HospitalInspections.org

Based on interview and review of hospital policies, it was determined that the Governing Body of the hospital failed to ensure the Executive Committee of the Medical Staff monitored the policies governing the hospital's Medical Staff, and failed to ensure the "Medical Staff Bylaws" governing the services provided by the hospital were presented to the hospital's Board of Directors for approval. This had the potential to affect all patients receiving services at the facility. Facility census at the time of survey was 6.

Findings include:

A. Review of the hospital policy, "By-Laws of the Board of Directors of the Gordon Memorial Hospital District," revised 1/23/13, indicated the hospital's Board of Directors (the Board) is responsible for the enforcement of "all rules and regulations necessary for the administration, government, protection, and maintenance of the hospital."

B. Review of hospital's policy, "Medical Staff Bylaws," approved in 2008, indicated the Executive Committee of the Medical Staff of the hospital is responsible for conducting utilization reviews of the services provided by the facility to include revising and updating the "Bylaws and Rules and Regulations of the Medical Staff," in cooperation with the Administrator and the Board.

C. Review of the "Medical Staff Bylaws" on 9/27/17 indicated the Bylaws were approved by the Medical Staff on 2/19/13, and approved by the Board of the hospital on 2/27/13. The review did not produce any documentation to indicate the Medical Staff had approved the "Bylaws and Rules and Regulations" or presented the Bylaws to the Governing Body for approval since 2/27/13.

D. During an interview on 9/28/17 at 9:15 a.m., the Medical Director (MD) of the hospital stated he/she was not aware the Bylaws had not been approved since 2/19/13. The MD also stated he/she was not aware the "Medical Staff Bylaws" required the Medical Staff to approve the Bylaws annually and present them to the Governing Body for approval.

E. During an interview on 9/27/17 at 9:30 a.m., the Chief Executive Officer (CEO) of the hospital stated he/she was not aware the "Medical Staff Bylaws" had not been reviewed by the Medical Staff since 2/19/13. The CEO further stated he/she was not aware the "Medical Staff Bylaws" required the Medical Staff to approve the Bylaws annually and present them to the Board of the hospital for approval.

Based on interview and review of hospital policies, it was determined the hospital failed to ensure the Executive Committee of the Medical Staff reviewed, updated as necessary, and approved the "Bylaws and Rules and Regulations of the Medical Staff," which governs the services provided by the hospital, since 2/19/13. This deficient practice had the potential to affect all patients receiving services at the facility. Facility census at the time of survey was 6.

Findings include:

A. Review of hospital's policy, "Medical Staff Bylaws," approved in 2008, indicated the hospital's Executive Committee of the Medical Staff was responsible for conducting utilization reviews of the services provided by the hospital and for revising, updating as necessary, and approving the "Bylaws and Rules and Regulations of the Medical Staff" on an annual basis.

B. Review of the "Bylaws and Rules and Regulations of the Medical Staff Bylaws" on 9/27/17 indicated the Medical Staff approved the Bylaws on 2/19/13. The review did not produce any documentation to indicate that the Executive Committee of the Medical Staff reviewed, updated, and approved the "Bylaws and Rules and Regulations of the Medical Staff" since 2/19/13.

C. During an interview on 9/28/17 at 9:15 a.m., the Medical Director (MD) of the hospital stated he/she was not aware that the Executive Committee of the Medical Staff had not reviewed, updated, and approved the Bylaws since 2/19/13. The MD added that he/she was unaware that the hospital's "Medical Staff Bylaws" policy required approval processes be completed on an annual basis.

D. During an interview on 9/27/17 at 9:30 a.m., the Chief Executive Officer (CEO) of the hospital stated he/she was not aware that the Executive Committee of the Medical Staff had not reviewed, updated, and approved the Bylaws since 2/19/13. The CEO added that he/she was unaware the hospital's "Medical Staff Bylaws" policy required the utilization review and approval processes be completed on an annual basis.

Based on observation and interview, it was determined the hospital failed to ensure the Rehabilitation Services Department had access to a departmental policy and procedure manual when the department's manual had been missing for approximately 2 months. This deficient practice had the potential to affect any patient receiving rehabilitation services at the facility. The facility census at the time of survey was 6.

Findings include:

A. Observation of the Rehabilitation Services Department on 9/27/17 at 11:35 a.m. revealed the department was located off the grounds of the hospital. Further observation of the department failed to identify the presence of a departmental policy and procedure manual.

B. During an interview on 9/27/17 at 11:45 a.m., the Rehabilitation Services Director (RSD) confirmed the department had no policy and procedure manual available to the staff. The RSD stated he/she assumed the position of departmental director July 2017 and added that the former director of the department took the policy and procedure manual with him/her when he/she resigned as director and is working on updating the manual.

C. During an interview on 9/27/17 at 1:10 p.m., the Chief Executive Officer (CEO) for the hospital stated he/she was not aware that the Rehabilitation Services Department's policy and procedure manual was missing from the department and the staff did not have access to departmental policies and procedures. After a subsequent query into the status of the departments' policy and procedure manual, the CEO confirmed the manual could not be located.