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Based on interview and document review, the facility failed to follow their own policy and respond in an appropriate time frame for 3 of 7 patients (P4, P5, P6) who had filed grievances.

Findings include:

P4's grievance dated 2/25/14, indicated P4's family member (F)-A contacted a physician regarding a concern with P4's emergency department visit on February 17, 2014 due to a delayed test result that was noted late in the evening. The grievance documentation did not include the date F-A contacted the physician to discuss the concern. There was no documentation of a letter being sent to F-A within seven days of the grievance to inform them the hospital was still working to resolve the grievance. There was no documentation of communication between F-A and hospital staff during the investigative process. A letter of resolution was sent to F-A on 3/6/14. During the interview on 3/26/14, at 10:00 a.m. the director of quality improvement (DQI) verified a letter was not sent to F-A within seven days of the grievance to inform them the hospital was still working to resolve the grievance per the Complaint and Grievance Policy dated 12/16/10.

P5's grievance dated, 2/6/14, indicated P5 had a concern regarding the manner in which they were addressed by the physician during their emergency department visit on 2/6/14. There was no documentation of a letter being sent to P5 within seven days of the grievance to inform them the hospital was still working to resolve the grievance. A letter of resolution was sent to P5 on 2/19/14. During the interview on 3/26/14, at 10:00 a.m. the DQI verified a letter was not sent to P5 within seven days of the grievance to inform them the hospital was still working to resolve the grievance per the Complaint and Grievance Policy dated 12/16/10.

P6's grievance dated, 2/26/14, indicated P6 had a ganglion cyst taken off right wrist and when that was being done the artery was cut and thus needed to be repaired. P6 did not feel they should have to pay for the repair of the artery. On 3/12/14, a letter was sent informing P6 the hospital required additional time to complete the investigation. The letter was dated 14 days after the hospital received the grievance. During the interview on 3/26/14, at 10:00 a.m. the DQI verified a letter was not sent to P6 within seven days of the grievance to inform them the hospital was still working to resolve the grievance per the Complaint and Grievance Policy dated 12/16/10.

The hospital's Complaint and Grievance Policy reviewed 12/16/10, stipulated, "The Quality Director Partners with the director or administrator of the area named in the grievance to complete the investigation within 7 days of original receipt of the grievance. The investigation may be extended beyond this timeframe if the case is particularly complicated, involves multiple departments, or if issues are identified that were not initially known. In this instance, the Quality Director provides a written notice to the complainant that the hospital is still working to resolve the grievance and that the Quality Director will follow up with a written response within 14-21 days."

Based on observation and interview, the hospital failed to ensure emergency crash carts were secured to prevent unauthorized access in 2 of 4 crash carts on the Medical/Surgical and Cardiac Care Unit.

Findings include:

On 3/25/14, at 8:00 a.m. a tour of the medical/surgical (M/S) and cardiac care unit (CCU) was conducted. Two crash carts were stored just around the corner in an alcove from the CCU nursing station and right across from a CCU patient room. The carts were not visible from the nurse's station. No cameras were visible. The M/S CCU department manager explained that the cart was stored in the hallway which was used by patients and visitors. She verified there were no cameras in the area and the CCU nurse's station was not always supervised.

On each of the two carts a plastic tab held the metal guard piece over the crash cart drawers. To open the cart, the plastic breakaway tab was twisted off and the swinging metal guard was moved and the drawers could be opened. The top drawer of the crash cart contained a hard plastic over the medication tray with a breakaway plastic tab to indicate the cart had not been tampered with. However, the breakaway tabs were not numbered to identify on the cart log on the nurse's daily check of the cart. The breakaway tabs were very easily broken and once in the drawer, the cover over the medications could be lifted enough to obtain medications even though there was a breakaway tab on the inside drawer. The M/S CCU department manager explained the carts are checked and logged daily by the nurses for security purposes. Every quarter the nurses check the carts for needed supplies and outdated medication. When the breakaway tab was removed for those checks, the nurse could get another one from the nurse's station to re-secure the carts.

The carts contained Atropine (used to speed up the heart), Calcium Chloride (used to improve pumping of the heart), Dextrose (medication to raise blood sugar), Epinephrine (medication to improve heart function), Glucagon (to elevate blood sugar), Lidocaine ( used to prevent ventricular arrhythmia), sodium bicarbonate (used to improve renal function), Adenosine (used to slow the heart temporarily), Esmolol hydrochloride (to decrease heart rate, contractility and blood pressure), Flumazenil (used for reversal of sedation effects), Naloxone hydrochloride (used to reverse sedating narcotics), Nitroprusside (to lower blood pressure), Norepinephrine (restore blood pressure), Procainamide (an anti-arrhythmic that decreases excitability in the heart), Vasopressin (increases renal function), Amiodarone (used to prevent ventricular arrhythmias), Dopamine (used to improve heart function by constricting extremity circulation), Nitroprusside (relaxes smooth muscle of heart), and Magnesium sulfate (used to improve heart function). The carts contained syringes, IV (intravenous) kits, and needles as well.

On 3/26/14, at 2:00 p.m. a pharmacist (Ph)-I was interviewed regarding security of the crash carts on the M/S CCU area. Ph-I indicated the breakaway tags were used to seal the carts both on the outside and inside drawers where medication was located. The breakaway tags were meant to be able to be broken quickly in an emergency. Ph-I indicated the carts had been stored in that area for several years and verified there were no cameras in the area. The pharmacist also indicated it was a hallway where patients and visitors frequented.

Based on interview and document review, the hospital failed to develop a plan to ensure water and adequate medical gases (nitrogen, oxygen and nitrous oxide) were available in the event of an emergency and or a disruption of supply. This had the potential of affecting 11 patients which represented the hospital's average daily census.

Findings include:

Water:
On 3/26/14, at 9:15 a.m. and interviewed was conducted with the director of facility services (DFS). He provided the hospital's Reserve Water Supply policy last updated 2/2014. The policy identified the purpose: "to ensure that a resource water supply is available to residents, patients and staff during a city water supply failure." The policy did not specify the amount of potable and non-potable water required per patient, staff, visitors and the different departments per day.

The DFS stated at that time, the hospital had a contract with Northfield Culligan as an outside provider of water in the event of disruption of water service. The agreement dated, 3/13/14, stipulated; "In the event of an emergency (local disaster, flood, etc.) Northfield Culligan agrees to supply: Northfield Hospital and Clinic, Northfield MN with bottled water under the following conditions:
1. Northfield Culligan has fulfilled its primary obligation to its current, active customer base first.
2. Northfield Culligan employees are available to provide safe distribution of product in the event of an emergency
3. Northfield Culligan has sufficient product to distribute.

The agreement further stipulated, "Northfield Culligan does not guarantee that any or all the products will be available during and after an emergency and they reserve the right to substitute products based on availability."

During the interview, the DFS agreed the current agreement with Northfield Culligan and the facility's water policy did not meet the requirements of the regulation.

Medical Gases:
In an interview with the DFS on 3/27/14, at 8:35 a.m. stated the only facility policy regarding medical gases addressed how to ensure patient safety if an emergency shutdown was to be implemented.

Policy titled: Piped Patient Medical Gas and Vacuum Systems Emergency Shutdown, last dated February 2014, stipulated "an emergency shutdown shall not take place until the House Nursing Supervisor and affected patient care area has been notified."

The policy did not identify if there was an interruption of medical gases what measures would be taken to provide the necessary medical gases to the patients.

Based on observation and interview, the facility did not maintain sanitary baking pans and frying pans in the kitchen. This had the potential of affecting 11 patients which represented the hospital's average daily census, staff and visitors.

Findings include:

During observation tour of the kitchen on 3/26/14, at 9:30 a.m. seven of seven baking sheet pans contained brown, crusty residue or loose debris on the interior surface of the pans, which would come in direct contact with food. Eleven of 12 frying pans had pitted or marred interior surfaces or a heavy coating of sticky, brown residue on the exterior of the pans, and the pans were nested on a shelf, with the exterior of a pan in contact with the interior of the pan beneath it which would come in direct contact with food. The baking sheets and pans were stored ready for use.

When interviewed on 3/26/14, at 10:00 a.m. the nutrition services director acknowledged the issues with the pans and stated that it was probably time she replaced the baking sheets and frying pans.

Based on interview and document review, the facility failed to ensure timely notification was completed to the Organ Procurement Organization (OPO) for 3 of 27 patients (P1, P2, P3) reviewed for whose death was imminent.

Findings include:

Notification to the OPO, Life Source, following patient death was not completed timely within one hour for P1, P2 and P3.

P1 had a date and time of death documented as 3/31//13, at 8:42 p.m. in the medical record. However, the time of notification to Life Source was documented at 10:23 p.m. per the Death and Validation 2013 report from Life source. The medical record did not have a documented time of the referral to Life Source.

P2 had a date and time of death documented as 12/13/13, at 9:39 p.m. in the medical record. However, the time of notification to Life Source was documented as 10:50 p.m.

P3 had a date and time of death documented as 12/30/13, at 3:40 p.m. in the medical record. However, the time of notification to Life Source was documented as 5:21 p.m.

During interview on 3/26/14, at 1:00 p.m. the director of the emergency department (DED) stated a register nurse was responsible to contact Life Source regarding all deaths occurring in the hospital as soon as possible after the death. The DED verified Life Source was not notified within one hour for P1, P2 and P3 following their deaths. The DED stated a review of notification of death to Life Source was completed on a quarterly basis; however, investigations of late notifications to Life Source were not part of the review process. The DED verified there had been no investigation completed regarding the late notification to Life Source on P1, P2 and P3.

During interview on 3/27/14, at 12:23 p.m. the DED verified the Life Source training through the Learning Management System by Health Stream trained staff to contact Life Source within one hour of cardiac death.

During interview on 3/27/14, at 12:48 p.m. registered nurse (RN)-D stated, "We have to contact Life Source within the first hour after a death."

During interview on 3/27/14, at 1:03 p.m. RN-E stated, "I need to contact Life Source within one hour of a death and I follow the death checklist."