HospitalInspections.org

Based on review of the Medical Staff credentialing files, hospital policies and procedures, and interview with the staff, it was determined the hospital failed to ensure that the Medical Staffs' credentials were up to date in 3 of 4 Medical Doctor credentialing files reviewed.

Findings include:

Hospital Policy: Credentialing Privileges Process revised July 2009

Policy: The credentialing and privileging process is a function of the Medical Staff...

Procedure:
The responsibility of credentialing and staff privileges is assumed by the Medical Staff Executive Committee...

The objective of the credentialing and privileging process is to ensure that individuals who will diagnose and treat patients has appropriate training, experience and current competence. Privileges are only granted on this basis.

Medical Staff members will be re-appointed every two (2) years and prior to this re-appointment they must be re-appraised... Recommendations for continued staff privileges based on the findings, of these re-appraisals, will be made by the Governing Body...

The applications are returned to the Medical Staff Service Office. Following verification (as necessary) they are submitted to the Medical Staff Executive Committee.

1. Medical Staff Member # 1 was laste credentialed with re-appointment approval on 6/15/08. Review of the credentialing file revealed no current credentialing by the Department/Service Director, Credentialing Committee, Medical Staff Executive Committee or the Governing Body.

2. Medical Staff Member # 2 was laste credentialed with re-appointment approval on 6/25/08. Review of the credentialing file revealed no date for the current credentialing by the Department/Service Director, Credentialing Committee, and the Medical Staff Executive Committee.

3. Medical Staff Member # 3 was laste credentialed with re-appointment approval on June of 2008. Review of the credentialing file revealed no documentation if the Physician had been approved or denied for the current credentialing by the Department/Service Director, Credentialing Committee, and the Medical Staff Executive Committee.

An interview with Employee Identifier # 1, the Director of Quality Management on 9/23/10 at 2:00 PM verified the above credentialing files were incomplete.

Based on review of the Inventory Control List, policies and procedures and interview, the facility failed to assure all medical equipment available for patient use in the Emergency Department (ED) had the annual scheduled Preventive Maintenance. This had the potential to affect all patients served by the ED.

Hospital Policy: Preventive Maintenance Policy effective December 2005

Policy:
It is the policy of Clay County Healthcare Authority that equipment that is used in this facility will be maintained as per the accompanying service manual

Review of the Inventory Control List for the ED revealed the following equipment were due an annual Preventive Maintenance on 7/1/2010:
Exam Light x 1
Otoscope x 5
VSM (Vital Sign Monitor) x 3
X-Ray View Box x 1
Doppler x 2
Refrigerator x 1
Cast Cutter x 1
Sphygmomanometer x 2
Ultra Violent Light x 1
Defibrillator x 2
Scale x 2

An interview with Employee Identifier # 1, the Director of Quality Management on 9/23/10 at 1:40 PM verified this equipment listed above is to have a preventative maintenance annually and was not Completed for 7/1/10.