HospitalInspections.org

Based on record review and interview, the facility failed to ensure the medical staff is organized under written by-laws that are approved by the governing body for one staff A that was practicing as a House Physician.


The findings:

On 03/11/2015 at 4:30 pm during an interview with the Chief Executive Officer (CEO) who is the CEO for both Westchester hospital and Southern Winds, she stated that we are a multi-hospital system. She also stated that we have had a unified medical staff since 7 to 8 years ago. She also stated that we had two house physicians one is on FMLA (family medical leave) and the other works here as an L.P.N. (licensed practical nurse). The CEO confirmed that staff A was on staff and working as an L.P.N. since 2009, and he was also completing H/P (Histories/Physicals) at the facility. She also stated, he was recruited to become a house physician and was doing both. He was working through an arrangement with a [named] medical doctor. She further stated he was working through a contract under the physician who is part of the medical staff. She then stated he was working as a house physician after hours. The CEO then stated, she ended the arrangement sometime in November 2014 because it made me uncomfortable. The CEO could not provide a copy of the contract with the physician, or any billing information, or documentation of when the contract began and ended, or any Memos written to the medical staff.

Review of the personnel record of staff A showed that he was hired as a Licensed Practical Nurse (L.P.N.) since 2010. The application for hire as a L.P.N is dated 12/10/2009. The application also showed that staff A was also a licensed House Physician. The personnel records also have a copy of his house physician license/registration. According to the staffing sheets, staff A was scheduled to work as an L.P.N. on 3/7/2015 on the 3-11 shift, and 3/8/2015 on the 7-3 shift.

During an interview on 03/11/2015 at 2:29 pm, the Director of Human Resource/ Medical Staff & Education reviewed the personnel record and also stated that staff A was hired as a L.P.N on 1/5/2010. She then stated that he also worked as a House Physician per diem (as needed) at this facility, completing H/P (Physical/ History). She also stated that he no longer does it anymore; he hasn't worked as a house physician since 09/22/2014. She also provided a copy of an expired (11/7/2014) house physician licensed/registration.


Review of the copy of the of the facility, "Rules And Regulations For The Medical Staff of [both named] Hospitals", state the duties of the house physician employed by the hospital will be to assist in conducting the professional work of the institution by writing histories, doing and recording physician examinations. The facility could not provide documentation that staff A was ever employed by the hospital as a house physician.

Based on record review and interview, the facility failed to ensure the medical staff visited the patients and written progress notes on a daily basis for 2 Sampled Patients (#1 and #5) of 10 sampled patients.

The findings:

Review of the facility "Rules And Regulations For The Medical Staff of [both named] Hospital" dated 04/18/2014, showed on page 7, in section: Required Physician Visits- A physician is required to visit a patient within 24 hours of their admission to the hospital and daily thereafter.

Review of the facility's " Rules and Regulation for the Medical Staff of [both named] Hospital " , dated 09/30/12, showed that progress notes shall be written daily.

1. Review of sampled patient #1 medical record showed, she was coming from a substance abuse treatment center, and was admitted on 02/24/2015 for aggressive behavior. Further review of the record showed that there are no physician notes for 03/01/2015 and 03/07/2015.


2. Review of sampled patient (SP) #5 medical records showed that the patient was admitted to the facility on 03/05/15. The medical record showed that no physician progress notes were completed on 03/08/15.

During an interview with the compliance officer on 03/11/2015 at 4: 30pm, she stated there are no physician notes for 03/01/2015 and 03/07/2015 and for sampled patient (SP) #5 there are any physician progress notes completed on 03/08/15. She also stated that the physician should see the patient every day and notes should be documented.