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Based on observation and interview, the hospital failed to ensure patients received care in a safe setting. This deficient practice was evidenced by non-functioning nurse call buttons located on the hand rails of patient beds for 6 of 6 beds located in the ICU (intensive care unit). This failure had the potential to delay or prevent assistance from the nursing staff if the patient pressed the nurse call button on the bed hand rail rather than the hand held call light.

Findings:

In an observation on 11/14/2024 at 4:20 p.m. - 4:44 p.m. of the ICU accompanied by S2CNO and S3CQO revealed the patient beds in rooms 'a' and 'b' had non-functioning nurse call buttons located on the hand rails.

In an interview during the observation S2CNO and S3CQO verified all 6 patient beds in the ICU had non-functioning nurse call buttons on the hand rails.

Based on record reviews and interviews, the hospital failed to ensure an effective system was in place to ensure that each physician/practitioner providing services in the hospital was credentialed. This deficient practice was evidenced by failing to credential a physician for core procedures in emergency medicine.

Findings:

Review of the Medical Staff By-Laws revealed in part, "Determination of Clinical Privileges: Section 10.1- Practicing Within Scope of Privileges: Medical Staff members or others practicing at Abbeville General Hospital shall, in connection with such practice, be entitled to exercise only those privileges specifically granted by the Board of Commissioners, except as otherwise provided in these bylaws. The privileges shall only be within the scope of the licensure, certification or other legal limitations authorizing the practitioner's practice. Delineated privilege list approved by the Board will be provided to the nursing staff for reference to ensure practitioners are practicing within their scope of practice. A list of the practitioner's procedures and admissions will also be reviewed at the time of reappointment to ensure the practitioner is practicing within their scope of privileges. Section 10.2 - Delineation of Privileges in General: A. Requests: Each application for appointment and reappointment to the Medical Staff must contain a request for the specific clinical privileges desired by the applicant. A request by a Medical Staff member, pursuant to Article IX, Section 9.6, for a modification of privileges, must be supported by documentation of training and/or experience supportive of the request."

Review of S8MD's credentialing file revealed a reappointment date of 11/16/2022. Review of the Application for Clinical Privileges revealed in part, Emergency Medicine Core privileges were approved for the reappointment period of 12/31/2022 - 12/30/2024. Further review revealed a list of core procedures under Emergency Medicine with a notation that indicated for these core procedures to check all procedures that the applicant wish to request. Review of this list failed to reveal any core procedures checked.

Review of Patient #1's emergency department record revealed Patient #1 presented to the emergency department on 04/09/2024. Further review revealed in part, Patient #1 was intubated by S8MD.

In an interview on 11/20/2024 at 9:57 a.m. S9MSC verified S8MD did not check any of the core procedures under emergency medicine which included airway management and intubation. S9MSC verified S8MD was not credentialed in any of the core procedures under emergency medicine which included airway management and intubation.

In an interview during record review on 11/20/2024 S2CNO verified S8MD was the physician that intubated Patient #1.

Based on record review and interview, the hospital failed to ensure respiratory services were administered in accordance with hospital policy. This deficient practice was evidenced by failure to document patient ventilator system checks every 2 hours as per hospital policy for 1 (Pt #3) of 3 (Pt #1, Pt #2, Pt #3) medical records reviewed.

Findings:

Review of the hospital's policy titled "Patient Ventilator System Checks" review date 06/19/2024, revealed in part, "I. Objective: A patient-ventilator system check is documented evaluation of a mechanical ventilator and of the patient's response to mechanical ventilator support. This procedure is often referred simply as a ventilator check. II. Policy: a.) All data relevant to the patient-ventilator system check must be recorded on the appropriate hospital forms at the time of performance, must be included as an official part of the patient's medical record, and include observations indicative of the ventilator's operations at the time of the check q [every] 2 hours."

Review of Patient #3's medical record revealed an admission date of 06/06/2024. Review of the ventilator management notes revealed there was documentation on 06/12/2024 at 5:10 p.m. Further review revealed the next ventilator management note was documented on 06/13/2024 at 6:51a.m. (approximately 13 hours)

In an interview on 11/20/2024 at 3:50 p.m. S2CNO verified there was no documentation of a ventilator management note between 06/12/2024 at 5:10 p.m. and 06/13/2024 at 6:51 a.m. S2CNO verified there should have been a ventilator management note documented every 2 hours according to hospital policy.