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Based on observation, document review, and interview, it was determined for 1 of 1 (E#21) Physician Assistant (PA) who delegate tasks to Certified Medical Assistants (CMA), the Hospital failed to ensure the PA collaborative agreement addressed the medical supervision and delegation of tasks to the CMAs. This has the potential to affect all patients receiving services from the PA.

Findings include:

1. An observational tour of off site location was conducted on 4/11/17 between approximately 8:00 AM and 9:00 AM with the Manager Intermediate Care and Occupational Medicine (E#22) and the Vice President of Ambulatory Services (E#23). In the physician office, the PA (E#21) was observed providing care to patients.

2. An interview was conducted with E#22 on 4/11/17 at approximately 8:45 AM. E#22 stated the physician office is staffed with a Registered Nurse (RN) for phone triage, a RN for Pediatrics, a Licensed Practical Nurse (LPN) for Internal Medicine, and Certified Medical Assistants for Family Practice. When asked what staff the PA delegates tasks to, E#22 stated "... (E#21) can delegate to all of the staff (RN, LPN, and CMAs)."

3. The (225 ILCS 95/) Physician Assistant Practice Act of 1987 was reviewed on 4/12/17 at approximately 10:00 AM. The Act stated "(225 ILCS 95/4) Sec. 4. In this Act: 3... The supervising physician may delegate tasks and duties to the physician assistant... The delegated tasks or duties shall be specific to the practice setting and shall be implemented and reviewed under a written supervision agreement established by the physician or physician/physician assistant team... Physician assistants shall practice only in accordance with a written supervision agreement."

4. The collaborative agreement for E#21 was reviewed on 4/12/17 at approximately 9:30 AM. The agreement failed to address whether the PA could supervise and delegate tasks to the CMA.

4. An interview was conducted with the the Quality Manager (E#24) on 4/12/17 at approximately 9:30 AM. E#24 reviewed the collaborative agreement and stated the agreement failed to address whether the PA could supervise and delegate tasks to the CMA.

Based on document review, interview, and observation, it was determined the Hospital failed to ensure for 4 of 4 (Pt# 31, #10, #32, and #33) patients with a retention catheter, that the catheter was properly secured in accordance with its' policy. This has the potential to affect all patients with retention catheters.

Findings include:

1. The policy titled "Clinical References for Patient Procedures" (revised 8/16) was reviewed on 4/12/17 at approximately 3:30 PM. The policy noted under "B. Nurses will reference Lippincott's Nursing Procedures. 7th Edition for procedures not defined in PCM or Nursing Procedures;. The reference "Lippincott Nursing Procedures' utilized for guidance "Inserting Retention Catheter" noted on page 783 to "Tape catheter to abdomen with 1-in tape if client is not ambulatory or use securement device made with Velcro strap....Tape catheter to upper thigh if client is ambulatory".

2. During an observational tour of the Medical Surgical 2 South Unit on 4/12/17 at approximately 4:00 PM with the Manager of the Medical Surgical 2 South Unit (E #14), the following patients failed to have a securement device of tape or Velcro to secure the retention catheter.
a) Pt #31 in room #204
b) Pt #10 in room #208
c) Pt #32 in room #220
d) Pt #33 in room #218-2
During the tour, E#14 verbally confirmed that the catheters were not properly secured per policy.

3. During an interview on 4/12/17 at approximately 5:15 PM, Registered Nurse (E #13) stated "A catheter secure is only applied if the patient is constantly pulling on the urinary catheter."

Based on document review, observation and interview it was determined for 2 of 4 medication carts, the Hospital failed to ensure medication carts were secured. This has the potential to affect all inpatients and outpatients serviced by the Hospital with a current in-patient census of 53 patients and an average monthly Outpatient census of 10,093 patient.

1. The policy titled "Medication Administration, Ordering, Standardized Dosing" (reviewed 10/16) was reviewed on 4/13/17 at approximately 9:30 AM. The policy required "Medication carts shall be locked when unattended".

2. A tour of the Medical Surgical 2 East Unit was conducted with the Unit Manager (E#10) on 4/11/17 at approximately 2:00 PM. Medication cart 12 and medication cart 13 were unattended and unlocked. Cart 12 had one drawer open which contained 8 (eight) 18 Gauge needles, 2 (two) 18 Gauge 1 1/2 inch safety needles, 4 (four) 10 ml (milliliters) 0.9% NACL (Normal Saline) Injection Flushes and 6 (six) 10 ml syringes. Cart 13 had 10 drawers open which contained 10 (ten) 18 Gauge needles and 7 (seven) 10 ml syringes.

3. During an interview conducted on 4/11/17 at approximately 2:20 PM, E#10 stated that the medication carts should be locked at all times.

Based on document review, observation, and interview, it was determined the Hospital failed to ensure defective lead shielding devices were removed from service. This has the potential to affect all staff providing and/or assisting in the provision of radiological services.

Findings include:

1. The Hospital policy titled "Care, Cleaning, and Annual Checking of the Lead Aprons and Thyroid Collar Shields - Cath (Catheterization) Lab (Laboratory)" (effective date 2/1/2017) was reviewed on 4/12/17 at approximately 12:00 PM. The policy stated the lead aprons and thyroid collar shields were to be checked annually and "II. C. 3. Results are documented and defective equipment is replaced."

2. The Cardiovascular Catheterization Laboratory annual shielding device check, dated 6/6/16 and 6/27/16, was reviewed on 4/12/17 at approximately 10:30 AM. The document stated 6 of 26 shielding devices were found to have defects. The document lacked documentation as to whether the defective devices were removed from service.

3. A tour of the Catheterization Laboratory was conducted on 4/12/17 at approximately 10:40 AM with the Director Radiology and Patient Access (E#5) and the Manager Imaging Services (E#6). The Director of Cardiovascular Services (E#19) and The Supervisor of the Catheterization Laboratory (E#18) compared the defective shielding list against the shielding devices present for use in the department. Four of the six defective shielding devices (Vest #IC2187, Thyroid #5, Bottom #1B, and Bottom #3B) were present and actively being used during procedures per E#18 and E#19.

4. An interview was conducted with E#18 on 4/12/17 at approximately 10:40 AM with E#5 and E#6 present. E#18 stated being unaware of having any shields that were defective and stated "They should have been taken out of service and new ones ordered."

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 April 11 thru April 13, 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 April 11 thru April 13, 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 and interview, it was determined the Hospital failed to ensure infection control measures were followed to prevent the potential of cross contamination. This has the potential to affect all inpatients and outpatients serviced by the Hospital with a current inpatient census of 53 and an average monthly outpatient census of 10,093.

Findings include:

1. On 4/11/17 at approximately 1:45 PM, in the Radiology hallway, the Pathologist (E#4) was observed walking down the hallway with another laboratory person who was pushing a cart with a microscope on it. E#4 was wearing a pair of purple gloves and walked into the Ultrasound room. The Patient Safety Nurse (E#7), the Director of Radiology and Patient Access (E#5), and the Manager of Imaging Services (E#6) were present and also observed this.

2. An interview was conducted with E#5, E#6, and E#7 concurrently. E#5 stated that the Pathologist (E#4) was going to the Ultrasound room for a biopsy and "was going to check to make sure they had a good sample before the Ultrasound was completed". All three stated uncertainty as to why E#4 would be wearing gloves while walking through the hallways and then into the Ultrasound room to care for a patient, as "This shouldn't be done."

3. On 4/11/17 at approximately 1:55 PM, the Phlebotomist (E#8) was observed performing a laboratory draw on Pt #5. E#7 was also present. E#8 placed supplies (including a roll of coban-an elastic pressure wrap applied to prevent bleeding) on Pt #5's bed, drew Pt #5's laboratory tests, unrolled and applied a portion of the coban to the site, and then returned the remainder of the coban to the laboratory drawing cart.

4. An interview was conducted with E#7 on 4/11/17 at approximately 2:00 PM. E#7 stated "I saw that too, (E#8 placing the coban on Pt #5's bed, using a portion of it, and returning the remainder to the laboratory drawing cart) and that shouldn't happen."

5. An interview was conducted with E#8 on 4/11/17 at approximately 2:05 PM. E#8 stated "I didn't even think of that." E #8 verbally agreed the coban could be taken to another patient and used and could be a potential source of cross contamination.

6. During an observational tour on 4/12/17 at approximately 2:00 PM with E#7, room #271 had a "Contact/Droplet Precaution" sign posted on the door frame. Registered Nurse (E#29) was in room #271 conducting patient care with a personal protective gown unfastened. E#29 then closed the room door. When the door was reopened, E#29's gown was fastened and properly donned.

7. During an interview on 4/12/17 at approximately 2:00 PM, E#7 verbally agreed E#29's gown was incorrectly donned.

B. Based on observation, document review, and interview, it was determined the Hospital failed to ensure the first in, first out (FIFO) procedure was utilized in the Nutrition Department to assure the prevention of spoilage and/or contamination of dry/canned goods, in accordance with its' policy. This has the potential to affect all patients, visitors, and staff who consume food from the Dietary Department.

Findings include:

1. An observational tour was conducted on 4/12/17 at approximately 2:15 PM with the Dietary Manager (E#25) and the Dietary Supervisor (E#26). In the dry storage area, all canned items, such as seven 112 ounce cans of Gran Sazon Refried Beans, were without an expiration date on the cans and no date of receipt, and/or date to discard.

2. The Hospital policy titled "Hazard Analysis Critical Control" (last reviewed/revised 02/2014) was reviewed 4/12/17 at approximately 2:30 PM. The policy stated the Nutrition Services Department "has the following procedures in effect to define potential hazards in the preparation of food that can be monitored by control points... can more accurately ensure a safe food supply.. D. Storage 3. The first in, first out (FIFO) inventory system is used. Stock is rotated upon delivery according to procedure."

3. An interview was conducted with E#25 and E#26 on 4/12/17 at approximately 2:15 PM. Both stated that the box the cans come in have the expiration date; however, they do not transfer this information to the cans when they remove them from the boxes. Both further stated that they do not date when they receive the canned goods or when they should be discarded. Both stated, "We just know they (the staff) rotate things and they (the canned items) aren't here very long because we use them so fast."

C. Based on observation, document review, and interview, it was determined the Hospital failed to ensure curtains were laundered and monitored to assure the prevention of potential cross contamination, in accordance with its' policy. This has the potential to affect all inpatients, outpatients, visitors, and staff.

Findings include:

1. Observational tours of the Hospital were conducted between 4/11/17 and 4/12/17. Cloth curtains were observed throughout the Hospital with staff, patients, and visitors touching the curtains to pull them open, closed, or out of the way. Examples are as follows:
a. Dividing the semi private rooms on the patient floors.
b. Dividing the treatment bays in the Emergency Department.
c. Surrounding the treatment bed in the Stress Department.

2. The Hospital policy titled "Cleaning Discharge Room" (last review/revision 05/2016) was reviewed on 4/12/17 at approximately 2:50 PM. The policy stated "IV. Procedure: C. 5. Inspect bedside curtains and window treatments, if visibly soiled report to supervisor for replacement."

3. The Hospital policy titled "Terminal Cleaning of Isolation Rooms" (last reviewed/revised 05/2016) was reviewed on 4/12/17 at approximately 2:50 PM. The policy stated "VI. EVS (environmental services) Tech II Tasks A. Remove curtains first and place them in a soiled linen bag. This step includes, when indicated, window treatments/curtains, privacy curtains, and shower curtains. Reusable curtains will be cleaned using approved detergents."

4. Both policies stated the "Reference: Practical Guidance for Healthcare Environment Cleaning, Second Edition, Association for the Healthcare Environment of the American Hospital Association, 2012".

5. An interview was conducted with the Team Lead Environmental Services (E#27) on 4/12/17 at approximately 2:00 PM with the Director Cardiovascular Services (E#19) and the Quality Management Specialist (E#20) present. E#27 stated "I know we take them (the curtains) down when we have an airborne case, but the others, I'm not sure. My manager is off right now. I don't know how that's tracked."

6. An interview was conducted with the Environmental Services personnel (E#28) on 4/13/17 at approximately 10:00 AM. E#28 stated "I'm not sure when they (the curtains) get changed or cleaned. Once a patient is discharged from the Hospital from isolation, I think they're cleaned but I'm not sure."

7. An interview was conducted with Quality Manager (E#24) on 4/12/17 at approximately 2:00 PM. E#24 stated "They (environmental services) doesn't have anything that tracks that (the laundering of curtains) and they don't have the reference information here. It's at the Manager's home and (the Manager) is off." E#24 nodded "yes" when asked if E#24 was aware that staff are not knowledgeable of the policy and when the curtains are to be laundered.


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D. Based on document review, observation and staff interview, it was determined the Hospital failed to ensure an injectable medication was drawn up properly to prevent the potential for cross contamination, in accordance with its' policy. This has the potential to affect all patients requiring injectable medications.

Findings include:

1. The policy titled "Clinical References for Patient Procedures" (revised 8/16) was reviewed on 4/12/17 at approximately 3:30 PM. The policy noted under "B. Nurses will reference Lippincott's Nursing Procedures. 7th Edition for procedures not defined in PCM (Patient Care Manuel) or Nursing Procedures". The nursing reference "Lippincott Nursing Procedures" utilized for guidance in "Drawing up medications for injection" noted on page 380 "Single-dose or multidose vials ...Wipe the stopper of the medication vial with alcohol with an alcohol pad, and then draw up the prescribed amount of medicine".

2. During an observational tour of the Medical Surgical Unit 2 East with the Unit Manager (E#10) on 4/12/17 at approximately 12:00 PM, Registered Nurse (E#12) failed to disinfect the rubber septum with alcohol prior to piercing with the needle.

3. During an interview on 4/12/17 at approximately 12:10 PM, E#10 stated "I have never heard of cleaning the rubber septum with alcohol when the cap is taken off the vial. It is considered sterile; therefore there is no need to disinfect the septum."

E. Based on document review, observation, and interview, it was determined for 1 of 1 (Pt #15) patient observed with an IV (Intravenous) solution, the Hospital failed to ensure the IV solution and tubing was changed to prevent the potential for cross contamination, in accordance with its' policy. This has the potential to affect all patients receiving IV therapy.

1. The policy titled "IV (Intravenous) Therapy" (revised 6/14) was reviewed on 4/11/17 at approximately 4:00 PM. The policy required "E. Changing the Solution; Plain IV solutions should be changed when infused or every 48 hours...F. Changing the Tubing 10. ...replace administration sets that are continuously used, including secondary sets and add-on-devices, at 96 hour intervals."

2. During an observational tour on 4/11/17 at approximately 1:30 PM, Pt #15 was observed to have a 0.9 Normal Saline flush bag with approximately 250 ml (milliliters) remaining in the bag with a label on the tubing "to be discarded on 4/7/17" and an empty Diflucan 100 mg (milligrams)in 60 ml of Norma Saline bag with a label on the tubing "discard 4/8/17".

3. The Registered Nurse (E#11) assigned to Pt # 15 was interviewed on 4/11/17 at approximately 1:35 PM. E#11 stated that the 0.9 Normal Saline flush bag should have been discarded as well as the tubing.

F. Based on document review, observation, and interview, it was determined the Hospital failed to ensure proper procedure was followed when refrigerator/freezer temperatures were found out of range to prevent spoilage and/or contamination of products, in accordance with its' policy. This has the potential to affect all patients with a current inpatient census of 53.

1. The policy titled "Refrigerator /Freezer Temperature Checklist" (reviewed 1/16) was reviewed on 4/12/17 at approximately 11:00 AM. It required "Refrigerators that house milk will be maintained between 35 degrees and 40 degrees Fahrenheit ... If temperature is not within the acceptable parameters, notify maintenance for repair, assess integrity of contents, and move contents to a functioning refrigerator until repairs have been made and temperature readings meet the standard. Document all findings on the Refrigerator Freezer Temperature Checklist".

2. During an observational tour on 4/11/17 of the Medical Surgical Unit at approximately 1:00 PM with the Manager of Medical Surgical Unit (E#10), the Refrigerator Breast Milk/Formula log noted the refrigerator was not in the acceptable range on 4/1/17, 4/4/17, 4/5/17, 4/7/17 and 4/8/17. The Refrigerator Log lacked documentation of the action taken when the refrigerator was out of range on these 5 days.

3. During an interview on 4/11/17 at approximately 1:15 PM, E#10 stated that the staff did not follow the policy and should have.