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Based on interview and record review, the hospital failed to ensure the medical staff memberships were properly processed and approved as evidenced by:

1. The medical staff failed to ensure the Governing Body approved the reappointments of MD 1, MD 2, and NP 1. Required approvals from the Credentialing Committee and Board of Trustees were either missing or future-dated without proper review.

2. The hospital did not follow the reappointment process required by the Medical Staff Bylaws. The reappointment applications and updated health status for MD 1 and MD 2 were missing.

3. The hospital failed to complete and approve a new privilege form when NP 2 changed supervising physicians.

These failures created the increased risk that unqualified medical staff could provide medical services to the patients.

Findings:

1. During a review of Hospital's Medical Staff Bylaws under Article 4: "Procedures for Appointment & Reappointment," effective date 2/22/23, showed the following:

4.5.2. The Governing Body's Action. The Governing Body shall review any favorable approval and/or recommendation from the Medical Executive Committee and take action by adopting, rejecting, modifying or sending the recommendation back for further consideration. The Governing Body shall make its final determination if needed giving great weight to the actions, approvals and recommendations of the Medical Executive Committee.

During a concurrent interview and record review on 8/26/25 at 1040 hours, with the Quality Analyst and Director of PI/Risk Management, the credential files for MD 1 and MD 2 were reviewed.

a. During a concurrent interview and record review on 8/26/25 at 1040 hours, with the Quality Analyst, the credential file documentation for MD 1 was reviewed. The Quality Analyst stated MD 1 was reappointed to the hospital from 6/23/22 to 6/23/25. The Psychiatrist Privilege Request form dated 5/7/25, showed MD 1 requested privileges to practice in the hospital. The form was signed by the Medical Director and Medical Executive Committee on 8/27/25. Further record review failed to show signatures from the Credential's Committee and Board of Trustees on the form. However, the form was dated 8/27/25. The Quality Analyst stated the Governing Body meeting was scheduled on 8/27/25 and that the form was future-dated for the Credential's Committee and Board of Trustees.

b. During a review of MD 2's credential files, it showed MD 2 was reappointed to the hospital from 6/23/22 to 6/23/25. Review of the Psychiatrist Privilege Request Form dated 6/23/25, showed MD 1 requested privilege to practice in the hospital. Further record review showed the areas to sign for Medical Director, Credential's Committee, Medical Executive Committee, and Board of Trustee were left blank. The options of approved, denied, or deferred were also left blank.

c. During a review "Hospital's Medical Staff Bylaws" under Article 6: Allied Health Professionals. 6.2. Categories effective 2/22/23, showed the Governing Body shall determine, based upon comments of the Medical Executive Committee and such other information as it has before it, those categories of AHPs that shall be eligible to exercise privileges in the hospital.

During a concurrent interview and record review on 8/26/25 at 1245 hours, with the Quality Analyst, NP 1's credential files were reviewed. NP 1's credential file showed NP 1 was appointed to practice at the hospital from 6/23/22 to 6/23/25. Review of the Nurse Practitioner Privilege delineation dated 8/27/25, showed the Medical Director and Medical Executive Committee signed on the form. Further record review failed to show Credential's Committee and Board of Trustee signed on the form. However, the 8/27/25 was dated. The Quality Analyst stated the Governing Body meeting was scheduled for 8/27/25 and the Quality Analyst future-dated for Credential's Committee and Board of Trustee.

2. Review of Hospital's Medical Staff Bylaws under Article 4: "Procedures for Appointment & Reappointment," effective 2/22/23, showed the following:

4.4 Application for Initial Appointment and Reappointment. 4.4.1. Application Form. Practitioners applying for appointment and reappointment shall complete a written application form that seeks information regarding the applicant and documents the applicant's agreement to abide by the Medical Staff bylaws and Rules (including the standards and procedures for evaluating applicants contained therein) and to release all persons and entities from any liability that might arise from their investigation and/or acting on the application.

4.4.3. Basis for Reappointment. Recommendation for reappointment to the Medical Staff and for renewal of privileges shall be based upon a reappraisal of the member's health status, current proficiency in the hospital's general competencies in light of his/her performance at this hospital and in other settings.

During a concurrent interview and record review on 8/26/25 at 1040 hours, with the Director PI/Risk Management, MD 1 and MD 2's credential file were reviewed. MD 1 and MD 2's credential files failed to show the reappointment application and health status. The Director PI/Risk Management stated there was no application or updated health status required for reappointment because those were done during initial appointment.

3. During a concurrent interview and record review on 8/26/25 at 1315 hours, with the Quality Analyst, NP 2's credential file was reviewed.

During a review of the Nurse Practitioner Privilege Delineation for NP 2 dated 8/28/25, showed MD 3 agreed to be a supervising physician for NP 2.

During a review of the Letter in NP 2's credential files dated 8/21/23, the Letter showed NP 2 had requested a change on their privilege form. Effective, August 21, 2023, the practitioner's supervising physician was MD 1. The official privilege form would go through the next Credential, MEC and Governing Board meeting. Further credential record review failed to show the new Nurse Practitioner Privilege Delineation for NP 2 signed by MD 1 as supervising physician.

During an interview on 8/26/25 at 1415 hours, with the Director PI/Risk Management, the Director PI/Risk Management verified the above findings.

Based on interview and record review, the hospital failed to ensure the Medical Staff Bylaws were aligned with the hospital's P&P regarding the appointment/reappointment duration. This failure created the risk of poor health outcomes for the patients in the hospital.

Findings:

During a review of the hospital's "Medical Staff Governance and Credentialing Committee Minutes," dated 2/17/25, the "Medical Staff Governance and Credentialing Committee Minutes" showed to accept the change from two to three years between credentialing cycles.

During a review of the hospital's P&P titled "Appointment, Advancement and Reappointment to the Medical and Allied Staff," revised on 2/17/25, the P&P showed "... a practitioner's reappointment is scheduled for three years from the date of their initial staff appointment ..."

During a review of the "Medical Staff Bylaw," under Article 4: Procedures for Appointment & Reappointment revised on 5/12/25, the Procedures for Appointment & Reappointment showed "reappointment and privileges to be once every two years."

During an interview and concurrent record review on 8/26/25 at 1120 hours, the Director PI/Risk Management verified the above findings.

During an interview on 8/26/25 at 1120 hours, with the Director of PI/Risk Management, the Director of PI/Risk Management stated the above findings were accurate.