HospitalInspections.org

Based on observation, review of documents,and staff interview the Critical Access Hospital (CAH) failed to limit the available beds to 25 beds available for inpatients. Qualifications for a hospital to be a CAH, includes a maximum inpatient bed count of 25. The CAH administrative staff identified a census of 8 inpatients at the time of the survey.

Failure to limit the number of inpatient beds to 25 could potentially result in the CAH providing care to too many patients.

Findings include:

1. Review of the undated document titled, "Health Care Services Provided at West Union Iowa by Palmer Lutheran Health Center" stated in part, "...Critical Access Hospital Acute and observation medical surgical 25 bed hospital..."

2. Observation on 6/1/15 at 2:30 PM, with Staff A and B, Registered Nurses (RN's), during the initial tour of the medical/surgical/obstetric units revealed a total of 25 beds and 2 cribs. The assembled cribs were kept in a storage room, ready for use on the medical surgical unit, increasing the total bed count to 27.

3. During and interview on 6/2/15 at 11:05 AM Staff B, verified the number of beds available for use was 27.

Based on review on policies, documentation, meeting minutes, and staff interview, the Critical Access Hospital (CAH) staff failed to ensure the required group of professionals, including a mid-level provider and a physician, reviewed all patient care policies for 17 of 17 patient care departments (Anesthesia, Nursing, OB, Surgery, Emergency Department, Cardiac Rehab, Pulmonary Rehab, Nutritional Services/Diabetic Education, Laboratory, Occupational Therapy, Physical Therapy, Speech Therapy, Radiology, Respiratory Therapy, Wound & Ostomy Services, Infection Control, and Pharmacy).

Failure to ensure the required group of professionals reviewed all patient care policies annually could potentially result in CAH's failure to identify, address patient care needs, an opportunity to increase the quality of care, and an opportunity to update the policies to ensure they continued to be consistent with current patient care practices.

Findings include:

1. Review of CAH policy titled "Development and Maintenance of Policies and Procedures", dated 4/2015, revealed in part, "Policies are reviewed at least annually by the CAH Advisory Board."

2. Review of document titled "Critical Access Hospital Advisory Board 2014" revealed members of the advisory board included a physician and a mid-level provider.

Review of CAH Advisory Board committee meeting minutes dated August 21, 2014 revealed in part, ". . . Policy review has been completed by all departments. Following review it was agreed to accept all department policies of the CAH. . . ." A physician and a mid-level provider attended the meeting.

3. During an interview on 6/3/15 at 1:40 PM, Staff H, Compliance, stated all policies and procedures were reviewed at the last annual meeting of the CAH Advisory Board on August 21, 2014. Staff H reported that prior to the annual meeting, each committee member, except the physician and mid-level provider, would take the policy section of previously assigned department manuals and review only the policies that were changed from the previous year. The committee members would then bring any recommendations regarding any policy changes from the previous year to the annual meeting. Staff H stated the CAH Advisory Board committee did not review entire department policy and procedure manuals and the physician or mid-level provider did not review the revised policies and the policies/procedures were not reviewed by the required group of professionals.

I. Based on observation, document review, and staff interview the Critical Access Hospital (CAH) failed to ensure staff monitored and replaced expired Avagard (antiseptic hand sanitizer) from 2 of 2 scrub sinks. The CAH administrative staff reported an annual surgery volume of 292 surgeries.

Failure to remove expired antiseptic hand sanitizers used to sanitizer hands prior to a patient's procedures resulted in the Operating Room (OR) staff and Providers used expired antiseptic hand sanitizer prior to patient's surgical and pain procedures.

Findings include:

1. Review of the document titled, "OR Cleaning Assignments" did not include information regarding monitoring the manufacturer printed outdates for the Avagard antiseptic hand sanitizers in the surgery area. The CAH Administrative staff failed to develop and implement a policy to ensure staff monitored, removed, and replaced expired supplies in the surgical area.

2. Observation on 6/3/15 at 9:55 AM, during the tour of the surgery department showed 1 expired wall mount Avagard antiseptic hand sanitizer next to the scrub sink outside of the OR in the surgical area. (expired on 1/28/15) 1 expired wall mount Avagard antiseptic hand sanitizer next to the scrub sink by the pain procedure room in the surgery area. (expired on 1/2011) Staff C, Surgery Director agreed both Avagard antiseptic hand sanitizers were expired. Staff C reported the staff were not aware the Avagard antiseptic hand sanitizer expired.


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II. Based on review of personnel records, policies, and staff interview the Critical Access Hospital (CAH) administrative staff failed to ensure the CAH had a system in place to monitor the contracted sleep study staff personnel required licensing, education, new employee and health physicals.

Failure to ensure the CAH had a system in place that included monitoring of the contracted sleep study staff personnel required licensing, education, employee health physicals for new and current employees could potentially result in causing harm to patients in the event an employee had an exposure and transmitted the communicable disease to the patients. The CAH failed to ensure 2 of 2 contracted sleep study staff had an employee health physical in accordance with the CAH policy.(Staff D and Staff E). Administrative staff identified a census of 8 patients.

Findings include:

1. Review of a document titled, "Independent Contracting Agreement for Independent Sleep Lab Services, with Midwest Sleep Services" dated 1 June 2005, Addendum dated 2/18/13, revealed it failed to identify the responsibilities of Midwest Sleep Services to ensure there would be documented evidence the contracted staff met all regulatory requirements and that Midwest Sleep Services would provide such information upon request.

2. Review of a human resources policy titled "Post-Offer - Pre-Employment Health Examination and Employee Health", dated 8/2013, revealed in part, "...Objective: To ensure the entering employee/volunteer's ability to perform job-related functions and maintain a control health environment...policy also covers . . . contracted services staff (referenced under procedure item #11) . . . 9. Physical Wellness Examinations will be done on employees/volunteers every four years after hire . . ." The policy failed to address the health exam requirements for contracted staff in procedure item #11 or anywhere else in the policy.

3. During an interview on 6/3/15 at 9:55 AM Staff F, Chief Human Resources Officer reported she did not have personnel records on Staff D and Staff E, contracted sleep study staff. Staff F reported the department director would have the information.

4. Review of an undated document titled "Cardiopulmonary Services Compliance Tracking/Contracted Services" failed to show documented evidence of a completed health exam for both Staff D and Staff E.

5. During an interview on 6/3/15 at 4:05 PM, Staff G, Human Resources Assistant, reported CAH staff communicated with the contracted sleep study service to obtain documentation of a health exam for Staff D and Staff E, but had not received anything yet. Staff G reported the understanding with the contracted company included the entity would have documented evidence of required licensing, education and health status and would provide the information to the CAH, upon request. At 4:25 PM, the surveyor received documents faxed from Midwest Sleep Services regarding the health status of Staff D and Staff E. Review of a document dated 11/3/08 revealed Staff D's health exam. (6 1/2 years prior) Staff E lacked documented evidence of any health exam.