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Based on medical record review, document review and staff interview, the facility failed to ensure the competence of MD #17 prior to giving him/her privileges to perform surgical procedures within the facility.

Findings include:

1. Review of patient #1 medical record indicated the following:
(A) The patient (22 year old male) was admitted on 1/2/08. Per history and physical (H&P) dictated by MD #17, the patient was admitted with a history of gallstones. The patient underwent an attempted laparoscopic cholecystectomy on 1/3/08. Per operative report, "the patient was kept on bleeding around the incision and finally it was decided that _____ was also incised during the procedure and the patient bled quite a bit. A cholecystostomy tube was placed."
(B) The patient was discharged on 1/8/08 and readmitted to the hospital on 1/25/08 to have an exploratory laparotomy and open cholecystectomy by MD#17.
(C) The patient had elevated white blood count, elevated temperature and received I.V. antibiotics and pain medications during the second stay.
(D) The patient was transferred to facility #2 on 2/1/08. The transfer/discharge summary dictated by MD #17 on 2/6/08 indicated the patient was transferred with discharge diagnosis of possible right upper quadrant abscess secondary to open cholecystectomy.

2. Staff member #2 indicated the following in interview at 3:10 p.m.:
(A) He/she was informed of a concern voiced by staff member #15, assisting with the surgery for patient #1 on 1/3/08, requesting MD #1 to come to the O.R. He/she went to the unit and asked MD #1 to come to the surgery department. MD #1 informed the staff member that he/she wanted no part of MD #17 and refused to come to the OR.
(B) He/she found MD #17's techniques to be "dated" and the surgeon was unable to carry out the laparoscopic procedure on patient #1.
(C) MD #17 performed 17 cases at the facility. Patient #1 was the only open abdominal surgery performed.

3. Staff member #7 indicated the following in interview at 5:40 p.m.:(A) Facility was unable to obtain documents or evidence of competence from other countries that MD # 17 practiced in. MD #17 was last in Saudi Arabia. MD #1 was to mentor or proctor MD #17, however refused to do so.
(B) An outside review was conducted and contract with MD #17 was terminated.

4. Review of MD #17's credential file indicated the following:
(A) He/she was granted privileges in general surgery November 26, 2007.
(B) Document titled "The Federation of State Medical Boards of the United States, Inc." indicated that the physician had an order against license on 1/20/1993 for unprofessional conduct/practice which is or might be harmful/dangerous to the health of the patient/public, and failure to maintain adequate medical records. An order dated 1/2/2002 indicated that the practitioners medical license was reinstated on probation and stated "Practitioner shall comply with any court imposed probationary terms, submit to periodic office and practice survey and engage the service of a Board-approved consultant to advise him in the area of practice management, record keeping and billing."
(C) The application indicated that the surgeon was in Saudi Arabia from 1997-2000, was a critical care fellow in Delaware 2002-2003, and was in India 2000-2002 and 2003-2006.
(D) The file contained three (3) references faxed to the facility on 9/13/07 that were dated July 2004 (2 references) and April 2005 (1 reference). The references did not speak to his/her competence in general surgical procedures including a laparoscopic cholecystectomy or open cholecystectomy.
(E) There were no references from India or Saudi Arabia.
(F) The file contained a document titled "CONFIDENTIAL SEPARATION AND RELEASE AGREEMENT" was dated 3/5/2008 which indicated contract with facility was terminated.

5. Review of MD #17's credentials and medical records review by an outside surgeon indicated there was concern with the physician's multiple practice locations and inability to verify the quality and scope of his practice during the years that he/she had practiced out of the country. The document stated "There was no ability by your hospital to determine the nature of his recent practice by objective and verifiable means as he had been out of the country.".................Page 2, paragraph 3 of the document stated "the terms of his 1996 suspension required that he take a mini residency. This was later modified to a requirement that he attend the (university #1) PACE course. Again this was not disclosed and evidence of completion was not provided to you.............Regardless, there is a significant gap in his practice that leaves the matter of establishing competence of great importance." Page 3 indicated that medical records were reviewed and there was "significant concerns" regarding care that was provided by the practitioner.

6. Review of medical staff bylaws adopted 7/19/07 stated on page 29 under application for appointment, "b. The names of at least three (3) persons who have had extensive experience in observing and working with the applicant and who will provide adequate statements pertaining to the applicant's profession competence and ethical character as well as the applicant's ability to perform specific procedures or services. The must also be able to give well-formed opinions as to the applicants ethical character and ability to work cooperatively with the others in the provision of health care;"

7. Although MD #17 was terminated, there was no evidence that the facility had taken action to prevent future occurrences of failure to assure verification prior to performance of surgical procedure.

Based on document review, the facility failed to assure accurate and complete documentation for 1 of 3 medical records reviewed (patient #1).

Findings include:

1. Review of patient #1 medical record indicated the following:
(A) The patient (22 year old male) was admitted on 1/2/08. The history and physical (H&P) completed by MD #17 indicated the patients only medication was Flexeril 10 mg. three times a day. The document stated "He does not take any Aspirin.........and he cannot take Tylenol or Aleve as he gets pain in the abdomen."
(B) Admission orders included an order for Tylenol 650 mg every 4 hours as needed. Nurse notes indicated that nursing staff questioned the patient about the problem with the Tylenol as indicated in the H&P. The patient indicated to the nurse it was not true.
(C) Medication reconciliation form completed on day of admission indicated the patient had taken Flexeril 10 mg tid with last dose on 12/31. The document also indicated the patient was taking Levabid twice daily with the last dose on 1/1/08.
(D) The patient underwent an attempted laparoscopic cholecystectomy on 1/3/08. The operative report dictated by MD #17 at 12:40 p.m. on 1/3/08 stated "The patient was (known possible error) kept on bleeding around the incision and finally it was decided that _________(blank not filled in) was also incised during the procedure and the patient bled quite a bit, probably a reaction from taking Aspirin"
(E) The patient was discharged on 1/8/08. Discharge medications included Darvocet (for pain) and Amoxicillin 500 mg (antibiotic).
(F) The discharge summary dictated by MD #17 on 1/18/08 stated ".......was given pain mediations (known misspelling), Tylenol with Codeine one tablet po three times a day.........." (The patient was sent home with Darvocet for pain and not Tylenol with Codeine.)