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Based on interviews, record review and policy review, the facility's Governing Body failed to ensure the medical staff providing care at the hospital was appointed with approval of requested clinical privileges in accordance with written By-Laws for 1 of 7 providers sampled. (Provider #2).

Findings:

Review of physician #2's credentialing file was conducted on 3/15/17 commencing at approximately 2:00pm. Review of the file included documentation of temporary privileges granted for a period of six months, commencing October 29, 2015 and expiring April 1, 2016. The file failed to include the provider's request for clinical privileges, failed to include the approval of Medical Staff for applied privileges and failed to include approval by the Governing Body.

Further review of the file included recommendation for temporary privileges by Medical Staff and Governing Body, dated 10/31/16. The filed failed to indicate privileges for which the provider applied for.

The practitioner's credentialing file included an application for reappointment, dated 1/10/17, with Emergency Medicine privilege form with indications of requested privileges, and documentation of approval by the Medical Staff on 1/19/17. Interview with the Chief of Staff on 3/15/17 revealed the request for privileges will be presented to the Board on 3/23/17.

Interview conducted with Employee I, staff member designated to be responsible for credentialing and privileging of the providers was conducted on 3/15/17 at approximately 3:00pm. The employee was informed the physician was not credentialed with approved privileges by the Governing Body. She stated the provider was not currently practicing at the facility and only stopped by occasionally. The facility's consulting Risk Manager, present during the interview, also stated this physician is not currently practicing at the hospital.

Interview conducted with Emergency Department (ED) nurse, Employee H, on 3/15/17 at approximately 3:30pm revealed the physician works in the ED 1-2 times per month. Review of the ED schedule revealed the physician worked in the ED most recently on 3/11/17.

In interview conducted with the facility's Chief of Staff, who also serves as Medical Staff Chairman, on 3/15/17 at approximately 4:00pm, he stated the physician is not currently scheduled to work any other shifts in March; and will not be scheduled again until after Board approval.

Review of the Medical Staff By-Laws, dated 10/31/16, documented initial appointments and reappointments to the Medical Staff shall be made by the Governing Body. Documented the Governing Body shall act on appointments, reappointments or revocation of appointments; or revision of privileges only after there has been a recommendation from the Medical Staff as provided by these By-Laws. The By-Laws document appointment to the Medical Staff shall confer on the appointee only such clinical privileges as have been granted by the Governing Body in accordance with these By-Laws.

Further interview conducted with Employee I on 3/16/17 at approximately 11:20am revealed the physician's credentialing file is still missing his continuing education requirements and missing another professional reference. She confirmed those items must be received prior to presenting to the Governing Body for approval for reappointment to medical staff.

Based on interview, record review and policy review the facility failed to ensure the emergency department physician signed the patient transfer certification form within 72 hours of the transfer for 11 of 12 records sampled for transfers (Patients #3, 5, 6, 7, 8, 9, 10, 11, 12, 13 & 14); and failed to ensure a patient transfer certification form was initiated for 1 of 5 records sampled for transfers. (Patient #4). The facility failed to complete the EMTALA transfer from for 11 of 12 transfer records reviewed, per facility policy.

The findings are:

An interview with the emergency department physician (Staff A) commenced on 03/13/2017 at approximately 11:00am, he stated that he authorizes all patient transfers, when he is present in the Emergency Room. If he is not present, then a phone call is placed to him, to advised for need of transfer to a higher level of care. He will then grant permission for transfer, and will sign the transfer form within 72 hours of the transfer, per regulation. He stated that he is the only Physician for this emergency department and he oversees the functions and practices of the Advance Registered Nurse Practitioner (ARNP), used in this emergency room to provide care.

Upon record review of 12 transfers from the emergency room, it was found that 11 (see evidence) where never signed by the Physician within 72 hours of transfer, per the facility policy and regulation. 1 of 12 transfer forms was never completed for the transfer or was not included in the chart. Sample patient #4 had no documented transfer form, from the facility.

On review of the EMTALA policy on 03/14/2017 it was discovered that an EMTALA transfer forms for 12 of 12 (see evidence) reviewed transfer records were not completely filled out per facility policy. On review of the Campbellton-Graceville Hospital transfer (form) records. EMTALA transfer forms were missing information such as Receiving Physician, receiving nurse, time of transfer, medical information sent with patient, and social security numbers. The facility policy titled: Transfer ACLS BCLS Private Automobile, Policy review dated: March 2013, states that the information on this sheet must be completed before being sent with transfer. These transfer records were found to be incomplete per regulation and facility policy.

Based on observation, interview and review of the facility's records, the facility failed to maintain an emergency crash cart with all the needed supplies that were immediately available for 1 of 2 crash carts. (Acute Unit)

The findings include:

On 03/13/2017 at approximately 10:50am the Acute Unit crash cart was inspected with the assistance of the Director of Nursing. She indicated that the night time shift during down time will check the crash cart. They document that the locked medication section remains intact, when it has been changed and that medications have been checkd. They also run a rhythm strips. This information is contained and documented in a log book that remains on the crash cart. There is no documentation to indicate what other components of the crash cart are checked. The defibrillator, showing with a green light, sits on top of the crash cart. Pads for the defibrillator were NOT present and no where on the crash cart. The DON indicated she would have to locate some and if they could not find any, in the event of an emergency - would get the crash cart from the Emergency Department. DON indicated she would order pads. The crash cart did contain emergency medication, suction, oxygen, ambu-bag and other essential emergency supplies. The facility lacks a process to ensure that "all" equipment and supplies are immediately available when needed.

A review of the policy and procedure entitled "Crash Cart Checks" indicates "Medications on the crash carts will be checked at regularly scheduled times (at least monthly) to identify outdated medications. The Lifepak defibrillator will be checked daily and signed off in Crash Cart Check Sheet Log to ensure that it is functioning properly."

Based on interviews and record reviews the facility failed to maintain records and prevent loss of information/records of patients. Missing records are from a period of time from May 13, 2015 to October 31, 2016, due to a management company taking the patient records for this period.

The findings are:

On 03/13/2017 an interview was conducted with the Medical Records Clerk (Staff G) and she stated that she has no access to patient records from May 13, 2015 to October 31, 2016, because the Hospital was under a management company and has been locked out of the system and denied access to the medical records. Therefore, the Hospital does not have any patient medical records for this time period.

On 03/15/2016, the following records were requested from the Medical Records Clerk (Staff G):

Patient V 03/01/2016
Patient W 02/16/2016
Patient X 02/06/2016
Patient Y 02/05/2016
Patient Z 01/26/2016

I was advised by Samantha Skipper, Medical Records Clerk, that the hospital does not have these patient medical records and the facility was unable to product them. The records were never obtained from the facility, during this survey. I letter, on hospital letter head was obtained stating that these records were not available. (Photo evidence).

Based on interviews and record reviews the facility failed to maintain records and prevent loss of information/records of patients. Missing records are from a period of time from May 13, 2015 to October 31, 2016, due to a management company taking the patient records for this period.

The findings are:

On 03/13/2017 an interview was conducted with the Medical Records Clerk (Staff G) and she stated that she has no access to patient records from May 13, 2015 to October 31, 2016, because the Hospital was under a management company and has been locked out of the system and denied access to the medical records. Therefore, the Hospital does not have any patient medical records for this time period.

On 03/15/2016, the following records were requested from the Medical Records Clerk (Staff G):

Patient V 03/01/2016
Patient W 02/16/2016
Patient X 02/06/2016
Patient Y 02/05/2016
Patient Z 01/26/2016

I was advised by Samantha Skipper, Medical Records Clerk, that the hospital does not have these patient medical records and the facility was unable to product them. The records were never obtained from the facility, during this survey. I letter, on hospital letter head was obtained stating that these records were not available. (Photo evidence).