HospitalInspections.org

Based on a review of the Medical Staff By Laws, Rules and Regulations, as compared with the Active Medical Staff reappointment process and staff interview, the Medical Staff failed to follow the Rules and Regulations in the granting of privileges. This failed practice had the potential to affect all patients receiving services at the hospital. The acute patient census was 32 on the first survey day.

Findings are:

1. A review of the Medical Staff By Laws Rules and Regulations for Active Medical Staff - Appointment and Reappointment, specified on page 42, that the Medical Executive Committee would include 'Clinical Judgement and Technical Skill' in deciding whether to reappoint clinicians. On page 44, these same rules indicated that 'minimum threshold for procedures' would be established to determine competency.

2. Privileges were reviewed for a selected sample of 8 Active Medical Staff members (Physicians A, B, C, D, E, F, G and H). All 8 received privileges to perform Lumbar Punctures (removal of spinal fluid from around the spinal chord), Arthrocentesis ( aspiration of fluid from a joint or injection of medication into a joint), Thoracentesis (aspiration of excess fluid from the space between the chest wall and lungs).

3. An interview conducted with the Director of Quality (on 3-21-2018 at 5:50 P.M) revealed Physicians A & B (who were Internal Medicine Specialists) served as Hospitalists (treating only acute inpatients), Physicians F & G were Family Practitioners; Physicians E & H were Pulmonologists who primarily performed bronchoscopies (examination of the large passageways of the lungs).

4. According to this same interview, the Medical Executive Committee had failed to establish minimum thresholds for any of these procedures to assess physician competency, as the Rules and Regulations specified. In addition, the facility was unable to determine how many, or if any of each type of procedure had been performed, which doctors had performed them and what the outcomes had been. The file of Physician H (a Pulmonologist) included a list of broncoscopies performed and the dates, however, the patient outcomes were not included to assess the physician's competency.

5. For Active Medical Staff members to remain in good standing, on page 6 of these same Rules and Regulations, the priviledged staff were to attend at least 50% of the Medical Staff meetings. None of the 8 files reviewed included medical staff meeting attendance records. An interview with the Director of Health Information Management (on 3-21-2018 at 5:30 P.M), confirmed attendance records of medical staff meetings were not maintained in the individual physician reappointment files.