HospitalInspections.org

Based on document review and staff interviews, the Medical staff failed to ensure the Medical Staff followed the Medical Staff Bylaws/Rules and Regulations which required a physician admit all patients to the hospital for 14 of 19 patient medical records reviewed (Patient #1, Patient #4, Patient #5, Patient #6, Patient #9, Patient #10, Patient #11, Patient #12, Patient #13, Patient #14, Patient #16, Patient #17, Patient #18, and Patient #19). Failure to follow the Medical Staff Bylaws/Rules and Regulations requiring a physician to write the admission order could potentially result in the patient being admitted to the hospital by an individual without the training identified by the medical staff to ensure the patients received adequate pre-admission assessment and care. The hospital administrative staff identified a current census of 29 patients at the beginning of the survey.

Findings include:

1. Review of the hospital's "Bylaws of the Medical Staff," dated 2021, approved by the Medical Staff 1/22/2021 and approved by the Governing Board 2/8/2021, revealed in part as follows:

"Members of the active staff are appointed to a specific service area. They have primary duties and responsibilities for patient care and clinical education including, admission and discharge of patients, and are entitled to exercise those clinical privileges granted to them by the terms of their appointment or reappointment. Independent patient admission privileges at EAGLE VIEW BEHAVIORAL HEALTH shall only be granted to those currently licensed Doctor of Medicine or Osteopathy. Allied Health Professionals ("AHP") may exercise only those privileges granted to them."

"The following definitions apply to terms used in the bylaws: 1. Allied Health Professional or AHP - means an individual, other than a licensed physician, who exercises independent judgment within the areas of his or her professional competence and the limits established by the Governing Board, the Medical Staff, and applicable federal and State laws; who is licensed or certified to render direct or indirect medical care; and who may be eligible to exercise privileges and prerogatives in conformity with the rules of the Medical Staff and these Bylaws. For the purposes of these Bylaws, this definition shall include, but is not limited to nurse practitioners ("NP") and physician assistant ("PA") ... 6. Clinical Privileges - means the specific permission granted to a practitioner by the Board, based on staff recommendations in accordance with these bylaws, rules and regulations, to provide medical or other patient care services in the hospital whether in person or through the use of any medium (including an electronic medium)."

Review of the hospital's "Medical Staff Rules and Regulations," dated 2021, approved by the Medical Staff 1/22/2021 and approved by the Governing Board 2/8/2021, revealed in part, "Admission of the Patient. The Facility will admit (by order of a physician who is a member of the active medical staff) patients suffering from all types and psychiatric illness...."

2. Review of the hospital's "Governing Board Bylaws," dated 2021, revealed in part, "Final action on all matters relating to Staff status, clinical privileges and corrective action shall be taken by the Board and documented in writing ... The terms and conditions of staff status in the Medical Staff, and of the exercise of clinical privileges, shall be as specified in the Medical Staff bylaws."

3. Review of the hospital policy "Assessment and Referral: Pre-Admission Screening and Admission Process," dated 6/12/20, revealed in part, "Patients will be admitted to any level of care in the continuum only on the order of a physician or licensed provider with admitting privileges ..."


4. Review of credential files revealed the following:

a. The Medical Staff approved Nurse Practitioner A's privileges on 6/17/20 and the Governing Board approved Nurse Practitioner A's privileges on 6/17/20. Nurse Practitioner A's credential file lacked evidence the Medical Staff or Governing Board approved Nurse Practitioner A to admit patients to the hospital.

b. The Medical Staff approved Nurse Practitioner B's privileges on 6/27/20 and the Governing Board approved Nurse Practitioner B's privileges on 6/27/20. Nurse Practitioner B's credential file lacked evidence the Medical Staff or Governing Board approved Nurse Practitioner B to admit patients to the hospital.

c. The Medical Staff approved Nurse Practitioner C's privileges on 9/29/20 and the Governing Board approved Nurse Practitioner C's privileges on 9/17/20. Nurse Practitioner C's credential file lacked evidence the Medical Staff or Governing Board approved Nurse Practitioner C to admit patients to the hospital.

d. The Medical Staff approved Nurse Practitioner E's privileges on 6/17/20 and the Governing Board approved Nurse Practitioner E's privileges on 6/17/20. Nurse Practitioner E's credential file lacked evidence the Medical Staff or Governing Board approved Nurse Practitioner E to admit patients to the hospital.

e. The Medical Staff approved Nurse Practitioner F's privileges on 6/17/20 and the Governing Board approved Nurse Practitioner F's privileges on 6/17/20. Nurse Practitioner F's credential file lacked evidence the Medical Staff or Governing Board approved Nurse Practitioner F to admit patients to the hospital.


5. Review of patient medical records revealed the following:

a. Nurse Practitioner A admitted Patient #5 to the hospital on 5/17/21.
b. Nurse Practitioner A admitted Patient #12 to the hospital on 4/12/21.
c. Nurse Practitioner A admitted Patient #16 to the hospital on 5/2/21.
d. Nurse Practitioner A admitted Patient #18 to the hospital on 5/11/21.
e. Nurse Practitioner B admitted Patient # 9 to the hospital on 3/17/21
f. Nurse Practitioner C admitted Patient #1 to the hospital on 5/7/21.
g. Nurse Practitioner C admitted Patient #6 to the hospital on 5/18/21.
h. Nurse Practitioner E admitted Patient #10 to the hospital on 3/26/21.
i. Nurse Practitioner F admitted Patient #4 to the hospital on 5/16/21.
j. Nurse Practitioner F admitted Patient #11 to the hospital on 4/19/21.
k. Nurse Practitioner F admitted Patient #13 to the hospital on 3/26/21.
l. Nurse Practitioner F admitted Patient #14 to the hospital on 5/2/21.
m. Nurse Practitioner F admitted Patient #19 to the hospital on 5/14/21.




6. During an interview on 5/26/2021 at 3:50 PM, the Chief Executive Officer (CEO) acknowledged the Medical Staff Rules and Regulations required only physicians to admit patients to the hospital, and did not allow Nurse Practitioners to admit patients to the hospital.


7. During an interview on 5/27/2021 at 11:40 AM, the CEO and Executive Assistant, upon review of requested and approved privileges for nurse practitioners, acknowledged the privileges for nurse practitioners did not include admitting privileges.