HospitalInspections.org

Based on personnel file review, facility policy review and staff interview, administrative staff failed to ensure all employees receive Mandatory Dependent Adult Abuse training, every 5 years, according to State law, for 2 of 20 personnel files reviewed (Staff A, RN and Staff B, RN). The facility identified a census of 11 patients and approximately 180 employees.

(Iowa Code section 235E.2(2): A staff member or employee of a facility or program who, in the course of employment, examines, attends, counsels, or treats a dependent adult in a facility or program and reasonably believes the dependent adult has suffered dependent adult abuse, shall report the suspected dependent adult abuse to the department. Iowa Code section 235B.16(5)b: A person required to report cases of dependent adult abuse pursuant to sections 235B.3 and 235E.2 . . . The person shall complete at least two hours of additional dependent adult abuse identification and reporting training every five years.)

Failure to ensure current Dependent Adult Abuse training for all employees with patient contact may result in the lack of reporting of suspected dependant adult abuse.

Findings included:

1. Review of a facility policy titled "Child and Dependent Adult Abuse/Neglect Reporting", approved on 12/11/13, identified all staff must complete two hours of combined dependent adult and child abuse reporting every five years.

2. Review of 20 personnel files revealed 2 files lacked documentation of required mandatory reporter training every five years.
a. The most current training for Staff A, RN was documented on 9/21/08.
b. The most current training for Staff B, RN was documented on 10/29/08.

During an interview on 12/18/13 at 11:00 AM, the Director of Support Services reported the facility entered into a new agreement with NetLearning for the provision of mandatory education topics, including mandatory reporter training in August 2013. She relayed they immediately identified the mandatory reporter presentation would not open and the facility has been working with them to get it operational. The Director of Support Services confirmed she was aware there were a couple employees that were overdue for the mandatory reporter training and acknowledged they had not been provided an alternative form of education, while the NetLearning program was not operational.

Based on review of documents and interview with the CEO (Chief Executive Officer), the CAH (Critical Access Hospital) failed to have the current Blood Bank Agreement Approved by the Medical Staff. The CAH identified a census of 11 at the time of the survey.

Failure of the Medical Staff to approve the Blood Bank Agreement could potentially result in a lack of available blood when needed for the patients of the CAH.

Findings include:

Review of the Blood Supply and Services Agreement, dated 11/4/11, showed it lacked approval by the Medical Staff.

A review of the Blood Supply and Service Agreement/Addendum, dated 2/28/13, showed it lacked approval by the Medical Staff.

A review of the Medical Staff Monthly Meeting Minutes dated 1-11/13 lacked any discussion involving the current Blood Supply Service Agreement/Amendment by the Medical Staff members.

During an interview on 12/19/13 at 8:45 AM, the CEO verified the Medical Staff had not been involved with the current Blood Supply and Services Agreement/Addendum.

Based on observation, review of documents, and interviews with staff, the CAH (Critical Access Hospital) failed to replace 3 of 3 water filters for the Endoscope Reprocessing System used for sterilization and terminal cleaning of the endoscopes. The facility identified completing 89 endoscopy procedures from 5/13 to the time of the survey that required the use of the Endoscope Reprocessing System.

Failure to properly maintain the Endoscope Reprocessing System could potentially result in inadequate cleaning of the endoscopes.

Findings include:

On 12/17/13, at 8:00 AM, during the tour of the Surgical Department, Staff F, RN (Registered Nurse), demonstrated the use of the Endoscope Reprocessing System. Staff F stated that the machine was new and has been in operation since 5/13. Inspection of the machine revealed 1 large water intake filter, labeled replace in 6 months, located in the bottom of the machine; and 2 smaller water intake filters mounted on the adjacent wall connected to the copper water supply line, labeled replace in 3 months. An interview at this time with Staff F revealed that the filters had not been replaced since the machine was installed and placed in operation in May of 2013. Review of documents related to the operation of the machine sanitizing properties was found to be in compliance with the manufacturer's guidelines for operation.

A review of the online education provided by the manufacture for the Endoscope Reprocessing System shows a Daily Checklist and a Filter Change Log for the system to confirm all filters are being changed at the required pressure or time intervals. The CAH surgical staff failed to use the Daily Checklist and Filter Change Log forms and were unaware that these forms existed and were available for use.

A review of the undated Endoscope Reprocessing System User Manual, showed it stated in part ... page 7 Water Quality and Filtration the routine maintenance schedule recommends replacing the water filter every 6 months or sooner, depending on the pre-filtration system and the quality of the incoming water. The pre-filtration system should be monitored for excessive pressure drop indicating blocker filter membranes. A review of the Lease Agreement for Endoscope Reprocessing System, dated 3/27/13, shows a 3 year agreement for use of the machine and preventive maintenance contract.

A phone interview on 12/17/13 at 15:17 PM, with Endoscope Reprocessing System Technical Support revealed the water filter replacement will not change or effect the sterilization of the endoscope, and the number of scopes cleaned will not affect the filter. The filter is only for the water filtration system. The chemical used for sanitization is a one shot delivery system each time a scope is cleaned.

During an interview on 12/17/13 at 10:20 AM, Staff F and G, Surgical RN ' s, revealed a company technician spent 1 day explaining and demonstrating the correct use of the Endoscope Reprocessing System. The technician failed to train us on changing the water filters and stated he would return when it was time for filter changes. We have not changed the 3 water filters, and were not aware of the Filter Change Log and the Daily Checklist that were available for use.

Based on observation, review of policies, and interviews with staff interviews, the facility pharmacy staff failed to develop and maintain a system to track and account for the receipt and distribution of sample drugs used in 1 of 4 offsite clinics. Problem were identified in the Nevada Medical Clinic.

The Director of Clinics reported an average of 2 to 3 patients a month in the Nevada Medical Clinic received medications acquired from a medication repository (pharmacy that re-dispenses medications).

Failure of pharmacy staff to provide oversight of repository medications could result in expired or recalled medications available for physicians and mid-level providers to give to patients, and/or the potential theft of medications by unauthorized persons.

Findings include:

1. Observation during tour of the Nevada Medical Clinic on 12/18/13 at 2:05 PM with Staff D, Director of Clinics, revealed 1 of 1 locked medication cabinets containing approximately 72 antibiotics, 197 anti-hypertensive medications, 197 anti-depressant medications, 139 acid reducer medications, 19 asthma medications, and 74 allergy medications of various doses.

2. Review of Pharmacy policy titled "Accountability for the Pharmacy Department", revised 3/23/09, revealed it stated in part... " The Pharmacy Department Director, under the guidance of the Pharmacy and Therapeutics Committee, shall be held accountable for all pharmaceutical services within Story County Medical Center."

Review of Pharmacy policy titled " Duties and Responsibilities of the Pharmacy Department Director" revised 6/16/09 revealed it stated in part... "9. The maintaining of adequate control over the requisitioning and dispensing of all medications and pharmaceutical supplies. 13. Providing the necessary inspections of all pharmaceutical supplies."

3. During an interview on 12/18/13 at 2:40 PM, Staff C, LPN (Licensed Practical Nurse) at the Nevada Medical Clinic stated all repository medications are ordered from the repository website and provided to low income patients after ordered by the physician or provider.

During an interview on 12/19/13 at 8:20 AM, Staff D stated pharmacy staff do not have oversight of the repository medications at the clinic. The clinic provides 2 to 3 low income patients with these medications a month. The clinic staff have been providing these medications to low income patients for about 3 years.

During an interview on 12/19/13 at 9:20 AM, Staff E, Pharmacist stated the pharmacy staff do not have oversight of the repository medications in the Nevada Medical Clinic and had no knowledge the clinic still provided the medications to low income patients. Staff E said instructions were given to the Director of the Clinics about 2 to 3 years ago to dispose of all repository medications.

Based on review of documents and staff interview, the CAH (Critical Access Hospital) failed to ensure completion of external peer review for all practitioners at time of their reappointment. The credentialing files for 4 of 13 sampled medical staff lacked evidence of external peer review for the current reappointment period (Practitioners A, B, C, and D). The CAH ' s administrative staff credentialed approximately 100 medical providers for a 24 month reappointment period.

Failure to provide up-to-date external peer review for all physicians and other practitioners during the current reappointment period could potentially result in the hospital allowing physicians and other practitioners continuing to practice without evidence that they continued to provide safe and effective medical care to the patients of the CAH.

Findings include:

1. Thirteen medical provider credentialing files were selected for review. The review showed 4 members of the files, including 2 physicians, a dentist, and a mid-level practitioner, lacked contain current external peer review for the reappointment period reviewed. A reappointment period is 24 months.

a. The Provider Reappointment Evaluation, dated 6/28/13, and external peer review, dated 7/26/11, for Practitioner A, Certified Registered Nurse Anesthetist (CRNA), were not in the current reappointment period.

b. The Provider Appointment Evaluation, dated 6/21/13, for Practitioner B, a Dentist, , lacked an external review.

c. The Provider Reappointment Evaluation, dated 6/25/13, for Physician C, DO, lacked an external peer review.

d. The Provider Reappointment Evaluation, dated 6/25/13, and external peer review dated 6/16/11 for Physician D, MD, were not in the current reappointment period.

2. A review of the CAH Network Agreement, dated 2/1/13, showed it stated in part "...Quality Assurance CIHC (Central Iowa Hospital Association) shall assist Hospital in reviewing the quality and appropriateness of the diagnoses and treatment by Hospital ' s physicians and other practitioners for purposes of carrying out the requirement of its quality assurance plan. This process shall be accomplished through external peer review, to be conducted by CIHC, or by a cooperative review within the Iowa Health System, on a quarterly basis for selected physicians based on specialty, quality concerns or other areas identified by Hospital ..."

The Quality Improvement Management, dated 6/21/12, stated in part "... The Medical Staff shall be responsible for the review and evaluation of all the clinical aspects of patient care as stated in the Medical Staff Bylaws as well as a review of the CQI (Continuous Quality Improvement) Committee activities. Two representatives of the Medial Staff shall also review the credentialing files prior to Medical Staff approval. All information gathered in the process of completing peer reviews of the medical staff shall be kept secure ..."

The Utilization and Peer Review Plan (Internal and External), dated 12/1/13, stated in part ... "Health Information Management Director will randomly select a representative sample of at least one medical record per provider per year for external review. Credentialing will coordinate peer review of credentialed providers with Health Information Management and document accurate date of providers peer review results in the provider credentialing file..."

Review of the CQI minutes, dated 8/19/13, showed it stated in part "...the CNO (Chief Nursing Officer) reported that the peer review process is being revamped for clinic, midlevel, CRNA (Certified Registered Nurse Anesthetist, and external peer review based on current best practice."

3. During an interview on 12/19/13 at 10:00 AM, the CNO verified that external peer reviews for physicians and other practitioners were not completed since June of 2013. The CAH changed network hospital affiliation and there was a change in leadership resulting in the delay.