HospitalInspections.org

Based on document review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to conduct a timely investigation into a patient's fall and potentially create interventions to prevent another patient from falling for 1 of 1 patient reviewed who suffered a serious injury associated with the fall which necessitated transferring a patient to another hospital (Patient #1). Failure to conduct a timely investigation and potentially create interventions to prevent another patient from falling could potentially result in another patient falling and suffering a serious injury, potentially including fracturing a hip or potentially even dying from bleeding in the patient's brain because the CAH did not identify and mitigate any risk factors or contributing factors to the fall. The CAH administrative staff identified an average daily census of 7 inpatients.

Findings include:

1. Review of Physician A's documentation in Patient #1's medical record revealed Patient #1 was admitted to the CAH on 03/25/20 after Patient #1 was hospitalized at another hospital for treatment of a bone infection, treatment of bacteria in Patient #1's bloodstream, treatment of a possible infection in Patient #1's heart, and intravenous (IV) antibiotics. Physician A noted that Patient #1 initially had a fairly unremarkable course during the hospitalization with routine administration of IV Rocephin (an antibiotic). Patient #1 participated in Physical Therapy (PT) and Occupational Therapy (OT) regularly but fatigued easily. Physician A further noted that on 04/07/20, Patient #1 was found on the floor outside of Patient #1's bathroom. Patient #1 was alert and responsive at the time of the fall. Patient #1 was confused after the fall and Patient #1 indicated they were trying to find the bathroom (Patient #1 was sitting outside their bathroom). Patient #1 was monitored throughout the day, was noted to have difficulty with PT, and more confused. Physician A examined Patient #1 at that time, ordered various testing, and Patient #1 was given some IV fluids overnight.

On the morning of 4/8/20, Patient #1 complained of left ear pain with coughing and was not paying attention to objects on Patient #1's right side. Physician A ordered a CT scan of Patient #1's head (a detailed x-ray), which revealed Patient #1 had bleeding in their brain. Later that day, the CAH staff transferred Patient #1 to another hospital for treatment of the bleeding in Patient #1's brain.


2. Review of the undated "Quality Assurance and Quality Improvement Plan," revealed in part, "Support a medical center-wide commitment to improving the quality of patient care and patient care delivery ... Develop a culture of performance improvement of all staff, utilizing [CAH] identified methodology and tools ... Coordinate and integrate the measurement and improvement responsibilities of all service lines including Inter- and Intra- departmental participation ... To support employees and leadership on Incident Reporting on Patient ... events. Identify
changes that will lead to improvements and identify when an improvement process is needed ... Promote optimal patient care through ongoing, objective, systematic measurement and improvement of processes and outcomes."

3. Review of the policy "Incident Reporting - Safety Zone," effective 04/01/14, revealed in part, "All Incidents/Occurrences resulting in a major injury or death shall be reported immediately to the Chief Nursing Officer and Senior Administration. Any significant event shall have a follow-up Root Cause Analysis investigation and report completed by the Director of Quality, the Chief Nursing Officer, with the assistance of the Department Director, staff involved in the incident and if necessary, Medical Director. The investigation shall focus on gathering enough information to determine if there is any system failure that would necessitate a change in policy/procedure, etc."

4. Review of the undated CAH Fall Investigation, revealed the CAH's plan to investigate Patient #1's fall included the CAH staff would perform a Root Cause Analysis with an interdisciplinary team of professionals, perform staff education, review the CAH's applicable policies, and have another member of the medical staff review the patient's medical record.

5. During an interview on 4/29/20 at 4:00 PM, Occupational Therapist (OT) C revealed they provided care to Patient #1. OT C verified the CAH staff had not performed an investigation into Patient #1's fall, nor had the CAH staff implemented any changes as a result of Patient #1's fall.

6. During an interview on 4/29/20 at 1:00 PM, Physical Therapy Aide (PTA) D revealed they provided care to Patient #1. PTA D verified the CAH staff had not conducted an investigation into Patient #1's fall, nor had the CAH staff implemented any changes as a result of Patient #1's fall.

7. During an interview on 4/29/20 at 1:15 PM, Physical Therapy Aide (PTA) B revealed they provided care to Patient #1. PTA B verified the CAH staff had not conducted an investigation into Patient #1's fall, nor had the CAH staff implemented any changes as a result of Patient #1's fall.

8. During an interview on 4/29/20 at 3:30 PM, Certified Occupational Therapy Assistant (COTA) E revealed they provided care to Patient #1. COTA E verified the CAH staff had not previously conducted an investigation into Patient #1's fall, nor had the CAH staff implemented any changes as a result of Patient #1's fall. The CAH staff first began investigating Patient #1's fall on 4/29/20 (22 days after Patient #1 fell, and 2 days after the Iowa Department of Inspections & Appeals began an on-site investigation).

9. During an interview on 4/29/20 at 9:00 AM, Patient Care Technician (PCT) F revealed they provided care to Patient #1 on the morning of 4/7/20 (the day Patient #1 fell). PCT F revealed the CAH staff had not conducted an investigation into Patient #1's fall, nor had the CAH staff implemented any changes as a result of Patient #1's fall.

10. During an interview on 4/29/20 at 11:00 AM, Registered Nurse (RN) G revealed they provided care to Patient #1 on the morning of 4/7/20 (the day Patient #1 fell) and on 4/8/20 (the day after Patient #1 fell). RN G verified the only investigation the CAH staff performed was when the Inpatient Director asked RN G if Patient #1 hit their head during the fall. RN G verified the CAH staff had not otherwise conducted an investigation into Patient #1's fall, nor had the CAH staff implemented any changes as a result of Patient #1's fall.

11. During an interview on 5/5/20 at 10:00 AM, Physician's Assistant (PA) H recalled a PCT notified them that Patient #1 had fallen, but did not require PA H's assistance. PA H verified the CAH staff had not conducted an investigation into Patient #1's fall, nor had the CAH staff implemented any changes as a result of Patient #1's fall.

12. During an interview on 4/28/20 at 3:15 PM, Registered Nurse (RN) I revealed they provided care to Patient #1 on 4/7/20 (the day Patient #1 fell). RN I verified the CAH staff had not conducted an investigation into Patient #1's fall, nor had the CAH staff implemented any changes as a result of Patient #1's fall.

13. During an interview on 4/29/20 at 9:00 AM, Registered Nurse (RN) J revealed they provided care to Patient #1 on the night after Patient #1 fell. RN J verified the CAH staff had not conducted an investigation into Patient #1's fall, nor had the CAH staff implemented any changes as a result of Patient #1's fall.

14. During an interview on 4/30/20 at 11:00 AM, the Patient Care Coordinator revealed they discussed Patient #1's fall with the Inpatient Director on 4/29/20 (22 days after the fall, the first time the Patient Care Coordinator became involved in the process changes, and 1 day after the Iowa Department of Inspections and Appeals began their on-site investigation). The Patient Care Coordinator verified the CAH staff had not conducted an investigation into Patient #1's fall, nor had the CAH staff implemented any changes as a result of Patient #1's fall.

15. During an interview on 4/29/20 at 3:00 PM, the Acting Rehab Director revealed they provided care to Patient #1 on the day prior to their fall. The Acting Rehab Director revealed the therapy staff discuss patient status changes at the rehab department's weekly huddle, but do not document any of the changes they note. The therapy staff frequently speak with the nursing staff if they notice changes in a patient's condition. However, the Acting Rehab Director verified the CAH staff had not conducted an investigation into Patient #1's fall, nor had the CAH staff implemented any changes as a result of Patient #1's fall.

16. During an interview on 4/28/20 at 2:30 PM, the Inpatient Director revealed they learned about Patient #1's fall on 4/8/20 (1 day after Patient #1 fell). The Inpatient Director started the CAH's internal investigation into Patient #1's fall and interviewed RN G on 4/10/20 (3 days after Patient #1 fell). The next time the CAH staff would perform any part of the CAH's investigation was on 4/29/20 (22 days after Patient #1 fell and 1 day after the Iowa Department of Inspections and Appeals began their on-site investigation) when the Inpatient Director met with the Patient Care Coordinator to review possible changes to the CAH's policy. The Inpatient Director planned to present the policy changes to the CAH's policy committee on 4/30/20 (23 days after Patient #1 fell and 2 days after the Iowa Department of Inspections and Appeals began their on-site investigation).

The Inpatient Director acknowledged the CAH staff needed to improve their current process for reviewing the circumstances surrounding the investigation a patient's fall and any potential changes needed to prevent other patients from falling. The Inpatient Director acknowledged the CAH lacked a clear mechanism for communication between the nursing staff and therapy staff regarding changes in a patient's condition. Currently, nursing staff and therapy staff only discussed changes in the patient's condition once a week, at the weekly care planning meeting.

The Inpatient Director revealed they "hoped" the nurses would read the progress notes from the Occupational Therapy (OT) and Physical Therapy (PT) staff. The Inpatient Director acknowledged they did not know how the OT and PT staff communicated with the nursing staff, and had not interviewed the OT and PT staff to gain further understanding of Patient #1's fall (21 days after Patient #1 fell).


17. During an interview on 4/28/20 at 10:52 AM, the Director of Quality revealed they first learned that Patient #1 fell on 4/8/20 (1 day after Patient #1 fell). On 4/10/20 (3 days after Patient #1 fell) the Director of Quality began discussing Patient #1's fall with the Inpatient Director. The CAH staff performed internal research, reviewed Patient #1's medical record, developed a timeline of events, reviewed the CAH's policies, and identified training opportunities. The Director of Quality and Inpatient Director also reported the incident to the Iowa Department of Inspections and Appeals on 4/10/20. The CAH staff performed the review of Patient #1's medical record on 4/24/20 (17 days after Patient #1 fell).

The CAH staff planned to review the CAH's relevant policies at the CAH's regularly scheduled policy committee meeting on 4/29/20 (22 days after Patient #1 fell and 1 day after the Iowa Department of Inspections and Appeals began their on-site investigation). The CAH staff would then perform any needed education in the month of May (at least 24 days after Patient #1 fell).

The Director of Quality acknowledged the CAH staff had not implemented any measures to prevent another patient from falling or any measures to address any potentially identified communication issues, as the CAH staff would address any issues with the upcoming education offered to the staff in May, and the Director of Quality did not know what the CAH staff would determine they needed to provide during the upcoming education in May.

I. Based document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to evaluate and improve the quality and appropriateness of patient care and to improve quality on a continuous basis for all services offered at the CAH for 2 of 9 contracted services (DEXA Scan, used to measure bone density, and Tele-psych visits) in 2 departments (Radiology and Emergency). Failure to create and implement an effective quality improvement program that included involvement of all of the CAH's departments to improve quality on a continuous basis could potentially result in the CAH staff's failure to identify, monitor, address, and improve patient care problems in each patient care area through the efforts of all involved departments. The CAH administrative staff identified they performed 63 DEXA Scans and approximately 8 Tele-psych visits in fiscal year 2019.

Findings include:

1. Review of the undated "Quality Assurance [QA] and Quality Improvement Plan", revealed in part, "Support a medical center-wide commitment to improving the quality of patient care and patient care delivery...The scope of the Quality Improvement Plan is hospital-wide participation including all clinical, non-clinical, and contract services provided..."

2. Review of the CAH Annual Report, Fiscal Year 2019, revealed in part, "All patient care services and other services affecting patient care and safety provide regular quality improvement reports that are reviewed and evaluated by the QA committee."

3. Review of the undated "Active Contract Complete Listing", revealed the CAH provides radiology services (DEXA Scans) and Tele-psych Services through contracts with other organizations.

4. Review of the 6 most recent CAH Quality QA Meeting Minutes (last one dated 1/21/20) revealed the meeting minutes lacked any documentation of quality improvement activities (problem prevention, identification, corrective action taken, and the outcomes of effective action for contracted services) related to DEXA scans or Tele-psych services.

5. During an interview on 05/05/20 at 3:00 PM, the Director of Quality acknowledged the CAH's QA committee did not review or evaluate any quality improvement information for DEXA Scans or Tele-psych Services.




II. Based on document review and staff interview, the Critical Access Hospital (CAH) medical staff failed to evaluate all patient care services and other services affecting the health and safety of all patients. Failure of the medical staff to evaluate all patient care services may result in missed opportunities to identify, monitor, address, and improve patient care problems in each patient care area. The CAH administrative staff identified an average daily census of 7 with approximately 55 surgeries and 271 Emergency Department visits per month.

Findings include:

1. Review of the undated "Quality Assurance [QA] and Quality Improvement Plan," revealed in part, "Department/Service Specific Quality Assurance - Each Department or service will have their own specific monitoring reports. They will follow the overall hospital wide Quality Improvement Plan ... The Department Director is responsible for all QA audit completion for their department/service ... Reporting to: ... [includes the] Medical Staff committee ..."

2. Review of the Medical Staff Meeting Minutes, dated 3/27/20, revealed the document lacked evidence that quality improvement data from the CAH departments and services was shared with the CAH medical staff.

3. During an interview on 05/06/20 at 12:55 PM, the Director of Quality confirmed that the CAH now has 2 physicians on the Quality Committee but this information is not shared at the Medical Staff meetings. There is no process to ensure all medial staff receive all quality assurance and quality improvement information. The Director of Quality revealed the CAH's active medical staff includes 8 physicians and 6 Advanced Practice Practitioners.