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.

FULTON MEDICAL CENTER LLC 10 SOUTH HOSPITAL DRIVE FULTON, MO 65251 Jan. 30, 2019
VIOLATION: CHIEF EXECUTIVE OFFICER Tag No: A0057
Based on interview and record review, the facility failed to ensure that the Governing Body appointed the Chief Executive Officer (CEO). This failure had the potential to affect the quality of care and safety of all patients. The facility census was 16.

Findings included:

1. Even though requested, the facility failed to provide a list of Governing Body policies and procedures and a current list of members of the Governing Body.

Review of the facility's 2018 Board Meeting Minutes showed no appointment of Staff C as CEO.

During an interview on 01/29/19 at 2:30 PM, Staff C, CEO, stated that he started working at the facility as the CEO in June of 2018. He was not officially appointed by the Governing Body as the CEO.

During a telephone interview on 01/31/19 at 10:30 AM, Staff Z, Governing Body Board Member, stated that the current CEO was hired by the facility's management company. The Governing Body was not consulted before Staff C was hired and the Governing Body did not appoint Staff C as CEO.
VIOLATION: MEDICAL STAFF - APPOINTMENTS Tag No: A0046
Based on interview and record review, the facility failed to follow Medical Staff Bylaws that give only the Governing Body the authority to grant medical staff privileges. This deficient practice had the potential for all patients admitted to the facility to receive substandard care. The facility census was 16.

Findings included:

1. Review of the facility's document titled, "Medical Staff By-Laws," dated 01/01/17, showed the following:
- The Board of Managers was also known as the Governing Body and/or Board of Directors of the Hospital.
- The purpose of the By-Laws was to establish accountability of the Medical Staff to the Board of Managers for appropriateness of professional performance and ethical conduct of its members, and to monitor the quality of medical care provided by all Practitioners authorized to practice in the Hospital, through the appropriate delineation of Clinical Privileges and an ongoing review and evaluation of each Practitioner's performance in the Hospital.
- Appointment to and membership on the Medical Staff shall confer on the appointee or member only such Clinical Privileges as have been granted by the Board of Managers in accordance with these By-Laws, the Medical Staff Rules and Regulations, and other Policies and Procedures.

Review of the facility's Board Meeting minutes on 12/06/17, 01/15/18 and 04/17/18 showed no list of physicians that the Board had approved for credentialing, appointment or reappointment.

During an interview on 01/30/19 at 9:00 AM, Staff L, Physician and Chief of Staff, stated that the Governing Body was not involved in the process of appointing Medical Staff.

During an interview on 01/29/19 at 2:20 PM, Staff C, Chief Executive Officer (CEO), stated that he did not know if the Board of Directors was involved in Medical Staff appointments or credentialing. They have hired physicians in the Emergency Department through the Medical Executive Committee.

During a telephone interview on 01/31/19 at 10:30 AM, Staff Z, Governing Body Board Member, stated that he was not involved in Medical Staff appointments. Medical Staff appointments were approved through the Medical Executive Committee.
VIOLATION: CONSULTATION WITH MEDICAL STAFF Tag No: A0053
Based on interview and record review, the facility failed to ensure that the Governing Body had direct consultation with the leader of the Medical Staff, or the designee, to discuss matters related to the quality of medical care provided to patients. This failure had the potential to affect the quality of care and safety of all patients. The facility census was 16.

Findings included:

Review of the facility's document titled, "Medical Staff By-Laws," dated 01/01/17, showed that the Chief of Staff duty was to provide day to day liaison on medical matters with the Chief Executive Officer (CEO) and the Board of Managers. He was to oversee that programs are clinically and professionally sound in accomplishing their objectives and are in compliance with regulatory requirements and report to the Board of Managers regarding such programs and activities.

Record review of the Governing Body Board Meeting Minutes did not contain any evidence that there were scheduled direct consultations between the Governing Body and the leader of the Medical Staff. The two Board meetings during 2018, 01/15/18 and 04/17/18, showed that neither the Chief of Staff nor any Medical Staff member, were present during the meetings.

During an interview on 01/30/19 at 9:00 AM, Staff L, Physician and Chief of Staff, stated that he did not meet with the Governing Body last year.

During a telephone interview on 01/31/19 at 10:30 AM, Staff Z, Governing Body Board Member, stated that the Governing Body had not had any direct consultations with the Chief of Staff in the last year.
VIOLATION: GOVERNING BODY Tag No: A0043
Based on interview, record review and policy review, the facility's Governing Body failed to effectively provide oversight in the conduct of the facility when:
- Physicians with expired privileges and unapproved appointments by the Governing Body were allowed to work. (A-0044)
- The Governing Body did not participate in Medical Staff Appointments. (A-0046)
- The Governing Body did not have direct consultations with the Medical Staff Leader. (A-0053)
- The Governing Body did not appoint the Chief Executive Officer. (A-0057)
- The facility failed to have an institutional plan and budget approved by the Governing Body. (A-0077)

The severity and cumulative effect of these systemic practices resulted in the facility being out of compliance with 42 CFR 482.12 Condition of Participation: Governing Body, and resulted in the facility's failure to ensure quality health care and safety. The facility census was 16.
VIOLATION: MEDICAL STAFF Tag No: A0044
Based on interview, record review and policy review, the facility failed to ensure that four physicians (Staff L, N, T and X) out of six physician medical staff records reviewed, had approved and current privileges to provide medical care at the facility. This failure had the potential to affect the quality of care and safety of all patients. The facility census was 16.

Findings included:

1. Review of the facility's document titled, "Medical Staff By-Laws," dated 01/01/17, showed the following:
- The Board of Managers was also known as the Governing Body and Board of Directors of the Hospital.
- The purpose of the By-Laws was to establish accountability of the Medical Staff to the Board of Managers for appropriateness of professional performance and ethical conduct of its members, and to monitor the quality of medical care provided by all Practitioners authorized to practice in the Hospital, through the appropriate delineation of Clinical Privileges and an ongoing review and evaluation of each Practitioner's performance in the Hospital.
- Appointment to and membership on the Medical Staff shall confer on the appointee or member only such Clinical Privileges as have been granted by the Board of Managers in accordance with these By-Laws, the Medical Staff Rules and Regulations, and other Policies and Procedures.
- No Practitioner shall admit or provide services to patients in the Hospital unless she/he has been granted Clinical Privileges in accordance with the procedures set forth in these By-Laws.

Review of the facility's document titled, "Medical Staff Rules and Regulations," showed no date that it had been adopted by the Medical Staff and no signature of the President of the Medical Executive Committee. There was no date that it was approved by the Board of Managers and no signature of the Chairperson of the Board of Managers. The Medical Staff Rules and Regulations stated that patients will be treated by ethical and competent Medical Staff members who have submitted proper credentials, met standards and requirements of the Hospital By-Laws and who have been duly appointed by the Board of Managers.

Review of the facility's Board Meeting minutes on 12/06/17, 01/15/18 and 04/17/18 showed no list of physicians that the Board had approved for credentialing.

Review of the credentialing file and recent work schedule for Staff T, Physician, showed the following:
- Bureau of Narcotic and Dangerous Drugs (BNDD) license (individuals who prescribe and dispense controlled substances) expired 12/31/18.
- No documented date that his privileges were requested and approved.
- No documented date or signatures that the Medical Staff recommended, or the Governing Body approved, his appointment.
- His start date at the facility was 07/15/18.
- In the last two months he had worked in the Emergency Department on 12/10/18, 12/16/18, 12/17/18,12/21/18, 01/06/19, 01/07/19, 01/13/19 and 01/14/19.

Review of the credentialing file and recent work schedule for Staff N, Physician and Psychiatric Director, showed that her privileges at the facility expired 01/06/19 and there were no documented date or signatures that the Medical Staff recommended, or that the Governing Body approved, her reappointment. Staff N worked on 01/07/19, 01/08/19, 01/16/19 and 01/23/19 through 01/31/19 as the Psychiatric Director since her privileges had expired.

Review of the credentialing file for Staff L, Physician and Chief of Staff, showed that his professional license expired 01/31/18, BNDD license expired 02/28/18 and hospital privileges expired 01/06/19. There was no documented dates or signatures that the Medical Staff recommended, or the Governing Body approved, his reappointment.

Review of the credentialing file and recent work schedule for Staff X, Physician, showed that his professional license expired 01/31/18, Drug Enforcement Administration (DEA) license (an identifier assigned to a health care provider allowing them to write prescriptions for drugs that are addictive and at risk for abuse) expired 10/31/18, BNDD license expired 01/31/17 and hospital privileges expired 01/06/19. There was no documented dates or signatures that the Medical Staff recommended, or the Governing Body approved, his reappointment. Staff X worked in the Emergency Department on 01/21/19.

During an interview on 01/29/19 at 2:20 PM, Staff C, Chief Executive Officer (CEO), stated the following:
- He did not know if the Board of Directors were involved in Medical Staff appointments or credentialing;
- They had hired physicians in the ED through the Medical Executive Board;
- He was surprised to hear that physician privileges had expired; and
- Physicians should not have worked if their privileges were expired.

During an interview on 01/29/19 at 4:45 PM, Staff K, Medical Staff Coordinator, stated that the position was new for her and she was trying to get caught up. When a physician was appointed or reappointed to the Medical Staff, the Medical Executive Committee approved or denied the appointment. The appointment was not approved or denied by the Governing Body with a vote, it just had to be signed by a member of the Governing Body.

During an interview on 01/31/19 at 10:30 AM, Staff Z, Governing Body Board Member, stated that he was not involved in Medical Staff appointments. Medical Staff appointments were approved through the Medical Executive Committee.