HospitalInspections.org

Based on observation, document review and staff interview it was determined in 1 of 1 (Pt #35) patients records reviewed receiving C-ARM (radiology device used for imaging) usage during surgery, the Hospital failed to ensure privileges were granted to MD#1 (Orthopedic Surgeon) to use and interpret radiographs during surgery. This has the potential to affect all patients who receive radiological services in the Operating Room.

Findings include:

1. During a tour of the Main Surgical Unit storage room on 1/12/22 at approximately 11:15 AM with the Director of Peri-operative Services (E#18), 2 mini C-ARM were observed. E#18 stated "The orthopedic surgeons use the mini C-ARM during the procedures. The radiology technicians are not present. They read their own (images)."

2. The record of Pt #35 was reviewed on 1/14/22 at approximately 1:30 PM. The record noted during an open reduction and internal fixation of the bimalleolar ankle fracture, C-ARM imaging was conducted and interpreted by MD#1.

3. The Physician file of MD#1 was reviewed on 1/13/22 at approximately 3:00 PM, with Division Director of Medical Staff Services (E#20). E#20 stated "The surgeons are not credentialed for the use of the C-ARM".

4. An email dated 1/14/22 at 12:36 PM noted "We do not have fluoro (fluoroscopy/radiology services) on our surgical privilege forms... As of now, credentialing does not include competency on mini or standard C-Arm usage."

5. An interview was conducted on 1/14/22 at approximately 1:00 PM with the Director of Radiology (E#19). E#19 stated "We don't credential surgeons for the use a the C-ARM".

Based on observation, document review, and staff interview, it was determined the Hospital failed to ensure opened food items were dated 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 and Supply Storage (date revised by the facility: 5/21)" was reviewed on 1/11/22 at approximately 3:00 PM. The policy noted "...Procedures:...label and date unused portions and opened packages..."

2. A tour of the dietary department was conducted on 1/11/22 at approximately 1:45 PM with Executive Chef (E#9). During the tour the following items were opened and undated:
a) 1- 128 ounces of Olive Oil
b) 1 box of uncooked potatoes
c) 3 bags of shrimp
d) 3 boxes of bananas

3. During the tour on 1/11/22 an interview was conducted with the E#9. E#9 verbally agreed the food items should have been labeled with a date.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Full Survey Due to a Complaint conducted on January 11-13, 2022, the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

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 January 11 - 13, 2022, 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, document review and interview, it was determined the Hospital failed to ensure emergency carts were checked and maintained per policy. This has the potential to affect all visitors and in patients who receive care in the Hospital.

Findings include:

1. The policy titled "Crash Cart Inspection Procedure" was reviewed on 1/11/22 at approximately 3:15 PM. The policy noted "...Guidelines/ Procedures: A. Each crash cart is checked once a day...."

2. During a tour of the Newborn Nursery on 1/11/22 at approximately 11:15 AM, with the Manager of Obstetrics (E#11) the "Women and Infants Crash Cart Quality Check" logs were reviewed. The logs lacked documentation of the required daily checks:

a) July 2021 lacked 9 out 31 days
b) August 2021 lacked 11 out of 31 days
c) September 2021 lacked 8 out of 30 days
d) October 2021 lacked 8 out of 29 days
e) November 2021 lacked 8 out of 30 days
f) December 2021 lacked 4 out of 31 days

3. During an interview on 1/11/22 at approximately 2:45 PM, E#11 verbally confirmed the crash cart wasn't checked daily. E#11 stated "the crash cart is in the nursery and hasn't been used so wasn't checked daily."


4. On 1/12/22 at approximately 11:45 AM, the Malignant Hypothermia cart in the Main Operating unit was observed to have unsecured medications in drawer 1.

5. On 1/12/22 at approximately 1:30 PM, the anesthesia pyxis cart was observed to have a non-locked drawer with 10- 5 ml bottles of Lidocaine 1% labeled "Lidocaine for use in the sterile field" on the anesthesia cart in room #3 of the Cardiac Surgery Unit.

6. During an interview on 1/12/22 between 11:45 AM and 1:30 PM, E#18 (Director of Peri-Operative Services) stated the anesthesiologists check the medications on the cart once a week and the anesthesia technicians check the supplies once a week although there was no policy or checklist to ensure the checks were conducted and to identify what medications and supplies and the amount of medications and supplies to be on the cart. E#18 verbally agreed the Lidocaine medication should have been in a locked cabinet.

Based on document review and interview, it was determined the Hospital failed to ensure a clean and sanitary environment to prevent the transmission of infectious diseases. This has the potential to affect all staff, visitors, outpatients and inpatients who receive care by the Hospital.

Findings include:

1. The policy titled "... Division Transmission Based Precautions" (not dated) was reviewed on 1/12/22. The policy noted "VI. Contact Precautions:... I. Patient-Care Equipment and Instruments/Devices:... If common use of equipment for multiple patients in unavoidable, equipment shall be cleaned and disinfected prior to use on another patient. X. Special Airborne Precautions A... are to be used for patients with confirmed or suspected infection from SARS-COV-2 (COVID-19)... CDC (Center for Disease Control) recommendations and includes additional respiratory protection... Eye Protection... and gown."

2. The Contact/Airborne Isolation With Eye Protection and the Contact Isolation Plus signs (numbered as RO6-21) were reviewed on 1/13/22. The signs noted "Cleaning/Disinfecting PDI "purple top" Super Sani-Cloths are used to clean all surfaces and must stay "wet" for TWO MINUTES to be effective."

3. During observational tours conducted throughout the survey, the following were observed:

-Emergency Department:
a) On 1/11/22 at approximately 11:45 AM, the Computerized Tomography (CT) Technician Assistance was observed to exit Room M with the CT machine with gloves on, walk down the hall and retrieved a warm blanket, re-entered Room M and place the blanket on the patient without performing hand hygiene or changing gloves.
b) On 1/11/22 at approximately 12:10 PM, Room R was observed to have a Contact Isolation Plus and a Contact/Airborne Isolation sign posted on the outside of the door. E#12 (Radiology Technician) was observed to exit Room R without without cleaning the x-ray machine.
c) On 1/11/22 at approximately 12:15 PM, Room Q was observed to have a Contact/Airborne Isolation sign posted on the door. E#13 (Respiratory Therapist) was observed to enter Room Q without donning gloves or a gown.
d) During an interview on 1/13/22 at approximately 2:30 PM, E#14 (Clinical Care Educator) stated "The COVID screen determines if the patient gets a COVID test. If the risk assessment results in testing, the Special Airborne Precaution sign is posted on the door. For any COVID patient or presumed COVID positive patient staff must wear gloves, gowns and a N-95 mask." E#13 verbally agreed the Contact/Airborne Isolation sign is the "COVID" sign and was referred to as the "Special Airborne Precaution sign.

Laboratory Department:
a) On 1/11/22 at approximately 1:30 PM, the reverse osmosis water system was observed to be grossly contaminated with dust, debris on the floor, the polisher and worker tanks had a tag labeled "Out 11/2/21", the salt observed in the water softener tank was tinged a brown color, soiled linen and tubing were on the floor.
b) During an interview on 1/11/22 at approximately 2:30 PM, E#15 (Laboratory Manager) stated the water system was used with 2 laboratory processing machines (Siemens Centaur XPT and Sysmex XN 3000).

Main Operating Rooms:
a) On 1/12/22 at approximately 10:30 AM, Room #13 was observed to be cleaned and available for patient use although a piled up sheet was observed on the anesthesia chair. It was unable to be determined if the sheet was clean or dirty
b) On 1/12/22 at approximately 11:30 AM, staff were observed to turnover/clean Room #3 for the next case. E#16 (Anesthesia Technician) was observed pushing the Anesthesia Cart out of Room #3 into the hallway without cleaning the cart or had gloves on. The Anesthesia Cart was observed to have an open garbage sack with a bloody suction canister and tubing and a 1000 ml (milliliter)bottle with yellow fluid (urine) unsecured on top of the cart.
c) During an interview on 1/12/22 at approximately 11:35 AM, E#17 (Anesthesia Technician) verbally explained and demonstrated the Anesthesia Workroom's process for cart cleaning. While in the dirty side of the workroom which had no dirty carts, E#17 sated "The dirty carts come in here. We discard the garbage and if there are any needles or anything they go here (red needle boxes). We wipe it down (pointed to the purple sani-wipes) and take it to the clean side (of the anesthesia workroom) to stock it back up." During the interview with E#17, E#16 was observed to push an anesthesia cart into the clean side. E#17 verbally agreed the cart should not have come in through the clean side. During an interview on 1/12/22 at approximately 11:45 AM, E#16 stated "I cleaned the cart in the hallway." E#16 verbally agreed the garbage contained bloody equipment and the bottle was filled with urine and was unsecured. When asked why the garbage and urine was not thrown away in the operating room with the other used equipment and supplies, E#16 stated "That's just how we do it."
d) During an interview on 1/12/22 at approximately 11:50 AM, E#18 (Director of Peri-Operative Services) verbally agreed the garbage and bottle of urine should not have been transported through the hallway, the anesthesia cart should have been wiped down prior to exiting the room nor should the anesthesia cart be cleaned in the hallway and taken directly to the clean side of the anesthesia workroom.

Cardiac Surgery:
a) On 1/12/22 at approximately 1:30 PM, Room #3 was observed to have 2 chairs torn with stuffing hanging out; 6 empty sterile water bottles in the clean supply cabinet; and the anesthesia cart had an opened package with a yankauer with bulb tip.
b) On 1/12/22 at approximately 1:20 PM, Room #5 was observed to have a mop head on the monitor cart; a sterile package for surgical preparation was on the floor; EKG (electrocardiogram) leads soiled with dirt and adhesive laying on a clean table; and 2 chairs were observed torn with stuffing hanging out.
c) On 1/12/22 at approximately 1:10 PM, Room #10 was observed to have Gayman Medi-Thermill cord grossly contaminated with dried blood; and 1 chair was observed torn with stuffing hanging out.
d) During the tour on 1/12/22 between 1:10 PM and 1:30 PM, E#18 observed the above findings and verbally agreed the rooms were not appropriately cleaned and supplies were appropriately stored and should have been.
Cardiac Catheter (Cath) Laboratory:
a) On 1/13/22 at approximately 9:30 AM, the hallway floor leading to the Cardiac Cath Unit was observed to be dusty, stained and had trash items on it.
b) During an interview on 1/13/22 at approximately 9:30 AM, E#5 (Director of Adult Medical Services) verbally agreed the hallway floor were not clean and should have been.

Based on document review and interview, it was determined in 1 of 1 (Pt#17) newborn patient record reviewed for surgical consents, the Hospital failed to follow the policy to ensure consents were complete. This has the potential to affect all patients who are having surgery.

Findings include:

1. The policy titled "Illinois Informed Consent Policy" was reviewed on 1/14/22 at approximately 10:30 AM. The policy noted "...D. Content of the Informed Consent Documentation...2. Name of the specific procedure..."

2. The clinical record of Pt#17 was reviewed on 1/14/22 at approximately 11:00 AM. Pt#17 was a born on 1/11/22 and diagnosed with Ankyloglossia (tongue tied). The record noted a procedure to repair the tongue ( Lingual Frenulotomy) was conducted on 1/11/22. The consent form dated 1/11/22 lacked the specific procedure that was conducted.

3. During an interview with the Manager of Obstetrics (E#11) on 1/13/22 at approximately 2:00 PM, E #11 verbally confirmed the consent form lacked the specific procedure that was performed.