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A. Based on review the Hospital Bylaws, Rules and Regulation of the Medical Staff, review of personnel file and staff interview, it was determined that the Hospital failed to ensure suspension of E#2 as required by the Hospital's Bylaws.

Findings include:

1. The "Hospital Bylaws, Rules and Regulation of the Medical Staff" was reviewed on 2/9/10 at approximately 1:30 PM. The Medical Staff Bylaws, under Article VII: Actions Affecting Medical Staff Members Part B. Automatic Suspension of Clinical Privileges, Section 1 Reasons for Automatic Suspension A. Licensure, required, " Physicians shall maintain a valid license to practice Medicine in Illinois. In the event a Physician's licenses are expired, terminated, suspended or placed on probation by the state of Illinois, the Physician shall immediately contact the Chief of Staff and CMO. Medical staff member's clinical privileges are automatically suspended until such time as the license has been fully restored."

2. The personnel file for E #2 was reviewed on 2/9/11 at approximately 1:00 PM. The file contained a documentation of a State Licensure Action against E #2 on 2/18/10, with a fine and probation, for the following reason: " for violation of Medical Practice Act related to issuance of prescription for controlled substance without conducting proper examinations and evaluations of patients " The file lacked any documentation that E #2's clinical privileges were suspended according to the Medical Staff ByLaws.

3. An interview with the Chief Medical Officer (CMO) and the Family Medicine Center Director was conducted on 2/9/10 at approximately 2:30 PM. The CMO indicated that E #1's license is on probation with the State ' s Division of Professional Regulation (IDPR). The CMO indicated that E #1 ' s license is on probation due to E #1's ambulatory outpatient practice and not the inpatient practice associated with the Hospital and therefore his clinical privileges were not suspended.

4. The above findings were discussed with the VP of Quality, during an interview on 2/9/10 at approximately was 3:00 PM

A. Based on review of Bylaws, Rules and Regulations of the Medical Staff, clinical record review and staff interview it was determined that for 4 of 10 (Pt's. #1, 2, 5 and 6) surgical patient clinical records reviewed, the Hospital failed to ensure physician post operative orders and progress notes were timed.

Findings include:

1. The "Bylaws, Rules and Regulations of the Medical Staff"were reviewed on 2/10/11 at 10:00 AM. The Bylaws include "When the physician writes orders on hospital approved order sheets, the following applies: ... 2. All orders written on an order sheet must include authentication... date and time... The content of physician's progress note includes the following: ... Authentication including physicians signature, date and time".

2. The clinical record of Pt. #1 was reviewed on 2/10/11 at 8:30 AM. Pt. #1 was a 55 year old male admitted on 8/10/10 for a Radical Prostatectomy. The physician post operative note and orders lacked documentation of the time they were written.

3. The clinical record of Pt. #2 was reviewed on 2/10/11 at 8:45 AM. Pt. #2 was a 48 year old female admitted on 12/7/10 for a Left Uteral Re-Implantation. The physician post operative note and orders lacked documentation of the time they were written.

4. The clinical record of Pt. #5 was reviewed on 2/10/11 at 9:30 AM. Pt. #5 was a 58 year old male admitted on 11/23/10 for a Laparoscopic Hand Assisted Nephrectomy. The physician post operative note and orders lacked documentation of the time they were written.

5. The clinical record of Pt. #6 was reviewed on 2/10/11 at 9:45 AM. Pt. #6 was a 30 year old female admitted on 12/29/10 for a Flexible Cystoscopy Pelvic Exam. The physician post operative note and orders lacked documentation of the time they were written.

6. The above findings were confirmed with the Manager, Quality Improvement on 2/10/11 at 10:00 AM, during an interview.