HospitalInspections.org

Based on document review, policy review and interview, the facility failed to have a provider on duty in the Emergency Department (ED) at all times who was qualified to write outpatient prescriptions for controlled substances for ED patients.

Findings Include:

Review of the Medical Executive Committee meeting minutes dated August 14, 2012 revealed Staff #5 has started full time in the emergency department. Staff #5 is listed as a new applicant to emergency services on the credentialing report.

Review of the Credential file for Staff #5 noted the following:
- Application for employment dated 6/26/12 indicated his license to practice as a physician assistant has been subjected to probationary conditions and his narcotics registration has been voluntarily revoked. However, a Federal Drug Enforcement Agency (DEA) number with an expiration of 5/31/2012 is listed under licensure.
- The National Practitioner Data Bank document dated 7/3/12 noted a permanent, voluntary surrender of DEA registration/license on 2/18/10 based on an investigation.
- The emergency medicine privileging form dated 8/1/12 documented approval for all emergency medicine privileges.
. No evidence was found in the credential file to indicate Staff #5 had a current DEA #
to prescribe medication.

Review of the Medical Bylaws revealed Article 6 " Application Review " indicates the Chief Executive Officer shall make inquiries required by law to verify all information contained in the application. The application will be forwarded to the designated department chair or committee who shall make a written statement to the credential committee including a clear delineation of clinical privileges to be considered for the applicant and consideration of the response by the National Practitioner Data Bank.

During interview on 9/25/12 at 1450, Staff #14 stated he was aware Staff #5 did not have a current DEA registration. Originally Staff #5 was supposed to be paired up with another physician or midlevel practitioner.
During interview on 9/26/12 at 0850, Staff #5 stated he does not currently have a DEA registration. Under the terms of his probation, he can prescribe in-house controlled substances but cannot write outpatient prescriptions. In the event that he would need to write a prescription for a controlled substance, he would have a midlevel practitioner or the emergency department director do so.

Review of the ED provider schedule for August and September 2012 documented Staff #5 was the sole provider in the ED for a period of time on multiple days from August 3 to September 25, 2012.

Review on 9/26/12 of the DEA document provided by Staff #5 revealed as one of the terms and conditions of his probation, his controlled substance activities will be limited to exclusively prescribing in a medical practice setting.