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.
|SAYRE COMMUNITY HOSPITAL||911 HOSPITAL DRIVE SAYRE, OK||Dec. 2, 2014|
|VIOLATION: MEDICAL STAFF BYLAWS||Tag No: A0353|
|Based on review of medical staff bylaws and meeting minutes, the hospital failed to ensure the medical staff followed and enforced its bylaws and rules and regulations approved by the governing body.
On 12/02/14, administrative staff (Staff A, B, E) told the surveyors that the medical staff met as a "whole" .
1. The medical staff bylaws, Article 15.2, which comply with Federal and State regulations, require the medical staff to meet monthly.
The surveyors requested medical staff meeting minutes for 2014. Meeting minutes provided to the surveyors, labeled "Medical Executive Meeting Minutes", did not demonstrate the medical staff met monthly. The meetings provided were for May 13, 2014, September 15, 2014, and November 11, 2014.
2. Article 14 describes medical staff committees, their duties and meetings, including, but not limited to: Medical Committee, Emergency Department Committee, Pharmacy and Therapeutics Committee, and Medical Records Committee. Review of meeting minutes (listed above in Finding #1) did not demonstrate these functions/committee requirements were being fulfilled. The finding was review and verified with administrative staff on the afternoon of 12/02/14.
3. The medical staff bylaws required all physicians and allied health staff to be credentialed, with delineation of clinical privileges, and be appointed. (Categories of membership were provided with details under Article 7) . Two of five physician and allied health credential files reviewed (Staff N and O) did not contain appointment by the governing body or temporary appointment/approval by the Chief Executive Officer and the Chief of Staff. Staff P's credential file did not contain State and Federal narcotic permits.