HospitalInspections.org

Based on a review of Medical Staff reappointment documentation and staff interview, as compared with the Medical Staff Bylaws, Rules and Regulations, the Governing Body failed to follow the Medical Staff Bylaws, Rules and Regulations in the reappointment process and failed to establish performance criteria for the Active and Courtesy Staff. The Medical Staff consists of 10 active physicians, 4 mid-level practitioners and 2 consulting surgeons Practitioners 1, 2, 3, 4, 5 and 6). This affected all practitioners appointed to the medical staff and had the potential to affect the quality of care provided to all patients.

Findings include:

1. The Medical Staff Bylaws, Rules and Regulations on page 15, Section 3.
Reappointment Process B states, "Each recommendation concerning the reappointment of a medical staff member and the clinical privileges to be granted upon reappointment shall be based upon such member's professional competence and clinical judgement in the treatment of patients as demonstrated by reviews and evaluations conducted by committees and quality assurance activities, peer recommendations, timely, accurate, and complete medical records...attendance at medical staff meetings...cooperation with hospital personnel...general attitudes toward patients, the hospital and the public."

2. A review of 4 current Active Medical Staff and 2 Courtesy Staff Member's credential and reappointment files revealed all 6 lacked evidence of quality assurance activities, medical record completion, medical staff meeting attendance or the practitioners (Practitioners 1, 2, 3, 4, 5 and 6) clinical competence, judgment and treatment of patients served in the hospital.

3. An interview with the Administrator on 3/4/2015 at 3:30 PM confirmed the Medical Staff (1, 2, 3, 4, 5 and 6)were reappointed without benefit of performance criteria, as specified in the Bylaws.

4. The form utilized for the specialty of Family Practice stated, " To be eligible to renew core privileges in geriatric medicine, the applicant must meet the following maintenance of privilege criteria: Current demonstrated competence and an adequate volume of experience ({n} inpatients with acceptable results, reflective of the scope of privileges requested, for the past 24 months based on results of ongoing professional practice evaluation and outcomes...."
('n' is a mathematical symbol used to represent any number).

5. Physicians 1 and 5 were reappointed to the medical staff in the specialty of Family Practice in 2014. The Governing Body failed to establish the number of patients treated by each physician, for continued membership, the physicians were reappointed, without this data. The forms had '(n)' rather than a specified number of patients ('n' is a mathematical symbol used to represent any number).

6. The form utilized for the specialty of General Surgery, Colonoscopy with Polypectomy stated, "Required previous experience: Demonstrated current competence and evidence of performance of at least {n} procedures in the past 24 months. (Colonoscopy is the examination of the large bowel and part of the small bowel with a small camera. A Polypectomy is the removal of a growth from the intestine) and ('n' is a mathematical symbol used to represent any number).

7. The Governing Body failed to establish the number surgeries performed by each physician for continued membership; however, the physicians were reappointed without this data or the patient outcomes (example Physician 2).

8. An interview with Administrator on 3/4/2015 at 3:30 PM confirmed the thresholds for physician performance had not been established (example Physician 2).

Based on Review of Medical Staff Bylaws and staff interview; the CAH (Critical Access Hospital) failed to ensure its practitioners completed their medical records within 30 days of the patients discharge for 22 of 67 total discharged patient's (Patients XXXXX) between the dates of 12/1/14 through 3/2/15. This failed practice had the potential to affect all discharged patients of the CAH. Patient census first day of survey 5 (1 acute inpatient and 4 swingbed patients).

Findings include:

A. Interview with the Director of Financial Services (DFS) and the Medical Records Coordinator (reports to the DFS) on 3/3/15 at 10:30 AM revealed it was 'unknown' if there were medical records over 30 days of a patient's discharge, they "did not run a query report to check for incomplete records before" and there were no policy and procedures in place to do so.

B. Review of the Medical Staff Bylaws (no date) stated the following:
"A temporary suspension in the form of withdrawal of practitioner's admitting privileges, effective until medical records are completed, shall be imposed automatically after a seven (7) day written warning of delinquency for failure to complete medical records within 30 days of a patient's discharge. Any practitioner whose admitting privileges who have been terminated because of delinquent records continuously for thirty (30) days (exclusive of illness, vacation,or other extenuating circumstances that would justify the delinquency) shall have his medical staff membership and privileges canceled. The practitioner must then reapply for staff membership and clinical privileges."

B. Interview with the DFS on 3/4/15 at 8:55 AM confirmed the number of incomplete discharged patient medical records and that there are no practitioners on temporary suspension due to their incomplete medical records. The DFS stated there are no policies and procedures in place to monitor for incomplete patient records within 30 days of a patient's discharge.

Based on medical record review and staff interview; the CAH (Critical Access Hospital) failed to ensure that surgical patient medical records contained documentation of the pre-surgical physical examination to evaluate for the risk of the procedure to be performed by the physician(s) for 6 of 6 patient surgical medical records (Patients 12, 13, 14, 15, 16 and 17) reviewed. This failed practice had the potential to affect all surgical patients of the CAH. The average number of procedures performed at the CAH on a monthly basis is 4.

Findings include:

A. Review of Patient 12's medical record on 3/2/15 at 10:00 AM revealed the patient had bilateral hernia repair on 5/29/14. Review of the entire medical record revealed no evidence of the physician documentation of the pre-surgical examination for the risk of the procedure to be performed.

- Review of Patient 13's medical record on 3/2/15 at 10:25 AM revealed the patient had re-excision (procedure of removing by cutting out) of back on 7/3/14. Review of the entire medical record revealed no evidence of the physician documentation of the pre-surgical examination for the risk of the procedure to be performed.

- Review of Patient 14's medical record on 3/2/15 at 10:35 AM revealed the patient had umbilical hernia repair on 10/23/14. Review of the entire medical record revealed no evidence of the physician documentation of the pre-surgical examination for the risk of the procedure to be performed.

- Review of Patient 15's medical record on 3/2/15 at 10:50 AM revealed the patient had laproscopy cholecystectomy (removal of the gallbladder and any gallstones through several small incisions in the abdomen) on 11/13/14. Review of the entire medical record revealed no evidence of the physician documentation of the pre-surgical examination for the risk of the procedure to be performed.

- Review of Patient 16's medical record on 3/2/15 at 10:55 AM revealed the patient had laproscopy cholecystectomy on 12/4/14. Review of the entire medical record revealed no evidence of the physician documentation of the pre-surgical examination for the risk of the procedure to be performed.

- Review of Patient 17's medical record on 3/2/15 at 11:00 AM revealed the patient had right carpal tunnel release (release of the carpal ligament taking pressure off the median nerve) on 1/22/15. Review of the entire medical record revealed no evidence of the physician documentation of the pre-surgical examination for the risk of the procedure to be performed.

B. Interview with the Director of Clinical Services on 3/3/15 at 11:45 AM confirmed the missing documentation of the physician pre-surgical examinations for the risk of the procedure to be performed in the above patient's surgical medical records and stated "did not know it was a regulation."

C. Interview with surgical Pre-op Nurse A on 3/4/15 at 9:00 AM stated that the surgeons do an assessment on their patients all 15-30 minutes before surgery depending on how many patients they have that include listening to the heart, lung sounds, talking to patients regarding surgical risks and complications and answer any questions.