St. Peter’s ousts employees after surprise inspection; Hospital maintains Joint Commission approval despite deficiencies

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A private accrediting agency found multiple high-priority deficiencies during a recent surprise inspection of St. Peter’s Hospital.

Though they showed a potential for risk, none of the findings put patients in harm’s way, hospital spokeswoman Katy Peterson said.

Shortcomings that were identified included inadequate documentation in patient records, facility faults that didn’t meet code and holes in a process for medical staff to pass grievances up the chain of command.

The hospital fired “no more than two” staff members following the review, CEO Nate Olson said. He declined to say which departments the employees worked in or elaborate on the reasoning behind the terminations, citing the privacy of personnel. 

“Changes are made to ensure we’re providing the highest quality and safety to our community,” he said.

The hospital has 30 days to show improvement in order to maintain its accreditation from The Joint Commission, the accrediting body that made an unannounced visit on Sept. 28 to inspect St. Peter’s.

The Joint Commission is a nonprofit organization that evaluates over 20,000 health care organizations around the country for standards that deem them eligible for Medicare and Medicaid reimbursement. It completes a comprehensive survey of hospitals once every three years and gives the organization a 90-day window in which it will conduct the inspection.

The commission releases its decision after surveying a hospital but does not make survey details public. St. Peter’s Hospital and home care services maintained their “seal of approval” from The Joint Commission after the most recent survey, according the organization’s website.

Hospitals can choose to contract with a different accrediting body, and Olson said St. Peter’s continues with The Joint Commission because it is considered the “gold standard.”

“It’s something we want to hold ourselves to the highest level of care possible,” he said.

Though deficiencies are routinely found, the commission identified more than the hospital administration expected.

“We probably had a few more opportunities (for improvement) than we anticipated,” Olson said. “It wasn’t exactly what we expected in terms of our preparedness.”

In the provision and record of care category, the hospital was dinged for inadequate and inconsistent documentation of patient records, including a signature, date and time by all physicians.

The Joint Commission faulted hospital leadership for not providing consistent performance reviews, documentation of department meetings and recommended changes.

Hospital staff was also knocked for not putting all staff requirements in a single document, inadequately documenting history and physical reports and not adhering to policy for handwritten physician prescriptions.

Olson said all 1,200 St. Peter’s staff members are more aware because of the findings, and improvements to quality are being made as a team effort.

“There is no detail too small. We’re going to focus on anything and everything that comes up,” he said.

Filed under: General Problems