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Iowa Administrative Code Chapter "51: 51.24(3) Health Examinations" requires: "Health examinations for all personnel shall be required at the commencement of employment and there after at least every four years. The examination shall include at a minimum, the health and tuberculosis status of the employee...."

Based on review of documents and staff interviews the Critical Access Hospital (CAH) administrative staff failed to include a hands on assessment, in the health assessment, for 7 of 25 employee files reviewed. (Staff E, F, G, H, I, J, K, L, and M) The CAH administrative staff reported a census of 4 patients.

Failure to include a hands on assessment, in the health assessment could potentially result in employees health risks being undetected.

Findings include:

1. Review of the employee health records on 11/8/11, revealed completion of an initial health assessment, done upon the date of hire, that included a hands on assessment of lung sounds, heart rate, B/P, or respirations.

Seven of 25 employee records reviewed (Staff E, F, G, H, I, J, K, L, and M) included health assessments completed every 4 years following the initial health assessment, documented on a form titled, "Associate Routine Well Physical Examination Form." The Associate Routine Well Physical Examination Form revealed no evidence of a hands on assessment.

Review of a policy titled, "Post Job Offer and Routine Associate Physicals," approved on February 2010, stated in part ...Every four years, Associates will be required to have a physical examination by their primary care provider...."

2. During an interview on 11/8/11 at 3:00 PM, Staff E, Human Resources Manager, reported, only the initial physical, upon hire, includes a pulse, B/P, and lung sounds. The Associate Routine Well Physical Examination Form contains a space for the provider to date that a hands on assessment was completed.

Based on observations, document review and staff interviews, the Critical Access Hospital (CAH) maintenance staff failed to ensure patient safety related to hot water temperatures in patient care areas of Emergency Department (ER) and off site Physical Therapy (PT) Department. Problems identified with hot water temperatures in 3 of 5 sinks in the ER treatment rooms and a sink in the PT patient area. The CAH identified a monthly average of 275 ER visits and 500 monthly visits for outpatient Physical Therapy (PT).

Failure to monitor hot water temperatures could potentially cause serious scalding burns to patients. The depth of injury relates directly to the temperature and duration of exposure to the water. The length of exposure required for a third degree burn to occur is 1 second at 155 degrees, 2 seconds at 148 degrees, 5 seconds at 140 degrees, 15 seconds at 133 degrees, 1 minute at 127 degrees, and 3 minutes at 124 degrees for adults.

Findings include:

1. Review of CAH documents revealed:

a. The CAH policies lacked a policy/procedure for monitoring water temperatures in the CAH.

b. "QI [Quality Improvement] Water Temp. Hot" log revealed water temperatures over 120 degrees Fahrenheit (F) on:

i. 9/13/11 ER room #4 127

ii 9/22/11 ER room #4 125, ER room #5 121.2

iii. 6/13/11 ER room #4 122.3, ER room #5 120.6

During an interview on 11/8/11 at 4:10 PM, the Director of Nursing confirmed the "QI Water Temp. Hot" log lacked documented water temperature logs for July and August water temperatures. The Director of Nursing stated the maintenance staff could not find any documented evidence of water temperatures for these months.

c. "GCMH (Grundy County Memorial Hospital) Action Plan to reduce water temps" provided on 11/8/11 at 3:00 PM by the Director of operations revealed in part, "Problem: For the safety of our patients...water temperatures in patient care areas should be maintained between 110-120 degrees. On 11/7/11, temperatures were found above 120 degrees in Inpatient rooms, 103, 107, the Outpatient Treatment room and ED [Emergency Department] rooms 3, 4 and 5."

d. Job Description, Maintenance Mechanic-plumber revealed in part, "...this position includes involvement with safety...prevention/protection...assures all equipment operates and is kept in condition assuring safety in its use...Ability to perform daily environmental checks (water...keeps...utilities in good working order."

2. Observation during a tour of the ER, accompanied by the Director of Nursing, on 11/7/11 at 11:10 AM revealed the following hot water temperatures confirmed by the Director of Nursing:

a. ER room #3 sink, water temperature of 126 degrees F

b. ER room #4 sink, water temperature of 130 degrees F

c. ER room #5 sink, water temperature of 124 degrees F

Observation, during a tour of the offsite PT, accompanied by the Physical Therapist manager, on 11/8/11 at 8:20 AM, revealed a hot water temperature of 125.2 degree F in the sink in the PT patient area. The Physical Therapist confirmed the water temperature and stated patients would have access to the sink.

Observation on 11/7/11 at 11:30 AM revealed Staff D, Maintenance, in ER taking water temperatures in Room #5. Staff D confirmed the above water temperatures in the ER. Staff D stated staff found water temperatures above 120 degree F in patient care rooms. Staff D did not know the accurate water temperature of the patient care rooms, but stated the temperatures were over 120 degrees and water temperatures for patient areas should not be above 120 degrees F.

3. During an interview on 11/9/11 at 10:50 AM, Staff D stated the maintenance staff did not document the high water temperatures found on 11/7/11, but stated the water temperatures were over the 120 degrees F. Staff D stated the maintenance staff adjusted the water temperatures until the temperatures stayed under 120 degrees F.

During an interview on 11/8/11 at 3:00 PM, the Director of Operations confirmed the elevated water temperatures on the water temperature log and stated the maintenance staff did not document follow up when they found elevated temperatures.

The Director of Operations stated the maintenance staff checked water temperatures in the same patient rooms and patient care areas twice monthly, as indicated on the water logs but this did not include the PT area.

The Director of Operations provided a copy of a policy; "Water Temperature Testing" dated 11/11 and stated the Administrative staff just created this policy because the CAH did not have a policy/procedure for testing water temperatures.
The Director of Operations, also, provided the above "GCMH Action Plan to reduce water temps" and stated the maintenance staff started this procedure immediately.

Based on observation, review of policies and procedures and staff interview, the Critical Access Hospital (CAH) failed to develop policies and procedures that addressed a record system that tracked movement of all scheduled drugs from the time they are delivered to the CAH until the time they are removed by the reverse vendor.

The acute care nurse manager identified an average daily census of 6 patients.

Facility policies and procedures should minimize scheduled drug diversions, failure to develop policies and procedures could potentially cause delays in identifying loss or diversion of all controlled substances minimizing the time frame between the actual loss or diversion to the time of detection and determination of the extent of loss or diversion.

Findings include:

1. Review of the pharmacy policy and procedure manual on 11/7/11, did not provide evidence that the hospital had established procedures in the manual that specify how Controlled Substances Medications were tracked from the time they were delivered to the pharmacy until the time they were removed by the reverse vendor.

2. Observation during tour of the pharmacy between 2:00 and 3:30 PM on 11/7/11, revealed a plastic bin located in a bar code entry locked cabinet, beneath the pharmacy technician work station.

During an interview at the time of the tour, Staff A, Pharmacy Technician, stated the following outdated medications were inside the bin:

a. 42 tablets of Diphenoxylate and Atropine, placed in the bin by pharmacy technician staff on 10/21/11.

b. 21.75 milliliters (ml) of Lorazepam syrup, placed in the bin by pharmacy technician staff on 10/28/11.

c. 10 - 15 milligram (mg) tablets of Morphine Sulfate, placed in the bin by pharmacy technician staff on 10/21/11.

d. 30 ml of Morphine oral solution, placed in the bin by pharmacy technician staff on 10/21/11.

Staff A said the bin lacked an excel spread sheet for inventory count. Staff A stated the controlled substance medications stored in the bin required an inventory sheet. Staff A stated, "I'll do that tomorrow." Staff A said the outdated controlled substance medications were picked up every three months by the reverse vendor.

3. During an interview on 11/8/11, at approximately 1:50 PM, the pharmacist confirmed the CAH had no current policy or procedure that addressed a record system that tracked movement of Controlled substance medications from the time they were delivered to the pharmacy until the time they were removed by the reverse vendor.

4. During an interview on 11/8/11 at 2:10 PM, Staff J, Pharmacy Technician said the pharmacy technicians are responsible for "pulling" outdated medication from all areas in the hospital and pharmacy including controlled substance medications. Staff J said she did not use the excel spread sheets for inventory count but did document the outdated medications on the perpetual inventory log sheets.

5. During an interview on 11/8/11 at 3:05 PM, the Director of Nursing (DON) acknowledged the CAH had no current pharmacy policy and procedure that specified how controlled substance medications were tracked from the time they were delivered to the pharmacy until the time they were removed by the reverse vendor.


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Based on observation, review of records, and staff interview the Critical Access Hospital (CAH) failed to secure 1 of 2 medication drawers in the Emergency Department (ED). The CAH administrative staff reported a monthly average of 275 ED visits.

Failure to secure the medications in the ED crash cart could potentially result in medication loss/theft.

Findings include:

1. An observation on 11/7/11 at 11:27 AM, with Staff N, ED RN (Registered Nurse), revealed 2 crash carts, 1 Adult and 1 Pediatric. The surveyor easily opened the Pediatric crash cart medication drawer. The red plastic breakaway lock (# 3194906) was broke away, lying on the floor directly under the crash cart.

2. A review of the policy titled, " Crash Cart Drug Drawer " , approved January 2004, stated in part ... The crash cart drug drawer shall be sealed into the crash cart in such a manner that the seal must be broken to gain access to the medications ....
The " Pediatric Crash Cart Checklist " , dated November 2011 revealed daily checks to ensure the lock was intact and lock #3194906 was in place at the last check on 11/7/11. All daily checks of the crash cart were completed and signed by an ED staff member.

3. During an interview on 11/7/11 at 11:41 AM, Staff N verified the Pediatric crash cart was unlocked and medications were unsecured.