HospitalInspections.org

Based on record review and interview, the facility failed to ensure it enforced the bylaws to carry out its responsibilities in regardes to Physician Peer Review, in that, 1 of 10 patients (Patient #7) quality of care grievance was not sent through their peer review process.

Findings Included

There was no peer review process documented or performed for Patient #7's family complaint/grievance submitted 1/04/17.


During an interview on 10/31/17 ending at 11:36 AM, Personnel # 4 was informed the Peer Review policy required Patient #7's record to be peer reviewed due to the quality of care complaint and it was not Peer reviewed. Personnel #4 stated, "I know."

The facility's 6/2017 last reviewed, "Peer Review" policy required, "the evaluation of medical and health care services...patient care provided...quality of care provided by the health care practitioners...Circumstances requiring peer review may include: Readmission to CCU with same or related diagnosis...Delay in treatment...Patient/family complaint of inappropriate medical care...Request to determine the medical reasonableness of a physician's order or plan of care..."