HospitalInspections.org

Based on review of two active staff members credential files and interview with staff the facility failed to ensure that the Medical Staff conducted appraisals and reappointments of its members as required by medical staff bylaws.

Findings were:

Based on review of the credentialing files of the two active physicians, there was no current information in 2 of 2 files for recredentialling. The latest complete credentialing process was in 2002.
Interview with the administrator confirmed these findings on 12/20 in the workroom.

Based on review of the log of fire drills and interview with staff, the hospital failed to ensure that staff were prepared in safety measures in the event of a fire, as only one fire drill had been held in 2011.

Findings were:

Review of the fire drill log revealed only one fire drill held in the calendar year 2011, as of 12/20/11. Interview on 12/20 in the work room with the administrator and nursing director confirmed only one fire drill had been held in 2011.

Based on review of the swing bed policy manual, 3 swingbed clinical records and interview with staff, there were no social services provided to residents as there was not a social worker employed or contracted to provide services to the hospital or swingbed patients.

Findings were:

Based on review of three swingbed clinical records, there was no documentation of any social service interview or services provided in 3 of 3 records. Interview with staff revealed that there is not a social worker employed or contracted to provide services to the hospital. These findings were confirmed in interview with the nursing director on 12/20/11 in the workroom