HospitalInspections.org

Based on document review, policy review and staff interview the Critical Access Hospital (CAH) administrative staff failed to ensure the established system to identify and prevent communicable diseases included TB screening for all volunteers. Problems were identified for 3 of 5 volunteers. Administrative staff identified a staff of 54 volunteers..

Failure to identify infections and communicable diseases could potentially result in causing harm to patients through exposure and transmission of communicable diseases.

Review of the Iowa Administrative Code, Chapter 51 titled "Hospitals", last updated 2/5/14, revealed in part ". 51.24(3) Health examinations. . . . Screening and testing for tuberculosis shall be conducted pursuant to 481-Chapter 59.

Review of a CAH policy titled "Tuberculosis (TB) Control Plan", last revised in 5/13, revealed in part ". . . all health care workers (employees and volunteers) must receive a baseline TB screening upon hire . . ."

1. Review of the employee health information for Staff B, Volunteer, revealed the file lacked documentation of a TB test. Administrative staff identified Staff B has been a volunteer since 11/12/07.

2. Review of the employee health information for Staff C, Volunteer, revealed the file lacked documentation of a TB test. Administrative staff identified Staff C has been a volunteer since 11/1/10.

3. Review of the employee health information for Staff D, Volunteer, revealed the file lacked documentation of a TB test. Administrative staff identified Staff D has been a volunteer since 10/22/12.

During interviews on 11/5/14 at 8:55 AM and 9:25 AM, Staff A, Chief Nursing Officer, confirmed the CAH lacked documented evidence to confirm the identified volunteers had a TB test at the time their services began.

I. Based on review of physician's surgery privileges, Medical Staff Bylaws, policies/procedures, operating room log, and staff interviews, the Critical Access Hospital (CAH) failed to ensure delineation of privileges for procedures performed at the CAH for 5 of 9 physicians performing surgery reviewed. (Physicians A, B, C, D, and E)

Failure to ensure specific privileges for all physicians performing surgery could put the patient at risk for surgical complications and could result in patients receiving surgical interventions from unqualified professionals.

Findings include:

1. Review of privileges for Physicians as follows:
a. Physician A's privileges, maintained in the Surgical Services area, revealed no privileges for laparoscopic cholecystectomy or laparoscopic hernia repair procedures.

b. Physician B's privileges, maintained in the Surgical Services area, revealed no privileges for laparoscopic cholecystectomy procedures.

c. Physician C's privileges, maintained in the Surgical Services area, revealed no privileges for laparoscopic appendectomy or laparoscopic hernia repair procedures.

d. Physician D's privileges, maintained in the Surgical Services area, revealed no privileges for lens implants during cataract surgical procedures.

e. Physician E's privileges, maintained in the Surgical Services area, revealed no privileges for endoscopic procedures.

2. During an interview on 11/4/14 at 11:45 AM, Staff G, Director of Surgery and Out Patient Services, verified the following physicians lacked privileges for the following procedures performed at the CAH and documented in the operating room log:

a. Physician A performed 3 laparoscopic cholecystectomy and 2 laparoscopic hernia repair procedures in the past 12 months.

b. Physician B performed 1 laparoscopic cholecystectomy procedure in the past 12 months.

c. Physician C performed 1 laparoscopic appendectomy and 12 laparoscopic hernia repair procedures in the past 12 months.

d. Physician D performed 77 cataract surgeries with lens implant procedures in the past 12 months.

e. Physician E performed 102 endoscopic procedures in the past 12 months.

3. Review of the Medical Staff Bylaws, dated July 2014, revealed the following, in part, ". . . Each Medical Staff member practicing in the Hospital by virtue of the practitioner's membership on the Medical Staff is entitled to exercise only those clinical privileges specifically granted to the practitioner by the governing body. . . ."

Review of surgery policies/procedures titled "Designation of Qualified Practitioners", dated 10/09 revealed the following, in part, ". . . All surgical procedures must be conducted by a practitioner who meets the medical staff criteria and procedures for the privileges granted, who has been granted surgical privileges in accordance with those criteria established by the governing body/medical staff, and who is working within the scope of those granted and documented privileges."


II. Based on document review and staff interview, the Critical Access Hospital (CAH) failed to delineate and grant privileges for 1 of 1 Field Service Technician reviewed, who was not an employee of the hospital, to assist with surgical procedures. The field service technician assisted with 68 of 77 surgical procedures in the past 12 months completed by physician D. (Other staff AA)

Failure to ensure delineation of privileges for the field service technician could potentially result in unauthorized individuals assisting with surgical procedures that could put the patient at risk for surgical complications or the loss of vision.

Findings include:

1. Review of the Medical Staff Bylaws, dated July 2014, revealed the following, in part, ". . . Each Medical Staff member practicing in the Hospital by virtue of the practitioner's membership on the Medical Staff is entitled to exercise only those clinical privileges specifically granted to the practitioner by the governing body. . . ."

Review of surgery policies/procedures titled "Designation of Qualified Practitioners", dated 10/09 revealed the following, in part, ". . . All surgical procedures must be conducted by a practitioner who meets the medical staff criteria and procedures for the privileges granted, who has been granted surgical privileges in accordance with those criteria established by the governing body/medical staff, and who is working within the scope of those granted and documented privileges."

Review of the "Agreement, for Mobile Cataract and Laser Services", dated June 2013, revealed the following, in part, ". . . Provide technician during the procedure to monitor the proper performance of the instrumentation and supplies. The credentials of these technicians shall be submitted to the Hospital for review and approval by their credential committee. . . ."

Review of the Operating Room Log on 11/4/14 at 10:30 AM revealed Other Staff AA, Field Service Technician, provided surgical assistance for Practitioner D during surgical interventions for patients. The surgical technician assisted with 68 of 77 surgical procedures in the past 12 months completed by Practitioner D.

Review of the privileges maintained in the operating room on 11/4/14 at 10:30 AM lacked documentation of privileges for Other Staff AA.

Review of Other Staff AA's, Field Service Technician, personnel file on 11/4/14 at 11"00 AM lacked documentation of privileges for Other Staff AA.

2. During an interview on 11/4/14 at 10:30 AM, Staff G, Director of Surgery and Out Patient Services, verified that Other Staff AA lacked surgical privileges to provide assistance during surgical procedures with Practitioner D. Staff G stated Other Staff AA scrubbed in and assisted Practitioner D during surgical procedures.

Based on document review and staff interviews, the Critical Access Hospital (CAH) failed to ensure 1 of 12 active physicians, selected for review, received outside entity peer review performed by the Network Hospital to evaluate the appropriateness and diagnosis and treatment furnished to patients at the Critical Access Hospital in accordance with the facility's agreement with the Network Hospital. (Physician J). The CAH credentialed 159 active physicians.

Failure to ensure all medical staff members received outside entity peer review affects the facility's ability to assure physicians provide quality care to their patients.

Findings include:

1. Review of CAH policy titled "Routine Clinical Peer Review Process", dated 2/14, revealed in part, ". . . Each physician credentialed at JRMC will have one external peer review performed per credentialing cycle. The external review is performed by a physician from our network hospital. Each physician's review information is shared with the medical staff for use during the re-credentialing process only. The chart/peer review information is not kept in the credentialing file, but kept in a secure location in administration. . . ."

2. Review of CAH documentation on 11/5/14 revealed the facility failed to ensure the Network Hospital completed peer review for Physician J.

3. During an interview on 11/5/14 at 12:20 PM, Staff H, Director of Performance Improvement, stated the CAH staff choose 1 patient medical record from each physician on staff at the CAH and send it to the Network Hospital for review. Staff H further stated the outside entity peer review for Physician J was not a patient from the CAH and lacked documentation of Network Hospital peer review for Physician J.

Based on document review and staff interviews, the Critical Access Hospital (CAH) failed to ensure the medical staff received the results of outside entity peer review for 12 of 12 active physicians, selected for review, performed by the Network Hospital to evaluate the appropriateness and diagnosis and treatment furnished to patients at the Critical Access Hospital in accordance with the CAH's policy during the re-credentialing process. (Physicians B, C, D, F, G, H, I, K, L, M, N, and O). The CAH credentialed 159 active physicians.

Failure to inform the medical staff of the results of the outside entity peer review affects the medical staff members ability to assure physicians provide quality care to their patients.

Findings include:

1. Review of CAH policy titled "Routine Clinical Peer Review Process", dated 2/14, revealed in part, ". . . Each physician credentialed at JRMC will have one external peer review performed per credentialing cycle. The external review is performed by a physician from our network hospital. Each physician's review information is shared with the medical staff for use during the re-credentialing process only. The chart/peer review information is not kept in the credentialing file, but kept in a secure location in administration. . . ."

2. Review of CAH documentation on 11/5/14 revealed the facility obtained completed outside entity peer review from the Network Hospital for Physicians B, C, D, F, G, H, I, K, L, M, N, and O.

3. During an interview on 11/5/14 at 12:20 PM, Staff H, Director of Performance Improvement, stated the CAH staff choose 1 patient medical record from each physician on staff at the CAH and send it to the Network Hospital for review. Staff H further stated the outside entity peer review results were kept in a locked file cabinet and were not shared with the medical staff during the re-credentialing process for the physicians.

During an interview on 11/5/14 at 3:05 PM, Staff I, Director of Human Resources, responsible for credentialing, stated the outside entity peer review results were not included as part of the re-credentialing process for Physicians B, C, D, F, G, H, I, K, L, M, N, and O.