HospitalInspections.org

Based on a review of the Medical Staff reappointment process as compared with the current privileges granted, meeting minutes, and staff interviews, the Governing Body failed to follow the policies in the reappointment process and failed to grant privileges that matched actual medical practices for 3 current Active Medical staff members and 3 Mid-Level Practitioners. (Practitioners A,B,C, D, E, F)

This failed practice had the potential to affect all patients receiving services at the hospital.

The hospital reported census of 3 patients on the first survey day.

Findings include:

1. A review of the files of three (3) current Active Medical Staff (Practitioners A, B, C, D, E, and F) Practitioners revealed that all 6 six received privileges to perform Lumbar Punctures.
(A Lumbar Puncture is a procedure where a needle is inserted into the spinal canal to remove fluid for examination.) The form had a space to indicate the number of procedures performed by the practitioner, however, this was left blank for all six practitioners (A, B, C, D, E, and F).

2. A review of the historical data for the facility from 2015 until the present confirmed lumbar punctures had not been performed during that time frame, in the facility.

3. An interview with the Nursing Surgical Supervisor on 2-7-2018 at 2:00 P.M. confirmed Lumbar Punctures had not been performed in the facility.

4. A review of meeting minutes from the Peer Review/Utilization Review Committee dated 11-6-2017, stated, "Providers felt they would never use a lumbar tray. It was decided to no longer stock this item in the Emergency Department."
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