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Based on review of facility documents, credentials files (CF) and staff interview (EMP), it was determined the facility failed to complete required professional Focused and Ongoing Professional Practice Evaluation review during the re-credentialing process before granting privileges for eight of nine credential files reviewed (CF1, CF2, CF3, CF4, CF5, CF6, CF7 and CF9).

Findings include:

Review on September 19, 2019, of the facility's Medical Staff Bylaws, last reviewed and approved September 13, 2019, revealed "... 4.4 Reappointment ... 4.4.3-k relevant specific information from Hospital performance-improvement activities, which is reviewed and compared to aggregate data where appropriate for comparison and evaluation of professional performance, judgement, and skills: such information may be obtained form (among other sources) the following processes: (1) medical assessment and treatment of patients; (2) use of medications; (3) use of blood and blood components; (4) use of operative and other procedures; (5) efficiency of clinical practice patterns; (6) significant departures from established patterns or standards of clinical practice; (7) education of patients and families; (8) coordination of care with other practitioners and hospital personnel, as relevant to the care of individual patients; and (9) accurate, timely, and legible completion of patients' medical records ..."

Review on September 19, 2019, of the facility's "Ongoing and Focused Professional Practice Evaluation" policy, last reviewed/revised June 1, 2017, revealed "1.1 Purpose and Scope The organized medical staff has a leadership role in the organizations' Performance Improvement activities. When the performance of a process is dependent on activities of one or more individuals with clinical privileges, the Medical Staff provides leadership for the process measurement, assessment and improvement activities. ... The emphasis of Performance Improvement is the Evaluation and Improvement of Processes and Outcomes. the Medical Executive Committee has the responsibility to ensure Performance /Quality Improvement and Ongoing/Focused Professional Practice Evaluations are perused, activities and functions are performed in a timely and responsible manner, and in compliance with requirements as outlined is the Medical Staff Governing documents and in the current Joint Commission standards. Focused Professional Practice Evaluation (FPPF): Applies to a Provisional practitioner in the Medical or AHF Staff, which the hospital does not have evidence of competently performing the requested privilege(s) at the organization. It may also apply when a question arises concerning the ability of a practitioner with current privileges to provide safe, high-quality care. All privileged practitioners will be subject to the requirements of this policy. Ongoing Professional Practice Evaluation (OPPE): Is the process utilized for the Active, Consulting and Courtesy Staff members and AHP Staff members, ensuring the provision of high quality and safe patient care of ALL practitioners who are granted privileges. The process is designed to identify negative practice trends that may affect quality of care and patient safety in a timely manner, allowing early intervention with the practitioner in question. Information resulting from the Ongoing Professional Practice Evaluation (OPPE), is utilized to determine whether to continue, limit, or revoke (any) existing privileges(s). ... 3.2 Medical Staff Peer Review Derogatory Findings Process Purpose: To define process to follow when deficiencies are noted by the Physician Peer Reviewer in order to take appropriate and necessary action. ... All correspondence will be permanently filed in the physician Quality Review folder which is reviewed each time at ReAppointment."

Review of CF1 on September 19, 2019, revealed the facility re-credentialed and granted this physician privileges for March 30, 2018 to March 30, 2020. There was no documentation the facility completed the required Focused and Ongoing Professional Practice Evaluation during the re-credentialing process before granting privileges for CF1.

Review of CF2 on September 19, 2019, revealed the facility re-credentialed and granted this physician privileges for November 29, 2018 to November 29, 2020. There was no documentation the facility completed the required Focused and Ongoing Professional Practice Evaluation during the re-credentialing process before granting privileges for CF2.

Review of CF3 on September 19, 2019, revealed the facility re-credentialed and granted this physician privileges for November 10, 2017 to November 10, 2019. There was no documentation the facility completed the required Focused and Ongoing Professional Practice Evaluation during the re-credentialing process before granting privileges for CF3.

Review of CF4 on September 19, 2019, revealed the facility re-credentialed and granted this physician privileges for April 16, 2019 to April 16, 2021. There was no documentation the facility completed the required Focused and Ongoing Professional Practice Evaluation during the re-credentialing process before granting privileges for CF4.

Review of CF5 on September 19, 2019, revealed the facility re-credentialed and granted this physician privileges for October 30, 2018 to October 30, 2020. There was no documentation the facility completed the required Focused and Ongoing Professional Practice Evaluation during the re-credentialing process before granting privileges for CF5.

Review of CF6 on September 19, 2019, revealed the facility re-credentialed and granted this physician privileges for October 30, 2018 to October 30, 2020. There was no documentation the facility completed the required Focused and Ongoing Professional Practice Evaluation during the re-credentialing process before granting privileges for CF6.

Review of CF7 on September 19, 2019, revealed the facility re-credentialed and granted this physician privileges for October 3, 2018 to October 3, 2020. There was no documentation the facility completed the required Focused and Ongoing Professional Practice Evaluation during the re-credentialing process before granting privileges for CF7.

Review of CF9 on September 19, 2019, revealed the facility re-credentialed and granted this physician privileges for June 19, 2018 to June 19, 2020. There was no documentation the facility completed the required Focused and Ongoing Professional Practice Evaluation during the re-credentialing process before granting privileges for CF9.

Interview with EMP1, EMP3 and EMP5 on September 19, 2019, at approximately 3:00 PM confirmed the facility did not complete the required professional Focused and Ongoing Professional Practice Evaluation review during the re-credentialing process before granting privileges for CF1, CF2, CF3, CF4, CF5, CF6, CF7 and CF9.

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure a physician signed, dated and timed Do Not Resuscitate orders for four of 10 applicable medical records reviewed (MR12, MR16, MR25, and MR32) and the facility failed to ensure the physician documented the conversation with the patient or responsible party regarding a Do Not Resuscitate decision for five of 10 applicable medical records reviewed (MR12, MR14, MR21, MR30 and MR32).

Findings include:

Review on September 17, 2019, of facility policy "Code Status," revised July 19, 2019, revealed "Purpose To describe the hospital's classification for patient resuscitation in the event of a cardiopulmonary arrest and the procedure for communicating code/status during the hospital stay. ...Definitions ...Category DNR No CPR [Cardio Pulmonary Resuscitation] will be administered in the event of cardiac or pulmonary arrest. Also may be referred to as a Do Not Resuscitate (DNR), also known as a "No Code". Category Modified Code Patient will receive those items designated per their wishes. Procedure ...Resuscitation orders will be reviewed in a manner consistent with accepted medical, legal and ethical standards. ...In a physician "no Code" order situation, the physician will have discussed the "No Code" with the patient, or if the patient is not capable, his authorized representative. The discussion will be documented in the chart, and the physician will write a "Do No [Sic] Resuscitate" or "DNR" order in the chart."

1) Review of MR12 on September 17, 2019, revealed this patient was admitted to the facility on August 23, 2019. MR12's Do Not Resuscitate order was not signed and dated by the physician. MR12 was transferred on August 25, 2019, to a hospital for further evaluation and treatment of a medical emergency.

Interview with EMP2 on September 17, 2019, at approximately 1:00 PM confirmed MR12's physician did not date and time MR12's Do Not Resuscitate order and MR12 was transferred on August 25, 2019, to a hospital for further evaluation and treatment of a medical emergency.

Review of MR16 on September 17, 2019, revealed MR16 was admitted on August 14, 2019. MR16 contained physician documentation the patient and MR16's responsible party requested MR16 to be a Full Code. MR16 passed away on September 10, 2019, at 2:40 AM. There was no documentation MR16 was coded by the facility staff. There was documentation MR16's physician signed a Do Not Resuscitate order on September 10, 2019, at 7:00 PM.

Interview with EMP1, EMP2 and EMP3 on September 17, 2019, at approximately 1:30 PM confirmed MR16 contained physician documentation the patient and MR16's responsible party requested MR16 to be a Full Code; MR16 passed away on September 10, 2019, at 2:40 AM and there was no documentation MR16 was coded by the facility staff. EMP1, EMP2 and EMP3 confirmed the documentation MR16's physician signed a Do Not Resuscitate order on September 10, 2019, at 7:00 PM.

Review of MR25 on September 17, 2019, revealed this patient was admitted to the facility on September 4, 2019. There was a Do Not Resuscitate form in MR25's medical record signed by this patient's responsible party requesting MR25 not be resuscitated. The Do Not Resuscitate order was not signed, dated and timed by this patient's physician.

Interview with EMP1 on September 17, 2019, at approximately 2:30 PM confirmed MR25 contained a Do Not Resuscitate form in their medical record signed by MR25's responsible party requesting MR25 not be resuscitated. EMP1 confirmed the Do Not Resuscitate order was not signed, dated and timed by this patient's physician.

Review of MR32 on September 17, 2019, revealed this patient was admitted to the facility on August 23, 2019. There was a Do Not Resuscitate form in MR32's medical record signed by this patient's responsible party requesting MR32 not be resuscitated. The Do Not Resuscitate order was not signed, dated and timed by this patient's physician. MR32 passed away on September 2, 2019 and was not resuscitated.

Interview with EMP1, EMP2 and EMP3 on September 17, 2019, at approximately 2:00 PM confirmed MR32 was admitted to the facility and there was a Do Not Resuscitate form in MR32's medical record signed by this patient's responsible party requesting MR32 not be resuscitated. EMP1, EMP2 and EMP3 confirmed The Do Not Resuscitate order was not signed, dated and timed by this patient's physician and that MR32 passed away on September 2, 2019 and was not resuscitated.

2) Review of MR12 on September 17, 2019, revealed a Do Not Resuscitate order. There was no physician documentation regarding the conversation with MR12 or MR12's responsible party regarding a Do Not Resuscitate decision.

Review of MR14 on September 17, 2019, revealed a Do Not Resuscitate order. There was no physician documentation regarding the conversation with MR14 or MR14's responsible party regarding a Do Not Resuscitate decision.

Review of MR21 on September 17, 2019, revealed a Do Not Resuscitate order. There was no physician documentation regarding the conversation with MR21 or MR21's responsible party regarding a Do Not Resuscitate decision.

Review of MR30 on September 17, 2019, revealed a Do Not Resuscitate order. There was no physician documentation regarding the conversation with MR30 or MR30's responsible party regarding a Do Not Resuscitate decision.

Interview with EMP1, EMP2 and EMP3 on September 17, 2019, at approximately 2:00 PM confirmed MR12, MR14, MR21 and MR30 had Do Not Resuscitate orders and there was no physician documentation regarding the conversations with these patients or these patients' responsible parties regarding a Do Not Resuscitate decision.

Review of MR32 on September 17, 2019, revealed this patient was admitted to the facility on August 23, 2019. There was a Do Not Resuscitate form in MR32's medical record signed by this patient's responsible party requesting MR32 not be resuscitated. There was no physician documentation regarding the conversation with MR32 or MR32's responsible party regarding a Do Not Resuscitate decision. MR32 passed away on September 2, 2019 and was not resuscitated.

Interview with EMP1, EMP2 and EMP3 on September 17, 2019, at approximately 2:00 PM confirmed there was a Do Not Resuscitate form in MR32's medical record signed by this patient's responsible party requesting MR32 not be resuscitated and there was no physician documentation regarding the conversation with MR32 or MR32's responsible party regarding a Do Not Resuscitate decision. EMP1, EMP2 and EMP3 confirmed MR32 passed away on September 2, 2019 and was not resuscitated.

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure diet orders were written by practitioners approved via the Medical Staff bylaws to write orders for two of five pertinent medical records (MR15 and MR17) and the facility failed to ensure verbal orders were issued by practitioners approved via the Medical Staff bylaws to issue verbal orders for five of five pertinent medical records reviewed (MR5, MR6, MR15, MR16 and MR17).

Findings include:

Review on September 17, 2019 of the facility's "Medical Staff Bylaws" last approved September 13, 2019, revealed "... 5.6 Privileges for Limited License Practitioners 5.6.1 Dentists ... 5.6.2 Podiatrists ... 5.7 Practice Privileges for Allied Health Practitioners (AHP's) 5.7.1 Scope of Practice AHP's are subject to varying degrees of supervision and directions by Medical Staff Members while practicing in this Hospital, even though Pennsylvania law may permit certain AHP's to provide health care services without Physician direction or supervision. Each AHP's scope of practice is defined by the relevant Pennsylvania practice act and by the granting Practice Privileges as described by these Bylaws. Practice Privileges may be more restrictive than the scope of practice allowed by the relevant Pennsylvania practice act, but they may not exceed it. ... 5.7.4 Categories of AHPs 5.7.4-a Independent Practitioners ... (1) Psychologists ... (2) Audiologists ... (3) Certified Registered Nurse Anesthetist (DRNA) ... 5.7.4-b Dependent Practitioners Dependent AHP's are those practitioners who are subject to the general supervision and direction of a {physician while practicing in the Hospital. (1) Physician's Assistant ... (2) Registered Nurse Practitioner ... (3) Surgical Assistant (non-physician) ..."

Review on September 17, 2019, of the facility's policy "Adjustment of Physician Diet Orders," effective date of June 2013, revealed Medical Nutrition Therapy Guidelines: Adjustment of Physician Diet Orders by Licensed Dietitian Nutritionist-Registered Dietitian (LDN/RDN) ... Policy: Diet order adjustments may be implemented by the licensed, registered dietitian under the direction of the physician or Licensed Independent Practitioner (LIP) in order to meet an individual patient's nutritional needs as indicated by the nutrition assessment. The initial diet order placed by the physician/LIP will include the order for the LDN/RDN to adjust the order in accordance with the procedure that follows ...."

1) Review on September 17, 2019, of MR15 revealed an order dated June 11, 2019, from the dietician to increase the water flush 100 milliliters every six hours.

Interview with EMP1, EMP2 and EMP3 on September 17, 2019, at approximately 12:45 PM confirmed MR15 ' s order from the RD, dated June 11, 2019.

Review of MR17 on September 17, 2019, revealed an order dated June 20, 2019, from the dietician to decrease tube feeding to 70 ml/hour.

Interview with EMP1, EMP2 and EMP3 on September 17, 2019, at approximately 1:00 PM confirmed MR17's order from the RD dated June 20, 2019.

2) Review of MR5 on September 17, 2019, revealed a verbal order dated September 12, 2019, from the RD to the Registered Nurse (RN) for Ensure Enlive BID (Lunch and Supper), Vitamin C 500 milligrams BID for wound healing and Therapeutic Multivitamin one daily for wound healing.

Interview with EMP1, EMP2, EMP3, EMP7 and EMP8 on September 17, 2019, at approximately 12:40 PM confirmed MR5's verbal order from the RD to the RN dated September 12, 2019.

Review of MR6 on September 17, 2019, revealed a verbal order dated September 12, 2019, from the RD to the RN for Nutrition pump to be set at 30 milliliters every four hours for tube patency.

Interview with EMP1, EMP2 and EMP3 on September 17, 2019, at approximately 12:40 PM confirmed MR6's verbal order from the RD to the RN dated September 12, 2019.

Review of MR15 on September 17, 2019, revealed a verbal order dated June 11, 2019, from the RD to the RN to increase water flush 100 milliliters every six hours.

Interview with EMP1, EMP2 and EMP3 on September 17, 2019, at approximately 12:45 PM confirmed MR17's verbal order from the RD to the RN dated June 11, 2019.

Review of MR16 on September 17, 2019, revealed a verbal order dated August 15, 2019, from the RD to the RN for Juven 1 packet bid (two times a day) mix with 180 ml water via peg, therapeutic Multivitamin 1 daily, and Vitamin C 500 milligrams BID.

Interview with EMP1, EMP2 and EMP3 on September 17, 2019, at approximately 12:50 PM confirmed MR16's verbal order from the RD to the RN dated August 15, 2019.

Review of MR17 on September 17, 2019, revealed an order written by a RN dated June 20, 2019, indicating nutrition order to decrease tube feeding to 70 ml/ hour.

Interview with EMP1, EMP2 and EMP3 on September 17, 2019, at approximately 1:00 PM confirmed MR17's order written from the RD to the RN dated June 20, 2019.

Interview with EMP1, EMP3, EMP7 and EMP8 on September 17, 2019, at approximately 12:40 PM revealed dieticians are responsible for writing their own orders regarding dietary orders and that nursing staff are not to take verbal orders from a dietician.

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined that the facility failed to ensure the Certificate of Referral/Request For Anatomical Donations form was completed for three of five deaths reported to the Organ Procurement Organization (OPO) [Gift of Life] (MR15, MR17 and MR18).

Findings include:

Review on September 18, 2019, of the facility's "Organ and Tissue Donation" policy, last revised July 30, 2019, revealed "Purpose To establish guidelines for identification and referral of potential organ, tissue and eye donors. To comply with federal and state laws that has been established for organ, tissue and eye donation. Policy The hospital has an agreement with an Organ Procurement Organization (OPO), at least one Tissue Bank, and at least one Eye Bank. The OPO and tissue/eye bank will be notified in a timely manner of all individuals whose death is imminent or who have died in the hospital. The hospital and OPO will define guidelines for time lines when referral will occur. ... Procedure ... Staff will contact the OPO prior to the removal of life support or just after death for all patients. The OPO will determine suitability of donation. ... Identification and Referral of Potential Organ or Tissue / Eye Donors: Referrals for potential organ donation will occur in a timely manner as defined by the OPO. The Organ Procurement Coordinator, or designee, determines medical suitability for organ donation, after consultation with transplant physicians. Referrals regarding potential tissue / eye donation will occur at or near the time of cessation of cardiopulmonary function, regardless of age or medical history. The designated hospital employee will make the referral by notifying the OPO/designated third party, and/or tissue/eye bank. The designated hospital employee will make the referral by notifying the OPO/designated third party, and/or tissue/eye bank. ... All referrals will be documented in the patient's medical record."

Review on September 18, 2019, of the facility's "Certificate Of Referral/Request For Anatomical Donations form," no review date, revealed "... Section I: Must be completed for all patient deaths ... C. Referral to DVTP: Referred to DVTP by Date of Referral Time of Referral Name of DVTP Staff ... Section II: Must be completed when patient meets screening criteria for donation A. patient meets preliminary criteria for donation per DVTP: (Check all that apply) Organ Tissue Eyes/Corneas Other Research Only B. Consent was not required of legal Next-of-Kin as evidenced by document of gift: (Attach copy of Document of Gift in patient's record) Validly Executed Donor Care Driver's License Donor Registration Advanced Directive Regarding Donation Other Document of Gift C. Consent not Requested due to actual notice of objection to donation from Advance Directive Attorney-In-Fact (Name) legal Next-of-Kin (Name) D. Consent required and requested form Attorney-in-Fact legal Next-of-Kin E. Consent was requested by DVTP Coordinator DVTP Certified Designated Requestor F. Outcome of Consent Consent Denied/Explain Consent Given If consent is given, a separate consent form must be signed denoting which anatomical gifts have been donated and placed in the patient's medical record. Section III: Person completing the form: Name/Credentials/Title today's Date and Time".

Review of MR15 on September 18, 2019, revealed this patient expired on July 23, 2019. MR15's Certificate of Referral/Request For Anatomical Donations form revealed no documentation the facility completed part C of Section I or Section III.

Interview with EMP1, EMP2 and EMP3 on September 18, 2019, at approximately 1:00 PM confirmed MR15's Certificate of Referral/Request For Anatomical Donations form contained no documentation the facility completed part C of Section I and Section III.

Review of MR17 on September 18, 2019, revealed this patient expired on June 23, 2019. MR17's Certificate of Referral/Request For Anatomical Donations form revealed no documentation the facility completed any part of Section I, Section II and Section III.

Interview with EMP1, EMP2 and EMP3 on September 18, 2019, at approximately 1:30 PM confirmed MR17's Certificate of Referral/Request For Anatomical Donations form contained no documentation the facility completed any part of Section I, Section II and Section III.

Review of MR18 on September 18, 2019, revealed this patient expired on April 27, 2019. MR18's Certificate of Referral/Request For Anatomical Donations form revealed no documentation the facility completed part C of Section I or Section III.

Interview with EMP1, EMP2 and EMP3 on September 18, 2019, at approximately 2:00 PM confirmed MR18's Certificate of Referral/Request For Anatomical Donations form contained no documentation the facility completed part C of Section I and Section III.