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A. Based on a review of Hospital policy and procedure, medical record review, and staff interview, it was determined that in 1 of 4 (Pt #26) medical records reviewed in which the patient had an invasive procedure performed, it was determined that the Hospital failed to ensure an informed consent was signed prior to the invasive procedure.

Findings include:

1. The Hospital policy and procedure titled, "Informed consent for Procedure" was reviewed on 05/05/09. It indicated under, " II. Policy: All invasive procedures must have an Informed Consent for Procedures stating the procedure...The medical record shall contain evidence of a patient's informed consent for any procedure or treatment for which it is appropriate..."

2. The medical record of Pt #26 was reviewed on 05/05/09. It indicated that the patient presented to the Emergency Department (ED) on 03/27/09 with a diagnosis of Trauma. Documentation indicated that after labs, radiology examination and consultation, a chest tube was placed. There was no documentation that indicated an informed consent was signed for the placement of the chest tube.

3. During an interview with the Vice President of Nursing, conducted on 05/05/09 at 1:45 PM, the above finding was confirmed.

A. Based on a review of Hospital policy and procedure, medical record review and staff interview, it was determined that in 5 of 7 (Pt #'s 13, 16, 22, 23, 29) medical records reviewed in which the patient received blood transfusions, the Hospital failed to ensure there were 2 registered nurse (RN) signatures that verified the blood was transfused to the correct patient.

Findings include:

1. The Hospital policy and procedure titled, "Administration of Blood and Blood Products" was reviewed on 05/05/09. It indicated under IV. PROCEDURE: I. ...the patient and unit of blood must be identified carefully. This must be done at the patient's bedside...One nurse should read this information...while the other RN verifies this by reading the same information on the blood bag...Both RNs must sign their names on the Blood Bank Requisition slip."

2. The medical record of Pt #13 was reviewed on 05/05/09. It indicated that Pt #13 was admitted on 04/28/09 with a diagnosis of Anemia Secondary to Gastrointestinal Hemorrhage. Documentation indicated that the patient received 2 units of packed red blood cells on 05/13/09. There was no documentation that indicated 2 RNs signed the lab slip after the correlating information was read on the blood bag and the patient's blood transfusion band at the patient's bedside.

3. The medical record of Pt#16 was reviewed on 05/5/09. It indicated that Pt#16 was admitted on 04/14/09 with diagnoses of Liver Cancer, Change in Mental Status, Cerebral Vascular Accident, Anemia and Dehydration. Documentation indicated that Pt#16 received 2 units of packed red blood cells on 04/16/09. There was no documentation to indicate that 2 RN's signed the lab slip after the correlating information was read on the blood bag and the patient's blood transfusion band at the patient's bedside.

4. The medical record of Pt #22 was reviewed on 05/05/09. It indicated that Pt #22 was admitted on 09/08/08 with the diagnoses of Severe Abdominal Pain, Gastric Lymphoma & Gastric Perforation. Documentation indicated that Pt #22 received a total of 4 units of Packed Red Blood Cells, 2 on 09/08/08 and 2 on 09/16/08. There was no documentation to indicate that 2 RN's signed the lab slip after the correlating information was read on the blood bag and the patient's blood transfusion band at the patient's bedside.

5. The medical record of Pt #23 was reviewed on 05/05/09. It indicated that Pt #23 was admitted on 05/02/09 with a diagnosis of Diabetic Ketoacidosis. Documentation indicated that Pt #23 received a total of 2 units of Fresh Frozen Plasma on 5/3/09.. There was no documentation to indicate that 2 RN's signed the lab slip after the correlating information was read on the blood bag and the patient's blood transfusion band at the patient's bedside.

6. The medical record of Pt #29 was reviewed on 05/06/09. It indicated that Pt #29 was admitted on 03/14/09 with the diagnoses of Bloody Diarrhea and Colitis. Documentation indicated that Pt #29 received 2 units of Fresh Frozen Plasma on 03/17/09. There was no documentation to indicate that 2 RN's signed the lab slip after the correlating information was read on the blood bag and the patient's blood transfusion band at the patient's bedside.

7. During an interview conducted on 05/06/09 at 2:45 PM with the Vice President of Nursing, the above findings were confirmed.


B. Based on a review of Hospital policy and procedure, medical record review and staff interview, it was determined that in 2 of 7 (Pt #13, #29) medical records reviewed in which the patient received a blood transfusion, the Hospital failed to ensure that all patient vital signs were taken at the appropriate times.

Findings include:

1. The Hospital policy and procedure titled, "Administration of Blood and Blood Products" was reviewed on 05/05/09. It indicated under, "IV. Procedure: E. ...Temperature, pulse, respirations and blood pressure need to be done by an RN at 15 minutes after initiation and upon completion..."

2. The medical record of Pt #13 was reviewed on 05/05/09. It indicated that Pt #13 was admitted on 04/28/09 with a diagnosis of Anemia Secondary to Gastrointestinal Hemorrhage. Documentation indicated that on 05/13/09 the patient received 2 units of packed red blood cells. There was no documentation that the 15 minute vital signs were taken during the administration of the first unit of blood.

3. The medical record of Pt #29 was reviewed on 05/06/09. It indicated that Pt #29 was admitted on 03/14/09 with a diagnoses of Bloody Diarrhea and Colitis. Documentation indicated that on 03/17/09, Pt #29 received 2 units of Fresh Frozen Plasma. There was no documentation that the 15 minute vital signs were taken during the administration of the first unit.

4. During an interview with the Vice President of Nursing, conducted on 05/06/09 at 2:45 PM, the above findings were confirmed.

A. Based on medical record review and staff interview, it was determined in 1 of 20 (Pt #7) medical records reviewed in which the patient was admitted from the Emergency Department (ED), the Hospital failed to ensure that the ED medical exam for admission was documented.

Findings include:

1. The medical record of Pt #7 was reviewed on 05/05/09. Pt #7 was admitted to the hospital on 04/28/09 with the diagnosis of Dehydration. ED documentation indicated that Pt #7 was evaluated in the ED at 3:52 PM on 04/28/09 with chief complaint of Diarrhea and was discharged home at 5:10 PM by ED physician #1. ED nursing documentation indicated that Pt #7 returned to the ED at 9:26 PM the same day and was admitted to the Intensive Care Unit by ED physician #2. There was no documentation of a the medical exam for the second ED visit for admission to the hospital..

2. During an interview conducted on 05/05/09 at 3:00 PM with the VP of Nursing, the above finding was confirmed.

B. Based on medical record review and staff interview, it was determined in 1 of 7 (Pt #8) medical records reviewed, in which Pt # 8 patient received medication without documentation of a physician order.

Findings include:

1. The medical record of Pt #8 was reviewed on 05/05/09. Pt #8 was admitted to ED on 04/29/09 with the chief complaint of Chest Pain. There was no documentation of a physician order for Plavix. Nursing documentation indicated that Plavix 300 mg was given at 1:55 AM.

2. During an interview conducted on 05/05/09 at 3:00 PM with the VP of Nursing, the above finding was confirmed.

A. Based on Hospital Bylaws Rules and Regulations, a review of the medical records delinquency report and staff interview, it was determined that the Facility failed to ensure all medical records were completed within 21 days following discharge.

Findings include:

1. The Hospital Bylaws, Rules and Regulations were reviewed on 05/06/09. It indicated that discharge records shall be completed within twenty-one days of patient discharge.

2. As of 05/06/09, a written delinquency record rate was recorded at 4 delinquent records. All records were 30 days past due.

3. During an interview conducted on 05/06/09 at 11:00 AM with the Vice President of Nursing, the above finding was confirmed.

A. Based on observation and staff interview, it was determined that the Hospital failed to ensure all expired drugs and biologicals were removed from patient use areas.

Findings include:

1. During a tour of the Hospital, conducted on 05/05/09, it was observed that in the following areas did not remove all expired drugs and biologicals from patient use areas:

- Laboratory area, it was noted that there were 11 MRSA culture plates, all expired as of 4/23/09. There were 3 BacT/Alert FA Aerobic and 3 BacT/Alert FN Anaerobic culture bottles, all expired 4/30/09, observed in the laboratory draw boxes.

- Intensive Care Unit (ICU), it was noted that there were 11 - 3.32 ml Blood Culture Tubes, all expired as of 01/2009. Also, there were 13 large Blood Culture Tubes, all expired as of 02/2009.

- The crash cart on the ICU, it was noted that there was one 1000 ml bag of Normal Saline with an expiration of 04/2009.

- Respiratory Department, 1 liter of 0.9% Normal Saline injection was observed in the crash cart, expired 3/1/09.

5. During an interview conducted on 05/05/09 with the Vice President of Nursing, the above finding was confirmed.


B. Based on a observation and staff interview, it was determined that the Hospital failed to ensure that all patient identifying information was removed from all returned medications.

Findings include:

1. During a tour of the Pharmacy Department, conducted on 05/04/09 at 1:45 PM, the following intravenous admix antibiotics were observed on the medication shelves with discharged patient identifying information attached to them and available for patient use: 2 - Ampicillin/Sulbactam 1.5 gram in 100 ml 0.9% Normal Saline, 3 - Ampicillin 1 gram in 100 ml 0.9% Normal Saline, and 3 - Cefoxitin 1 gram in 50 ml 5% Dextrose in Water.

2. During an interview conducted on 05/05/09 at 3:00 PM with the Vice President of Nursing, the above findings were confirmed.

A. Based on a review of the specimen log for those cultures sent to the State of Illinois laboratory and staff interview, it was determined that the Hospital failed to ensure the receipt of the results were documented on the log.

Findings include:

1. On 05/04/09 the log that indicated what specimens were sent to the State of Illinois laboratory for further examination was reviewed. There was no documentation on the log that indicated when or if the results of the findings were received by the lab.

2. During an interview with the Laboratory Supervisor, conducted on 05/04/09 at 11:20 AM, it was verbalized that the receipt of the results should have been documented on the log and confirmed the above findings.

A. Based on a review of Hospital policy and procedure, a review of dietary refrigerator/freezer logs, and staff interview, it was determined that the Hospital failed to ensure that all abnormal temperatures were followed up by supervisory or maintenance staff.

Findings include:

1. The Hospital policy and procedure titled, "Recording refrigerator and Freezer Temperatures" was reviewed on 04/05/09. It indicated under, "IV. Procedure: 5. All temperatures are recorded in the morning at the beginning of the shift. All discrepancies are reported to Supervisor and Maintenance is notified."

2. The dietary refrigerator/freezer temperature record log for March 2009 was reviewed on 04/05/09. It indicated that the recommended temperature for refrigerators is 32 - 40 degrees F and "Any discrepancy should be followed up by supervisor and maintenance notified if needed." The log indicated that there were 7 refrigerator temperatures during March that exceeded the 40 F. maximum temperature. There was no documentation that indicated the abnormal temperatures were reported to a supervisor and that maintenance was notified.

3. During an interview with the Dietary Manager, conducted on 04/05/09 at 9:15 AM, the above findings were confirmed.

A. Based on a review of medical record review and staff interview, it was determined that in 2 of 4 (Pts #14 & #17) medical records reviewed, in which the patient required anesthesia services, the Hospital failed to ensure that the pre-anesthesia evaluation was performed within 48 hours prior to the surgery or procedure requiring anesthesia services.

Findings include:

1. The medical record of Pt #14 was reviewed on 05/05/09. Pt #14 was admitted to the hospital on 03/30/09 with the diagnosis of Left Knee Arthritis and underwent Total Knee Arthroplasty the day of admission. Anesthesia documentation indicated that the Pre-Anesthesia evaluation was completed on 03/19/09.

2. The medical record of Pt #17 was reviewed on 05/05/09. Pt #17 was admitted to the hospital on 04/27/09 with the diagnosis of Right Renal Mass and underwent surgical removal of the mass the day of admission. Anesthesia documentation indicated that the Pre-Anesthesia evaluation was completed on 04/20/09.

3. During an interview conducted on 05/06/09 at 11:00 AM with the Vice President of Nursing, the above findings were confirmed.