HospitalInspections.org

A. Based on document review and interview, it was determined for 1 of 4 (Pt. #3) clinical records reviewed for patients receiving Phototherapy (light treatment to lower bilirubin levels in babies), the Hospital failed to ensure a physician's order was in place, as required.

Findings include:

1. On 5/8/18 at approximately 11:00 AM, the clinical record of Pt. #3 was reviewed. Pt. #3 was a 10 day old female born on 4/28/18 with diagnoses of prematurity, jaundice, and at risk for hyperbilirubinemia. The clinical record indicated that Pt. #3 was placed on Phototherapy from 5/6/2018 at 11:00 AM until 5/8/2018 at 9:45 AM. However, the clinical record did not include a physician's order for the Phototherapy.

2. On 5/8/18 at approximately 1:00 PM, the Hospital's guidelines titled, "Hyperbilirubinemia (high level of bilirubin/orange-yellow pigment in the body) in Term and Late Pre-term Infants," (dated 12/2015) was reviewed and required, "... F. Initiation of Phototherapy: 1. Phototherapy is the primary therapy for hyperbilirubinemia..."

3. On 5/8/18 at approximately 1:30 PM, the Hospital's document titled, "Nursing Services 2017, Newborn RN (Registered Nurse) Obstetrical Orientation Check List" (dated 7/11/2017) was reviewed and required, "...Page 11 Newborn Phototherapy, check provider orders..."

4. On 5/8/18 at approximately 2:00 PM, the Hospital's job description titled, "Staff Nurse I" and "Staff Nurse II" (revision date 1/30/17) was reviewed and required, "...Verifies and implements orders from physician, physician assistant, and/or advance practice nurse..."

5. On 5/8/18 at approximately 2:20 PM, findings were discussed with E #4 (Associate Chief Nursing Officer of Maternal and Child Health). E #4 stated that there should have been an order for the Phototherapy. E #4 added that she could not find the physician's order for the Phototherapy.

B. Based on document review and interview, it was determined for 4 of 4 (Pt. #1, #2, #3, and #4) clinical records reviewed for patients that received Phototherapy (light treatment to lower bilirubin levels in babies), , the Hospital failed to ensure nursing interventions, regarding the use of the Bilirubin light, were implemented, as required.

Findings include:

1. On 5/8/18 at approximately 1:00 PM, the Hospital's guidelines titled, "Hyperbilirubinemia (high level of bilirubin/orange-yellow pigment in the body) in Term and Late Pre-term Infants" (dated 12/2015) was reviewed and required, "... F. Initiation of Phototherapy: 1. Phototherapy is the primary therapy for hyperbilirubinemia...7.a. Eye shields should be used whenever an infant is receiving overhead phototherapy..."

2. On 5/8/18 at approximately 1:30 PM, the Hospital's document titled, "Nursing Services 2017, Newborn RN Obstetrical Orientation Check list (dated 7/11/2017) was reviewed and required, "...Newborn Phototherapy... Check light intensity...Protect infant eyes..."

3. On 5/9/18 at approximately 10:00 AM, the Hospital's policy titled, "Physical Assessment and Monitoring of Newborns in the Intensive Care and Intermediate Care Nurseries" (dated 7/2017) was reviewed and required, "...Procedure... 2. Physical Assessment...ii. Routine care (diaper change, position change)... should not have intervals that exceed 6 hours."

4. On 5/8/18 at approximately 11:00 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 5 week old female born on 4/1/18 with diagnoses of prematurity and respiratory distress. The clinical record included a physician's order for Phototherapy dated 4/1/2018 until 4/4/2018. On 4/3/18, the clinical record lacked documentation that Pt #1 was repositioned every 6 hours: from 8:00 AM to 5:00 PM (9 hours).

5. On 5/8/18 at approximately 10:45 AM, the clinical record of Pt. #2 was reviewed. Pt. #2 was a 5 day old male born on 5/2/2018 with diagnoses of prematurity, jaundice, and at risk for hyperbilirubinemia. The clinical record indicated that Phototherapy was initiated on 5/4/2018 at 8:00 AM and continued until 5/8/2018 at 11:00 AM. The clinical record lacked daily documentation of the bili-meter reading (measures the intensity of the Phototherapy light) from 5/4/2018 to 5/7/2018.

6. On 5/8/18 at approximately 11:00 AM, the clinical record of Pt. #3 was reviewed. Pt. #3 was a 10 day old female born on 4/28/18 with diagnoses of prematurity, jaundice, and at risk for hyperbilirubinemia. The clinical record indicated that Pt. #3 was placed on Phototherapy from 5/6/2018 at 11:00 AM until 5/8/2018 at 9:45 AM. The clinical record lacked daily documentation of the bili-meter reading from 5/6/2018 to 5/8/2018.

7. On 5/8/18 at approximately 11:15 AM, the clinical record of Pt. #4 was reviewed. Pt. #4 was a 4 day old male born on 5/3/18 with a diagnosis of hyperbilirubinemia. The clinical record indicated that Pt. #4 was receiving Phototherapy from 5/7/18 at 9:00 AM until 5/8/18 at 9:00 AM. However, the clinical record lacked every 3 hour documentation that the eye mask (to protect the infant's eyes) was on, from 10:00 AM to 4:00 PM on 5/7/18 (6 hours).

8. On 5/8/18, at approximately 11:30 AM and at 2:20 PM, the findings were discussed with E #2 (Clinical Nurse Specialist) and E #4 (Associate Chief Nursing Officer of Maternal and Child Health). E #2 and E #4 stated that the Hospital's required practice, while babies receive the phototherapy includes daily documentation of bili-meter reading and every 3 hour documentation that the eye mask is in place.

9. On 5/9/18 at approximately 10:30 AM, another interview was conducted with E #2. E #2 stated that position changes (including while babies receive Phototherapy) should be documented in the clinical record every 6 hours.


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C. Based on document review and interview, it was determined that for 1 of 4 (Pt #8) clinical records reviewed on the 7 East Unit, the Hospital failed to ensure physicians' orders were followed, as required.

Findings include:

1. The clinical record of Pt #8 was reviewed on 5/8/18 at approximately 10:35 AM. Pt #8 was a 62 year old female who was admitted on 5/2/18 with a diagnosis of non-healing surgical wound. Pt #8's clinical record contained a physician's order dated 5/2/18 that required, "Please resume free water flush 300 cc's (cubic centimeters) q (every) 6 hours." Pt #8's clinical record lacked documentation that Pt #8 received the required 300 cc's water from 5/5/18 at 6:00 AM to 5/8/18 at 5:59 AM (72 hours).

2. The Associate Chief Nursing Officer (E #3) stated during an interview on 5/9/18 at approximately 10:30 AM, that there was only one documented time the patient received the required 300 cc's of fluid.

D. Based on document review and interview, it was determined that for 1 of 4 (Pt # 8) clinical records reviewed on the 7 East Unit, the Hospital failed to ensure the patient was turned and repositioned, as required, to prevent skin breakdown.

Findings include:

1. The Hospital's policy entitled, "University of Illinois Hospital Clinics Clinical Care Guideline," (dated July 2016) required, "Addendum 1: Medical/Surgical Units...Q2h (every 2 hours)...pt repositioning..."

2. The clinical record of Pt #8 was reviewed on 5/8/18 at approximately 10:35 AM. Pt #8 was a 62 year old female who was admitted on 5/2/18 with a diagnosis of non-healing surgical wound. Pt #8's clinical documentation included that on 5/5/18, Pt #8 was on bedrest, requiring passive range of motion (the therapist or equipment moves the joint with no effort from the patient). Pt #8's clinical record lacked documentation that Pt #8 was repositioned every 2 hours as required from: 2:13 AM to 9:01 AM on 5/5/2018 (8 hours and 48 minutes); on 5/5/18 from 9:01 AM until 8:00 AM on 5/6/2018 (22 hours and 59 minutes); and 5/6/2018 from 12:28 PM until 5/8/2018 at 4:50 AM (40 hours and 22 minutes).

3. The Associate Chief Nursing Officer (E #3) stated, during an interview on 5/9/18 at approximately 10:30 AM, that the patient was not turned every 2 hours, as required.


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E. Based on document review and interview, it was determined for 1 of 2 (Pt. #6) clinical records reviewed of patients with documented pain, the Hospital failed to ensure that a pain reassessment was done, as required.

Findings include:

1. The Hospital's policy titled, "Inpatient Guidelines For Adult Documentation (effective 8/11/2016)" reviewed on 5/8/18, required, "Addendum 1: Medical/Surgical Units...PCA, every 4 hours."

2. The clinical record of Pt #6 was reviewed on 5/8/18. Pt #6 was a 26 year old female admitted on 5/1/18 with a diagnosis of sickle cell crisis. The clinical record indicated that Pt #6 was receiving Morphine (pain medication) via a Patient Analgesic Pump (PCA). The clinical record lacked documentation of a pain assessment as required, on 5/3/18 from 1:18 AM to 5/3/18 8:00 AM (6 hours, 38 minutes).

3. The Chief Nursing Officer E #3 was interviewed on 5/8/18 at approximately 1:30 PM. E #3 stated, "Pain assessments should be done every shift or every 4 hours."

F. Based on document review and interview it was determined that for 1 of 1 (Pt. #1) clinical record reviewed with a documented wound, the Hospital failed to ensure that the patient was free of injury/skin breakdown.

Findings include:

1. On 5/8/18 at approximately 11:00 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 5 week old female born on 4/1/18 with diagnoses of prematurity and respiratory distress. The History and Physical dated 4/1/18, indicated when Pt. #1 was born there was no indication of skin breakdown.

The nursing assessment sheet indicated that an abrasion on the patient's foot was first identified on 04/03/2018 at 8:00 PM. The physician's progress note, dated 04/04/18 indicated, "Left lower leg abrasion likely 2/2 [secondary to] ID band, no acute signs of infection-wound care. R [right] foot abrasion, likely trauma or pressure induced no acute signs of infection-wound care ..."

The discharge addendum note dated, 4/8/18 at 10:58 PM, included "Skin - On day of life 4, a left lower leg abrasion (thought to be likely secondary to ID band) and a right foot abrasion (thought to secondary to pressure/trauma) was identified ..." Pt. #1 was discharged home on 4/8/18 with an order of Bacitracin [antibiotic ointment] to be applied twice a day.

2. On 5/8/18 at approximately 3:50 PM an interview was conducted with (Registered Nurse) E #1. E #1 stated, "I cannot recall how this scab came on, it was an old injury when I came on. This is not a common injury."

3. On 5/9/18 at approximately 8:58 AM, an interview was conducted with Pt. #1's Attending Neonatologist (MD #1). MD #1 stated, " ...the nurse told me the skin findings. We discussed types of diagnoses. No diagnosis was made, just this finding. The clinical picture is clear it did not look like a burn. I looked at the dorsal aspect of foot , bilateral actually, this was another weird thing. We did not have a treatment on our hands."

Based on document review and interview, it was determined that for 1 of 1 (Pt #7) clinical record reviewed, of a patient requiring subcutaneous medications, the Hospital failed to ensure the medication was administered and documented, as required.

Findings include:

1. The Hospital's policy requiring medication administration for injectable medications, was requested on 5/9/18. The Associate Chief Nursing Officer (E #3) stated, "The Hospital does not have a policy for medication administration that required site rotation."

2. The clinical record for Pt #7 was reviewed on 5/8/18. Pt #7 was a 47 year old male who was admitted on 5/7/18, with a diagnosis of fluid overload. The clinical record for Pt #7 contained a physician's order dated 5/8/18, that required, "Insulin Aspart 13 units subcutaneous 3 times a day, and Insulin Glargine 40 units subcutaneous every 12 hours." The clinical record indicated that Pt #7 received the prescribed insulin in the same site (right upper arm) on 5/7/18, at 11:51 PM, 5/8/18 at 9:52 AM, and 5/8/18 at 1:00 PM.

3. The Associate Chief Nursing Officer (E #3) was interviewed on 5/9/18 at approximately 10:45 AM. E #3 stated, "The patient told the nurse he only wanted to use his right arm. When we hire a new nurse, they are expected to have the knowledge of rotation of injection sites when administering injections."

Based on document review and interview, it was determined that for 1 of 3 (Pt #10) clinical records reviewed for blood transfusions, the Hospital failed to ensure the blood was infused, as required.

Findings include:

1. The Hospital's policy entitled, "Blood Component Therapy," (effective August 18, 2017) required, "...Initiation of Blood...2. Verify physician order for transfusion...."

2. The clinical record of Pt #10 was reviewed on 5/10/2018 at approximately 11:45 AM. Pt #10 was a newborn male admitted to the Hospital on 6/30/17 with a diagnosis of bronchopulmonary dysplasia of newborn. Pt #10's clinical record included a physician's order dated 8/14/17, which required that Pt #10 receive 37 cc's of blood over 2 hours. However, Pt #10's clinical record contained documentation that the blood was transfused from 4:02 PM on 8/14/17 to 7:05 PM on 8/14/17 (3 hours), not the required 2 hours.

3. The Associated Chief Nursing Officer (E #3) stated, during an interview on 5/10/18 at 11:45 AM, that the patient received the blood over 3 hours and not the required 2 hours.