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Based on record review and staff interview, the Governing Body failed to ensure members of the medical staff were appointed after considering the recommendations of the medical staff. The Governing Body failed to follow the bylaws regarding appointment of medical staff members and the Governing Body failed to ensure the medical staff bylaws were followed for appointment of medical staff members for 3 (SF12Physician, SF14Physician, SF15Physician) of 7 (SF5MD, SF8Physician, SF11Physician, SF12Physician, SF13Physician, SF14Physician, SF15Physician) current physician medical staff members. Findings:

Review of the GB by laws revealed in Section 12. Practitioners providing contractual professional services: A practitioner who is providing such contract services to the hospital must meet the same membership qualifications; must be processed for appointment, reappointment, and clinical privilege delineation in the same manner....

Review of the Medical Staff Bylaws, provided by SF4QA/RM (Quality Assessment/Risk Management) as the revised bylaws (06/17/15) revealed in part the following:
Article VI. 6.1 Procedure for Appointment/Delineated Clinical Privileges
1. All applications for appointment/clinical privileges to the Medical Staff will be submitted in the form designated by the Medical Executive Committee (MEC) and the Board. The application will be submitted by the practitioner to the Medical Staff Office. The application will request information including, but not limited to: (a) Documentation of professional qualifications, including continuing medical education (CME); (d) evidence of financial responsibility for professional liability claims; (e) Peer recommendations.
3. The applications will be investigated thoroughly.
6. When the recommendation of the Medical Executive Committee is favorable to the practitioner, the Chief Executive Officer will forward it together with all supporting documentation, to the Board.
6.4 Action on an individual's application for staff appointment, reappointment, and/or clinical privileges is withheld until all information required by these bylaws is made available and verified.

On 06/29/15 a review of the Governing Body meeting minutes dated 6/12/15, revealed the credentials for SF12Physician, SF14Physician and SF15Physician were received and verified and the medical staff (chief of staff) approved the credentials. The minutes revealed the Governing Body appointed SF14Physician and SF15Physician as Directors over Laboratory Services, and SF12Physician as Director of Radiology.

On 07/01/15 a review of the MEC meeting minutes dated 06/17/15 (5 days after the Governing Body appointed these physicians to the medical staff) revealed new medical staff appointments/Governing Body approvals included SF14Physician and SF15Physician as Directors over Laboratory Services, SF12Physician as Director of Radiology.

SF12Physician
On 06/29/15 a review of the credentialing file for SF12Physician revealed the file included an AMA (American Medical Association) profile dated 6/22/15, a CV (Curriculum Vitae), CME for 2013 and 2014, copy of current medical license and a copy of malpractice insurance verification. The Delineation of Privileges form revealed the privileges requested were checked by the applicant, and the privileges request was signed only by SF12Physician on 6/19/15 (6 days after the Governing Body appointed him as Director of Radiology). There was no documentation in the credentialing file of an application for appointment. There was no documentation that the MEC had reviewed the credentials and recommended the appointment to the medical staff. There was no documented evidence of peer recommendations.

SF14Physician
On 06/29/15 a review of the credentialing file for SF14Physician revealed the file included only an AMA physician profile dated 06/22/15, and a letter from a hospital in the adjacent state that indicated SF14Physician had privileges at that hospital. Review of the AMA profile revealed SF14Physician had an inactive license in the state where the hospital was located. There was no documented evidence of an application for appointment, delineation of privileges, or approval by the medical staff. There was no documented evidence of CME, professional liability insurance, current licensure, or peer recommendations as outlined in the Medical Staff Bylaws for appointment/reappointment.


SF15Physician
On 06/29/15 a review of the credentialing file for SF15Physician revealed the file included only a certificate from an accreditation organization for laboratories, an AMA profile dated 6/22/15, a copy of the physician's license, and a CV. There was no documented evidence of an application for appointment, delineation of privileges, or approval by the medical staff. There was no documented evidence of CME, professional liability insurance, or peer recommendations as outlined in the Medical Staff Bylaws for appointment/reappointment.

In an interview on 06/29/15 at 4:00 p.m. with SF4QA/RM (Quality Assessment/Risk Management) reviewed the credentialing files for SF14Physician and SF15Physician. She confirmed SF14Physician and SF15Physician were approved by the Governing Body as Directors of Laboratory, but neither physician went through the credentialing process. She stated SF15Physician refused to be on their medical staff. She stated the consultant the hospital hired to assist with the plan of correction insisted the statement that the lab director was a credentialed member of the medical staff be included in the plan of correction when they knew they could not get that done. SF4QA/RM confirmed SF14Physician was not currently licensed in the state where the hospital was located. SF4QA/RM confirmed the application and supporting documents for SF12Physician were not in the credentialing file and stated SF20HR told her she had credentialing documents for SF12Physician and she would fax them to her.

In an interview on 06/30/15 at 3:50 p.m. SF4QA/RM provided an appointment application and delineation of privileges that was approved by SF5MD (Medical Director & Chief of Staff) and the Governing Body for SF12Physician. She confirmed that the hospital did not have the application and supporting documents when the Governing Body appointed SF12Physician on 6/12/15. SF4QA/RM confirmed the hospital had not followed the medical staff bylaws and governing body bylaws in the appointment of SF12Physician, SF14Physician, and SF15Physician.

Review of the plan of correction submitted by the hospital to correct an identified deficiency related to failure to ensure an effective system was in place to ensure that each physician was credentialed in accordance with the Medical Staff Bylaws on 05/18/15 revealed the following: "The Governing Body will ensure that an effective system is in place to ensure that each physician/practitioner providing services in the hospital is credentialed in accordance with the Medical Staff Bylaws."