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.

ERLANGER MEDICAL CENTER 975 E 3RD ST CHATTANOOGA, TN 37403 March 13, 2019
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on facility policy review, medical record review, and interview, the facility failed to obtain informed consent for admission and treatment for 1 patient (#16) of 50 patients reviewed.

The findings included:

Review of facility policy "Patient Consent/Authorization for Treatment/HIPAA [Health Insurance Portability and Accountability Act] Consent," dated 11/2011, revealed "...To ensure appropriate signatures are obtained for all Consents to Treatment and Authorization of Benefits...The staff of Patient Access is responsible for obtaining consents to treatment...A copy of the conditions of admission and HIPAA consents are to be obtained both in the patient's medical record and in the Patient's Financial Service Imaging..."

Medical record review revealed Patient #16 was admitted to the facility on [DATE] for Acute Respiratory Failure and Diabetes and continued to remain in the facility on 3/6/19. Further review revealed no Consent for Admission/Outpatient Treatment was obtained for Patient #16 upon admission.

Interview with the Patient Safety and Quality Director on 3/7/19 at 11:00 PM, in the Administration Conference Room, confirmed there was no Consent for Admission/Outpatient Treatment for Patient #15. Further interview revealed the facility failed to obtain a Consent for Admission/Outpatient Treatment until 3/6/19 for Patient #16 (16 days after admission). Continued interview confirmed a Consent for Admission/Outpatient Treatment was to be completed and signed for each patient.
VIOLATION: MEDICAL STAFF PRIVILEGING Tag No: A0355
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of Medical Staff Bylaws, review of medical records, review of credentialing files, and interviews, the facility failed to ensure one physician (#6) was granted privileges for procedures performed of 7 physicians reviewed for one patient (#14) of 40 patients reviewed.

The findings included:

Review of facility Medical Staff Bylaws "BYLAWS OF THE MEDICAL STAFF," not dated, revealed "...Every Physician providing direct clinical services at this Hospital shall...be entitled to exercise only those clinical privileges or services specifically granted to him/her by the board...The Board shall approve the list of specific privileges and limitations for each category of physician..."

Medical record review revealed Patient #14 was admitted to the facility on [DATE] with diagnoses including Hypertension, [DIAGNOSES REDACTED], Prior Myocardial Infarctions (heart attack), Uncontrolled Diabetes Mellitus, History of Prior Coronary Artery Bypass Graft, and Recent Myocardial Infarction. Further review revealed on 2/13/19 at 5:30 PM Physician #6 performed an Extracorporeal Membrane Oxygenation (ECMO a prolonged cardiac and respiratory support procedure) procedure on Patient #14.

Review of Physician #6's credentialing file revealed the physician had not been granted privileges to perform ECMO procedures by the hospital's governing body.

Interview with the Medical Staff Manager on 3/7/19 at 12:05 PM, in the Administration Conference Room, confirmed Physician #6's credentialing file did not contain documentation the physician was privileged for ECMO procedures by the governing body.