HospitalInspections.org

Based on document review and staff interview, the acute care hospital's administrative staff failed to ensure the Medical Staff followed their Bylaws/Rules and Regulations for admitting patients only under the order of a physician and ensuring that Nurse Practitioners did not admit patients without admission privileges approved by the Governing Board. Please refer to A-0047.

The cumulative effect of these failures and deficient practices resulted in the Governing Board's inability to ensure the hospital staff provided safe care for all patients. The hospital's administrative staff identified a census of 29 patients at the beginning of the investigation.

Based on document review and staff interview, the acute care hospital's administrative staff failed to ensure the Medical Staff followed their Bylaws/Rules and Regulations for admitting patients only under the order of a physician and ensuring that Nurse Practitioners did not admit patients without admission privileges approved by the Medical Staff. Please refer to A-0341.

The cumulative effect of these failures and deficient practices resulted in the Medical Staff's inability to follow the hospital's Medical Staff Bylaws. The hospital's administrative staff identified a census of 29 patients at the beginning of the investigation.

Based on document review and staff interviews, the Governing Board failed to ensure the Medical Staff followed the Medical Staff Bylaws/Rules and Regulations which required a physician admit all patients to the hospital for 14 of 19 patient medical records reviewed (Patient #1, Patient #4, Patient #5, Patient #6, Patient #9, Patient #10, Patient #11, Patient #12, Patient #13, Patient #14, Patient #16, Patient #17, Patient #18, and Patient #19). Failure to follow the Medical Staff Bylaws/Rules and Regulations requiring a physician to write the admission order could potentially result in the patient being admitted to the hospital by an individual without the training identified by the medical staff to ensure the patients received adequate pre-admission assessment and care. The hospital administrative staff identified a current census of 29 patients at the beginning of the survey.

Findings include:

1. Review of the hospital's "Bylaws of the Medical Staff," dated 2021, approved by the Medical Staff 1/22/2021 and approved by the Governing Board 2/8/2021, revealed in part as follows:

"Members of the active staff are appointed to a specific service area. They have primary duties and responsibilities for patient care and clinical education including, admission and discharge of patients, and are entitled to exercise those clinical privileges granted to them by the terms of their appointment or reappointment. Independent patient admission privileges at EAGLE VIEW BEHAVIORAL HEALTH shall only be granted to those currently licensed Doctor of Medicine or Osteopathy. Allied Health Professionals ("AHP") may exercise only those privileges granted to them."

"The following definitions apply to terms used in the bylaws: 1. Allied Health Professional or AHP - means an individual, other than a licensed physician, who exercises independent judgment within the areas of his or her professional competence and the limits established by the Governing Board, the Medical Staff, and applicable federal and State laws; who is licensed or certified to render direct or indirect medical care; and who may be eligible to exercise privileges and prerogatives in conformity with the rules of the Medical Staff and these Bylaws. For the purposes of these Bylaws, this definition shall include, but is not limited to nurse practitioners ("NP") and physician assistant ("PA") ... 6. Clinical Privileges - means the specific permission granted to a practitioner by the Board, based on staff recommendations in accordance with these bylaws, rules and regulations, to provide medical or other patient care services in the hospital whether in person or through the use of any medium (including an electronic medium)."

Review of the hospital's "Medical Staff Rules and Regulations," dated 2021, approved by the Medical Staff 1/22/2021 and approved by the Governing Board 2/8/2021, revealed in part, "Admission of the Patient. The Facility will admit (by order of a physician who is a member of the active medical staff) patients suffering from all types and psychiatric illness...."

2. Review of the hospital's "Governing Board Bylaws," dated 2021, revealed in part, "Final action on all matters relating to Staff status, clinical privileges and corrective action shall be taken by the Board and documented in writing ... The terms and conditions of staff status in the Medical Staff, and of the exercise of clinical privileges, shall be as specified in the Medical Staff bylaws."

3. Review of the hospital policy "Assessment and Referral: Pre-Admission Screening and Admission Process," dated 6/12/20, revealed in part, "Patients will be admitted to any level of care in the continuum only on the order of a physician or licensed provider with admitting privileges ..."


4. Review of credential files revealed the following:

a. The Medical Staff approved Nurse Practitioner A's privileges on 6/17/20 and the Governing Board approved Nurse Practitioner A's privileges on 6/17/20. Nurse Practitioner A's credential file lacked evidence the Medical Staff or Governing Board approved Nurse Practitioner A to admit patients to the hospital.

b. The Medical Staff approved Nurse Practitioner B's privileges on 6/27/20 and the Governing Board approved Nurse Practitioner B's privileges on 6/27/20. Nurse Practitioner B's credential file lacked evidence the Medical Staff or Governing Board approved Nurse Practitioner B to admit patients to the hospital.

c. The Medical Staff approved Nurse Practitioner C's privileges on 9/29/20 and the Governing Board approved Nurse Practitioner C's privileges on 9/17/20. Nurse Practitioner C's credential file lacked evidence the Medical Staff or Governing Board approved Nurse Practitioner C to admit patients to the hospital.

d. The Medical Staff approved Nurse Practitioner E's privileges on 6/17/20 and the Governing Board approved Nurse Practitioner E's privileges on 6/17/20. Nurse Practitioner E's credential file lacked evidence the Medical Staff or Governing Board approved Nurse Practitioner E to admit patients to the hospital.

e. The Medical Staff approved Nurse Practitioner F's privileges on 6/17/20 and the Governing Board approved Nurse Practitioner F's privileges on 6/17/20. Nurse Practitioner F's credential file lacked evidence the Medical Staff or Governing Board approved Nurse Practitioner F to admit patients to the hospital.


5. Review of patient medical records revealed the following:

a. Nurse Practitioner A admitted Patient #5 to the hospital on 5/17/21.
b. Nurse Practitioner A admitted Patient #12 to the hospital on 4/12/21.
c. Nurse Practitioner A admitted Patient #16 to the hospital on 5/2/21.
d. Nurse Practitioner A admitted Patient #18 to the hospital on 5/11/21.
e. Nurse Practitioner B admitted Patient # 9 to the hospital on 3/17/21
f. Nurse Practitioner C admitted Patient #1 to the hospital on 5/7/21.
g. Nurse Practitioner C admitted Patient #6 to the hospital on 5/18/21.
h. Nurse Practitioner E admitted Patient #10 to the hospital on 3/26/21.
i. Nurse Practitioner F admitted Patient #4 to the hospital on 5/16/21.
j. Nurse Practitioner F admitted Patient #11 to the hospital on 4/19/21.
k. Nurse Practitioner F admitted Patient #13 to the hospital on 3/26/21.
l. Nurse Practitioner F admitted Patient #14 to the hospital on 5/2/21.
m. Nurse Practitioner F admitted Patient #19 to the hospital on 5/14/21.




6. During an interview on 5/26/2021 at 3:50 PM, the Chief Executive Officer (CEO) acknowledged the Medical Staff Rules and Regulations required only physicians to admit patients to the hospital, and did not allow Nurse Practitioners to admit patients to the hospital.


7. During an interview on 5/27/2021 at 11:40 AM, the CEO and Executive Assistant, upon review of requested and approved privileges for nurse practitioners, acknowledged the privileges for nurse practitioners did not include admitting privileges.

Based on review of policies, documents, patient medical records, and staff interviews, the hospital quality failed to implement corrective measures to address the timeliness of the medical staff entering orders after they determined a patient required admission to the hospital for 16 of 19 patient medical records reviewed (Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12, Patient #13, Patient #14, Patient #15, Patient #16, and Patient #17). Failure of the medical staff to enter orders in a timely manner could potentially result in the nursing staff lacking orders to provide care to the hospital's patients while waiting on the medical staff providers to enter the orders. The hospital administrative staff identified a current census of 29 patients at the beginning of the survey.

Findings include:

1. Review of the hospital's "Quality/Performance Improvement Plan Overview of the Program," dated 2021, revealed in part, "The purpose of this Quality/Performance Improvement Plan is to describe the program that is used to systematically design, assess, monitor, and improve processes, structures, outcomes, and patient safety at Eagle View Behavioral Health. This program is designed to provide a consistent, systematic evaluation of performance/processes across departments/services. The goal of the Performance Improvement Program at Eagle View Behavioral Health is to improve the safety and quality of care, treatment, and services at the Hospital by monitoring, aggregating, analyzing, and comparing data and using the data to make improvements, as appropriate...."

2. Review of the agreement with "Integrated Telehealth Partners," dated 8/1/20, revealed in part, "[Strategic Behavioral Health] manages inpatient psychiatric services at Eagle View Behavioral Health (Hospital) located in Bettendorf, Iowa and SBH wished to develop, manage, and administer a network of contracted physicians and other healthcare providers to ensure the availability of high-quality, cost-effective professional medical and psychiatric services through telehealth technology to its patients ... All medical records produced by Physician/NP/PA shall be promptly signed and dated by the Physician/NP/PA responsible for ordering, providing, or evaluating the service furnished. This includes, but is not limited to, timely Hospital inpatient admission orders...."

The agreement failed to define timely admission orders.

3. During an interview on 5/27/2021 at 9:25 AM, the Medical Director identified they expected the medical staff members to enter patient admission orders within 20 to 30 minutes.


4. Review of patient medical records for patients admitted between 2/5/2021 and 5/18/2021 revealed the following:

a. The medical staff admitted Patient #14 to the hospital on 5/2/21 at 6:25 PM. The medical staff entered Patient #14's admission orders on 5/2/21 at 11:33 PM (8 hours and 8 minutes after Patient #14's admission.

b. The medical staff admitted Patient #8 to the hospital on 2/5/21 at 3:36 PM. The medical staff entered Patient #8's admission orders on 2/5/21 at 11:41 PM (8 hours and 5 minutes after Patient #8's admission).

c. The medical staff admitted Patient #11 to the hospital on 4/9/21 at 12:19 PM. The medical staff entered Patient #11's admission orders on 6:24 PM (4 hours and 37 minutes after Patient #11's admission).

d. The medical staff admitted Patient #13 to the hospital on 3/26/21 at 10:31 AM. The medical staff entered Patient #13's admission orders on 3/26/21 2:08 PM (4 hours and 37 minutes after Patient #13's admission).

e. The medical staff admitted Patient #15 to the hospital on 3/28/21 at 3:10 AM. The medical staff entered Patient #15's admission orders on 3/28/21 at 6:47 AM (3 hours and 57 minutes after Patient #15's admission).

f. The medical staff admitted Patient #5 to the hospital on 5/17/21 at 3:23 PM. The medical staff entered Patient #5's admission orders on 5/17/21 at 6:25 PM (3 hours and 22 minutes after Patient #17's admission).

g. The medical staff admitted Patient #17 to the hospital on 5/28/21 at 12:44 PM. The medical staff entered Patient #17's admission orders on 5/28/21 at 3:34 PM (2 hours and 50 minutes after Patient #17's admission).

h. The medical staff admitted Patient #9 to the hospital on 3/17/21 at 2:30 PM. The medical staff entered Patient #9's admission orders on 3/17/21 at 5:20 PM (2 hours and 50 minutes after Patient #9's admission).

i. The medical staff admitted Patient #3 to the hospital on 5/10/21 at 11:16 AM. The medical staff entered Patient #3's admission orders on 5/10/21 at 2:02 PM (2 hours and 48 minutes after Patient #3's admission).

j. The medical staff admitted Patient #4 to the hospital on 5/16/21 at 9:58 AM. The medical staff entered Patient #4's admission orders on 5/16/21 at 12:25 PM (2 hours and 27 minutes after Patient #4's admission).

k. The medical staff admitted Patient #10 to the hospital on 3/26/21 at 6:16 PM. The medical staff entered Patient #10's admission orders on 3/26/21 at 7:56 PM (1 hour and 40 minutes after Patient #10's admission).

l. The medical staff admitted Patient #12 to the hospital on 4/21/21 at 7:04 PM. The medical staff entered Patient #12's admission orders on 4/21/21 at 8:37 PM (1 hour and 33 minutes after Patient #12's admission).

m. The medical staff admitted Patient #6 to the hospital on 5/18/21 at 02:02 AM. The medical staff entered Patient #6's admission orders on 5/18/21 at 3:35 AM (1 hour and 33 minutes after Patient #6's admission).

n. The medical staff admitted Patient #7 to the hospital on 4/19/21 at 4:00 PM. The medical staff entered Patient #6's admission orders on 4/19/21 at 5:20 PM (80 minutes after Patient #7's admission).




5. During an interview on 5/26/2021 at 9:10 AM, the Director of Quality & Risk Management revealed the hospital's quality improvement staff had identified the medical staff took longer then 30 minutes to enter admission orders for patients. However, the quality improvement staff had not developed a system to track how long it took the medical staff to enter patient admission orders, had not collected any data regarding how long it took the medical staff to enter patient admission orders, nor had the quality improvement staff implemented any interventions to address the extended times it took the medical staff to enter patient admission orders.

Based on document review and staff interviews, the Medical staff failed to ensure the Medical Staff followed the Medical Staff Bylaws/Rules and Regulations which required a physician admit all patients to the hospital for 14 of 19 patient medical records reviewed (Patient #1, Patient #4, Patient #5, Patient #6, Patient #9, Patient #10, Patient #11, Patient #12, Patient #13, Patient #14, Patient #16, Patient #17, Patient #18, and Patient #19). Failure to follow the Medical Staff Bylaws/Rules and Regulations requiring a physician to write the admission order could potentially result in the patient being admitted to the hospital by an individual without the training identified by the medical staff to ensure the patients received adequate pre-admission assessment and care. The hospital administrative staff identified a current census of 29 patients at the beginning of the survey.

Findings include:

1. Review of the hospital's "Bylaws of the Medical Staff," dated 2021, approved by the Medical Staff 1/22/2021 and approved by the Governing Board 2/8/2021, revealed in part as follows:

"Members of the active staff are appointed to a specific service area. They have primary duties and responsibilities for patient care and clinical education including, admission and discharge of patients, and are entitled to exercise those clinical privileges granted to them by the terms of their appointment or reappointment. Independent patient admission privileges at EAGLE VIEW BEHAVIORAL HEALTH shall only be granted to those currently licensed Doctor of Medicine or Osteopathy. Allied Health Professionals ("AHP") may exercise only those privileges granted to them."

"The following definitions apply to terms used in the bylaws: 1. Allied Health Professional or AHP - means an individual, other than a licensed physician, who exercises independent judgment within the areas of his or her professional competence and the limits established by the Governing Board, the Medical Staff, and applicable federal and State laws; who is licensed or certified to render direct or indirect medical care; and who may be eligible to exercise privileges and prerogatives in conformity with the rules of the Medical Staff and these Bylaws. For the purposes of these Bylaws, this definition shall include, but is not limited to nurse practitioners ("NP") and physician assistant ("PA") ... 6. Clinical Privileges - means the specific permission granted to a practitioner by the Board, based on staff recommendations in accordance with these bylaws, rules and regulations, to provide medical or other patient care services in the hospital whether in person or through the use of any medium (including an electronic medium)."

Review of the hospital's "Medical Staff Rules and Regulations," dated 2021, approved by the Medical Staff 1/22/2021 and approved by the Governing Board 2/8/2021, revealed in part, "Admission of the Patient. The Facility will admit (by order of a physician who is a member of the active medical staff) patients suffering from all types and psychiatric illness...."

2. Review of the hospital's "Governing Board Bylaws," dated 2021, revealed in part, "Final action on all matters relating to Staff status, clinical privileges and corrective action shall be taken by the Board and documented in writing ... The terms and conditions of staff status in the Medical Staff, and of the exercise of clinical privileges, shall be as specified in the Medical Staff bylaws."

3. Review of the hospital policy "Assessment and Referral: Pre-Admission Screening and Admission Process," dated 6/12/20, revealed in part, "Patients will be admitted to any level of care in the continuum only on the order of a physician or licensed provider with admitting privileges ..."


4. Review of credential files revealed the following:

a. The Medical Staff approved Nurse Practitioner A's privileges on 6/17/20 and the Governing Board approved Nurse Practitioner A's privileges on 6/17/20. Nurse Practitioner A's credential file lacked evidence the Medical Staff or Governing Board approved Nurse Practitioner A to admit patients to the hospital.

b. The Medical Staff approved Nurse Practitioner B's privileges on 6/27/20 and the Governing Board approved Nurse Practitioner B's privileges on 6/27/20. Nurse Practitioner B's credential file lacked evidence the Medical Staff or Governing Board approved Nurse Practitioner B to admit patients to the hospital.

c. The Medical Staff approved Nurse Practitioner C's privileges on 9/29/20 and the Governing Board approved Nurse Practitioner C's privileges on 9/17/20. Nurse Practitioner C's credential file lacked evidence the Medical Staff or Governing Board approved Nurse Practitioner C to admit patients to the hospital.

d. The Medical Staff approved Nurse Practitioner E's privileges on 6/17/20 and the Governing Board approved Nurse Practitioner E's privileges on 6/17/20. Nurse Practitioner E's credential file lacked evidence the Medical Staff or Governing Board approved Nurse Practitioner E to admit patients to the hospital.

e. The Medical Staff approved Nurse Practitioner F's privileges on 6/17/20 and the Governing Board approved Nurse Practitioner F's privileges on 6/17/20. Nurse Practitioner F's credential file lacked evidence the Medical Staff or Governing Board approved Nurse Practitioner F to admit patients to the hospital.


5. Review of patient medical records revealed the following:

a. Nurse Practitioner A admitted Patient #5 to the hospital on 5/17/21.
b. Nurse Practitioner A admitted Patient #12 to the hospital on 4/12/21.
c. Nurse Practitioner A admitted Patient #16 to the hospital on 5/2/21.
d. Nurse Practitioner A admitted Patient #18 to the hospital on 5/11/21.
e. Nurse Practitioner B admitted Patient # 9 to the hospital on 3/17/21
f. Nurse Practitioner C admitted Patient #1 to the hospital on 5/7/21.
g. Nurse Practitioner C admitted Patient #6 to the hospital on 5/18/21.
h. Nurse Practitioner E admitted Patient #10 to the hospital on 3/26/21.
i. Nurse Practitioner F admitted Patient #4 to the hospital on 5/16/21.
j. Nurse Practitioner F admitted Patient #11 to the hospital on 4/19/21.
k. Nurse Practitioner F admitted Patient #13 to the hospital on 3/26/21.
l. Nurse Practitioner F admitted Patient #14 to the hospital on 5/2/21.
m. Nurse Practitioner F admitted Patient #19 to the hospital on 5/14/21.




6. During an interview on 5/26/2021 at 3:50 PM, the Chief Executive Officer (CEO) acknowledged the Medical Staff Rules and Regulations required only physicians to admit patients to the hospital, and did not allow Nurse Practitioners to admit patients to the hospital.


7. During an interview on 5/27/2021 at 11:40 AM, the CEO and Executive Assistant, upon review of requested and approved privileges for nurse practitioners, acknowledged the privileges for nurse practitioners did not include admitting privileges.