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Based on record review and interview the hospital failed to ensure that all physicians who are currently providing care and treatment to patients in the hospital have current written appointment to the Medical Staff, based on recommendation of the Medical Staff, by the Governing Body for 3 of 3 physicians currently providing care at the Hospital. (S7, Medical Director/Attending; S8, Family Practice/Attending; and S11, Family Practice/Attending) Findings:

Review of the credentialing file for S7MD, Medical Director, on 03/15/11 at 1:00 p.m. revealed no documented evidence of current appointment to the Medical Staff from the Governing Body, no current CDS (controlled dangerous substance) license, no current documentation of malpractice insurance, and no documentation of approval of delineation of privileges requested.

Review of the credentialing file for S8MD, Family Practice/Attending physician, on 03/15/11 at 1:10 p.m. revealed no documented evidence of current appointment to the Medical Staff from the Governing Body, no current CDS (controlled dangerous substance) license, no current documentation of malpractice insurance, and no documentation of approval of delineation of privileges requested.

Review of the credentialing file for S11MD, Family Practice/Attending physician, on 03/15/11 at 2:00 p.m. revealed no documented evidence of current appointment to the Medical Staff from the Governing Body, no current CDS (controlled dangerous substance) license, no current documentation of malpractice insurance, and no documentation of approval of delineation of privileges requested.

In an interview on 03/15/11 at 1:00 p.m. with S1Admin and S7MD, Medical Director, both confirmed that there was no current Governing Body approval for S7MD, S8MD, or S11MD. Both stated that the person responsible for re-credentialing had left employment with the hospital approximately one year ago and the hospital failed to reappoint the duties of Medical Staff re-credentialing.

Review of the Medical Staff By-Laws, Attachment III, Membership, last revised November 1, 2003, revealed: "...Section 3. Appointments. Appointments of physicians and dentists to the Medical Staff shall be made by the Administrator and Medical Director and shall be subject to renewal every two years...Section 4. Procedure of Appointment. A. Application for membership on the Medical Staff shall be presented to the Administrator in writing, stating the qualifications and references to the applicant and shall also signify his/her agreement to abide by the By-Laws, Rules and Regulations of the Medical Staff. B. An application must be made in writing to include but not necessarily limited to: 1. Personal Identification Data. 2. Identification numbers. 3. Specialty information. 4. Clinical Privileges - other hospitals. 5. Professional liability information. 6. Status category - active or consulting. 7. Consent and release from liability. 8. Privileges required...Applications for re-appointment must be completed every two (2) years. Copies of the following documents must be supplied when applicable with an application for initial appointment or re-appointment every two (2) years: a. Current license to practice. b. Narcotic registration's certification (State and Federal). c. Professional liability insurance policy and certification of coverage from carrier. d. Evidence of board certification. e. Two (2) letters of recommendation from colleagues in your specialty that can verify your competency. f. CPR (cardiopulmonary resuscitation) and ACLS (advanced cardiac life support). g. Documentation of Continuing Medical Education. C. After due investigation of the applicant, in regards to his/her personal and professional qualifications, the Administrator, after counsel with the Medical Staff, shall decide if the application is to be accepted, deferred, rejected. The final responsibility shall rest with the Administrator..."

Review of the Governing Body By-Laws, last revised October 21, 2004, revealed in part: "...Article II. Purpose. It shall be the purpose of this organization to provide medical care and treatment, of the highest quality, for all patients admitted to Villa Feliciana Medical Complex. In order to maintain such service, each physician assumes responsibility for carrying out the following duties:..2. The adoption of by-laws conforming to the principles expressed by the Conditions for Participation in the Medicare Program and the Minimum Standards for Hospitals...Article III. Membership. Section 1. Qualifications. Each member of the Medical Staff shall be...licensed to practice in the State of Louisiana...Section 3. Appointments. Appointments of physicians and dentists to the medical staff shall be made by the Administrator upon recommendation from the credentials committee, and shall be renewed every two years...Section 4. Procedure of Appointment. A. Application for membership on the Medical Staff shall be presented to the Administrator in writing, stating the qualifications and references to the applicant and shall also signify his/her agreement to abide by the By-Laws, Rules and Regulations of the Medical Staff. B. An application must be made in writing to include but not necessarily limited to: 1. Personal Identification Data. 2. Identification numbers. 3. Specialty information. 4. Clinical Privileges - other hospitals. 5. Professional liability information. 6. Status category - active or consulting. 7. Consent and release from liability. 8. Privileges requested...Applications for re-appointment must be completed every two (2) years. Copies of the following documents must be supplied when applicable with an application for initial appointment or re-appointment every two (2) years: a. Current license to practice. b. Narcotic registration's certification (State and Federal). c. Evidence of board certification. d. Two (2) letters of recommendation from colleagues in your specialty that can verify your competency. e. CPR (cardiopulmonary resuscitation) and ACLS (advanced cardiac life support). e. Documentation of Continuing Medical Education. f. Copy of privileges requested. After due investigation of the applicant, in regards to his/her personal and professional qualifications, the Administrator, after counsel with the Medical Staff, shall decide if the application is to be accepted, deferred, rejected. C. The final responsibility for the appointment or cancellation shall rest with the Administrator..."

Based on record review and interview, the facility failed to ensure that nursing staff developed a nursing care plan for each patient in 1 of 16 closed charts from a total sample of 18 patients (#9). Findings:

Review of the chart for patient #9 revealed she was admitted to the facility on 1/12/11 with diagnoses including leukocytosis, UTI, COPD and hypoxia. The patient was discharged on 1/20/11, and a nursing care plan was not developed during her stay at the hospital. Review of the Hospital/ICU Care Plan reflected it was blank and had no documentation on it.

Interview with S2 RN/DON on 3/15/11 at 3:00 p.m. confirmed the nursing care plan had not been developed and was blank. She indicated all patients should have a nursing care plan developed upon admission.

Based on record review and interview, the facility failed to ensure all MD verbal and/or telephone orders were authenticated via signature with a date and time consistent with hospital policies and procedures for 3 of 16 closed records from a total sample of 18 patients (#7, #9 and #13). Findings:
1. Patient #7
Review of patient #7's physician's orders revealed S8MD authenticated verbal/telephone orders via signature without documenting the date and time of his signature on the following: 1/8/11 @ 7:20 a.m. and 3:50 p.m.; 1/11/11 @ 8:00 a.m.; 1/16/11 @ 8:20 p.m.; 1/17/11 @ 9:00 a.m. and 1/19/11 @ 1:45 p.m.
2. Patient #9
Review of patient #9 ' s physician ' s orders revealed S8MD authenticated verbal/telephone orders via signature without documenting the date and time of his signature on the following: 1/12/11 @ 8:40 a.m. and 6:45 p.m.; 1/14/11 @ 3:55 a.m.; 1/18/11 @ 10:55 a.m.; 1/18/11 @ 10:00 a.m. and 1/19/11 @ 12:45 p.m. and 4:35 p.m.
3. Patient #13
Review of the medical record for patient #13 reflected verbal orders were written on 2/10/11 @ 7:20 p.m.; 2/11/11/ @ 7:25 a.m.; 2/12/11 @7:15 a.m. and 12:30 p.m.; 2/14/11 @7:30 p.m.; 2/15/11 @ 1:00 a.m., 10:40 a.m. and 7:30 p.m.; 2/16/11 @7:00 p.m. and 2/18/11 @ 7:20 p.m. There was no documentation to reflect the physician signed, dated and/or timed the verbal orders as per the facility's policy.
Review of the facility's current policy on Resident Charts - Physician Responsibilities dated 2/27/03 revealed the attending physician would complete, or have completed under his supervision, all verbal orders with a dated countersignature.
Review of a Memorandum dated 10/7/10 that was sent to all nursing staff at the facility and written by S2DON reflected all verbal and telephone orders must be signed, dated and timed by the ordering physician within 48 hours.
Interview with S2DON on 3/15/11 at 3:00 p.m. confirmed the MD should date and time his signature authenticating a verbal and/or telephone order. She stated she had written the above memorandum in October, 2010 to address the above issue.

Based on record review and interview, the facility failed to ensure all orders, including verbal and telephone orders, were authenticated by the ordering physician in accordance with hospital policy to include a read-back and verification process for 3 of 16 closed charts from a total sample of 18 patients (#7, #9 and #13). Findings:

1. Patient #7

Review of the chart for patients #7 revealed the nurse did not ensure a read-back and verification process was completed/documented when verbal/telephone orders were obtained from the MD on the following dates and times: 1/8/11 @ 5:00 a.m., 7:20 a.m. and 3:50 p.m.; 1/11/11 @ 8:00 a.m. and 11:40; 1/16/11 @ 8:20 p.m.; 1/17/11 @ 9:00 a.m. and 1/19/11 @ 1:45 p.m.

2. Patient #9

Review of the chart for patients #9 revealed the nurse did not ensure a read-back and verification process was completed/documented when verbal/telephone orders were obtained from the MD on the following dates and times: 1/12/11 @ 8:40 a.m. and 6:45 p.m.; 1/14/11 @ 3:55 p.m.; 1/18/11 @ 10:55 a.m.; 1/18/11 @ 10:00 p.m. (late entry) and 1/19/11 @ 12:45 p.m. and 4:35 p.m.

3. Patient #13
Review of the medical record for patient #13 reflected verbal orders were written on 2/10/11 @ 7:20 p.m.; 2/11/11/ @ 7:25 a.m.; 2/12/11 @7:15 a.m. and 12:30 p.m.; 2/14/11 @7:30 p.m.; 2/15/11 @ 1:00 a.m., 10:40 a.m. and 7:30 p.m.; 2/16/11 @7:00 p.m. and 2/18/11 @ 7:20 p.m. There was no documentation to reflect the verbal orders were dated and timed when authenticated by the physician.
Review of a Memorandum dated 10/7/10 that was sent to all nursing staff at the facility and written by S2DON reflected when verbal and telephone orders were issued, they must be written and read back to the physician.
Interview with S2DON on 3/15/11 at 3:00 p.m. revealed the facility did not have an actual policy and procedure regarding read-back order verification. She stated she had issued the above memorandum to staff to ensure all orders were being written and read back to the MD for verification.

Based on record review and interview the hospital failed to ensure there was an agreement with a tissue and eye bank. Findings:

Review of the hospital contract with an OPO (Organ Procurement Organization) revealed it was not signed by a representative of the hospital.

Review of a letter dated March 09, 2010 from the former Administrator of the hospital revealed: "...Although the 334 beds are licensed ...as hospital beds, the beds are actually surveyed utilizing the Centers for Medicare and Medicaid Services' long term care standards..."

In an interview on 03/14/11 at 2:30 p.m. with S2DON she confirmed the hospital has 37 acute care beds and that the hospital has no current contract with an OPO.

Based on record review and interview, the hospital failed to implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program by failing to implement identified priorities for its performance improvement activities that are focused on high-risk or problem-prone areas that affect health outcomes, safety, and/or quality of care. This was evidenced by the hospital's failure to implement an effective system that included the identification of a breakdown in the credentialing process by not ensuring members of the hospital's medical staff were credentialed to practice medicine in the hospital. Findings:


The credentialing files for S7MD (Medical Director), S8MD (Family Practice/Attending physician), and S11MD (Family Practice/Attending physician) were reviewed. This review revealed no documented evidence to indicate that these practitioners were credentialed by the hospital as documented in the hospital bylaws resulting in the hospital's inability to ensure 1) the practitioners maintained a current medical license; 2) the practitioners maintained a current CDS license; 3) the practitioners maintained a current DEA license; 4) the practitioners were covered under malpractice insurance; and 4) the current delineation of privileges were granted in order to provide care to patients in the hospital.

In an interview on 03/15/11 at 1:00 p.m. with S1Administrator and S7MD, Medical Director, both confirmed that there was no current Governing Body approval for S7MD, S8MD, or S11MD. Both stated that the person responsible for re-credentialing had left employment with the hospital approximately one year ago and the hospital failed to reappoint the duties of Medical Staff re-credentialing.

The Governing Body By-Laws were reviewed. Documentation revealed that each member of the Medical Staff shall be licensed to practice in the State of Louisiana and that appointments of physicians and dentists to the medical staff shall be made by the Administrator upon recommendation from the credentials committee, and shall be renewed every two years. Documentation revealed that an application for membership of the Medical Staff shall be presented to the Administrator in writing and shall include but not necessarily limited to: 1. Personal Identification Data. 2. Identification numbers. 3. Specialty information. 4. Clinical Privileges - other hospitals. 5. Professional liability information. 6. Status category - active or consulting. 7. Consent and release from liability.

The hospital's QAPI (Quality Assurance Performance Improvement) data was reviewed. This review revealed no evidence to indicate that the hospital had identified, and implemented corrective action, relating to the breakdown in the credentialing process by not ensuring members of the hospital's medical staff were credentialed to practice medicine in the hospital. Review of the minutes from the most recent two (2) meetings of the QA committee (meetings dated 12/16/11 & 01/20/11) revealed no documentation regarding the credentialing process.

The Director of Nursing was interviewed on 3/15/11 at 2:55 p.m. The Director of Nursing confirmed that the hospital's QAPI program failed to identify and implement corrective action relating to the breakdown in the credentialing of members of the medical staff.