HospitalInspections.org

Based on record review and interview, the governing body failed to ensure radiologists were eligible for medical staff membership and were properly credentialed before providing services for the hospital. The deficient practice is evidenced by radiology reports for imaging studies performed at the facility and signed by physicians not listed on the medical staff roster in 2 (#1, #3) of 3 (#1-#3) reviewed medical records.
Findings:

Review of the Medical Staff By-Laws, adopted January 2020, revealed in part, "Categories of accepted physician applicants include internists, general practitioners, orthopedists, psychiatrists, ENT's, neurologists and surgeons. Other applicants will be reviewed on a case by case basis."

Review of the medical record for Patient #1 revealed the patient had x-rays of the right and left knees performed on 01/03/2024 at the facility by a mobile x-ray company. The x-rays were read by a physician not listed on the list of active medical staff.

Review of the medical record for Patient #3 revealed the patient had a chest x-ray performed on 03/15/2024 at the facility by a mobile x-ray company. The x-rays were read by a physician not listed on the list of active medical staff.

In interview on 03/19/2024 at 11:50 a.m., S2DMCD verified the radiologists were not on the medical staff and had not been credentialed.

Based on record review and interview, the facility failed conduct periodic appraisals of its members. The deficient practice is evidenced by failure to conduct medical staff reappointments at least every 24 months.
Findings:

Review of the Medical Staff By-Laws, adopted January 2020, revealed in part, "Each applicant will be reappointed not more than every two years."

Review of the medical staff file for S3MD revealed an initial appointment to the medical staff on 09/08/2023. Further review revealed S3MD was not reappointed within 2 years as stated in the medical staff by-laws.

Review of the medical staff file for S4MD revealed an initial appointment to the medical staff on 01/30/2020. Further review revealed S4MD was not reappointed within 2 years as stated in the medical staff by-laws.

In interview on 03/19/2024 between 1:00 p.m. and 1:15 p.m., S2DMCD verified the medical staff files did not include documentation that either had been through the reappointment process after the initial appointment to the medical staff.

Based on observation an interview, the facility failed to ensure expired and unusable drugs and supplies were not used for patient care. The deficient practice is evidenced by the presence of expired and unlabeled open topical medications and supplies in the wound care cart.
Findings:

Inspection of the wound care cart on 03/19/2024 at 11:20 a.m. revealed the cart contained and open and undated tube of triamcinolone cream, an open and undated tube of nystatin cream, an open unlabeled jar of silver sulfadiazine cream, 2 jars of iodoform gauze with an expiration date of 09/2023, and a foam dressing with and expiration of 12/23.

In interview at the time of discovery, S2DMCD verified the open multidose topical medications should have been labeled with the date of opening or the date of expiration. S2DMCD also verified the expired supplies need to be destroyed.

Based on record review and interview, the facility failed to ensure infection control standards were maintained. The deficient practice is evidenced by failure of the facility to maintain separate storage for clean and dirty items.
Findings:

Tour of the facility on 03/19/2024 at 11:15 a.m. revealed a large storage room with packaged sterile supplies on open shelving units, a large laundry cart with clean laundry in bags, open plastic bags of disposable underpads on the floor, a mop bucket with dirty water, a bottle of bathroom disinfectant, a large floor buffer, 6 broken bedside tables, a box of television routers, a wheel chair, a rolling chair, 3 bedside commodes, a small filing cabinet, and a dirty pedestal fan.

In interview at the time of discovery, S2DMCD verified the dirty and clean supplies should not be stored in the same area and the disposable underpads should not have been on the floor.