The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
|NORTH METRO MEDICAL CENTER||1400 BRADEN STREET JACKSONVILLE, AR 72076||Nov. 3, 2016|
|VIOLATION: COMPOSITION OF THE MEDICAL STAFF||Tag No: A0342|
|Based on review of the Memorandum of Understanding and interview, it was determined the Facility was operating under an expired telemedicine contract. The failed practice did not ensure the expertise of Neurologists and medications available via telemedicine equipment were readily available to patients who presented to the Facility with stroke-like symptoms. The failed practice had the potential to affect any patient who presented to the Facility with symptoms suggestive of a stroke. Findings follow:
Review of the Memorandum of Understanding received from the Executive Assistant at 1500 on 11/02/16 revealed the following: "NOW, THEREFORE, both parties hereto agree as follows:
1. The term of this Memorandum of Understanding is one year, renewable annually (July 1, 2015 to June 30, 2016). This agreement may be terminated by sixty day (60) written notice...".
The above findings were verified during an interview with the Quality/Risk Director, the Executive Assistant, Surveyor #1 and #2 at 1510 on 11/02/16.
|VIOLATION: MEDICAL STAFF PRIVILEGING||Tag No: A0355|
|Based on review of the Medical Staff Bylaws, provider list, credential file and interview, it was determined the Facility failed to develop and identify the duties, scope and possible privileges of the Medical Staff category for telemedicine for one (#7) of one (#7) physician practicing telemedicine in the Facility. The failed practice did not allow the Facility to ensure the telemedicine practitioner was practicing within the guidelines of the Medical Staff Bylaws, within the confines of his abilities, limitations and education. The failed practice had the potential to affect any patient whose care was received from or consulted on by Physician #7. Findings follow:
A. Review of the Medical Staff Bylaws received from the Executive Assistant at 0915 on 11/01/16 revealed the following under:
...ARTICLE IV. CATEGORIES OF THE MEDICAL STAFF:
The medical staff shall be divided into active, senior, courtesy and honorary categories...
...ARTICLE VI. CLINICAL PRIVILEGES
6.1 EXERCISE OF PRIVILEGES
Every physician or allied health practitioner providing direct clinical services or telemedicine services at this hospital by virtue of medical staff membership or otherwise, shall in connection with such practice and except as provided in Section 6.5 be entitled to exercise only those clinical privileges or provide patient care services as are specifically granted by the governing body...
B. A list of active providers was requested and received from the Executive Assistant at 0915 on 11/01/16. Review of the list revealed Physician #7 was listed as "Courtesy" in the Status column.
AC. During an interview with the Chief of Staff at 1330 on 11/02/16 she was asked if Physician #7 was in the Medical Staff category of courtesy or telemedicine. The Chief of Staff stated Physician #7 was telemedicine.
D. Review of Physician #7's credential file revealed no privileges marked as requested on the untitled form with the initial heading of Special Medical Procedures. The form was signed by Physician #7 on 08/29/16 and by the Chief of Staff on 10/19/16. Review of the form titled Neurology Clinical Privileges Form revealed no privileges marked as requested on page one, and only telemedicine hand-written in on the line next to "other" on page two. Review of the form titled Credentialing Process Form revealed no written indication under the Medical Staff Department, Medical Executive Committee and the Board of Directors Sections if the applicant was recommended to staff with privileges as requested, Deferred appointment or did not recommend the applicant. The findings in #3 were verified by the Chief of Staff during an interview with Surveyor #1 and Surveyor #2 at 1330 on 11/02/16.