HospitalInspections.org

Based on record review and interview, the hospital failed to ensure each physician/practitioner providing services in the hospital, including radiologists performing telemedicine (radiology) services, was credentialed and privileged to provide services to hospital patients. This deficient practice was evidenced by radiology reports read by physicians who were not privileged or credentialed for 3 of 3 (#6, #7, #12) patient records reviewed for radiology reports, of a total sample of 12.

Findings:

Patient #6
Review of the medical record for Patient #6 revealed she had a Chest X-ray taken 4/03/18 in the hospital by a contracted mobile X-ray company . Further review of the radiology report revealed the X-ray was read, interpreted, and electronically signed by S5MD.

Patient #7
Review of the medical record for Patient #7 revealed an admission date of 1/10/18. Further review revealed the patient had a chest X-ray taken during his hospitalization, by a contracted mobile X-ray company. Additional review of the radiology report revealed the X-ray was read and interpreted by S4MD.

Patient #12
Review of the medical record for Patient #12, admitted 9/12/17, revealed he had a chest X-ray taken 9/15/17 by a contracted mobile X-ray company. Further review of the radiology report revealed the x-ray was read, interpreted, and electronically signed by S6MD.

Review of the list of credentialed/privileged physicians and practitioners revealed S4MD, S5MD, and S6MD were not listed as credentialed/privileged providers of services for the hospital.

Review of the Governing Board and Medical Staff Meeting minutes for 2017 and 2018 revealed no appointment of privileges for any radiologist.

In an interview 5/29/18 at 2:45 p.m., with S1Administrator and S3HIM, S1Administrator confirmed the hospital had no radiologists credentialed/privileged. The administrator verified that the hospital used contracted services for radiology and ultrasounds performed in the hospital, and the results were interpreted by physicians outside of the hospital.

Based on record review and interview, the hospital failed to ensure radiological services were under the direction of a radiologist. This deficient practice was evidenced by failure of the hospital to appoint a radiologist to supervise/direct the hospital's contracted radiological services.

Findings:

Review of the hospital's contracted services revealed a contract with an area mobile x-ray service.
Review of the hospital's Governing Board meeting minutes dated April 30, 2018 revealed S13MD had been appointed as director of the hospital's contracted radiological services.

Review of S13MD's credentialing file revealed S13MD had a specialty in Internal Medicine and not in radiology.

During an interview on 5/30/18 at 11:08 a.m., S1Administrator acknowledged the hospital did not currently have a radiologist appointed to supervise/direct the hospital's contracted radiological services.

Based on record review, and interview the hospital failed to ensure each patient received a psychiatric evaluation within 60 hours of admission as evidenced by 4 (#2, #4, #6, #9) of 10 psychiatric evaluations reviewed that were performed more than 60 hours after admission.

Findings:

Record review for patient #2 revealed the patient was admitted on 05/25/18 at 4:45 p.m. Further review of the record revealed the patient received a psychiatric evaluation on 05/28/18 at 9:10 a.m., 64 hours and 25 minutes after admit.

Record review for patient #4 revealed the patient was admitted on 05/25/18 at 7:45 p.m. Further review of the record revealed the patient received a psychiatric evaluation on 05/28/18 at 8:15 a.m., 61 hours and 30 minutes after admit.

Record review for patient #6 revealed the patient was admitted on 03/30/18 at 4:00 p.m. Further review of the record revealed the patient received a psychiatric evaluation on 04/02/18 at 4:05 p.m., 72 hours and 5 minutes after admit.

Record review for patient #9 revealed the patient was admitted on 12/15/17 at 5:45 p.m. Further review of the record revealed the patient received a psychiatric evaluation on 12/18/17 at 10:57 a.m., 65 hours and 12 minutes after admit.

Interview on 05/29/18 at 3:30 p.m. with S10 RN verified that the psychiatric evaluations were not done within 60 hours of admission.