HospitalInspections.org

Based on a review of Medical Staff reappointment documentation and staff interview, as compared with the Medical Staff By-Laws, Rules and Regulations, the Critical Access Hospital (CAH) failed to follow the Medical Staff By- Laws, Rules and Regulations in the reappointment process and failed to establish performance criteria for the Active and Courtesy Staff. In addition, application forms for three clinicians were incomplete and all six(6) received privileges for procedures not performed in the CAH.

The Medical Staff consisted of 5 active physicians, 3 mid-level practitioners, 1 consulting surgeon.

This pattern of practice puts all patients at risk. The CAH reported 262 acute inpatient admissions during the most recent fiscal year

Findings Include:

1. The Medical Staff By-Laws, Rules and Regulations on page 10, Section 5.
Competence. states, "Each member shall:
Possess and maintain demonstrated clinical competence, including current knowledge, judgement, and technique, in his or her specialty area and for all privileges held or applied for demonstrate that he or she will have sufficient patient care contact at the Hospital to permit the Medical Staff to continually assess competency of all requested privileges. Active Staff attends at least twenty four(24) inpatients and seventy-two (72) outpatients at the Hospital each year; '

Article XIII Meetings:
Minimum attendance. ' Members of the Active Staff and Executive Committee must attend at least two-thirds(2/3) of all meetings.'

2. A review of 5 current Active Medical Staff and 1 Courtesy staff member's credential and reappointment files revealed all 6 lacked evidence of quality assurance activities, medical staff meeting attendance , the number of inpatients or out patients served or treatment outcomes, to determine the practitioners clinical competence and judgement . (Examples: Physicians A ,B,C,D,E,G)

3. An interview with the Health Information Director on 3/24/16 at 9:30 AM confirmed the Medical Staff were reappointed without benefit of performance criteria, number of patients served, or medical staff meeting attendance, as specified in the By-Laws.

4. Physicians B and D failed to complete the ' privileges requested' section of the form and signed the blank form. Physician C(a general surgeon) drew a line through the entire privilege list,under the heading 'requested' rather than selecting specific procedures, reflecting actual practice in this CAH. The section designated 'recommended'(by the medical staff) was blank. The file lacked any evidence of the number or type of procedures performed by this physician, or the treatment outcomes.

5. Physicians A E, and G requested and received privileges to perform circumcisions, a procedure which the facility did not perform routinely, as they did not offer obstetric services. These files lacked any evidence of the number of procedures performed, or treatment outcomes.
(Circumcision is the removal of the foreskin of the head of the penis, routinely performed on male newborn infants)
6. An interview with the Director of Nursing on 3/24/2016 at 11:00AM confirmed circumcisions were not routinely performed in the CAH and had not been performed in' at least 5 years, or longer.'

Based on direct observation, staff interview and a review of the current policies and procedures for the care and maintenance of the paraffin bath and a lack of documented evidence, the Rehabilitation Therapy Services staff failed to check the temperature of the bath prior to patient use. In addition, the bath was stored in an unsafe, unsupervised location.

This failure threatened the safety of all patients receiving paraffin bath treatments.

The hospital reported 262 acute inpatients for the most recent fiscal year.

Findings include:

1. On 3/25/2016 at 9:00 AM a tour of the Physical Therapy department was conducted with the Director of Physical Therapy. A store room(approximately 6' x 6') located in the back of the department, with the door closed, contained 4 wheel chairs, 1 office chair and several walkers, also contained a paraffin bath, which was plugged into a wall outlet. The crowded nature of the room made it difficult to reach the bath and the location of the store room, was in an out of the way location. This location presented a significant risk of fire.

2. An interview conducted with the Director of the department revealed the staff did not routinely check the temperature of the bath, prior to placing patients limbs into the hot wax.
(Paraffin baths are routinely used to treat patient for decreased range of motion in small joints. Paraffin is a petroleum by-product and is flammable treatment temperatures range from 126-130 degrees Fahrenheit(F). The paraffin, itself, can achieve temperatures of 180 F or more without significant, observable change, therefore presented a significant risk of burns to the skin. )

3. A review of the policy and procedure dated 10/2014 for use of the paraffin bath specified ,"Check the paraffin temperature.(This was noted 5 times throughout the the document) Do not apply paraffin if the temperature is above 130 degrees F"..."If the unit is used daily, the temperature should be checked first thing each morning and prior to each use."

Based on medical record review, review of policy and procedure and staff interview; the CAH (Critical Access Hospital) failed to ensure that a physician examined the patient immediately before surgery to evaluate the risk of the planned procedure for 3 of 6 outpatient surgical medical records (Patients 21, 23 and 25) reviewed. This failed practice had the potential to affect all surgical patients of the CAH. The average number of procedures performed at the CAH on a monthly basis is 15.

Findings are:

A. Review of Patient's 21 medical record on 3/23/16 at 10:20 AM revealed the patient had a laprascopic cholecystectomy (surgery to remove gallbladder) on 3/21/16. Review of the Surgical Care Record revealed the patient arrived to the OR (operating room) at 1304 (1:04 PM), start time of procedure 1328 (1:28 PM), stop time of procedure 1406 (2:06 PM) . Review of the Surgical Risk Assessment revealed evidence the physician examined the patient for the risk of the procedure to be performed on 3/21/16 at 1400 (2:00 PM).
-Review of Patient's 23 medical record on 3/23/16 at 11:05 AM revealed the patient had laprascopic appendectomy (surgery to remove the appendix) on 2/22/16. Review of the entire medical record lacked evidence of an examination of the patient by a physician immediately before surgery to evaluate the risk of the procedure to be performed.
- Review of Patient's 25 medical record on 3/23/16 at 11:20 AM revealed the patient had a laprascopic cholecystectomy on 12/28/15. Review of the Surgical Care Record revealed the patient arrived to the OR at 1414 (1:14 PM), start time of procedure 1436 (2:36 PM), stop time of procedure 1503 (3:03 PM). Review of the Surgical Risk Assessment revealed evidence the physician examined the patient for the risk of the procedure to be performed on 12/28/15 at 1500 (3:00 PM).
B. Review of policy and procedure titled Peri-operative Forms (Revised 3/1/16) revealed the following:
1. Surgeon will assess and evaluate patient prior to transferring to operating suite.
2. Surgeon will complete Surgical Risk Assessment Form.
C. Interview with the Nurse Manager on 3/24/16 at 10:15 AM confirmed the lack of documented patient examinations immediately before surgery to evaluate the risk of the procedure to be performed on the above patient medical records.