HospitalInspections.org

Based on review of four active medical staff members credential files and interview with staff the facility failed to ensure that the Governing body and Medical Staff conducted appraisals and reappointments of its members as required by medical staff bylaws.

Findings were:

Based on review of the credentialing files of the four active physicians, there was no current information in 4 of 4 files for recredentialling. The latest complete credentialing process was in 2009 for 3 physicians and 2008 for one physician. Current Medical Staff bylaws require credentialing every two years. Interview with the administrator confirmed these findings on 1/4/12 in the workroom.

Based on a review of 7 patient records in which there were verbal and/or telephone orders, 7 of 7 records contained physician orders which were not timed, dated and/or signed within 48 hours as required.

Findings were:

A review of 7 patient clinical records in which there were verbal and/or telephone orders, 7 of 7 records contained physician orders which had not been timed, dated and/or signed within 48 hours as required. Interview with the nursing director confirmed the above findings 1/4/12 in the work room.

Based on review of the log of fire drills and interview with staff, the hospital failed to ensure that staff were prepared in safety measures in the event of a fire, as only two fire drills had been held in 2011.

Findings were:

Review of the fire drill log revealed only two fire drills held in the calendar year 2011. Interview on 1/4/12 in the work room with the administrator and maintenance director confirmed only two fire drills had been held in 2011.