HospitalInspections.org

Based upon review of 5 of 5 Physicians Assistant (PA) (#s S6, S7, S8, S9, S10) Credentialing files, Medical Staff Bylaws/Rules/Regulations, and Administrative interviews, the hospital's Governing Body failed to ensure all PAs who had requested privileges at the hospital: 1) had documented proof of their approved clinical duties by their supervising physicians in their credentialing files as stated in the Medical Staff Bylaws/Rules/Regulations as evidenced by a lack of documented protocols in their respective credentialing files; and 2) the supervising physician (S5) countersigned the PA's (S6) medication orders within 24 hours per the delineation of privileges as evidenced by a failure of the supervising physician (S5) to document dates and times the medication orders (patient #28 and #37) were cosigned. Findings:

Review of Credentialing files for PAs, (S6, S7, S8, S9, and S10), revealed a document titled "Delineation of Privileges Specialty: Allied Health Professional Physician's Assistant (PA)". Review of this document revealed (on page 10 of 10): "XVIII. SUPERVISING PHYSICIAN STATEMENT SUPERVISING PHYSICIAN: Your signature indicates that you have received the above applicant's qualifications and you attest that the Allied Health Professional (AHP) is eligible to request the scope and practice as documented in attached protocol...Based on your review you feel the AHP is currently clinically competent to perform under the requested protocol and you recommend this practitioner for: ...Agree to supervise the applicant for intervention and procedures performed in your clinical setting per attached protocol." Continued document review revealed there were areas for the printed name of the physician, signature of the applicant and date.

Review of page 10 of the Medical Staff Rules & Regulations revealed: "Allied Health Personnel 1. Prior approval must be obtained through the normal credentialing process for specific professional personnel...a. verification of the applicant's training program,...c. the scope of privileges requested, d. the applicant's qualifications through training and experience, and e. the assurance that the applicant will work under the direct supervision of a physician member..."

Review of Medical Staff Bylaws revealed: "ARTICLE V. CATEGORIES OF THE MEDICAL STAFF...(see page 17) 5.4 ALLIED HEALTH PROFESSIONALS A. Only Allied Health Professionals (AHPs) licensed, certified or otherwise approved by the laws of this state and federal law, who document their current licensure, relevant training and/or experience, current competence, demonstrated ability,...that they are qualified to provide a needed service within the Hospital. B. An application for appointment, reappointment and/or clinical privileges...shall be submitted...Each applicant shall be evaluated by the Medical Executive Committee...the recommendations of the MEC shall be sent to the Governing Body for final decision...E. The AHP shall not practice beyond the scope of the AHP's license, certificate or other legal credential...G. Retain appropriate responsibility within the AHP's area of professional competence for the care and supervision of each patient in the Hospital for whom the AHP is providing services, or arrange a suitable alternative for such care and supervision..."

Review of the PA's (S 6, 7, 8, 9, and 10) credentialing files revealed there failed to be documentation of the protocol that the PA were to follow in relation to the PAs practice in the hospital to ensure that their patients received competent care.

Telephone interview, on 01/27/12 at 1:15 PM, with S5 Supervising Physician for S6 PA revealed when questioned as to what types of medications S6 PA had been approved to write, S5 Physician stated antibiotics, laxatives, no narcotics and "if he writes a Scheduled II Narcotic I am there". S5 Physician further stated that he had always cosigned medication orders written by S6 PA within the 24 hour requirement; however, the surveyors informed S5 Physician there were several orders that had not been cosigned within 24 hours and that S6 PA had written a Scheduled II Narcotic (Morphine) for Intravenous use on a patient for which S5 had not documented the date nor the time he cosigned the order.

Review of patient #37's medical record revealed S6 PA had written an order for Morphine (a scheduled II narcotic) on a Physician Order Sheet, dated 06/10/11, 6:30 AM. Continued review of this order revealed there failed to be a documented date and time that S5 Physician cosigned the order.

Review of patient #28 medical record revealed Physician Order Sheets on which S6 PA had written orders: 01/12/12 at 6 AM increase Theodur to 300 milligrams and increase Digoxin to 0.2 milligrams, S5 Physician cosigned the orders 01/19/12 at 1 PM; and on 01/14/12, timed 10 AM, S6 PA had written an order for laboratory studies, S5 Physician cosigned the order on 01/19/12 8 AM -- both orders cosigned more than the 24 hour requirement on the delineation of privileges for PAs.

The Governing Body failed to ensure the protocols related to the PAs practice in the hospital were examined and included in the credentialing file of each individual PA.

The Governing Body failed to ensure that the supervising physicians followed the requirement relative to the PA they were supervising and cosigned the PA's medication orders within the 24 hour requirement as documented on the delineation of privileges for PAs.

Based upon review of incident/accident reports and staff interviews, the hospital failed to ensure each death that occurred while a patient was in restraints was reported to the Center for Medicare/Medicaid Services (CMS) as evidenced by failing to report to CMS the death of patient #16 who died while in two point soft wrist restraints on 12/16/11. Findings:

Review of the incident/accident reports revealed a form titled "Hospital Restraint/Seclusion Death Report Worksheet" was completed on 12/16/11 related to patient #16, a 94 year old female, who died while in two point wrist restraints. Further review of the death reporting form revealed the patient was diagnosed with pneumonia and chronic renal failure. The bilateral soft wrist restraints were applied for the patient's safety due to "pulling at lines". For the "circumstances surrounding the death" it was documented "chemical code only, expected death, patient deemed terminal at admission to facility."

Interview with the Quality Assurance/Risk Management Director (RN S4) on 01/25/12 at 1:05 PM, revealed when asked if the restraint death was reported to CMS, RN S4 replied "no" and stated she had not received the report or was aware there was an occurrence in which a patient died while in restraints. When asked the procedure for reporting, RN S4 replied if a patient died while in any type of restraint, the Registered Nurse would complete the death reporting worksheet and then forward the completed form on to their nurse manager. RN S4 further stated once the nurse manager received and reviewed the form, it would then be forwarded on to herself, the QA/Risk Management Director, for reporting to CMS. When asked why she had not received the restraint death reporting form, S4 stated she did not know; however, would immediately inform CMS of the restraint death.

Based upon review of 5 of 5 Physicians Assistant (PA) (#s S6, S7, S8, S9, S10) Credentialing files and Administrative interviews, the hospital's Medical Staff failed to ensure all PAs who had requested privileges at the hospital had documented proof of their approved clinical duties by their supervising physicians in their credentialing files as stated in the Medical Staff Bylaws/Rules/Regulations as evidenced by a lack of documented protocols in their respective credentialing files. Findings:

Review of Credentialing files for PAs, (S6, S7, S8, S9, and S10), revealed a document titled "Delineation of Privileges Specialty: Allied Health Professional Physician's Assistant (PA)". Review of this document revealed (on page 10 of 10): "XVIII. SUPERVISING PHYSICIAN STATEMENT SUPERVISING PHYSICIAN: Your signature indicates that you have received the above applicant's qualifications and you attest that the Allied Health Professional (AHP) is eligible to request the scope and practice as documented in attached protocol...Based on your review you feel the AHP is currently clinically competent to perform under the requested protocol and you recommend this practitioner for: ...Agree to supervise the applicant for intervention and procedures performed in your clinical setting per attached protocol." Continued document review revealed there were areas for the printed name of the physician, signature of the applicant and date.

Review of page 10 of the Medical Staff Rules & Regulations revealed: "Allied Health Personnel 1. Prior approval must be obtained through the normal credentialing process for specific professional personnel...a. verification of the applicant's training program,...c. the scope of privileges requested, d. the applicant's qualifications through training and experience, and e. the assurance that the applicant will work under the direct supervision of a physician member..."

Review of Medical Staff Bylaws revealed: "ARTICLE V. CATEGORIES OF THE MEDICAL STAFF...(see page 17) 5.4 ALLIED HEALTH PROFESSIONALS A. Only Allied Health Professionals (AHPs) licensed, certified or otherwise approved by the laws of this state and federal law, who document their current licensure, relevant training and/or experience, current competence, demonstrated ability,...that they are qualified to provide a needed service within the Hospital. B. An application for appointment, reappointment and/or clinical privileges...shall be submitted...Each applicant shall be evaluated by the Medical Executive Committee...the recommendations of the MEC shall be sent to the Governing Body for final decision...E. The AHP shall not practice beyond the scope of the AHP's license, certificate or other legal credential...G. Retain appropriate responsibility within the AHP's area of professional competence for the care and supervision of each patient in the Hospital for whom the AHP is providing services, or arrange a suitable alternative for such care and supervision..."

Review of the PA's (S 6, 7, 8, 9, and 10) credentialing files revealed there failed to be documentation of the protocol that the PA were to follow in relation to the PAs practice in the hospital to ensure that their patients received competent care.

Telephone interview, on 01/27/12 at 1:15 PM, with S5 Supervising Physician for S6 PA revealed when questioned as to what protocol his PA was to follow, S5 stated he was not certain what the surveyor was referring to; the surveyor stated that the credentialing file stated that there was an attached protocol (specific to what the PA may perform in the hospital), approved by the supervising physician and stated the PA was competent to perform specified procedures. S5 Physician stated he was not certain what "protocol" the credentialing file referred to but he was not aware of one.

The Medical Staff failed to ensure the protocols related to the PAs practice in the hospital were examined and included in the credentialing file of each individual PA and that each PA had been found to be competent to perform those procedures as stated in the protocols.