HospitalInspections.org

A. Based on document review, observation, and interview, it was determined that on the Obstetric Unit (OB) and Nursery, the Hospital failed to ensure the infant banding protection mechanism was functional to help promote infant safety. This potentially affected all eight (8) infants on the unit as of 12/19/12.

Findings include:

1. Hospital policy #65.060.004, reviewed 10/1/12, titled, "Infant Abduction Event (Code Pink Activation) was reviewed. The policy failed to provide instructions on the use of infant banding.

2. On 12/19/12 at 9:30 AM, an observational tour was conducted in the OB and Nursery Units. Infants were wearing an infant protection band on their leg.

3. On 12/19/12 at 9:40 AM, the OB Charge Nurse (E #9) stated that the bands are activated when placed on the infant and were designed to cause the doors of the unit to lock, should an abduction attempt occur.

4. On 12/19/12 at 11:30 AM, a second observational tour was conducted in the OB and Nursery Units. An infant abduction band was activated and taken to the North exit door. The door remained unlocked and was able to be opened. Hence, the protection system failed.


B. Based on document review and staff interview, it was determined that on the Obstetric Unit (OB) and Nursery, the Hospital failed to ensure Infant Abduction Drills were conducted on at least an annual basis, to help promote infant safety.

Findings include:

1. Hospital policy #65.060.004, reviewed 10/1/12, titled, "Infant Abduction Event (Code Pink Activation) was reviewed. The policy failed to provide instructions or frequency of Infant Abduction Drills.

2. On 12/19/12 at 12:30 PM, Code Pink drills were requested. There were no drills in 2011 or 2012. The Manager of Public Safety provided Public Safety reports for 2011 that included events when the OB Unit doors were opened causing an accidental alarm activation. The most current date of alarm testing was on 8/15/11. There was no documentation of staff instruction or evaluation related to infant abduction in 2011 or 2012. The Manager of Public Safety stated on 12/19/12 at 1:10 PM, that code pink drills are to be performed annually.

3. On 12/19/12 at 1:30 PM, an interview was conducted with the Manager of Performance Improvement and Public Safety. The Manager stated there have been no Code Pink drills in 2011 or 2012. The Manager stated she did not recall when the last Code Pink drill took place.

4. An observational tour was conducted on the Transitional Care Unit (TCU). Pt. #12 was observed in room 457 with a large bandage on her right foot.

5. The clinical record of Pt. #12 was reviewed and included that Pt. #12 was an 82 year old female, admitted on 12/14/12, with a diagnosis of Pneumonia. A progress note dated 12/17/12, included a Right Heel Wound, "3 cm x 2 cm x 0 cm oval shaped eschar tissue noted. 100% purplish black colored necrotic tissue noted..." However, Pt. #12's initial nursing assessment dated 12/14/12 thru 12/17/12, did not include an assessment of Pt. #12's right foot.


6. An interview was conducted with the TCU's Assistant Manager on 12/17/12 at 2:15 PM. The Assistant Manager stated that Pt. #12 had a Right Foot Wound which should have been assessed upon admission.





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Based on review of documents, interview and observation, it was determined that for 2 of 3 (Pt. #9 and #12) clinical records reviewed of patients with wounds, the Hospital failed to assess the wounds per policy.

Findings include:

1. Hospital policy titled, "Skin Integrity: Care & Treatment of the Skin (revised 2/1/10)" included, "Documentation of skin assessment will be on admission. Document skin reassessments. Documentation of a pressure ulcer or wound will be completed on each shift or at the prescribed dressing change intervals ..."

2. The clinical record of Pt. #9 included that Pt. #9 was a 90 year old male admitted on 12/9/12 with diagnoses of Sepsis, Congestive Heart Failure and Decubitus Ulcers. A Physician's orders were written on 12/9/12 for "wound care consult" and "measure pressure ulcers". The clinical record included a progress note from the wound care nurse dated 12/12/12 that lacked an assessment of Pt. #9's multiple wounds. The clinical record lacked documentation of a complete wound assessment with measurements as of survey date 12/17/12.

3. During an interview on 12/17/12 at 2:00 PM, the Manager of ICU (Intensive Care Unit) stated she would find the report from the wound care nurse. On 12/18/12 this surveyor was presented with a chart progress note dated 12/17/12 at 3:54 PM with all the measurements of Pt. #9's wounds.

7. The clinical record of Pt. #5 was reviewed and included that Pt. #5 was a 45 year old female, admitted on 12/7/12, with a diagnosis of Diabetic Foot Ulcer. Pt. #5 was on the 4 South Unit. A blood culture report dated 12/7/12 included a right foot wound culture with Rare Gram Positive Cocci and Rare Staphylococcus. Pt. #5 was in contact isolation. However, Pt. #5's care plan did not include documentation of the infection or isolation.

8. An interview was conducted with the 4 South Unit's Assistant Manager on 12/17/12 at 10:45 AM. The Assistant Manager stated that Pt. #5's care plan did not include infection and isolation, which should have been addressed.

9. The clinical record of Pt. #10 was reviewed and included that Pt. #10 was a 47 year old female, admitted on 12/13/12, with diagnoses of Fever and Right Pleural Effusion. Pt. #10 was on the 4 North West Unit. A physician's order dated 12/13/12, required, "telemetry". Pt. #10 was wearing a heart monitor. However, Pt. #10's care plan did not include cardiac monitoring.

10. An interview was conducted with the 4 North West Unit's Interim Clinical Manager on 12/17/12 at 1:30 PM. The Manager stated that Pt. #10's care plan did not include cardiac monitoring, which should have been addressed.

11. The clinical record of Pt. #12 was reviewed and included that Pt. #12 was an 82 year old female, admitted on 12/14/12, with a diagnosis of Pneumonia. Pt. #12 was on the Transitional Care Unit (TCU). A Physician's order dated 12/14/12, included nebulizer treatments every 6 hours and the order dated 12/15/12, included a nasal canula at 3 liters. A Physician's order dated 12/17/12, included dialysis treatment. However, Pt. #12's care plan did not include respiratory or renal problems.

12. An interview was conducted with the TCU's Assistant Manager on 12/17/12 at 2:15 PM. The Assistant Manager stated that Pt. #12's care plan did not include respiratory or renal problems, which should have been addressed.










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Based on document review and interview, it was determined that for 6 of 12 (Pt. #s 3, 7, 8, 5, 10 and 12) clinical records reviewed on the nursing units, the Hospital failed to ensure nursing care plans were current for each patient.

Findings include:

1. Hospital policy titled, "Plan of Care - Inpatient (reviewed 10/1/12)" included, "The Plan of Care (POC) is developed through an interdisciplinary process individualized to the patient's specific needs ..."

2. The clinical record of Pt. #3 included that Pt. #3 was a 74 year old female admitted on 12/13/12 with the diagnosis of Chest Pain. Pt. #3 was on hemodialysis for Chronic Renal Failure. The POC dated 12/13/12 did not include hemodialysis.

3. During an interview on 12/17/12 at 10:45 AM the Nurse Manager of 2 North Telemetry Unit stated that hemodialysis should have been included on the POC.

4. The clinical record of Pt. #7 included that Pt. #7 was an 86 year old male admitted on 12/11/12 with the diagnoses of Sepsis and Renal Failure. Pt. #7 was placed on contact isolation on 12/12/12. The POC updated on 12/13/12 did not include isolation.

5. The clinical record of Pt. #8 included that Pt. #8 was an 83 year old female admitted on 12/7/12 with the diagnosis of Pancreatitis. Pt. #8 was placed on contact isolation for a positive MRSA (Methicillin Resistant Staphylococcus Aureus) screening culture on 12/16/12. The POC dated 12/16/12 did not include isolation.

6. During an interview on 12/17/12 at 2:00 PM, the Manager of ICU (Intensive Care Unit) stated that isolation should have been included on both care plans, for Pt. #7 and Pt. #8.

Based on document review and interview, it was determined that the Hospital failed to ensure all clinical records were completed, as required.

Findings include:

1. The "General Rules and Regulations of the Medical Staff (2010)" included, "If, thirty (30) days after discharge, items ... are incomplete, the record will be considered to be delinquent".

2. On 12/18/12 at 11:20 AM the Hospital presented an attestation letter that indicated as of December 18, 2012, the Hospital had 149 incomplete records greater than 30 days post discharge (delinquent).

3. The Director of Health Information Management stated during an interview on 12/18/12 at approximately 11:10 AM, that there are 149 delinquent records.

A. Based on document review and interview, it was determined that for 4 of 4 walk-in cooler/freezer, the Hospital staff failed to ensure all refrigerator temperatures were documented. This potentially affected all 142 patients on census.

Findings include:

1. The Hospital policy titled, "Food Storage Under Proper Condition" (reviewed 10/12) required, "Food Storage will be monitored and non-conformances identified and tracked using the following tools: Refrigerator/Freezer temperature log...temperatures are documented for all days on all logs."

2. The Food and Nutrition Service refrigerator and Freezer temperature log (Dairy, Meat Fruit) for December 11, 2012 to December 17, 2012 was reviewed on 12/18/12 at approximately 11:45 AM. Four (4) of four temperature logs were incomplete, lacking documentation of temperatures on 12/11/12 and 12/14/12 for the dairy refrigerator and meat freezer; and temperatures on 12/11/12 for the meat and fruit/vegetable refrigerator.

3. The above findings were discussed with the Manager of Nutritional Services on 12/18/12 at approximately 11:30 AM, who stated that refrigerator and freezer temperatures should be documented in the logs as required by policy.


B. Based on observation and interview it was determined that, for 1 of 1 food cart, the Hospital failed to ensure cooked food was not stored below raw meat. This practice potentially affects all 142 patients on census.

Findings include:

1. During an observational tour of the kitchen and dietary services on 12/18/12 between 10:50 and 11:30 AM, a food cart in the meat refrigerator contained a pan of cooked meat that was stored below a tray of raw chicken.

2. An interview with the Food Production Supervisor was conducted during the tour on 12/18/12. The Supervisor stated that it is the department practice to store cooked food and raw meat in separate carts and that cooked food/meat should never be stored under raw meat. The findings were discussed with the Manager of Nutritional Services and the Food Production Supervisor on 12/18/12, during the interview at 11:30 AM.


C. Based on observation, document review, and interview, it was determined that for 1 of 4 staff stationed on the tray line (E #8), the Hospital failed to ensure adherence to policies governing attire in the kitchen.

Findings include:

1. During an observational tour of the kitchen and dietary services on 12/18/12 between 10:50 and 11:30 AM, E #8 was observed wearing dangling earrings.

2. The Hospital policy titled, "Dress Code Policy" (Revised 8/1/12), reviewed on 12/18/12, required, "All associates must be in uniform at work... Cooks...no jewelry, ...Food Production Associate...no jewelry. No jewelry is permitted except a wedding ring or band...."

3. The above findings were discussed with the Manager of Nutritional Services and the Food Production Supervisor on 12/18/12, who stated that dangling earrings were not allowed to be worn in the kitchen.

Corrected 03/01/16

B. Based on document review, observation, and interview, it was determined that, the Hospital failed to ensure the chlorine testing strips met required sensitivity for dialysis chlorine/chloramine testing. This potentially affected all patients receiving hemodialysis, 11 patients on 12/17/12 and 5 patients on 12/18/12.

Findings include:

1. The Hospital policy for chlorine/chloramine testing of the carbon tanks was requested on 12/17/12 and on 12/18/12. No policy was provided.

2. The Water Log Sheets for December 2012 were reviewed and included that chloramine testing each shift from the carbon tanks (worker and polisher) was less than 0.1 ppm.

3. On 12/17/12 at 10:10 AM, an observational tour was conducted in the dialysis treatment room. The Serim Guardian residual chlorine test strips, used to check chlorine from the carbon tanks, included the description, "Test for residual chlorine in rinse water." The bottle included test calibrations for chlorine sensitivity at 0, 0.5, 1, 2, and 5 ppm, but were not calibrated to detect a sensitivity of 0.1 ppm, as documented on the water log sheets.

4. On 12/18/12 at 9:45 AM, an interview was conducted with the Director of Cardiac and Medical Services, Biological Equipment Technician, and Dialysis Registered Nurse. Each of these individuals stated they were not aware that the chlorine testing strips did not include sensitivity calibration for 0.1 ppm readings.




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A. Based on document review, observation and interview it was determined for 1 of 2 (2 South) Telemetry nursing units, the Hospital failed to ensure oxygen tanks were stored properly for safety. This potentially affected all 22 patients on census on the 2 South Unit.

Findings include:

1. Hospital policy titled, "Oxygen Storage, Handling and Transport (origination date 9/29/08)" included, "Cylinders should be properly secured in a cylinder cart, stand, etc., to avoid being tipped over".

2. An observational tour of the 2 South Telemetry Unit was conducted on 12/17/12 at approximately 10:45 AM. The linen room contained a storage unit for oxygen tanks that was full. Three (3) full oxygen tanks were unsecured next to the cart.

3. During an interview on 12/17/12 at approximately 11:00 AM, the Manager of 2 South stated that she was aware the tanks were there and a call had been made to have them removed.

Based on document review and interview, it was determined for 1 of 3 (Pt.#16)death records reviewed, the Hospital failed to ensure an Organ Procurement Organization was notified of a patient's death.

Findings include:

1. The Hospital Policy #65.007.018, titled "Organ and Tissue Procurement Donation Process" (revised 6/21/07) was reviewed and required, "It is the policy of Advocate Trinity Hospital to notify Gift of Hope (GOH) of all imminent deaths and deaths..."

2. On 12/18/12 at approximately 10:00 AM the clinical record of Pt.#16 was reviewed. Pt.#16 was a 79 year old male admitted on 10/18/12 with a diagnosis of non-radiating Chest Pain, and a medical history of Metastatic Colon Cancer, and Renal Failure. Pt.#16 was pronounced deceased on 10/21/12. The clinical record lacked notification to an Organ Procurement Organization of the imminent death or death of Pt.#16.

3. These findings were confirmed by the Hospital's Medical Director (E#7) during an interview on 12/18/12 at approximately 11:00 AM.

A. Based on observation, interview and document review, it was determined that for 1 of 5 (E#6) staff observed in OR#4, the Hospital failed to ensure contaminated items were not available for patient use.

Findings include:

1. On 12/18/12 at approximately 7:20 AM, E#6 entered OR #4 and dropped a box of 4-O POS II suture on the floor and then placed the box of sutures back into a case.

2. The above finding was discussed with the Manager of Surgical Services on 12/18/12.

3. Hospital policy titled, "Aseptic Technique Basic Practices"( revised 12/03/12) was reviewed on 12/18/12 at 12:45 PM. The policy included, "All packages dropped to the floor must be discarded."


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B. Based on review of Hospital documents, observation and interview, it was determined that for 5 of 10 staff (E # 1, 2, 3, 4, & 5) observed in Operating Rooms (OR's) 3 & 5, the Hospital failed to ensure staff adhered to policy on OR attire.

Findings include:

1. The Hospital policy titled "Operating Room Attire" (reviewed 9/24/12) was reviewed on 12/18/12. The policy required, "The following procedure is to be observed when Operating Room access is necessary- Initial entry-complete scrub attire is worn and consist of ...cap, ...mask."

2. The reference "Lippincott-Surgical asepsis: Surgical attire" (reviewed 3/31/12) reviewed on 12/18/12, required, "...The restricted area includes the operating room suite, procedure rooms and clean core. Surgical attire and hair coverings are required... Implementation: ... put on a surgical head cover or hood and ensure that all hair and facial hair, including sideburns, are covered to prevent hair, dandruff and microorganisms from falling onto the sterile field. ...Ensure that the mask covers your mouth and nose completely. Mold the malleable metal strip on the top of the mask to your nose...."

3. During an observational tour of the operating room suites on 12/18/12 between 7:00 AM and 7:45 AM the following were observed:

This was found in OR 3.
-At 7:23 AM, E #1, a CRNA, entered the room holding a mask over her nose and mouth, and approximately 1 inch of hair was exposed at the back of her neck, below the cap.

-At 7:30 AM, E #2, a surgeon, entered the room with approximately 2 inches of hair exposed at the back of the neck, below the skull cap.
Surveyor: 19840

This was found in in OR #4.

-On 12/18/12 between 7:15 AM and 7:45 AM the following was observed.
-E#3 (anesthesiologist) entered OR. #4 while tying the surgical mask.
-E#4 (surgeon) entered OR. #4 while tying the surgical mask.
-E#5 (surgical assistant) entered OR #4 with approximately 2 inches of hair exposed from under the surgical cap.

Surveyor: 07105

4. The above findings were discussed with the Operating Room Manager, during an interview on 12/18/12.