HospitalInspections.org

Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to inform each patient of their visitation rights, including any clinical restriction or limitation on such rights, and the reasons for the clinical restriction or limitation for 1 of 1 emergency departments (ED) and 10 of 10 outpatient services. The inpatient's and outpatient's medical records also lacked documentation that the required notice was provided to each patient in advance of care whenever possible. Failure to inform each patient of their visitation rights could potentially result in limiting/restricting access of visitors to patients that infringed on their right to have a support person when they are provided any type of care, services, or treatment. The CAH's administrative staff identified 649 ED patients and the following outpatient services volumes in Fiscal Year 2020 ( July 1, 2020 - June 30, 2021) as follows:

Lab - 1,795 patients
Physical Therapy - 162 patients
Radiology - 248 patients
Occupational Therapy - 28 patients
Same Day Surgery - 12 patients
Endoscopy - 88 patients
Cardiac Rehab - 85 patients
Speech Therapy - 1 patients
Sleep Studies - 3 patients
Diabetic Education - 19 patients


Findings include:

1. Review of the "Visitation Policy", last revised 2/2021, lacked direction for CAH staff to provide each patient, or each patient's support person, with their visitation rights before the CAH provided care and lacked guidance to document the provision of this information in the patient's medical record.

2. Review of the policy "Patient Registration and Verification of Insurance", last revised 7/2021, revealed the policy lacked direction for the registration staff to disclose to a patient their visitation rights in advance of care and to document the provision of this information in the patient's medical record..

3. Observations during a tour of the Emergency Department (ED) on 9/13/2021 at 2:35 PM revealed the CAH staff failed to post or otherwise make the patient's visitation rights information available to patients of the Emergency Department.


4. Observations on 9/14/2021 at 10:45 AM at the Patient Registration and Admitting desk revealed the CAH staff failed to post or otherwise make available the patient's visitation rights information available to the CAH's patients.

During a interview on 9/14/21, at the time of the observation, the Billing Coordinator verified outpatients present to the registration desk prior to receiving outpatient hospital services. The Billing Coordinator reported registration staff do not disclose, verbally or otherwise, make the patient's visitation rights information available to outpatients that come to the CAH for services.

During an interview on 9/14/21, at the time of the observation, the Director of the CAH, acknowledged the Patient Registration and Admitting Desk lacked the required notice of the patient's visitation rights.


5. During an interview on 9/16/21 at 9:45 AM, the Director of the CAH acknowledged that Patient's Visitation Rights information was not posted, disclosed, or otherwise made available to ER and Outpatients and that all of the CAH's patients medical records lacked documentation that the required notice was provided to the patient or, as appropriate, the patient's support person..

Based on document review and staff interview, the Critical Access Hospital's administrative staff failed to to ensure the Continuous Quality Improvement (CQI) program included quality improvement measures related to improved patient care outcomes for 5 of 25 departments (Ambulatory Care, Discharge Planning/Social Services, Nutritional Services, Occupational Therapy, and Physical Therapy) involved with patient care. Failure to utilize quality improvement measures related to improved patient care resulted in the CAH staff monitoring items which did not improve patient care. The CAH administrative staff identified a census of 2 inpatients at entrance.

Findings include:

1. Review of the "MercyOne Primghar Medical Center and Clinics Quality Improvement Plan 2021," revised 1/2020, revealed in part, "Clinical/Administrative Functions: ... Monitor and evaluate the appropriateness patient care and clinical performance ..."


2. Review of the "MercyOne Primghar Medical Center CQI Dashboard" meeting minutes from August/September 2020 through July/August 2021 revealed the following:

a. The Ambulatory Care department tracked the process of recruiting a new cardiologist.

b. The Discharge Planning/Social Services department did not include any quality improvement measures.

c. The Nutritional Services department tracked the patient satisfaction scores.

d. The Occupational Therapy department tracked documentation to ensure the staff correctly counted the number of patient visits.

e. The Physical Therapy department tracked documentation to ensure the staff correctly counted the number of patient visits.


3. During an interview on 9/16/21 at 9:30 AM, the Director of the CAH acknowledged the departments failed to track quality improvement activities related to improved health outcomes.

Based on review of policy/procedure and staff interview, the Critical Access Hospital's (CAH) administrative staff failed to ensure 1 of 1 abuse policy contained the required language in the regulations that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) for swing bed patients. The CAH administrative staff identified 9 skilled patients for the fiscal year July 2020 until June 2021. Failure to include the required language in the abuse policy could potentially prevent CAH staff from reporting alleged violations involving abuse to the CAH administrator and to other officials (including to the State Survey Agency) in a timely manner.

Findings include:

1. Review of the CAH's policy "Dependent Adult Abuse Prevention and Reporting," last revised 5/2021, failed to include the required language in the regulations that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency).

Further review of the policy revealed the policy lacked direction to require all direct care staff members to receive education of Mandatory Reporting every 3 years.


2. During an interview on 9/16/21 at 9:00 AM, the Chief Executive Officer/Chief Nursing Officer acknowledged the abuse policy failed to include the required language in the regulations that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency).