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Based on review of the medical record, staff interview, review of physician credentialing files, hospital policy and procedure, and review of the medical staff bylaws it was determined the hospital failed to review the credentials of a candidate and grant or deny privileges (A 341). The hospital failed to ensure that the medical staff bylaws contained a procedure for the granting of or denial of privileges (A 363). The cumulative effect of these deficient practices resulted in the hospital's failure to ensure that patients were provided quality medical care, delivered safely by only qualified staff. This placed all patients of Staff D; past, current and future, who required surgical procedures,delivered in the cardiac catheterization lab, at risk for receiving inadequate care provided by a non qualified practitioner.

Based on review of the medical record, staff interview, review of hospital policies and procedures, and review of physician credentialing files it was determined the medical staff failed to examine the credentials of a candidate and grant or deny clinical privileges as appropriate. The hospital also failed to ensure that the practitioner, patient care areas and departments were aware of what clinical privileges had been granted to the practitioner. This involved 1 of 2 physicians whose credentialing files were reviewed. The hospital census was 70.
Findings include:
The medical record for Patient 10 was reviewed on 08/26/11. Patient 10 was admitted on 08/23/11 with a history of a recent heart attack, high blood pressure and high cholesterol. Patient 10 was scheduled on 08/16/11 for the implantation of an AICD (Automated Implantable Cardioverter Defibrillator), this device, implanted in the chest, has the ability to speed up or slow down the heart rate and deliver a life saving electrical shock if a fatal heart rhythm should occur. This procedure was completed by Staff D, a Cardiologist.
The hospital incident report was reviewed on 08/25/11. This report stated, that on the morning of Patient 10's procedure, Staff C was approached by the Medical Director of the Catheterization Lab, (Staff E), who told Staff C that Staff D was not privileged by the hospital to perform AICD implants. Staff C and Staff E then walked to the Medical Staff office and reviewed Staff D's credentialing file and verified the hospital had not granted Staff D the privilege to perform AICD implants.
Staff D's credentialing file was reviewed on 08/25/11. Staff D's credentialing file contained a request for privileges that pertained to the Cardiac Cath Lab. This form had three (3) columns, one (1) to request the procedure and one (1) to grant and one (1) to deny the privilege. The procedure, listed as ICD implantation, was never requested by Staff D. According to the request for privileges form, none of the clinical procedures requested by and performed by Staff D had been marked as granted or denied. Staff D has been performing the clinical procedures since his/her start on 02/07/11.
An interview was conducted with Staff D on 08/25/11 at 3:05 PM, Staff D stated that he/she had believed they had privileges to perform an AICD implantation on Patient 10 and that it had been scheduled 3-4 business days prior to that morning. When questioned in regard to the hospital's appointment process and the granting of privileges, Staff D stated that all that he/she had received was a letter that stated the privileges had been approved as requested but did not identify which clinical privileges were approved.
Staff D's credentialing file did not contain a copy of the letter that he/she said was sent in regard to his/her appointment on the hospital's medical staff. An interview, conducted with Staff B, the Chief Operating Officer of the hospital, revealed there was no system, currently in place, to inform the practitioner specifically of what clinical procedures he/she is privileged to perform at the hospital. At appointment the practitioner receives a letter that states that privileges are approved as requested. Staff B said there is currently no system in place to notify the patient care areas or departments of what clinical procedures a practitioner is privileged to perform in the hospital. There is no system in place to ensure that a practitioner only performs procedures for which he/she has been credentialed/approved by the Medical Staff to perform.
Currently there are no hospital policies in regard to the granting of approval of clinical privileges or for the notification of the practitioner or patient care areas and departments.
This deficiency substantiates Complaint Number OH00062104.

Based on review of the physician credentialing files, staff interview and review of the medical staff bylaws it was determined that the medical staff failed to ensure that the bylaws contained a procedure for the granting or denial of clinical privileges to practitioners. This involved one physician. The hospital census was 70.
Findings include:
Staff D's credentialing file was reviewed on 08/25/11. Staff D's credentialing file contained a request for privileges that pertained to the Cardiac Catheterization Lab. This form had three (3) columns, one (1) to request the procedure and one (1) to grant and one (1) to deny the privilege. The procedure listed as ICD implantation was never requested by Staff D and was not marked as granted or denied for any of the clinical procedures requested that Staff D has been performing since his/her start on 02/07/11.
An interview conducted with Staff D on 08/25/11 at 3:05 PM, Staff D stated that he/she received a letter that stated the privileges had been approved as requested but not what clinical privileges had been approved. Staff D stated that someone should have notified him/her if the form had been modified or what the approved clinical privileges were.
Review of the medical staff bylaws revealed the bylaws did not contain any directions nor procedures to be followed for the granting of nor the denial of clinical privileges. There was no procedure for notification of the practitioners in regard to which clinical privileges are approved or denied nor give direction as to who can grant or deny privileges.
This was confirmed with Staff B on 08/26/11 at 1:00 PM.


This deficiency substantiates Complaint Number OH00062104.