North Shore Health

“PATIENTS RIGHTS CFR(s): A CAH must protect and promote each patient’s rights. This Condition is not met as evidenced by: 42587 Based on interview and document review, the hospital failed to ensure restraint application, assessment, observation, and documentation was performed consistent with hospital policy and accepted standards of practice for 3 of 4 patients (P3, P1, P2), who had restraints applied for the management of violent behavior. In addition, the facility failed to ensure all nursing staff including travel nursing staff had completed training on restraints. This deficient practice had the potential to affect all hospital and Swing Bed patients. As a result of these failures, these deficient practices resulted in a condition level deficiency for P1, P2, P3. The hospital was found out of compliance with the Condition of Participation Patient Rights at 42 CFR 482.13. A condition-level deficiency was issued. Findings include: See C-2553 Based on interview and document review, the hospital failed to ensure restraint application, assessment, observation, and documentation was performed consistent with hospital policy and accepted standards of practice for 3 of 4 patients (P3, P1, P2), reviewed for the use of restraints for management of violent behavior. See C-2560 Based on interview and document review, the facility failed to ensure staff were trained on restraint and seclusion. This deficient practice had the potential to affect all hospital patients receiving services at the critical access hospital (CAH). See C-2561 Based on interview and document review, the facility failed to ensure hospital staff and contracted personnel were trained on restraint and seclusion to include patient-centered, trauma informed competency-based training and education. This deficient practice had the potential to affect all hospital patients receiving services at the critical access hospital (CAH). See C-2563 Based on interview and document review, the facility failed to ensure hospital staff and contracted personnel were trained on alternatives to restraint and seclusion. This deficient practice had the potential to affect all hospital patients receiving services at the critical access hospital (CAH).”

“ROUTINE STORAGE AND DISPOSAL OF TRASH CFR(s): (2) There is proper routine storage and prompt disposal of trash; This Standard is not met as evidenced by: 48109 Based on observation, interview, and document review, the facility failed to ensure proper storage and prompt removal of trash, including biohazard trash, in the laboratory. Findings include: On 10/14/24 at 2 p.m., during a tour of the laboratory, a large, mostly full red plastic bag with biohazard logos on it was sitting directly on the floor just to the left of the laboratory entrance. To access two coolers which contained reagents necessary to perform tests, the red plastic bag had to be stepped around due to the size of the space. The lab director (LD)-A stated the bags were to be picked up by maintenance either when they are called to do so or otherwise, just whenever they come by. On 10/17/24 at 8:27 a.m., a large clear plastic bag containing trash was sitting directly on the floor just to the left of the laboratory entrance in the same place the red plastic bag was sitting three days ago. A medical lab specialist (MLS)-A stated the laboratory staff brought their own regular trash to the dumpster, but sometimes maintenance would take it for them. MLS-A also stated maintenance was responsible for taking the red bag trash. There used to be a red plastic container that held the biohazard trash, but it was removed a couple of months ago by another staff member because it was in the way. MLS-A stated they could contact maintenance at any time to come remove the biohazard trash. On 10/17/24 at 8:34 a.m., the director of maintenance (DM)-A stated they made rounds to collect trash throughout the day and when contacted by a department. The DM-A confirmed maintenance was responsible for collecting the biohazard trash. On 10/17/24 at 10:55 a.m., LD-A stated he didn’t expect trash to be stored directly on the floor, and they now had a red plastic container to place the biohazard trash liner and trash into. This was important because it could be an infection control concern if the bag were to tear or break. On 10/17/24 at 11:30 a.m., the administrator stated she expected biohazard waste to be contained in a plastic container, along with the red plastic liner. This was important for infection control measures. The facility policy Waste Management and Disposal for Housekeeping dated 7/22/24, directed biohazard waste was collected by maintenance and housekeeping. The red biohazard bags were identified as those containing infectious waste. Maintenance then places the biohazard waste bags into a red plastic drum in the maintenance garage.”

“LIFE SAFETY FROM FIRE CFR(s): §485.623(c) Standard: Life Safety From Fire (1) Except as otherwise provided in this section: (i) The CAH must meet the applicable provisions and must proceed in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.) (ii) Notwithstanding paragraph (d)(1)(i) of this section, corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors. This Standard is not met as evidenced by: 47263 Based on observation, interview and document review, the critical access hospital (CAH) was found to be out of compliance with Life Safety Code requirements. These findings have the potential to affect all patients in the hospital. Findings include: Please refer to the Life Safety Code inspection tags: K-0211, K-0223, K-0226, K-0321, K-0353, K-0372, K-0912, and K-0920.”

“RESPONSIBLE FOR MEDICAL DIRECTION CFR(s): This Standard is not met as evidenced by: 47263 Based on interview and document review, the critical access hospital failed to provide notification to the State Agency when the medical director changed. Findings include: Medical staff Minutes dated 12/20/23, identified doctor of osteopath (DO-E) as the new chief of medical staff. Cook County Hospital District Board Minutes dated 1/18/24, line item Medical Staff Minutes December 20,2023 identified the new chief of medical staff as DO-E. On 10/16/24 at 10:59 a.m. the hospital administrator confirmed they had a new chief medical director (DO)-E. They had not notified the State Agency when the new chief medical director took the role over. The facility policy Reporting Changes in the Hospital Medical Director and/or North Shore Health Emergency Department Medical Director of Cook County hospital District d/b/a North Shore Health dated 7/9/24, instructed changes in the medical director and emergency department director must be reported to the state agency, Minnesota Department of Health, licensing and certification.”

“RECORDS SYSTEM CFR(s): For each patient receiving health care services, the CAH maintains a record that includes, as applicable-- (i) Identification and social data, evidence of properly executed informed consent forms, pertinent medical history, assessment of the health status and health care needs of the patient, and a brief summary of the episode, disposition, and instructions to the patient; This Standard is not met as evidenced by: 42587 Based on interview and document review, the facility failed to ensure Informed Consent forms included the signature, date and time of the witness for 2 of 6 records (P4, P5) reviewed for colonoscopy procedures. Findings include: P4’s document titled Informed Consent to Undergo Colonoscopy North Shore Health was signed, dated and timed by P4. However, the witness signature, date and time were blank. P5’s document titled Informed Consent to Undergo Colonoscopy North Shore Health was signed, dated and timed by P5. However, the witness signature, date and time were blank. The facility policy Informed Consent: Procedures and Treatments dated 11/20/23, directed an informed consent would be obtained for specific procedures and treatments, and colonoscopy was included in the list. The policy identified the purpose of the consent was to verify the patient or responsible party was making an informed decision as to whether or not to engage in the described procedure. The facility Colonoscopy Procedure dated 5/6/24, identified the physician would explain the procedure to the patient and the nurse would witness the consent by signing, dating and timing the consent after the patient signed. On 10/16/24 at 9:30 a.m., the director of nursing (DON) verified P4 and P5’s consents lacked a witness, and stated the consents were incomplete.”

“RECORDS SYSTEM CFR(s): All orders of doctors of medicine or osteopathy or other practitioners, reports of treatments and medications, nursing notes and documentation of complications, and other pertinent information necessary to monitor the patient’s progress, such as temperature graphics, progress notes describing the patient’s response to treatment; and This Standard is not met as evidenced by: 42587 Based on interview and document review, the facility failed to ensure medical records were complete and contained all pertinent information necessary to monitor each patient’s condition, progress and response to treatment for 2 of 6 records (P6, P7) reviewed for colonoscopy procedure. Findings include: P6 was admitted on 9/26/24, and discharged 9/26/24. The medical record lacked a post anesthesia care unit (PACU) assessment on admison to the PACU and every 15 minutes for the following: breath sound, respiratory effort, skin warm/dry, emesis/nausea, and oral intake. In addition, the medical record lacked every 15 minute assessments for discharge for limb movement, deep breaths and coughs, blood pressure in relation to preanesthesia, level of consciousness, skin color, and vital signs. P7 was admitted on 9/26/24 and discharged 9/26/24. P7’s Post-Sedation Record lacked a nursing assessment, PACU admission assessment and every 15 minute documentation, also a date, post-sedation medication summary, discharge criteria (tolerating oral food and fluids, passing flatus, post-anesthesia score, driver present, intravenous line removal), a signature of the registered nurse, instructions given to patient and responsible caregiver, and the time the patient was discharged and the location. On 10/16/24 at 9:30 a.m. the director of nursing (DON) verified the information listed above for P6 and P7 was missing. The facility policy Colonoscopy Procedure dated 5/6/24, directed post procedure documentation would include the patient’s vital signs and sedation level would be documented every 15 minutes and a patient would not be discharged until their Aldrete score (also known as the post anesthetic recovery score, is a quantitative scoring system used to determine when a patient can be safely discharged from the post-anesthesia care unit). The policy identified patients receiving sedation must have a driver to take them home, the driver’s signature was required at discharge.”

“LEADERSHIP RESPONSIBILITIES CFR(s): (2) The infection prevention and control professional(s) is responsible for:] (ii) All documentation, written or electronic, of the infection prevention and control program and its surveillance, prevention, and control activities. This Standard is not met as evidenced by: 42587 Based on interview and document review, the facility failed to ensure audits were being completed to ensure staff were following proper infection control practices. This deficient practice had the potential to affect all hospital and Swing Bed patients receiving services at the critical access hospital. Findings include: On 10/16/24 at 3:00 p.m., the director of nursing (DON) and the infection preventionist (IP) were interviewed. The DON verified they were not auditing adherence to infection prevention and control policies and procedures by the critical access hospital staff personnel. The DON verified he had not conducted any audits over the past year. The facility Nososcomial Surveillance policy dated 3/7/24, directed surveillance activities were used to identify infection prevention and control risks pertaining to patients, staff and visitors and families. The facility Infection Control Program dated 3/12/24, indicated goals as protecting the patient, protecting health care works, visitors and others in the health care environment, to reduce the number of facility-acquired infections, to take necessary measures to prevent the spread of infection, and to maintain surveillance of infected patients/residents, employees, and the facility environment.”

“QAPI CFR(s): (b) Standard: QAPI Program Design and scope. The CAH’s QAPI program must: (2) Be ongoing and comprehensive. (3) Involve all departments of the CAH and services (including those services furnished under contract or arrangement). This Standard is not met as evidenced by: 47263 Based on interview and document review the hospital failed to ensure all service lines and departments had active quality improvement projects. The 2024 Continuous Quality Improvement/Peer Review Committee Plan dated 2024 indicated the following departments were to participate in QAPI: dietary, laboratory, radiology, housekeeping, maintenance, ambulance, purchasing, billing, health information, human resources, hospital nursing, cardiac rehab, emergency department, infection control, social services, home health, and rehab services. The plan indicated departments are expected to report on their scheduled time and reports should include description of monitors completed, a summary of findings utilizing statistical approach, professional analysis and plan of action and future monitoring and evaluation plans. The 2024 Continuous Quality Improvement/Peer Review Committee Minutes and hospital submitted documents were reviewed. There was a lack of evidence that the following departments/service lines had active quality improvement projects: swing bed patients, colonoscopy service, homecare, maintenance, pharmacy services, rehabilitation/therapy department, sterile processing, housekeeping, finance, infusion/chemotherapy, and social services. The minutes reflected multiple department reports being deferred each meeting. On 10/16/24 at 8:30 a.m., the director of nursing (DON) confirmed the hospital did not have any current quality initiatives being worked on in the surgical/colonoscopy area. On 10/16/24 at 1:05 p.m., the pharmacist (P)-A confirmed there were no current quality improvement projects for the pharmacy. On 10/17/2024 at 8:30 a.m., the Continuous Quality Improvement/Peer Review committee coordinator (CC)-A stated they had been in their role for two years, and had been working to get QAPI program up and running. It needed to be more data driven. The hospital did not have any current quality projects for housekeeping, swing beds, or the inpatient population. On 10/17/24 at 10:44 a.m., the social services designee (SSD)-A confirmed they did not have a current quality improvement project.”

“QAPI CFR(s): (d) Standard: Program activities. For each of the areas listed in paragraph (b) of this section, the CAH must: (3) Set priorities for performance improvement, considering either high volume, high-risk services, or problem prone areas. This Standard is not met as evidenced by: 47263 Based on interview and document review, the facility failed to identify and incorporate the high risk low volume care areas of restraint use and trauma care into thier quality assurance and improvement activities (QAPI). Findings incude: Medical staff meeting minutes dated 8/21/24, indicated the director of nursing (DON) and the quality assurance & process improvement director (ID)-A were in attendance. In the minutes, the DON reviewed the restraint policy. A medical staff member indicated restraints were not used on a regular basis and suggested QI [quality improvement] review should be done on each restraint episode. In addition, the medical director (MD)-A also suggested a check list be used to ensure that the policy was exactly followed due to the infrequency of use. The notes reflected the DON would work on developing a checklist and QI review. On 10/17/2024 at 12:32 p.m., registered nurse (RN)-W, stated the facility did not have a stroke and trauma designation, and since those expired, they were no longer reviewing trauma patients for quality. RN-W stated the hospital did not review restraint events and confirmed restraint use was not part of their quality program. On 10/17/2024 at 2:24 p.m., the DON stated because the use of restraints at the hospital was so infrequent, they did not track the frequency of restraint use or perform any kind of quality review on restraint use episodes. The DON did not identify restraint use as high risk because the use of restraints was so low at the hospital. On 10/17/2024 at 8:30 a.m., the QAPI committee coordinator (CC)-A stated they had not identified restraint or trauma use as high-risk low volume, nor had they prioritized them for incorporation into QAPI program. The hospital policy Hospital/Restraint Policy dated 8/2/24, under the sub-title Quality and Monitoring directed the use of restraint/seclusion will be monitored and evaluated on a continual basis and aggregate data will be collected and analyzed for the identification of patterns, trends and injuries. The hospital Continuous Quality Improvement Peer Review Committee Plan dated 2024, identified restraint use as an item that required performance measures because restraint use was a performance process that involved risk or may result in sentinel events. The plan reads that measurement will include monitoring of improvements in performance to determine the effectiveness of change and that sustained improvement continues.”

“ORGAN, TISSUE, & EYE PROCUREMENT CFR(s): Ensure that the CAH works cooperatively with the designated OPO, tissue bank and eye bank in educating staff on donation issues, reviewing death records to improve identification of potential donors, and maintaining potential donors while necessary testing and placement of potential donated organs, tissues, and eyes takes place. §485.643(f) For purpose of these standards, the term “organ” means a human kidney, liver, heart, lung, pancreas, or intestines (or multivisceral organs). This Standard is not met as evidenced by: 42587 Based on interview and document review, the CAH had failed to ensure staff received ongoing education regarding organ/tissue donations. Findings include: Review of staff education/inservice material revealed the last training was assigned in 2021 “LifeSource Update 2021.” A review of new employee “General Orientation” revealed there were no courses related to organ, tissue, eye donation. A review of “New Traveler Orientation Checklist” revealed there were no courses related to organ, tissue, eye donation. The agreement titled Organ and Tissue Recovery Memorandum Of Understanding Between North Shore Health and Lifesource dated 6/17/24 directed the hospital would work cooperatively with LifeSource in educating all hospital team members on donation issues. On 10/17/24 at 10:00 a.m., the administrator verified the facility had not established a formal check off to ensure staff watched a LifeSource video annually. The administrator stated they would send out an email to staff as a reminder to watch the video, but did not follow up to ensure all staff watched the video.”

“RESTRAINT AND SECLUSION CFR(s): The CAH must have written policies and procedures regarding the use of restraint and seclusion that are consistent with current standards of practice. This Standard is not met as evidenced by: 47263 Based on interview and document review, the critical access hospital failed to ensure restraint application, assessment, observation, and documentation was performed consistent with hospital policy and accepted standards of practice for 3 of 4 patients P3, P1, P2, reviewed for the use of restraints for management of violent behavior. Findings include: P3: P3 arrived at the emergency department (ED) on 1/1/24 at 12:07 p.m. A nurse note entered in the EMR indicated the provider was in with P3 on 1/1/24 at 1:00 p.m. The provider note time stamped on 1/1/24 at 2:23 p.m., documented P3 had arrived at the facility in restraints and was not released out of restraints until an hour or so after P3 had received 5 mg [milligrams] of Ativan. The EMR included an order on 1/1/24 at 13:05 p.m., for 5 mg of Haldol which was administered intramuscularly at 1:21 p.m., (there was no evidence of an order for 5 mg of Ativan or an administration). On 1/1/24 at 3:43 p.m., nurse entry in the EMR identified P3 had exhibited behavior that was identified as harm towards others, but with reassessment P3 was no longer exhibiting those behaviors so P3’s restraints were discontinued at 3:44 p.m. On 1/1/24 at 1545 p.m., a second nurse entry was made that indicated P3’s restraints were discontinued at 3:45 p.m. P3’s EMR indicated P3 had been in restraints in the ED for approximately 3 hours and thirty-eight minutes. P3’s EMR lacked evidence of the following: order for restraints, completed initial and on-going RN assessments, documented rationale for the use/continued use of restraints, one on one observation of P3 while restrained, range of motion was performed, nutrition, elimination, and hydration needs were addressed and that every fifteen-minute documentation had been completed while P3 was in restraints. P1: P1 arrived at the ED on 9/12/24 at 8:41 p.m. At 10:55 p.m., P1 was placed in restraints for the management of violent behavior. P1 remained in restraints until transfer to another facility for mental health management on 9/13/24 at 1:31 p.m. A new order was placed for four-point restraints on 9/13/24 at 1:31 a.m. On 9/13/24 7:16 a.m., the registered nurse (RN) documented P1’s left arm restraint and left leg restraint had been removed for patient comfort. P1 then got themselves to a standing position on the side of the bed and patient had to be assisted back to bed, and restraints had to be reapplied to the left arm and leg. P1 remained in restraints for an additional elven hours and thirteen minutes. The EMR lacked evidence of restraint orders being renewed every four hours for the continuation of restraints. The EMR also lacked evidence of every fifteen-minute documentation being completed while P1 was in restraints. P2: P2 arrived at the ED on 10/16/23 at 10:42 p.m., and was placed in four-point restraints for the management of violent behavior at 11:29 p.m. The provider order for four-point restraints was placed (one hour and 20 minutes after the initiation of restraints) on 10/17/23 at 12:49 a.m. On 10/17/23 at 10:00 a.m., based on nurse assessment, P2 was found to no longer be a threat to self or others and was released from four-point restraints. P2 was in restraints for a total of ten hours and 30 minutes. The EMR lacked evidence of renewal orders every four hours for the continuation of restraints. The EMR also lacked evidence of every fifteen-minute documentation being completed while P2 was in restraints. On 10/18/24 at 5:20 p.m., the medical director stated they were not aware there were any concerns with restraint use in the emergency department and indicated they expected restraint procedure and protocol to be followed. The facility policy Hospital/ED Restraint Policy dated 8/2/24, included the following instruction for patients in violent/self-destructive restraints: -When releasing from four-point violent destructive restraints, do so by releasing the opposite wrist and ankle. -Order for violent restraints should be obtained immediately or with-in one hour of restraint application. -Orders are time limited and need to be obtained every four hours for adults. -A documented RN assessment is required every 2 hours. -Documentation is completed on the appropriate restraint/seclusion/suicide prevention form. Documentation must occur every 15 minutes and indicates uninterrupted continuous monitoring of the patient has occurred. -Restraint documentation should include location of patient, behaviors, interventions, RN assessed, alternatives attempted, type and location of restraints, patient informed of criteria for discontinuation, review for active order, least restrictive alternatives attempted. -Discontinuation of restraint documentation should include the patient is no longer meeting criteria for restraint use and that the patient understands and agrees to follow safety instructions.”

“RESTRAINT AND SECLUSION CFR(s): Staff training requirements. The patient has the right to safe implementation of restraint or seclusion by trained staff. This Standard is not met as evidenced by: 42587 Based on interview and document review, the facility failed to ensure staff were trained on restraint and seclusion. This deficient practice had the potential to affect all hospital patients receiving services at the critical access hospital. Findings include: On 10/17/24 at 3:47 p.m., registered nurse (RN)-W stated restraint education was completed “annually” by having each nurse complete the restraint competency with a hands on demonstration, and by reviewing the restraint policy. CNM verified there had not been any restraint competencies completed in 2024. Below is a list of RN’s and the date of their last restraint competency check off: RN-A 1/27/23 RN-B 10/10/23 RN-C 1/27/23 RN-D 2/3/23 RN-E 1/27/23 RN-F hired 9/16/24, none RN-G hired 5/22/24, none RN-H hired 5/22/24, none RN-I hired 6/5/24, none RN-J hired 12/4/23, none RN-K hired 8/21/23, none RN-L 2/5/23 RN-M 3/27/23 On 10/18/24 at 2:33 p.m., RN-J stated there had been no formal class on restraints, RN-J thought she read the policy when she first started but had never been checked off with a competency to place a patient in restraints. On 10/18/24 at 3:45 p.m., RN-A stated restraint training consisted of how to apply restraints safely. RN-A could not recall being assigned any computer modules on the use of restraints. On 10/18/24 at 3:52 p.m., RN-D stated she was shown the current restraints and said she had to read and sign the policy, she could not recall when this occurred. She could not recall if she had ever had to demonstrate her ability to apply restraints but stated she had applied restraints to patients. On 10/18/24 at 4:08 p.m., RN-F stated his restraint training was to read the restraint policy in the first two days of work prior to working on the floor. On 10/18/24 at 4:17 p.m., RN-M stated restraint training was when they received new restraints “limb holders, Velcro quick release” and he was shown how to use them. Stated he was assigned a learning module in the computer, stated he did not complete a competency but was shown how and where to attach the restraints to a cot. A review of New employee orientation titled “NSH” (North Shore Health) General orientation dated 10/16/24, lacked restraint training. It did include a learning module “Preventing and De-escalation Crisis Situation.” Nursing, Acute Care Orientation dated 9/14/23, lacked restraint training. 2024 Annual Learning Quarter 1 - All Staff, lacked restraint training. 2024 Annual Learning Quarter 2 - All Staff, lacked restraint training. 2024 Annual Learning Quarter 3 - All Staff, lacked restraint training. 2024 Annual Learning Quarter 4 - All Staff, lacked restraint training. The Hospital/ED Restraint Policy dated 8/2/24, lacked how or when hospital staff would be trained on restraint use. On 10/18/24 at 5:20 p.m., the chief of staff (DO)-E stated he was not aware the facility was not training staff on restraint use. DO-E verified it was a high risk, low volume procedure, and he would expect training for staff on restraint use.”

“RESTRAINT AND SECLUSION CFR(s): The CAH must provide patient- centered, trauma informed competency- based training and education of CAH personnel and staff, including medical staff, and, as applicable, personnel providing contracted services in the CAH, on the use of restraint and seclusion. This Standard is not met as evidenced by: 42587 Based on interview and document review, the facility failed to ensure hospital staff and contracted personnel were trained on restraint and seclusion to include patient-centered, trauma informed competency-based training and education. This deficient practice had the potential to affect all hospital patients receiving services at the critical access hospital (CAH). Findings include: On 10/17/24 at 3:47 p.m., registered nurse (RN)-W stated restraint education was completed annually by having each nurse complete the restraint competency with a hands on demonstration and by reviewing the restraint policy. CNM verified there had not been any restraint competencies completed in 2024. Below is a list of RN’s and the date of their last restraint competency check off: RN-A 1/27/23 RN-B 10/10/23 RN-C 1/27/23 RN-D 2/3/23 RN-E 1/27/23 RN-F hired 9/16/24, none RN-G hired 5/22/24, none RN-H hired 5/22/24, none RN-I hired 6/5/24, none RN-J hired 12/4/23, none RN-K hired 8/21/23, none RN-L 2/5/23 RN-M 3/27/23 Below is a list of agency RN’s (travel RN’s) and the date of their last restraint competency check off: RN-N none RN-O none RN-P none RN-Q none RN-R none RN-S 1/27/23 RN-T none RN-U none RN-V none On 10/18/24 at 2:09 p.m., RN-U stated they were employed as a agency nurse at the end of 2022 through March 2024. RN-U did not recall if there was any orientation provided on the use of restraints. RN-U did recall placing at least one patient in restraints during the time period listed. On 10/18/24 at 2:33 p.m., RN-J stated there had been no formal class on restraints, RN-J thought she read the policy when she first started but had never been “checked off” with a competency to place a patient in restraints. On 10/18/24 at 2:55 p.m., RN-V stated they were employed as a travel agency RN last winter, thought maybe there was a computer module assigned but did not recall any restraint competency check off. RN-V did not recall placing any patients in restraints while they were employed at the CAH. On 10/18/24 at 3:35 p.m., RN-T stated they were currently a travel agency nurse at the CAH. RN-T stated they reviewed the policy in the previous week on an education link. On 10/18/24 at 3:45 p.m., RN-A stated restraint training consisted of how to apply restraints safely. RN-A could not recall being assigned any computer modules on the use of restraints. On 10/18/24 at 3:52 p.m., RN-D stated she was shown the current restraints and said she had to read and sign the policy, she could not recall when this occurred. She could not recall if she had ever had to demonstrate her ability to apply restraints but stated she had applied restraints to patients. On 10/18/24 at 4:08 p.m., RN-F stated his restraint training was to read the restraint policy in the first two days of work prior to working on the floor. On 10/18/24 at 4:17 p.m., RN-M stated restraint training was when they received new restraints “limb holders, Velcro quick release” and he was shown how to use them. Stated he was assigned a learning module in the computer, stated he did not complete a competency but was shown how and where to attach the restraints to a cot. A review of New employee orientation titled “NSH” (North Shore Health) General orientation dated 10/16/24, lacked restraint training. It did include a learning module on “Preventing and De-escalation Crisis Situation.” Nursing, Acute Care Orientation dated 9/14/23, lacked restraint training. 2024 Annual Learning Quarter 1 - All Staff, lacked restraint training. 2024 Annual Learning Quarter 2 - All Staff, lacked restraint training. 2024 Annual Learning Quarter 3 - All Staff, lacked restraint training. 2024 Annual Learning Quarter 4 - All Staff, lacked restraint training. The New Traveler Orientation Checklist dated 9/24, lacked restraint training. The Hospital/ED (emergency department) Restraint Policy dated 8/2/24, did not address how or when hospital staff would be trained on restraint use. On 10/18/24 at 5:20 p.m., the chief of staff (DO)-E stated he was not aware the facility was not training staff on restraint use. DO-E verified it was a high risk low volume procedure and would expect training on restraint use for all staff.”

“RESTRAINT AND SECLUSION CFR(s): The training must include alternatives to the use of restraint/ seclusion. This Standard is not met as evidenced by: 42587 Based on interview and document review, the facility failed to ensure hospital staff and contracted personnel were trained on alternatives to restraint and seclusion. This deficient practice had the potential to affect all hospital patients receiving services at the critical access hospital (CAH). Findings include: On 10/17/24 at 3:47 p.m., registered nurse (RN)-W stated restraint education was completed annually by having each nurse complete the restraint competency with a hands on demonstration and by reviewing the restraint policy. On 10/18/24 at 2:09 p.m., RN-U stated they were employed as a travel [agency] nurse at the end of 2022 through March 2024. RN-U did not recall if there was any orientation provided on the use of restraints. RN-U did recall placing at least one patient in restraints during the time period listed. On 10/18/24 at 2:33 p.m., RN-J stated there had been no formal class on restraints, RN-J thought she read the policy when she first started. On 10/18/24 at 2:55 p.m., RN-V stated they were employed as a travel [agency] RN last winter, and thought maybe there was a computer module assigned. On 10/18/24 at 3:35 p.m., RN-T stated they were currently a travel aency nurse at the CAH. RN-T stated they reviewed the policy in the previous week on an education link. On 10/18/24 at 3:45 p.m., RN-A stated restraint training consisted of how to apply restraints safely. RN-A could not recall being assigned any computer modules on the use of restraints. On 10/18/24 at 3:52 p.m., RN-D stated she was shown the current restraints and said she had to read and sign the policy, she could not recall when this occurred. On 10/18/24 at 4:08 p.m., RN-F stated his restraint training was to read the restraint policy in the first two days of work prior to working on the floor. On 10/18/24 at 4:17 p.m., RN-M stated restraint training was when they received new restraints “limb holders, Velcro quick release” and he was shown how to use them. Stated he was assigned a learning module in the computer. A review of New employee orientation titled “NSH” (North Shore Health) General orientation dated 10/16/24, lacked restraint training. It did however, include a learning module on “Preventing and De-escalation Crisis Situation”. Nursing, Acute Care Orientation dated 9/14/23, did not include alternatives to restraints. 2024 Annual Learning Quarter 1 - All Staff, lacked training on alternatives to restraints. 2024 Annual Learning Quarter 2 - All Staff, lacked training on alternatives to restraints. 2024 Annual Learning Quarter 3 - All Staff, lacked training on alternatives to restraints. 2024 Annual Learning Quarter 4 - All Staff, lacked training on alternatives to restraints. The New Traveler Orientation Checklist dated 9/2024, lacked training on alternatives to restraints. The Hospital/ED (emergency department) Restraint Policy dated 8/2/24, did not address how or when hospital staff would be trained on alternatives to restraint use. On 10/18/24 at 5:20 p.m., the chief of staff (DO)-E stated he was not aware the facility was not training staff on restraint use. DO-E verified it was a high risk low volume procedure and would expect training on restraint use for all staff.”

“FIRE SAFETY An annual Life Safety recertification survey was conducted by the Minnesota Department of Public Safety, State Fire Marshal Division on 10/15/2024. At the time of this survey, Northshore Hospital CAH was found not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR, Subpart 483.70(a), Life Safety from Fire, and the 2012 edition of National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care and the 2012 edition of NFPA 99, Health Care Facilities Code. THE FACILITY’S POC WILL SERVE AS YOUR ALLEGATION OF COMPLIANCE UPON THE DEPARTMENT’S ACCEPTANCE. YOUR SIGNATURE AT THE BOTTOM OF THE FIRST PAGE OF THE CMS-2567 FORM WILL BE USED AS VERIFICATION OF COMPLIANCE. UPON RECEIPT OF AN ACCEPTABLE POC, AN ONSITE REVISIT OF YOUR FACILITY MAY BE CONDUCTED TO VALIDATE THAT SUBSTANTIAL COMPLIANCE WITH THE REGULATIONS HAS BEEN ATTAINED IN ACCORDANCE WITH YOUR VERIFICATION. PLEASE RETURN THE PLAN OF CORRECTION FOR THE FIRE SAFETY DEFICIENCIES (K-TAGS) TO: IF PARTICIPATING IN THE E-POC PROCESS, A PAPER COPY OF THE PLAN OF CORRECTION IS NOT REQUIRED. Healthcare Fire Inspections State Fire Marshal Division 445 Minnesota St., Suite 145 St. Paul, MN 55101-5145, OR By email to: FM.HC.Inspections@state.mn.us THE PLAN OF CORRECTION FOR EACH DEFICIENCY MUST INCLUDE ALL OF THE FOLLOWING INFORMATION: 1. A detailed description of the corrective action taken or planned to correct the deficiency. 2. Address the measures that will be put in place to ensure the deficiency does not reoccur. 3. Indicate how the facility plans to monitor future performance to ensure solutions are sustained. 4. Identify who is responsible for the corrective actions and monitoring of compliance. 5. The actual or proposed date for completion of the remedy. Cook County Northshore Hospital CAH is a 1-story building with a full basement. The original building was constructed in 1958 and was determined to be of Type II(111) construction. In 1963, 68, 95 & 2003 additions were constructed to the building that was determined to be of Type II(111) construction. Because the original building and its additions meet the construction type allowed for existing buildings, this facility was surveyed as a single building. The building also has a nursing home and clinic attached that are properly separated. The building is fully sprinklered throughout, the facility has a fire alarm system with smoke detection in the corridors and spaces open to the corridors that is monitored for automatic fire department notification. It also has smoke detection in all resident rooms. Other hazardous areas have either heat detection or smoke detection that are on the fire alarm system in accordance with the Minnesota State Fire Code. The facility has a capacity of 16 beds and had a census of 2 at the time of the survey. The requirements at 42 CFR, Subpart 483.70(a), are NOT MET as evidenced by:”

“Means of Egress - General CFR(s): NFPA 101 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1 This Standard is not met as evidenced by: 45748 Based on observation and staff interview, the facility failed to maintain a clear path of egress system per NFPA 101 (2012 edition), Life Safety Code, sections 19.2.1 and 7.1.10.1. This deficient finding could have a patterned impact on the residents within the facility. Findings include: On 10/15/2024, between 0730am and 1130am, it was revealed by observation that there was medical equipment in the egress corridor in the following areas: 1) Imaging hallway 2) Materials Management Area An interview with Director of Environmental Services verified these deficient findings at the time of discovery.”

“Doors with Self-Closing Devices CFR(s): NFPA 101 Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8 This Standard is not met as evidenced by: 45748 Based on observation and staff interview, the facility failed to install self-closing device per NFPA 101 (2012 edition), Life Safety Code, section 19.2.2.5, 19.2.2.5.1 through 19.2.2.5.4 and chapter 7, section 7.2.4 These deficient findings could have a widespread impact on the residents within the facility. Findings include: On 10/15/2024, between 0730am and 1130am, it was revealed by observation that the egress vestibule in the Material Management area was filled with medical materials and boxes. An interview with Director of Environmental Services verified these deficient findings at the time of discovery.”

“Horizontal Exits CFR(s): NFPA 101 Horizontal Exits Horizontal exits, if used, are in accordance with 7.2.4 and the provisions of 18.2.2.5.1 through 18.2.2.5.7, or 19.2.2.5.1 through 19.2.2.5.4. 18.2.2.5, 19.2.2.5 This Standard is not met as evidenced by: 45748 Based on observation and staff interview, the facility failed to install self-closing device per NFPA 101 (2012 edition), Life Safety Code, section 19.2.2.5, 19.2.2.5.1 through 19.2.2.5.4 and chapter 7, section 7.2.4 These deficient findings could have a widespread impact on the residents within the facility. Findings include: On 10/15/2024, between 0730am and 1130am, it was revealed by observation that the egress path in the Material Management area was filled with medical materials and boxes. An interview with Director of Environmental Services verified these deficient findings at the time of discovery.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 45748 Based on observation and staff interview, the facility failed to maintain hazardous storage rooms per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.2.1.3 and 7.2.1.8.1. These deficient finding could have an isolated impact on the residents within the facility. Findings include: On 10/15/2024, between 0730am and 1130am, it was revealed by observation that hospital room that has been converted to a storage room did not have a self-closing device. An interview with Director of Environmental Services verified these deficient findings at the time of discovery.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 45748 1) Based on observation and staff interview, the facility failed to maintain spacing between storage and the sprinkler system per NFPA 101 (2012 edition), Life Safety Code, Section 9.7.5, NFPA 25 (2011 edition), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, Section 5.2.1.2, and NFPA 13 (2010 edition), Standard for the Installation of Sprinkler Systems, Sections 8.6.5.3.2 and 8.15.9. These deficient findings could a patterned impact on the residents within the facility. Findings include: On 10/15/2024, between 0730am and 1130am, it was revealed by observation that storage materials had been placed on a storage rack, bringing the storage materials within the required 18 inch clearance area under the sprinkler heads. These obstructions were found in: 1) Med room in hospital 2) On top of refrigerator in Lab 3) Shelves in Imaging - Mammography Office 4) On top of refrigerator in Pharmacy 5) Shelves in shipping & Receiving in Materials Management area 6) Occupational Therapy 7) Clean Linen room in main hall way 2) Based on observation and staff interview, the facility failed to maintain the automatic fire sprinkler system per NFPA 101 (2012 edition), Life Safety Code, section 9.7.5, and NFPA 25 (2011 edition), the Standard for the Inspection, Testing, and Maintenance of Water Based Fire Protection Systems, section 5.4.1.4, and 5.4.1.4.2. This deficient finding could have an isolated impact on the residents within the facility. Findings include: On 10/15/2024, between 0730am and 1130am, it was revealed by observation that there were unsecured fire sprinkler heads that were not protected from being damaged, stored loosely within the spare sprinkler head boxes located by the fire sprinkler riser room. An interview with Director of Environmental Services verified these deficient findings at the time of discovery.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 45748 Based on observation and staff interview, the facility failed to maintain their smoke barrier per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.7.1, 19.3.7.3, 8.5.2.2, and 8.5.6.5. These deficient findings could have a widespread impact on the residents within the facility. Findings include: On 10/15/2024, between 0730am and 1130am, it was revealed by observation that there was a penetration running from one smoke compartment to another above doors in the main hallway between hospital and nursing home around the emergency room entrance. An interview with Director of Environmental Services verified these deficient findings at the time of discovery.”

“Electrical Systems - Receptacles CFR(s): NFPA 101 Electrical Systems - Receptacles Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover. If used in patient care room, ground-fault circuit interrupters (GFCI) are listed. 6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99) This Standard is not met as evidenced by: 45748 Based on observation and staff interview, the facility failed to maintain the electrical system per NFPA 101 (2012 edition), Life Safety Code, section 9.1.2, and NFPA 70 (2011 edition), National Electrical Code, section 406.6. This deficient finding could have an isolated impact on the residents within the facility. Findings include: On 10/15/2024, between 0730am and 1130am, it was revealed by observation that there was a missing cover on an electrical junction box in the electrical room (Switch Gear Room) An interview with Director of Environmental Services verified these deficient findings at the time of discovery.”

“Electrical Equipment - Power Cords and Extens CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This Standard is not met as evidenced by: 45748 Based on observation and staff interview, the facility failed to maintain the usage of electrical adaptive devices per NFPA 99 (2012 edition), Health Care Facilities Code, sections 10.5.2.3.1 and 10.2.4.2.1, NFPA 70, (2011 edition), National Electrical Code, sections 400-8, and UL 1363. This deficient finding could have an isolated impact on the residents within the facility. Findings include: On 10/15/2024, between 0730am and 1130am, it was revealed by observation that there were several electrical appliances plugged power-strips, multi-plug adapters and/or extension cords in the following areas; 1) Power-strip in EMS Coordinator Office 2) Power-strip in Break area in Imaging 3) Multi-plug in Doctor Sleeping room 4) Power-strip in House Keepers Office 5) Power-strip in Ambulance Garage 6) Power-strip in office area outside of the Board Room An interview with Director of Environmental Services verified these deficient findings at the time of discovery.”