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RESTRICTED DELIVERY CERTIFIED MAIL

RETURN RECEIPT REQUESTED

Before the Iowa Department of Public Health

Pursuant to the provisions of Iowa Code Sections 17A.18, 147A.23 and Iowa Administrative

Code (I.A.C.) 641—134.3(1) the Iowa Department of Public Health is proposing to issue a

Citation and Warning to the Trauma Care Facility identified above.

The department may cite and warn a Trauma Care Facility when it finds that the facility has not

operated in compliance with Iowa Code section 147A.23 and 641 IAC Chapter 134 including:

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The following resulted in issuance of this proposed action:

On February 5, 2018 the facility submitted the Self-Assessment Categorization Application

(SACA). An on-site verification was conducted by a Department Trauma Facility Verification

team on March 2, 2018. The final report dated March 19, 2018 noted criteria deficiencies for

over-triage and under-triage reporting, bypass protocol, annual provider evaluations, trauma

activation, physician anesthesiologist liaison, multidisciplinary peer review meeting attendance,

registry concurrency, and disaster committee. These deficiencies were resolved before April

2019, including the following three deficiencies noted below:

Criteria (11-13) – The anesthesiology liaison to the trauma program must attend at least 50

percent of the multidisciplinary peer review meetings, with documentation by the trauma PIPS

program.

Deficiency – The anesthesiology liaison to the trauma program has not attended 50 percent of the

multidisciplinary peer review meetings.

Resolution – Provide electronic documentation to the State of Iowa Trauma Nurse Coordinator

which demonstrates a 50% or greater attendance record to the multidisciplinary trauma peer

review committee by the anesthesiology liaison 12 months from the date of this final report.

least 50% of meetings 12 months from the date of this final report.

On February 15, 2021 the facility submitted the SACA. A virtual on-site verification was

conducted by a Department Trauma Facility Verification team on April 19, 2021. During the

April 19, 2021 virtual on-site verification survey the following three deficiencies were noted on

the verification team report:

Criteria (11-12) – In Level III trauma centers participation in the trauma PIPS program by the

anesthesia liaison is essential.

Deficiency – The anesthesia liaison has not participated in the trauma PIPS program

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Criteria (11-13) – The anesthesiology liaison to the trauma program must attend at least 50

percent of the multidisciplinary peer review meetings, with documentation by the trauma PIPS

program.

Deficiency – The anesthesiology liaison to the trauma program has not attended 50 percent of the

multidisciplinary peer review meetings.

Resolution – Provide electronic documentation to the State of Iowa Trauma Nurse Coordinator

which demonstrates a 50% or greater attendance record to the multidisciplinary trauma peer

review committee by the anesthesiology liaison 12 months from the date of this final report.

Deficiency – Each member of the committee has not attended at least 50% of all

multidisciplinary trauma peer review committee meetings.

Resolution – Provide electronic documentation to the State of Iowa Trauma Nurse Coordinator

which demonstrates each member of the multidisciplinary peer review committee attending at

least 50% of meetings 12 months from the date of this final report.

The facility failed to fully resolve the deficiencies related to anesthesia liaison participation in

the multidisciplinary PIPS program criteria following the 2018 survey and the facility remains

noncompliant with this criteria as demonstrated in the 2021 verification survey.

Deficiency – The facility has not provided the trauma program manager the necessary time or

additional personnel to carry out the functions of the program.

Resolution – Provide electronic documentation to the State of Iowa Trauma Nurse Coordinator

which demonstrates an increase in FTE to support the TPM role 12 months from the date of this

final report.

Criteria (15-3) – The trauma registry is essential to the performance improvement and patient

safety (PIPS) program and must be used to support the PIPS process.

Deficiency – The trauma registry is not used to support the PIPS process.

Resolution – Provide electronic documentation to the State of Iowa Trauma Nurse Coordinator

which demonstrates use of the trauma registry to identify injury prevention priorities that are

appropriate for local implementation 12 months from the date of this final report.

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Resolution – Provide electronic documentation to the State of Iowa Trauma Nurse Coordinator

which demonstrates use of the trauma registry findings to identify injury prevention priorities

that are appropriate for local implementation 12 months from the date of this final report.

Criteria (18-1) – Trauma centers must have an organized and effective approach to injury

prevention and must prioritize those efforts based on local trauma registry and epidemiologic

data.

Deficiency – The trauma center does not have an organized and effective approach to injury

prevention that is prioritized based on the local trauma registry.

Resolution – Provide electronic documentation to the State of Iowa Trauma Nurse Coordinator

date of this citation and warning may result in further disciplinary action including suspension or

revocation of the Trauma Care Facility Designation.

request for a hearing must be submitted in writing to the Department by certified mail, return

receipt requested, within twenty (20) days of receipt of this Notice of Proposed Action. The

written request must be submitted to the Iowa Department of Public Health, Bureau of

Emergency and Trauma Services, Lucas State Office Building, 321 E 12

50319. If the request is made within the twenty (20) day time limit, the proposed action is

suspended pending the outcome of the hearing. Prior to or at the hearing, the Department may

If no request for a hearing is received within the twenty (20) day time period, the

_____________________________________ __May 7, 2021_

Rebecca Curtiss Date