HospitalInspections.org

Based on record review and interview the hospital failed to provide written notice of appointment which included the staff category, the division they will be assigned to, and the specific clinical priviliges being granted to 78 (Staff P to JJJ and LLL to OOOO) of 78 practitioners.

This failed practice has the likelihood to place patients at risk for harm by not communicating to the practitioner the specific privileges they have been granted to perform.


Findings

A policy titled Atoka County Medical Center Medical Staff Bylaws read in part, "The applicant shall receive written notice of appointmennt and special notice of any adverse final decision. A decision and notice of appointment includes the staff category to which the applicant is appointed, the division to which he/she is assigned, the clinical privileges he/she may exercise, and any special conditions attached to the appointment."

Staff P did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 08/01/18 (549 days).

Staff Q did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 02/01/20 (30 days).

Staff R did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 01/01/20 (61 days).

Staff S did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 11/01/19 (122 days)

Staff T did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 06/30/19 (246 days).

Staff U did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 01/01/20 (61 days)

Staff V did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 02/01/20 (20 days)

Staff W did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 06/01/19 (275 days).

Staff X did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 06/01/19 (275 days).

Staff Y did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 06/01/19 (275 days).

Staff Z did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 06/01/19 (275 days).

Staff AA did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 06/01/19 (275 days).

Staff BB did not receive a written notice of appointment that included staff category, assigned divisiuon, and clinic
privileges since 06/01/19 (275 days).

Staff CC did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 06/01/19 (275 days).

Staff DD did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 06/01/19 (275 days).

Staff EE did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 06/01/19 (275 days).

Staff FF did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 06/01/19 (275 days).

Staff GG did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 06/01/19 (275 days).

Staff HH did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 06/01/19 (275 days).

Staff II did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 06/01/19 (275 days).

Staff JJ did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 06/01/19 (275 days).

Staff KK did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 06/01/19 (275 days).

Staff LL did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff MM did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff NN did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff OO did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff PP did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff QQ did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff RR did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff SS did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff TT did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff UU did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff VV did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff WW did not receive a writtn notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff XX did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff YY did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff ZZ did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff AAA did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff BBB did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff CCC did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff DDD did not receive a written notice of appointment that included staff categorty, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff EEE did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff FFF did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff GGG did not receive a written notice of appointment that included staff category, assigned division, and clinic
privileges since 03/07/19 (360 days).

Staff HHH did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff III did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff JJJ did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff LLL did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff MMM did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff NNN did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff OOO did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff PPP did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff QQQ did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff RRR did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff SSS did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff TTT did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff UUU did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff VVV did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff WWW did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff XXX did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff YYY did not receive a written notiuce of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff ZZZ did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff AAAA did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff BBBB did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff CCCC did not receive a written notice of appointment that included staff category, assigned division, and climic privileges since 03/07/19 (360 days).

Staff DDDD did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff EEEE did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff FFFF did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff GGGG did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff HHHH did not receive a written notice of appointment that includfed staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff IIII did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff JJJJ did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff KKKK did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff LLLL did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff MMMM did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges sincer 03/07/19 (360 days).

Staff NNNN did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

Staff OOOO did not receive a written notice of appointment that included staff category, assigned division, and clinic privileges since 03/07/19 (360 days).

On 02/27/20 at 9:10 am, Staff C stated not all credentialed practitioners received a written notice of appointment that included dates of appointment and reappointment, staff category, assigned division, and clinical privileges granted. Staff C stated the failure to provide a written notice of appointment was an oversight.

On 02/27/20 at 12:30 pm, Staff E stated there were no policies and procedures for credentialing and the Atoka County Medical Staff Bylaws were followed.

Based on record review and interview the hospital's governing board failed to provide documentation of an internal review of the contracted doctors of medicine or osteopathy's performance to their distant site hospital for use in periodic appraisals for 56 (Staff LL to JJJ and LLL to OOO) of 56 doctors.

This failed practice has the likelihood to increase the risk to patient safety and the quality of care they receive by not performing an internal review to be used in appraisals of performance.


Findings

A document titled Atoka County Medical Center Medical Staff Bylaws read "With respect to a distant-site physician or practitioner, who holds current privileges at the hospital whose patients are receiving the physician telemedicine/ teleradiology services, the hospital has evidence of an internal review of the originating and distant-site physician's or practitioner's performance of these privileges and sends the distant-site hospital such performance information for use in the periodic appraisal of the distant-site physician or practitioner."


An internal review of the distant site practitioner's performance was not provided to the distant site on 56 of 56 practitioners.

Staff LL had no internal review of their performance sent to the distant-site hospital.

Staff MM had no internal review of their performance sent to the distant-site hospital.

Staff NN had no internal review of their performance sent to the distant-site hospital.

Staff OO had no internal review of their performance sent to the distant-site hospital.

Staff PP had no internal review of their performance sent to the distant-site hospital.

Staff QQ had no internal review of their performance sent to the distant-site hospital.

Staff RR had no internal review of their performance sent to the distant-site hospital.

Staff SS had no internal review of their performance sent to the distant-site hospital.

Staff TT had no internal review of their performance sent to the distant-site hospital.

Staff UU had no internal review of their performance sent to the distant-site hospital.

Staff VV had no internal review of their performance sent to the distant-site hospital.

Staff WW had no internal review of their performance sent to the distant-site hospital.

Staff XX had no internal review of their performance sent to the distant-site hospital.

Staff YY had no internal review of their performance sent to the distant-site hospital

Staff ZZ had no internal review of their performance sent to the distant-site hospital.

Staff AAA had no internal review of their performance sent to the distant-site hospital.

Staff BBB had no internal review of their performance sent to the distant site-hospital.

Staff CCC had no internal review of their performance sent to the distant-site hospital.

Staff DDD had no internal review of their performance sent to the distant-site hospital.

Staff EEE had no internal review of their performance sent to the distant-site hospital.

Staff FFF had no internal review of their performance sent to the distant-site hospital.

Staff GGG had no internal review of their performance sent to the distant-site hospital.

Staff HHH had no internal review of their performance sent to the distant-site hospital.

Staff III had no internal review of their performance sent to the distant-site hospital.

Staff JJJ had no internal review of their performance sent to the distant-site hospital.

Staff LLL had no internal review of their performance sent to the distant-site hospital.

Staff MMM had no internal review of their performance sent to the distant site hospital.

Staff NNN had no internal review of their performance sent to the distant-site hospital.

Staff OOO had no internal review of their performance sent to the distant-site hospital.

Staff PPP had no internal review of their performance sent to the distant-site hospital.

Staff QQQ had no internal review of their performance sent to the distant-site hospital.

Staff RRR had no internal review of their performance sent to the distant-site hospital.

Staff SSS had no internal review of their performance sent to the distant site hospital.

Staff TTT had no internal review of their performance sent to the distant-site hospital.

Staff UUU had no internal review of their performance sent to the distant-site hospital.

Staff VVV had no internal review of their performance sent to the distant-site hospital.

Staff WWW had no internal review of their performance sent to the distant-site hospital.

Staff XXX had no internal review of their performance sent to the distant-site hospital.

Staff YYY had no internal review of their performance sent to the distant-site hospital.

Staff ZZZ had no internal review of their performance sent to the distant-site hospital.

Staff AAAA had no internal review of their performance sent to the distant-site hospital.

Staff BBBB had no internal review of their performance sent to the distant-site hospital.

Staff CCCC had no internal review of their performance sent to the distant-site hospital.

Staff DDDD had no internal review of their performance sent to the distant-site hospital.

Staff EEEE had no internal review of their performance sent to the distant-site hospital.

Staff FFFF had no internal review of their performance sent to the distant-site hospital.

Staff GGGG had no internal review of their performance sent to the distant-site hospital.

Staff HHHH had no internal review of their performance sent to the distant-site hospital.

Staff IIII had no internal review of their performance sent to the distant-site hospital.

Staff JJJJ had no internal review of their performance sent to the distant-site hospital.

Staff KKKK had no internal review of their performance sent to the distant-site hospital.

Staff LLLL had no internal review of their performance sent to the distant-site hospital.

Staff MMMM had no internal review of their performance sent to the distant-site hospital.

Staff NNNN had no internal review of their performance sent to the distant-site hospital.

Staff OOOO had no internal review of their performance sent to the distant-site hospital.


On 02/27/20 at 12:30 pm Staff E stated there was no documentation of an internal review of distant-site practitioners being sent to the distant site.

Based on record review and interview the hospital failed to ensure a doctor of medicine or osteopathy reviewed emergency room records and counter signed them with the date and time on the patients that were cared for by the physician assistant they were supervising on four (Patient #11, 13, 14, and 15) of six patients.

This failed practice has the likelihood to affect the quality of patient care that could influence patient recovery, functional status, and quality of life by a doctor not reviewing the medical decisions of the physician assistant.


Findings

A doctor of medicine or osteopathy failed to review emergency room records and counter sign them with the date and time for patients that were cared for by the physician assistants they supervised on four (Patient #11, 13, 14, and 15) of six patients.

· Patient #11 showed no documentation of emergency room records being reviewed and signed with the date and time by the physician assistant's supervising doctor of medicine or osteopathy.

· Patient #13 showed no documentation of emergency room records being reviewed and signed with the date and time by the physician assistant's supervising doctor of medicine or osteopathy.

· Patient #14 showed no documentation of emergency room records being reviewed and signed with the date and time by the physician assistant's supervising doctor of medicine or osteopathy.

· Patient #15 showed no documentation of emergency room records being reviewed and signed with the date and time by the physician assistant's supervising doctor of medicine or osteopathy.


On 03/02/20, Staff B stated the supervising doctors of medicine or osteopathy had not counter signed, dated, and timed the emergency room records on the patients that had been treated by the physician assistants they supervised.

Based on record review and interview the hospital failed to ensure a doctor of medicine or osteopathy provided overall medical direction for the treatment and transfer of patients receiving services in the emergency room by physician assistants they supervise on three (Patient #11, 14, and 15) of six patients.

This failed practice has the likelihood to cause injury and worsening of health conditions due to the inappropriate treatment and patient transfers to other locations for treatment.


Findings

The hospital failed to notify and involve doctors of medicine or osteopathy about the treatment and transfer of patients from the emergency room to other locations for treatment for three (Patient #11, 14, and 15) of six patients.

Patient #11 was treated and transferred to another location for treatment without a doctor of medicine or osteopathy being notified.

Patient #14 was treated and transferred to another location for treatment withough a doctor of medicine or osteopathy being notified.

Patient #15 was treated and transferred to another location for the treatment without a doctor of medicine or osteopathy beint notified.

On 03/08/20 Staff B stated they could not locate documentation of a doctor of medicine or osteopathy being notified of the patient's treatment and transfer.

Based on record review and interview the hospital failed to ensure the documentation of

1. the completion of the Mandated Uniform Credentialing Application
2. the completion of a curriculum vitae
3. a request for specified privileges
4. peer recommendations
5. a query and evaluation of the National Practitioner Data Bank (NPDB) information
6. current liability insurance
7. a query and evaluation of the Office of Inspector General (OIG) SanctionLlist
8. a current Drug Enforcement Agency (DEA) license
9. a current Oklahoma Bureau of Narcotis and Dangerous Drugs (OBNDD) / Oklahomsa State Burea of Narcotics and Dangerous Drugs (OSBNDD) license.

This failed practice has the likelihood to place patients at risk for harm, including abuse and poor quality of care, by not gathering and reviewing information regarding the past behavior of the practitioners granted privileges at the hospital.

Findings

A policy titled Atoka County Medical Center Medical Staff Bylaws read in part, " It is the policy of ACMC to process applications for appointment to the medical staff only for individuals who meet the following criteria: Completion of the Mandated Uniform Credentialing Application with curriculum vitae and specified privileges; Verification of current licensure status in current or past states; Peer and/or faculty recommendation and practitioner's performance upon renewal of privileges; Office of Inspector General (OIG), Drug Enforcement Agency (DEA), Oklahoma State Bureau of Narcotics and Dangerous Drugs (OSBNDD); and the Query and evaluation of the National Practitioner Data Bank (NPDB).


1. The hospital failed to ensure the documentation of the completion of the Mandated Uniform Credentialing Application for 15 (Staff W, X, Y, Z, AA, BB, CC, DD, EE, FF, GG, HH, II, JJ, and KK ) of 15 practitioners.

· Staff W had no documentation of a completed Mandated Uniform Credentialing Application
· Staff X had no documentation of a completed Mandated Uniform Credentialing Applications
· Staff Y had no documentation of a completed Mandated Uniform Credentialing Application
· Staff Z had no documentation of a completed Mandated Uniform Credentialing Application
· Staff AA had no documentation of a completed Mandated Uniform Credentialing Application
· Staff BB had no documentation of a completed Mandated Uniform Credentialing Application
· Staff CC had no documentation of a completed Mandated Uniform Credentialing Application
· Staff DD had no documentation of a completed Mandated Uniform Credentialing Application
· Staff EE had no documentation of a completed Mandated Uniform Credentialing Application
· Staff FF had no documentation of a completed Mandated Uniform Credentialing Application
· Staff GG had no documentation of a completed Mandated Uniform Credentialing Application
· Staff HH had no documentation of a completed Mandated Uniform Credentialing Application
· Staff II had no documentation of a completed Mandated Uniform Credentialing Application
· Staff JJ had no documentation of a completed Mandated Uniform, Credentialing Application
· Staff KK had no documentation of a completed Mandated Uniform Credentialing Application

On 02/27/20 at 9:10 am, Staff C stated there was no documentation of a completed Mandated Uniform Credentialing Application for Staff W, X, Y, Z, AA, BB, CC, DD, EE, FF, GG, HH, II, JJ, and KK.

On 02/27/20 at 2:20 pm, Staff E stated the distant-site facillity and this hospital had not credentialed the telemedicine practitioners.


2. The hospital failed to ensure the documentation of the completion of a curriculum vitae for 15 (Staff W, X, Y, Z,
AA, BB, CC, DD, EE, FF, GG, HH, II, JJ, and KK ) for 15 practitioners.

· Staff W had no documentation of a curriculum vitae.
· Staff X had no documentation of a curriculum vitae.
· Staff Y had no documentation of a curriculum vitae.
· Staff Z had no documentation of a curriculum vitae.
· Staff AA had no documentation of a curriculum vitae.
· Staff BB had no documentation of a curriculum vitae.
· Staff CC had no documentation of a curriculum vitae.
· Staff DD had no documentation of a curriculum vitae.
· Staff EE had no documentation of a curriculum vitae.
· Staff FF had no documentation of a curriculum vitae.
· Staff GG had no documentation of a curriculum vitae.
· Staff HH had no documentation of a curriculum vitae.
· Staff II had no documentation of a curriculum vitae.
· Staff JJ had no documentation of a curriculum vitae.
· Staff KK had no documentation of a curriculum vitae.

On 02/27/20 at 9:10 am, Staff C stated there was no documentation of a curriculum vitae for Staff W, X, Y, Z, AA, BB, CC, DD, EE, FF, GG, HH, II, JJ, and KK.

On 02/27/20 at 2:20 pm, Staff E stated the distant-site hospital and this hospital had not credentialed the telemedicine practitioners.


3. The hospital failed to ensure the documentation of specified privileges requested for 15 (Staff W, X, Y, Z, AA,
BB, CC, DD, EE, FF, GG, HH, II, JJ, and KK ) of 15 practitioners.

· Staff W had no documentation of a request of specified privileges
· Staff X had no documentation of a request of specified privileges
· Staff Y had no documentation of a request of specified privileges
· Staff Z had no documentation of a a request of specified privileges
· Staff AA had no documentation of a a request of specified privileges
· Staff BB had no documentation of a a request of specified privileges
· Staff CC had no documentation of a a request of specified privileges
· Staff DD had no documentation of a request of specified privileges
· Staff EE had no documentation of a request of specified privileges
· Staff FF had no documentation of a request of specified privileges
· Staff GG had no documentation of a request of specified privileges
· Staff HH had no documentation of a request of specified privileges
· Staff II had no documentation of a request of specified privileges
· Staff JJ had no documentation of a request of specified privileges
· Staff KK had no documentation of a request of specified privileges

On 02/27/20 at 9:10 am, Staff C stated there was no documentation of a request of specified privileges for Staff W, X, Y, Z, AA, BB, CC, DD, EE, FF, GG, HH, II, JJ, and KK.

On 02/27/20 at 2:20 pm, Staff E stated the distant-site facillity and this hospital had not credentialed the telemedicine practitioners.


4. The hospital failed to ensure the documentation of peer recommendations for 15 (Staff W, X, Y, Z, AA, BB,
CC, DD, EE, FF, GG, HH, II, JJ, and KK ) of 15 practitioners.

· Staff W had no documentation of peer recommendatiuons
· Staff X had no documentation of peer recommendations
· Staff Y had no documentation of peer recommendations
· Staff Z had no documentation of peer recommendations
· Staff AA had no documentation of peer recommendations
· Staff BB had no documentation of peer recommendations
· Staff CC had no documentation of peer recommendations
· Staff DD had no documentation of peer recommendatiuns
· Staff EE had no documentation of peer recommendations
· Staff FF had no documentation of peer recommendations
· Staff GG had no documentation of peer recommendations
· Staff HH had no documentation of peer recommendations
· Staff II had no documentation of peer recommendations
· Staff JJ had no documentation of peer recommendations
· Staff KK had no documentation of peer recommendations

On 02/27/20 at 9:10 am, Staff C stated there was no documentation of peer recommendations for Staff W, X, Y, Z, AA, BB, CC, DD, EE, FF, GG, HH, II, JJ, and KK.

On 02/27/20 at 2:20 pm, Staff E stated the distant-site facillity and this hospital had not credentialed the telemedicine practitioners.


5. The hospital failed to ensure the documentation of the query and evaluation of the National Practitioner Data Bank
(NPDB) information for 15 (Staff W, X, Y, Z, AA, BB, CC, DD, EE, FF, GG, HH, II, JJ, and KK ) of 15
practitioners.

· Staff W had no documentation of the query and evaluation of the National Practitioner Data Bank (NPDB) information
· Staff X had no documentation of the query and evaluation of the National Practitioner Data Bank (NPDB) information
· Staff Y had no documentation of the query and evaluation of the National Practitioner Data Bank (NPDB) information
· Staff Z had no documentation of the query and evaluation of the National Practitioner Data Bank (NPDB) information
· Staff AA had no documentation of the query and evaluation of the National Practitioner Data Bank (NPDB) information
· Staff BB had no documentation of the query and evaluation of the National Practitioner Data Bank (NPDB) information
· Staff CC had no documentation of the query and evaluation of the National Practitioner Data Bank (NPDB) information
· Staff DD had no documentation of the query and evaluation of the National Practitioner Data Bank (NPDB) information
· Staff EE had no documentation of the query and evaluation of the National Practitioner Data Bank (NPDB) information
· Staff FF had no documentation of the query and evaluation of the National Practitioner Data Bank (NPDB) information
· Staff GG had no documentation of the query and evaluation of the National Practitioner Data Bank (NPDB) information
· Staff HH had no documentation of the query and evaluation of the National Practitioner Data Bank (NPDB) information
· Staff II had no documentation of the query and evaluation of the National Practitioner Data Bank (NPDB) information
· Staff JJ had no documentation of the query and evaluation of the National Practitioner Data Bank (NPDB) information
· Staff KK had no documentation of the query and evaluation of the National Practitioner Data Bank (NPDB) information

On 02/27/20 at 9:10 am, Staff C stated there was no documentation of the query and evaluation of the National Practitioner Data Bank (NPDB) information for Staff W, X, Y, Z, AA, BB, CC, DD, EE, FF, GG, HH, II, JJ, and KK.

On 02/27/20 at 2:20 pm, Staff E stated the distant-site facillity and this hospital had not credentialed the telemedicine practitioners.


6. The hospital failed to ensure the documentation of current liability insurance for 15 (Staff W, X, Y, Z, AA, BB,
CC, DD, EE, FF, GG, HH, II, JJ, and KK ) of 15 practitioners.

· Staff W had no documentation of current liability insurance
· Staff X had no documentation of current liability insurance
· Staff Y had no documentation of current liability insurance
· Staff Z had no documentation of current liability insurance
· Staff AA had no documentation of current liability insurance
· Staff BB had no documentation of current liability insurance
· Staff CC had no documentation of current liability insurance
· Staff DD had no documentation of currrent liability insurance
· Staff EE had no documentation of current liability insurance
· Staff FF had no documentation of current liability insurance
· Staff GG had no documentation of current liability insurance
· Staff HH had no documentation of current liability insurance
· Staff II had no documentation of current liability insurance
· Staff JJ had no documentation of current liability insurance
· Staff KK had no documentation of current liability insurance

On 02/27/20 at 9:10 am, Staff C stated there was no documentation of current liability insurance for Staff W, X, Y, Z, AA, BB, CC, DD, EE, FF, GG, HH, II, JJ, and KK.

On 02/27/20 at 2:20 pm, Staff E stated the distant-site facillity and this hospital had not credentialed the telemedicine practitioners.


7. The facility failed to ensure the documentation of a query and evaluation of the Office of Inspector General (OIG)
Sanction List for 15 (Staff W, X, Y, Z, AA, BB, CC, DD, EE, FF, GG, HH, II, JJ, and KK ) of 15 practitioners.

· Staff W had no documentation of a query and evaluation of the Office of Inspector General (OIG) Sanction List
· Staff X had no documentation of a query and evaluation of the Office of Inspector General (OIG) Sanction List
· Staff Y had no documentation of a query and evaluation of the Office of Inspector General (OIG) Sanction List
· Staff Z had no documentation of a query and evaluation of the Office of Inspector General (OIG) Sanction List
· Staff AA had no documentation of a query and evaluation of the Office of Inspector General (OIG) Sanction List
· Staff BB had no documentation of a query and evaluation of the Office of Inspector General (OIG) Sanction List
· Staff CC had no documentation of a query and evaluation of the Office of Inspector General (OIG) Sanctiobn List
· Staff DD had no documentation of a query and evaluation of the Office of Inspector General (OIG) Sanction List
· Staff EE had no documentation of a query and evaluation of the Office of Inspector General (OIG) Sanction List
· Staff FF had no documentation of a query and evaluation of the Office of Inspector General (OIG) Sanction List
· Staff GG had no documentation of a query and evaluation of the Office of Inspector General (OIG) Sanction List
· Staff HH had no documentation of a query and evaluation of the Office of Inspector General (OIG) Sanction List
· Staff II had no documentation of a query and evaluation of the Office of Inspector General (OIG) Sanction List
· Staff JJ had no documentation of a query and evaluation of the Office of Inspector General (OIG) Sanction List
· Staff KK had no documentation of a query and evaluation of the Office of Inspector General (OIG) Sanction List

On 02/27/20 at 9:10 am, Staff C stated there was no documentation of a query and evaluation of the Office of Inspector General (OIG) Sanction List for Staff W, X, Y, Z, AA, BB, CC, DD, EE, FF, GG, HH, II, JJ, and KK.

On 02/27/20 at 2:20 pm, Staff E stated the distant-site facillity and this hospital had not credentialed the telemedicine practitioners.


8. The facility failed to ensure the documentation of a current Drug Enforcement Agency (DEA) license for 15 (Staff
W, X, Y, Z, AA, BB, CC, DD, EE, FF, GG, HH, II, JJ, and KK ) of 15 practitioners.

· Staff W had no documentation of a current Drug Enforcement Agency (DEA) license
· Staff X had no documentation of a current Drug Enforcement Agency (DEA) license
· Staff Y had no documentation of a current Drug Enforcement Agency (DEA) license
· Staff Z had no documentation of a current Drug Enforcement Agency (DEA) license
· Staff AA had no documentation of a current Drug Enforcement Agency (DEA) license
· Staff BB had no documentation of a current Drug Enforcement Agency (DEA) license
· Staff CC had no documentation of a current Drug Enforcement Agency (DEA) license
· Staff DD had no documentation of a current Drug Enforcement Agency (DEA) license
· Staff EE had no documentation of a current Drug Enforcement Agency (DEA) license
· Staff FF had no documentation of a current Drug Enforcement Agency (DEA) license
· Staff GG had no documentation of a current Drug Enforcement Agency (DEA) license
· Staff HH had no documentation of a current Drug Enforcement Agency (DEA) license
· Staff II had no documentation of a current Drug Enforcement Agency (DEA) license
· Staff JJ had no documentation of a current Drug Enforcement Agency (DEA) license
· Staff KK had no documentation of a current Drug Enforcement Agency (DEA) license

On 02/27/20 at 9:10 am, Staff C stated there was no documentation of a current Drug Enforcement Agency (DEA) license for Staff W, X, Y, Z, AA, BB, CC, DD, EE, FF, GG, HH, II, JJ, and KK.

On 02/27/20 at 2:20 pm, Staff E stated the distant-site facillity and this hospital had not credentialed the telemedicine practitioners.


9. The facility failed to ensure the documentation of a current Oklahoma Bureau of Narcotics and Dangerous Drugs
(OBNDD) license for 15 (Staff W, X, Y, Z, AA, BB, CC, DD, EE, FF, GG, HH, II, JJ, and KK ) of 15
practitioners.

· Staff W had no documentation of a current Oklahoma Bureau of Narcotics and Dangerous Drugs (OBNDD) license
· Staff X had no documentation of a current Oklahoma Bureau of Narcotics and Dangerous Drugs (OBNDD) license
· Staff Y had no documentation of a current Oklahoma Bureau of Narcotics and Dangerous Drugs (OBNDD) license
· Staff Z had no documentation of a current Oklahoma Bureau of Narcotics and Dangerous Drugs (OBNDD) license
· Staff AA had no documentation of a current Oklahoma Bureau of Narcotics and Dangerous Drugs (OBNDD) license
· Staff BB had no documentation of a current Oklahoma Bureau of Narcotics and Dangerous Drugs (OBNDD) license
· Staff CC had no documentation of a current Oklahoma Bureau of Narcotics and Dangerous Drugs (OBNDD) license
· Staff DD had no documentation of a current Oklahoma Bureau of Narcotics and Dangerous Drugs (OBNDD) license
· Staff EE had no documentation of a current Oklahoma Bureau of Narcotics and Dangerous Drugs (OBNDD) license
· Staff FF had no documentation of a current Oklahoma Bureau of Narcotics and Dangerous Drugs (OBNDD) license
· Staff GG had no documentation of a current Oklahoma Bureau of Narcotics and Dangerous Drugs (OBNDD) license
· Staff HH had no documentation of a current Oklahoma Bureau of Narcotics and Dangerous Drugs (OBNDD) license
· Staff II had no documentation of a current Oklahoma Bureau of Narcotics and Dangerous Drugs (OBNDD) license
· Staff JJ had no documentation of a current Oklahoma Bureau of Narcotics and Dangerous Drugs (OBNDD) license
· Staff KK had no documentation of a current Oklahoma Bureau of Narcotics and Dangerous Drugs (OBNDD) license

On 02/27/20 at 9:10 am, Staff C stated there was no documentation of a current Oklahoma Bureau of Narcotics and Dangerous Drugs (OBNDD) license for Staff W, X, Y, Z, AA, BB, CC, DD, EE, FF, GG, HH, II, JJ, and KK.

On 02/27/20 at 2:20 pm, Staff E stated the distant-site facility and this hospital had not credentialed the telemedicine practitioners.

Based on record review and interview the hospital failed to ensure a completed history and physical examination (H&P) recorded in the patient's health record within 48 hours of admission for three (Patient #3, 7, and 9) of ten patients.

This failed practice had the potential for patients to have a delayed recognition of medical conditions that could influence recovery, functional status, and quality of life.

Findings:

Document titled "Rules and Regulations of the Medical Staff" states in part, a complete H&P shall be recorded in the patient's chart within 48 hours of admission.

Patient #3
On 02/27/20 at 1:00 PM, a review of patient record showed an admission date of 09/03/19 and an H&P signed and dated on 09/23/19.

Patient #7
On 02/27/20 at 1:05 PM, a review of patient record showed an admission date of 02/22/20 and an H&P with no signature.

Patient #9
On 02/27/20 at 1:15 PM, a review of patient record showed an admission date of 02/24/20 and an H&P with no signature.

On 02/27/20 at 1:20 PM. Staff A stated "H&Ps not being signed and dated per policy had been an opngoing issue and had been reported to Med Exec Committee, and Governing Body.