HospitalInspections.org
Bringing transparency to federal inspections
WESTERN PEAKS SPECIALTY HOSPITAL
MEDICAL STAFF PRIVILEGING
Tag No.: A0355
Based on interview and record review, it was determined that the hospital did not grant specific privileges or limitations for 7 out of 7 sampled medical staff. (Medical Staff identifiers: 1, 2, 3, 4, 5, 6 and 7.)
Findings include:
On 12/06/2016, the personnel files for medical staff 1 ,2 ,3, 4, 5, 6 and 7 were reviewed. None of the files contained evidence that privileges were granted.
On 12/06/2016, at 9:30 A.M., the medical records manager was interviewed. When he was asked about the granting of medical staff privileges, he stated he did not know that the hospital needed to grant privileges to the medical staff.
On 12/06/2016, at 12:30 P.M., the Administrator was interviewed. He stated that their governing body had not been granting privileges to their physicians.
On 12/6/2016, the hospital's "Bylaws of the Medical Staff" dated 2012 was reviewed. The following was documented; "In Article VII", Exercise of Privileges: "Every practitioner or other professional providing clinical services at this hospital by virtue of his/her Medical Staff membership, or otherwise, shall, in connection with such practice, will be entitled to exercise only those clinical privileges or specified services specifically granted him/her by the Board of Directors."