HospitalInspections.org

Based on review credential files, Board meeting minutes review, and interview, it was determined the Board failed to document the appointment or reappointment of six of six medical staff members reviewed to the medical staff. The failed practice did not ensure the hospital staff had completed information on the member of the medical staff and had the likelihood to affect all patients treated by the medical staff. The findings follow:

A. Review of the credential files for six of six medical staff members, the Board approval document did not include appointment status. The form titled Physician Credentialing Appointment Status provided an option for the Board of Governors to select "Appointment Recommended", "Appointment Not Recommended" or "Appointment Deferred" and also has a blank for Comment and a signature. Four of six had a signature and did not include a selection of one of the three options. Two of six did not have a signature and did not include a selection of one of the three options.
B. Review of the Board meeting minutes from April 2023 to April 2024 showed there was no evidence of actions by the Board regarding medical staff appointment.
C. The findings of A and B were confirmed in an interview with the Chief Executive Officer on May 15, 2024 at 2:30 PM.

Based on physician credential file review, Medical Staff Bylaws review and interview, it was determined the Medical Staff failed to reappraise the privileges for six of six Medical Staff members reviewed. The failed practice did not ensure the medical staff was practicing with appropriate credentials and had the likelihood to affect all patients treated by the medical staff. The findings follow:

A. Review of medical staff credential files showed the delineation of clinical privileges list (a list indicating the care and treatment medical staff have been given authority to perform at this facility) for five of six medical staff members were incomplete. The medical staff credential files contained several different versions of a delineation of clinical privileges list (LIST).
1) One of the LIST had a line at the top of the page to document the physicians's name. In two of six this line was blank.
2) One of the LIST had the option for the physician to indicate which privilege was "requested" with a second and third section to document if the privilege was "approved" or "denied". The "approved" or "denied" was not completed for any of the privileges "requested" in one of six files reviewed.
3) The letter sent from the facility to the medical staff member indicating appointment or re-appointment stated the appointment was for a two year term. The clinical privileges for one of six medical staff members had a form dated 12/12/15 with Medical Executive Committee approval. The file did not contain a form indicating Governing Body approval. There were letters dated February 1, 2018, June 19, 2021, and March 23, 2023 granting re-appointment for a two year term. The time between each of the four dates exceeded two years. Interview with the Chief Executive Officer (CEO) confirmed the medical staff member was providing patient care during the times exceeding two years.

B. The findings were confirmed in an interview with the CEO on May 15, 2024 at 2:30 PM.

Based on policy and procedure review, Infection Prevention and Control Committee Meeting minutes review and interview, it was determined the facility failed to conduct bi-monthly (every two months) infection prevention and control meetings for two (November 2023 and March 2024) of six (May 2023 through March 2024) meetings reviewed. The failed practice did not ensure the infection control committee was up-to-date on the infection control concerns in the facility. The failed practice had the likelihood to affect all patients seen in the facility. Findings follow:

A. Review of the facility's policy titled, "Infection Control Manual," with a revision date of 6/2023 showed the Infection Control Committee was responsible for the determination of all hospital policy related to infection control including bi-monthly meeting were required but may be held more often if necessary.
B. Review of the facility's policy titled, "Infection Control Officer Duties," with a revision date of 6/2023 showed, "Bimonthly: hold an Infection Control meeting every other month."
C. Review of the Infection Control Committee Meeting minutes from May 2023 to March 2024 showed there was no evidence an infection control committee meeting was conducted in November 2023 or March 2024.
D. The findings in A through C were confirmed in an interview with the Chief Nursing Officer on 05/15/2024 at 10:00 AM.



Based on policy and procedure review, Infection Prevention and Control Committee Meeting minutes review and interview, it was determined the facility failed to ensure a physician member of the infection control committee was present during the infection control committee meetings for six of six (May 2023 through March 2024) meetings reviewed. The failed practice did not ensure physician input and involvement was given to direct the infection control committee. The failed practice had the likelihood to affect all patients seen in the facility. Findings follow:

A. Review of the facility's policy titled, "Infection Control Manual," with a revision date of 6/2023 showed, "Infection Epidemiologist/Chairman job description and requirements: Physician with knowledge of epidemiology and infectious disease and familiarity of fundamental biostatistics; Must be a member of Infection Control Committee, rotation of this is position will be infrequent as possible so skills and familiarity can be developed."
B. Review of the Infection Control Committee Meeting minutes from May 2023 to March 2024 showed there was no evidence an infection control committee meeting was conducted in November 2023 or March 2024. There was no evidence of a physician present during the meetings on 05/12/2023, 07/21/2023, 09/25/2023 or 01/19/2024.
C. The findings in A and B were confirmed in an interview with the Chief Executive Officer on 05/25/2024 at 3:25 PM.

Based on observation, review of the Daily Hydrocollator Temperature Record and interview, it was determined the facility failed to ensure the hydrocollator's temperature was verified daily to be in a safe operating temperature range when in use for 44 of 44 (04/01/2024 to 05/14/2024) days. The failed practice placed patients at risk of skin burns from heating pads being used out of established temperature ranges. The failed practice had the likelihood to affect all patients on which a heating pad from the hydrocollator was used. Findings follow:

A. Observation of the Physical Therapy Department on 05/14/2024 at 1:10 PM showed a hydrocollator being used to heat pads for patient use.
B. Review of the Daily Hydrocollator Temperature Record on 05/14/2024 showed there was no evidence the hydrocollator's temperature was recorded from 02/23/2024 to 05/14/2024.
C. In an interview with Physical Therapy Director on 05/14/2024 at 1:10 PM, he stated the hydrocollator had not been used for patient care from 02/23/2024 to 04/01/2024. The Physical Therapy Director checked the temperature of the hydrocollator at that time and the temperature was 145 degrees Fahrenheit. He confirmed there was no evidence the temperature was recorded from 04/01/2024 to 05/14/2024.



Based on observation and interview, it was determined the facility failed to ensure expired supplies (Intravenous (IV) solutions) were not available for patient use. The failed practice did not ensure the efficacy of the IV solutions and had the likelihood to affect all patients receiving IV fluids. Findings follow:

A. Observation of the Supply Room on 05/14/2024 at 1:40 PM showed the following expired IV solutions:
1) Five D5NS (Dextrose 5% and Normal Saline) 1000 mL (milliliters) expired April 2024.
2) Three LR (Lactated Ringers) 1000 mL expired January 2024
3) One D5 1000 mL expired November 2023
4) Fiver D5 1000 mL expired April 2023
B. The findings in A were confirmed in an interview with the Chief Nursing Officer on 05/14/2024 at 1:40 PM.