HospitalInspections.org

Based on a review of current Medical Staff privileges and Medical Staff By-laws Rules and Regulations, as compared with actual practice, staff interviews and review of the surgical logs, the Governing Body failed to follow the bylaws in the medical staff reappointment process. The Active Medical Staff consisted of 2 full-time Family Practitioners, one Physician Assistant, one part-time General Surgeon. The hospital reported 96 acute patient admissions in 2014. These failures have the potential to affect all patients.

Findings include:

A. A review of the current privileges for the 2 family practitioners revealed both had privileges to perform IV (intravenous sedation).
- The Medical Staff Bylaws page 10 Section 2 Qualifications, b. Competence, states " Each member shall possess and maintain demonstrated clinical competence, knowledge, judgment and technique for all privileges held or applied for."
- On 6/18/15 at 10:30 AM the Administrator confirmed neither physician had performed this procedure within the past 2 years and therefore, the Governing Body lacked confirmed clinical competence of these practitioners to administer type of anesthesia.
- A review of the Surgery log of procedures performed, confirmed IV sedation had not been performed in all of 2013, 2014 and the first 6 months of 2015 (Physicians 2 and 4).

(IV or intravenous sedation is an anesthesia medication which induces a state of unconsciousness. The patient is able to breath independently, without additional support. The patient remains responsive to verbal commands, but typically does not remember or recall the experience and returns to full consciousness quickly.)

B. A review of the surgical privileges for the General Surgeon included colon resection (removal of part of the lower bowel), total mastectomy (removal of the breast), anastamosis(connection of 2 structures).
- A review of the Surgery log revealed the only procedure performed since 2014 was colonoscopy (insertion of a long tube into the large intestine through the rectum to observe for abnormalities).
- An interview with the Administrator on 6/18/15 at 10:30 AM confirmed only colonoscopies had been performed in the hospital within the past 2 years (Physician 1).

C. An interview with the Radiology Supervisor on 6/18/15 at 1:00 PM revealed that the current medical staff routinely read emergency room patients' radiology images, and initiated treatment. They did not request the 'on call' radiologist to interpret the images on an emergent basis and render a diagnosis.
- A review of the privileges for the 2 Family Practitioners and the one Physician Assistant confirmed all 3 lacked privileges to interpret their own radiology images (examples are Practitioners 2, 3 and 4).

Based on review of the written definition of responsibility of the Activity Director and staff interview; the CAH (Critical Access Hospital) failed to have a qualified professional to direct the swing bed activities program. This failed practice had the potential to affect all swing bed patients of the hospital. The hospital had 52 swing bed admissions for the fiscal year 7/1/13 - 6/30/14.

Findings are:

A. Interview with the Activities Director on 6/18/15 at 8:00 AM revealed that [gender] has worked at the hospital for 7 years with the last 2 years being the Social Service Designee and the Activities Director. There was evidence of training provided for the social service designee but evidence was lacking for the activities role. The Activities Director confirmed a training program for activities was not completed.

B. Interview with the Director of Nursing on 6/18/15 at 2:30 PM confirmed they have not completed a training program for activities due to "The old Administrator said [gender] didn't need to since [gender]had [gender] social service designee training."

C. Review of the form titled Activity Service Director (no date) stated under education "Has completed the NHCA [Nebraska Health Care Association] Activity Service Director training or equivalent."