supervision. One procedure per year would not constitute sufficient volume to remain proficient in the procedure, as are the facts in this situation.


II. 1. A review of the reappointment file for Physician H, an Orthopedic surgeon, who was listed as Courtesy staff, had performed 7 unspecified procedures. This was the only evidence listed in the reappointment file. In addition the data also lacked outcomes of the procedures to further assess competence.

2. The Medical staff Rules and Regulations Surgical Privileges states,
"Applicants and members of the Medical Staff must show evidence of recognized, relevant surgical training to be granted major surgical privileges".

3. The Credentials Committee failed to follow the By Laws, Rules and Regulations in evaluating physicians, failed to adequately assess competence based on actual data or collect historic data of physician performance from previous experience failed to ensure physicians had submitted adequate evidence of relevant surgical training prior to granting privileges to perform procedures, as specified in the Medical Staff Rules and Regulations.