HospitalInspections.org

Based on record reviews and interview the hospital failed to ensure Physician Credentialing files were kept up to date for 3 of 3 records reviewed. (S3, S6, S7). Findings:

Review of the credentialing file on 01/26/10 at 2:00 p.m. for S3, MD revealed it contained no current Data Bank Query, no documented evidence of annual TB (Tuberculosis) screening, and no documented evidence of current Malpractice Insurance.

Review of the credentialing files on 01/26/10 at 1:50 p.m. for S6, MD revealed the credentialing file contained no re-appointment application, no documented evidence of annual TB (Tuberculosis) screening, and no current CDS (Controlled Dangerous Substance) license.

Review of the credentialing file on 01/26/10 at 1:50 p.m. for S7, MD revealed it contained no current Data Bank Query, no documented evidence of annual TB (Tuberculosis) screening, no current CDS (Controlled Dangerous Substance) license, and no documented evidence of current Malpractice Insurance.

In an interview on 01/26/10 at 2:00 p.m. with S1, Administrator she confirmed these are required components of a complete Physician Credentialing File.

Based on record reviews (medical records, contracted radiology service contract) and interview the hospital failed to ensure the contracted radiology service was in compliance with it's contractural obligation to provide a completed x-ray report with 12 hours for 1 of 9 sampled patients, (#3). Findings:

Review of the medical record for patient #3 on 01/26/10 at 8:45 a.m. revealed an order dated 01/22/10 (no time documented) for an x-ray of the left foot/ankle of #3.

Review of the report generated by the contracted radiology service revealed a service date of 01/24/10, time of service 3:25 p.m., 2 days after being ordered.

Further review of the report generated by the contracted radiology service revealed a report date of 01/24/10 at 4:46 p.m., 2 days after the x-ray was ordered.

This finding was confirmed by S1, Administrator and S2, DON on 01/25/10 at 1:20 p.m.

Review of the contract with the contracted radiology service on 01/25/10 at 1:00 p.m. under "9. Same Day Service" reads in part: "(D) "Service will be provided on a first call basis (Average time of 2 hours) but will always be within 12 hours of the "request for service"....." Under "11. Reports" the contract reads in part: "(A). A "Completed Electronically Signed Report" will be faxed....the final written report will be provided within (12) hours of the initial call for services."