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.
|EVERGREENHEALTH MONROE||14701 179TH AVE SE MONROE, WA 98272||Oct. 4, 2019|
|VIOLATION: MEDICAL STAFF CREDENTIALING||Tag No: A0341|
Based on record review and interview, the hospital failed to ensure that the medical staff followed medical staff bylaws, policies, and procedures when approving clinical privileges during medical staff reappointments for 2 of 3 medical staff reviewed (Staff #201 and #202).
Failure to follow medical staff bylaws, policies, and procedures when approving medical staff privileges risks inappropriate approval of staff member privileges that could lead to inadequate or unsafe patient care.
1. Record review of the document, "Medical Staff Bylaws," revised 10/17, showed that the duties of the Medical Executive Committee (MEC) include review of medical staff applications presented by the Quality Management and Credentials Committee (QMCC) for all initial and reappointment applicants before final presentation to the board. A workflow diagram for the appointment process was also present in the bylaws. Review showed that if the department chair, QMCC, or MEC need more information to approve an application or privileging request, the request should be resubmitted to the department chair for reevaluation.
Record review of the "Medical Staff Policies and Procedures," revised 06/17, showed that the QMCC shall review the privilege request and present it to the MEC, which will conduct further review and submit to the Board of Directors for final review.
2. Record review of the medical staff credentialing files for 2 of 3 physicians reviewed (Staff #201 and #202) showed the following:
a. Staff #201 (a physician) requested reappointment and continuation of clinical privileges on 12/14/17. The department chair signed the form on 03/26/18, but did not select approval or denial of the reappointment or requested clinical privileges of Staff #201. The QMCC signed the form on 03/26/18 but did not mark approval or denial of the reappointment or privilege request. The MEC signed the form on 03/26/18 but did not mark approval or denial of the requested clinical privileges. No additional documentation was in the file that the various committees made a request for more information regarding the missing recommendation from the previous person or committee that signed the form.
b. Staff #202 (a physician) requested internal medicine privileges, but did not mark which specific privileges were requested on the delineation form. The department chair signed the reappointment signature page on 06/25/18 and approved reappointment and privileges. THE QMCC signed the page on 06/25/18 but did not mark approval or denial of clinical privileges. The MEC signed the page on 06/25/18 but did not mark approval or denial of clinical privileges. No additional documentation was in the file that the various committees made a request for more information regarding the missing recommendation from the previous committee that signed the form.
3. On 10/04/19 at 10:20 AM, Surveyor #2 interviewed the Medical Staff Coordinator (Staff #203) regarding the privileging and reappointment forms. Staff #203 confirmed the missing approvals on the reappointment signature pages. Staff #203 also stated they were aware that Staff #202 had not selected which privileges he was requesting and had made multiple attempts to have the physician submit a corrected form, which had not occurred by the time of review.