HospitalInspections.org

Based on review of documents and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the Medical Staff approved the Blood Supply and Services Agreement. The CAH laboratory manager reported approximately 4 inpatient blood transfusions daily and approximately 30 outpatient blood transfusions daily.

Failure to ensure medical staff approval of an updated blood bank agreement could potentially result in a lapse of the agreement and/or interrupt the availability of blood products needed for emergencies.

Findings included:

1. Review of the Blood Supply and Services Agreement revealed an agreement date effective on April 1, 2011. The agreement lacked documented approval by the CAH medical staff.

2. Review of Medical Staff Meeting Minutes from 4/13/11 through 10/12/11 showed the medical staff failed to approve the Blood Supply and Services Agreement.

3. During an interview on 10/18/11 at 8:00 AM, the laboratory manager acknowledged the medical staff failed to approve the Blood Supply and Services Agreement.

4. During an interview on 10/18/11 at 1:45 PM, the Chief Executive Officer (CEO) stated, the CAH did not have policies and procedures that addressed the blood bank agreement. Additionally, the CEO stated, the federal requirements clearly state the medical staff must approve the blood bank agreement and "we did not."

5. Review of a document provided by the CEO on 10/18/11 at 1:45 PM, revealed in part, " ...The Blood Supply Agreement was not taken to the Medical Staff for their approval at the time it was signed."

Based on review of credential files, documents, medical records, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure 1 of 3 emergency room (ER) physicians, selected for review, had privileges to provide patient care services.

The Quality Director identified 7 routine ER physicians.

The ER Director identified an average daily census of approximately 12 ER patients.

The Quality Director identified Physician A provided care services to approximately 154 patients from 1/11 to 9/11.

Failure to assure that all physicians provided only those services they had the appropriate and approved privileges to provide could potentially result in a physician performing a procedure he or she did not have the knowledge or skills to perform and/or a physician performing a procedure the CAH did not have the necessary staff or equipment to accommodate. This could potentially result in patient injury or death.

Findings include:

1. Review of Physician A's Delineation of Privileges Form revealed an effective date from 9/23/09 to 9/23/11.

2. Review of Medical Staff Bylaws dated 3/11, revealed in part, "...All care rendered in the Hospital must be on the authority of a practitioner privileged to order such care."

3. Review of policy "Credentialing of Physicians" revised 1/4/11, revealed in part, "...Privileges to practice at Clark County Hospital are granted by the governing body (Board of Trustees) following review of Quality Executive Committee and recommendation of the Medical Staff."

4. Review of document "Amendment to CAH Network Agreement dated 6/15/06, revealed in part, "...Credentialing . Hospital will fulfill its responsibilities for credentialing through the Medical Staff, although the decision as to any application shall remain with the Hospital's Board of Trustees."

5. Review of Patient #2's medical record revealed: Patient #2 arrived to the Emergency Room (ER) on 9/24/11 at 2:44 AM complaining of nausea and vomiting. Physician A examined and treated Patient #2. Physician A diagnosed Patient #2 with Hyperemesis gravidarum upon discharge at 3:30 AM.

6. Review of Patient #3's medical record revealed: Patient #3 arrived to the ER on 9/24/11 at 2:44 AM complaining of chest pain. Physician A examined and treated Patient #3. Physician A diagnosed Patient #3 with pleurisy upon discharge at 3:48 AM.

7. Review of Patient #4's medical record revealed: Patient #4 arrived to the ER on 9/24/11 at 4:58 AM complaining of a cough and difficulty breathing. Physician A examined and treated Patient #4. Physician A diagnoses Patient #4 with croup upon discharge at 7:37 AM.

8. During an interview on 10/19/11 at 1:55 PM, the Director of Quality acknowledged Physician A ' s privileges expired on 9/23/11 and the Physician had examined and treated patients in the ER from midnight to 9:00 AM on 9/24/11. The Director of Quality verified at the time Physician A examined and treated patients 2, 3, and 4 the Physician ' s privileges had expired.

I. Based on review of policies/procedures, medical records, and staff interview, the Critical Access Hospital (CAH) nursing and physician staff failed to notify the Department of Human Services (DHS) of suspected child abuse for 1 of 5 pediatric patients (Patient #5).

The Chief Nursing Officer identified the emergency room staff see approximately 8 cases of suspected child abuse annually.

Failure to notify DHS of suspected child abuse could place vulnerable children at risk for further potentially life-threatening abuse.

Findings include:
1. Review of policy "Child Abuse: Identification, Assessment and Reporting" dated 4/15/11, revealed in part, "...The law requires the reporting of suspected child abuse. It is not the reporter's role to validate the abuse...Mandatory Reporter: Every health care who examines, attends, or treats a child (licensed physicians...nurses...Physical abuse is defined as any non-accidental physical injury...common indicators could include unusual or unexplained burns...if reporting suspected child abuse an oral report is needed immediately to the DHS...after an oral report is given, a written report is required within 24 hours."
2. Review of policy "Photographing Patients" dated 4/19/11, revealed in part, "...Photographs must be taken under the direction or order of the attending physician...in incidents of actual or suspected physical abuse, objectively define and document, pursuant to Iowa state laws and regulations, areas of physical injury...actual/suspected abuse injury: an initial photograph shall be taken of each area of physical injury."
3. Review of Pediatric Patient #5's medical record revealed:
a. Patient #5, a 4-year-old child, arrived to the emergency room on 7/5/11 at 9:19 PM, accompanied by his/her father.
b. Clinical nurse triage notes dated 7/15/11 at 9:36 PM, documented chief complaint: Stated possible assault and stated possible abuse.
c. Clinical nurse report physical assessment notes dated 7/15/11 at 9:43 PM, revealed in part, "...Right buttock: ecchymosis (1.5 centimeter {cm} bruise to right check, right gluteal fold...left forearm: swelling and erythema (1 cm raised spot to upper forearm noted)...left wrist: swelling and erythema (small swelling to left inner wrist that is 2 millimeters {mm} wide, slightly raised..." Staff F, Registered Nurse (RN) completed the physical assessment.
d. Clinical report - Physician notes dated 7/15/11 at 9:55 PM, revealed in part, "Historian - father...Chief complaint- POSSIBLE PHYSICAL ABUSE. It is unknown when this occurred...Father sharing custody of [child] with wife...Wants to know if [he/she's] being physically abused...Unsure if possible sexual abuse. Here because he saw red spots on left arm and bruise on right lower back/buttock. He stated [child] told him [he/she] was burned with a cigarette...The patient has had bruising (right lower back/buttock). right forearm with possible burn - or maybe insect bites - unsure...."
Instructions at time of discharge: "...Follow up with patient's doctor and DHS if you have concerns for abuse by others, best done tomorrow morning. Do not allow the child to be alone in the care of another if you are concerned for that person abusing your child...."
Physician D, Medical Doctor (MD) completed the clinical report and discharged the patient at 10:56 PM accompanied by the father.
e. Patient #5's medical record lacked documentation that showed Staff F, RN or Physician D reported the suspected child abuse to DHS, in accordance with mandatory reporter requirements.

3. During an interview on 10/19/11 at 8:20 AM, the Chief Nursing Officer (CNO) acknowledged Patient #5 ' s medical record lacked documented evidence that showed Staff F or Physician D had notified DHS of the suspected child abuse. The CNO stated at the very least, nursing staff should have called DHS. The CNO confirmed that hospital policy required all nursing and physician staff to report all suspected child abuse to DHS. The CNO stated DHS would direct the staff to complete a notice of intake decision and fax it to DHS offices and after the investigation by DHS; the hospital would receive a notice of child abuse assessment confirmed or not confirmed. Additionally, the CNO stated Staff F was currently on military leave for 6 months and would be unavailable for interview.

4. During an interview on 10/19/11 at 9:30 AM, the ER Nurse Manager verified ER nursing staff received training when hired that required all staff to report suspected child abuse. Additionally, the ER Nurse Manager confirmed the nurse or the physician should have contacted DHS.

5. Review of Staff F's personnel file revealed:

i. An Employee certification revealed, " I pledge to act in compliance with...any policies applicable to my responsibilities. "

ii. A certificate of completion of Mandatory reporter training dated 6/9/10.

6. During a telephone interview on 10/19/11 at 10:10 AM, Physician D stated if there was a policy at Clark County Hospital about reporting suspected cases of child abuse, he/she was not aware and the hospital failed to " bring " the policy to "my attention." Physician D acknowledged Patient #5's medical record lacked evidence that showed nursing and physician staff contacted DHS of suspected child abuse.

7. Review of Physician D's credential file revealed a certificate of completion for Mandatory reporter training dated 5/4/08.

II. Based on review of policies/procedures, medical records, documents, and staff interview, the Critical Access Hospital (CAH) nursing staff failed to notify the Department of Inspections and Appeals (DIA) of suspected adult abuse for 1 of 3 acute care patients (Patient # 1).

The Chief Nursing Officer identified the emergency room staff see approximately 3 cases of suspected adult abuse annually.

Failure to notify DIA of suspected adult abuse could potentially delay investigations to determine if abuse did or did not occur, placing vulnerable adults at risk for further potentially life-threatening abuse.

Findings include:

1. Review of policy "Suspected Dependent Adult Abuse in Facilities and Programs" dated 4/15/11, revealed in part, "...Facility is a health care facility that included long term care facilities...If suspected abuse occurs in a facility...the practitioner or other health professionals interviewing or treating the patient will apply criteria for identifying signs of suspected dependent adult abuse and will be responsible for reporting the suspected abuse. If suspected dependent adult abuse is assessed document such in the patient's chart...If reporting suspected dependent adult abuse an oral report is needed within 24 hours to the Department of Inspections and Appeals...A written report that includes the reporting requirements...is required by faxing or e-mail to the Iowa Department of Inspections and Appeals."

2. Review of Patient #1's medical record revealed:

a. Patient #1 arrived to the ER via ambulance from a Long Term Care Facility on 7/23/11 at 9:30 AM. Following examination and treatment in the ER, the physician admitted Patient #1 to the medical/surgical nursing unit at 12:20 PM.

b. An ER physician's progress note dated 7/24/11 at 9:10 AM, revealed in part, "...Multiple abrasions and bruises on [bilateral upper extremities] and [bilateral lower extremities]. [Lower left extremity] with 2+ edema and erythema surrounding the ankle. Coccyx with erythematous decubitus ulcer, some scabbing."

c. A history and physical dated 7/23/11, revealed in part, "...Cellulitis right lower leg, 5 cm decubitus on sacrum."

d. Initial interview/nursing assessment forms upon admission to the medical/surgical nursing unit, dated 7/23/11 at 3:03 PM, revealed in part, "...skin tears to forearms, fragile skin...easy bruising...coccyx open...non-healing wounds to coccyx, cellulitis of right lower extremity/foot."

3. Review of "Iowa Department of Human Services - Suspected Dependent Adult Report" dated 7/24/11 revealed: Staff A, RN a nursing supervisor on the medical/surgical nursing unit documented the following in part, "...[Patient #1], lives at a nursing home. Type of abuse noted: Physical injury...denial of critical care by caretaker...Information about suspected abuse: Patient has cellulitis to right lower leg with sloughing of skin on right lower leg. Patient has multiple scabbed skin tears to hands and forearms. Patient has approximately 3-4 inch scabbed skin tear on left forearm. Patient has decubitus on his/her coccyx." Staff A faxed the report to DHS on 7/24/11 at 2:57 AM.

4. Review of Patient #1's medical record lacked documentation of notification to the DIA of suspected adult abuse.

5. On 10/19/11, the Social Services Coordinator presented the surveyor with a document. Review of the document revealed in part, ..."Date of Suspected Dependent Adult Abuse was reported 7/24/11. After reviewing patient's [#1] chart that the DIA [surveyor] had requested, it was discovered that when the RN [A] called to report suspected dependent adult abuse [he/she] had called the wrong agency. The RN had called DHS instead of DIA. This writer called the RN to get an update. [He/she] stated [he/she] called the report to DHS and faxed a written report to DHS in "the middle of the night". When [he/she] had gone home after [his/her] shift had ended DHS called to inform [him/her] that [he/she] had called the wrong agency and that "they would take care of it".

6. During an interview on 10/19/11 at 1:30 PM, the CNO acknowledged nursing staff failed to notify DIA of suspected adult abuse. The CNO stated Staff A is a mandatory reporter training and this is hospital policy. The CNO stated, "We do know DHS did forward this to DIA that does not discount the fact that DIA should have been notified."

7. Review of Staff A's personnel file revealed a Mandatory Reporter Training for Dependent Adult Abuse dated 7/20/10.

8. During a telephone interview on 10/19/11 at 7:30 PM, Staff A acknowledged he/she received orientation to hospital policies and procedures upon hire. Staff A said that nursing staff had access to hospital policies and procedure on the intranet or in binder notebooks located at the nurse's station. Staff A confirmed sending the report to DHS and did not know Clarke County Hospital policy required that staff contact or fax DIA.

Based on review of policies/procedures, documentation, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure physician notification for the occurrence of a medication error for 14 of 15 medication errors reviewed. (Patients # 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, and 19) The CAH administrative staff reported a census of 16 patients.

Failure to notify the physician of medication errors could potentially result in life threatening conditions, or other related health conditions that could lead to serious harm.

Findings include:

1. Review of the CAH Nursing policy/procedure titled "Occurrence Reporting", dated reviewed 5/01/2011, stated in part, ". . . When an Occurrence happens: Notify the patient's physician immediately at the time of the occurrence of all major injuries and the minor-moderate injuries that require medical intervention (i.e. medication order change, sutures) . . . ."

2. Review of the medication errors from August 2011 to September 2011 revealed 14 of 15 medication errors lacked the date and time staff notified the physician of the medication errors. (Patients # 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 and 19)

3. During an interview on 10/20/11 at 7:36 AM, Staff C, Director of Outcomes, acknowledged the documentation lacked evidence that staff notified the physicians of the medication errors for Patients # 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 and 19.

During an additional interview on 10/20/11 at 11:10 AM, Staff G and H, Registered Nurses reported when a medication error occurs, they notify the physician immediately.

Based on review of policies/procedures, documentation, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the Medical Staff and Board of Trustees had access to external peer review results when considering re-credentialing for 8 of 8 sampled physicians. (Physicians B, C, E, F, G, H, I, J)

Failure to ensure the Medical Staff and Board of Trustees received results of peer reviews, conducted by an outside entity, evaluating the quality and appropriateness of the diagnosis and treatment furnished by doctors at the CAH, prior to credentialing, could potentially result in medical staff members misdiagnosing patients and/or providing inappropriate or substandard patient care without the knowledge of the Medical Staff and Board of Directors.

Findings include:

1. Review of policy " Credentialing of Physicians" revised 1/4/11, revealed in part, "Medical Staff will review each application and vote on recommendation to the Board of Trustees as to whether requested privileges should be granted at Clark County Hospital (CCH). The Medical Staff recommendation will be presented to the governing board of CCH for final determination."

2. Review of policy "Physician Peer Review (Internal and External) revised 1/7/11 revealed in part, ..."Every practitioner delivering medical care at the Hospital by virtue of medical staff membership shall be evaluated by CCH based on quality improvement reviews...retrospective review of patient records and evaluation of the practitioner's participation in the delivery of care...A minimum of one chart per physician providing services at CCH will be submitted to our Network Hospital for external physician peer review per credentialing period. The external peer review results will be submitted to the President of Medical staff and Medical Staff Quality Improvement Committee for discussion and action as indicated by the review."

3. Review of the Medical Staff Bylaws dated 3/11, revealed in part, ..."External peer review...the quality and appropriateness of the diagnosis and treatment furnished by physicians are evaluated by Central Iowa Hospital Corporation, a member of the rural health network. The purpose of the evaluation is to determine whether the utilization of services is appropriate, established policies and procedures are followed...Privileges to practice at the hospital are granted by the Board following recommendation of the Medical staff."

4. Review of documentation related to the credentialing period from 3/2010 - 2012, revealed the following information related to Physicians B and E.

a. Review of Physician B's credential file showed the Medical Staff re-credentialed Physician B on 7/9/2010 and the Board of Trustees re-credentialed Physician E on 7/28/2010. The credential file lacked documentation that showed the external peer review results were available and reviewed by the Medical Staff and Board of Trustees at the time they re-credentialed Physician E.

The Quality Director reported Physician B had performed 419 outpatient surgical procedures and 99 inpatient surgical procedures during the previous 12 months.

b. Review of Physician E's credential file showed the Medical Staff re-credentialed Physician E on 3/10/2010 and the Board of Trustees re-credentialed Physician E on 3/31/2010. The credential file lacked documentation that showed the external peer review results were available and reviewed by the Medical Staff and Board of Trustees at the time they re-credentialed Physician E.

The CAH administrative staff identified Physician E had provided services to 12 patients (in-patients and out-patients) from 3/2008 to 3/2010.

5. Review of documentation related to the credentialing period from 3/2011 - 2013, revealed the following information related to Physicians C and F.

a. Review of Physician C's credential file showed the Medical Staff re-credentialed Physician C on 4/13/11 and the Board of Trustees re-credentialed Physician B on 4/27/11. The credential file lacked documentation that showed the external peer review results were available and reviewed by the Medical Staff and Board of Trustees at the time they re-credentialed Physician C.
The CAH Quality Director identified Physician C had performed 21 surgical procedures during the previous 12 months.

b. Review of Physician F's credential file showed the Medical Staff re-credentialed Physician F on 3/9/2011 and the Board of Trustees re-credentialed Physician F on 3/23/2011. The credential file lacked documentation that showed the external peer review results were available and reviewed by the Medical Staff and Board of Trustees at the time they re-credentialed Physician F.

The CAH administrative staff identified Physician F had provided services to 127 out-patients from 6/2010 to 6/2011.

6. Review of documentation related to the credentialing period from 1/2010 - 2012, revealed the following related to Physician G.

Review of Physician G's credential file showed the Medical Staff re-credentialed Physician G on 1/13/2010 and the Board of Trustees re-credentialed Physician G on 1/27/2010. The credential file lacked documentation that showed the external peer review results were available and reviewed by the Medical Staff and Board of Trustees at the time they re-credentialed Physician G.

The CAH administrative staff identified Physician G had provided services to 27 out-patients from 6/2010 to 6/2011.

7. Review of documentation related to the credentialing period from 6/2010 - 2012, revealed the following related to Physician H.

Review of Physician H's credential file showed the Medical Staff re-credentialed Physician H on 5/12/2010 and the Board of Trustees re-credentialed Physician H on 6/2/2010. The credential file lacked documentation that showed the external peer review results were available and reviewed by the Medical Staff and Board of Trustees at the time they re-credentialed Physician H.

The CAH administrative staff identified Physician H had provided services to 2 out-patients from 6/2010 to 6/2011.

8. Review of documentation related to the credentialing period from 8/2011 - 2013, revealed the following Physician I and J.

a. Review of Physician I's credential file showed the Medical Staff re-credentialed Physician I on 8/10/2011 and the Board of Trustees re-credentialed Physician I on 8/24/2011. The credential file lacked documentation that showed the external peer review results were available and reviewed by the Medical Staff and Board of Trustees at the time they re-credentialed Physician I.

The CAH administrative staff identified Physician I had provided services to 3 patients (in-patients and out-patients) from 10/2009 to 10/2011.

b. Review of Physician J's credential file showed the Medical Staff re-credentialed Physician J on 8/10/2011 and the Board of Trustees re-credentialed Physician J on 8/24/2011. The credential file lacked documentation that showed the external peer review results were available and reviewed by the Medical Staff and Board of Trustees at the time they re-credentialed Physician J.

The CAH administrative staff identified Physician J had provided services to 6 patients (in-patients and out-patients) from 8/2010 to 8/2011.

9. During an interview on 10/19/11 at 4:00 PM, Staff C, Director of Outcomes, acknowledged the lack of documented evidence that showed an evaluation of the quality and appropriateness of the diagnosis and treatment they furnished to CAH patients had occurred at the time Physicians E, F, G, H, I, J were re-credentialed. Staff C confirmed Physicians E, F, G, H, I, J had provided services to patients of the CAH during their last credentialing period.

10. During an interview, at the time of the credential file review, the Quality Director acknowledged the lack of documented evidence that showed an external entity had evaluated the quality and appropriateness of the diagnosis and treatment they furnished to CAH patients and that the results of the review were available at the time of the Physicians reappointment. Therefore, the medical staff and board of trustees lacked information from the external peer review process, including the quality and appropriateness of the diagnosis and treatment furnished by physicians at the CAH, in the physician's credential files at the time of reappointment for 8 of 8 applicable physicians.


19125

Based on review of contracted services agreements, policies/procedures, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to maintain a current agreement with a dentist to provide routine and 24-hour emergency dental care for swing bed patients. The CAH had a census of 13 swing bed patients.

Failure to maintain a current agreement for routine and emergency dental care for swing bed patients could potentially prevent swing bed patients from receiving needed dental care.

Findings include:

1. Review of the contracted services agreements revealed no evidence of a contract or agreement with a dentist for routine and emergency dental care for swing bed patients.

2. Review of Clarke County Hospital policy/procedure titled, "Dental Services for Swing Bed Patients (Skilled and Extended Swing)," reviewed 2/25/2011, revealed in part, ". . . Dental services may be done with the patient dentist of choice or the dental services contracted through the hospital. . . ."

3. During an interview on 10/19/11 at 8:45 AM, the Chief Executive Officer acknowledged the lack of a contract or agreement with a dentist to provide dental care for swing bed patients at the CAH.