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Based on review of a blood bank agreement, Medical Staff Meeting minutes, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the CAH's Medical Staff approved the updated blood bank agreement. The Chief Nursing Officer reported CAH staff transfused an average of 8 units of blood products to CAH patients per month.

Failure to ensure a current, approved blood bank agreement was in place could potentially interrupt the availability of blood products needed for emergencies resulting in patient harm and/or death.

Findings include:

1. Review of "Blood and Blood Product Full Service Agreement", signed by the CAH's Chief Executive Officer on 12/14/2009 revealed revisions in the contract commencing on January 1, 2010.

The blood agreement lacked evidence of approval by the Medical Staff.

2. Review of the CAH's Medical Staff Meeting minutes from 12/14/2009 through April 2011 showed the blood agreement lacked approval by the CAH's Medical Staff.

3. During an interview on 4/12/11 at 2:40 PM, Staff C, Medical Staff Coordinator, reported, he/she did not believe the medical staff had approved the blood agreement dated January 1, 2010. Staff C reported looking through late 2009 to April 2011 Medical Staff Meeting minutes and was unable to locate documented evidence that showed Medical Staff approval of the blood agreement.

Based on observation and staff interview, the Critical Access Hospital's (CAH) clinic administrative staff failed to ensure clinic staff removed all expired supplies from 3 of 3 clinics (Medical Clinic, Surgical Clinic, and Women's Health Clinic). The Clinic Director identified an average of 25 patients per day in the Medical Clinic, an average of 20 patients per week in the Surgical Clinic, and an average of 30 patients per day in the Women's Health Clinic.

Failure to remove expired supplies could possibly result in staff using non-sterile or ineffective supplies on patients.

Findings include:

1. Observations during a tour of the Medical Clinic on 4/12/11 at 8:40 AM revealed expired supplies available for patient use in the following Treatment and Exam rooms:

A. Treatment Room #2
a. 2 of 2 4 oz tubes of McKesson Lubricating Jelly, expired 07/07 and 10/09.
b. 1 of 1 50 mL syringe, expired 8/09.
c. 1 of 1 16 oz bottle of 70% Rubbing Alcohol, expired 12/08.
d. 5 of 5 Hemoccult test strips, expired 10/10.
e. 29 of 29 4-0 Dexon S 18 inch sutures, expired 7/08.

B. Exam Room #13:
a. 1 of 3 1/2 inch Steri-Strips, expired 12/07.
b. 1 of 1 16 oz bottle Rubbing Alcohol, expired 12/08.
c. 2 of 2 4 oz tubes McKesson Lubricating Jelly, expired 5/08 and 10/09.
d. 1 of 1 4 oz bottle of Provodine, expired 12/10.

C. Exam Room #7:
a. 1 of 1 Hemoccult test strip, expired 4/10.
b. 24 of 24 Coloscreen Fecal Occult Blood test strips, expired 11/10.
c. 1 of 1 16 oz bottle of Rubbing Alcohol, expired 2/11.

D. Exam Room #1:
a. 1 of 1 Venturi Transystem Swab, expired 02/11.
b. 1 of 3 1/2 inch Steri-Strips, expired 12/07.
c. 1 of 4 alcohol swabsticks, expired 06/09.

2. Observations during a tour of the Surgical Clinic on 4/12/11 at 9:50 AM revealed expired supplies available for patient use in the following Exam room and Supply Closet:

A. Supply Closet:
a. 3 of 3 5-0 Ethilon Sutures, expired 1/09.
b. 33 of 33 3-0 Vicryl Sutures, expired 7/10.
c. 31 of 31 3-0 Chromic Gut Sutures, expired 1/11.
d. 3 of 3 4 oz bottles of Provodine Iodine solution, expired 12/07, 10/08, and 8/10.
e. 1 of 1 bottle Ethyl Chloride topical anesthetic, expired 7/08.
f. 6 of 6 packets of Provodine ointment, expired 10/07, 9/08, 8/09, and 3 packets expired 2/09.
g. 1 of 1 Benzoin swabstick, expired 6/06.
h. 1 of 1 3 mm dermal punch, expired 12/05.
i. 5 of 5 6 mm dermal punches, expired 5/10.

B. Exam Room #1:
a. 5 of 16 1 inch Steri-Strips, expired 1/08.
b. 9 of 9 1/2 inch Steri-Strips, expired 3/08.
c. 6 of 22 1/4 inch Steri-Strips, expired 1/09.
d. 23 of 23 1/8 inch Steri-Strips, expired 8/09.
e. 6 of 6 5 gram tubes of Surgilube, expired 2/09.
f. 2 of 2 Venturi Transystem Swabs, expired 2/11.
g. 1 of 1 16 oz bottle of rubbing alcohol, expired 12/07.
h. 1 of 1 4 oz bottle of Betasept Surgical Scrub, expired 8/06.

3. Observations during a tour of the Women's Health Clinic revealed expired supplies available for patient use in the following Treatment Rooms, Exam rooms, and Supply Closet:

A. Treatment Room:
a. 18 of 18 1/2 inch Steri-Strips, expired 10/09.
b. 31 of 21 1/8 inch Steri-Strips, expired 10/09.
c. 23 of 23 3-0 Vicryl Sutures, expired 1/08.
d. 1 of 1 tube 2% Lidocaine jelly, expired 11/08.
e. 8 of 8 14 French Clear vinyl urinary catheters, expired 4/09.
f. 1 of 2 Female Catheter kits with gloves, expired 2/11.

B. Exam Room #2:
a. 7 of 7 Annular Curettes with 60 mL hand vac syringe, with 1 expired in 2/09, and 6 expired in 1/10.
b. 3 of 3 14 French Clear vinyl urinary catheters, expired 4/09.
c. 2 of 2 4 gram tubes of Trimo-San Vaginal Jelly, expired 1/07 and 1/08.
d. 4 of 4 6 mm dermal punches, expired 5/10.
e. 21 of 21 1/4 inch Steri-Strips, with 16 expired 11/09 and 5 expired 11/10.
f. 1 of 1 4 oz bottle of Provodine iodine solution, expired 8/07.
g. 1 of 1 1/2 inch plain packing strips, expired 10/10.
h. 8 of 8 3 gram packages of Surgilube, expired 12/10.
i. 56 of 56 Silver Nitrate/Potassium Nitrate applicators, expired 9/08.
j. 13 of 13 Endocell endometrial cell samplers, expired 5/10.
k. 1 of 1 Hemoccult developer solution, expired 11/10.

C. Clean Supply Closet:
a. 6 of 6 14 French urological catheters, expired 1/11.
b. 86 of 86 Endocell endometrial cell samplers, expired 5/10.

D. Exam Room #3:
a. 5 of 5 14 French clear vinyl urethral catheters, expired 4/09.
b. 3 of 3 6 mm dermal punches, expired 5/10.
c. 3 of 3 4 mm dermal punches, expired 6/10.
d. 5 of 5 8 French urological catheters, expired 1/11.
e. 4 of 4 1/8 inch Steri-Strips, expired 11/09.
f. 1 of 1 4 oz bottle of Provodine iodine solution, expired 8/10.
g. 2 of 2 1/2 inch Steri-Strips, expired 10/09.
h. 2 of 2 27 Gauge 5/8 inch needles, expired 10/10.
i. 5 of 5 0.9 gram packets of Triple Antibiotic ointment, expired 8/10.
j. 1 of 1 tube of 2% Lidocaine jelly, expired 2/10.
k. 2 of 2 1/4 inch Steri-Strips, expired 3/08.
l. 3 of 3 2-0 Ethilon Sutures, expired 1/11.
m. 3 of 3 3-0 Ethilon Sutures, expired 1/11.
n. 3 of 3 5-0 Ethilon Sutures, expired 1/11.
o. 1 of 1 Trimo-San vaginal jelly, expired 2/11.
p. 13 of 13 Asepti-Chlor towels, expired 2/11.

4. During an interview on 4/12/11 at 8:40 AM, the Clinic Director acknowledged the expired supplies, and stated each nurse was responsible for removing outdates supplies in their assigned rooms every month. The Clinic Director also stated the CAH lacked a policy addressing the removal of outdated supplies.

I. Based on observation, document review, and staff interview, the Critical Access Hospital's (CAH) pharmacy administrative staff failed to provide supervision for 1 of 1 Medical Clinic's supply of sample medications. The Clinic Director identified an average of 25 patients per day in the Medical Clinic.

Failure to supervise the supply of sample medications could potentially result in patients that received inappropriate or expired medications.

Findings include:

1. Observations during a tour of the Medical Clinic on 4/12/11 at 8:20 AM revealed 1 sample medication storage area.

2. During an interview on 4/12/11 at 8:20 AM, the Clinic Director stated the Pharmacy Director did not provide oversight for the medications stored in the sample medication storage area.

3. Review of the policy "Drug Samples", revised 11/03, revealed in part, "Samples ... for outpatient only use are the sole responsibility of the prescribing physician. The physician will ensure that these samples have been properly stored, are not expired, and are safe for the patient to use. The hospital pharmacy will not assure responsibility for any samples that are given to a patient under these circumstances."

4. During an interview on 4/13/11 at 8:10 AM, the Pharmacy Director stated the CAH administrative staff consider clinic patients as CAH patients. The Pharmacy Director acknowledged, since clinic patients are CAH patients, when clinic staff gave sample medications to clinic patients, the CAH patients received medications the pharmacy did not control.

II. Based on document review, observation, and staff interview, the Critical Access Hospital (CAH) clinic administrative and pharmacy staff failed to ensure all staff wrote the date opened on each multi-dose medication vials in 2 of 3 clinics (Medical Clinic and Women's Health). The clinic director identified an average of approximately 25 patients per day in the Medical Clinic, and an average of approximately 30 patients per day in the Women's Health clinic.

Failure to write the date opened on multi-dose vials of medication could potentially allow bacteria to grow in the vial, and potentially result in a patient that developed an infection after receiving the medication.

Findings include:

1. Review of the policy "MULTI-DOSE VIAL POLICY", reviewed 7/08, revealed in part, "All multi-dose vials will be dated when opened." The policy also revealed staff should discard the multi-dose vial 30 days after staff opened the vial.

2. Observations during a tour of the Medical Clinic on 4/12/11 at 8:40 AM, revealed 2 of 2 opened 20 mL multi-dose vials of 2% Lidocaine, in Treatment Room #2, lacked documented evidence of the date staff opened the vial.

3. During an interview on 4/12/11 at 8:40 AM, the Clinic Director stated staff write the date they open a Multi-Dose vial, and discard the vial 30 days after they opened the vial. The Clinic Director acknowledged the staff failed to document the date they opened the multi-dose vials.

4. Observations during a tour of the Women's Health Clinic on 4/12/11 at 10:20 AM, revealed the following:

a. 1 of 1 opened 10 mL multi-dose vial of 2% Lidocaine, in the Dirty Lab. Staff had documented the date opened as "9/29/11".

b. 1 of 1 opened 5 mL multi-dose vial of Dexamethasone, in the Dirty Lab, lacked documented evidence of the date staff opened the vial.

c. 1 of 1 opened 20 mL multi-dose vial of 2% Lidocaine, in the Treatment Room, lacked documented evidence of the date staff opened the vial.

d. 1 of 1 opened 10 mL multi-dose vial of 1% Lidocaine, in the Treatment Room, lacked documented evidence of the date staff opened the vial.

e. 1 of 1 opened 20 mL multi-dose vial of 2% Xylocaine, in the Treatment Room, lacked documented evidence of the date staff opened the vial.

4. During an interview on 4/12/10 at 10:20 AM, the Clinic Director acknowledged staff failed to document the date they opened the multi-dose vials.

5. During an interview on 4/13/11 at 8:10 AM, the Pharmacy Director stated staff document the date they open a multi-dose vial, and could use the multi-dose vial for 30 days after they opened the vial.

Based on observation, document review, and staff interview, the Critical Access Hospital (CAH) Radiology administrative staff failed to ensure surgical staff tested the disinfecting solution in 1 of 1 disinfecting bottle prior to each use per manufacturer's recommendations. (Ultrasound) The Radiology Director identified an average of 21 ultrasound procedures using the transvaginal probe per month.

Failure to test the disinfecting solutions prior to each use could potentially result in the disinfecting solution lacking sufficient strength of the active ingredient to kill all microorganisms, resulting in the spread of infectious microorganisms between patients.

Findings include:

1. Observations, during a tour of the Radiology Department, on 4/12/11 at 9:50 AM revealed 1 of 1 disinfecting bottle contained Cidex OPA Solution.

2. Review of the Cidex OPA Solution Test Log, revealed Staff F, Sonographer, failed to test the Cidex OPA Solution prior to each use in accordance with the manufacturer's recommendations.

3. During an interview, at the time of the tour, Staff F, Sonographer, stated he/she only tested the Cidex OPA Solution daily.

4. Review of the manufacturer's directions for Cidex OPA Solution, dated 2006, revealed in part, "The [active ingredient] concentration of Cidex OPA Solution during its use-life must be verified by the Cidex OPA Solution Test Strips piror to each use. . . ."

5. Review of CAH policy/procedure on 4/12/11 titled, "Cidex OPA Ultrasound Disinfection P & P", dated revised 2/10/10, revealed in part, "Cidex OPA will be used for disinfecting the transvaginal Ultrasound probe. . . The Ultrasound tech will be responsible . . . follow the manufacturer recommendations and instructions from Phillips and the Cidex manufacturer. This will include testing the Cidex each morning with the test strips provided by the Cidex manufacturer. . . ."

The policy/procedure failed to address testing the Cidex OPA disinfecting solution prior to each use per the manufacturer's recommendations.

Based on review of policies/procedures, meeting minutes, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the required group of professionals reviewed all patient care policies annually for 14 of 14 patient care departments. (Medical/Surgical, Obstetrics, Pharmacy, Physical Therapy, Occupational Therapy, Speech Therapy, Pulmonary Rehabilitation, Respiratory Therapy, Radiology, Social Services, Surgical Services, Dietary, Emergency Services, Infection Control) The CAH administrative staff identified a census of 7 patients.

Failure to ensure the required group of professionals reviewed all patient care policies annually could potentially increase the risk that the policies/procedures failed to address all patient care needs.

Findings include:

1. Review of policy/procedure titled, "Hospital Policies and Procedures", dated revised 8/10, revealed in part. ". . .All policies and procedures will be reviewed and/or revised as needed, bur annually at a minimum. All patient care policies are developed with the advise of and accepted by a group of professional personnel that includes one or more doctors of medicine or osteopathy and one or more physician assistant, nurse practitioner, or clinical nurse specialists, and at least one member who is not a staff member of WCHC. (TOPIC Committee). . . ."

The policy/procedure failed to address the requirement of annual approval by the required group of professionals.

2. Review of TOPIC (Total Organizational Performance Improvement Council) Committee Meeting minutes from April 2010 through March 2011 showed the facility failed to ensure a person who was not a member of the hospital staff attended the meetings when the following policies were reviewed.

a. 7/28/10 - Social Services
b. 9/22/10 - Dietary
c 2/23/11 - Obstetrics

The TOPIC Committee Meeting minutes only addressed patient care policies that were new, revised or retired and not all patient care policies.

The TOPIC Committee Meeting minutes lacked evidence of annual approval for all patient care policies.

3. During an interview on 4/13/11 at 12:45 PM, Staff E, Chief Nursing Officer, Director of Quality, acknowledged the TOPIC Committee only approved the new, revised or retired patient care policies/procedures annually. Staff E stated the TOPIC Committee had not reviewed the patient care policies/procedures that were not new, revised, or retired annually.

Based on observation, review of policies/procedures, documentation, and staff interview, the CAH Radiology staff failed to ensure periodic inspection occurred for all radiology equipment. Problem identified with 1 of 5 radiographic units located in the Radiology and Fluoroscopy [R & F] Room. The Radiology Director identified an average of 50 procedures performed in the R & F Room per month.

Failure to ensure periodic inspection of radiology equipment could potentially result in patient's exposure to excessive quantities of radiation, and cause symptoms ranging from nausea, vomiting, skin reddening, tiredness and fever to increased risk of cancer and/or exacerbating cancer.

Findings include:

1. Tour of the Radiology Department on 4/12/11 at 9:00 AM with Staff D, Radiology Director, revealed 5 pieces of Radiology equipment in the Radiology Department.

2. Review of CAH policy titled "Equipment Inspections and Repairs", dated effective 12/2/2000, revealed in part "Policy . . . The physicist inspecting any equipment will provide a written report. . . ."

3. Review of physicist inspection reports dated 9/16/10 lacked documentation of inspection of the R & F unit. Review of physicist inspection reports for the R & F unit showed the last inspection occurred on 7/16/08.

4. During an interview on 4/12/11 at 9:50 AM, Staff D stated the physicist last inspected the R & F unit in 2008 and the physicist had failed to inspect the R & F unit during the 2010 inspection. Staff D stated inspection of the radiology equipment should occur every 2 years.

Based on document review, observation, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure all patient medical information was secured in 1 (of 1) Obstetrical department, 2 of 3 clinics (Medical Clinic and Women's Health Clinic), and 1 (of 1) Health Information Management department. The Clinic Administrator identified an average of 25 patients per day in the Medical Clinic, and an average of 30 patients per day in the Women's Health Clinic. The Administrator identified an average of 14 inpatients per day.

Failure to secure all medical records could result in unauthorized CAH staff accessing the patients' medical record, potentially resulting in unauthorized staff obtaining knowledge of the patient's medical history. In addition, unauthorized staff could potentially obtain patient information that could lead to identity theft.

Findings include:

1. Observations on 4/12/11 at 8:38 AM during the initial tour of the physical environment, with Staff A, Plant Operations Supervisor and Staff B, Housekeeping supervisor; revealed the HIM (Health Information Management) department contained approximately 15,000 active and closed patient medical records. An electronic badge reader secured the exterior doors of the department. The housekeeping staff had access to and cleaned the HIM department at the close of business. Housekeeping staff did not need to access or know confidential patient information as part of their job duties.

2. During an interview on 4/12/11 at 8:38 AM, Staff B reported all evening housekeeping staff had access to the HIM department, and housekeeping cleaned the department without HIM staff present.

3. Review of the policy "Security of Medical Records" effective 5/08 stated in part..."Only authorized personnel are allowed in this area...The main door to the HIM Department is locked after regular work hours. Records are accessible to Medical Staff on an emergency basis. Keys are maintained at the Medical/Surgical Nursing Station..."

4. Review of the Card holder Access To Readers dated 2009 revealed 180 individuals had access to the HIM department. Twelve of the 180 individuals were from various departments including housekeeping, storeroom and outside contractors. These individuals did not need to access or know confidential patient medical information as part of their job duties.

5. Review of the policy "MEDICAL RECORDS", effective 7/07, revealed in part, "[Medical Records] will be stored in such a manner as to provide protection from ... unauthorized access."

6. Observations during a tour of the Obstetrical Department, on 4/11/11 at 1:20 PM, revealed the following unsecured medical records:

a. Five of 5 delivery log books that contained approximately 15,000 entries from January 1958 to May 1992. The entries included the patient's name, date of birth, and protected medical information.

b. One (of 1) outpatient registration book that contained approximately 3,000 entries from February 1993 to May 2001. The entries included the patient's name, date of birth, telephone number, and protected medical information. Further observations revealed 2 of 2 outpatient registration books at the nurses' station. The registration books contained over 3,000 medical entries from June 2001 to present. The entries included the patient's name, date of birth, telephone number, and protected medical information.

c. One (of 1) infant hearing screening book that contained approximately 700 medical records from January 1999 to November 2006. The entries included the patient's name, date of birth, parent's names, address, phone number, and protected medical information.

d. One (of 1) Bilirubin level log in the nursery that contained approximately 575 entries. The entries included the patient's name, and protected medical information.

e. One (of 1) set of orders at the nurses' station that contained the patient's name, date of birth, and protected medical information.

f. One (of 1) report titled "Unlocked E-form Report" that contained 24 patient's names and date of service.

g. Two of 2 Delivery Room registration books, contained over 3,000 entries from August 2001 to present. The entries included the patient's name, date of birth, parent's names, and protected medical information.

7. During an interview on 4/11/11 at 1:20 PM, the Emergency Room (ER)/Obstetrics (OB) Nurse Manager stated housekeeping staff cleaned the OB department after the OB staff had left the department. The ER/OB Nurse Manager acknowledged that housekeeping staff had access to the medical records, which contained protected medical information, and did not have a need to know the protected medical information.

8. Observations during a tour of the Medical Clinic on 4/12/11 at 8:40 AM revealed the following unsecured medical records:

a. A large office space, that included an unsecured storage area for approximately 9,000 medical records, which included the patient's name, date of birth, and protected medical information.

b. An old record storage area, with 145 shelves that contained approximately 14,500 medical records. The medical records included the patient's name, date of birth, and protected medical information.

9. During an interview on 4/12/11 at 8:40 AM, the Clinic Director stated the housekeeping staff cleaned the Medical Clinic after clinic staff had left for the day. The housekeeping staff had a key to gain entrance into the office area that contained approximately 9,000 medical records. The key housekeeping staff used to enter the office area also gave the housekeeping staff access to the old record storage area. The housekeeping staff did not have a need to access the medical records as part of their job duties.

10. Observations, during a tour of the Women's Health clinic, on 4/12/11 at 10:20 AM revealed approximately 2,200 medical records stored in 4 unlocked filing cabinets, in the front office of the clinic.

11. During an interview on 4/12/11 at 10:20 AM, the Clinic Director stated housekeeping staff cleaned the clinic after clinic staff left for the day. The housekeeping staff had access to the medical records stored in the front office. The housekeeping staff did not need to know the information in the medical records to perform their jobs.



27303

Based on review of policies/procedures, documentation, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure that external peer reviews were completed and the results were included for review during the credentialing process for all practitioners that provided care and services to the CAH patients for 8 of 13 practitioners selected for review. (Practitioners A, B, C, D, E, F, G, I) The CAH administrative staff reported a current census of 7 patients.

Failure to ensure an external entity evaluated the quality and appropriateness of the diagnosis and treatment furnished by doctors at the CAH could potentially result in medical staff members misdiagnosing patients and/or providing inappropriate or substandard patient care.

Findings include:

1. Review of documentation for the 6/08 through 6/10 credentialing period showed the quality staff failed to include external peer review results during the credentialing process for physicians A and I.

a. The Medical Staff recommended Physicians A and I for reappointment on 6/14/2010 and the Board of Directors approved their reappointment on 6/30/2010 without access to external peer review results.

b. Documentation showed Physician A had provided care to 5 patients from 6/1/08 to 5/31/10.

2. Review of documentation for the 4/08 through 4/10 credentialing period showed the quality staff failed to include external peer review results during the credentialing process for Physicians C and E.

a. The Medical Staff recommended Physicians C and E for reappointment on 4/12/10 and the Board of Directors approved their reappointment on 4/29/10 without access to external peer review results.

b. Documentation showed Physician C provided care to 89 patients from 4/30/09 through 3/3/09. Physician E provided care to 755 patients from 4/30/09 to 3/31/10.

3. Review of documentation for the 7/08 through 7/10 credentialing period showed the quality staff failed to include external peer review results during the credentialing process for Physician D.

a. The Medical Staff recommended Physician D for reappointment on 7/12/10 and the Board of Directors approved the reappointment on 7/29/10 without access to external peer review results.

b. Documentation showed Physician D provided care to 99 patients from 7/30/09 to 5/31/10.

4. Review of documentation for the 5/07 through 5/09 credentialing period showed the quality staff failed to include external peer review results during the credentialing process for Physician F.

a. The Medical Staff recommended Physician F for reappointment on 5/11/09 and the Board of Directors approved the reappointment on 5/28/09 without access to external peer review results.

b. Documentation showed Physician F provided care to 390 patients from 5/1/07 to 2/28/09.

5. Review of documentation for the 12/07 through 12/09 credentialing period showed the quality staff failed to include external peer review results during the credentialing process for Physician B.

The Medical Staff recommended Physician B for reappointment on 12/24/09 and the Board of Directors approved the reappointment on 12/29/09 without access to external peer review results.

6. Review of documentation for the 3/09 through 3/11 credentialing period showed the quality staff failed to include external peer review results during the credentialing process for Physician G.

The Medical Staff recommended Physician G for reappointment on 3/14/11 and the Board of Directors approved the reappointment on 3/31/11 without access to external peer review results.

2. Review of the CAH policy/procedure on 4/12/11 titled, "Quality Reviews", dated revised 4/09, revealed the following in part, "Quality reviews shall be performed for all patient care services and other services affecting patient health and safety. . . ."

Review of the CAH Network agreement dated 7/2008 revealed the following in part, ". . . Assist hospital in identifying and arranging for qualified physicians and other practitioners to consult with Hospital on peer review matters as needed. . . ."

3. During an interview on 4/13/11 at 10:30 AM, Staff C stated the CAH administrative staff had not sent records for Practitioners A or I for external peer review. According to Staff C, administrative staff had sent records for Practitioners C, D, E, and F for external peer review. However, they had not received the results of those reviews therefore; the results were not available for the Medical Staff and Board of Trustees to review during Physicians C, D, E, and F's re-appointment period. Staff C further stated the administrative staff had not sent records for Practitioners B or G to a required entity. Staff C confirmed Practitioners A, B, C, D, E, F, G, I had provided services to patients of the CAH during the last credentialing period.