HospitalInspections.org

The Condition of Physical Plant and Environment at 485.623 is NOT met as evidenced by the failure of the facility to ensure compliance with the applicable provisions of the 2000 life safety code relating to penetrations in the firebarrier walls, lack of evidence of testing of emergency lighting, exit egresses allowed access to the common way, relative humidity in the operating room was not maintained to provide humidity levels at 35% or greater, smoke detectors located in areas where air flow could prevent normal functioning of the detectors, portable fire extinguishers lack evidence of monthly checks and lacked evidence of weekly testing and monthly load testing of the emergency generator. This was determined by observation and staff interview. The facility census was 9 at the time of the survey.

Findings include:

Please see C228 relating to emergency lighting cited at K46 in the Northfield Medical building which was toured by Staff G and the surveyor on 01/13/10.

Please see C231 relating to the seven other deficiencies cited , five in the main hospital and two others at the satellite location. These observations were verified by Staff G during the tour of the main hospital on 01/12/10 and the satellite location on 01/13/10.

Based on observation and staff interview, the facility did not assure that emergency lighting would be available if needed in building 2 of 2, a satellite of the hospital.

Findings include:

A tour of Northfield Medical Center was conducted on 01/13/10 by the surveyor while accompanied by Staff G, the plant operations director. No documentation for verification of testing of the emergency egress lights was provided for surveyor review when requested. This was cited at K46 in the life safety code. This finding was verified by Staff G on 01/13/10.

Based on observation and staff interview, the facility did not meet the applicable provisions of the 2000 edition of the life safety code relating to penetrations in the fire barriers, lack of paved access to the common way from the exit egresses, relative humidity in the three operating rooms not maintained at 35% or greater at all times, smoke detectors located in areas where air flow could intefer with the functioning of the smoke detectors, lack of evidence portable fire extinguishers were checked monthly and lack of evidence of weekly testing and monthly load testing of the emergency generator in 2 of 2 buildings inspected.

Findings include:

1. Penetrations were observed in fire barriers. This includes door not latching. Both findings were found in the main hospital (Building 1 of 2) and were cited at K11 in the life safety code.

2. Penetrations were observed in smoke barriers in the main hospital and were cited at K25 in the life safety code.

3. During the life safety tour of the main hospital on 01/12/10, no paved access from the exit egress to common way from the main hospital was observed and cited at K38 in the life safety code.

4. Per review of humidity logs kept for the 3 operating rooms in the main hospital on 01/11/10, humidity levels were not maintained between 35-60%. This was cited at K78 in the life safety code.

5. Per observation during the tour of the facility on 01/12/10, smoke detectors were located where air flow might prevent normal functioning in the main hospital. This was cited at K130.

All of these findings were verified by Staff G, the plant operations director,who accompanied the surveyor throughout the facility tour on 01/12/10.

Findings in building 2 of 2, Northfield Medical Center were observed on 01/13/10 and include the following:

1. K46 No documentation for testing emergency egress lights was provided for surveyor review.

2. K64 Documentation was not provided for the surveyor's review which verified portable fire extinguishers were checked monthly.

3. K144 Documentation for weekly and monthly emergency generator checks and load tests were not provided for surveyor review to ensure appropriate testing was being conducted.

These findings were verified by Staff G on 01/13/10 during the tour of building 2 of 2 and on 01/14/10 at 1:30 PM by Staff A, the facility's chief executive officer.

Based on observation, staff interview and medical record review the facility failed to implement a policy that differentiated the level of care a patient would receive in the Intensive Care Unit (ICU) and the Progressive Care Unit (PCU) and/or the types of patients that are appropriate for each area. This includes Patient #2. The facility census was 9 at the time of the survey.

Findings Include:

Medical record review conducted on 01/13/10 at 11:50 AM revealed that Patient #2 was admitted on 01/10/10 to the Progressive Care Unit (PCU) with Hyperglycemia, Renal Insufficiency and Electrolyte Imbalance. While conducting a tour of the Intensive Care Unit (ICU) area on 01/11/10 at 11:55 AM , Staff E was asked why, due to the absence of a visible rhythm on the bedside monitor, was Patient #2 connected to a heart monitor. Staff E stated "patient is admitted as a PCU patient so portable monitor is used, not the ICU bedside monitor". The policy regarding care of the PCU and ICU patients was requested for review. On 01/13/10 at 11:45 AM the surveyor met with Staff E and Staff T regarding the difference between PCU and ICU. Staff T stated "PCU is for cardiology such as patients diagnosed with Atrial Fibrillation or any new cardiology or respiratory problems." Staff T was further questioned about guidelines for the physicians in determining whether PCU or ICU would be most appropriate for their patients, Staff E stated "Physicians determine where their patients are to be admitted and that is based on the physician's years of training". Further interview with Staff E and T revealed there are no specific policies in place that provide nursing staff with guidelines on how to provide care to the ICU or PCU patients.

Based on observation and staff interview the facility failed to ensure that unlabeled medications/biologicals were stored and labeled and/or discarded to ensure they were not available for patient use. The facility's census was 9 at the time of the survey.

Findings Include:

Tour of Operating Suites 1, 2 and 3 conducted on 1/12/10 at 10:00 AM revealed medications/biologicals that were used by the facility for multi patient use were not labeled with the date and time they had been opened. O.R. #2 contained 2 (two) bottles of isopropyl rubbing alcohol 70% that had been opened and not dated or timed and stored in the cabinets for further patient use. OR #3 contained a bottle of sterile water used for irrigation that had been opened and not dated and timed. OR #1 contained one bottle of isopropyl rubbing alcohol 70% that had been opened and not dated or timed and stored in a cabinet. This was confirmed by Staff E at 11:00 AM.

Based on observation, staff interview, review of the medical record and policy and procedure it was determined that the facility failed to ensure that staff adhered to current policies and procedures regarding patient care and to ensure patients were adequately assessed, and monitored in accordance with the patients needs. This involved Patient #2 in the progressive care unit and Patients #5, # 6 and #7 in the emergency room. The facilitys census was 9 at the time of the survey.

Findings Include:

Chart review conducted on 01/11/10 at 3:00 PM of Patient #2 revealed that the patient had three episodes of asystole (absence of a heartbeat) lasting between 4-5 seconds. On 01/10/10 the patient had an episode of asystole at 9:44 PM. A second and third episode was also noted on 01/11/10 at 6:50 AM and at 7:56 AM. Review of correlating nursing documentation for all three of these episodes lacks any notation that these periods of asystole had occurred and contained no indication that the physician was notified of a change in the patient' status. Staff interview conducted on 01/12/10 at 3:00 PM with Staff V revealed that "no one sits and watches the monitors, unit clerks are not monitor trained. Monitor strips are run once per shift and evaluated for PCU patients and once per hour for ICU patients and before and after administration of cardiac medications". Staff interview conducted on 01/13/10 at 11:50 AM with Staff U revealed that the parameters for cardiac monitoring are set to alarm for a heart rate at or lower that 45 beats per minute (bpm) and at or higher than 150 bpm. The cardiac monitor can be set to print automatically for periods of arrythmia, but Staff U stated that "it is unclear if this is what it was set on during the patient's periods of asystole".

Chart review of Emergency Department (E.D.) patients conducted on 1/12/10 at 1:25 PM revealed that three out of six records lacked frequent reassessment as per policy. This involved Patients #5, 6 and 7. Per review of the medical record of Patient #5, the patient arrived in the E.D. on 01/10/10 at 11:42 PM. Triage and nursing assessment was completed at 12:05 AM on 01/11/10 and the patient was assigned a triage Level of 3. No further documentation was present on the medical record to indicate that the patient was reassessed until the discharge time of 2:05 AM.

Per medical record review, Patient #6 arrived in the E.D. on 01/11/10 at 11:30 AM with a complaint of dropping objects and unable to stay awake. The patient was assessed and triaged at 11:35 AM as a Level 4. No further documentation of vital signs was found from the initial assessment until discharge at 2:50 PM.


Per medical record review, Patient #7 arrived at the E.D. on 01/12/10 at 6:28 AM with a complaint of chills, increased weakness and feeling jittery. At the time of triage, Patient #7 was assessed as meeting criterion for Level 3. Patient #7 had vital signs documented at frequent intervals during the E.D. stay but no further nursing reassessment documentation was evident in the medical record.

These findings were confirmed by Staff M at 2:25 PM. on 01/13/10.

Per review of facility policy and procedures entitled "Emergency Department Assessment and Reassessment Intervals" policy #ED-207, this policy discussed the frequency of reassessment and taking of vital signs as follows:

"1. All patients will have an assessment and focused reassessments in accordance to the ESI standards for acuity classification.

3. Vital signs will be taken every 5-15 minutes on all unstable patients or even more frequently depending on their stability.

ESI 1- every 5-15 minutes vital signs and assessment.
ESI 2-every one hour vital signs and assessment.
ESI 3-every two hours vital signs and assessment.
ESI 4 & 5- vital signs and assessment as needed.

Based on medical record review, staff interview and review of hospital policy and procedure it was determined the facility failed to develop a nursing care plan for skin breakdown and/or follow a nursing care plan for skin breakdown. This affected three patients (Patients # 9, 12 and 14). The sample size was 29 patients.

Findings include:

The medical record review for Patient # 9 was completed 01/14/10. The patient was admitted to the facility on 10/21/09 with a diagnosis of aspiration pneumonia. Upon admission to the acute care floor, nursing staff noted a decubitus ulcer on the patient's coccyx and on both heels. A pressure ulcer risk assessment at admission scored the patient as a "7", which put the patient in the high risk category. A care plan developed by the nursing staff at the time of admission determined the patient should be turned and repositioned every two hours as a comfort standard. The nursing care plan lacked an intervention for the integumentary (skin) standard. The nursing staff documented repositioning of the patient every two hours throughout his/her hospital admission until 3:10 AM on 10/27/09. The patient was discharged from the facility 10/27/09 at 2:55 PM. The record did not indicate whether the patient had been repositioned during the last 12 hours of his/her hospital stay as per the nursing care plan. This finding was verified with Staff E on 1/14/10 at 4:05 PM.

The medical record review for Patient # 12 was completed 01/14/10. The patient was admitted to the facility on 12/26/09 with a diagnosis of difficulty breathing/possible aspiration pneumonia. Upon admission to the acute care floor, nursing staff noted decubitus ulcers on both sides of the patient's coccyx. A pressure ulcer risk assessment at admission scored the patient as a "13", which put the patient in the moderate risk category. A care plan, developed by the nursing staff at the time of admission, determined the patient should be turned and repositioned every two hours as a comfort standard and an integumentary standard. Nursing documentation noted the patient was repositioned on 12/27/09 at 10:20 AM and 4:30 PM during the 7:00 AM to 7:00 PM shift, no repositioning was documented on 12/28/09 during the 7:00 AM to 7:00 PM shift and on 12/29/09 during the 7:00 AM to 7:00 PM shift the patient was repositioned one time at 8:30 AM. The patient was discharged back to an extended care facility at 11:55 AM on 12/29/09. This finding was verified with Staff E on 1/14/10 at 4:05 PM.

The medical record review for Patient # 14 was completed on 01/14/10. The patient was admitted to the facility on 10/26/09 with a diagnosis of aspiration pneumonia. Upon admission to the acute care floor, nursing staff noted decubitus ulcers around the patient' coccyx. A pressure ulcer risk assessment at admission scored the patient as a "10", which put the patient in the high risk category. A care plan developed by the nursing staff at the time of admission determined the patient should be repositioned as needed as a comfort standard. The nursing care plan lacked an intervention for the integumentary (skin) standard. The patient's hospital admission continued until 11/04/09 at 3:30 PM at which time the patient was transferred back to an extended care facility. The medical record lacked consistent documentation of the patient's positioning or repositioning for comfort as planned. This finding was verified with Staff E on 1/14/10 at 4:05 PM.

On 1/14/10 between 1:15 PM and 2:00 PM three acute care nursing staff were interviewed individually. Each verified the use of the Braden scale as the tool used in the facility as the risk assessment for skin breakdown. Each verified the facility lacked a policy for interventions to implement based on the result of the patient's Braden scale score. According to the acute care nursing staff, interventions to prevent skin breakdown were determined subjectively by the nurse and were followed inconsistently by nursing staff during the patient's hospital admission. Staff E was present at the time of all three nurse interviews.




03193

According to review of policies and procedures presented to the surveyor as current for skin breakdown prevention, the hospital is using the two page policy written and reviewed by their separately certified extended care facility. No documentation was found to verify this extended care facility policy had been approved and accepted as the hospital's skin breakdown prevention policy. Per interview with Staff E on 01/14/10 at 8:45 AM, she was unable to find evidence of staff training/competency in skin breakdown prevention or policies which direct nursing staff to implement nursing protocols based on the Braden skin risk assessment.

Based on staff interviews and review of quality meeting minutes for the past year, the facility failed to integrate the evaluation of quality and appropriateness of treatment furnished in the facility between hospital departments. The survey sample was 29 patients whose medical records were reviewed.

Findings include:

Review of the nursing quality committee meeting minutes for 10/21/09 and 12/18/09, discussions occurred relating to the need to have the hospital wide performance improvement report made available to the nursing quality committee as "it seems there is no follow through or transparency." Per interview on 01/13/10 at 4:15 PM, Staff E, the interim nursing vice president, in the presence of Staff M, the emergency room director, stated "nursing is not aware of other departments' performance improvement goals and we may be serving as a road block to their efforts." Review of the performance improvement/quality assurance committee meeting minutes from 03/18/09-11/18/09 revealed discussion of a nursing issue relating to Warfarin education for patients at the 03/18/09 meeting. No other nursing issues were documented as presented at the other four meetings conducted where all departments were represented.
Per interviews of six registered nurses on 01/14/10, six different responses were given relating to what the current nursing performance improvement project is. One of the six nurses responded correctly when she stated they are working on patient falls.
Review of nursing quality committee meetings including ones conducted on 02/18/09, 04/15/09, 05/20/09, 06/17/09 and 07/15/09 lacked clarity relating to what quality goals nursing staff were following. This was confirmed by Staff E on 01/13/10 at 4:15 PM.