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Based on document review and interview, it was determined for 2 of 4 (Pt #7 and Pt #8) patients, reviewed for violent restraints, the Hospital failed to ensure a restriction of rights was completed, as determined by hospital policy. This has the potential to affect all patients who require the use of violent restraints.

Findings include:

1. The Policy titled "Restraint, Policy (revised 9/8/21)" was reviewed on 11/3/22 at approximately 1:00 PM. The policy violent restraints algorithm noted, "Complete Illinois Restriction of Rights form. Document patient education regarding use of restraints and discontinuation criteria."

2. The clinical record of Pt #7 was reviewed on 11/3/22 at approximately 10:30 AM. Pt #7 to the Emergency Department on 8/12/22 at 9:35 AM with a chief complaint of Aggressive Behavior. Pt #7 was placed in violent restraints on 8/12/22 at 9:37 AM. The clinical record lacked documentation of a completed Illinois Restriction of Rights form.

3. The clinical record of Pt #8 was reviewed on 11/3/22 at approximately 11:00 AM. Pt #8 presented to the ED on 8/1/22 at 5:50 PM with a chief complaint of Aggressive Behavior. Pt #8 was placed in violent restraints on 8/1/22 2:47 PM. The record lacked documentation of a completed Illinois Restriction of Rights form.

4. An interview was conducted with the Risk Manager (E #2) on 11/4/22 at approximately 9:30 AM. E #2 reviewed the medical records of Pt #7 and Pt #8 and verbally agreed the medical record lacked documentation that the Illinois Restriction of Rights was completed.

Based on observation, document review and staff interview, it was determined the Hospital failed to ensure that oxygen cylinders were secured safely to avoid injury, property damage or fire in the facility. This has the potential to affect all patients, staff and visitors at the facility.

Findings include:

1. On 11/2/2022 at approximately 9:00 AM, a tour of the MICU (Medical Intensive Care Unit) was conducted with the Nurse Manager (E #9). During the tour, a full oxygen cylinder was observed standing free, unsecured in the storage room.

2. On 11/3/2022 at approximately 10:00 AM the policy titled "Compressed Gas Cylinder Storage and Handling (reviewed 4/20/21)" was reviewed. The policy required, "Provide safe storage,,,of medical compressed gas cylinders. Cylinder storage: Secure stored cylinders to prevent movement. Use a approved storage system in a secured, free standing stand..."

3. During an interview on 11/2/2022 at approximately 9:15 AM, E #9 verbally agreed the oxygen cylinders should have been secured in a stand.

Based on document review and interview, it was determined for 1 of 1 (Pt #6) patient records reviewed, who required the use of non-violent restraints, the Hospital failed to ensure restraints were ordered by a physician or other licensed practitioner (LP), authorized to order restraints. This has the potential to affect all inpatients and outpatients who require the use of restraints by the Hospital.

Findings include:

1. The Policy titled "Restraint, Patient (revised 9/8/21)" was reviewed on 11/3/22 at approximately 1:00 PM. The policy noted, "When restraint is necessary, assessment is completed, the device is selected, a physician's order is obtained, and the reason for restraint is explained to the patient and family...Continued use of restraint beyond the first 24 hours is authorized by a physician primarily responsible for the patient's ongoing care renewing the original order "

2. The clinical record of Pt #6 was reviewed on 11/3/22 at approximately 11:30 AM. The "Emergency Department Notes" dated 8/8/22 at 11:12 PM stated, "Patient was given Geodon (psychotropic medication) and then put in non-violent restraints per the hospitalist at this time." Pt #6's record lacked an order for non-violent restraints. Further documentation noted Pt #6 was in non-violent restraints from 8/8/22 through 8/13/22. The record lacked an order for non-violent restraints on 8/8/22, 8/10/22, and 8/11/22.

3. An interview was conducted on 11/4/22 at approximately 10:00 AM with Risk Manager (E #2). E #2 stated, "There is not an order on those days for the non-violent restraints."

Based on document review and interview, it was determined that for 1 of 2 patient records (Pt #15) reviewed for blood transfusions, the Hospital failed to ensure that vitals signs were monitored and documented in accordance with approved policies and procedures. This has the potential to affect all patients receiving blood transfusions.

Findings include:

1. The Hospital's policy titled, "Blood Product Administration" (revised 9/30/21), was reviewed on 11/3/22. The policy noted "Vitals will be obtained: Once the blood product reaches the patient...Hourly until the transfusion is complete...within the hour post-infusion completion."

2. The clinical record of Pt #15 was reviewed on 11/3/22. Pt #15 was admitted to the SICU (surgical intensive care unit) on 11/1/22 with a diagnosis of Post Transaortic Valve Replacement. The clinical record indicated the blood transfusion started 11/1/22 at 11:14 AM and ended at 2:20 PM. Vitals were taken 11/1/22 at 11:14 AM, 11:23 AM, 11:28 AM, 11:33 AM and 11:38 AM. The clinical record lacked documentation of vital signs hourly and within the hour post-infusion completion per policy.

3. An interview was conducted with the Clinical Informatics (E #15) on 11/3/22 at 9:30 AM. E #15 agreed with the above finding that the vitals signs were not taken appropriately during a blood transfusion.

Based on observation, document review, and staff interview, it was determined the Hospital failed to ensure expired food items were disposed of per Hospital policy. This has the potential to affect all patients, staff and visitors of the dietary service areas in the Hospital.

Findings include:

1. The policy titled "Food Handling- Standards and Procedures (FS- FH-07)" was reviewed on 11/4/22 at approximately 10:15 AM. The policy noted "...Labeling Standards and Procedures...Discard foods that are not used by the...use by date."

2. On 11/1/22 at approximately 1:30 PM, a tour of the dietary department was conducted with the Manager of Dietary (E#3). During the tour the following items were observed to be outdated:
a) 1 container of chopped ham with expiration date of 10/27/22
b) 1 pan of jello with expiration date of 10/30/22

3. An interview was conducted during the tour with E#3. E#3 verbally confirmed the items were outdated and should have been removed.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety code portion of the Full Survey Due to a Complaint conducted on November 1 & 2, 2022, the surveyors find that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety code portion of the Full Survey Due to a Complaint conducted on November 1 & 2, 2022, the surveyors find that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

A. Based on observation and interview, it was determined the Hospital failed to ensure outdated or expired supplies were not available for patient use. This has the potential to affect all patients who receive care at the facility with a current average daily census of 191 patient.

Findings include:

1. On 11/1/2022 at approximately 1:30 PM, a tour of the Med-Surg (Medical-Surgical) Unit was conducted with the Nurse Manager (E#9). During the tour 1000 ml bag of Sterile Water for Inhalation was noted to be expired on 9/22 in the Storage Supply Room.

2. On 11/1/2022 a approximately 1:45 PM, an interview was conducted with E#9. E#9 verified the supplies were expired and should not have been available for patient use.

3. On 11/1/2022 at approximately 1:45 PM, a tour of the Radiology Department was conducted. During the tour a one (1) step valved centesis catheter was noted to have a use by date of 10/13/22 (expired) was available for patient use on the supply cart.

4. On 11/1/22 at approximately 1:50 PM, an interview with the Radiology Manager (E#4) was conducted. E#4 verbally agreed the supplies were expired and should not have been available for patient use.


B. Based on observation, staff interview, and document review, it was determined the Hospital failed to ensure that all mechanical, electrical, and patient-care equipment is maintained in safe operating condition. This has the potential to affect all patients receiving care at the Hospital with a current census of 191 patients.

Findings include:

1. On 11/1/22 at approximately 1:30 PM, a tour of 6 North was conducted with the Nurse Manager (E#9). During the tour the "refrigator/ freezer temperature control chart" log noted on 11/1/22, temperature 30 degrees. The "refrigerator/ freezer temperature control chart noted temperatures should be between 33-40, if temperatures not within ranges stated, send a work order to maintenance. Then call Nutrition Services..." The log lacked documentation of Maintenance, Nutrition Services being notified and no corrective active done.

An interview was conducted with E#9 during the tour. E#9 verbally confirmed that no corrective action was taken for the temperature of 30 degrees.

2. On 11/2/22 at approximately 11:45 AM, a tour of the off site clinic was conducted with the Clinic Administrator (E#16). During the tour the following items lacked the required maintenance checks as required:

a) exam tables with electrical cords in rooms #1 and #4 lacked an "approved for use" sticker
b) Otoscope/ ophthalmoscope charging base with cords in rooms #2 and #4 lacked "approved for use" sticker
c) AED (automated external defibrillator) machine lacked daily checks
d) refrigerator lacked temperature monitoring

The policy titled "Clinical Engineering- Standard Operational Procedures (effective date: 2/1/22" was reviewed on 11/2/22 at approximately 2:15 PM. The policy noted "...Devices to be tagged with light green "CLINMISC (Clinical Miscellaneous) approved for use sticker...Non motorized exam tables...Otoscopes/ Ophthalmoscopes charging bases..."

The policy titled "Daily/ Shift Check Procedure" was reviewed on 11/3/22 at approximately 11:10 AM. The policy noted..."Check the Ready For Use (RFU) indicator on the...front panel. Verify that the RFU symbol is displayed."

An interview was conducted with the Administrator (E#16) during the tour. E#16 verbally confirmed the lack of approved stickers for use, daily AED checks and no temperature monitoring on the refrigerator.

3. On 11/02/2022 at approximately 1:00 PM, an observational tour of the Respiratory Therapy department was conducted. The following equipment was found to be out of date for yearly biomed checks:
a. 3 GE Carescape Ventilators indicated preventative maintenance was due 08/22 and 1 ventilator that was due 10/22.
b. In the ICU overflow equipment stock room there was a Maximove Hoyer lift which indicated preventative maintenance was due 10/22.

An interview was conducted with the Manager of Respiratory Therapy (E #15) during the tour. E #15 confirmed the preventative maintenance tags indicated the maintenance was over due and verbally agreed that the items were not checked annually as they were required by policy.

4. On 11/02/2022 at approximately 9:00 AM, The facility policy "Equipment Management Program (reviewed date 5/7/21) was reviewed. The policy noted, on page 5 "EC.02.04.01 (4) The hospital identifies the activities and associated frequencies, in writing, for maintaining, inspecting, and testing all medical equipment on the inventory. These activities and associated frequencies are in accordance with manufacturer's recommendations or with strategies of an alternative equipment maintenance (AEM) program...."

Based on observation, interview, and document review, it was determined 1 of 3 patients in isolation (Pt #2) the Hospital failed to ensure staff followed infection control policies and procedures. This has the potential to affect all patients who receive care at the facility with a current average daily census of 191 patient.

Finding include:

1. On 11/1/2022 at approximately 1:30 PM- 2:45 PM, a tour of the Medical-Surgical Unit was conducted with the Nurse Manager (E#12). During the tour a Certified Nursing Assistant (CNA) (E #13), was observed entering Contact Isolation room #654.
without a gown to do vital signs with a vital cart. E #13 was then observed existing room #654 and did not sanitize hands after removing gloves. E #13 failed to sanitize the vital cart (portable electronic monitoring machine for blood pressure, pulse and temperature) when existing room #654.

2. Pt #2's record was reviewed on 11/1/2022 at approximately 2:30 PM. Pt #2 was admitted on 10/25/2022 to room #654 with a diagnosis of Sepsis. Pt #2 was placed in contact isolation for MRSA (Methicillin Resistant Staphylococcus Aureus) of a wound on 10/27/2022 at 10:15 AM.

3. On 11/1/2022 and interview was conducted with the Unit Manager (E#12) during the observational tour. E #12 stated the CNA is not following isolation policy

4. On 11/2/2022 at approximately 9:00 AM, a tour of the MICU (Medical Intensive Care Unit) was conducted with the Nurse Manager (E #9). A phlebotomist (E #7) was observed transferring blood via syringe to a vial, removed gloves and did not perform hand hygiene.

5. On 11/2/2022 during the observational tour, an interview was conducted with the MICU Manager (E #9). E #9 stated, "Hand hygiene was not being done appropriately."

6. On 11/3/2022 at approximately 11:00 AM the policy titled "Hand Hygiene" (revised 8-20-20) was reviewed. The policy required " "II. Indications for hand hygiene...G. after removing gloves."

7. On 11/3/2022 at approximately 11:10 AM, the policy titled "Isolation (Transmission-Based) Precautions (reviewed 12-8-20) was reviewed. The policy required under Contact Precautions,"PPE (Personal Protective Equipment) is to be worn when entering a Contact Precaution room includes: a. gown b. gloves. The HCW (Health Care Worker) should remove their PPE before leaving the room and perform hand hygiene."

8. On 11/3/2022 at approximately 11:30 AM, the policy titles "Cleaning, Disinfection and Sterilization" (reviewed 1/5/21) was reviewed. The policy required "Non-critical items: Cleaning and disinfection. All items must be cleaned and disinfected between patients and after patient use..."