HospitalInspections.org

Based on record review and interview, the medical staff failed to follow their medical staff bylaws and failed to conduct the initial focused professional practice evaluation (FPPE) proctoring recommendations on 1 of 2 physicians requiring FPPE (Physician R) of 5 credentialing and privileging records reviewed, in a total of 9 physicians on the medical staff.

Findings include:

Record review of "Hospital Credentialing/Privileging Plan" #11023487, last approved 1/13/2022 revealed "privilege determinations, to be made in connection with periodic reappointment or otherwise, shall include observed clinical performance and documented results of the patient care audit... shall be added to and maintained in the hospital's file established for members of the medical staff."

Record review of "Initial Focused Professional Practice Evaluation Plan," not dated, listed for Psychiatrist under column titled "FPPE (focused professional practice evaluation) Activities"revealed "Review of at least 5 medical records monthly... Review of any pharmacy data related to errors, therapeutic duplication, pharmacy interventions monthly. Minimum of five (5) staff (RN and Therapists) interviews will be conducted during provisional period."

On 4/05/2023 from 4:50 PM to 5:20 PM during review of credentialing files with Executive Assistant Z. Credentialing record review of Physician R revealed Physician R start date of 2/22/2022. Letter of approval of Medical Staff status dated 2/22/2022 revealed "you have successfully completed the FPPE process and the Governing Board has granted you full status." Request was made to view the initial FPPE results for Physician R.

On 4/06/2023 at 10:15 AM during interview with Director of Clinical Services C, Interim Chief Executive Officer/Divisional Vice President (CEO) J, and Executive Assistant Z, when asked for initial FPPE for provisional status for Physician R when s/he was hired 2/22/2022, Executive Assistant Z stated there was none. Director of Clinical Services C stated Physician R left and came back and CEO J confirmed that by shaking his/her head. CEO J stated "medical records" would have that documentation. .

On 4/06/2023 at 10:58 AM during interview with Director of Health Information Management L, Director L confirmed s/he had no further FPPE documentation on Psychiatrist R.

Based on record review and interview, the Medical Executive Committee (MEC) failed to follow their Medical Staff Bylaws by failing to provide oversight of the evaluation of the credentialing and privileging process in 2 of 2 emergency privileges given to medical physicians (Physician X and Physician Y) and failed to communicate the MEC recommendations to the Governing Board for approval of privileges in 7 of 9 physicians (Physician AA, Q, R, BB, EE FF and GG) applying for initial privileges or change in Medical Staff appointments in a total medical staff of 9 physicians.

Findings include:

Record review of policy "Credentialing/Privileging Plan" #11023487 last revised 9/10/2021 revealed "A request for clinical privileges shall be evaluated on the basis of the professional's license, education, training, experience, demonstrated current competence and judgment, and physical and mental health status... The following are specific criteria to be used as part of the decision-making process of granting specific clinical privileges" which includes... documentation of all training, and continuing demonstration of competency evidenced by at least twenty hours of continuing education for the past two years, specific to privileges requested.

Record review of approval of provisional privileges for Medical Physicians X and Y, dated 3-23-2023, was signed by Interim Chief Executive Officer (CEO) J. There was no date or time when CEO J signed the approvals.

Record review of letters to Physicians X & Y regarding "Emergency Privileges Granted - Effective: 3.23.23" revealed "Based upon a review of required documents by the CEO and Medical Director, you are hereby granted emergency privileges as an Internal Medicine/Family Practice Physician with the following privileges: History and Physical Examination, General Medical Management and EKG [electrocardiogram) Interpretation (Internal Medicine Only)".

On 4/05/2023 at 12:00 PM during telephone interview with Interim Medical Director (MD) N, MD N stated s/he had not not been provided, nor has s/he reviewed any documents for credentialing of Physicians X and Y. MD N stated Interim Chief Executive Officer/Division Vice President J, Chief Financial Officer V, and President W of the health care system, "told" me on a telephone call "that I signed and agreed" to the recommendation for privileging of Physicians X and Y.

Record review of the Medical Staff Bylaws approved by the Interim Medical Director 1/22/2022, under Medical Executive Committee (MEC), Composition, revealed MEC shall consist of Members, "a majority of who shall be fully licensed physician Members of the Active Staff." Under MEC Duties revealed "receive and act upon reports and recommendations from ... quality management activities... recommend to the [Governing] Board all matters relating to appointments, reappointments."

Record review of MEC meeting minutes dated 10/24/2022 under new business, Credentialing, under Reappointments - Approved revealed Physician AA, "extended through 2/12/23," Physician Q "extended through 2/25/23," Physician R "extended through 2/25/23."

Record review of MEC meeting minutes dated 11/28/2022 under New Business, Credentialing, New Appointments - Approved revealed Physician BB - "recommended to the active medical staff with initial provisional status." Under Moves from Provisional to Full medical staff status - "APPROVED"- Physician AA, Physician CC, Physician Q listed.

Record review of MEC "ad hoc" meeting minutes dated 12/12/2022 under Credentialing/Privileging "None" was listed.

Record review of Governing Board Meeting minutes from last quarter of the year (October, November and December 2022) dated 12/30/2022 at 11:00 AM under New Business Credentialing/Privileging of Active Medical Staff revealed Physician EE "from Provisional to Full Status," Physician FF "Extending Provisional Status to 2.28.2023," and Physician GG "Extending Provisional Status to 2.28.2023." (There were no recommendations for these physicians in the MEC meeting minutes.) Recommendations from the MEC meeting minutes for the initial provisional status for Physician BB, approval of extensions for Physician AA, Physician R, and Physician Q, and recommendation from Provisional to Full/Active medical staff for Physician Q, Physician AA, and Physician CC, were not documented in the Governing Board meeting minutes.

On 04/06/2023 at 10:15 AM during interview with Interim Chief Executive Officer/Divisional Vice President (CEO) J, and Director Clinical Services C, Director C stated the MEC makes recommendations to the Governing Board regarding the credentialing and privileging of their providers. When asked if all recommendations of credentialing and privileging go through the MEC, CEO J stated, "yes" sometimes we discuss them in "ad hoc" meetings and not all the members of the MEC are present.

On 04/06/2023 at 12:15 PM during interview with Executive Assistant Z, when asked for Governing Board meeting minutes from the last 6 months, Assistant Z stated "that's all we have."

Based on record review and interview, the Medical Executive Committee failed to provide an organized accountable structure who provides information to the Governing Board on the quality of the medical care provided to patients as evidenced in 5 out of 6 months of Medical Executive Committe meeting minutes (10/24/2022, 11/28/2022, 12/12/2022, 1/23/2023, and 2/01/2023) reviewed.

Findings include:

Record review of the Medical Staff Bylaws approved by the Interim Medical Director 1/22/2022, under Medical Executive Committe (MEC), Composition, revealed MEC shall consist of Members, "a majority of who shall be fully licensed physician Members of the Active Staff. The Medical Director shall be a member and serve as chair of the MEC. The CEO shall be an ex officio member. The CEO shall attend every meeting of the MEC." Under MEC Duties revealed "receive and act upon reports and recommendations from ... quality management activities... recommend to the Board all matters relating to administrative remedies, quality management activities and corrective action... account to the Board and to the Staff for the overall quality, uniformity, and efficiency of medical care rendered to patients."

Record review of attendance of the Medical Executive Meeting minutes September 2022 through February 2023 revealed 10/24/2022 - interim psychiatrist/chief medical officer (CMO) N, interim CEO, and 3 other attendees, 11/28/2022 with interim psychiatrist/CMO N (by phone), interim CEO, and 4 other attendees, 12/12/2022 - under "CALL TO ORDER" revealed "This meeting was held via e-mail communication to the Committee Members on December 12, 2022," no members were listed, 1/23/2023 - medical physician O, interim CEO, interim psychiatrist/CMO N (by phone), interim CNO and 2 other attendees, and 2/01/2023 - interim psychiatrist/CMO N, medical physician O and 4 other attendees (no CEO). 2 of the 5 meetings had 2 licensed physicians with 1 holding an interim position, the majority of the attendees of each meeting were not physician members of the active staff. There was nothing in the minutes listed under the columns "Action Taken" and "Follow-up."

On 4/05/2023 at 9:25 PM during interview with Director Clinical Services C, Director C stated it is difficult to make changes for improvement of patient care when there is so much turn-over in the Director of Nursing and physician positions, stating it is hard to determine "issues to focus on."

On 4/05/2023 at 12:00 PM during telephone interview with interim Chief Medical Officer (CMO) N, CMO N stated information is not shared between the CEO and medical staff and stated information shared in MEC, "they" meaning the AdHoc Governing Board "don't use."

Based on record review and interview, the nursing staff failed to complete an evaluation on 1 of 10 inpatient admissions (Patient #4) in a total of 10 medical records reviewed.

Findings include:

Record review of policy "Initial Nursing Admission Assessment" #11023315, effective 1/13/2022 revealed "each patient will be assessed by a registered nurse within eight (8) hours of admission."

Patient #4's medical record was reviewed and revealed Patient #4 was a 15-year-old who was voluntarily admitted 3/27/2023 for suicidal ideations with a diagnosis of severe major depressive disorder with psychotic features and remains inpatient. The nursing assessment remains blank.

On 4/06/2023 at 12:23 PM during interview with Clinical Services Director C while reviewing findings, Director C stated "I don't know what happened with that one."

Based on record review and interview, the medical staff failed to complete progress notes on 3 of 9 patients requiring progress notes (Patient # #5, #2 and #7) in a total of 10 medical records reviewed.

Findings include:

On 4/04/2023 at 2:00 PM review of Patient #2's medical record revealed patient was a 21-year-old admitted voluntarily on 3/29/2023 for acute psychosis and remains inpatient. There were no psychiatric progress notes in this medical record for 3/30/2023, 3/31/2023, 4/01/2023, and 4/02/2023.

On 4/04/2023 at 12:45 PM review of Patient #5's medical record revealed patient was a 51-year-old was admitted voluntarily on 3/23/2023 for depression and suicidal ideation and was discharged 4/03/2023. Psychiatric progress notes were missing on 3/25/26, 3/26/2023, 3/27/2023, 3/30/2023, and 4/01/2023.

On 4/06/2023 at 10:12 AM review of Patient #7's medical record revealed patient #7 was a 15-year-old admitted voluntarily on 3/17/2023 with worsening symptoms of psychosis, depression, and suicidal ideation's and remains inpatient on 4/06/2023. Psychiatric progress note were missing on 3/18/2023, 3/22/2023, 3/24/2023, 3/25/2023, 3/26/2023, 3/28/2023, 4/01/2023, 4/02/2023, 4/03/2023 and 4/04/2023.

On 4/06/2023 at 12:23 PM during interview with Clinical Service Director C, Director C stated a minimum of "5 progress notes" are required every 7 days and confirmed there were missing progress notes in Patient #2, #5 and #7's medical records.

Based on record review and interview, the facility failed to provide therapeutic services by failing to develop a treatment plan for 1 of 10 patients admitted to the facility (Patient #6) in a total of 10 medical records reviewed.

Findings include:

Record review of "Interdisciplinary Patient Centered Care Planning" policy #11022911 effective 1/13/2022, under Procedure revealed "The Nurse completing the Nursing Assessment or designee shall develop the initial Treatment Plan within eight (8) hours of admission."

Patient #6's medical record was reviewed and revealed Patient #6 was a 34 year-old who was voluntarily admitted 4/01/2023 with suicidal ideation and a diagnosis of borderline personality disorder and discharged 4/03/2023. There was no treatment plan in Patient #6's medical record.

On 4/06/2023 at 12:23 PM during interview with Clinical Service Director C, when told Patient #6 was admitted on a Saturday, Director C confirmed, "yes," there still should be a treatment plan.