HospitalInspections.org

The Medicare Modernization ACT has changed the total number of beds a Critical Access Hospital (CAH) may have and maintain. The CAH may not have more than 25 beds that could be used for inpatient care.

Based on observation, review of policy, procedure, and staff interview the CAH failed to ensure the total number of beds available for inpatients did not exceed 25.

Failure to ensure the CAH maintained a total bed count of 25 beds could potentially result in the CAH's inability to provide adequate care and services.

Findings include:

1. Review of the CAH's policy titled "Critical Access Hospital Parameters" stated in part, "...Policy: It is the policy of Mahaska Health Partnership, (MHP) to adhere to the Critical Access Hospital (CAH) guidelines...patient census will be maintained at or below 25 acute and swing bed (SNF) patients..."

2. Observation on 12/7/15 at 12:50 PM during tour of the inpatient care area with Staff G, Director of Inpatient Services revealed 25 medical/surgical beds, 5 obstetric beds and 2 overflow beds located between the medical/surgical and obstetric units combined together for a total of 32 available beds in the CAH for inpatient use.

3. During at interview on 12/7/15 at 12:50 PM, Staff G acknowledged the hospital had a total of 32 beds available for inpatient use. Staff G acknowledged there were 25 medical/surgical beds, 5 obstetric beds and 2 overflow beds located between the medical/surgical and obstetric units.

During an interview on 12/7/15 at 2:35 PM, Staff I, Utilization Review Coordinator, acknowledged the hospital's total number of beds available for inpatients was 32. Staff I reported the CAH utilized a tracking system to ensure no more than 25 patients received care daily.

During an interview on 12/8/15 at 7:15 AM, Staff F, Chief Executive Officer, acknowledged the hospital's total number of beds available for inpatients was 32. Staff F reported the CAH utilized a tracking system to ensure no more than 25 patients were in the CAH receiving care daily.

Based on review of polices, procedures, documents, and staff interview the Critical Access Hospital (CAH) failed to include a mid-level practitioner on the committee to review the CAH policies. The CAH identified 1171 policies.

Failure to ensure mid-level practitioners participated in the development and periodic review of policies for the services at the CAH could potentially result in the lack of updated and consistent mid-level practitioners standards of practice policies and procedures.

Findings include:

1. Review of documents titled, "Policy Review Committee Minutes" dated 10/16/14-8/20/15 lacked documentation of a mid-level practitioner participation in the annual policy review and approval of new, revised, and deleted policies.

2. During an interview on 12/9/15 at 2:30 PM, Staff E, Chief Nursing Officer, acknowledged a mid-level practitioner did not attend the Policy Review Committee Meetings.

I. Based on review of policy, documents, and staff interviews the Critical Access Hospital (CAH) hospital failed to ensure employees, contracted staff and volunteers completed a physical exam every four years to identify infections and communicable diseases. Problems were identified for 1 of 3 volunteers (Staff EEE), 2 of 3 contracted employees (Staff GGG and HHH) and 5 of 20 employees selected for review (Staff LL, FFF, III, JJJ and LLL).

Failure to ensure all staff completed a physical exam every four years to identify infections and communicable diseases could potentially result in causing harm to patients through exposure and transmission of communicable diseases.

Findings include:

1. Review of a CAH policy titled, "Employee Health Services", reviewed 2/2015 included in part "... The preplacement/post offer assessment includes: ... physical exam ... Periodic assessments include: ... Health examinations at least every four years ..."

2. Review of the selected health information files revealed Staff FFF, Registered Dietitian, Staff GGG, Contracted Occupational Therapist and Staff JJJ, Registered Nurse (R.N.), lacked documentation of a physical exam. The files for Staff LL, Director of Food and Nutrition Services, Staff EEE, Volunteer, Staff HHH, Contracted Physical Therapist, Staff III, RN and Staff LLL, Certified Nurse Aide, lacked documentation of a physical exam completed in the past 4 years.

3. During an interview on 12/10/15, at 8:05 AM, Staff DDD, Registered Nurse (RN) Occupational and Employee Health, reported the CAH requires a physical exam for employees and volunteers every 4 years. She reported the contracted therapy company is responsible for documentation of health exams for the contracted therapy staff but would expect them to also have one completed a minimum of every 4 years.

During a follow-up interview on 12/10/15, at 10:45 AM, Staff DDD confirmed the health information files for Staff FFF, GGG and JJJ lacked documentation of a physical exam and the files for Staff LL, EEE, HHH, III and LLL lacked documentation of a physical exam completed in the past 4 years.

II. Based on observations, policy review and staff interviews, the Critical Access Hospital (CAH) Food and Nutrition Services (FANS) Department failed to use sanitary practices during food handling and patient meal service. The administrative staff identified a census of 18 patients. The Director of Food and Nutrition Services identified dietary staff provided an average of 60 patient meals daily.

Failure to ensure staff maintained sanitary practices during meal service and food handling could potentially result in contamination of the patient's food leading to foodborne illness.

Findings include:

1. Observations during food preparation and meal service on 12/8/15 from 10:57 AM to 12:08 PM, revealed Staff LL, Director of FANS, assigned to prepare and dish patient food for lunch during 4 different occasions donned and removed gloves to handle patient ready-to-eat foods but failed to wash her hands prior to donning the gloves. Observation showed Staff LL touched multiple surfaces, including but not limited to, microwave, bread, dinner roll and hamburger bun packages, drawer handles, steamer handle/timer and oven mits, after donning the gloves resulting in contaminated gloves and handled ready-to-eat food for 4 patients, including grilled cheese sandwiches, dinner roll and hamburger bun with the contaminated gloves.

2. Observation during the same meal period revealed Staff MM, Food Service Worker, assigned to assist Staff LL by placing cold items on the patient trays. Observations during 3 different occasions, Staff MM donned and removed gloves to handle patient ready-to-eat food but failed to wash her hands first. Staff MM touched multiple surfaces, including but not limited to, packages of shortcake biscuits, container of strawberries, microwave and refrigerator handle after donning the gloves resulting in contaminated gloves and handled the shortcake biscuits with the gloves.

3. During an interview on 12/9/15, at 9:00 AM, Staff LL reported she expected FANS staff to wear gloves when handling ready-to-eat foods and wash their hands prior to donning the gloves. Staff LL acknowledged once the gloves touch other surfaces they would be considered contaminated and should be removed, hands washed and new gloves donned. She provided a copy of the hospital-wide hand hygiene policy and reported the FANS department did not have a policy to address glove use with food handling.

4. Review of an infection control policy titled, "Hand Hygiene", reviewed 4/2015, revealed it failed to address hand hygiene and glove use specific to food handling.

5. 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 gloves to 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.

Based on document review and staff interview, the Critical Access Hospital (CAH) failed to ensure 1 of 7 active, 1 of 1 consulting and 1 of 1 hospital based 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. In addition the CAH failed to ensure 3 of 3 courtesy and 7 of 7 consulting physicians identified to have provided services to CAH patients, 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 JJ, Staff OO and Staff QQ, Staff RR, Staff SS, Staff TT, Staff UU, Staff VV, Staff WW, Staff XX, Staff AAA, Staff BBB, and Staff CCC). The CAH identified 21 active physicians, 44 consulting physicians, 9 courtesy physicians and 2 hospital based physicians.

The CAH administrative staff identified the practitioners provided services to patients, during their last credentialing period, as follows:

Staff JJ, M.D., Psychiatry - 812 patients
Staff OO, D.P.M. Podiatry - 128 patients
Staff QQ, D.O., Emergency Medicine - 3,408 patients
Staff RR, M.D., Radiology - 25,433 exam reads
Staff SS, M.D., Pathology - 50 frozen sections/consult
Staff TT, M.D., Ophthalmology - 661 procedures
Staff UU, D.O., Surgery - 11 procedures
Staff VV, D.O., Surgery - 16 procedures
Staff WW, D.O., Urology - 88 procedures
Staff XX, D.P.M., Podiatry - 22 procedures
Staff AAA, M.D., Pathology - 3 frozen sections/consult
Staff BBB, M.D., Radiology - 8,760 exam reads
Staff CCC, M.D., Radiology - 41 exam reads

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

Findings include:

1. During an interview on 12/9/15, at 10:00 AM and 2:15 PM, Staff NN, Medical Staff Coordinator, reported she sends out a minimum of 1 case per physician to the Network Hospital, during each recredentialing cycle, for an outside entity peer review. The Medical Staff Coordinator acknowledged the reviews do not always come back before the credentialing file is submitted to the medical staff and governing body for approval. Staff NN confirmed the files for Staff JJ, OO and QQ lacked documentation of an outside entity peer review completed during the providers last credentialing period. Staff NN reported she does not send out non-employed physician cases for an outside entity peer review and acknowledged that these physicians would lack any evaluation of the appropriateness of diagnosis and treatment furnished to patients at the CAH, prior to their recredentialing cycle. Staff NN reported the CAH did not have a policy specific to the hospital's process for an outside entity peer review.

Based on Patient document review, medical record review and staff, patient and family interviews, the Critical Access Hospital (CAH) failed to ensure patients, inpatients and outpatients were informed of their patient visitation rights including the ability to receive designated visitors, but not limited to a spouse, a domestic partner (including same-sex domestic partner) and another family member or friend for 6 of 6 swing bed patients (Patient #2, #3, #4, #5, #6, and #7) and 10 of 10 acute inpatients (Patient #10, #11, #12, #13, #14, #15, #16 and #17) and all outpatients. The CAH administrative staff reported a census of approximately 21, 948 outpatients visits a month receiving services.
Failure to ensure staff provided inpatients, skilled patients and outpatients with patient visitation 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 the policy titled "Patient Visitation Rights" revised 7/2015 revealed in part..."The visitors designated by the patient or support person (including a same sex domestic partner)...a support person includes but is not limited to a person who is the patient's spouse, a domestic partner...a same sex partner...a person whom the patient is in a civil union, or a same sex marriage."

2. Review of a document titled, "Swing Bed Patient Information" undated, provided to swing bed patients and/or family members upon admission to the CAH, lacked documentation regarding the patient's consent to receive visitors whom he or she designates. The document lacked information to include the patient's ability to receive designated visitors but not limited to, a spouse, a domestic partner (including a same sex domestic partner), another family member or friend.

Review of a document titled, "Patient Rights and Responsibilities" located at the main registration desk, dated 7/15 provided to acute care patients and outpatients upon admission to the CAH. The document lacked information regarding the patient's consent to receive visitors whom he or she designates, including but not limited to, a spouse, a domestic partner (including a same sex domestic partner), another family member or friend

3. Review of Patient #1, #3, #4, #5, #6, #7, #10, #11, #12, #13, #14, #15, #16 and #17 medical records included a copy of the Swing Bed Program Admission Agreement and Patient's Bill of Rights. The documents lacked information to include the patient's ability to receive designated visitors but not limited to, a spouse, a domestic partner (including a same sex domestic partner), another family member or friend.
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4. During an interview on 12/7/15 at 1:10 PM, Patient #1 and family members acknowledged nursing staff provided the Swing Bed Patient Rights pamphlet.

During an interview on 12/7/15 at 3:05 PM, Staff H, Utilization Review Coordinator, acknowledged the Swing Bed Patient Rights provided to swing bed patients lacked information for same sex domestic partner.

During an interview on 12/7/15 at 3:10 PM, Staff W, Standards Coordinator acknowledged the Patient Rights provided to swing bed patients, acute care patients and outpatients lacked information for same sex domestic partner.

During an interview on 12/7/15 at 3:35 PM, Staff Y, Registration Clerk Supervisor acknowledged registration staff failed to provide acute care patients and outpatients information regarding their visitation rights and responsibilities.

During an interview on 12/9/15 at 7:50 PM, the Chief Nursing Officers acknowledged the Patient Rights provided to swing bed patients, acute care patients and outpatients lacked information for same sex domestic partner.