HospitalInspections.org

Based on record review and interview the hospital failed to ensure that the contracted radiologists who provide radiographic interpretations have been credentialed according to the medical staff by-laws for 0 of 148 contracted radiologists who interpret radiology studies after hours and weekends.

Review of the Medical Staff By-Laws for American Legion Hospital adopted by the Medical Staff on 03/15/10 and adopted by the Governing Body on 03/25/10, presented as the current Medical Staff By-Laws, under Article 1. Application for appointment to Medical Staff and/or Clinical Privileges reads in part: "1.1 General Procedure. The applicant shall file the required application through the Hospital's Chief Executive Officer. Upon receipt of completed application, the Chief Executive Officer will forward the application to the Medical Staff Secretary, at which time letters of inquiry regarding verification of credentials and references will be sent out. Upon receipt of all verifications, including current licensure, and health status statement, the application will be submitted along with verifications to the Executive Committee for review, considerations, and recommendation to the board for approval or denial. When this has been accomplished, the application will be forwarded to the Board for final action...."

Review of a contract agreed to and signed on 02/28/2002 between American Legion Hospital and the contracted Radiology group "a" revealed the following: "1. The (contracted Radiology group "a") shall supply physicians who are licensed to practice medicine in the State of Louisiana. All physicians retained or employed by the (contracted Radiology group "a") who provide professional interpretation of radiology services for Hospital shall maintain active status on the Medical Staff of the Hospital, as defined by the Medical Staff By-Laws, Rules and Regulations.....4. Physician's staff privileges will be in a manner consistent with Hospital's Medical Staff Bylaws, Rules and Regulations.....B. Provide Full Time Medical Services. 1. The (contracted Radiology group "a") shall provide for radiology department coverage, twenty four (24) hours a day, three hundred sixty-five (365) days a year...."

Review of a list of contracted Radiology group "b" physician's revealed there were 148 names on the list.

In an interview on 08/11/10 at 8:15 a.m. with S5 who does Medical Staff Credentialing she revealed that 0 of the 148 radiologists on the list are on the Medical Staff of American Legion Hospital and none have been credentialed or granted privileges by the Governing Body of American Legion Hospital to interpret radiology films.

In an interview on 08/11/10 at 8:20 a.m. with S1CEO he stated that (contracted Radiology group "a") has a sub-contract with (contracted Radiology group "b") and that (contracted Radiology group "a") is supposed to read all films. The radiologists from (contracted Radiology group "a") are credentialed members of the medical staff.