HospitalInspections.org

I. Based on personnel record review and staff interview the Critical Access Hospital (CAH) failed to ensure pre-employment criminal background checks for all employees were conducted appropriately, as required by state law. Problems were identified for 2 of 8 new sampled employees selected for review.

Failure to ensure the required background checks were conducted, as required, may result in the employment of staff with founded criminal or abuse charges posing a risk to patients.

Findings include:

Iowa Administrative Code Department of Inspections and Appeals 50.9(4) Validity of background check results. The results of a background check conducted pursuant to this rule shall be valid for a period of 30 calendar days from the date the results of the background check are received by the facility.

1. Review of the personnel file for Staff D, Occupational Therapist, revealed a hire date of 6/4/15. The Single Contact License and Background Check showed a completion date of 4/2/15, for the required background checks .

2. Review of the personnel file for Staff B, Chief Nursing Executive, revealed a hire date of 6/2/14. The Single Contact License and Background Check showed a completion date of 3/26/14, for the required background checks.

During an interview on 8/4/15, at 11:00 AM, Staff C, Director of Organizational Development/Human Resources, confirmed the background checks performed for Staff B and D exceeded the 30 day timeframe from the time of completion to their date of hire.


II. Based on personnel record review and staff interview the Critical Access Hospital (CAH) failed to ensure contracted staff completed mandatory reporter training, as required by state law. Problems were identified for 1 of 2 contracted staff selected for review.

Failure to ensure the required mandatory reporter training is provided may potentially result in harm to the patient related to the lack of identification and reporting of abuse.

Findings include:

1. Iowa Administrative Code Human Services 235B.16 Information, education, and training requirements.
5. b. A person required to report cases of dependent adult abuse . . . shall complete two hours of training relating to the identification and reporting of dependent adult abuse within six months of initial employment or self-employment which involves the examination, attending, counseling, or treatment of adults on a regular basis . . .The person shall complete at least two hours of additional dependent adult abuse identification and reporting training every five years.
5. e . . . A person who is a mandatory reporter for both child abuse and dependent adult abuse may satisfy the combined training requirements . . . through completion of a two-hour training program, if the training program curriculum is approved by the appropriate licensing board or the director of public health . . ."
2. Review of a Personnel policy titled "Employee Education Requirements", approved in 2/2014, revealed in part ". . . Dependent Adult and Child Abuse training will be required of hospital personal upon hire and renewed every five years . . ."

Review of the personnel file for Staff F, contracted Speech Therapist, revealed a hire date of 6/9/11. The personnel file lacked evidence of the completion of the required abuse training.

3. During an interview on 8/4/15, at 1:20 PM, Staff C provided a certificate copy for the completion of a program titled "Dependent Adult Abuse and Elder Justice Act", which showed only 1 credit hour and lacked verification of curriculum approval from the Department of Public Health or a licensing board. Staff C reported she confirmed with Staff F she lacked completion of child abuse training and could potentially treat children in the course of her work at the CAH. Staff C reported the CAH did not have a separate policy for the required education requirements of contracted staff but would follow the same requirements of employed staff and Staff F's abuse training did not meet their requirements.

Based on document review, policy review and staff interviews, the Critical Access Hospital (CAH) failed to consider the facility's usual fuel and water supply on hand and the criticality of quantities needed during an interruption in service, as part of the planning for emergency fuel and water agreements. The administrative staff identified an average census of 5 inpatients and 143 employees.

Failure to ensure emergency water and fuel are available to meet the facility's critical functions during an emergency or crisis situation could potentially cause a lack of necessary resources to provide adequate patient care.

Findings include:

1. During the environment tour on 8/4/15, beginning at 1:45 PM, Staff E, Maintenance Supervisor, reported the CAH had written agreements with W & H Coop for fuel and US Foods for potable water and provided copies of the agreements.

2. Review of a CAH policy titled "Disruption of Natural Gas Service and Back-Up Fuel Supply", revealed a signed agreement with W & H Coop, as part of the policy, dated 3/20/14. The agreement lacked details to outline the quantity of fuel and timeframe of delivery to ensure CAH needs were met.

Review of a document titled "Subject: Disaster and Emergency Response", dated 1/10/14, revealed a generic letter directed to the company's "valued customers", which lacked details to outline the quantity of potable water and time frame of delivery the company agreed upon.

Review of a CAH policy titled "Estimating Formula for Emergency Water Supplies", revealed in part, "To establish a method for estimating the volume of water needed daily to continue providing medical care to residents, patients and staff in the event of an interruption in water . . . ." The policy calculated water needs for nursing, dietary, environmental services and maintenance and included a total daily need but failed to address how the needs would be met.

3. During an interview on 8/5/15, at 10:00 AM, Staff E reported the only potable water agreement he knew of was the document from US Foods. Staff E acknowledged the CAH did not have a formal assessment of their usual supply of fuel and potable water on hand, to determine the quantity needed and how quickly they would need a delivery, in order to continue care to patients.

During an interview on 8/5/15, at 8:00 AM, Staff K, Dietary Supervisor, reported the dietary department did not have a supply of water designated specifically for emergency use, but normally ordered 8 cases a week. Staff K acknowledged the department has used a local HyVee grocery store for bottled water, but does not have a written agreement with them or any other business for the provision of potable water, in the event of a disruption of service.

Based on review of the Critical Access Hospital (CAH) Board of Directors meeting minutes and staff interviews, the CAH failed to document an evaluation of all contracted services. The CAH administrative staff reported a current census of 3 swing bed inpatients, 1 inpatient and an outpatient case volume of 321 patients weekly. The CAH had 62 contracted services.

Failure to evaluate all contracted services provided to patients could allow contracted staff to provide the services without current qualifications and might result in patients receiving substandard care.

Findings include:

Review of the Board of Directors committee meeting minutes from 7/28/14 to 6/29/15 revealed a lack of documentation regarding the evaluation of the contracted services and if those service were meeting the needs of the CAH.

During an interview on 8/4/15 at 12:45 PM, Staff B, Chief Nursing Executive (CNE) confirmed the Board of Directors committee meeting minutes lacked documentation regarding the evaluation of the contracted services.

II. Based on review of the CAH Board of Directors meeting minutes and staff interviews, the CAH failed to document information of Quality Improvement meeting minutes information being presented and evaluated at the Board of Directors meetings. The CAH administrative staff reported a current census of 3 swing bed patients, 1 inpatient and an outpatient case volume of 321 patients weekly.

Failure to review and evaluate Quality Improvement meeting minute information could result in an ineffective Quality Improvement program and might result in patients receiving substandard care.

Findings include:

Review of the Board of Directors committee meeting minutes from 7/28/14 to 6/29/15 revealed a lack of documentation regarding Quality Improvement meeting minutes information was reviewed and evaluated by the board members.

During an interview on 8/4/15 at 12:45 PM, Staff B, Chief Nursing Executive (CNE) confirmed the Board of Directors committee meeting minutes lacked documentation regarding the evaluation of Quality Improvement information.

Based on policy review and staff interviews, the Critical Access Hospital (CAH) failed to secure the CAH's Pharmacy from unauthorized access in accordance with their policy.

Failure of CAH staff to secure the pharmacy and follow CAH policy, could potentially result in unauthorized access to a variety of medications and opportunity for medication diversion.

Findings include:

1. Review of a Pharmacy policy titled "Security of Pharmacy", approved 7/14/15, revealed in part ". . . Personnel authorized to have keys to the pharmacy: Pharmacy manager, Staff pharmacists, Nursing supervisor, Certified pharmacy technician . . ."

2. During the facility environment tour on 8/4/15, beginning at 1:45 PM, Staff E, Maintenance Supervisor, acknowledged maintenance had a key to the pharmacy, accessible to all maintenance staff. He reported the key was sealed in plastic, to indicate if it had been used. Staff E reported he had never used the key and maintenance had one in case they ever had to enter in case of an emergency, such as fire or broken water pipes.

3. During an interview on 8/4/15, at 3:30 PM, Staff B, Chief Nursing Executive, reported he did not know maintenance had a key to the pharmacy. During a follow-up interview on 8/5/15 at 7:30 AM, Staff B reported he retrieved the key from maintenance and displayed the key, sealed in a clear specimen bag and confirmed they would no longer have one. Staff B reported pharmacy access changed to an employee badge system, with nurses and pharmacy staff designated as authorized to access. He reported the nursing supervisor carries a pharmacy key, in case the badge reader became non-functional, but planned to place it in the Pyxis Medication Management System, to increase security of the key.

During an interview on 8/5/15, at 8:10 AM, Staff L, Pharmacy Director, reported several years ago, maintenance requested a key to the pharmacy in case of an emergency, so one was provided, sealed in a bag, so use would be detected. He relayed the department did not have a policy to define the process, if the maintenance pharmacy key had to be utilized. Staff L relayed the pharmacy converted to employee badge access, approximately a year ago and did not realize maintenance still had a key. Staff L reported nursing accessed the pharmacy via their employee badge and could then enter a code to disarm the motion sensor alarm in the pharmacy, which allowed 10 minutes before an automatic reset and relayed they no longer had a key. He relayed the motion sensor alarms after about 45 seconds, if the code is not entered and maintenance does not have the code. Staff L reported the department had a policy on pharmacy security but did not believe it had been updated to reflect the current badge access system.

During an interview on 8/5/15, at 8:30 AM, Staff M, Registered Nurse (RN), confirmed the RN has a key to the pharmacy, during their shift, so can enter the pharmacy via their badge or the key.

During an interview on 8/5/15, at 8:45 AM, Staff L acknowledged he did not know that nursing still had a key and had assumed it had been removed from the area. Staff L confirmed if a nurse entered the area by use of the key and silenced the alarm, there would be no record of entry.

Based on document review, policy review and staff interview the Critical Access Hospital (CAH) administrative staff failed to follow their system to identify and prevent transmission of infections and communicable diseases for contracted employees. Problems were identified for 1 of 2 sampled contracted staff selected for review.

Failure 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 Personnel policy titled "Employee Health", approved in 2/2014, revealed in part ". . . After infinitival employment, all employees are required to have on record, a physical . . . at least every 4 years . . . Repeat tuberculin tests are required every four years . . . "

Review of an Employee Health policy titled "Tuberculosis (TB) Testing and Hepatitis Vaccine Series 801", approved 7/20/15, revealed in part ". . . All employees are required to have TB testing done every 4 years . . . "

2. Review of the personnel file for Staff G, contracted Sleep Study, revealed a hire date of 8/31/10. The file contained a health exam dated 8/25/10 and a TB test dated 4/14/09.

3. During an interview on 8/4/15, at 11:00 AM, Staff C, Director of Organizational Development/Human Resources, reported the CAH did not have a separate policy for the required health requirements of contracted staff, but would follow the same requirements of employed staff. Staff C acknowledged contracted Staff G's health exam and TB extended beyond 4 years.

Based on observation, policy review and staff interviews, the Critical Access Hospital (CAH) staff failed to secure and protect patient information from unauthorized users in the basement record storage area.

The basement contained approximately 1500 radiology films, 30 emergency room log books, 400 file storage boxes and 5,000 closed medical records.

Failure to secure the patient information could potentially cause a misuse of patient information and/or stolen identity for the individual patients.

Findings include:

1. Observation of the basement record storage area on 8/4/15, at 2:30 PM, revealed access to the area obtained through use of a punch code lock. Staff E, Maintenance Supervisor, reported Radiology, Laboratory and Health Information Management (HIM) departments stored patient records in the area and had the code, along with maintenance staff. The area had two unlocked metal cages to the far left and far right of the stairs. Staff E reported one of the areas held HIM records and the other held laboratory files. The center area, just to each side of the stairs contained radiology films.

An additional observation of the basement record storage area on 8/5/15, at 11:00 AM, along with Staff E and an additional surveyor, revealed in addition to radiology, laboratory and closed medical records, the area contained boxes of records from cardiac rehab, pulmonary rehab, accounting/billing, ER log books and multiple additional records. The records contained patient names, birth dates, addresses and a variety of personal health information. An estimate of the records contained in the area included 1500 radiology films, 30 ER log books, 400 file boxes and 5,000 medical records. Staff E confirmed that anyone with access to the storage area would have the ability to look at all the information stored in the area.

2. Review of a document, provided by Staff B, Chief Nursing Executive, on 8/5/15 at 7:30 AM, revealed 25 staff from Administration, HIM, Laboratory and Radiology, along with 6 Maintenance staff had the punch code to the basement record storage area.

Review of a HIPAA (Health Information Portability and Accountability Act) titled "Protection of Information Guidelines", approved on 7/15/15 in part ". . . All information, regardless of where it is handled or stored . . . must be protected from unauthorized access, modification, disclosure, and/or destruction . . . Information must be consistently protected whether in a computer system, file cabinet . . . " The data matrix of the policy defined handling standards for print, film, fiche and video to include reasonable measures to prevent unauthorized parties from viewing information and active measures and close control to limit information to as few persons as possible.

3. During an interview on 8/4/15, at 9:50 AM, Staff H, HIM Manager, reported the majority of records in the basement storage area were several years old. She reported maintenance staff accessed the area to assist with placing or removing boxes from the area, but acknowledged maintenance employees would not have the need to access personal health information in the course of their job. Staff H reported Laboratory and Radiology staff have some access to the electronic medical record, but would not need access to the variety of medical information that would be accessible in the basement.

Based on review of documents and administrative staff interview the Critical Access Hospital (CAH) failed to include review of open and closed records in the annual total program evaluation. The CAH administrative staff reported a current census of 3 swing bed inpatients, 1 inpatient, and an outpatient case volume of 321 patients weekly.

Failure to include review of open and closed records in the annual total program evaluation could potentially result in CAH failing to provide quality care to all of their patients.

Findings include:

1. Review of the document titled Critical Access Hospital Annual Report dated July 1, 2013 - June 30, 2014 revealed it failed to contain documentation regarding open and closed record review. The document stated in part...All clinical departments are responsible for conducting open and closed record review. Based on the finding of the clinical records review, opportunities for improvement were identified and ongoing monitoring developed. Monitoring is reported through the Quality Improvement/Risk Management Committee and/or the practitioner related through the Medical Staff Committee.

This is an area that all departments and Quality Improvement staff are currently working on to determine the best practice and procedure to follow for clinical record review. During fiscal year 2015, a policy and procedure will be developed to determent the process that will be followed to meet this standard.

2. During an interview on 8/4/15 at 3:15 PM, with Staff A, Director of Quality; and Staff B, Nursing Executive Officer acknowledged the CAH failed to document review of closed and active records required for the annual total program evaluation.

Based on review of documents and administrative staff interviews, the Critical Access Hospital (CAH) failed to ensure all departments of the CAH were evaluated through the Quality Assurance program. The CAH had 32 departments.

Failure to have all departments of the hospital evaluated thru the Quality Assurance program could potentially result in failure to ensure a high quality of care in all departments and the opportunity to address any concerns or problem areas were discussed and addressed.

Findings include:

1. Review of the Quality/TQM (Total Quality Monitor) Pillar Meeting minutes dated 7/17/14-7/16/15, lacked reporting from Employee Health and Outpatient Infusion Clinic.

Review of the Total Quality Management Reporting Schedule reviewed 8/13/15, lacked the inclusion of the Outpatient Infusion Clinic. Review of the undated Organization Chart showed it included the Outpatient Infusion Clinic as a department of the hospital.

2. During an interview on 8/4/15 at 11:00 Staff A, acknowledged the lack of Employee Health and Outpatient Infusion Clinic evaluations through the Quality Assurance program.

Based on document review, medical record review staff interviews, the Critical Access Hospital (CAH) failed to ensure inpatients and outpatients were informed of their 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 2 of 3 current swing bed patients (Patients # 1 and 2), 5 of 5 closed swing bed patients (Patients #3, 4, 5, 6, and 7) and outpatients. The CAH administrative staff reported a current census of 3 swing bed patients and approximately 321 outpatients a week receiving services.
Failure to provide all patients, including outpatients, with patient rights information could potentially result in limiting/restricting access of visitors to patients that infringed on the patients' right to have a support person present when they are provided any type of care services or treatments.

Findings include:

1. Review of the policy "Patient Visitation Rights" revised 12/2010 revealed in part... "2. Each patient (or support person) has the right, subject to his/her 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."

2. Review of documents "Resident Rights for Skilled Nursing Care and Rights and Responsibilities" revised 1/15/2002, provided to patients on admit to the CAH, revealed the documents lacked the documentation regarding his/her 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.

Review of documentation in Patient #1 and 2's, current patients, medical record, revealed the patient's signed they received a copy of the Patient Rights and Responsibilities information.

Review of documentation in Patient #3, 4, 5, 6, and 7's medical records, discharged patients, revealed the patients signed indicating they received a copy of the Patient Rights and Responsibilities information.

3. During an interview on 7/29/15 at 1:00 PM, Staff A, Director of Quality acknowledged the Patient Rights provided to the inpatients and and outpatients lacked the verbiage a domestic partner (including a same sex domestic partner), as stated in the CAH policy. The patients receiving these Patient Rights did not receive a complete set of rights.