HospitalInspections.org

Based on personnel record review, policy review and staff interviews the Critical Access Hospital (CAH) failed to ensure contracted staff completed mandatory reporter training for dependent adult abuse, as required by state law. Problems were identified for 1 of 1 out-of-state contracted sleep study staff selected for review.

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

Findings include:

Iowa Administrative Code 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.

Review of Human Resources policy titled "Mandatory Training", revised January 1, 2010, revealed in part ". . . any person employed by Floyd Valley Hospital or contracted employee will be required to complete mandatory reporter training through a certified Mandatory Reporting training program every five years. New employees . . . must become certified within approximately six months of hire . . ."

Review of the employment information for Contracted Staff H, Sleep Study Technicians, lacked evidence for the completion of the required abuse training.

During an interview on 11/24/15, at 2:00 PM, Staff G, Director of Human Resources, reported she contacted Staff N, CardioPulmonary Manager, and discovered the sleep study technicians likely did not have the required abuse training because they provide patient services through a contracted South Dakota company, and this state does not require mandatory reporter training.

During an interview on 11/25/15, at 10:00 AM, Staff N confirmed Staff H has provided services to hospital patients for at least a year, and lacked mandatory reporter training.

Based on observation, review of policy, and staff interview the Critical Access Hospital (CAH) failed to ensure outpatient clinic (Family Medicine Clinic) staff secured the 1 of 1 radiation exposure cord to prevent staff access into the x-ray room during a patient's x-ray procedure in the general radiology room. The clinic reported staff completed 5 to 8 x-rays per day.

Failure to ensure staff secured the 1 of 1 radiation exposure cord could potentially result in unnecessary exposure of radiation when staff could enter the x-ray room while performing a patient's x-ray procedure.

Findings include:

1. Review of the CAH policy titled, "Radiographic Monitoring and Protection", Revised 7/15/2014 stated in part, "...Protection for the Technician... 5. Another protection for the x-ray technician is the length of the exposure switch. The length of the exposure switch shall not be so long that it can be operated outside of the shielded control booth. This is a requirement that is set forth by the Joint Commission Standards and State Department of Health...."

2. During a tour of the Family Medicine Clinic on 11/24/15 at 1:00 PM revealed 1 of 1 unsecured approximately 10 feet long radiation exposure cord in the general x-ray room. Observation showed the unsecured radiation exposure cord extended approximately 5 feet into the x-ray room, allowing staff access into the x-ray room during the x-ray procedure.

3. During an interview on 11/24/15 at 1:30 PM, Staff D, Radiology Technician for the clinic acknowledged the radiation exposure cord was 10 feet long, not secured, and would allow staff access to the x-ray room during x-ray procedures. Staff D agreed the cord should be secured at a shortened length to prevent staff access into the x-ray room during x-ray procedures.

Based on observation, policy review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure a licensed pharmacist provided oversight, tracked storage and dispensing of sample medications to patients in 1 of 1 CAH offsite clinics, (Family Medicine Clinic). The Clinic Manager reported an average of 2225 patient visits per month, 4 patients a day received sample medications in the clinic.

Failure to ensure a licensed pharmacist provided oversight, tracked the storage and dispensing of sample medications to patients in the offsite clinic could potentially result in outdated or recalled medications being available for physicians and mid-level providers to dispense to patients, inappropriate medications or doses of medications, 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. Review of the CAH policies and procedures lacked a policy and/or procedure for the tracking, storage and dispensing of sample medications including pharmacy oversight of those sample medications in the Family Medicine Clinic.

2. Observation on 11/24/15 at 1:00 PM during the tour of the Family Medicine Clinic with Staff P, Clinic Nurse Manager showed 6 locked cabinets and 2 locked drawers that contained sample medications dispensed for the following medical diagnoses:

Diabetic - 1649 tablets
Lipids (cholesterol) - 359 tablets
Constipation - 276 tablets
Fibromyalgia - 271 tablets
Dermatitis - 43 doses
Menopause - 251 tablets
Prostate - 28 tablets
Overactive bladder - 357 tablets
Nerve pain - 266 tablets
Smoking cessation - 70 tablets
Acid reflux - 15 tablets
Antihypertensives (blood pressure) - 189 tablets
Anticoagulants - 711 tablets
Antidepressants - 630 tablets
Antipsychotic - 40 tablets
Alzheimer - 523 tablets
Respiratory (inhalers) - 1728 doses

3. During an interview on 11/24/15 at 2:10 PM, with Staff O, Clinic Manager, and Staff P, Clinic Nurse Manager, when asked if the pharmacist provided oversight of the sample medications. Staff O and Staff P stated the CAH pharmacist had no oversight of the sample medications and did not come to the clinic to review the sample medications.

During an interview on 11/25/15 at 7:55 AM, Staff Q, Pharmacist stated he has never provided oversight of the sample medications in the Family Medicine Clinic and had not been to the clinic to review the sample medications. Staff Q stated there was not a policy for pharmacy oversight for sample medications in the clinic.

I. Based on observation, review of policy, and staff interview the Critical Access Hospital (CAH) failed to ensure staff in the Gastrointestinal Lab cleansed the rubber septum on the top of 2 of 2 medication vials prior to the insertion of a needle and withdrawal of medication.

Failure to ensure staff cleansed the rubber septum on the top of 2 of 2 new medication vials prior to the insertion of a needle and withdrawal of medication could result in introducing micro-organisms into the medication vial affecting the efficacy of the medication and potentially harming the patient. (Registered Nurse, Staff I)

Findings include:

1. Review of CAH policy/procedure titled "Multiple/Single Use Vials" dated 8/1/10 included in part, "...Rubber closures shall be swabbed with 70% alcohol prior to each entry into the vial..."

2. Observation on 11/24/15 at 8:55 AM in the Gastrointestinal lab showed RN, Staff I removed the protective cap on 1 of 1 vial of medication (Versed). Without wiping the rubber septum, Staff I inserted the needle attached to the syringe into the medication vial and withdrew the medication into the syringe.

Observation on 11/24/15 at 9:55 AM in the Gastrointestinal lab showed RN, Staff I removed the protective cap on 1 of 1 vial of medication (Versed). Without wiping the rubber septum, Staff I inserted the needle attached to the syringe into the medication vial and withdrew the medication into the syringe.

Versed is a medication used to produce sleepiness or drowsiness and to relieve anxiety before or during surgical procedures.

3. During an interview on 11/24/15 at 10:00 AM, RN Staff I acknowledged the failure to cleanse the rubber septum on top of both the medication vials (Versed) prior to inserting the needle and withdrawal of the medication.


22064


II. Based on observation, review of policy, manufacturer's instructions, and staff interview the Critical Access Hospital (CAH) staff failed to date the Nova StatStrip glucose test strips and high/low glucose control solutions upon opening for use in the medical/surgical, obstetric (OB) units and Emergency Department (ED).

Failure to ensure staff documented the opened date on 2 of 2 Nova StatStrip glucose test strips and 2 of 2 sets of high/low glucose control solution bottles could result in the use of glucose test strips and high/low glucose control solution beyond the 3 months after the bottles were opened. The use of expired glucose test strips and/or high/low glucose control solutions could potentially alter the performance of the Nova StatStrip blood glucose machine and/or patient glucose test results.

Findings include:

1. Review of the CAH policy titled "Bedside Blood Glucose Testing Protocol", revised 10/26/2015 stated in part... "B. Nursing, 3. Date controls when opened. Controls are stable 90 days after opening."

2. Review of the manufacturer's instructions titled, "Nova StatStrip Glucose Test Strip For Use ONLY with the Nova StatStrip Family of Meters" Dated 3/2012, included in part, "...Once opened, the StatStrip Test Strips are stable... up to 180 days or until the expiration date, whichever comes first...Control solution is good for only 3 months after opening..."

3. Observations on 11/23/15 at 9:10 AM, in the medical/surgical and OB units, Staff A, Clinical Coordinator, revealed Nova StatStrip blood glucose monitoring test strips and high/low control solution bottles stored in the medical surgical store room lacked a date when staff opened the bottles. The Nova StatStrip blood glucose monitoring test strips stored in the OB nursery lacked a date when staff opened the bottle.

During an interview on 11/24/15 at 11:10 AM, Staff A acknowledged the Nova StatStrip blood glucose monitoring test strip bottles and high/low control solution bottles for the Nova StatStrip blood glucose machine lacked an opened date on the medical/surgical unit and the Nova StatStrip blood glucose monitoring test strip bottles lacked an opened date in the OB nursery. Staff A stated the control solutions and test strips should be dated when opened because they are only good for 180 days after opening.

During an interview and observation on 11/23/15 at 3:05 PM, Staff B, ED Manager acknowledged the Nova StatStrip blood glucose test strips and high/low control solution bottles for the Nova StatStrip blood glucose machine lacked an open date on all the containers. Staff B stated the control solutions and test strips should be dated when opened because they are only good for 180 days after opening.

Based on observation, policy review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to secure and protect patient information from unauthorized users. The problem was identified for the Health Information Management (HIM) department.

The Manger of the Health Information Management reported the department contained approximately 180 folders, each folder containing protected health information on multiple patients.

Failure to ensure staff secured and protected the patient information from unauthorized users could potentially result in misuse of patient information and/or stolen identity for the individual patients.

Findings include:

1. Review of an Administrative policy titled "Confidentiality of Protected Health Information", dated 1/20/10 included in part, "..Floyd Valley Hospital employees...are responsible for protecting the security of all protected health information (oral or recorded in any form... Protected health information shall be protected during its collection, use storage, and destruction within Floyd Valley Hospital..."

Review of a Health Information Management policy titled, "Storage of Records " Revised 2/1/10 included in part, "...Floyd Valley Hospital must safeguard the information in the record against...use by unauthorized persons..."

2. During an observation and interview on 11/24/15 at 10:10 AM, revealed the HIM department contained 3 large open shelves, which held multiple folders containing patient information. Staff F, HIM Manager, reported the folders contained patient information, which had been scanned into the electronic record. Staff F reported once the information is scanned into the computer, the information is retained for 6 months and then destroyed. The information in the folders included patient face sheets that included the patient name, date of birth, address, date of services. In addition, the folders included signed patient procedure consents and documents that contained patient information provided by other facilities. Staff F reported housekeeping staff cleaned the HIM department during unstaffed hours on the weekend and entered the area with the Housekeeping's own key.

During an interview on 11/24/15, at 2:45 PM, Staff E, Plant Operations Manager, confirmed housekeeping staff entered the HIM department during unstaffed hours on the weekends to clean. He reported there are a total of 10 housekeeping staff supplied with a key to access the HIM department area. In addition, Staff E reported himself and 4 plant operations staff have a key to the HIM department area. Staff E acknowledged housekeeping and plant operations staff have no need to access patient information as part of their job duties.

During an interview on 11/25/15, at 8:30 AM, Staff M, Patient Relations Manager/Privacy Officer, confirmed housekeeping and plant operations staff are considered unauthorized users of protected health information.

Based on review of policy, document, and staff interview, the Critical Access Hospital (CAH) failed to ensure 3 of 3 emergency room physicians selected for review, received an outside entity peer review prior to reappointment to the Medical Staff to evaluate the appropriateness of diagnosis and treatment furnished to patients at the CAH. (Staff L, R, and S)

The CAH administrative staff identified the practitioners provided services to patients, from 10/1/2014 to 10/31/2015, as follows:

Staff L, MD, Emergency Medicine - 1351 patients
Staff R, MD, Emergency Medicine - 2243 patients
Staff S, MD, Emergency Medicine - 1704 patients

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

Findings include:

1. Review of CAH Administrative Policy and Procedure titled, "Periodic Evaluation and Quality Assurance Review", dated August 18, 2014 included in part, "...Contract for Medical Staff Peer Review with [Network Hospital] provided quarterly review of random 10% of closed records...Quarterly reports are reviewed by Medical Staff..."

2. Review of the CAH's Network Agreement revealed in part the network hospital "...shall assist CAH in reviewing the quality and appropriateness of the diagnosis and treatment furnished by the CAH's doctors of medicine or osteopathy for purposes of assisting the CAH carry out the requirements of its quality assurance plan..."

3. Review of CAH documentation on 11/25/15 revealed the facility failed to ensure the CAH completed outside entity peer review on the services provided to patients at the CAH for Staff L, R, and S, during their last full credentialing cycle.

4. During an interview on 11/25/15 at 8:00 AM, Staff K, Medical Credentialing Specialist, acknowledged Staff L, R, and S physicians lacked an outside entity peer review during their last full credentialing cycle.