HospitalInspections.org

Based on policy review and staff interview the Critical Access Hospital (CAH) failed to schedule patient meals in accordance with applicable state regulations. The Director of Food and Nutrition reported 15-20 patients meals served daily.

Failure to avoid extensive lapses between meals could potentially result in failure to provide a patient with adequate nutrition.

Review of the Iowa Administrative Code for the Department of Inspections and Appeals, Chapter 51 titled "Hospitals", last updated 12/10/14, revealed in part ". . . 51.20(2)b.(2) Not more than 14 hours shall elapse between the evening meal and breakfast of the following day.

Findings include:

During an interview on 6/8/15 at 1:50 PM, Staff I, Director of Food and Nutrition Services reported the scheduled patient meal times as 7:45 AM (breakfast), 11:45 AM (lunch) and 4:45 PM (dinner).

Review of a Food and Nutrition policy titled "Patient Meal Service", approved April 2015 revealed in part ". . . Trays will arrive on the nursing unit at the following times: Breakfast 7:45-7:50 AM; Lunch 11:45-11:50 AM; Dinner 4:45-4:50 PM.

During an interview on 6/9/15 at 3:30 PM Staff I reported she did not have documented evidence of a waiver excluding them from the state rule.

Based on policy review and staff interview the Critical Access Hospital (CAH) administrative staff failed to follow established policies and procedures for the provision of surgical services during cataract surgical procedures. The Director of Surgical Services reported 156 cataract procedures completed in the 2014 fiscal year.

Written policies and procedures provide guidance and consistency among staff and serve as a resource in the provision of patient care. Failure to follow established Surgical Services policies and procedures could potentially result in causing harm to patients.

1. Review of a Surgery policy, titled "Health Care Industry Representative in Surgical Services Areas", approved in 8/2013, revealed in part "...The representative will not scrub in..."

2. During an interview on 6/10/15, at 8:20 AM, Staff J, Director of Surgical Services, reported Non-Hospital Staff N, Surgical Technician, assisted with equipment during cataract surgeries. She clarified he attended surgeries as an equipment technician, not to assist the physician, but scrubbed in for each procedure.

Based on review of medication error reports, patient medical records, policies/procedures, and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure notification the physician when medication errors occurred for 3 of 12 patients. (Patients # 4, 5, and 6) The CAH staff reported a census of 3 inpatients at the start of the survey.

Failure to report medication errors when they occur to the physician could potentially cause harm to patients if patients receive the wrong medication, medication at the wrong time, or by the wrong route.

Findings include:

1. Review of CAH policy/procedure titled "Adverse Drug Reactions and Medication Errors", dated 5/14, revealed in part, ". . . Medication errors and adverse drug reactions are reported immediately to the physician, documented on the VOICE [incident reports] and documented in the medical record with at least the medication administered and the reaction observed. . . ."

2. Review of the Medication Error Reports for Patients # 4, 5, and 6 and review of the patient's medical records lacked documentation the physician was notified of the medication errors occurred.

3. During an interview on 6/9/15 at 8:10 AM, Staff A, Chief Nursing Officer, stated the nurses were to notify the physician of all medication errors that occurred. Staff A verified the lack of documentation the physicians were notified when medication errors occurred for Patients # 4, 5, and 6.

Based on observation, review of documents, and staff interview the Critical Access Hospital (CAH) lacked documentation for the nursing staff responsible for the care of the sleep lab patients. The CAH administrative staff reported 8-10 sleep lab patients per month.

Failure to have documentation of nursing staff responsible for the sleep lab patient could potentially result in sleep lab patients lacking required nursing care during the procedure.

1. Observation on 6/8/10 at 2:00 PM during an initial tour of the nursing area with Staff H, RN Director of Acute Care revealed the sleep lab was located on the nursing area. The sleep lab showed a camera monitor, and the patients' sleep monitor was located in an adjacent office located inside the clean utility room. The clean utility room was located across the hall from the nurses station, with the door closed at all times. The office door, containing then sleep lab monitor, was closed at all times.

2. Review of the Polysomnography Interpretation Service Agreement, dated 3/10 with an automatic renewal date, revealed the network hospital provides Sleep Lab monitoring via telemonitoriong.

3. Review of the policy/procedure titled Sleep Lab Study Process, dated 5/12, states in part... Sleep studies will be performed at the CAH and monitored by a polysomnographer technologist at network hospital. If problems arise or patient needs CPAP/BIPAP (breathing assistive devices) therapy, the nursing staff will do what they are directed by the network Sleep Lab. If there are computer problems, sleep technician will be called and will handle all computer problems as they arise.
The Sleep Lab Technician will be trained by our staff. They will be supervised by current staff for a minimum of 4 studies or until tech is comfortable performing study on their own. New techs will be asked to perform a complete study on their own with visual supervision from experienced techs; and if study performed correctly, they will be allowed to perform them on their own.

4. Review of Sleep Lab Technician Job Description ,undated, states in part... The polysomnographic Technician performs all types of sleep disorder testing, including set-up and performance of nocturnal polysomnograms on all select groups. Must demonstrate working knowledge of polysomnography, oximetry and administration of supplemental O2, continuous positive airway pressure (CPAP/BIPAP) studies, and the basis of sleep medicine. Able to take the patient vital signs accurately.

5. Review of Sleep Lab Technician Procedure, dated 5/14, states in part... After sleep technician goes home, nursing staff is responsible for:
1. Help with patient issues if need arises in the night such as toileting, etc.
2. Provide change of mask for patients if needed or apply oxygen cannuula.
3. Do what network hospital sleep lab tech instructs them within their comfort level.
4. Nursing staff should document if CPAP was applied on Sleep Study Notes.
5. Nursing staff should disconnect sleep study electrodes.
6. Nursing staff should have patient fill out morning questionnaire and CPAP questionnaire and CPAP questionnaire if CPAP applied.
7. Awaken patient as directed and discharge home.
8. Nursing staff should sign Sleep Study Notes.
9. Nursing staff should discharge sleep lab patient per normal protocol.
6. Review of Staff C and D, Sleep Lab Techs, employee file revealed a lack of training in skills for sleep lab patients enabling them to perform their job functions.

7. Review of Patient #1 medical record revealed a lack of nursing documention for the care of the sleep lab patient. Nursing documentation includes a nurses signature on the form titled, Sleep Study Notes.
Review of Patient #2 medical record revealed a lack of nursing documention for the care of the sleep lab patient. Nursing documentation includes a nurses signature on the form titled, Sleep Study Notes.
Review of Patient #3 medical record revealed a lack of nursing documention for the care of the sleep lab patient. Nursing documentation includes a nurses signature on the form titled, Sleep Study Notes.

8. During an interview on 6/9/15 at 6:30 AM Staff M, RN reported the RN takes over care for the sleep lab patient at 11:00 PM from the Sleep Lab Tech. I would assist the patient to the bathroom or replace a lead, if I am unable to replace a lead I would call the on call tech. The patient is monitored by an outside facility and they call us if the patient needs something or a lead needs replaced. We do have a sleep lab monitor in the office area located in the clean supply room that shows the patient's EKG, heart rate, and oxygen saturation level, I would only look at this monitor if I went into the clean utility room. I have not received any training on care of the sleep lab patient, the outside facility tells us what to do. The patient is assigned to nurses working the shift, and any one available would answer the call light.

During an interview on 6/10/15 at 11:15 AM, with Staff E, Senior Director of Human Resources, revealed the facility lacks documentation of competency training for the Sleep Lab Technicians.

Based on document review and staff interview, the Critical Access Hospital (CAH) failed to delineate privileges for 1 of 1 Surgical Technicians (Non-Hospital Staff N), to assist with cataract procedures. Non-Hospital Staff N assisted courtesy physician, Practitioner A, Ophthalmologist, with 156 cataract procedures, during the 2014 fiscal year.

Failure to privilege all staff that assist providers could result in patients receiving surgical intervention from unqualified professionals.

Findings include:

1. Review of the Bylaws of the Medical Staff, approved 12/19/14, revealed, in part, ". . . Every practitioner practicing at this hospital by virtue of medical staff membership or otherwise shall, in connection with such practice, be entitled to exercise only those clinical privileges specifically granted to him/her by the governing body . . ."

Review of the Surgical Privileges book, kept in the surgery area, showed the lack of documented privileges for Non-Hospital Staff N.

2. During an interview on 6/9/15 at 3:25 PM, as part of credential file review, Staff K, Administrative Assistant, reported she did not have a credential file on Non-Hospital Staff N to document the approval of any privileges and not aware he provided services in surgery.

During an interview on 6/10/15, at 8:20 AM, Staff J, Director of Surgical Services, reported Non-Hospital Staff N, Cataract Surgical Technician, assisted with equipment during cataract surgeries. She clarified he was an equipment technician, and not the physician assistant, but scrubbed in for each procedure. Staff J reported she lacked privileges for Non-Hospital Staff N approved by the medical staff and governing board.

Based on review of policies/procedures, documentation, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the periodic evaluation of its total CAH program included the number of patients served and the volume of services for 16 of 18 patient care services. (Anesthesia, Diabetes Education, Emergency Room, Food and Nutrition, Laboratory, Surgery, Wound Care, Pharmacy, Radiology, Outpatient Treatment Center, Physical Therapy, Occupational Therapy, Speech Therapy, Sleep Lab, Cardiac Rehabilitation, and Stress Lab)

The CAH administrative staff reported the average monthly volume of services for the following:

Anesthesia - 49
Diabetes Education - 42
Emergency Room - 254
Food and Nutrition - 1968 meals
Laboratory - 3115 tests
Surgery - 55
Wound Care - 5
Pharmacy 7884 units
Radiology - 921 tests
Outpatient Treatment Center - 202
Physical Therapy - 856
Occupational Therapy - 151
Speech Therapy - 16
Sleep Lab - 7
Cardiac Rehabilitation - 35
Stress Lab - 117

Failure to include the periodic evaluation of its total CAH program could result in failure to identify potential changes needed in services provided.

Findings include:

1. Review of policy/procedure titled "Medical Executive Advisory Committee for CAH", dated February 2014, revealed in part, ". . . The CAH Program evaluation is completed on an ongoing basis with a formal total annual review at least once a year. And includes the review of: Utilization of CAH services, including at least the number of patients served and the volume of services. . . ."

2. Review of the "Annual CAH Program Evaluation - FYE 14" failed to include the number of patients served and the volume of services for Anesthesia, Diabetes Education, Emergency Room, Food and Nutrition, Laboratory, Surgery, Wound Care, Pharmacy, Radiology, Outpatient Treatment Center, Physical Therapy, Occupational Therapy, Speech Therapy, Sleep Lab, Cardiac Rehabilitation, and Stress Lab.

3. During an interview on 6/11/15 at 8:10 AM, Staff A, Chief Nursing Officer, acknowledged the annual evaluation of the CAH total program evaluation lacked evidence to include the number of patients served and the volume of services for Anesthesia, Diabetes Education, Emergency Room, Food and Nutrition, Laboratory, Surgery, Wound Care, Pharmacy, Radiology, Outpatient Treatment Center, Physical Therapy, Occupational Therapy, Speech Therapy, Sleep Lab, Cardiac Rehabilitation, and Stress Lab.

Based on review of policies/procedures, documentation, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the periodic evaluation of its total CAH program included a review of a representative sample of both active and closed clinical records for all services provided. (Nursing, Swing Bed, Anesthesia, Diabetes Education, Emergency Room, Food and Nutrition, Laboratory, Surgery, Wound Care, Pharmacy, Radiology, Outpatient Treatment Center, Physical Therapy, Occupational Therapy, Speech Therapy, Sleep Lab, Cardiac Rehabilitation, and Stress Lab) The CAH staff reported a census of 3 inpatients at the start of the survey.

Failure to include review of a representative sample of both active and closed clinical records in the periodic evaluation could result in failure to identify potential changes needed in services provided.

Findings include:

1. Review of policy/procedure titled "Medical Executive Advisory Committee for CAH", dated February 2014, revealed in part, ". . . The CAH Program evaluation is completed on an ongoing basis with a formal total annual review at least once a year. And includes the review of: A representative sample of both active and closed clinical records. . . ."

2. Review of the "Annual CAH Program Evaluation - FYE 14" lacked documentation of a review of a representative sample of both active and closed clinical records for Nursing, Swing Bed, Anesthesia, Diabetes Education, Emergency Room, Food and Nutrition, Laboratory, Surgery, Wound Care, Pharmacy, Radiology, Outpatient Treatment Center, Physical Therapy, Occupational Therapy, Speech Therapy, Sleep Lab, Cardiac Rehabilitation, and Stress Lab.

3. During an interview on 6/11/15 at 8:10 AM, Staff A, Chief Nursing Officer, verified the annual evaluation of the CAH total program lacked documentation of a review of a representative sample of both active and closed clinical records for Nursing, Swing Bed, Anesthesia, Diabetes Education, Emergency Room, Food and Nutrition, Laboratory, Surgery, Wound Care, Pharmacy, Radiology, Outpatient Treatment Center, Physical Therapy, Occupational Therapy, Speech Therapy, Sleep Lab, Cardiac Rehabilitation, and Stress Lab.

Based on review of the Quality Plan, Quality Meeting minutes and activities, Board of Trustees meeting minutes, and staff interviews, the Critical Access Hospital (CAH) quality improvement staff failed to evaluate all patient care services provided for 7 of 7 contracted services (Wound Care, Sleep Lab, MRI, Nuclear Med, Physical Therapy, Occupational Therapy, and Speech Therapy) and 6 of 14 departments (Bone Density, Stress Lab, Anesthesia, Laboratory, Radiology, and Pharmacy) The CAH staff reported a census of 3 inpatients at the start of the survey.

Failure to evaluate all patient care services for quality of care could potentially expose patients to inappropriate and/or substantial care.

Findings include:

1. Review of CAH policy "Quality Plan", dated 7/2014, revealed in part, ". . . Maintain an on-going organization wide, comprehensive, objective, systematic and effective data driven approach to improvement including monitoring, designing, implementing, maintaining and evaluating the service, quality and appropriateness of care and services. . . The Governing Board ensures an effective, organization wide program for quality improvement and patient safety, to evaluate clinical care and services reflecting the complexity of the organization and services provided. . . ."

2. Review of Quality Meeting minutes and activities for the past 12 months lacked evidence that Wound Care, Sleep Lab, MRI, Nuclear Med, Physical Therapy, Occupational Therapy, Speech Therapy, Bone Density, Stress Lab, Anesthesia, Laboratory, Radiology, and Pharmacy evaluated quality activities regarding patient care services.

3. Review of the Board of Trustees Meeting minutes for the past 12 months revealed the lack of documentation the governing board received quality information from Diabetes Education, Emergency Room, Food and Nutrition, Wound Care, Pharmacy, Outpatient Treatment Center, Physical Therapy, Occupational Therapy, Speech Therapy, Sleep Lab, Cardiac Rehabilitation, and Stress Lab to ensure an effective organization wide program for quality improvement.

4. During an interview on 6/11/15 at 8:35 AM, Staff A, Chief Nursing Officer, acknowledged the lack of evidence that Wound Care, Sleep Lab, MRI, Nuclear Med, Physical Therapy, Occupational Therapy, Speech Therapy, Bone Density, Stress Lab, Anesthesia, Laboratory, Radiology, and Pharmacy evaluated quality activities regarding patient care services. Staff A also acknowledged the lack of documentation the governing board received quality information from Diabetes Education, Emergency Room, Food and Nutrition, Wound Care, Pharmacy, Outpatient Treatment Center, Physical Therapy, Occupational Therapy, Speech Therapy, Sleep Lab, Cardiac Rehabilitation, and Stress Lab to ensure an effective organization wide program for quality improvement.

Based on document review and staff interview the Critical Access Hospital (CAH) administrative staff failed to up date the visitation rights portion of patient rights for skilled care and rehab patients. The CAH identified 7-8 swing patients and 10-12 patients per month.

Failure to provide the updated visitation rights to all patients could potentially result in all patient visitors being denied access to visit the patient.

Findings include:

1. Review of the Swing Bed Bill of Rights, dated January 07, states in part... Each resident has the right to receive others at any reasonable hour or at times other than established visiting hours, particularly at times of critical illness subject to the resident's right to deny or withdraw consent for such visits. The document lacked the verbiage regarding a domestic partner (including a same-sex domestic partner).

Review of Your Rights and Responsibilities as a Patient, undated, states in part... You may have the right to accept or refuse visitors. The document lacked the verbiage regarding a domestic partner (including a same -sex domestic partner).

2. During an interview on 6/9/15 at 7:30 AM, with Staff F, RN Case Management, acknowledged the Swing Bed Bill of Rights lack the verbiage related to same sex partners visitation.

During an interview on 6/9/15 at 9:30 AM, with Staff G, PT Director of Rehab Services, acknowledged the Rights and Responsibilities as a Patient lack the verbiage related to same sex partners visitation.