| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 531311 | (X3) Date Survey Completed 11/17/2011 |
| Name of Provider or Supplier Crook County Hospital | Street Address, City, State 713 Oak Street, Sundance, WY | |
| For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency. | ||
| (X4) ID Prefix Tag | Summary Statement of Deficiencies
(Each deficiency should be preceded by full regulatory or LSC identifying information) |
| C0257 | RESPONSIBILITIES OF MD OR DO CFR(s): 485.631(b)(1)(i) The doctor of medicine or osteopathy-- Provides medical direction for the CAH's health care activities and consultation for, and medical supervision of, the health care staff; This STANDARD is not met as evidenced by: Based on staff interview; review of peer review activities, minutes of medical staff meetings, and policies and procedures; and interview with the medical director, the facility failed to ensure the medical staff conducted adequate peer review activities and provided direction and supervision of hospital staff. The findings were: Review of minutes from medical staff meetings since November 2010 revealed six inpatient charts were sent out for peer review. Three patient charts were sent out in December 2010 and three in April 2011. A "Hospital Peer Review" form was filled out by the consultant physician after each record was reviewed. Each form had multiple comments, recommendations and suggestions. Further review of minutes from the general medical staff meetings failed to show if any of these comments, recommendations or suggestions were discussed or acted upon. In addition, meeting minutes also revealed executive (closed) sessions were held only in January, August and September 2011. Review of facility policy HIM-021 "Peer Review" revised 7/31/08 revealed "peer review is to assist in assuring quality of care of our patients and efficiency of services rendered." The policy goes on to state that review of patient records "will be done on a regular monthly basis" by physicians in [network CAH]. On 11/16/11 at 9:50 AM interview with HIM clerk #1 and the CNO revealed specific criteria for selecting medical records for peer review was lacking. The clerk stated they just picked records of patients who had a "...difficult stay..." She did not keep a list of which records were selected. She further stated the records were sent to another facility for review, returned, and then the recommendations were sent to the medical staff for review. Finally, although hospital policies required peer review to be performed monthly, the clerk stated that, until the CEO recently requested two records be reviewed, a peer review had not been performed since April 2011. During the interview, both the clerk and the CNO stated, "The system is broken." On 11/16/11 during an interview at 3:30 PM, the medical director stated she asked for a review of one of the records requested by the CEO. She acknowledged the reason for her request was a concern related to an ordered amount of an administered medication versus the amount the ordering physician dictated in his note. However, follow-up with the ordering physician was lacking. 20082 |