HospitalInspections.org

Based upon record review and interview, the facility failed to have an organized governing body responsible for the conduct of the hospital.

Review of governing body bylaws revealed bylaws last revised on 12/26/08 and written for the organization that was responsible for the conduct of the hospital prior to March 2, 2009. Prior to this date, the hospital was owned by a hospital district with a Board of Directors that were community leaders who held officer positions and administrative personnel of the facility as members of the Board of Directors.

Review of a lease agreement between the Hospital (Landlord) and new owner (Tenant) revealed the agreement as follows: "Landlord owns the "Hospital; and Landlord believes it is in the best interests of the community to lease the Hospital to Tenant in order to continue providing medical care to the community; and this Agreement provides for the Lease by Landlord to Tenant of the assets, real and personal, tangible and intangible, constituting the Hospital as described herein; and this Agreement will accomodate the transfer of all licenses, permits, certification, and other agreements as necessary from the Landlord to Tenant for continued operations of Hospital by Tenant." Review of the Lease further revealed the following in Article IV-Section 2.0 - "Tenant and Landlord acknowledge and agree that on and after the Delivery Date (3/2/09), Tenant will have sole responsibility for the operations, business decisions, assets and liabilities, and other committments Tenant enters into associated with operating Hospital. Landlord is not a risk for the operations of Hospital and shall be held harmless with respect to the operation of the Hospital and, in addition, Landlord has no financial responsibility, contractual or otherwise, for Hospital. Section 2.1 - Tenant will maintain all license, permits, assignments, and agreements necessary for operating Hospital, including, but not limited to, business permits, state licensure, Medicare and Medicaid Certifications, and any and all payor agreements."

An interview with the Administrator on 7/15/10 at 11:30 am revealed the new owner did take over operation of the facility on March 2, 2009. The Administrator reported he began at the facility in March, 2010 and he thought the governing body bylaws and the medical staff bylaws were developed by the new management. The Administrator reported he had not reviewed the governing body bylaws or the medical staff bylaws. The Administrator reported there currently was a governing body that included the new owner, a regional director for the company, the Director of Nurses, the Medical Director, and the Administrator. The Administrator also reported the governing body had met on several occasions but the Administrator was unable to provide evidence of an agenda, a schedule marked with the date of meeting, a notice to the members of a meeting, or meeting minutes. The Administrator reported the new owner had not notified Centers for Medicare/Medicaid Services or the fiscal intermediary of the change of ownership and has not applied for hospital licensure with the State Licensing Agency.

Based upon record review and interview, the facility failed to have an organized medical staff by ensuring bylaws were approved by the governing body. The facility failed to ensure 6 of 8 medical staff members reviewed had been provided due process in their appointment to the medical staff. Review of physician credentialing files revealed 6of 8 medical staff members reviewed had no current appointment to the medical staff.

Review of medical staff bylaws, rules and regulations revealed a cover sheet dated 9/25/08 as the date the medical staff bylaws, rules and regulations were reviewed and approved for continued use. The cover sheet was signed by the President of the Governing Body, the Chief of Staff, and the Chief Executive Officer of the facility prior to the change of ownership that was effective on March 2, 2009. The current owner/administration and governing body had not reviewed and approved medical staff bylaws, rules and regulations.

An interview with the Administrator on 7/15/10 at 11:30 am revealed the new owner did take over operation of the facility on March 2, 2009. The Administrator reported he began at the facility in March, 2010 and he thought the medical staff bylaws were developed by the new management prior to his becoming administrator. The Administrator reported he had not reviewed the medical staff bylaws, rules and regulations.

Review of credentialing files of 6 of 8 physicians revealed physicians were not provided due process in their appointment to the medical staff and 6of 8 physicians reviewed did not have current appointments to the the medical staff. The findings of the review of credentialing files was as follows:

Review of credentialing file of physician #1 revealed the last credentialing application was dated 7/24/07. A form titled "Reappointment Review and Recommendation" revealed an approval for reappointment with continued delineation of privileges dated 9/27/07 and expired on 9/27/09. This was the most recent reappointment to the medical staff. The only delineation of privileges in the credentialing file was on the initial application for appointment dated 6/23/84. The delineation of privileges from 6/23/84 revealed privileges for services not provided at the facility any longer. Physician #1's copy of his medical license showed it expired on 5/31/09 and copy of DPS showed it expired on 4/30/10. Verification was not obtained for the renewal of these licenses. Physician #1 was not currently appointed to the medical staff. An interview with the administrator on 7/15/10 at 11:30 am revealed Physician #1 was functioning as the current Chief of Staff.

Review of credentialing file of physician #2 revealed the last credentialing application was dated 11/30/06. A form titled "Temporary Medical Staff Privileges" revealed temporary privileges were granted on 1/24/07. A form titled "Physician Appointment" revealed approval of a provisional 6 month appointment dated 4/24/07. A form titled "Provisional Appointment Six-Month Review" revealed approval for advance to a two-year appointment with privileges requested was granted 12/6/07and expired on 12/6/09. This was the last appointment granted. The last verification documented of Physician #2's medical license revealed it expired 2/28/10. The last verification of Physician #2's controlled substance registration (DPS) revealed it expired 9/30/09. Physician #2 was not currently appointed to the medical staff.

Review of credentialing file of physician #3 revealed the last credentialing application was dated 11/3/08. Review of form titled "Independent Contractor Emergency Medicine Privileges" revealed temporary privileges approved on 11/20/08. Review of form titled "Physician Appointment" revealed the Chief of Staff recommended a Provisional Six-Month Appointment dated 6/19/09 and there was a signature on the form of the President of the Governing Body dated 7/14/09 but the President failed to mark if appointment was denied or approved. This 6 month provisional appointment dated 7/14/09 expired 1/14/10 and was the last appointment granted. The last verification of Physician #3's controlled substance registration (DPS) revealed it expired 4/30/10. The last verification documented of Physician #3's medical license revealed it expired 5/31/10. There was no delineation of privileges found in the credentialing file. Physician #3 was not currently appointed to the medical staff.

Review of credentialing file of physician #5 revealed the last credentialing application was dated 8/13/09. There also was a form titled "Physician Request for Reappointment" dated 8/19/09. There was no documentation in the credentialing file that the application and request for reappointment was acted upon. Review of form titled "Reappointment Review and Recommendations" revealed the last reappointment granted for physician #5 was 3/8/07.
Physician #5 was not currently appointed to the medical staff.

Review of credentialing file of physician #7 revealed a credentialing application was dated 5/20/09. There was no documentation in the credentialing file that the application had been acted upon. There was no request for appointment form and no approval of appointment form. There was no appointment for temporary and or provisional privileges. Physician #7 was not currently appointed to the medical staff.

Review of credentialing file of physician #8 revealed a credentialing application was dated 3/3/10. There was a form titled "Physician Appointment" with the approval of temporary privileges by the Chief of Staff and Administrator dated 4/8/10. The credentialing file had all the documents requested for the physician to provide but no action had been taken by the facility to process the credentialing application for 6 month provisional appointment. The privileges requested by physician #8 were for Tele-radiology and physician #8 resided in Reno, Nevada. Physician #8 was not physically practicing within the facility. Physician #8 was not currently appointed to the medical staff.

Based upon record review and interview, the governing body failed to ensure the credentialing process for appointing members of the medical staff was functional. The governing body failed to ensure 6 of 8 medical staff members reviewed had been provided due process in their appointment to the medical staff. 6of 8 medical staff members reviewed had no current appointment to the medical staff.

REFER TO TAG A-0338

Based upon record review and interview, the governing body failed to approve medical staff bylaws, rules and regulations.

Review of medical staff bylaws, rules and regulations revealed a cover sheet dated 9/25/08 as the date the medical staff bylaws, rules and regulations were reviewed and approved for continued use. The cover sheet was signed by the President of the Governing Body, the Chief of Staff, and the Chief Executive Officer of the facility prior to the change of ownership that was effective on March 2, 2009. The current owner/administration and governing body had not reviewed and approved medical staff bylaws, rules and regulations.

An interview with the Administrator on 7/15/10 at 11:30 am revealed the new owner did take over operation of the facility on March 2, 2009. The Administrator reported he began at the facility in March, 2010 and he thought the medical staff bylaws were developed by the new management prior to his becoming administrator. The Administrator reported he had not reviewed the medical staff bylaws, rules and regulations.

Based upon record review and interview, the governing body failed to approve the medical staff bylaws, rules and regulations.


Refer to TAG A - 0048

Based upon observation, record review, and interview, the facility failed to ensure adequate RN staffing on all units of the facility on 3 out of 26 shifts.

On entrance to the facility, an observation tour was conducted to determine nurse staffing in the facility. The Medical/Surgical Unit was staffed with 2 RNs, 1 patient care technician, and 1 ward clerk and the patient census was 6. The Emergency Room was staffed by 1 RN and 1 patient care technician. There were no patients in the Emergency room at the time. There was no nursing staff in surgery due to being a non-surgery day of the week.

An interview was conducted with Staff #11 on 7/15/10 at 9:15 am. Staff #11reported he started working in the facility as the Assistant Director of Nurses on 7/5/10 and had been working at a sister facility in Terrell. He reported the Chief Nursing Officer in Terrell was also the Director of Nurses at this facility. Mr. Curtis reported he is working to ensure adequate staffing for the facility.

Review of the Nurse Staffing Plan revealed an RN to be present on the Medical Surgical Floor and the ER on 7am-7pm and 7pm-7am shifts. The Staffing Plan also made accommodations for an RN or LVN from 11am-11pm in the ER as these hours have been determined to be the busiest.

Review of the Nurse Staffing for 7/1/10 - 7/14/10 revealed 3 shifts that did not have adequate RN coverage in the facility: 7/5/10 - 7pm-7 am, no RN on the Medical Surgical Unit; 7/6/10 - 7am-7pm, no RN on the Medical Surgical Unit; 7/13/10 - 7pm-7am, no RN on the Medical Surgical Unit.