HospitalInspections.org

Based on document review and interview, the Governing Body failed to ensure the hospital followed the Medical Staff Bylaws, Rules, and Regulations when credentialing 2 (Nurse Practitioner #3 and #6) of 2 Nurse Practitioner (NP) files reviewed.

A review the credential files for NP #3 and NP #6 was conducted with Director of Nurses Staff #2 on 1/18/2025 and 1/19/2025.

Findings:

NP Staff #3
A review of the credential file for NP #3 revealed a current medical staff appointment for 2/24/2023-2/24/2025. Further review revealed NP #3 failed to submit three letters of personal reference as required by the Medical Staff Bylaws, Rules, and Regulations.


NP #6
A review of the credential file for NP #3 revealed a current medical staff appointment for 8/23/2024-8/23/2026. Further review revealed NP #6 failed to submit 2 of 3 letters of personal reference as required by the Medical Staff Bylaws, Rules, and Regulations.


A review of the Medical Staff Bylaws, Rules, and Regulations adopted on January 17, 2025, was as follows:

" ...Section 7: Application Requirements and Initial Appointment:

a. An applicant seeking appointments as an AHP/APP must apply as follows:

1) ...
vii. References: The applicant submits three letters of reference, including at least one from a practicing physician, other than the Sponsoring Member, who has knowledge of the Applicant's Current competence and conduct ..."


An interview was conducted with DON Staff #2 on 2/18/2025 at 3:15 PM. DON Staff #2 was asked if NP #3 or NP #6 had letters of reference in the credential file. DON Staff #2 confirmed NP #3 did not submit any personal reference letters, and NP #6 only had one of the three required personal reference letters in the credential file.