HospitalInspections.org

Based on observation and interview, the facility failed to ensure the diagnoses and treatments created by nurse practitioners were evaluated for quality and appropriateness in accordance with the facility's standard care arrangement. This affected one (Staff K) of two sampled nurse practitioners.

Findings include:

On 08/20/19 a review of Staff I's credentialing file revealed a standard care arrangement initiated on 08/14/19. The arrangement stated the nurse practitioner would have, at least annually, a random selection of patient records selected by her and the collaborating physician reviewed for care outcomes; and at least semi-annually, she and the collaborating physician would select a random sample of patient records for purposes of reviewing the care outcomes of prescriptions written by her. The review of the credentialing file revealed a monthly list of patients who required their treatment plan revised. The review did not reveal the annual sample for care outcomes and the semi annual sample for outcomes of prescriptions written.

On 08/20/19 at 1:38 PM in an interview, Staff K said he only records what records needed revision. He said he did not randomly sample patients for care outcomes or outcomes of prescriptions.

Based on interview and record review, the facility failed to ensure its agreement with the transplant organ procurement organization included provisions that the facility is not required to perform credentialing and privileging for the qualified, trained individuals sent to perform organ recovery. This has the potential to affect all potential organ donors.

Findings include:

On 08/20/19 a review of the contract between the organ procurement organization and the facility revealed no documentation where the organ procurement organization's qualified, trained individuals were excluded from requiring credentialing and privileging.

On 08/20/19 at 2:41 PM in an interview, Staff A confirmed the contract did not include the exclusions.