HospitalInspections.org

Based on document review and interview, the medical staff failed to enforce their bylaws for 1 of 2 physician (MD#2) credential files reviewed.

Findings included:

1. Review of the medical staff bylaws on 10-17-12 indicated medical staff appointments must not exceed 2 years; these bylaws were approved 5-24-10.
2. Review of MD#2's medical staff credential file on 10-17-12 contained a letter from Medical Staff Services, signed by MD#3, dated August 23, 2012, indicating the following: This letter is to notify you that your Medical Staff Membership and Clinical Privileges at IU Health Morgan Hospital expired as of Wednesday, August 22, 2012 due to non-compliance with the Medical Staff Reappointment Policy. You may not have privileges to attend, admit and/or operate within IU Health Morgan Hospital facilities after this date.
3. Review of the Physician Schedule for September 2012 on 10-17-12 indicated MD#2 worked in the Emergency Department (ED) on September 13, 2012 from 7:00 am to 7:00 pm and September 20, 2012 from 7:00 am to 1:00 pm.
4. Interview with B#2 on 10-17-12 at 1350 hours confirmed MD#2 does not have current privileges at the hospital
5. Interview with B#1 on 10-17-12 at 1400 hours confirmed MD#2 does not have current privileges at the hospital and worked in the ED on September 13, 2012 from 7:00 am to 7:00 pm and September 20, 2012 from 7:00 am to 1:00 pm.