HospitalInspections.org

Based on document review and interview, in 2 of 2 credentials files reviewed (Staff A, Midlevel Provider and Staff B, Midlevel Provider) the hospital did not ensure that physicians conducted random periodic reviews of the midlevel providers' (physician assistants and nurse practitioners) medical records (MR). Additionally the hospital did not have a policy and procedure (P&P) for oversight of midlevel providers. This could lead to untoward outcomes for patients.

Finding include:

-- Review of the credentials files for Staff A and Staff B revealed each lacked documentation of random MR reviews and sign off by their collaborating physician or any other physician.

-- Per interview of Staff C, Emergency Department (ED) Medical Director, on 9/17/2025 at 10:00 am, there are no random MR reviews of ED charts completed for the midlevel providers. If there is a concern about a patient's care, they have a verbal discussion and review the MR.

-- Per interview of Staff D, Chief Nursing Officer on 9/17/2025 at 11:00 am, there is no P&P regarding midlevel provider oversight by their collaborating physician.

-- Per interview of Staff E, Chief Medical Officer (CMO) on 9/17/2025 at 11:45 am, all inpatients are seen by a physician during their stay and discussed every morning on rounds with the interdisciplinary team (provider, midlevel provider, pharmacy, social work, etc.). Inpatient MRs are all signed off by a physician after discharge. Staff E was not sure if physicians sign off ED MRs. There is no P&P pertaining to collaborating physician oversight of midlevel providers.

-- Per interview of Staff G, ED Physician on 9/17/2025 at 2:20 pm, during ED meetings they sometimes discuss a case if there was a concern. All of the midlevel providers in the ED are experienced. Staff G has recently been assigned as the collaborating physician for five midlevel providers in the ED. There is not presently a process in place to do random MR reviews of each midlevel to review the quality of care provided. Staff G is working with the CMO to develop a MR review tool for physician use.

-- During interview of Staff E, on 9/17/2025 3:45 pm, they acknowledged the above findings.