HospitalInspections.org

Based on observation, record review, and staff interview the Critical Access Hospital (CAH) failed to ensure medical staff followed governing body bylaws, rules, and regulations to ensure all members of the medical staff are credentialed with an appropriate delineation of privileges for one of one Advanced Practice Registered Nurse and that all medical staff provider reappointments occur at least every 2 years for two of two physicians (physician staff H and I) (Refer to C-0241).

The cumulative effect of the systemic failure of the CAH to ensure all medical staff have current credentials with delineation of privileges has the potential to affect the quality of care for all patients receiving services at the CAH.

Based on staff interview, document and medical record review, the Critical Access Hospital (CAH) failed to ensure medical staff followed bylaws, rules, and regulations approved by the governing body to ensure all medical staff are authorized to practice with an appropriate delineation of privileges for 1 of 1 Advanced Registered Nurse Practitioner (ARNP Staff C) affecting 7 of 20 patient records reviewed (Patient #'s 2, 4, 14, 15, 16, 17, and 19) and the CAH failed to reappoint two providers (Physician Staff H and Physician Staff I) to the medical staff of the Critical Access Hospital.

The CAH's failure to ensure the ARNP and two physician providers were appropriately credentialed with a delineation of privileges and reappointed every two years has the potential to impact the quality of care the patients receive.


Findings include:


- ARNP Staff C Interviewed on 5/3/2016 at 4:15 PM acknowledged they work independently of the physicians, but do receive some oversight. Staff C revealed they perform MSE's, place orders, admit and discharge patients without a physician's order. Staff C indicated they have not applied to be credentialed but they do have a formal agreement with Physician Staff E and Physician Staff F which includes using Staff C's college textbook to determine what the ARNP's privileges are.

- Policy titled "Credentialing" reviewed on 5/4/2016 at 4:30 PM, revealed, "....When all information is gathered, the Medical Records designee shall forward the applications to the Governing Board for approval.

Governing Body Meeting Minutes dated 4/29/2015 reviewed on 5/4/2016 at 9:00 AM revealed "...(ARNP Staff C) has not signed a contract yet, but is in the process..."

Governing Body Meeting Minutes dated 6/2/2015 reviewed on 5/4/2016 at 9:15 AM revealed "...(ARNP Staff C) is waiting for their licenses and contract of employment will be signed at a later date..."

Advanced Practice Registered Nurse (ARNP) Collaborative agreement reveiwed on 5/4/2016 at 9:00 AM revealed "... nurse practitioner protocols: Emergency Medicine, 7th edition, by Judith E Tintinalli, 2011 - Ferri's Clinical Advisor, by Fred F. Ferri, 2016, - Practice guidelines for Acute Care Nurse Practitioners, 2nd edition, by Thomas Barkley and Charlene Myers, 2008..." signed and dated 6/8/2015.

Medical Staff Meeting Minutes dated 7/31/2015 reviewed on 5/4/2016 at 9:30 AM revealed "...(ARNP Staff C) is now fully credentialed and has started seeing patients in the clinic and hospital.

Administrative Staff B acknowledged there is no evidence ARNP Staff C's credentials were presented and reviewed by the Governing Body.

- Governing Board Bylaws submitted with their plan of corrections dated 3/10/2016 and reviewed on 5/3/2016 at 7:30 PM revealed the following: "...To ensure a high level of professional performance of all practitioners and limited health practitioners authorized to practice in the hospital through the appropriate delineation of the clinical privileges that each practitioner may exercise in the hospital and through an ongoing review and evaluation of each practitioner's performance in the hospital ..." and :... " A qualified registered nurse practitioner may: (a) Make entries in the progress notes of medical records of patients. (b) Write on the physician's order sheet, orders dictated my members of the active medical staff in the same manner as does the staff nurse with the orders to be countersigned by the physician so ordering. (c) Carry out orders as designated by the physician in charge ... "


Credentialing Coordinator Staff D interviewed on 5/3/2016 at 3:00 PM revealed they were unaware of the need to credential an ARNP as they would a physician. Staff D indicated an application to the medical staff had never been completed for ARNP Staff C.

Assistant Administrator Staff B interviewed on 5/3/2016 at 3:30 PM revealed they were not sure if an ARNP needed to be credentialed and indicated the CAH has no evidence that credentialing or delineation of privileges had been performed for ARNP Staff C.

Medical Record Review

Patient #2 chosen because they were listed on the Emergency Department (ED) log. The patient presented to the ED on 4/27/2016 with a diagnosis of Hypertension and dehydration. The medical record revealed ARNP Staff C performed an MSE, ordered laboratory studies and medications, and admitted the patient without being an appropriately credentialed member of the CAH staff.

Patient #4, chosen because they were listed on the Emergency Department (ED) log. The patient presented to the ED on 4/17/2016 with a diagnosis of a left side acute otitis media (ear infection of the left ear). The medical record revealed ARNP Staff C performed an MSE, prescribed medications, and discharged the patient without being an appropriately credentialed member of the CAH staff.

Patient #14 chosen because they were listed on the Emergency Department (ED) log. The patient presented to the ED on 3/30/2016 with a diagnosis of right knee pain. The medical record revealed ARNP Staff C performed a medical screening evaluation, ordered an x-ray of right knee, and discharged the patient back to Swing Bed status without being an appropriately credentialed member of the CAH staff.

Patient #15 chosen because they were listed on the Emergency Department (ED) log. The patient presented to the ED on 3/30/2016 with a diagnosis of conjunctivitis to the left eye (swelling or infection to the eye). The medical record revealed ARNP Staff C performed a medical screening evaluation, ordered laboratory studies, and ordered medication without being an appropriately credentialed member of the CAH staff.

Patient #16 chosen because they wwere listed on the Emergency Department (ED) log as a patient that was transferred to a higher level of care. The patient presented to the ED on 4/1/2016 with a diagnosis of nausea, headache and post brain aneurysm. The medical record revealed ARNP Staff C performed medical screening evaluation, labs, vital sign monitoring, medications, appropriate transfers forms completed and follow-up instructions without being an appropriately credentialed member of the CAH staff.

Patient #17 chosen because they were listed on the Emergency Department (ED) log. The patient presented to the ED on 4/1/2016 with an Acute Trigeminal Neuralgia Maximum Nerve. The medical record revealed ARNP Staff C performed a medical screening evaluation, vital sign monitoring, medications, and discharged to observation without being an appropriately credentialed member of the CAH staff.

Patient #19 chosen because they were listed on the Emergency Department (ED) log. The patient presented to the ED on 4/9/2016 with a diagnosis of Dehydration and Emesis. The medical record revealed ARNP Staff C performed a medical screening evaluation, vital sign monitoring, labs, EKG and Swing Bed RN given discharge instructions without being an appropriately credentialed member of the CAH staff.



- Physician Staff H's credentialing file reviewed on 5/3/2016 at 2:00 PM revealed the last time the physician was credentialed was 3/31/2012. The CAH failed to provide evidence Physician Staff H was reappointed in 2014 or 2016 as required in their policy and their Governing Board Bylaws.

- Physician Staff I's credentialing file reviewed on 5/3/2016 at 2:00 PM revealed the last time the physician was credentialed was 12/2010. The CAH failed to provide evidence Physician Staff I was reappointed in 2012, 2014, or 2016 as required in their policy and their Governing Board Bylaws.

Administrative Staff C interviewed on 5/3/2016 at 3:30 PM indicated they were unaware Physician Staff H and Physician Staff I had no current credentials on file.

Credentialing Coordinator Staff D interviewed on 5/4/2016 at 3:30 PM acknowledged Physician Staff H and Physician Staff I did not have current credentials on file. Staff D indicated they try to look at the credential files every 6 months to check for needs, but stated "I messed up and I was told by Physician Staff I that they were not required to be recredentialed because they are a Locum (traveling physician that performs temporary services) physician." Staff D indicated they failed to update the two locum physicians' files.


- Policy titled "Credentialing" reviewed on 5/4/2016 at 4:30 PM, revealed, "....When all information is gathered, the Medical Records designee shall forward the applications to the Governing Board for approval. All staff members must apply for re-appointment at least every 2 years..."

- Governing Board Bylaws submitted with their plan of corrections dated 3/10/2016 and reviewed on 5/4/2016 at 3:18 PM revealed "...Reappointments shall be for a period of more than every two years. For purposes of these bylaws the medical staff year commences on the first day of January and ends on the thirty-first day of December of each year.

The Critical Access Hospital (CAH) reported a census of nineteen patients. Based on record review, interview, and policy review the CAH (Critical Access Hospital) failed to ensure the physician signed the orders on the medical record for one of thirty medical records (#6) reviewed. This practice has the potential to affect the patient's safety and quality of care.

Findings included:

Patient # 6's medical record reviewed on 5/3/2016 revealed they presented to the ED on 4/25/2016 with a diagnosis of Migraine headache and Bronchitis (inflammation of the bronchiole). Patient #6's medical record revealed the physician (physician staff E) failed to sign the orders on the medical record.

Staff J interviewed on 5/3/2016 at 9:00 AM acknowledged upon reviewing the medical record, the physician did not sign their orders.

- The CAH policy and procedure manual revealed a policy titled "Physician's Orders" states "...All diagnostic and therapeutic verbal and telephone orders must be transcribed, dated, timed and signed by the authorized recipient in the patient's medical record ... "