HospitalInspections.org

Based on observation, it was determined that the facility did not maintain an environment to ensure acceptable level of safety and quality in their off-site outpatient clinic
.
Findings include:

On the morning of 8/26/2014, a tour of the facility's outpatient off site clinic was conducted. The following was observed:

(1) In the patient exam room closest to the reception area, it was observed that the patient exam table had broken and torn vinyl at the 2 distal corners exposing the yellow foam underneath. This rendered the patient exam table un-sanitizable.

(2) The chair that patients sit in to have their blood drawn in the laboratory room had arm rests with numerous spider-like cracks in the vinyl, rendering the chair's arms un-sanitizable.

Based on review of the Medical Staff Bylaws, review of physicians' credentialing files, and interview with CAH staff it was determined that the Governing Body did not assume full legal responsibility for determining, implementing, and monitoring policies governing the CAH's total operation and for ensuring that those policies are administered so as to provide quality health care in a safe environment by not ensuring that the medical staff's appointments and the granting of credentials were current. Seven files were reviewed. Two of the physicians' reappointments to the medical staff were not current and two of the allied health care professionals were not current. Physicians 3,4,5,6.

Findings include:

1. Review of the CAH's Medical Staff By-Laws, revealed that each physician, and allied health professional was to be reappointed to the medical staff every two years after their initial appointment.

2. Review of the physicians' files revealed the following:

Physician 3 was last reappointed and re-credentialed to the medical staff on 5/9/12.

Physician 4 was last reappointed and re-credentialed to the medical staff on
5/25/12.

Number 5 was a Physician's Assistant last reappointed and re-credentialed on 7/11/12.

Number 6 was an Advanced Practice Registered Nurse whose last reappointment and re-credentialing was on 5/25/12.

All of the above were past the two year time limit as required by the medical staff by-laws.

3. An interview was conducted with the employee responsible for credentialing the physicians on 8/26/14. She stated that the above physicians were overdue for reappointment. She stated that she was working with the physicians to obtain the needed information.