HospitalInspections.org

481-51.41(135B) Criminal, dependent adult abuse, and child abuse record checks. 51.41(2) Requirements for employer prior to employing an individual. Prior to employment of a person in a hospital, the hospital shall request that the department of public safety perform a criminal history check and that the department of human services perform child and dependent adult abuse record checks of the person in this state.

I. Based on personnel record review, policy review and staff interview the Critical Access Hospital (CAH) failed to ensure criminal history and dependent adult abuse record checks were performed, as required by state law. A problem was identified for 1 of 7 new employees selected for review. The administrative staff identified a census of 17 inpatients at the time of the survey.

Failure to perform the required record checks may potentially result in the employment of individuals who could present a risk to patients due to a history of criminal and/or abusive acts.

Findings include:

Review of Staff J's personnel file revealed a hire date of 1/29/14, as a Paramedic. The personnel file contained evidence of a criminal history and abuse record check in the state of South Dakota, but lacked evidence of the required criminal and abuse record checks in the state of Iowa.

During an interview on 8/26/14 at 3:00 PM, Staff N, Human Resources Administrative Assistant reported criminal and abuse record checks for Staff J were completed in South Dakota, his state of residence at the time of hire.

During an interview on 8/27/14 at 9:45 AM, Staff I, Human Resources Director confirmed the criminal and abuse records checks for Staff J were only completed in the state of South Dakota. She reported their practice had been to check records in the applicant's state of residence.

Review of a Human Resources policy titled "Background/Sanction Screening", with an effective date of 3/27/06, revealed in part ". . . I. 2. b. Authorization to conduct the criminal background check will be secured from the individual to whom employment has been offered . . . c. The criminal background check will be conducted through the State of Iowa..."

II. 235B.16 Information, education, and training requirements.
5. b. A person required to report cases of dependent adult abuse pursuant to sections 235B.3 and 235E.2, . . . shall complete two hours of training relating to the identification and reporting of dependent adult abuse within six months of initial employment . . . The person shall complete at least two hours of additional dependent adult abuse identification and reporting training every five years.

Based on personnel record review, policy review and staff interview the CAH failed to ensure new employees and contracted staff completed mandatory reporter training for dependent adult abuse, as required by state law. Problems were identified for 1 of 4 applicable new employees and 1 of 2 contracted staff. Administrative staff identified a census of 17 inpatients at the time of the survey.

Failure to ensure the required training is provided may potentially result in harm to the patient related to the lack of identification and reporting of abuse by staff.

Findings include:

1. Review of Staff K's personnel file revealed a hire date of 11/26/13, as a Nurse Tech. The personnel file lacked evidence of the completion of the required abuse training.

During an interview on 8/27/14 at 10:30 AM, Staff M, Educator, confirmed Staff K had not completed the required abuse training. Staff M reported Staff K is a student, who only works a few shifts in the summer, but acknowledged the training should have been completed by the end of May.

During an interview on 8/27/14 at 1:30 PM, Staff N, confirmed Staff K worked as a nurse tech in June, July and August of 2014.

2. During an interview on 8/26/14 at 3:00 PM, Staff N reported she did not have any employment records on Staff L, contracted sleep study staff, and was not sure who did. Staff N identified Staff L had provided services to CAH patients since 4/24/13.

During an interview on 8/27/14 at 9:45 AM, Staff I reported the Human Resources Department maintained a file on contracted nursing staff but did not maintain any type of personnel file on contracted sleep study staff through Somni Tech, thus had no information on Staff L's registration as a sleep technologist or completion of mandatory abuse training.

During a follow-up interview on 8/27/14 at 10:00 AM, Staff I provided verification of Staff I's current registration as a sleep tech, faxed to the CAH from the contracted company, but had received no other information from them.

During an interview on 8/27/14 at 2:00, Staff O, Human Resources Administrative Assistant reported she had contacted Somni Tech regarding Staff I and they were unable to provide any verification she had completed the required mandatory abuse training.

Review of an Education/Wellness policy titled "Ongoing Education", with an effective date of 9/9/13, revealed in part " . . . IV. B. 1. All employees must complete Mandatory Abuse training every 5 years per Iowa Law Section 232.69 . . . 2. All new hires not having proof of attendance will need to take the training within 6 months of their date of initial employment . . ."

Based on observations, policy/procedure review, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure pharmacy oversight of manufacturer's medication samples in 1 of 3 off-site locations. (Outpatient Mental Health Clinic) The Mental Health clinic staff reported there were approximately 50 patients that could potentially receive sample medications.

Failure of pharmacy staff to provide oversight of sample medications could result in inappropriate medications or doses of medications, outdated, recalled, or otherwise unusable medications being available for use to patients, as well as, the potential for diversion of medications by unauthorized persons.

Findings include:

1. During an observation on 8/26/14 at 1:20 PM with Staff Q, Mental Health Clinic Receptionist, revealed 3 locked cabinets that contained sample medications including but not limited to medications to treat depression, anxiety, insomnia, seizures, and psychoactive mental disorders.

2. Review of CAH policy titled "Drug Samples", dated 5/14/14, revealed, in part, ". . . To provide effective control and distribution of drug samples within the Health Center, physician clinics, and mental health clinics. . . It is the responsibility of the Director of Pharmacy to see that this policy is enforced. . . ."

3. During an interview on 8/27/14 at 2:00 PM, Staff P, Director of Pharmacy, confirmed they were aware of the sample medications kept in the Mental Health Clinic but had no oversight of any of those medication samples.

Review of the Iowa Administrative Code, Chapter 7 titled "Hospital Pharmacy Practice", last updated 2/5/14, revealed in part ". . . 7.8(8) Samples. The use of drug samples within the institution shall be eliminated to the extent possible . . . If the use of drug samples is permitted for hospital outpatients, that use of samples shall be controlled and the samples shall be distributed through the pharmacy or through a process developed in cooperation with the pharmacy and the institution's appropriate patient care committee, subject to oversight by the pharmacy . . ."

Based on personnel record review, policy review and staff interview the Critical Access Hospital (CAH) administrative staff failed to establish a consistent system to identify and prevent transmission of infections and communicable diseases for contracted employees. Problems were identified for 1 of 2 contracted staff selected for review. Administrative staff identified a census of 17 patients.

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

Findings include:

During an interview on 8/26/14 at 3:00 PM, Staff N, Human Resources Administrative Assistant reported she did not have any employment records on Staff L, contracted sleep study staff, and was not sure who did.

During an interview on 8/26/14 at 4:00 PM, Staff T, Diabetic Self Management/Employee Health, reported employees are required to have a health exam and a 2 step tuberculosis test (TB) and would then need to have a health exam every 4 years, which included a TB questionnaire. Staff S relayed she did not have any health information on Staff L.

During an interview on 8/27/14 at 9:45 AM, Staff I, Human Resources Director, reported the Human Resources Department kept a personnel file on contracted nursing staff but did not have any type of personnel file on sleep study staff contracted through Somni Tech, thus had no information on Staff L's health status.

During an interview on 8/27/14 at 2:00, Staff O, Human Resources Administrative Assistant, reported she had contacted Somni Tech regarding Staff I and they were unable to provide any verification of her most recent health exam or TB test.

Based on review of patient medical records, Medical Staff Bylaws/Rules and Regulations, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure surgical providers dated and/or timed all medical record entries in 3 of 4 pre-operative orders and 2 of 4 post-operative orders in closed OR medical records (Patient #1, #2, #3, and #4) reviewed. The CAH administrative staff identified approximately 60 surgical cases yearly.

Failure to date and time medical record entries could potentially cause confusion as when the orders were entered.

Findings include:

1. Review of closed surgical medical records, on 8/27/14 at 11:15 AM, revealed the surgical providers failed to date and/or time all pre-operative orders in 3 of 4 closed medical records (Patients #2, #3 and #4), and failed to date and/or time all post-operative orders in 2 of 4 closed medical records (Patient #1 and #5).

2. Review of the Burgess Health Center Medical Staff Rules and Regulations amended 8/14/13 revealed in part, ". . . Medical record entries may be made by Medical Staff members. . . all entries shall be accurately dated and timed by the author."

3. During an interview on 8/27/14 at approximately 11:30 AM, Staff H, Risk Management and Compliance Director, acknowledged surgical providers failed to date and time the medical record entries for the patient's identified in closed medical record review. Staff H acknowledged the Medical Staff Rules and Regulations require the author to date and time all medical record entries and said the surgical providers should have dated and timed all entries.

Based on observation, review of policies and procedures, and staff interviews, the Critical Access Hospital (CAH) staff failed to secure and protect patient information from unauthorized users in Radiology and Health Information Management departments and in the Health Information Management (HIM) department. The Radiology staff reported approximately 15,000 patient file folders with reports in the Radiology file room and approximately 700 patient records in the HIM department.

Failure to secure the patient information could potentially cause a misuse of patient information and/or stolen identity for the individual patients.

Findings include:

1. An observation on 8/26/14 at 7:55 AM, during the initial tour of the radiology department revealed 1 of 1 radiology file room that contained open shelving units with patient file folders with reports. Each folder contained patient information consisting of name, name of doctor, medical record number, date of birth, age, and date.

2. Review of CAH policy/procedure titled "Secure Filing of Medical Records", dated 2-7-2012, revealed, in part, ". . . Medical records housed within the hospital shall be kept in secure areas at all times. Medical records shall not be left unattended in areas accessible to unauthorized individuals. . . ."

3. During an interview, at the time of the observation, Staff A, Director of Radiology, verified that housekeeping cleaned the Radiology department including the radiology file room prior to staff arrival in the morning. Staff A acknowledged the housekeeping staff have a master key to gain access to the radiology office and radiology file room.


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4. Review of a Health Information policy titled "Medical Record Access - After Hour Retrieval", with an effective date of 3/21/05, revealed in part ". . . IV. C. Access to the medical record is to be restricted to only those individuals who have a legitimate need to know and for use in the normal course of business . . ."

5. During a tour of the Health Information Management (HIM) Department on 8/27/14, at 11:15 AM, observation revealed the department had a keyless punch code door lock. Staff R, HIM clerk, reported the department door remained unlocked during staffed hours and accessed only by the punch code after hours. Staff R and Staff G, President, were unsure who had access to the department through the punch code. Staff G relayed the Plant Operations department set up the keyless punch code access and would ask them to run a report of the individuals who currently had access.

6. During an interview on 8/27/14, at 1:30 PM, Staff G provided a document which identified the individuals who had access to the HIM department. Staff G acknowledged the list was lengthy and included employees who had no need to enter the department after hours. He confirmed patient records in the area would not be locked up after hours and would be accessible to someone, if they entered after hours. Staff G confirmed the CAH currently did not have a defined process or policy to identify who had the need access to the area and acknowledged it was apparent they needed one.

During an interview on 8/27/14, at 3:10 PM, Staff H, Director of Compliance/Risk Management, identified the various departments represented on the document of employees currently able to access the HIM department. The departments identified included in part, Nutrition Services, Environmental Services, Billing, Laboratory, Radiology, Pharmacy, Speech Therapy, Physical Therapy, Occupational Therapy, Human Resources, Marketing, Finance and Purchasing. Staff H identified 11 of the 295 employees on the list needed access to the HIM department.

Based on document review and staff interview, the Critical Access Hospital (CAH) staff failed to delineate privileges for 1 of 1 surgical technician, who was not an employee of the hospital, to assist with surgical procedures. The surgical technician assisted with 38 of 38 surgical procedures from January 2014 to 8/26/14 completed by associated practitioner. (Other staff Z)

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

Findings include:

1. Review of Medical Staff Rules and Regulations, dated 8/14/14, revealed in part, ". . . Privileges to practice at the Hospital are granted by the Board following recommendation by the Medical Staff. . . Delineation of Privileges to perform surgery shall be based on approved privileges and shall be considered on an individual basis for each procedure requested upon review of the applicant's credentials by the Executive Committee."

Review of the Operating Room Log on 8/26/14 at 10:30 AM revealed Other Staff Z, Surgical Technician, provided surgical assistance to Practitioner A during surgical interventions for ophthalmology patients. The surgical technician assisted with 38 of 38 surgical procedures from January 2014 to 8/26/14 completed by Practitioner A.

Review of the Surgical Procedures Manual kept in the Surgery area on 8/26/14 lacked documentation of privileges for Surgical Technician.

Review of Other Staff Z's, Surgical Technician, personnel file on 8/26/14 at 12:10 PM lacked documentation of privileges for Other Staff Z.

2. During an interview on 8/26/14 at 12:30 PM, Staff H, Director of Compliance, verified that Other Staff Z lacked surgical privileges to provide assistance during surgical procedures with Practitioner A.

During an interview on 8/27/14, Staff E, Med Staff/Credentialing Coordinator, verified that Other Staff Z lacked surgical privileges to provide assistance during surgical procedures with Practitioner A.

Based on review of policies and staff interviews, the Critical Access Hospital (CAH) staff failed to provide all patients with patient rights and responsibilities that contained the current Patient Visitation Rights information at 2 of 3 off-site locations and 1 of 8 outpatient areas (Cardiac Rehabilitation).

Failure to provide all patients, including outpatients, with patient rights information could potentially result in limiting/restricting access of visitors to patients that infringed on their right to have a support person present when they are provided any type of care services or treatment modalities.

Findings include:

1. Review of CAH policy titled "Patient Rights and Responsibilities Satisfaction, and Complaints/Grievances", dated 2-9-12, revealed, in part, ". . . All patients are notified of their rights and responsibilities by posted information, having available a copy of the policy upon request. . . ."

2. During an interview on 8/26/14 at 11:15 AM, Staff A, Physical Therapist, acknowledged the out-patient physical therapy patients at the Dunlap off-site location were not provided the patient rights and responsibilities information. Staff A stated the patients were offered Privacy Practice Notices only.

During an interview on 8/26/14 at 12:15 PM, Staff A, Physical Therapist, acknowledged the out-patient physical therapy patients at the Mapleton off-site location were not provided the patient rights and responsibilities information. Staff A stated the patients were offered Privacy Practice Notices only.

During an interview on 8/26/14 at 12:50 PM, Staff S, Mental Health Therapist, acknowledged the out-patient mental health patients at the Mapleton off-site location were not provided the patient rights and responsibilities information. Staff S stated the patients were offered Privacy Practice Notices only.

During an interview on 8/27/14 at 10:45 AM, Staff F, Cardiac Rehabilitation Coordinator, acknowledged the out-patient cardiac rehab patients were not provided the patient rights and responsibilities information. Staff F stated the patients were offered Privacy Practice Notices only.