HospitalInspections.org

Based on document review and staff interview, administrative staff failed to ensure the Governing Body approved medical staff appointment for 1 of 4 physicians prior to providing care to patients of the hospital (Physician D) .

At the time of the survey, the hospital employed one full-time psychiatrist and three part-time psychiatrists to furnish services to patients.

Failure of the Governing Body to approve privileges for all physicians after reviewing recommendations for reappointment by the Medical Staff allowed the physician to continue to practice at the hospital without review and approval by the hospital's Governing Body.

Findings include:

1. Review of the "Current List of Medical Staff Roster", dated 2/25/14, revealed the list contained 1 psychiatric physician that rotated weekend call, to provide patient care (Physician D).

Review of "By-laws of the Governing Body" dated 6/10, revealed in part, ..."The by-laws of the Governing Body are attached to this chapter (Operational Manual, By-laws, Rules and Regulations of Medical Staff).

Review of Medical Staff By-laws, Rules and Regulations, dated 6/13, revealed in part, ..."Recognizing that the Medical Staff has overall responsibility for the quality of all care provided patients at the Clarinda Treatment Complex, and for the ethical conduct and professional practices of its members as well as accounting therefor to the Governing Body, ...the members of the Medical Staff hereby adopt the By-Laws, Rules and Regulations hereinafter stated...appointment and reappointment to membership in the Medical Staff, the granting, renewal...and curtailment of privileges are all done by the Governing Body based upon the recommendations of the Medical Staff."

Review of the "Quality Improvement Plan" dated 7/13 revealed the Governing Body directed responsibility for assuring recommendations for approval of privileges and/or reappointments from the Medical Staff to the Governing Body for review and/or approval to the Quality Improvement Coordinator.

2. Review of Physician D's credential file on 2/26/14 at 10:40 AM revealed the credential file lacked evidence of approval by the governing body after recommendations by the medical staff for recredentialing Physician D on 10/7/13.

3. During an interview on 2/25/14 at 10:00 AM, Staff B, the administrative secretary/quality improvement coordinator stated she was responsible for ensuring all physician's credential files were reviewed and approved by both the Medical Staff and Governing Body. Staff B said she assumed responsibility for oversight of credential files for all physicians approximately 2 years ago.

During a follow-up interview on 2/25/14 at 3:55 PM, Staff B acknowledged Physician D's credential file lacked approval by the governing body.

During an interview on 2/25/14 at 4:15 PM, the Superintendent acknowledged the findings and stated they were going to be addressing the problems identified.

Based on medical record review, policy review and staff interview, the hospital failed to ensure patients (or support person where appropriate) were informed of their visitation rights, including the ability to receive designated visitors, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, for 6 of 6 current patient records reviewed. (Patient #1, 2, 3, 4, 5 and 6). The hospital had a census of 6 inpatients at the time of the survey.

Failure to inform patients of their visitation rights could potentially result patients not understanding their visitation rights and the ability to designate visitors or to decline visitors as desired.

Findings include:

1. Review of the brochure titled, "Patient's Rights", dated 2/13, provided to all patients upon admission to the hospital, lacked the patient's rights to receive designated visitors, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend.

2. Review of policy/procedure titled, "Rights and Responsibilities of Patients", dated 2/13, did revealed in part..."Each individual, and the individual's parent or guardian or legal representative, or family contact, shall receive an explanation of the individual's rights and responsibilities in a manner and format the recipient understands.

3. Review of documentation found in patients #1, 2, 3, 4, 5 and 6's medical records, revealed the patients' signed a copy of the Patient Rights and Responsibilities that lacked verbiage about a domestic partner (including a same-sex domestic partner).

4. During an interview on 2/24/14 at 4:30 PM, Staff A, Nursing Supervisor stated patients were notified of the rights on admit to the hospital, but the rights lacked documentation of the up-dated rights, including same-sex domestic partners.

Based on document review and staff interview, the administrative secretary/quality improvement coordinator failed to ensure 4 of 4 psychiatric physicians' credential files contained all required information (reference checks, National Practitoner's Data Bank (NPDB Query) at the time of their reappointment to the Medical Staff (Physicians A, B, C, and D).

Failure to assure the credential files of the hospital's psychiatric physicians included all of the required criteria and supporting documentation prior to the Medical Staff review, resulted in the recommendation by medical staff to the governing body regarding appointment or reappointment based on incomplete information.

At the time of the survey, the hospital employed one full-time psychiatrist and three part-time psychiatrists to furnish services to patients.

Findings include:

1. The "Current List of Medical Staff Roster", dated 2/25/14, included 3 psychiatric physicians that rotated weekend call for patients at the psychiatric hospital (Physician A and C) and 1 clinical director (Physician B).

2. The "Quality Improvement Plan", dated 7/13, revealed in part, ..."It is the policy of the Quality Improvement Program to be able to objectively and systematically monitor and evaluate the quality and appropriateness of patient care, to pursue opportunities to improve patient care...objectives: ...to provide a mechanism for monitoring and evaluating the quality and appropriateness of patient care...Medical Staff will perform the following functions: ...credentialing/privileging:.the goal shall be to evaluate the qualifications of the medical staff and oversee the credentialing, privileging, reappointment of Medical staff based upon qualifications, performance, and results of quality improvement findings."

The Quality Improvement plan directed the Quality Improvement Coordinator responsible for assuring reports to the Medical Staff prior to reappointment/approval to medical staff were submitted to the Medical Staff, Administration, and Governing Body and to collate data from monitoring and evaluation activities for presentation to the Medical Staff.

The Medical Staff By-laws, Rules and Regulations, dated 6/13, revealed in part, ...Recognizing that the Medical Staff has overall responsibility for the quality of all care provided patients at the Clarinda Treatment Complex, and for the ethical conduct and professional practices of its members as well as accounting therefor to the Governing Body, ...the members of the Medical Staff hereby adopt the By-Laws, Rules and Regulations hereinafter stated...appointment and reappointment to membership in the Medical Staff, the granting, renewal...and curtailment of privileges are all done by the Governing Body based upon the recommendations of the Medical Staff...privilege reveal shall be based upon the criteria for the appropriate discipline, and supporting documentation shall include: ...NPDB Query...references."


2. During an interview on 2/25/14 at 10:00 AM, Staff B, the administrative secretary/quality improvement coordinator stated she was responsible for the coordinating and review of criteria and supporting documentation for the medical staff review prior to reappointment/approval of credentialing by Governing Body. Staff B reported assuming responsibility for oversight of credential files for all physicians approximately 2 years ago.

3. On 2/26/14 at 10:40 AM, the review of the physicians' credential files, showed the files lacked the NPDB Query and/or the results of the reference checks at the time of the Medical Staff making a recommendation to the Governing Body.

a. Review of Physician A's credential file revealed the credential file lacked evidence of a NPDB query and reference checks prior to the Medical Staff recommendation and Governing Body re-credentialing on 10/25/12.

b. Review of Physician B's credential file revealed the credential file lacked evidence of NPDB query and reference checks prior to the Medical Staff and Governing Body re-credentialing on 7/24/12.

c. Review of Physician C's credential file revealed the credential file lacked evidence of NPDB query prior to the Medical Staff and Governing Body re-credentialing on 4/12/12.

d. Review of Physician D's credential file on 2/26/14 at 10:40 AM revealed the credential file lacked evidence of NPDB query prior to the Medical Staff re-credentialing on 10/7/13.

4. During a follow up interview on 2/25/14 at 3:55 PM, Staff B acknowledged the credential files for Physician A, B, C, and D lacked NPDB query reports and references. Staff B said she lacked knowledge of the availability of the NPDB query for the recredentialing process and confirmed she failed to include the query when the Medical Staff and Governing Body granted renewal on 4/12/12.

During an interview on 2/25/14 at 4:15 PM, the Superintendent acknowledged the findings and stated they were going to be addressing the problems identified.

Based on document review and staff interview, the psychiatric hospital lacked a signed agreement for obtaining water in the even of an emergency. The hospital had a census of 6 patients at the time of the survey.

Failure to have a signed agreement for emergency water could potentially result in the lack of water during an emergency situation.

Findings include:

Review of the documents provided by the hospital staff revealed the hospital lacked a signed agreement for obtaining water during an emergency event. The lack of such an agreement was identified as a deficiency during the last recertification survey.

During an interview on 2/25/14 at 3:30 PM, the Superintendent verified the hospital lacked a signed agreement to obtain water during an emergency.

I. Based on observation, review of records, and interview with staff the psychiatric hospital's dietary staff failed to ensure a kitchen free from dirt and food debris on floor fans, pots and pans, cooler fans, and large metal paddles used for stirring food.

The hospital had a census of 6 patients and the kitchen served 18 patient meals per day at the time of the survey.

Failure to ensure dietary staff maintained the kitchen environment, free of dirt and food debris could potentially contaminate food during preparation.

Findings include:

1. Observations during the initial tour of the kitchen with the Food Service Director on 2/24/14 at 1:05 PM, revealed the following concerns with the cleanliness of the kitchen:

a. 3 of 5 walk-in cooler fans, located on the back wall of the cooling units, contained black-brown debris on the outside surface and fan blades;

b. 2 of 2 large metal paddles, used for stirring foods during cooking, contained black-brown debris on the outside surfaces of the paddle that would be in contact with the food;

c. 2 of 5 floor fans in the dish room contained black-brown debris on the blades and the air flowing from the fans was blowing on the clean dishes; and

d. 100 of 200 stored pots and pans ready for use had dried-on food debris and black-brown debris on the cooking surface.

2. A review of policy and procedures revealed the hospital lacked of policies and procedures addressing the cleaning and maintenance of the walk-in cooler fans, metal paddles, floor fans, and pots and pans in the kitchen.

A review of the forms titled, Dietary Cleaning Schedules for January and February of this year, revealed weekly cleaning of the floor fans. The Dietary Cleaning Schedules lacked an space to enter the date staff cleaned the cooler fans.

3. During an interview on 2/24/14 at 4:15 PM, the Food Service Director acknowledged a lack of policies and procedures for the cleaning of the walk-in cooler fans, metal paddles, floor fans, and pots and pans and with the need for additional cleaning of these items. The Food Service Director reported cleaning of the cooler fans would be added to the Dietary Cleaning Schedules.



II. Based on observation, review of records, and interviews with staff, the psychiatric hospital's dietary staff failed to ensure chemicals used for degreasing pots and pans were not stored with food items in the bakery area of the kitchen.

The hospital had a census of 6 patients and the kitchen served 18 patient meals per day at the time of the survey.

Failure to ensure chemicals used for cleaning were stored separately from food items places food safety at risk.

Findings include:

1. During the initial tour of the kitchen with the Food Service Director on 2/24/14 at 1:05 PM, observations showed 2 spray containers of de-greaser (used for degreasing pots and pans) were stored in the bakery cupboard with baking powder, baking soda, and other food items.

2. A review of policy and procedures revealed the hospital lacked policies or procedures that addressed separate storage areas for the cleaning chemicals and food items.

3. During an interview on 2/24/14 at 4:15 PM, the Food Service Director acknowledged the hospital lacked any policies and procedures for separate storage of cleaning chemicals from food items and agreed the chemical de-greaser was stored with food items in the bakery area.