HospitalInspections.org

Based on record review and interview, the facility failed to implement a comprehensive process to ensure contracted medical staff who provide on-call surgical coverage are appropriately privileged and credentialed to provide care in 6 of 14 privileging files reviewed (Surgeons B, F, L, P, Q, R, S).

The facility failed to implement a comprehensive process to ensure contracted medical staff who provide on-call surgical coverage are appropriately privileged and credentialed to provide care. See Tag A-0341.

Immediate Jeopardy was determined on 02/05/2025 at 2:18 PM under 42 CFR 482.22 regarding the facility's failure to ensure contracted medical staff who provide on-call surgical coverage were privileged and credentialed. Facility staff were notified of the Immediate Jeopardy on 02/05/2025 at 2:35 PM. The Immediate Jeopardy began on 05/09/2022 and was removed on 02/05/2025 at 3:10 PM after the facility developed a process and educated identified individuals (Executive Director H and ACMO K) responsible for reviewing on-call schedules to confirm medical staff hold current privileges on a daily basis. All medical staff held privileges at the time of the survey. The deficient practice remains at a Condition level pending evidence of ongoing sustainable and systemic implementation of corrective actions.

Based on record review and interview, the facility failed to implement a comprehensive process to ensure contracted medical staff who provide on-call pediatric surgical coverage are appropriately privileged and credentialed to provide pediatric care in 6 of 14 privileging files reviewed (Surgeons B, E, F, L, P, Q,).

Findings Include:

A review of "Master Agreement between Theda Care, Inc. and Children's Hospital of Wisconsin Inc. for Pediatric and Neonatal Program Services" revealed, " ... 3.3-1 ... Children's Convenance: (B). Any such physician practicing within the premises shall be a member in good standing of the medical staff of Children's Hospital of Wisconsin- Fox Valley with appropriate privileges ..."

Surgeon F started providing on-call pediatric surgical coverage on 10/09/2024. Review of Surgeon F's privileging file revealed he was granted privileges on 01/09/2025, nearly 3 months later. Review of the facility's on-call general surgery schedule revealed Surgeon F was the only surgeon on-call for 18 instances during the time period he was not privileged. There was no evidence that Surgeon F performed surgery during this time.

Surgeon Q's on-staff date was 01/03/2024. Review of Surgeon Q's privileging file revealed he was granted privileges on 02/22/2024 nearly 1.5 months later. Review of the facility's on-call general surgery schedule revealed Surgeon Q was the only surgeon on-call for 5 instances during the time period he was not privileged. There was no evidence that Surgeon Q performed surgery during this time.

Surgeon P's on-staff date was 10/11/2023. Review of Surgeon P's privileging file revealed he was granted privileges on 12/07/2023 nearly 2 months later. Review of the facility's on-call general surgery schedule revealed Surgeon P was the only surgeon on-call for 2 instances during the time period he was not privileged. There was no evidence that Surgeon P performed surgery during this time.

Surgeon L's on-staff date was 11/07/2022. Review of Surgeon L's privileging file revealed he was granted privileges on 03/01/2023, nearly 4 months later. Review of the facility's on-call general surgery schedule revealed Surgeon L was the only surgeon on-call for 4 instances during the time period he was not privileged. There was no evidence that Surgeon L performed surgery during this time.

Surgeon B's on-staff date was 05/09/2022. Review of Surgeon B's privileging file revealed he was not granted permanent pediatric privileges until 10/30/2023. Review of the facility's on-call general surgery schedule revealed Surgeon B was the only surgeon on-call for 13 instances during the time period he was not privileged.

Surgeon E's on-staff date was 04/20/2020. Review of Surgeon E's privileging file revealed he was granted privileges on 06/29/2023, nearly 38 months later. Review of the facility's on-call general surgery schedule revealed Surgeon E was the only surgeon on-call for 6 instances during the time period he was not privileged. There was no evidence that Surgeon E performed surgery during this time.

During an interview on 02/04/2025 at 1:27 PM with CMO (Chief Medical Officer) M, CMO M stated, "We know this is an issue ... There is supposed to be an alert that goes off if there is a chart from Hospital A opened by a non-privileged provider. It did not alert in this case. The process fell through."

During an interview on 02/04/2025 at 3:55 PM with Executive Director H, Executive Director H stated that pediatric privileging would be part of Hospital A's privileging process.