HospitalInspections.org

Based on a review of the Medical Staff By Laws as compared with actual practice and staff interview, the Medical Staff failed to follow the by laws in the privileging and reappointment process, for 8 Active Medical Staff (Medical Staff Members A, B, C, D, E, F, G, and H)..

This failed practice has the potential to affect all patients receiving surgical services at the hospital.

The hospital reported a total census of 19 inpatients on the first survey day.

Findings include:

1. The Medical Staff By-Laws (under Responsibilities) stated, 3.2-1"Accounting for the quality and appropriateness of patient care rendered by all practitioners authorized to practice in the Hospital through the following measures:
(a) A credentials program including mechanisms for appointment and reappointment and matching of clinical privileges to be exercised or of specific services to be performed with the verified credentials and current demonstrated performance of the applicant, staff member or allied health practitioner."

2. The files of 8 Active Medical Staff, (Medical Staff Members A, B, C, D, E, F, G, and H) who performed surgery in the hospital were reviewed. None of the 8 practitioners' files contained evidence of matching clinical privileges with the specific procedures the practioners were performing in the hospital, as specified in the By Laws.

3. An interview with the Credentials Coordinator on 1/18/17 at 1:30 P.M. (who supervised the Medical Staff reappointment process) confirmed that actual practice was not compared with the list of privileges for these 8 Medical Staff Members.

Based on a review of the practitioner's privilege list as compared with the surgery logs of procedures performed and staff interview, the Medical Staff failed to specify the privileges of each candidate with sufficient clarity so as to ensure the hospital staff understood which procedures the practitioners were approved to perform.

This failed practice had the potential to affect all patients receiving surgical services at the facility.

The hospital reported a total census of 91 on the first survey day, 1-18-2017.

Findings include:

1. A review of the privilege lists of 5 orthopedic surgeons (Physicians A, B, C, D, and E) revealed they received privileges to perform 'joint replacement'. (Orthopedic surgery includes the repair or replacement of joints in the body)

2. A review of the surgery roster fromDecember 1, 2016 to January 15, 2017 revealed surgeries to replace ankle, shoulder, knee and hip joints were performed. Each of these surgeries required a specific skill set, a unique type of technique and different prosthetic devices to replace the joint involved.

3. A review of the file of Physician G (a cosmetic surgeon) revealed that the physicaian had privileges to perform 'aesthetic surgery'. The specific body location or type of surgery performed was not indicated. (Cosmetic surgeons repair, improve or enhance areas of the body.)

4. Interview with the Director of Nursing, Chief Operations Officer, and Quality Assurance Officer on 1-19-17 at 5:30 P.M. confirmed the privilege lists for Physicians A, B, C, D, E, and G, lacked sufficient clarity to specify exactly what the procedures were intended to be.

Based on staff interview and a lack of documented evidence, the Radiology Department staff failed to ensure proper radiation safety precautions were maintained by not documenting annual defect checks of lead aprons, gloves and shields; not marking lead shielding devices so they could be tracked and by not having a policy or procedure in place regarding the testing, rejection and tracking of lead shielding devices.

This failed practice had the potential to affect all patients receiving radiological services at the hospital

The radiology department reported approximated 2500 procedures during the past year.

Findings include:

1. On 1-19-17 at 12:30 P.M. an interview conducted with Radiology Technician A revealed the lead aprons, gloves and shields were checked annually for defects, however, the results were not documented.
In addition, none of the lead shielding devices were marked with a unique identifier for tracking purposes.

2.The facility failed to produce a written policy or procedure outlining the process for testing the shielding devices, nor were there any specified criteria for rejection criteria if defects were identified.
(Lead aprons, gloves and shields are used by employees and patients to protect sensitive body parts from unnecessary exposure to radiation)