HospitalInspections.org

Based on review of the Medical Staff Bylaws, review of physician credential information from an Acute Care Hospital (located in another town/city) and staff interview, the Critical Access Hospital (CAH) failed to have an agreement with this Acute Care Hospital for credentialing and privileging of telemedicine physicians for 2 of 2 sample radiologists reviewed (Radiologists Q and R). A letter from the Acute Care Hospital identified 17 radiologists that could potentially provide services to the CAH. The failure to have an agreement for credentialing and privileging of telemedicine physicians has the potential to affect all patients receiving radiology services at the CAH.

Findings are:

A. Review of the Medical Staff Bylaws approved by the Governing Body on 4/22/09 revealed the following concerning radiologists providing services at the hospital under Article IV, D: "The Consulting Medical Staff shall consist of practitioners who act only as consultants and who come to the Hospital either on schedule or by call or who provide their written opinions in the medical record without coming to the Hospital, for example, radiologist...."

An addendum to the Medical Staff Bylaws Article VI Clinical Privileges dated 7/2/14 revealed the following: "Physicians providing services for interpretation of diagnostic tests (radiology, EKG [electrocardiogram - test that checks for problems with the electrical activity of the heart], echocardiogram [test that uses sound waves to create pictures of the heart], ultrasound [tests that use sound waves to create pictures of structures within the body], venous studies [a procedure used to assess the blood flow in arteries and veins], etc.) will not be required to be on the Medical Staff. Their credentials will be verified with [name of the Acute Care Hospital] or, in the case they are not member of [name of the Acute Care Hospital], the originating site of their practice. Their credential will be verified on a bi-yearly basis at the same time as Medical Staff reappointments."

(Credentials would include a license to practice medicine in the State, Registration with the Drug Enforcement Administration [DEA], malpractice insurance, etc.)

B. Review of the list of credentialed radiologists from the Acute Care Hospital dated 4/3/15 revealed Radiologists Q and R were on the list. The list contained the expiration dates for Radiologists Q's and R's Nebraska License to practice medicine, malpractice insurance and DEA registration.

C. Interview with the Health Information Manager (HIM) on 4/7/15 from 9:15 AM to 9:30 AM confirmed the CAH failed to have an agreement for credentialing and privileging of telemedicine physicians with the Acute Care Hospital for the radiologists even though they were relying on the Acute Care Hospital's credentialing information.

Based on review of Policy and Procedure Committee meeting minutes, review of the Policy and Procedure Process and staff interview, the Critical Access Hospital (CAH) failed to have 1 of 2 required professional members (doctor of medicine or osteopathy) included in the group of professional personnel that reviewed the policies on an annual basis. This failed practice has the potential to affect all patients served by the hospital.

Findings are:

A. Review of the undated Policy and Procedure Process revealed the following: "The Policy and Procedure committee consists of the DON (Director of Nursing), radiology dept (department) manager [name of a nurse practitioner], [name of a physician], [name of a physical therapy assistant who works for a group contracted by the CAH]."

B. Review of the Policy and Procedure Committee Meeting minutes dated 7/29/14 and 12/30/14 revealed the physician was not listed as present at these 2 meetings.

C. Interview with the DON on 4/9/15 at 10:50 AM to 10:55 AM revealed the following:
- Confirmed the policy and procedure committee only met 2 times in 2014; and,
- Confirmed a physician was not in attendance at either one of these meetings.

Based on medical record review, policy and procedure review and staff interview, the Critical Access Hospital (CAH) failed to ensure that 2 of 2 sampled outpatient Cardiac Rehabilitation patients (Medical Records 37 and 38) had a physician signed order and/or referral for Cardiac Rehabilitation. The CAH had 2 Cardiac Rehabilitation outpatients on 4/6/15. From 1/1/14 to 4/6/15 the CAH had 12 Cardiac Rehabilitation outpatients.

Cardiac Rehabilitation helps patients improve their health and live a more active life after major or ongoing heart problems.

Findings are:

A. Review of the Cardiac Rehabilitation (Rehab) medical record for Patient 37 on 4/6/15, revealed a Cardiac Rehab Referral Form with an admit date of 3/10/15 from an Acute Care Hospital in another city. The order was for Cardiac Rehab Consult but lacked the signature of the ordering physician. Interview with Cardiac Rehab Nurse-V on 4/6/15 at 2:50 PM revealed Physician-L (physician on the Medical Staff at the CAH) gave a verbal order for Cardiac Rehab but failed to write this verbal order in the medical record and get it signed by the physician.

B. Review of the Cardiac Rehab medical record for Patient 38 revealed no referral form or physician order for Cardiac Rehab. Interview with Cardiac Rehab Nurse-V on 4/6/15 at 3:10 PM revealed Physician-N (physician on the Medical Staff at the CAH) gave a verbal order for Cardiac Rehab and thought Physician-N wrote an order in the progress note at the clinic attached to the hospital. Review of the progress note provided by Cardiac Rehab Nurse-V revealed Patient 38 was seen by Physician-N on 1/30/15 for a follow up appointment for cardiac surgery. Review of the entire progress note revealed no order/referral for Cardiac Rehab.

C. Review of the policy and procedure for Clinical Documentation for Cardiac Rehabilitation with a revised date of November 2009 revealed the following: "The Cardiac Rehabilitation patient medical record shall include...Physician referral...."

Based on medical record review, review of policy and procedures and staff interview, the CAH (Critical Access Hospital) failed to ensure the physicians completed and documented their examinations of the patients immediately before surgery to evaluate the risk of the procedure to be performed for 2 of 6 discharged surgical patient records (Patients 26 and 27) reviewed. This failed practice had the potential to affect all surgical patients of the CAH. Total procedures/surgeries performed from 1/1/14 to 3/24/15 was 126.

Findings are:

A. Review of Patient 26's medical record revealed the patient had an umbilical hernia repair (surgical procedure to repair an umbilical hernia which is a sac/pouch formed from the inner lining of the abdominal cavity that pushes through a hole in the abdominal wall at the belly button) and EGD dilatation (Esophagogastroduodenoscopy - a procedure where a small tube with a camera is passed from the mouth down the esophagus to the stomach. A dilation is when during the procedure [EGD] the physician widens narrowed strictures of the esophagus) on 1/13/14. Patient 26's medical record lacked evidence of a documented patient examination by a physician immediately before surgery to evaluate the risk of the procedure to be performed.

B. Review of Patient 27's medical record revealed the patient had a colonoscopy with polypectomy (colonoscopy is a procedure where a small tube with a camera is inserted through the rectum and into the colon to evaluate the inside of the colon/large intestines. A polypectomy is the removal of polyps from the inside lining of the colon. A polyp is a small clump of cells that forms on the lining of the colon) on 2/10/15. Patient 27's medical record lacked evidence of a documented patient examination by a physician immediately before surgery to evaluate the risk of the procedure to be performed.

C. Review of policy and procedure titled Surgical Protocol last revised 6/2012 revealed "On the day of surgery, the patient must be re-evaluated by the surgeon or attending physician prior [in bold print and underlined] to the surgical procedure if receiving a general anesthetic or IV sedation [Intravenous sedation - a combination of medicines to help the patient relax and to block pain during a medical procedure]. The surgeon and/or attending physician evaluates the risk of anesthesia and the risks involved in the surgical procedure to be performed and documents on pt's [patient's] chart that patient is fit for surgery."

D. Interview with the Director of Nurses on 4/8/15 at 2:15 PM revealed, "I can't say the surgeons saw those patients (Patients 26 and 27) before surgery. The physicians know that they are to see the patients before the surgery. We will have to incorporate a check list to ensure this is being done."

Based on review of the Medical Staff Bylaws, review of physician credential information from an Acute Care Hospital (located in another town/city) and staff interview, the Critical Access Hospital (CAH) failed to have an agreement with this Acute Care Hospital for credentialing and privileging of telemedicine physicians for 2 of 2 sample radiologists reviewed (Radiologists Q and R). A letter from the Acute Care Hospital identified 17 radiologists that could potentially provide services to the CAH. The failure to have an agreement for credentialing and privileging of telemedicine physicians has the potential to affect all patients receiving radiology services at the CAH.

Findings are:

A. Review of the Medical Staff Bylaws approved by the Governing Body on 4/22/09 revealed the following concerning radiologists providing services at the hospital under Article IV, D: "The Consulting Medical Staff shall consist of practitioners who act only as consultants and who come to the Hospital either on schedule or by call or who provide their written opinions in the medical record without coming to the Hospital, for example, radiologist...."

An addendum to the Medical Staff Bylaws Article VI Clinical Privileges dated 7/2/14 revealed the following: "Physicians providing services for interpretation of diagnostic tests (radiology, EKG [electrocardiogram - test that checks for problems with the electrical activity of the heart], echocardiogram [test that uses sound waves to create pictures of the heart], ultrasound [tests that use sound waves to create pictures of structures within the body], venous studies [a procedure used to assess the blood flow in arteries and veins], etc.) will not be required to be on the Medical Staff. Their credentials will be verified with [name of the Acute Care Hospital] or, in the case they are not member of [name of the Acute Care Hospital], the originating site of their practice. Their credential will be verified on a bi-yearly basis at the same time as Medical Staff reappointments."

(Credentials would include a license to practice medicine in the State, Registration with the Drug Enforcement Administration [DEA], malpractice insurance, etc.)

B. Review of the list of credentialed radiologists from the Acute Care Hospital dated 4/3/15 revealed Radiologists Q and R were on the list. The list contained the expiration dates for Radiologists Q's and R's Nebraska License to practice medicine, malpractice insurance and DEA registration.

C. Interview with the Health Information Manager (HIM) on 4/7/15 from 9:15 AM to 9:30 AM confirmed the CAH failed to have an agreement for credentialing and privileging of telemedicine physicians with the Acute Care Hospital for the radiologists even though they were relying on the Acute Care Hospital's credentialing information.

Based on review of Policy and Procedure Committee meeting minutes, review of the Policy and Procedure Process and staff interview, the Critical Access Hospital (CAH) failed to have 1 of 2 required professional members (doctor of medicine or osteopathy) included in the group of professional personnel that reviewed the policies on an annual basis. This failed practice has the potential to affect all patients served by the hospital.

Findings are:

A. Review of the undated Policy and Procedure Process revealed the following: "The Policy and Procedure committee consists of the DON (Director of Nursing), radiology dept (department) manager [name of a nurse practitioner], [name of a physician], [name of a physical therapy assistant who works for a group contracted by the CAH]."

B. Review of the Policy and Procedure Committee Meeting minutes dated 7/29/14 and 12/30/14 revealed the physician was not listed as present at these 2 meetings.

C. Interview with the DON on 4/9/15 at 10:50 AM to 10:55 AM revealed the following:
- Confirmed the policy and procedure committee only met 2 times in 2014; and,
- Confirmed a physician was not in attendance at either one of these meetings.

Based on medical record review, policy and procedure review and staff interview, the Critical Access Hospital (CAH) failed to ensure that 2 of 2 sampled outpatient Cardiac Rehabilitation patients (Medical Records 37 and 38) had a physician signed order and/or referral for Cardiac Rehabilitation. The CAH had 2 Cardiac Rehabilitation outpatients on 4/6/15. From 1/1/14 to 4/6/15 the CAH had 12 Cardiac Rehabilitation outpatients.

Cardiac Rehabilitation helps patients improve their health and live a more active life after major or ongoing heart problems.

Findings are:

A. Review of the Cardiac Rehabilitation (Rehab) medical record for Patient 37 on 4/6/15, revealed a Cardiac Rehab Referral Form with an admit date of 3/10/15 from an Acute Care Hospital in another city. The order was for Cardiac Rehab Consult but lacked the signature of the ordering physician. Interview with Cardiac Rehab Nurse-V on 4/6/15 at 2:50 PM revealed Physician-L (physician on the Medical Staff at the CAH) gave a verbal order for Cardiac Rehab but failed to write this verbal order in the medical record and get it signed by the physician.

B. Review of the Cardiac Rehab medical record for Patient 38 revealed no referral form or physician order for Cardiac Rehab. Interview with Cardiac Rehab Nurse-V on 4/6/15 at 3:10 PM revealed Physician-N (physician on the Medical Staff at the CAH) gave a verbal order for Cardiac Rehab and thought Physician-N wrote an order in the progress note at the clinic attached to the hospital. Review of the progress note provided by Cardiac Rehab Nurse-V revealed Patient 38 was seen by Physician-N on 1/30/15 for a follow up appointment for cardiac surgery. Review of the entire progress note revealed no order/referral for Cardiac Rehab.

C. Review of the policy and procedure for Clinical Documentation for Cardiac Rehabilitation with a revised date of November 2009 revealed the following: "The Cardiac Rehabilitation patient medical record shall include...Physician referral...."

Based on medical record review, review of policy and procedures and staff interview, the CAH (Critical Access Hospital) failed to ensure the physicians completed and documented their examinations of the patients immediately before surgery to evaluate the risk of the procedure to be performed for 2 of 6 discharged surgical patient records (Patients 26 and 27) reviewed. This failed practice had the potential to affect all surgical patients of the CAH. Total procedures/surgeries performed from 1/1/14 to 3/24/15 was 126.

Findings are:

A. Review of Patient 26's medical record revealed the patient had an umbilical hernia repair (surgical procedure to repair an umbilical hernia which is a sac/pouch formed from the inner lining of the abdominal cavity that pushes through a hole in the abdominal wall at the belly button) and EGD dilatation (Esophagogastroduodenoscopy - a procedure where a small tube with a camera is passed from the mouth down the esophagus to the stomach. A dilation is when during the procedure [EGD] the physician widens narrowed strictures of the esophagus) on 1/13/14. Patient 26's medical record lacked evidence of a documented patient examination by a physician immediately before surgery to evaluate the risk of the procedure to be performed.

B. Review of Patient 27's medical record revealed the patient had a colonoscopy with polypectomy (colonoscopy is a procedure where a small tube with a camera is inserted through the rectum and into the colon to evaluate the inside of the colon/large intestines. A polypectomy is the removal of polyps from the inside lining of the colon. A polyp is a small clump of cells that forms on the lining of the colon) on 2/10/15. Patient 27's medical record lacked evidence of a documented patient examination by a physician immediately before surgery to evaluate the risk of the procedure to be performed.

C. Review of policy and procedure titled Surgical Protocol last revised 6/2012 revealed "On the day of surgery, the patient must be re-evaluated by the surgeon or attending physician prior [in bold print and underlined] to the surgical procedure if receiving a general anesthetic or IV sedation [Intravenous sedation - a combination of medicines to help the patient relax and to block pain during a medical procedure]. The surgeon and/or attending physician evaluates the risk of anesthesia and the risks involved in the surgical procedure to be performed and documents on pt's [patient's] chart that patient is fit for surgery."

D. Interview with the Director of Nurses on 4/8/15 at 2:15 PM revealed, "I can't say the surgeons saw those patients (Patients 26 and 27) before surgery. The physicians know that they are to see the patients before the surgery. We will have to incorporate a check list to ensure this is being done."