HospitalInspections.org

The facility's governing body failed to be legally responsible for the conduct of the hospital, as an institution, to ensure the credentialing function of the medical staff granted privileges to its member to perform patient care in a safe and competent manner. This deficient practice resulted in patients being treated by medical staff members whose credentials were not current. (Refer to A340)

The cumulative effective of these systemic problems resulted in the facility's inability to ensure the provision of quality health care in a safe environment for a general acute care hospital.

The facility's medical staff failed to be responsible to the governing body in failing to grant privileges to members in a manner that is legally appropriate for their practicing medicine in a safe and competent manner. This deficient practice resulted in patients being treated by medical staff members whose credentials were not current. (Refer to A340)

The cumulative effective of these systemic problems resulted in the facility's inability to ensure the provision of quality health care in a safe environment for a general acute care hospital.

Based on interview and record review, the medical staff failed to conduct appraisals (evaluate staff's qualifications and demonstrated competencies to perform tasks which she/he has been granted privileges/permitted to perform) for 57 of 200 of its members. This deficient practice resulted in patients being treated by medical staff members whose credentials were not current.

Findings:

On July 15, 2014 at 10 a.m., an interview of Staff 1 and Staff 2 together with a review of a final survey deficiency report following an accreditation survey conducted by the Healthcare Facilities Accreditation Program (HFAP) a Medicare deeming agency, it was revealed the medical staff office had failed to periodically conduct appraisals of 57 of 200 (28.5%) of its members resulting in appointment that exceeded 24 months. Of the 57 physicians and non-physicians with expired privileges, 20 continued to provide patient care. From the interview conducted, it was revealed that Staff 5 had ceased collecting the data required to perform the credentialing process.


According to the hospital's medical staff bylaws, the staff appraisal is required every 24 months. The potential consequences of this resulted in patients being provided care by members whose California medical licenses and Drug Enforcement Agency registrations may have expired. The former would be provided by BreEZe report from the Department of Consumer Affairs (DCA)/California Medical Board. (BreEZe Online Services is DCA's new licensing and enforcement system.) There failed to be substantiation of an absence of criminal activity on the part of the affected medical staff members determined through queries of the National Practitioner Data Bank. There failed to be evidence of physicians currently practicing in the hospital, being free from an active tuberculosis infection. The involved physicians had not been granted the usual requested privileges to practice in their specialties by the approval of qualified medical personnel.