Mitchell County hospital cited and warned by state regulators

State regulators have issued a warning to a Mitchell County hospital for alleged violations of trauma-center standards.

According to records of the Iowa Department of Health and Human Services’ Bureau of Emergency and Medical Trauma Services, a “virtual on-site verification” of services at the Mitchell County Regional Health Center was conducted in February 2022 after the hospital submitted an application for self-assessment to the state.

As a result of that inspection, five deficiencies were noted:

Corrective-action plans: The trauma medical director and trauma program manager failed to work together with the trauma peer review committee to develop corrective-action plans for deficiencies in care. The state found that “methods to ensure monitoring, reevaluation, and benchmarking” were not being documented.

Injury prevention: Findings from the trauma registry were not being used to identify injury prevention priorities for implementation.

Identifying events for corrective action: The hospital’s trauma program had no documentation of “event identification” and levels of review that would result in the development of corrective action plans.

Quality improvement: All elements of the hospital’s Trauma Performance Improvement and Patient Safety program – intended to enhance the quality of trauma care and ensure patient safety – were not being reviewed and updated at least annually.

Data used for injury prevention: The hospital’s injury prevention efforts were not being prioritized based on local trauma and epidemiologic data.

The hospital was given one year to correct the five deficiencies, all of which were deemed to be fully resolved in January 2023.

In November 2024, the hospital submitted another self-assessment application and in April 2025, a “virtual verification” inspection was conducted by a team of individuals with three additional deficiencies noted by the bureau:

Patient-transfer plans: The hospital did not have collaborative treatment and transfer guidelines that were regularly reviewed with input from higher-level trauma centers in the region. The hospital was given one year to correct the problem.

Brain-death criteria: All trauma centers are required to have written protocols defining the clinical criteria and confirmatory tests to diagnose brain death. The bureau alleges the hospital has failed to meet this standard. The hospital was given one year to correct the problem.

Corrective-action plans: While the trauma center was deemed efficient at identifying events that required corrective action, it failed to adequately develop corrective action plans and establish mechanisms for monitoring, reevaluation and benchmarking. While the bureau’s report indicates that a focused site visit is to be conducted within six to 12 months to determine whether this particular issue has been addressed, the report also states that the hospital currently “remains noncompliant” with this standard.

As a result of the findings, the bureau has issued the hospital a citation and warned the hospital that if it continues to fail to meet trauma-center standards after one year, further disciplinary action, including suspension or revocation of the hospital’s trauma care facility designation, may be imposed.

In a written statement, Beth Trees, chief nursing officer at Mitchell County Regional Health Center, said the hospital is “refining our peer review process in collaboration with our providers and will work closely with the state. Mitchell County Regional Health Center is proud of the high-quality emergency care we provide and confident in the services our team delivers.”

This article first appeared in the Iowa Capital Dispatch.