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SAINT CAMILLUS MEDICAL CENTER
MEDICAL STAFF - APPOINTMENTS
Tag No.: A0046
Based on interview and record review, the governing body failed to ensure 1 of 3 (Physician #11) credentialed files were in the facility's possession on 01/26/2021. It was not possible to find out if Physician #11's had a current license, appointment, delineation of privileges, and required training.
Findings included:
On the afternoon of 01/26/2021, credentialed files were reviewed. At 3:05 PM, Personnel # 1 was asked where Physician #11's file was. Personnel #1 replied it was out of the facility. The staff in-charged with credentialing duties had possession of the file.
ORGANIZATION OF NURSING SERVICES
Tag No.: A0386
Based on interview and record review, the director of nursing who was responsible for the facility's daily operation failed to ensure the following from 11/17/2020 to 12/02/2020:
1. Two of two glucometers in the preoperative and postoperative areas were able to obtain quality control checks each day prior to surgical procedures, citing 11 of 11 days; and
2. The patient's blood sugar were documented in the medical records, citing 9 of 61 patients, including Patient #9, #10, #11, and #12.
Findings included:
Review of records from 11/17/2020 to 12/02/2020 resulted the following:
1. The glucometer log books in the preoperative and postoperativeareas did not include results of quality control checks.
2. Patient medical records did not include blood sugar results for Patients #9 through #12.
During an interview on 01/26/2021, Personnel #1 confirmed the above findings. Personnel #1 stated the patients blood sugar were obtained and reported to the physician. However the results were not recorded because it would have been inaccurate since the quality control checks were not conducted during this time frame.
Lab Services Policy and Procedure # POCT.0003 "POC Quality Management and Control" origination date: 11/2016 reflected "Responsibilities. It is the responsibility of all staff to complete quality control on all testing performed...Quality Control Failures. In the event of a quality control failure, the testing personnel must take a series of actions designed to: prevent the release of false data derived from the assay...document corrective action directly on the back of the Testing Log Sheet Forms or the action logs provided."