HospitalInspections.org

Based on a review of Medical Staff reappointment documentation and staff interview,( as compared with the Medical Staff By-Laws, Rules and Regulations), the Critical Access Hospital(CAH) failed to follow the Medical Staff By- Laws, Rules and Regulations in the reappointment process for the Active and Courtesy Staff.
This failure on the part of the CAH to obtain sufficient data to evaluate the physicians individual performance and competence, has the potential to affect all patients receiving surgery in this facility.

The Medical Staff consisted of 1 active physicians, 2 mid-level practitioners, 2 consulting surgeons

The facility reported 114 acute inpatient admissions for the most recent annual program evaluation.

Findings Include:

1. The Medical Staff By-Laws, Rules and Regulations specified (page 10) Article V Clinical Privileges Section 2b "Competence"
stated, "Possess and maintain demonstrated clinical competence, including current knowledge, judgment, and technique, in his or her specialty area and for all privileges held or applied for."

Under this same section, m. Observation: "Perform a sufficient number of procedures, manage a sufficient number of cases, and have sufficient patient care contact with the Hospital to permit the ...Medical Staff to assess current competency for all requested privileges..."

2. A review of 1 of 1 current Active Medical Staff member's (A) file had this staff member had privileges to perform Circumcisions. (Circumcision is a procedure during which the foreskin, at the head of the penis is removed. This is most often performed on newborn infant males)


Interview with the Health Information Director on 2/10/16 at 2:30 P.M. revealed that the procedure had not been performed in the hospital since 2014. Furthermore, the hospital did not offer Obstetric services making the procedure unlikely to be performed in the future.
A review of Physician D,( a General Surgeon and Courtesy staff member) revealed this staff member received initial surgical privileges in November of 2014. He was granted privileges to perform Bowel Resection, Colostomy, Splenectomy,Thyroidectomy and Amputations.

(Splenectomy is a surgical procedure to remove the spleen. The spleen is an organ that filters the blood system in the body, removing old or damaged blood cells.)

( A Bowel Resection is a surgical procedure in which a part of the large or small intestine is removed. )

(Thyroidectomy is a surgical procedure to the removal of the Thyroid gland located at the base of the neck. The Thyroid gland is a butterfly shaped organ in the neck, which produces hormones to control all metabolism including heart rate, calcium and phosphorous levels. )

(Colostomy is a surgical procedure in which an opening is formed to connect the large intestine through an incision in the abdominal wall.)


An interview with the Health Information Director on 2/10/16 at 2:30 P.M. confirmed none of the afore mentioned procedures had been performed, in the facility, by this physician, since his initial appointment in 2014. Therefore, his competence to perform these procedures, in this facility, had not been established

Based on medical record review and staff interview; the CAH (Critical Access Hospital) failed to ensure a physician examine the patient immediately before surgery to evaluate the risk of the procedure to be performed for 5 of 6 surgical medical records (15, 16, 18,19 and 20) reviewed. This failed practice had the potential to affect all surgical patients of the hospital. The average number of procedures performed at the hospital on a monthly basis is 18.

Findings are:

A. Review of Patient 15's medical record on 2/10/16 at 9:10 AM revealed the patient had a cholecystectomy (surgical removal of the gallbladder) on 12/22/15. Review of the entire medical record revealed the record lacked evidence of a physician exam immediately before surgery to evaluate the risk of the procedure to be performed.
-Review of Patient 16's medical record on 2/10/16 at 11:15 AM revealed the patient had tympanostomy tubes (tubes help prevent infections in the ear) placed on 11/3/15. Review of the entire medical record revealed the record lacked evidence of a physician exam immediately before surgery to evaluate the risk of the procedure to be performed.
-Review of Patient 17's medical record on 2/10/16 at 11:40 AM revealed the patient had tympanostomy tubes placed on 10/6/15. Review of the entire medical record revealed the record lacked evidence of a physician exam immediately before surgery to evaluate the risk of the procedure to be performed.
-Review of Patient 18's medical record on 2/10/16 at 11:50 AM revealed the patient had a tonsillectomy and adenoidectomy (surgeries that remove the tonsils and adenoids) on 9/1/15. Review of the entire medical record revealed the record lacked evidence of a physician exam immediately before surgery to evaluate the risk of the procedure to be performed.
-Review of Patient 20's medical record on 2/10/16 at 12:05 PM revealed the patient had a colonoscopy (a procedure that enables an examiner to evaluate the inside of the colon or large bowel) on 1/8/16. Review of the entire medical record revealed the record lacked evidence of a physician exam immediately before surgery to evaluate the risk of the procedure to be performed.
B. Interview with the Director of Patient Services on 2/11/16 at 10:50 AM confirmed the above medical records lack the physician documented examinations immediately before surgery that evaluate the risk of the procedure to be performed.