HospitalInspections.org

Based on policy review and staff interview the Critical Access Hospital (CAH) failed to complete credentialing/reappointment (an evaluation of qualifications and work practice history) for 2 of 10 providers requiring credential/reappointment to the medical staff of the CAH (provider D and E).

Findings include:

- Medical Staff Bylaw titled, "Duration of Appointment and Reappointment", reviewed on 5/4/11 at 4:00pm revealed reappointments and appointments will be for a period of two Medical Staff Years.

- Provider D's credential file reviewed on 5/4/11 at 3:30pm revealed the last credentialing/reappointment date of 2008.

- Provider E's credential file reviewed on 5/4/11 at 3:30pm revealed the last credentialing/reappointment date of 2008.

Staff A interviewed on 5/4/11 at 4:00pm acknowledged the credential files for provider D and E lacked evidence of credentialing/reappointment for the year 2010.

Based on policy and procedure manual review and staff interview the Critical Access Hospital (CAH) failed to develop policies with the advice of a group of professional personnel that included at least one physician assistants or nurse practitioners for 15 of 15 policy and procedure manuals reviewed.

Findings include:

- Review of the policy and procedure manuals provided during the survey between 5/2/11 through 5/4/11 lacked evidence that a physician assistant or nurse practitioner was included as part of the group of professional personnel that developed and/or reviewed the policy and procedure manuals for the year 2010.

Staff A interviewed on 5/4/11 at 5:00pm acknowledged the CAH lacked knowledge of the requirement to include a physician assistant or nurse practitioner in the development/review of the procedure and policies. Staff A confirmed the review of the procedure and policy manuals did not include the physician assistant or nurse practitioner.

Based on record review and staff interview the Critical Access Hospital (CAH) failed to ensure medical staff dated and/or timed all entries in the medical record for 7 of 22 sampled medical records (#'s 13, 18, 23, 25, 26, 30, and 31).

Findings include:

- Hospital policy " Medical Record Documentation " reviewed on 5/4/11 at 4:pm directed " ...Every entry to the patient's record should be signed and dated with the time noted ..."

- Patient #13's medical record reveiwed on 5/3/11 at 2:00pm revealed an admission date of 2/11/11 with a diagnosis of chest pain. The medical record revealed the history and physical and discharge summary lacked a date and time when authenticated (signed) by the provider.

- Patient #18's medical record reviewed on 5/3/11 at 4:15pm revealed an admission date of 12/20/10 with diagnoses of alcoholism and diabetes mellitus. The medical record revealed the history and physical and discharge summary lacked a date and time when authenticated (signed) by the provider.

- Patient #23's medical record reviewed on 5/4/11 at 11:00am revealed an admission date of 1/17/11 with diagnoses of necrosis of liver (death of liver cells) and renal failure (kidney failure). The medical record revealed the history and physical lacked a date and time when authenticated (signed) by the provider.

Staff B interviewed on 5/4/11 at 12:25pm acknowledged the providers failed to date and time all entries into the medical record.

This deficient practice also affected patient #'s 25, 26, 30, and 31.