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Based on document review and interview, it was determined that for 1 of 3 (Pt. #2) patients receiving as needed (PRN) medications on the Orthopedic/Trauma/Medical Surgical Unit (Unit 50), the Hospital failed to ensure a reassessment was completed.

Findings include:

1. The Hospital policy titled, "Assessment - Re-assessment of Patients (reviewed 6/1/17)" was reviewed on 10/31/17. The policy required, "patient will be assessed ...within at least one hour after any intervention ..."

2. The clinical record of Pt. #2 was reviewed on 10/30/17 at 10:30 AM. Pt. #2 was a 69 year old male admitted on 10/27/17 with the diagnosis of espohageal (throat) cancer requiring gastrostomy (artificial opening into the stomach) tube placement. The Medication Administration Record included that Pt. #2 received PRN valium (treatment for anxiety) on 10/29/17 at 7:24 PM and on 10/30/17 at 12:15 AM. On 10/29/17, Pt #2 received PRN Zofran (for nausea) at 5:43 PM. The clinical record lacked a post assessment for these medications.

3. During an interview on 10/30/17 at 11:00 AM, the Assistant Manager of Unit 50 (E#1) stated, "When a PRN medication is given, the staff is required to document the response to the medication within one hour."

Based on document review and interview, it was determined that the Hospital failed to ensure all medical records were completed within 30 days of patient discharge.

Findings include:

1. On 11/1/17, the "Medical Rules and Regulations of Advocate Good Samaritan Hospital" (approved 4/8/15), were reviewed and required, "...2.1.18 The patient's medical record shall be completed at the time of discharge or within time frames according to regulation (CMS, accrediting bodies, etc.) which includes the progress notes, principal diagnosis, procedures, and a discharge summary."

2. On 11/1/17 at approximately 1:20 PM, an attestation letter was presented and signed by the Director of Health Information Management (E #9) that indicated, "As of November 1, 2017 (the Hospital) has 329 Delinquent Medical Records".

3. On 11/2/17 at approximately 11:25 AM, E #9 stated during an interview that a medical record is delinquent, if not completed within 30 days after discharge.

Based on observation, interview, and document review it was determined that for 4 of 4 pediatric cautery electrodes (Valleylab REM Polyester Infant Patient Return Electrode and Neonatal REM Poly Hesire III) in surgical suite #10, the Hospital failed to ensure expired patient care products were available for use, potentially affecting all pediatric patients scheduled for surgery in surgical suite #10.

Findings include:

1. On 10/31/17 between 9:45 AM and 11:00 AM, an observational tour was conducted in the Surgical Department. At 10:20 AM, in surgery suite #10, four (4) of 4 pediatric cautery electrodes (Valleylab REM Polyester Infant Patient Return Electrode and Neonatal REM Poly Hesire III) included the following expiration dates on the wrappers: September 2012; May 2013, November 2013, and September 2014.

2. On 10/31/17 at 10:25 AM, an interview was conducted with the Surgical Services Business Manager (E #5). E #5 stated that there are only "a handful a year" of pediatric patients who undergo surgery in surgical suite 10.

3. On 10/31/17 at 10:50 AM, an interview was conducted with the Director of Surgical Services (E #3). E #3 stated that outdated supplies should be removed.

4. On 11/1/17 at 9:20 AM, Hospital policy titled, "Control of Non-Conforming Products" (reviewed 3/5/15) was reviewed. The policy required, "III. Definitions/ Abbreviations...B. Non-conforming product: any product that fails to meet the specified requirements of its intended use. These products may be expired...Examples include...Medical Devices/Instruments/Equipment...IV Procedure...Any clinical supply item and reprocessed medical instruments...1. Supplies are monitored to identify expired, damaged or suspected products not suitable for use. 2. Supplies identified as non-conforming will be removed..."

Based on observation, interview, and document review, it was determined that for 2 of 15 plastic bowls, located in the clean area, the Hospital failed to ensure dishware was clean, potentially affecting approximately 150 patients on census.

Findings include:

1. On 11/1/17 between 10:45 AM and 11:25 AM, an observational tour was conducted in the dietary department. Two of fifteen 6 ounce plastic "cold cups" had been placed in a clean container after being washed, but still contained substantial debris resembling vanilla pudding. The cups were ready for service.

2. On 11/1/17 at 11:00 AM, an interview was conducted with the Clinical Nutrition Manager (E #6). E #6 stated the dishwashing person didn't catch the dirty cups - "didn't have good attention", but the dirty cups would have been caught before being used.

3. The Hospital policy entitled, "Dishwashing," (date of review 12/2/0) was reviewed on 11/1/17 at approximately 2:30 PM and required, "..Handling and Storing of Clean Dishes and Utensils. 1. Examine all dishes and utensils for cleanliness and re-wash if necessary..."

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 October 31- November 2, 2017, 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 October 31 - November 2, 2017, 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, interview, and document review, it was determined that for 1 of 1 Physician Assistant (PA) (E #2), the Hospital failed to ensure staff hand hygiene was performed.

Findings include:

1. On 10/30/17 at 10:15 AM, an observational tour was conducted on the Critical Care Unit (CCU). At 10:25 AM, in the trauma area, in room 42, a PA (E #2) was removing an EVD (external ventricular drain - used to relieve intercranial pressure) from Pt. #10. After performing the EVD procedure, E #2 removed 2 sets of surgical gloves, did not perform hand hygiene, donned new gloves, and removed the supplies used during the procedure.

3. On 10/30/17 at 10:30 AM, an interview was conducted with E #2. E #2 stated that hands should be disinfected after removing gloves.

3. On 10/30/17 at 3:00 PM, the Hospital policy titled, "Hand Hygiene" (reviewed 4/5/17) was reviewed. The policy required, "...B. Use soap and water or alcohol-based hand rub...2. During patient care activities including but not limited to...e) after removing gloves..."

B. Based on observation, interview, and document review, it was determined that for 1 of 1 Surgical Assistant (E #4), the Hospital failed to ensure that uncovered hands and arms were not extended over the a sterile field.

Findings include:

1. On 10/31/17 between 9:45 AM and 11:00 AM, an observational tour was conducted in the Surgical Department. At 10:00 AM, in surgery suite #10, an unscrubbed Surgical Assistant (E #4) was transferring sterile supplies onto a sterile field on a back table, including syringes, tubing, and a needle. E #4's hands and arms were uncovered and were extended over the top of the back table's sterile field where she was transferring the sterile supplies.

2. On 10/31/17 at 10:30 AM, an interview was conducted with the Director of Surgical Services (E #3). E #3 stated that the OR (operating troom) follows the standards of the AORN (Association of Perioperative Registered Nurses), and bare arms and hands should not extend over a sterile field.

3. On 11/1/17 at 12:00 PM, the AORN 2017 Guidelines for Perioperative Practice (reviewed September 2014) was reviewed. The Standard for "Sterile Technique" Recommendation VI included, "Items introduced to the sterile field should be opened, dispensed, and transferred by methods that maintain the sterility and integrity of the item and the sterile field... VI.b. Items should be delivered to the sterile field in a manner that prevents unsterile objects or unscrubbed team members from leaning or reaching over the sterile field. Microorganisms are shed from the skin of perioperative personnel. Maintaining distance from the sterile field decreases the potential for contamination when items are passed from unsterile to sterile areas."

C. Based on observation, interview, and document review, it was determined that for 1 of 3 surgical suites (Suite #3) toured, the Hospital failed to ensure equipment was disinfected between cases, potentially affecting 4 patients scheduled for surgery in surgical suite #3 on 10/31/17.

Findings include:

1. On 10/31/17 between 9:45 AM and 11:00 AM, an observational tour was conducted in the OR (Operating Room). At 10:45 AM, in surgery suite #3, cleaning between cases was taking place. Paper tape was observed on the surgical table, back table, and side tray table during the room cleaning. Paper tape was still present on the back table and side tray table after the room cleaning was completed, preventing thorough cleaning and disinfecting of these surfaces.

2. On 10/31/17 at 10:50 AM, an interview was conducted with the Director of Surgical Services (E #3). E #3 stated that paper tape should not be on surgical equipment.

3. On 11/1/17 at 9:40 AM, Hospital policy titled, "Operating Room Cleaning - End of Case Cleaning, Terminal Cleaning and Project Work" (lacking an implementation date) was reviewed. The policy required, "V. Procedure for After Case Cleaning... B. Disinfect Surfaces: 1. Saturate a cleaning rag with Ecolab Oxycide disinfectant solution... Wipe all surfaces and allow to stay wet for three minutes."

D. Based on observation, interview, and document review,it was determined that for 1 of 3 handwashing sinks in the Dietary Department, the Hospital failed to ensure proper handwashing, potentially affecting approximately 150 patients on census.

Findings include:

1. On 11/1/17 between 10:45 AM and 11:25 AM, an observational tour was conducted in the Dietary Department. One of 3 hand washing sinks (hot production/cook's sink) was approximately 6 inches by 8 inches in size and the faucet was approximately 2 inches from the sides of the sink. Therefore, hands could not be placed under the faucet without touching the sides of the sink.

2. On 11/1/17 at 11:05 AM, an interview was conducted with the Food Service Manager (E #7). E #7 stated that the sink was a "food safety hazard" and should not be used to wash hands.

3. On 11/1/17 at 12:50 PM, Hospital policy titled, "Hand Hygiene" (reviewed 4/5/17) was reviewed. The policy required, "G. Hygiene Technique: 1. Hand hygiene using soap and water a) Turn on faucet b) Wet hands with warm water... c) Apply soap d) Covering all surfaces, rub hands together... e) Rinse hands together with warm water f) Pat dry... g) Turn off faucet with disposable towel."