HospitalInspections.org

Based on review of hospital medical staff bylaws, service contracts, and administrative staff interviews the hospital's medical staff failed to examine credentials of telemedicine physicians for recommendation to the governing body for appointment of privileges to provide telemedicine services.

The findings include:

Review on 08/25/2011 of the current Medical Staff Bylaws revealed "Article 6 - Procedures for Appointment and Reappointment - 6.1 General Procedure. The Medical Staff, through its committees and officers, shall investigate and consider each complete application for appointment or reappointment, and each request for modification of appointment, and shall adopt and transmit recommendations thereon to the Board...A separate record will be maintained for each individual who has or applies for Clinical Privileges."

Review on 08/24/2011 of a facility contract for telemedicine services dated 11/20/2008 revealed "1. Services. (Name of contract agency) shall provide portable x-ray, EKG and Holter Monitor services to residents or patients of the facility...All exams will be interpreted by a duly licensed and qualified physician (radiologist/cardiologist as applicable)..."

Interview on 08/25/2011 at 1155 with the facility administrator revealed the contracted telemedicine service routinely provides onsite portable x-ray and EKG (electrocardiogram) services. Interview revealed the contracted service provides the interpretation of the diagnostic exams through a pool of physicians who have been credentialed by the contracted service. Interview revealed the physicians providing the diagnostic interpretations have not been credentialed through the hospital's medical staff. Interview revealed the credentialing information is provided to the hospital by the contract service, but the information was never reviewed by the hospital's physician credentialing process.

Based on review of radiologic service contracts, policies and procedures, quality monitoring meeting minutes and staff interview the facility failed to ensure monitoring of radiation safety practices of the radiologic services provided at the hospital.

Findings included:

Review on 08/24/2011 of a facility contract for telemedicine services dated 11/20/2008 revealed "1. Services. (Name of contract agency) shall provide portable x-ray, EKG and Holter Monitor services to residents or patients of the facility...All exams will be interpreted by a duly licensed and qualified physician (radiologist/cardiologist as applicable)..."

Review on 08/25/2011 of radiology policy "Radiation Protection Program" dated 10/2004 revealed "The following provisions have been evaluated and accurately describe the radiation protection program...1. The mobile x-ray machine operator is positioned as far from the radiation source as possible...2. The mobile x-ray machine operator wears a lead apron during all radiographic exposures. 3. The mobile x-ray machine is positioned at least 2 feet from any wall. 4. Less than 100 radiographic exposures are made per machine per week...8. The mobile x-ray machine operator wears a radiation monitor outside the lead apron. 9. The radiation monitor reports are reviewed. 10. When radiation monitor reports exceed 200 mR (milliREMs), the proper use of the mobile x-ray unit is reviewed and the applicable x-ray unit is submitted for inspection and calibration...11. The radiation protection program will be evaluated annually during the month of January."

Review of 12 months of Quality Assurance and Performance Improvement monitoring failed to reveal radiation safety monitoring of the radiologic service provided by contract.

Interview on 08/25/2011 at 1115 with administrative staff revealed the hospital contracts with a service to provide radiology services to include portable x-ray. Interview revealed the service routinely comes to the facility to perform portable x-rays. Interview revealed the staff member does not recall any information regarding monitoring of patient or personnel shielding, equipment testing or maintenance of personal radiation monitoring devices being monitored by the hospital. Interview revealed the staff member called management staff of the contracted agency and the information is reviewed by the contracted service. Interview revealed the hospital had never received the information being reviewed by the contracted service regarding radiation safety. Interview revealed the hospital had no record of monitoring the radiation safety practices for the radiologic services provided at the hospital.

Based on review of hospital medical staff bylaws, service contracts, and administrative staff interviews the hospital failed to ensure the radiology services provided at the facility were supervised by a radiologist who is a member of the medical staff.

The findings include:

Review on 08/25/2011 of the current Medical Staff Bylaws revealed "Article 6 - Procedures for Appointment and Reappointment - 6.1 General Procedure. The Medical Staff, through its committees and officers, shall investigate and consider each complete application for appointment or reappointment, and each request for modification of appointment, and shall adopt and transmit recommendations thereon to the Board...A separate record will be maintained for each individual who has or applies for Clinical Privileges."

Review on 08/24/2011 of a facility contract for telemedicine services dated 11/20/2008 revealed "1. Services. (Name of contract agency) shall provide portable x-ray, EKG and Holter Monitor services to residents or patients of the facility...All exams will be interpreted by a duly licensed and qualified physician (radiologist/cardiologist as applicable)..."

Interview on 08/25/2011 at 1155 with the facility administrator revealed the contracted telemedicine service routinely provides onsite radiology services. Interview revealed Physician #23 is the radiology director for the contracted service and would be considered the director for the services provided on-site at the hospital. Interview revealed the services provided include portable x-ray only. Interview revealed Physician #23 was not a member of the facility's medical staff. Interview revealed the credentialing information had been provided by the contracting service for Physician #23, but the information had not been reviewed by the hospital's medical staff for recommendation for membership to the Medical Staff by the hospital's governing body. Interview revealed there was no supervising radiologist for the radiologic services provided at the facility who has been qualified by the hospital's medical staff or recommended for membership on the hospital's medical staff by the governing body.

Based on therapeutic diet manual review and staff interview, the hospital failed to have a current therapeutic diet manual with the publication or revision date not more than 5 years old.

The findings included:

Review on 08/23/2011 of the hospital dietary department's current therapeutic diet manual, "Nutrition Care Manual, North Carolina Dietetic Association (NCDA), INC. 2005" revealed the manual was updated, edited, and revised in 2005 by the author. Review revealed the manual was last reviewed by the hospital's Food Service Director and Registered Dietitian on 05/22/2010. Review revealed the publication or revision date of the approved therapeutic diet manual was more than 5 years old.

Interview on 08/24/2011 at 1430 with the hospital's Food Service Director revealed the hospital's current therapeutic diet manual was a 2005 edition. Interview revealed the 2005 edition manuals were purchased one year ago. Interview revealed at the time of purchase, the NCDA did not have a newer edition available. Interview revealed a newer 2011 edition is available now for purchase from the NCDA. Interview revealed the Director was planning to purchase new manuals in October 2011. Interview confirmed the hospital's current approved therapeutic diet manual is greater than 5 years old.

Based on hospital new employee orientation curricula/schedule review, nursing competency checklist review, personnel file reviews, and staff interviews, the hospital failed to ensure appropriate hospital staff, including all patient care staff were educated annually and/or periodically on organ procurement and donation issues, policy, procedures, roles, and responsibilities.

The findings include:

Review on 08/25/2011 of the most recent "New Employee Orientation" curricula/schedule dated 08/01/2011 to 08/04/2011 revealed Organ Procurement and Donation was not a topic reviewed.

Review on 08/25/2011 of a RN/LPN Competency Checklist revealed Organ Procurement and Donation policy and procedures were not listed as a "Skill/Duty" requiring competency validation.

A sample of eight (8) nursing staff personnel files were reviewed on 08/25/2011. Review revealed no documented evidence in any of the files, of education and training upon hire or annually thereafter related to Organ Procurement and Donation issues, policy, procedures, roles, and responsibilities.

Interview on 08/23/2011 at 1319 with the Performance Improvement/Risk Management Director revealed the hospital does not have any specific training or education for hospital staff related to organ procurement and donation policies and procedures. Interview revealed the hospital does not provide staff with education and training related to organ procurement and donation upon hire or on an annual/periodic basis.

Interview on 08/23/2011 at 1337 with the Chief Nursing Officer revealed "we have not had any focused training on organ procurement and donation." Further interview revealed the hospital does not collaborate with the contracted Organ Procurement Organization to provide education for the staff. Interview revealed "when you review personnel files you will not see any evidence of organ procurement and donation training."