HospitalInspections.org

Based on record review, review of the governing body and medical staff bylaws, and staff interview, the facility's governing body failed to ensure that 1 (#3) of 2 sampled physicians was preappointed to the Medical Staff, and 2 (#s 4 and 5) of 2 sampled mid-level practitioners were appointed to the Medical Staff. Findings include:

On 8/21/10, the credential files were reviewed. The files did not include documentation that the governing body had re-appointed physician #3 and mid-level practitioners #4 and #5 with the recommendation of the Medical Staff. For physician #3, the most recent Medical Staff re-appointment documentation was dated 6/23/03. During review of the 2 mid-level practitioners' files, the files did not have documentation of appointment approval by the governing body.

The bylaws of the governing body stated the following about Medical Staff appointments: "The Board shall appoint all members to the Medical Staff, after considering the recommendations of the Medical Director, annually."

During an interview with staff #1 and staff #2 on 8/31/10 at 4:00 p.m., they acknowledged there was no documentation available to show the board had re-appointed the physician or appointed the mid-level practitioners.

Based on record review and staff interview, the facility failed to ensure that Patient Transfer Sheets were completed for 5 (#s 9, 11, 18, 21,and 22) of 26 records reviewed. Findings include:

1. The transfer policy was reviewed on 8/31/10. The policy indicated that a transfer sheet was to be completed with each patient transfer. The transfer sheet would provide all necessary patient information and consents.

2. Patient #9 was brought to the hospital emergency department on 8/23/10 at 12:58 a.m. with labor pains. According to the emergency room (ER) patient intake sheet, the patient was transferred to another hospital. There was documentation the receiving hospital had been notified and had accepted the patient. There was no documentation that a patient transfer sheet was completed.

3. Patient #11 was brought to the hospital emergency department on 7/4/10 at 3:15 p.m. for chest pain. According to the ER patient intake sheet, the patient was transferred to another hospital. There was documentation the receiving hospital was notified and accepted the patient. However, the consent for transfer on the transfer sheet was not signed.

4. Patient #18 was brought to the hospital emergency department on 7/6/10 at 8:35 p.m. with a puncture wound to the left foot. According to the ER patient intake sheet, the patient was transferred to another hospital. There was documentation the receiving hospital was notified and the patient was accepted. There was no documentation that a patient transfer sheet was completed.

5. Patient #21 was brought to the hospital emergency department on 5/26/10 at 7:05 p.m. with stomach pain. According to the ER patient intake sheet, the patient was transferred to another hospital. There was documentation the receiving hospital was notified and the patient was accepted. There was no documentation that a patient transfer sheet was completed.

6. Patient #22 was brought to the hospital emergency department on 4/12/10 at 6:30 a.m. with chest pain. According to the ER patient intake sheet, the patient was transferred to another hospital. There was documentation the receiving hospital was notified and the patient was accepted. There was no documentation that a patient transfer sheet was completed.

During an interview with staff #2 on 8/31/10 at 2:30 p.m., she stated transfer sheets were to be completed on all transferred patients. In addition, she acknowledged the 1 transfer sheet did not have the consent signed and the transfer sheets were not completed on the other patients.