HospitalInspections.org

Based on review of documentation and staff interview, the hospital failed to submit the hospital's budget plan to the state health planning agency as required by the regulation. The hospital administrative staff identified 1 of 1 hospital budget plan.

Failure to submit the hospital budget plan specific to the individual facility to the state health planning agency prevented the state health planning agency from reviewing the hospital's capital expenditures specific to that facility.

Findings include:

1. Review of documentation revealed the lack of evidence the hospital submitted the hospital's budget to the state health planning agency.

2. During an interview on 8/26/15 at 2:05 PM, Staff E, Chief Compliance Officer, acknowledged the hospital staff had not sent the hospital's budget to the state health planning agency.

Based on document review and staff interviews, the hospital failed to document an evaluation for 5 of 5 contracted services. (Anesthesia, Physical Therapy, Occupational Therapy, Speech Therapy, and Stereotactic Breast Biopsy) The hospital staff identified a census of 19 inpatients at the time of the survey.

Failure to ensure the Governing Body evaluated all contracted services at the hospital could potentially result in the contract services not meeting the needs of the patient.

Findings include:

1. Review of the "2015 Performance Improvement Plan", dated March 15, 2015, revealed in part, ". . . Contracted services providing direct patient care or service affecting the health and safety of patients are also included in the ongoing monitoring activities and as appropriate, the performance improvement process. Examples of involvement are participation on a performance improvement team, collecting assessment data and participating in data analysis. . . The Governing Board has the ultimate responsibility for the quality of care and services provided. . . ."

2. Review of Board of Directors Meeting minutes for the past 12 months showed the minutes lacked evidence of an evaluation of the contracted services to ensure the contracted services meet the needs of the patients.

3. During an interview on 8/26/15 at 2:10 AM, Staff E, Chief Compliance Officer, and Staff OO, Vice President Patient Services, verified the governing body did not receive quality information for the contracted services.

Based on review of the 2015 Performance Improvement Plan, Board of Directors Meeting minutes, and staff interviews, the hospital failed to ensure the governing body specified the frequency and detail of data collection for quality assessment and performance improvement. The hospital staff identified a current census of 19 inpatients at the time of the survey.

Failure of the governing body to specify the frequency and detail of data collection for quality assessment and performance improvement could potentially prevent the governing body from monitoring the effectiveness of quality patient care.

Findings include:

1. Review of the hospital's "2015 Performance Improvement Plan", dated March 2015, failed to specify the frequency and detail of data collection for quality assessment and performance improvement.

Review of the Board of Directors Meeting Minutes, dated May 26, 2015, revealed the Board of Directors approved the 2015 Performance Improvement Plan.

2. During an interview on 8/26/15 at 2:10 PM, Staff E, Chief Compliance Officer, and Staff OO, Vice President Patient Services, verified the 2015 Performance Improvement Plan failed to specify the frequency and detail of data collection for quality assessment and performance improvement.

Based on document review and staff interviews, the Governing Body failed to ensure the quality improvement program included an evaluation of 5 of 12 patient care departments (Cardiac Rehabilitation, Dietary, Infusion Services, Pharmacy, Sleep Study) and 5 of 5 contracted services.(Anesthesia, Physical Therapy, Occupational Therapy, Speech Therapy, and Stereotactic Breast Biopsy) The hospital staff identified a census of 19 inpatients at the time of the survey.

Failure to ensure the hospital performance improvement plan included all patient care services could potentially result in the inability of the Quality Oversight Committee and Quality Council to evaluate each patient care service for the quality of care for the patients.

Findings include:

1. Review of the "2015 Performance Improvement Plan" dated March 15, 2015, revealed in part, "...The overall scope of the Performance Improvement program is Trinity Muscatine in coordination with the regional improvement and system improvement priorities. All personnel and departments are expected to be actively involved in the program...Contracted services providing direct patient care or service affecting the health and safety of patients are also included in the ongoing monitoring activities and as appropriate, the performance improvement process. Examples of involvement are participation on a performance improvement team, collecting assessment data and participating in data analysis..."

2. Review of the documents titled, "Quality Oversight Committee and Quality Council Meeting Minutes" from 8/7/14 to 5/7/15 showed they lacked evidence of Cardiac Rehabilitation, Sleep Study, Dietary, Infusion Services, Pharmacy, Anesthesia, Physical Therapy, Occupational Therapy, Speech Therapy, and Stereotactic Breast Biopsy submitted quality improvement activity reports regarding patient care services.

3. During an interview on 8/26/15 at 2:10 AM, Staff E, Chief Compliance Officer, and Staff OO, Vice President Patient Services, verified the governing body did not receive quality improvement activity reports for contracted services.

During an interview on 8/27/15 at 10:40 AM, Staff PP, Quality Coordinator, acknowledged the lack of clinical quality monitors for Physical Therapy, Occupational Therapy, and Speech Therapy. Staff PP stated there are audits for Anesthesia contracted services but that information is not sent to the governing board.

Based on document review and staff interview the hospital administrative staff failed to ensure a qualified person served as the Food and Nutrition Services Director. The administrative staff identified a census of 19 patients, with an average daily census of 16 patients. The Director of Support Services reported the department served an average of 54 patient meals daily.

Failure to ensure an individual with adequate education and specialized training served as the Food and Nutrition Services Director could potentially result in inadequate education and training for department staff regarding food safety/sanitation and the patient nutritional needs.

Findings include:


1. Review of the job description titled "Food and Nutrition Services Director", revised in 6/2000, stated in part, "...Plans, organizes, directs, and coordinates the activities of the Food and Nutrition Services Department...Responsible for all functions and services including meal preparation and services, nutrition assessment and nutrition education/counseling..." The job description lacked the qualifications required to meet state regulations.

2. Review of a document titled, "Iowa Administrative Code 481-51.20(135 B)" stated in part, "...Food and nutrition services. 51.20(3) Food and nutrition service staff. b. If a licensed dietitian is not employed full-time, then one must be employed on a part-time or consultation basis with an additional full-time person who has completed a 250-hour dietary manager course and who shall be employed to be responsible for the operation of the food service..."

3. During an interview on 8/25/15, at 9:00 AM, Staff F, Director of Support Services, reported she had no specific coursework or training in nutrition and food service management. Staff F reported she has been responsible for the Environmental Services department and the Food and Nutrition Services department for about 10 years.

During an interview on 8/25/15, at 9:45 AM, Staff S, Registered Dietitian, reported she is employed by the hospital on a part-time basis and her responsibilities are primarily inpatient clinical activities and outpatient counseling/education. Staff S reported food service responsibilities are limited to consultation on policies/procedures, menu approval and staff education as needed.

During an interview on 8/26/15, at 1:10 PM, Staff I, Human Resources Director, reported Staff F assumed the role of Food and Nutrition Services Director in 2002 with additional responsibilities added in 2010 for the Environmental Services Department. She confirmed Staff F's position included the responsibility for all functions within the Food and Nutrition Services department as stated in the Food and Nutrition Services Director job description. Staff I reported the hospital Dietitian is employed on a part-time basis. Staff I reported there had been some recent discussions regarding Staff F's lack of qualifications as Director of Food and Nutrition Services and believed a plan had been developed to address this.

During an interview on 8/27/15, at 7:50 AM, Staff E, Chief Compliance Officer, reported the hospital identified Staff F did not meet the regulatory qualifications for responsibility of the Food and Nutrition Services Department in May 2015. Although, at this time no changes had been made.

Based on review of documents and staff interviews the administrative staff failed to ensure staff established written emergency fuel and water agreements that specified the amount of water and fuel or the delivery timeframe to the hospital in the event of an interruption of water and fuel services at the hospital. The administrative staff identified a census of 19 inpatients, an average daily census of 16 patients, and 262 employees.

Failure to ensure staff established written emergency fuel and water agreements that included the specific amount of fuel and water needed and the delivery timeframe to the hospital during an interruption of fuel and water services could potentially result in the lack of the water and fuel at the hospital to provide emergency care and treatment for the inpatients and those patients who arrived in the emergency department seeking emergency care and treatment.

Findings include:

1. During an interview on 8/25/15, at 1:50 PM, Staff T reported she is new to the Director of Safety role and currently worked with a group on an assessment of the hospital's supplies on hand, in regards to emergency/disaster planning. Staff T reported she did not have the emergency fuel agreement and reported Staff G, Director of Facilities, should have it.

During an interview on 8/25/15, at 3:05 PM, Staff G reported he did not know the location of the emergency fuel agreement but had instructed Staff H, Maintenance Tech, to call the company and request a copy be sent to the hospital. Staff G reported he had not been involved in any assessment of the quantity of fuel on hand to determine how quickly a delivery might be needed, in the development of an emergency fuel agreement.

2. During an interview on 8/26/15, at 12:00 PM, Staff G reported he had obtained something from the company for the emergency fuel agreement but acknowledged it did not include much information.

Review of the email document titled, "... Emergency Fuel Contract" dated 8/25/15 (during the survey) revealed in part, "...In the event that emergency fuel is needed...will do its best to provide you with the fuel that is required..." The email lacked the quantity of fuel and timeframe of delivery agreed upon. The hospital failed to provide documented evidence the hospital established an emergency fuel agreement prior to the survey.

3. During an interview on 8/26/15, beginning at 10:20 AM, Staff F, Director of Support Services, reported the hospital had an agreement for emergency water with their food service company previous to the initiation of the survey. Staff F, the Director of Support Services reported they were unable to locate the original agreement. Staff F provided a copy of a new agreement.

Review of the document titled, "PERFORMANCE Foodservice" dated August 25, 2015 (date of survey) revealed in part, "...Adequate water will be provided to service your residents...should be available within 48 hours of notification, however is subject to facility accessibility and availability of delivery equipment and products..." The document failed to identify the quantity of water agreed upon. The hospital failed to provide any documentation of evidence showing the hospital established an emergency fuel agreement prior to the survey.

I. Based on document review and staff interviews, the hospital failed to ensure the administrative staff had a system in place to monitor the 3 of 3 contract employee's personnel records to ensure health examinations were completed (Physical Therapist, Physical Therapist Assistant, and Occupational Therapist)

Failure to ensure the Administrative Staff had a system in place that included monitoring of the contracted staff personnel health examinations could potentially result in causing harm to patients in the event of an unknown staff's exposure and transmission of communicable disease to the patients.

Findings include:

1. During review of personnel files on 8/26/15, identified the following concerns:

a. Staff V, contracted Physical Therapist, revealed it lacked documented evidence of a health exam. The file contained evidence showing Staff V has provided services to patients at the hospital since 7/2002.

b. The personnel file for Staff W, contracted Physical Therapist Assistant, revealed it lacked documented evidence of a health exam. The file contained evidence showing Staff W has provided services to patients at the hospital since 7/2002.

c. The personnel file for Staff X, contracted Occupational Therapist, revealed it contained an attestation of physical health older than 4 years previously dated of 7/26/11.

2. During an interview on 8/27/15, at 10:40 AM, Staff I, Human Resources Director, reported health exams are required upon hire and must be repeated every 4 years but acknowledged the requirement did not appear in any of the employee health policies.

During an interview on 8/27/15 at 11:00 AM, Staff U confirmed she had not received a health exam for contracted Staff V, Staff W, and Staff X in over 4 years.


II. Based on observations, review of policies, documents, and staff interviews, the hospital Food and Nutrition Services (FNS) staff failed to maintain clean and sanitary food preparation equipment and perform hand hygiene and sanitary practices during food handling and patient meal service. The administrative staff identified a census of 19 inpatients, an average patient census of 16 patients and the FNS Director identified dietary staff provided an average of 54 patient meals daily.

Failure to maintain clean, sanitary food preparation equipment, perform hand hygiene, and use sanitary practices during food handling and meal service could potentially result in contamination of the patient's food leading to foodborne illness.

Findings include:

1. Review of a FNS policy titled "Employee Personal Hygiene", reviewed 4/2/2015, stated in part ". . . Employees must wash their hands before putting on gloves and when changing to a fresh pair. Food-handling gloves are for single-use only . . . Employees should change gloves: . . .before beginning a different task . . ."

Review of a FNS policy titled "Serving Foods", reviewed 4/2015, stated in part ". . . All ready to eat foods must be served with appropriate utensils or the food server's hand must be covered with a clean plastic food-handling glove . . ."

Review of an Infection Control policy titled "Hand Hygiene", effective 4/2015, revealed in part "Hand Hygiene is the single most important measure to prevent the transmission of microorganisms between patients . . . All staff will comply with Hand Hygiene Standard Work . . . Standard work for hand hygiene is to be used by all staff in all patient care areas . . . after contact with patient surroundings . . . Indications for hand hygiene include: After contact with surfaces or object in the patients' environment . . ."

2. Review of the document titled, "The Food Code", published by the Food and Drug Administration and considered a standard of practice for the food service industry, in both the 2005 and 2013 editions, requires (1)gloves should be used for only one task, such as working with ready-to-eat food and for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation and hands must be washed before donning gloves when working with food, (2) surfaces such as cutting blocks and boards, that are subject to scratching and scoring, shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced and (3) a handwashing sink may not be used for purposes other than handwashing.

3. During the initial kitchen environment tour on 8/24/15, beginning at 12:55 PM, the surveyor identified the cooks and cold prep area had 3 of 3 white, 4 of 4 green, and 2 of 2 red plastic cutting boards with heavily worn, unsanitizable surfaces and multiple stains. During in interview at the time, Staff J, FNS Lead, confirmed the worn and stained condition of the cutting boards.

4. Observations during patient food preparation on 8/25/15, from 8:05 AM, showed the following concerns:

a. Staff utilized the designated handwashing sink, located in the cooks area, for handwashing. However, observations showed staff used the same sink to rinse utensils, place dirty meat slicer parts and staff filled pans with water in the sink.

b. Staff O, Cook, touched the garbage can lid, without sanitizing hands, donned gloves, touched the refrigerator handle, package of tortilla shells, and a pan of breakfast burrito mix. Staff O with the same potentially contaminated gloves, picked up a burrito and placed it in a container for a patient.

c. Staff P, Dishroom/AM Cold, washed her hands, touched the potentially contaminated faucets, donned gloves and proceeded to slice ham and turkey. During an interview at the time, Staff P reported some of the ham and all of the turkey would be used for cold sandwiches.

d. Staff O removed the lid from the garbage container to discard a tuna package. She placed the package in the garbage container and pushed the garbage down farther into the container, replaced the lid and failed to wash her hands before she returned to performing various food preparation activities.

5. Observations during patient food preparation on 8/25/15, from 11:22 AM to 11:54 AM, revealed the following concerns:

a. Staff M dropped one potholder on the floor, picked it up, placed the potholder on a utility cart, without sanitizing hands, Staff M returned to meal service activities and used the pot holder on multiple occasions.

b. Staff O lifted the garbage container lid to discard items, without sanitizing hands, donned gloves and continued to participate in food preparation activities. A few minutes later she removed her gloves, lifted the garbage container lid to discard the gloves and failed to wash her hands prior to returning to food preparation activities.

6. Observation during patient meal tray service on 8/25/15, from 12:02 PM to 12:15 PM, revealed Staff K assisted with meal tray pass, which involved positioning the patient tray table to accommodate the trays. Staff K failed to perform hand hygiene between patient rooms.

7. During an interview on 8/26/15, at beginning at 10:20 AM, Staff F, Director of Support Services, confirmed the sink in the cooks area is intended to be a handwashing sink and acknowledged a concern when staff handle the garbage container lid after washing which decontaminated their hands. She reported staff are trained to wear gloves when touching food, but should wash their hands prior to donning gloves and after removing gloves.

During an interview on 8/26/15, at 10:10 AM, Staff B, Infection Control Preventionist, reported the hospital identified an opportunity for improvement with hand hygiene hospital wide. She relayed standard work practice for hand hygiene was developed and associated mandatory learning activity assigned to all staff in April 2015. Staff B reported she completed training with a group of hospital employees to become trained observers whom are asked to perform 30 observations a month and record results on a monitoring sheet for evaluation of compliance, with the standard work practice for hand hygiene.

During a follow-up interview, on 8/27/15, at 8:30, Staff B reported the trained observers were asked to complete observation in patient care areas and their own work areas with a 90% goal set for compliance with the standard set for hand hygiene. She reported Staff Q, AM Diet Office, is the trained observer for the FNS department and has provided valuable feedback with her monitoring results. She provided results of the FNS monitoring results for April - July 2015, which revealed a compliance rate of 81-88%.

During an interview on 8/27/15, at 8:30 AM, Staff B, Infection Control Preventionist, reported she would expect dietary staff to perform hand hygiene between patient rooms when participating patient meal tray delivery.