HospitalInspections.org

Based on document review and administrative staff interview the CAH (Critical Access Hospital) failed to have the Blood Bank Agreement approved by the medical staff. The CAH administrative staff identified 46 units of blood used since January 2016.

Failure to the Blood Bank Agreement approved by the medical staff could potentially result in a lack of provider input for changes in the agreement.

Findings include:

1. Review of the document titled Unity Point Health Contracting Services Pricing Agreement LifeServe Blood Center, signed 2/09/16 by the CFO (Chief Financial Officer), revealed a lack of approval by the CAH medical staff.

2. During an interview on 8/8/16 at 11:45 a.m., Staff A,Compliance Officer acknowledged the Blood Bank Agreement lacked approval by medical staff.

Based on review of policies/procedures, documentation, and staff interviews, the CAH failed to ensure the physician periodically reviewed 1 of 1 applicable mid-level practitioners' patient medical records, in conjunction with the mid-level practitioner. (Staff G)

The CAH administrative staff reported the volume of services provided by mid-level Staff G included 88 acute patients and 57 swing bed patients from January 1 to September 1, 2016.

Failure to ensure a physician periodically reviewed mid-level practitioners' patient medical records in conjunction with the mid-level practitioner could potentially result in misdiagnosing patient and/or providing inappropriate or substandard patient care.

Findings include:

1. Review of CAH policies/procedures revealed the lack of a requirement to ensure the physician periodically reviewed the mid-level practitioners' patient medical records, in conjunction with the mid-level practitioner.

2. Review of documentation revealed the lack of documentation of physician review of the mid-level practitioners' patient medical records, in conjunction with the mid-level practitioner.

3. During an interview on 9/1/16 at 8:40 a.m., Staff J, CEO/CNO (Chief Executive Officer/Chief Nursing Officer) acknowledged the CAH discontinued the requirement for a physician to periodically review patient medical records with the mid-level practitioners approximately 2 years ago. During a follow-up interview, Staff B, DON (Director of Nursing) Services and Staff J confirmed the CAH lacked documentation of physician chart review of patient medical records in conjunction with Staff G, ARNP/Hospitalist (Advanced Registered Nurse Practitioner/Hospitalist).

Based on review of policies/procedures, documentation, and staff interviews, the CAH failed to ensure the mid-level practitioner participated with a physician in the periodic review for 1 of 1 applicable mid-level practitioner's patient medical records. (Staff G)

The CAH administrative staff reported the volume of services provided by mid-level Staff G included 88 acute patients and 57 swing bed patients from January 1 to September 1, 2016.

Failure to ensure the mid-level practitioner participated with a physician in the periodic review of the mid-level practitioner's patient medical records could potentially result in the mid-level practitioner misdiagnosing patients and/or providing inappropriate or substandard patient care.

Findings include:

1. Review of CAH policies/procedures revealed the lack of a requirement to ensure the physician periodically reviewed the mid-level practitioners' patient medical records, in conjunction with the mid-level practitioner.

2. During an interview on 9/1/16 at 8:40 a.m., Staff J, CEO/CNO acknowledged the CAH discontinued the requirement for a physician to periodically review patient medical records with the mid-level practitioners approximately 2 years ago. During a follow-up interview, Staff B, DON and Staff J confirmed the CAH lacked documentation of physician chart review of patient medical records in conjunction with Staff G, ARNP/Hospitalist.

Based on closed medical record review and staff interview the CAH hospitalist mid-level provider failed to notify the hospitalist physician on staff for 3 of 5 (Patient #14,#15, & #16) swing bed admissions from March to August 2016.

Failure of the hospitalist mid-level provider to notify the hospitalist physician of the admission of patients to the swing bed unit could potentially result in lack of monitoring of the patient by the physician due to lack of knowledge of the admission.

Findings include:

1. Review of closed medical record for Patient #14 revealed an admit date of 3/7/16 to swing bed for Provider G, hospitalist mid-level provider. Provider H, physician, signed the admission orders on 3/12/16.
Review of closed medical record for Patient #15 revealed an admit date of 3/16/16 to swing bed for Provider G, hospitalist mid-level provider. Provider H, physician, signed the admission orders on 3/17/16.
Review of closed medical record for Patient #16 revealed an admit date of 7/22/16 to swing bed for Provider I, hospitalist mid-level provider. Provider H, physician, signed the admission orders on 7/23/16.

2. An interview on 8/31/16 at 10:30 a.m., with Staff B, DON, revealed the CAH lacked documentation of physician notification regarding admission of the swing bed patients.

Based on review of documentation and staff interviews, the Critical Access Hospital (CAH) quality improvement staff failed to ensure the evaluation of 2 of 3 contracted patient care services in accordance with the CAH's Quality Improvement Plan - 2016 (Nuclear Medicine and Teleradiology).

Nuclear Medicine - an average of 2 patients per month
Teleradiology - an average of 80 x-ray reads per month

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

Findings include:

1. Review of document titled "Patient care svcs furnished by GCMH through arrangement/agreement" revealed contracted services for Nuclear Medicine and Teleradiology.

Review of CAH's Quality Improvement Plan - 2016, revealed in part, ". . . The purpose, of the Quality Improvement Plan of Grundy County Memorial Hospital, is to continually monitor and improve the healthcare services, patient safety and processes of all care and services for the people we serve, in alignment with the mission, vision, and core values of the hospital and its health system. . . The Board requires that hospital departments/services implement and report quality improvement activities to the hospital Quality Improvement Committee. . . ."

2. Review of Quality Improvement Committee Meeting Minutes dated November 18, 2015, December 9, 2015, February 11, 2016, May 26, 2016, and August 11,2016 lacked evidence of quality reports for Nuclear Medicine and Teleradiology.

Review of quality improvement reports revealed the Radiology Department for 3rd and 4th quarter 2015 and 1st and 2nd quarter 2016 failed to address the monitoring of Nuclear Medicine and Teleradiology.

3. During an interview on 8/29/2016 at 3:00 p.m., Staff C, Radiology Manager acknowledged the lack of quality improvement monitoring reported to the CAH's quality committee for Nuclear Medicine and Teleradiology.

During an interview on 8/31/2016 at 10:30 a.m., Staff D, Quality Manager confirmed the lack of quality improvement monitoring reported to the CAH's quality committee for Nuclear Medicine and Teleradiology.

Based on review of policies/procedures and staff interviews, the CAH failed to update the patient rights' policy to ensure all patients were informed of their visitation rights, including the ability to receive designated visitors, but not limited to a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend. CAH census at time of entrance was 1 swing bed patient.

Failure to provide patients with current visitation rights could potentially result in patient's visitors being restricted.

The CAH staff identified number of patients served in the following areas:
- Average daily inpatient (acute and swing bed) census - 4
- 156 acute patients for 2015
- 123 swing bed patients for 2015
- 504 outpatients for 2015

Findings include:

1. Review of CAH policy titled "Access and Visitation Patient Rights", revised 2/2016, for inpatient and swing bed patients revealed the policy lacked the current patient visitation rights information regarding consent to receive visitors he or she has designated, either orally or in writing, including but not limited to, spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time. The CAH lacked a visitation policy for outpatients.

2. During an interview on 8/24/16 at 10:00 a.m., Staff A, Compliance Officer, acknowledged the Patient Rights policy lacked the current patient visitation rights information as required by the regulations.

Based on observation, document review, and staff interviews, the CAH failed to ensure outpatients who registered at the Out-Patient Registration Desk were informed of their visitation rights including the ability to receive designated visitors, but not limited to a spouse, domestic partner (including same-sex domestic partner) and another family member for Laboratory, X-ray, Cardiac Rehab, and Pulmonary Rehab outpatients. The CAH staff reported an average of 35 outpatients registered at the Out-Patient Registration Desk per day.

Failure to provide all 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. Based on observation of the Out-Patient Registration Desk area revealed the lack of Patient Rights and Responsibilities brochure available to outpatients that registered at that desk.

2. Review of "Consent for Treatment" document that the outpatients sign electronically included a statement in part ". . . I have been given a brochure about my Patient Rights and Responsibilities, Notice of Privacy Practices, and Advance Directives. . . ."

Review of CAH policies/procedures revealed the lack of a policy/procedure that addressed visitation rights for all outpatients.

3. During an interview on 8/29/2016 at 3:40 p.m., Staff E, Patient Accounts, stated Laboratory, X-ray, Cardiac Rehab, and Pulmonary Rehab outpatients register at the Out-Patient Registration Desk. Staff E acknowledged the outpatients electronically sign a "Consent for Treatment" document that included a statement in part ". . . I have been given a brochure about my Patient Rights and Responsibilities, Notice of Privacy Practices, and Advance Directives. . . ." Staff E confirmed the Patient Rights and Responsibilities brochures were not available to patients that registered at the Out-Patient Registration Desk. Staff E also stated the Patient Rights and Responsibilities brochures were only given to inpatients at the time of registration.

During an interview on 8/29/2016 at 3:50 p.m, Staff F, Patient Accounts Manager stated the Patient Rights and Responsibilities brochure was given to inpatients only and did not give to outpatients.