HospitalInspections.org

Based on a review of medical staff credentialing files, medical staff by-laws, rules and regulations and interview, the Governing Body failed to follow the by-laws in the reappointment process for 7 healthcare practitioner files reviewed. The Active Medical Staff, reported by the hospital, consisted of 5 family practitioners and 3 mid-level practitioners. This failed practice had the potential to affect all patients of the facility. The total number of admissions for the facility for 2014 was 113.

Findings are:

A. Review of the current Medical Staff By-Laws, p12 defines Active Medical Staff' as those who attend 36 patients at the Hospital each year. A review of the privileges and the reappointment process for 5 family practitioners (Practitioners 1, 2, 3, 4 and 5) listed as Active Medical Staff were reviewed. 5 of 5 files lacked any evidence of how many patients each physician had seen.

B. An interview with the Credentialing officer on 1/7/15 at 4:30 PM revealed that Practitioners 1, 2 and 3 had each seen 12 or less patients and confirmed these individuals did not meet the criteria for active medical staff membership.

C. A review of the Medical Staff Rules and Regulations p14 stated, "all medical records shall be completed within 30 days", or the practitioner's admitting privileges would be automatically suspended. Medical record completion information was not included in the reappointment files for 5 of 5 active medical staff and 2 of 2 mid-level practitioners(Practitioners 1, 2, 3, 4, 5, 6 and 7).

D. The Medical Staff By-Laws p12, Section B Competence stated that the practitioners needed to possess and maintain demonstrated clinical competence. 5 of 5 active medical staff and 2 of 2 mid-level practitioners lacked evidence of the results of peer review or other ongoing quality assurance monitors to demonstrate clinical competence to the governing body (Practitioners 1, 2, 3, 4, 5, 6 and 7).

E. Practitioner 7 had privileges to perform colonoscopies; however, according to the surgery roster and an interview with the Director of Nursing on 1/6/15 at 4:00 PM, did not perform this procedure in this hospital.

F. Practitioners 1, 2, 3 and 7 all viewed radiology images and initiated therapy prior to receiving the final radiology report from the radiologist; however, none of them had privileges to do so. (This was confirmed with the Radiology Supervisor on 1/7/15 at 2:00 PM).

G. Mid-level Practitioners 4 and 5 had privileges to perform plating and reading of bacterial cultures; however, these tests were not performed in the laboratory. (This was confirmed with the Laboratory General Supervisor on 1/6/15 at 4:30 PM).

Based on a review of infection control reports and confirmed with staff interview, the hospital failed to maintain an infection prevention program which included monitoring of hand hygiene practices of direct patient care staff. This failed practice had the potential to affect all patients of the facility. The facility reported 113 patient admissions for 2014.

Findings are:

A. A review of infection control reports, including the number of healthcare acquired infections and antibiotic therapy, as well as, the number and type of bacteria, for the time period 2014, lacked any monitoring of direct patient care staff hand hygiene documentation.

B. An interview with the Director of Nursing on 1/6/15 at 1:30 PM, who also serves as the Infection Control Coordinator, confirmed that hand hygiene practices had not been monitored for the past year.

Failure of direct patient care staff to perform hand hygiene before and after direct patient care and immediately preceding any invasive procedure, is the primary cause of health care acquired infection, according to the Centers for Disease Control.

Based on admission packet review, review of policy and procedure and staff interview, the facility failed to ensure that only designated requestors approached potential donors and their families to inform them of their donation options. This failed practice had the potential to affect all patients of the facility. The total number of admissions for the facility for 2014 was 113.

Findings are:

A. A review of patient admission packets revealed a form titled "Policy and Procedure for Organ, Eye, and Tissue Donation" (no date). The policy stated that "[the hospital] will provide a method to identify potential organ, eye, and tissue donors and assure that families of potential donors are informed of their option to donate organs, eye, tissue or to decline to donate. Discretion and sensitivity with respect with respect to the circumstances, views, and beliefs of the families will be considered throughout this process."

B. An interview with RN-D (Registered Nurse Charge Nurse) on 1/7/15 at 8:10 AM revealed that the admitting nurse goes over the policy and procedure included in the admission packet with each patient and/or their family on admission to the facility.

C. An interview with the Chief Nursing Officer on 1/7/15 at 9:00 AM confirmed that "No designated requestors [are] at [the] hospital."