HospitalInspections.org

Based on record review and interview, the facility failed to have current medical and DEA licensure, delineation of privileges, and appointment approval by the medical staff and governing board for 10 of 14 active facility physicians. Findings include:

During a record review of the facility credentialing files on 8/27/15 at 9:00 a.m., the following provider files did not include current documentation for:

1. Staff member B's credentialing file did not include documentation of a current appointment for privileges from the medical staff and governing board.

2. Staff member C's credentialing file did not include documentation of a current appointment for privileges from the medical staff and governing board.

3. Staff member D's credentialing file did not include documentation of current medical or DEA licensure.

4. Staff member E's credentialing file did not include documentation of current reappointment for privileges from the medical staff and governing board.



31093

5. Staff member F's credentialing file did not include documentation of a current reappointment for privileges from the medical staff and governing board.

6. Staff member G's credentialing file did not include documentation of the delineation of approved privileges for the current appointment from the medical staff and governing board.

7. Staff member H did not have a credentialing file available to substantiate medical staff and governing board appointment, delineation of privileges and a current medical or DEA licensure.

8. Staff member I did not have a credentialing file available to substantiate medical staff and governing board appointment, delineation of privileges and a current medical or DEA licensure.

9. Staff member J's credentialing file did not include documentation of the delineation of approved privileges for the current appointment from the medical staff and governing board.

In an interview on 8/27/15 at 11:15 a.m., staff member A, DON, stated the medical records staff member was in training. Staff member A stated she would fax additional information to address the above concerns.

During an interview on 8/27/15, staff member K, CEO, stated he didn't know much about the credentialing files, but they were in one drawer of the file cabinet in the medical records department. Staff member K stated the staff member responsible for maintaining the credentialing files was out of the facility, attending a training.

A fax was received from the facility on 8/28/15 with no further documentation submitted for the above concerns.

Based on record review and interview, the facility failed to ensure credentialing files were evaluated to substantiate medical staff and governing board appointments and reappointments, and medical and DEA licensure was current for active providers serving the facility. Findings include:

During a record review of the facility credentialing files on 8/27/15 at 9:00 a.m., the following physician files did not include current documentation for:

1. Staff member B's credentialing file did not include documentation of a current appointment for privileges from the medical staff and governing board.

2. Staff member C's credentialing file did not include documentation of a current appointment for privileges from the medical staff and governing board.

3. Staff member D's credentialing file did not include documentation of current medical or DEA licensure.

4. Staff member E's credentialing file did not include documentation of current reappointment for privileges from the medical staff and governing board.



31093

5. Staff member F's credentialing file did not include documentation of a current reappointment for privileges from the medical staff and governing board.

6. Staff member G's credentialing file did not include documentation of the delineation of approved privileges for the current appointment from the medical staff and governing board.

7. Staff member H did not have a credentialing file available to substantiate medical staff and governing board appointment, delineation of privileges and a current medical or DEA licensure.

8. Staff member I did not have a credentialing file available to substantiate medical staff and governing board appointment, delineation of privileges and a current medical or DEA licensure.

9. Staff member J's credentialing file did not include documentation of the delineation of approved privileges for the current appointment from the medical staff and governing board.

In an interview on 8/27/15 at 11:15 a.m., staff member A, DON, stated the medical records staff member was in training today. Staff member A stated she would fax additional information to address the above concerns.

During an interview on 8/27/15 at 9:30 a.m., staff member K, CEO, stated he didn't know much about the credentialing files, but they were in one drawer of the file cabinet in the medical records department. Staff member K stated the staff member responsible for maintaining the credentialing files was out of the facility, attending a training.

A fax was received from the facility on 8/28/15 with no further documentation submitted for the above concerns.

Based on record review and interview, the facility failed to maintain medical records that included entries that were timed, dated and authenticated by medical staff for two (#s 6 and 7) of 20 sampled patients. Findings include:

1. Patient #6 was seen in the emergency department on 5/2/15 and admitted to the CAH with a diagnoses of a right femur fracture and a urinary tract infection. On 5/3/14, staff member L wrote an order, "1. CBC, BMP 5/4 am 2. K+ 20 meq PO Q a.m. 3. NS @ 125ml/hr p 250cc bolus." The order entered into the medical record did not include a time for when it was written.

2. Patient #7 was admitted to the hospital from the ER on 5/3/15, for a suicide attempt and depression. On 5/5/15, staff member L wrote an order to, "1. D/C Cipro (not yet given), and 2. Levaquin 500mg p.o. X 5d)." The order entered into the medical record did not include a time for when it was written.

During an interview on 8/26/15 at 4:10 p.m., staff member A, DON, stated the providers should time, date, and sign orders. Because the transition to electronic health records was not completed at this point, some forms were duplicated. Some of the providers were not comfortable with writing orders in the electronic health records. The provider hand wrote the orders, and the nursing staff entered them into the electronic health records. The provider would then go into the electronic health record and sign it again after it was entered.

During an interview on 8/26/15 at 9:15 a.m., staff member M, medical records manager, stated there was not a deadline for providers to sign off on the medical record. Staff member L had six to eight charts that needed to be completed and signed, and dated back to June, 2015.