HospitalInspections.org

Based on document review and staff interview, the facility failed to create an operating budget that included the capital expenditures (large purchases) for 3 years in 1 of 1 budget reviewed (2012). The facility identified 1 organizational budget created per year.

Failure to include capital expenditures for 3 years in the operating budget could potentially result in the facility failing to anticipate large purchases in the future, and appropriate money to cover the cost of the large purchases.

Findings include:

1. Review of the 2012 hospital operating budget on 8/20/12 at 3:15 PM revealed the operating budget lacked evidence the hospital staff had planned capital expenditures for the next 3 years.

2. During an interview on 8/21/12 at 9:15 AM, the Chief Quality Officer stated the hospital had not created any planned capital expenditures for the prior 2 years. The Chief Quality Officer acknowledged the hospital had not planned for 3 years worth of capital expenditures, as required by regulations.

Based on document review and staff interview, the facility failed to submit their operating budget to the state planning agency. The facility identified 1 operating budget per year.

Failure to submit the hospital's 3-year capital budget to the state planning agency could potentially result in the hospital engaging in an expansion, or other major renovation to their facility, without the knowledge of the state planning agency. If the state planning agency did not know about a major change to the hospital, it could potentially result in the hospital offering services the state planning agency did not authorize the hospital to perform.

Findings include:

1. Documents provided by the hospital on 8/20/12 at 3:15 PM revealed the hospital lacked evidence they had submitted the hospital's operating budget for 2012 to the designated state planning agency.

2. During an interview on 8/21/12 at 9:15 AM, the Chief Quality Officer stated the hosptial had not submitted their operating budgets to the designated state planning agency for the prior 2 years.

Based on observations, document review, and staff interviews, the facility failed to protect all confidential information from unauthorized access in 2 of 2 offsite clinics (State Center Clinic and Conrad Clinic). The facility reported approximately 114 patient visits per week at the State Center Clinic. The facility reported approximately 776 patient visits per month at the Conrad Clinic.

Failure to secure medical records against unauthorized access could result in identity theft, theft of financial/insurance information, or unauthorized disclosure of personal medical information.

Findings include:

1. Observation on 8/21/12 at 11:55 AM, during tour of the State Center Clinic with Practitioner A, Nurse Practitioner, revealed a records area behind the reception desk with 3 of 3 open shelving units with approximately 7 - 3 foot wide shelves, 6 - 9 foot wide shelves, and 7 - 12 foot wide shelves full of patient medical records with confidential patient information that included birth date, social security number, insurance information, and personal health information. The records area had an open area above the reception desk and lacked doors on two doorways into the records area.

-The records area behind the receptionist's desk lacked a mechanism to lock and secure the patient medical records.

-During an interview on 8/21/12 at 12:05 PM, Staff F, State Center Clinic Manager, stated there were approximately 2500 patient medical records located in the records area behind the receptionist's desk. Staff F acknowledged the patient medical records located in the records area behind the receptionist's desk could not be secured. Staff F also stated contracted housekeeping staff clean the clinic area when there were not any clinic staff present.

2. Observation on 8/21/12 at 12:15 PM, during tour of the State Center Clinic with Practitioner A, Nurse Practitioner, revealed 1 of 1 x-ray dark room that contained approximately 1200 patient x-rays with written x-ray reports, and a log book of patient names with x-rays performed listed from March 1993 to August 2012.

-The x-ray dark room had 2 doors to enter the room and lacked a mechanism to lock and secure the patient x-rays and written reports.

-During an interview on 8/21/12 at 12:15 PM, Practitioner A, acknowledged the x-ray dark room had 2 doors to enter the room and lacked a mechanism to lock and secure the patient x-rays with written reports.

3. Observation on 8/21/12 at 3:25 PM, during tour of the Conrad Clinic with Staff I, Insurance Specialist/Receptionist, revealed a records area behind the reception desk with 3 of 3 open shelving units with approximately 14 - 3 foot wide shelves and 49 - 4 foot wide shelves full of patient medical records with confidential patient information that included birth date, social security number, insurance information, and personal health information. The records area had an open area above the reception desk and doors on two doorways into the records area.

-The records area behind the receptionist's desk lacked a mechanism to lock and secure the patient medical records.

-During an interview on 8/21/12 at 3:25 PM, Staff I, Insurance Specialist/Receptionist, stated there were approximately 4200 patient medical records located in the records area behind the receptionist's desk. Staff I acknowledged the patient medical records located in the records area behind the receptionist's desk could not be secured. Staff I also stated contracted housekeeping staff clean the clinic area when there were not any clinic staff present.

4. Review of facility policy/procedure titled "Security of Patient Information - Health Information Management," dated 5/07, revealed, in part, "Medical Records are protected from unauthorized access by assuring security of the areas used to store those records. . . ."

5. During an interview on 8/22/12 at 9:10 AM, Staff G, Health Information Management Quality Executive/Privacy Officer, acknowledged the inability to secure confidential patient medical records in the State Center Clinic and the Conrad Clinic.

Based on observations, document review, and staff interviews, the facility failed to ensure periodic inspection of x-ray equipment in 3 of 3 off-site clinics (State Center, Conrad, Tama).

Facility staff reported an average of 100 patient x-rays performed at State Center Clinic per month.
Facility staff reported an average of 90 patient x-rays performed at Conrad Clinic per month.
Facility staff reported an average of 90 patient x-rays performed at Tama Clinic per month.

Failure to ensure periodic inspection of x-ray equipment could result in unsafe equipment and potentially expose the patient and/or staff to excessive doses of radiation, which could result in cancer or death of the patient and/or staff.

Findings include:

1. Observation on 8/21/12 at 11:40 AM, during tour of Marshalltown Medical & Surgical Center Clinic - State Center, with Practitioner A, Nurse Practitioner, revealed 1 of 1 x-ray equipment in the clinic.

2. Observation on 8/21/12 at 3:05 PM, during tour of Marshalltown Medical & Surgical Center Clinic - Conrad, with Staff A, Lab/X-ray, revealed 1 of 1 x-ray equipment in the clinic.

3. Review of Radiology services policies/procedures revealed the lack of policy/procedure that required periodic inspection of x-ray equipment.

4. Documentation titled "Certification of X-Ray Performance," provided by facility staff, revealed the x-ray equipment in the State Center Medical Clinic, Conrad Medical Clinic, and Tama Medical Clinic were last inspected by a physicist 10/7/2008.

5. During an interview on 8/22/12 at 12:45 PM, Staff B, CT (Computed Tomography - an x-ray that shows small details of a patient's body) Coordinator stated the facility followed the requirements that a physicists inspected all x-ray equipment annually. Staff B acknowledged the x-ray equipment in the State Center Medical Clinic, Conrad Medical Clinic, and Tama Medical Clinic were last inspected by a physicist 10/7/2008.

I. Based on observations, document review, and staff interviews, the facility failed to have a system in place to monitor hot water temperatures at 1 of 2 offsite clinics (Conrad Clinic) and 1 of 1 Rehabilitation Center (Marshalltown) to ensure they were in an acceptable range (from 110 to 120 degrees). The facility reported approximately 776 patient visits per month at the Conrad Clinic. The facility reported approximately 1350 patient treatments per month at the Marshalltown Rehabilitation Center.

Failure to monitor hot water temperatures could potentially cause serious scalding burns to patients. The depth of injury is directly related to the temperature and duration of exposure to the hot water. The length of exposure required for a third degree burn (destroys the outer layer of skin and the entire layer beneath) to occur is 15 seconds at 133 degrees Fahrenheit, one minute at 127 degrees Fahrenheit, and 3 minutes at 124 degrees Fahrenheit.

Findings include:

1. Observation on 8/21/12 at 2:40 PM, during the environmental tour of Marshalltown Medical & Surgical Center Clinic - Conrad, with Practitioner B, Physician Assistant, revealed the following hot water temperatures:
a. Room 8 - 126.0 degrees Fahrenheit
b. Room 6 - 125.6 degrees Fahrenheit
c. Room 3 - 129.2 degrees Fahrenheit
d. Room 1 - 126.5 degrees Fahrenheit
e. Procedure room - 126.1 degrees Fahrenheit

The Conrad Clinic failed to maintain a hot water temperature monitoring log.

-Observation on 8/22/12 at 9:50 AM, during the environmental tour of Marshalltown Medical & Surgical Center Rehabilitation Center, revealed the following hot water temperatures:
a. Men's restroom - 126.1 degrees Fahrenheit
b. Main Physical Therapy room - 122.7 degrees Fahrenheit
c. Hydrotherapy room - 122.0 degrees Fahrenheit
d. Curtained treatment room - 124.3 degrees Fahrenheit

The Rehabilitation Center A failed to maintain a hot water temperature monitoring log.

2. Review of facility policy/procedure titled "Domestic Hot Water Supply", dated 6/10, revealed, in part, ". . . The MMSC [Marshalltown Medical & Surgical Center] domestic hot water supply shall be maintained at the temperature not above 120 degrees Fahrenheit (47C) or below 110 degrees Fahrenheit (43C). . . Patient rooms and shower areas will be maintained between 110 - 120 degrees in accordance with the Iowa State Regulations. . . ."

3. During an interview on 8/21/12 at 2:40 PM, Staff H, Clinic Registered Nurse, stated she did not know if maintenance monitored the hot water temperatures at the Conrad Clinic.

-During an interview on 8/22/12 at 7:25 AM, Staff C, Director of Facilities, stated the maintenance staff did not monitor hot water temperatures at the Conrad Clinic. Staff C stated the hot water temperatures were supposed to be between 110 - 120 degrees Fahrenheit per facility policy.

-During an interview on 8/22/12 at 9:50 AM, Staff D, Director of Rehabilitation, stated she did not know if maintenance monitored the hot water temperatures at the Marshalltown Rehabilitation Center.

II. Based on observation, record review, and facility policy review, the facility failed to date OPA Cidex test strips when opened as directed by the manufacturers guidelines and facility policy for 1of 2 (Ultrasound) areas using Cidex as a disinfectant. The facility reported an average of 2-3 procedures a week completed in Ultrasound requiring the use of Cidex as a disinfectant.

Failure to date OPA Cidex test strips when opened could potentially cause cross contamination between patients if the effectiveness of the Cidex decreases with use.

Findings include:

1. An observation during the tour of the Ultrasound department on 8/22/12 at 8:20 AM, with Staff J, (Ultrasound Coordinator) and Staff K, (Computed Tomography Coordinator) revealed a disinfectant room with Cidex test strips on the counter by the Cidex disinfectant solution. The test strips were open, with about 30 test strips remaining in the 60 test strip container. The ultrasound staff did not document the date the test strips were opened.

2. During an interview on 8/22/12 at 8:20 AM, Staff J confirmed the test strip container lacked a date when opened and stated the ultrasound staff always should date the container when opening it.

3. Review of the manufacturer's guidelines for Cidex OPA Solution Test Strips stated in part... "F. 2. Always note the date the bottle was opened and the "do not use after" date in the space provided on the bottle."

-Review of the facility policy titled Use of OPA Solution Test Strips, dated 7/11 stated in part... "3. Record the date that the bottle of Cidex OPA Test Strips was opened on the container label. Do not use any remaining strips 90 days afteropening the bottle."

I. Based on document review, observation, and staff interview, the facility failed to ensure staff members checked the minimum effective concentration (MEC) of the active ingredient in Cidex OPA in 2 of 2 areas (Surgery and Radiology) prior to each use of the Cidex OPA. The facility identified an average of 355 surgical procedures performed at the facility per month.

Failure to test the Cidex OPA for the MEC of the active ingredient could potentially result in the Cidex OPA lacking sufficient strength to kill all the microorganisms (bacteria, fungi, viruses), potentially allowing the microorganism to pass a life threatening infection to another patient.

Findings include:

1. Review of the undated manufacturer's instructions for the Cidex OPA test strips revealed in part, "It is recommended that CIDEX OPA Solution be tested before each usage with the CIDEX OPA Solution test strips in order to guard against dilution..."

-Review of the policy "Use of Cidex Opa [sic] Solution," authorized 7/11, revealed in part, "Test CIDEX OPA Solution prior to use with CIDEX OPA Solution test strips."

3. Observations during a tour of the Surgical Department on 8/21/12 at 10:20 AM revealed 1 of 1 small tub of Cidex OPA solution sitting on the Anesthesia work counter.

-Review of the "3M Gluteraldehyde Record Keeping" log, from 8/7/12 to 8/21/12, revealed facility staff members only tested the Cidex OPA solution once per day.

-During an interview at the time of the tour, Anesthesia Aide L stated they only tested the Cidex OPA once per day, and acknowledged the manufacturer required staff members to test the solution prior to each use.

4. Observations during a tour of the Ultrasound Department on 8/22/12 at 8:20 AM revealed a disinfectant room with Cidex OPA solution sitting on the counter. The Cidex Testing log hung on the left wall in the room. Review of the Cidex testing log showed facility staff members tested the Cidex OPA Solution once per day from 5/18/12 to 8/20/12.

-During an interview at the time of the tour, Ultrasound Coordinator J stated the ultrasound staff members only tested the Cidex OPA solution once per day, and did not test the solution prior to each use.

II. Based on document review, observation, and staff interview, the facility failed to ensure 1 of 1 observed Certified Registered Nurse Anesthetist (CRNA D) cleansed the intravenous (IV) access port prior to administering medications to the patient. The facility staff members identified an average of 355 surgical procedures performed per month.

Failure to cleanse the IV access port prior to administering medications could potentially result in the staff member introducing microorganisms, such as bacteria, into the patient's IV line, resulting in a potentially life threatening infection.

Findings include:

1. Review of facility policies revealed the facility used the book "Nursing Procedures" as a reference for basic nursing procedures.

-Review of "Lippincott's Nursing Procedures, 5th edition", copyright 2009, revealed in part, "... wipe the injection port [of the IV access line] with an antiseptic swab, and inject the medication."

2. Observations of CRNA D during a surgical procedure on 8/21/12 revealed:

-At 2:20 PM, CRNA D administered Versed (a medication to reduce anxiety) to the patient through their IV access. CRNA D did not cleanse the IV access port prior to administering the Versed to the patient.

-At 2:23 PM, CRNA D administered fentanyl (a powerful painkiller medication) to the patient through their IV access. CRNA D did not cleanse the IV access port prior to administering the fentanyl to the patient. CRNA D administered lidocaine (a local painkiller medication) to the patient through their IV access. CRNA D did not cleanse the IV access port prior to administering the lidocaine to the patient. CRNA D administered propofol (a sedative medication) to the patient through their IV access. CRNA D did not cleanse the IV access port prior to administering the propofol to the patient. CRNA D administered rocuronium (a muscle relaxant) to the patient through their IV access. CRNA D did not cleanse the IV access port prior to administering the rocuronium to the patient through their IV access. CRNA D administered succinylcholine (a muscle relaxant) to the patient through their IV access. CRNA D did not cleanse the IV access port prior to administering the succinylcholine to the patient through their IV access.

3. During an interview on 8/21/12 at 3:00 PM, Surgical Charge Nurse M acknowledged CRNA D failed to cleanse the IV access port prior to administering medications to the patient.

Based on document review, observations, and staff interviews, the facility failed to ensure it had 36 vials of Dantrolene in 1 of 1 Operating Room areas. The facility performed an average of 120 surgical procedures that involved general anesthesia.

Failure to have 36 vials of Dantrolene could potentially result in the facility lacking sufficient quantities of Dantroleneto treat a patient that developed Malignant Hyperthermia, a life threatening condition that could happen unexpectedly after a patient received general anesthesia. If the facility lacked sufficient Dantrolene, the patient could potentially die due to a delay in treatment.

Findings include:

1. Review of the policy "Malignant Hyperthermia Management", reviewed 4/12, revealed in part, "Adequate supply of [Dantrolene] will be kept in the anesthesia supply cupboard to manage one average size adult patient crisis."

-Review of the scientific article, "Current State of Malignant Hyperthermia And the Use of [Dantrolene intravenously] as treatment," from Anesthesiology News March 2010, provided by the facility, revealed in part, "Given that some patients may need 10 [milligrams/kilogram] for treatment, it has been recommended that 36 vials be on hand..."

2. Observations during a tour of the Surgical Department on 8/21/12 at 11:35 AM revealed a cupboard marked "Dantrolene Storage." Further observations in the cupboard revealed the facility had 32 vials of Dantrolene on premise.

3. During an interview at the time of the tour, Surgical Charge Nurse M stated the facility normally kept 36 vials of Dantrolene in the cupboard. Surgical Charge Nurse M did now know what had happened to the missing 4 vials of Dantrolene. Additionally, Surgical Charge Nurse M verified the facility did not have the other 4 vials of Dantrolene in another location, such as the pharmacy.

Based on document review and staff interview, the facility failed to ensure the anesthesia provider performed a post-anesthesia examination to determine possible side effects of anesthesia for 10 of 10 patients that underwent surgery with general or epidural anesthesia (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, and 10). The facility identified an average of 120 patients that received general anesthesia per month.

Failure to perform a post-anesthesia assessment after the patient had recovered from general anesthesia (when an anesthesia provider administers medication to render the patient unconscious during surgery) or epidural anesthesia (where an anesthesia provider injects medication into the patients's spine to decrease pain sensation in the lower half of the patient's body) could potentially result in the anesthesia provider failing to detect potentially life-threatening complications from the medications they administered, and failing to provide appropriate treatment for the complications.

Findings include:

1. Review of closed medical records on 8/22/12 at 11:30 AM revealed:

-On 5/24/12 Patient #1 underwent circumcision, and received general anesthesia as part of the surgical procedure. Review of Patient #1's medical record revealed the anesthesia provider failed to perform a post-anesthesia assessment after the patient had recovered from the general anesthesia.

-On 5/27/12 Patient #2 underwent surgical removal of an abscess (a small pocket of infection in the skin), and received general anesthesia as part of the surgical procedure. Review of Patient #2's medical record revealed the anesthesia provider failed to perform a post-anesthesia assessment after the patient had recovered from the general anesthesia.

-On 6/6/12 Patient #3 underwent repair of an umbilical hernia (a small band of bowel sticking through the abdominal wall), and received general anesthesia as part of the surgical procedure. Review of Patient #3's medical record revealed the anesthesia provider failed to perform a post-anesthesia assessment after the patient had recovered from the general anesthesia.

-On 6/22/12 Patient #4 underwent a colectomy (surgical removal of part of the large intestine), and received general anesthesia as part of the surgical procedure. Review of Patient #4's medical record revealed the anesthesia provider failed to perform a post-anesthesia assessment after the patient had recovered from the general anesthesia.

-On 7/11/12 Patient #5 underwent a Caesarian Section, and received epidural anesthesia as part of the surgical procedure. Review of Patient #5's medical record revealed the anesthesia provider failed to perform a post-anesthesia assessment after the patient had recovered from the epidural anesthesia.

-On 7/2/12 Patient #6 had a dental crown placed on a tooth, and received general anesthesia as part of the surgical procedure. Review of Patient #6's medical record revealed the anesthesia provider failed to document the time they performed a post-anesthesia assessment, which prevented surgical staff from knowing if the patient had recovered from the general anesthesia when the anesthesia provider examined Patient #6.

-On 5/29/12 Patient #7 underwent neck surgery, and received general anesthesia as part of the surgical procedure. Review of Patient #7's medical record revealed the anesthesia provider failed to perform a post-anesthesia assessment after the patient had recovered from the general anesthesia.

-On 6/27/12 Patient #8 underwent a total right knee replacement, and received general anesthesia as part of the surgical procedure. Review of Patient #8's medical record revealed the anesthesia provider failed to perform a post-anesthesia assessment after the patient had recovered from the general anesthesia.

-On 6/16/12 Patient #9 underwent a Caesarian Section, and received epidural anesthesia as part of the surgical procedure. Review of Patient #9's medical record revealed the anesthesia provider failed to perform a post-anesthesia assessment after the patient had recovered from the epidural anesthesia.

-On 8/2/12 Patient #10 underwent a Caesarian Section, and received epidural anesthesia as part of the surgical procedure. Review of Patient #10's medical record revealed the anesthesia provider failed to perform a post-anesthesia assessment after the patient had recovered from the epidural anesthesia.

2. During an interview on 8/23/12 at 9:30 AM, the Chief Nursing Officer acknowledged the anesthesia providers failed to perform a post-anesthesia examination of the patients identified above.