HospitalInspections.org

A. Based on the Hospital's Medical and Surgical Restraint Physician Orders, clinical record review, and staff interview, it was determined for 2 of 4 patients with restraints, (Pt. #3 and #5) the Hospital failed to ensure physician restraint orders were complete.

Findings include:

1. The Hospital's Medical and Surgical Restraint Physician Orders requires documentation of type of restraint/device, physician signature, date, and time.

2. The clinical record of Pt. #3 was reviewed on 2/19/08. This was an 86-year-old male, admitted 2/14/08 with a diagnosis of Spinal Stenosis. The record included documentation of the following incomplete restraint orders:
* 2/8/08- failed to include type of restraint device
* 2/12/08- failed to include type of restraint device.

3. On 2/19/08, the clinical record for Pt. #5 was reviewed. This was an 89-year-old female admitted on 2/18/08 with a diagnosis of Intracranial Hemorrhage. The restraint order dated 2/19/08 was untimed by the physician.

4. The above finding was conveyed to E #5 on 2/20/08 at approximately 10:30 A.M.

A. Based on Hospital policy, clinical record review, and staff interview, it was determined for 1 of 4 patients with restraints, (Pt. #3) the Hospital failed to ensure that the restraint order was not written as PRN (as needed).

Findings include:

1. Hospital policy # (RG) PTC.603 entitled, "Restraints: Medical/Surgical," requires, "No order for restraints shall be written as a standing or PRN order."

2. The clinical record of Pt. #3 was reviewed on 2/19/08. This was an 86-year-old male, admitted 2/14/08 with a diagnosis of Spinal Stenosis. The record included documentation of a physician's order for restraint dated 2/17/08 at 9:00 A.M. The order included, "Wrist restraints or Posey restrain as needed".

3. The above finding was conveyed to the Chief Executive Officer, (CEO) on 2/20/08 at approximately 3:00 P.M.

A. Based on Hospital policy review, clinical record review, and staff interview it was determined for 3 of 4 patients with restraints, (Pt. #3, #4, and #13) the Hospital failed to ensure the patients were monitored in accordance with policy.

Findings include:

1. Hospital policy (RG) PTC.603 entitled, "Restraints: Medical/Surgical," requires, "All patients shall be reassessed, monitored, and reevaluated minimally every two (2) hours, or more frequently, based upon the patient's condition... after application of a restraint device."

2. The clinical record of Pt. #3 was reviewed on 2/19/08. This was an 86-year-old male, admitted 2/14/08 with a diagnosis of Spinal Stenosis. The record included documentation of physicians' restraint orders for several dates, including 2/16/08 and 2/17/08. The record also included documentation that the patient was in restraints. The record lacked documentation of patient assessment and monitoring at least every 2 hours on both dates(2/16 and 2/17/08) as required by policy.

3. The clinical record of Pt. #4 was reviewed on 2/19/08. This was a 77-year-old male, admitted 2/2/08 with diagnoses of Sepsis and Bowel Obstruction. The record included documentation of physician restraint orders for 2/15/08 and 2/16/08. The record also included documentation that the patient was placed in restraints. The record lacked documentation of patient assessment and monitoring at least every 2 hours on (2/15 and 2/16/08) as required by policy.

4. The clinical record of Pt. #13 was reviewed on survey date 2/19/08. Pt. #13 was an 87 year old female admitted to the Hospital on 2/16/08 with a diagnosis of Hip pin Status Post Fall. The clinical record contained documentation that on 2/18/08 at 8:30 PM, Pt. #13 was placed in bilateral wrist and Posey restraint. The clinical record lacked documentation that Pt. #13 was monitored for restraint usage at 4:00 AM and 6:00 AM on 2/19/08.

5. The findings were conveyed to the Manager of 2 North Unit and Director of Peri-Operative Anesthesia and Pain during an interview on survey date 2/19/08 at 10:45 AM and to the CEO on 2/20/08 at approximately 3:00 P.M.

A. Based on review of Medical Staff Bylaws, Medical Executive Committee Meeting Minutes review, Medical Departments Committee Meeting Minutes review, and staff interview, it was determined that all departments did not report to the Medical Executive Committee (MEC).

Findings include:

1. The Medical Staff Bylaws required: "4.1.1. Medical Staff Departments. The medical staff shall be organized into departments of anesthesiology, emergency medicine, family medicine, medicine, obstetrics, pathology, pediatrics, psychiatry, radiology, and surgery. Each department shall have a chair and vice chair with overall responsibility for the supervision and satisfactory discharge of assigned functions...

5.2.3.1. Receive or act upon reports and recommendations concerning patient care quality and appropriateness reviews, evaluation and monitoring functions,...

6.7.3 Special Requirements. Whenever a pattern of suspected deviation by a practitioner from generally recognized clinical or professional practice is identified, the president of the medical staff or the applicable department or committee chair may require the practitioner to meet with him/her or with a standing or ad hoc committee that is considering the matter..."

2. On 2/20/08, the Medical Executive Committee (MEC) Meeting minutes for 12 meetings held in 2007, were reviewed. Two clinical departments did not submit meeting minutes (Departments of Emergency Medicine and Radiology) to the MEC for discussion for the entire year.

3. On 2/21/08, the clinical department meeting minutes for Radiology were reviewed. The following clinical issues were found in the Radiology minutes but not included in the MEC minutes.

- 3/21/07 meeting - Seven Patient Care Policies related to order sets for interventional radiology and other radiology policies were "Forward to CPIC and MEC for approval."

- 5/16/07 meeting - "The FDA recommended warnings for gadolinium-based contrast agents used to enhance magnetic resonance imaging (MRI).

4. On 2/21/08, the clinical meeting minutes for the Department of Emergency Medicine were requested. However no minutes were available for review.

5. On survey date 2/21/08 at 8:40 AM, an interview was conducted with the 2007 MEC Chairperson. The Chairperson stated that the Medical Departments report to the MEC after Department meetings. Medical Department meeting should be held quarterly. These findings were conveyed to the Chairperson during the interview.

A. Based on policy review, clinical record review and staff interview, it was determined that the Hospital failed to ensure skin care treatments and assessment were documented for 2 of 2 patients identified with impaired skin (Pt. #s 7 and 8) .

Findings include:

1. Hospital policy titled, "Interdisciplinary Plan of Care" required, "...D. Treatment/procedures: 2. Record your initials upon verification and/or completion of the treatment/procedure in the appropriate shift column..."

2. The clinical record for Pt. # 7 was reviewed on 2/20/08. Pt. # 7 was admitted on 1/12/08 with a diagnosis of Perforated Esophagus. The physician ordered dated 2/8/08 included, " Bacitracin to Abdominal wound twice a day, dressing twice a day..." Upon review of the nurse's notes dated 2/9, 2/10 and 2/13/08 the nurses failed to document the reason dressing changes were not performed twice a day.

3. The clinical record for Pt. # 8 was reviewed on 2/20/08. Pt. # 8 was admitted on 2/15/08 with a diagnoses of Urinary Tract Infection/ Vomiting. The clinical record contained a physician order dated 2/16/08 at 2:00 PM, that required, "wound care twice a day, irrigate with normal saline, pack with dry gauze" There was no wound care documented for 2/16/08.

4. The above findings were conveyed to the Nurse Manager on 3 East Medical Telemetry Unit, during an interview on 2/20/08 at approximately 11:30 AM.


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B. Based on review of Hospital policy, clinical record review and staff interview, it was determined that in 1 of 11 (Pt. #14) clinical record reviewed of a patient needing isolation precautions, the Hospital failed to ensure that all patients were isolated in a timely manner.

Findings include:

1. Hospital policy entitled, "Patient Isolation System" required, ...II. Policy - The Isolation system ...A physician order is not necessary to institute transmission precautions."

2. The clinical record of Pt. #14 was reviewed on survey date 2/19/08. Pt. #14 was a 92 year old female admitted to the Hospital on 2/15/08 with a diagnosis of Gastrointestinal Bleed. The clinical record contained a physician order dated 2/16/07 at 9:40 AM for a stool collection for C Difficile Toxin. The clinical record contained a lab report dated 2/15/08 at 8:45 PM that indicated a positive culture report for C Difficile Toxin. Clinical documentation indicated that Pt. #14 was not isolated until 2/18/08 at 8:39 PM (3 days later).

3. The findings were conveyed to 2 South Unit Manager and Director of Peri-Operative Anesthesia and Pain Services during an interview on survey date 2/19/08 at 11:15 AM. During the interview, the Director stated that the patient should have been isolated as soon as the order for the stool specimen was received.


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C. Based on review of Hospital policy, clinical record review, and staff interview, it was determined, for 1 of 2 clinical records reviewed on the 5 North unit (Pt. #2), the Hospital failed to ensure that patients at risk for skin breakdown, were turned/repositioned.

Findings include

1. Hospital policy titled: "Interdisciplinary Plan of Care (IPOC)" required: "J. Skin and Wound Care Management 1. The Braden Skin Risk Assessment score will be determined on the day shift and the appropriate risk category risk assigned..."

2. Braden scale instructions included:

- at risk (15 - 18) frequent turning
- moderate risk (13 - 14) turning schedule
- high risk (10 - 12) increase frequency of turning

3. On survey date 2/19/08 the clinical record of Pt. #2 was reviewed. Pt. #2 was a 72 year old male, admitted on 2/4/08, with a diagnosis of Myelodysplastic Syndrome. For 6 days (2/11/08 through 2/16/08), the Braden scale scores (14, 14, 12, 13, 16, & 16), included low, moderate, and high risk for skin breakdown. For 11 of 17 shifts, between 2/11/08 and 2/16/08, documentation was lacking for any turning.

4. These findings were conveyed to the Manager of Infection Control during an interview on 2/19/08 at 11:15 AM.

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A. Based on policy review, a review of "Pyxis" drug distribution system "discrepancy" reports, and staff interview, it was determined that the Pharmacy failed to ensure narcotic and medication discrepancy counts were investigated as required by policy for 2 of 16 patient care units (3 East and CV ICU).

Findings include:

1. Hospital policy titled, "Patient Medstation System (Pyxis) included, " Purpose: The Pyxis automated medication management system provides a safe mechanism for medication storage. 1. Inventory count: Discrepancies may be identified during inventory, refilling unloading or at any time when the nurse removes medication for a patient. During the shift, the RN informs the narcotic discrepancy to the Charge RN as they occur...the charge nurse is responsible for printing a report and resolving all discrepancies. All unresolved discrepancies will be documented on the Medication Variance Form."

2. On 2/20/08 units 3 East, 3 South and CV Intensive Care were toured. The surveyor requested a print out of all medication and narcotic discrepancies. The discrepancy report from the Pyxis system, dated 2/20/08 included the following information:

3 East

* Xanax 1 mg one missing tablet identified by the Pyxis system (expected count 17) on 2/18/08. The actual count was 16. Two nurses identified that the previous count was incorrect.

* Hydromorphone HCL 2 mg vial. The Pyxis expect count on 2/17/08 was 24. However the actual count was 25. Two nurse documented that the previous count was incorrect.

* Propoxyphine Nap Acetamine N100 (Darvocet) expected count on 2/19 was 23 with 22 actually found. Two nurses documented the reason as "counted incorrectly".

CV ICU

* Versed 2 mg/2 ml expected count was 16. However, the nurse documented that 15 were found. The reason documented included, "counted incorrectly".

* Morphine Sulfate 4 mg/1 cc expected count dated 2/18/08 was 29. However the nurse found 30. The reason for the discrepancy was identified by a Pharmacy Tech. as "wrong quantity previously entered".

3. The Director of Pharmacy was interviewed on 2/21/08 at approximately 10:00 AM. The Director stated that it is the responsibility of Nursing to resolve drug discrepancies and identify/report trends after reviewing the Pyxis discrepancy reports.

4. The Nurse Manager (E# 14) for 3 East including the Charge Nurse was unfamiliar with how to access discrepancy reports from the Pyxis system. There was no documentation that the RN notified the Charge Nurse of the above discrepancies in accordance with Hospital policy.

A. Based on observation, clinical record review and staff interview, it was determined for 2 of 2 (Pt. #5 and 6)clinical records reviewed for patients receiving oxygen in the Intensive Care Units (ICU), the Hospital failed to ensure a physician's order was written for the administration of oxygen.

Findings include:

1. On 2/19/08 a tour was conducted of the Neuro ICU, General ICU, and Neuro PCU (step down). Pt. #5 was on 2 liters oxygen per nasal cannula. Pt. #6 was on 1 liter oxygen per nasal cannula.

2. On 2/19/08, the clinical record for Pt. #5 was reviewed. This was an 89-year-old female admitted to the Neuro ICU on 2/18/08 with a diagnosis of Intracranial Hemorrhage. The record lacked documentation of a physician's order for oxygen.

3. On 2/19/08, the clinical record for Pt. #6 was reviewed. This was a 75-year-old female admitted to the General ICU on 2/17/08 with multiple diagnoses including Sepsis, Renal Failure, Atrial Flutter, and Hypotension. The record lacked documentation of a physician's order for oxygen.

4. The above findings were conveyed to the ICU Manager, (E #10) and the Lead RN, (E #5) during an interview on 2/19/08 at approximately 3:00 P.M.

A. Based on review of Hospital policy, clinical record review, and staff interview, it was determined that in 1 of 2 (Pt. #14) clinical record reviewed of a patient that had received a blood product transfusion, the Hospital failed to ensure that the transfusion completion time is documented.

Findings include:

1. Hospital policy entitled, "Administration of Blood and Blood Products," required, "...U. R. Documentation: 1. Place the completed white copy of the Blood Component Transfusion Record on the patient's chart..."

2. The clinical record of Pt. #14 was reviewed on survey date 2/19/08. Pt. #14 was a 92 year old female admitted to the Hospital on 2/15/08 with a diagnosis of Gastrointestinal Bleed. The clinical record contained a physician order dated 2/15/08 to transfuse 2 units fresh frozen plasma. The clinical record contained documentation that unit #0008180 was infused on 2/15/08 starting at 11:50 AM. The completion time, of the transfusion, was not documented as required by the transfusion record .

3. The findings were conveyed to the 2 South Unit Manager and Director of Peri-Operative Anesthesia and Pain Service during an interview on survey date 2/19/08 at 11:15 AM.

A. Based on review of documentation presented by Health Information Management, it was determined that the Hospital failed to ensure that all clinical records were completed within 30 days of discharge.

Findings include:

1. Documentation presented by the Hospital Information Management (HIM) on survey date 2/22/08 indicated that 1684 clinical records were delinquent.

2. The finding was conveyed to the Director of HIM during an interview on survey date 2/22/08 at 11:45 AM.

A. Based on policy review and staff interview, it was determined that the Pharmacy failed to ensure policy revision to reflect current Pyxis monitoring practices.

Findings include:

1. Policy ID number PTC.661 titled "Patient Medstation System (Pyxis) Section 1. Inventory count " required, "once a month expiration dates will be checked by pharmacy, controlled substances are inventoried during each transaction. Other medications all inventoried at loading and filling. Inventory level will be checked daily by printing the Refill report."

2. Policy PP-13 titled, "Unit inspections/expired medications" required, " Pharmacy staff will be assigned units/area inspections that are performed on a quarterly basis..."

3. The Pharmacy Director stated during an interview on 2/21/08 at approximately 10:30 AM that the policy (PTC 661) does not reflect current practice and drug inventory and expiration checks are performed quarterly and not monthly.

A. Based on Pharmacy stated practice, Hospital policy review, a review of Pyxis discrepancy reports, and staff interview, it was determined that the Pharmacy failed to ensure complete and accurate records for disposition of all scheduled drugs.

Findings include:

1. According to the Pharmacy Director, on 2/21/08 at approximately 10:15 A.M. the Pharmacy's practice for handling of expired narcotics is:
* Document the expired narcotic at the Pyxis console.
* A record of this documentation, of expired medication, is generated from the Pyxis computer system on a "Review Expire, Waste, & Recall Report".
* The expired narcotic should be brought back to the pharmacy by the technician and placed in the expired bin inside of the Pyxis machine.
* An outside distributor picks up the expired narcotics and a record is generated and maintained for receipt of the narcotics by the distributor.

2. The Hospital policy #(HH) PTC.661 failed to delineate the above procedures in tracking the movement of drugs through the Hospital to the point of departure either by administration, destruction, or return to the manufacturer.

3. On 2/21/08 the Pharmacy Manager, (E #16) provided an "All Stations Events" report for the ICU Pyxis system. The discrepancy for Midazolam (Versed) 0.5 mg/mL/100 mg intravenous bag dated 2/8/08 indicated, "Expected 1 Found 0".

4. In an interview with E #16 on 2/21/08 at approximately 8:45 A.M. E #16 stated that the bag of Midazolam had expired, but that the pharmacy technician, (E #23) failed to expire the narcotic in the Pyxis system. E #16 also stated that E #23 did not adhere to the above stated Hospital practice.

5. The above finding was conveyed to the Pharmacy Director and Pharmacy Manager during an interview on 2/21/07 at approximately 11:15 A.M.

6. On 2/19/08 an "All Discrepancies" report was obtained from the Pyxis console on the ICU. The report included several discrepancies for the month of February 2008 including one for Midazolam (Versed) 1 mg/ml/100 ml intravenous bag. The noted discrepancy was dated 2/18 at 7:53 A.M. It noted, "Expected 3, Found 0 (none)" The resolution documented included: "wrong quantity previously entered".

7. In an interview with the Pharmacy Director and Pharmacy Manager on 2/21/07 at approximately 2:00 P.M. The Pharmacy Manager failed to provide supporting documentation to verify that a wrong quantity was previously entered.

8. The above finding was conveyed to the Pharmacy Director and Pharmacy Manager during an interview on 2/21/07 at approximately 2:00 P.M.

A. Based on review of Hospital policy, observation, and staff interview, it was determined for 1 of 5 anesthesia carts (cystoscopy suite) reviewed, the Hospital failed to ensure all anesthesia carts were locked, to prevent unauthorized usage of medications.

Findings include:

1. Hospital policy titled: "Medication Security and Safe Handling..." required: "A. Security of Medications... 2. Medications present in the hospital(s) and ancillary patient care areas will be stored in secure areas at all times prior to administration. a. Secure areas include the locked Pharmacy Department, automated dispensing cabinets, locked medications rooms, carts..."

2. On survey date 2/20/08 between 8:00 AM and 10:00 AM, a tour was conducted of the surgical area. The anesthesia cart in the cystoscopy suite, which contained medications, was not locked. No one was in the suite.

3. This finding was conveyed to the Director of Surgery during the tour on 2/20/08 at 10:30 AM.

A. Based on review of Hospital policy, observation, controlled substance discrepancy log review, review of Department of Anesthesia Committee minutes, and staff interview, it was determined for 2 of 20 Anesthesiologist (E #6 & 7) and 2 of 5 Certified Registered Nurse Anesthetists (CRNA) (E #4 & 8), the Hospital failed to ensure that action was taken to reduce controlled substance discrepancies.

Findings include:

1. Hospital policy titled: "Medication Security and Safe Handling..." required: "C. Handling and disposition of returned/ unused medications. 1. Non-Pyxis medications that have not been administered to the patients are returned to the Pharmacy..."

2. On survey date 2/20/08 between 8:00 AM and 10:00 AM, a tour was conducted of the surgical area. The Anesthesiologist and CRNAs were provided controlled substances for the day's surgical cases from a surgical pharmacy satellite room that was managed by a Pharmacist (E#9). Unused control substance were returned and documented at the end of the day.

3. E #9 provided the logs for controlled substance discrepancies for unused and returned narcotics. During the past 7 months (July 07 through January 08), a number of discrepancies were found for 4 individuals:

- E #4 - 29
- E #6 - 37
- E #7 - 26
- E #8 - 20

4. Discrepancies included Versed and Fentanyl where the narcotic control sheet documented the medication as administered, but the patient's clinical anesthesia record did not indicate that the medication was given.

5. An interview was conducted with the Surgical Pharmacist (E #9) and the Pharmacy Director on 2/20/08 at 10:30 AM. The Pharmacy Director stated that no action was taken upon receipt of the quarterly narcotic discrepancy reports, because copies were sent to the Anesthesia Pharmacy. These findings were conveyed to the Surgery Pharmacist (E #9) and the Pharmacy Manager during an interview on 2/20/08 at 10:30 AM.

6. On 2/20/08, the Department of Anesthesia meeting minutes for 4/11/07 was reviewed. The minutes lacked indication that the controlled substance discrepancy reports had been reviewed or any action taken to resolve the issue.

7. The findings were conveyed during an inerveiw to the Anesthesia Department Chairperson on 2/21/08 at 9:05 AM.

A. Based on review of Hospital policy, observation and staff interview, it was determined that the Hospital failed to ensure, staff adhered to policies governing dietary services.

Findings include:

1. Hospital policy titled, "Sanitation/Infection Control-Nutritional Services" required, "...Clean and sanitize the work area at the beginning and the end of the shift... Employee Work Practices: a. manager/supervisor check and records refrigerator/freezer temperature daily at the beginning and /or end of each shift and records on the appropriate form.

2. A tour of the Hospital kitchen was conducted between 10:00 AM and 12:00 PM on 2/21/08. The following was observed:

-A table top Hobart mixer contained dried food debris.
-The hot cooks drawer had 2 steel containers with packets of Mrs. Dash flavoring and alcohol prep wipes stored together.
-The underside of a shelf in the hot food area contained dried food, dust and fuzzy particles. The shelf is located on top of the prep table above prepared food, a potential for the food debris to fall on to prepared food exist.
-The Dishmachine log lacked documentation of pre-wash, wash and rinse temperatures for the morning to 1/30/08 and 1/31/08.
-The Refrigerator log lacked documentation of the temperatures for all the refrigerators and freezers on 2/8/08.

3. The above findings were conveyed to the Director of Dietary Services during interview on 2/21/08 at approximately 11:50 AM.

A. Based on observation, clinical record review, and staff interview, it was determined for 1 of 4 patients observed in isolation, (Pt. #4) and 1 of 1 (E #1) Physican caring for paitients in Isolation, the Hospital failed to ensure adherence to Hospital policy governing Isolation Precautions.

Findings include:

1. Hospital policy # (HH) INC.263 entitled, "Patient Isolation System," requires, "Contact Precautions... Gloves are worn whenever entering the room... After glove removal and Hand Hygiene, ensure that hands do not touch potentially contaminated environmental surfaces or items in the patient's room".

2. On 2/19/08 during a tour of the General ICU, E #19 was in room 5427 touching the surfaces of a cabinet in the room. E #19 was not wearing gloves even though there was a Contact Precaution sign posted on the patient's room door.

3. The clinical record of Pt. #4 (room 5427) was reviewed on 2/19/08. This was a 77-year-old male, admitted 2/2/08 with diagnoses of Sepsis and Bowel Obstruction.

4. In an interview with the ICU Manager on 2/19/08 at approximately 11:00 A.M., the Manager stated that Pt. #4 was currently on Contact Precautions for Rule Out Clostridium Difficile (C-diff).

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5. Hospital policy titled: "Patient Isolation System" required: "... K. Contact Precautions... 5. A gown is worn if it is anticipated that clothing will have substantial contact with the patient, environmental surfaces, or items in the room..."

6. On survey day 2/19/08 between 10:00 AM and 11:25 AM, a tour was conducted on 5 North. At 10:05 AM, a Physician (E #1) was in room 5125, dressed in a suit without a cover gown. E #1's pants touched the bed linen. A contact isolation sign was posted on the door. The sign included: "Put on a gown and gloves if you will be touching the patient or linen.

7. The clinical record of the patient (Pt. #1) in room 5125 was reviewed on 2/19/08. Pt. #1 was a 52 year old female, admitted on 1/21/08, with diagnoses of Iron Deficiency Anemia, Methicillin Resistant Staff Aureus [which required contact isolation], and Fibromyalgia.

8. The above finding was conveyed to the Infection Control Manager during the tour on 2/19/08 at 10:10 AM. and to the ICU Manager during an interview on 2/19/08 at approximately 11:30 A.M.



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B. Based on observation and staff interview, it was determined that the Hospital failed to ensure all OR (operating room) equipment was maintained appropriately to prevent potential cross contamination.

Findings include:

1. During observation of OR suite 10, on 2/20/07 between 8:00 and 9:00 AM, the following was observed:

- 2 OR adjustable lights contained frayed tape in the joint area. A potential for pieces of the tape to fall on to the surgical site.

- Two EKG leads with new covers were hanging down touching the floor. A potential for cross contamination.

2. The above findings were conveyed to the Director of Surgical Services during interview on 2/20/08 at approximately 9:05 AM.

C. Based on review of Disinfecting solution insert, observation and staff interview, it was determined that the Hospital failed to ensure appropriate cleaning of equipment in the following areas of of the Radiology Department: Radiation Oncology, MRI and CT.

Findings include:

1. The insert for the disinfecting solution contained the direction for use that required,"Apply solution with a cloth, mop,sponge, or hand pump trigger sprayer such that all surfaces remain wet for 10 minutes...."

2. A tour of the Radiation Oncology, MRI and CT was conducted on 2/20/08 between 1:30 and 2:30 PM. Two bottles of Quat 25 disinfecting solution was observed in Radiation Oncology. The bottles did not contain direction for use to include contact time for the solution for effective disinfection.

3. An interview with the Radiation Oncology Supervisor (E #20) and a CT Tech (E #21) was conducted on 2/20/08 during the tour E #20 and E# 21 were not able to indicate the contact time for the solution to be effective.

4. The above findings were conveyed to the Director of Radiology during an interview on 2/20/08 at approximately 2:15 PM

D. Based on review of Hospital policy, observation, sterilizer log review, and staff interview, it was determined for 4 of 4 flash sterilizers, the Hospital failed to ensure that sterilizer logs were completed and available for investigating infections acquired by post surgical patients.

Findings include:

1. Hospital policy titled: "Flash Sterilizer and Monitoring" required: "For flash sterilization:... 5. Record your initials and case number on the sterilizer monitoring tape. record the item(s) being flashed on the steam strip indicator..."

2. On survey date 2/20/08 between 8:00 AM and 10:00 AM, a tour was conducted of the surgical area. Four steam sterilizers were found.

3. Seven (7) completed steam sterilizer monitoring tapes (7) were reviewed on 2/20/08. Three of the 7 tapes did not identify from which steam sterilizer the information was recorded.

4. The most current tape, removed on 2/20/08, from the steam sterilizer in sub room 3, was reviewed for load documentation. Nine of 10 loads lacked documentation of the operator, instrument sterilized, and patient's identification for the sterilized instrument.

5. An interview was conducted on 2/20/08 at 9:30 AM, with the Director of Surgical Services. The Director stated that the steam sterilizer monitoring tapes are not audited for completion,nor were the monitoring tapes reviewed when post surgical infections were identified, as a potential source of the infection. These findings were conveyed to the Director of Surgical Surgical Services during the interview.

A. Based on observation, Hospital Illinois Administrative Code and interviews it was determined that the Hospital failed to ensure that it adhered to the infant bed proximity requirements in the NICU.

Findings include:

1. Pt #9 is a 8 day old infant with a diagnosis of Prematurity.
Pt #10 is a 4 week old infant with a diagnosis of Prematurity.
Pt #11 was a 11 infant with a diagnosis of Prematurity.
Pt #12 was a 8 day old infant with a diagnosis of Prematurity.

1. During a tour of NICU conducted on 2/19/08 the following was observed: Pt #9 and Pt#10 were stationed in the NICU. The backs of the patients' isolettes were less than six inches apart. The numbered space indicated above the isolettes was 13.
Pt #11 and Pt #12 were stationed in the NICU. The backs of the patients' isolettes were less than six inches apart. The numbered space indicated above the isolettes was 14.

2. The Hospital 77 Illinois Administrative Code 250.1820 includes the following: F.) Consultation and Referral Protocols. 2) Intermediate and Intensive Care Nurseries shall meet all of the conditions described above except that infant cribs shall be separated by four to six feet of space to allow for ease of movement of additional personnel, and to allow space of additional equipment used in care of infants in these areas. There should be 80 to 100 square feet of space for each infant cared for in Level III or Intensive Care area.

3. During an interview on 2/19/09 at 4:00PM E #11 (Charge Nurse NICU) stated that the numbers posted above the infant beds are not used as bed space numbers. Infants are identified according to patients names. E #11 indicated that on 2/20/08 NICU census was 21 and the NICU bed capacity ranges from 18 to 20 depending on acuity level. E#11 was questioned regarding the close proximity of Pt's# 9, 10, 11 and 12. She indicated that the infants isolettes were positioned back to back allowing staff access through the front of the isolette.

4. During an interview conducted on 2/20/08 at 8:15 AM with E #12 (Director of Womens and Childrens Services) she indicated that Pt's 9 & 10 and 11 & 12 were positioned appropriately and that since the patients acuity status was level 2, they could be positioned within the proximity observed.

5. The above findings were conveyed to E #12 and E #17 during an interview on 2/21/08 at 10:00 AM.

B. Based on a review of the Hospitals approved bed occupancy floor plan for the NICU, observation, and interview it was determined that the Hospital failed to ensure that it adhered to the bed occupancy for the NICU.

Findings:

1. According to a NICU floor plan design submitted by E#12 the Hospitals bed occupancy for the NICU is 15.

2. During a tour of the NICU on 2/19/08 at 2:00PM and on 2/20/08 at 8:15AM the following was observed. On 2/19/08 the NICU census was 21 of which 17 infants were stationed in the NICU. Four of the infants were stationed within six inches of each other. Patients 9 &10 and Patients 11 &12.


3. On the following dates the census in the NICU exceeded 15, therefore the Hospital failed to adhere to the bed occupancy limit for the NICU:
September 15, 2007 census 20
September 20, 2007 census 20
October 4, 2007 census 19
October 8, 2007 census 20
November 5, 2007 census 20.
November 13, 2007 census 19
November 23, 2007 census 20
January 22, 2008 census 17
January 26, 2008 census 17
February 19,2008 census 21
February 20.2008 census 20

The NICU patient assignment sheet for 2/19 an 2/20/2008 failed to identify and distinguish between the patients listed on the census, as the NICU or as "overflow".

4. During an interview on 2/21/08 at 2:45 PM, E#12 stated that the some of the patients were in the regular nursery as overflow patients. The Hospital was unable to provide documentation that indicated that some of the patients listed on the NICU census were stationed in the regular nursery as "overflow" NICU patients .

5. The above findings were conveyed to E#12, and E#17 during an interview conducted on 2/21/08 at 1:00 PM and to E #13 and E #18 on 2/21/08 at 3:30PM.

A. Based on review of Hospital policy, observation, and staff interview, it was determined that in 2 of 3 (room #4 and 10) operating rooms toured, the Hospital failed to ensure adherence to the surgical department dress code.

Findings include:

1. Hospital policy entitled, "Infection Control: Dress," required, "Policy:...Disposable caps or hoods shall completely cover and contain all head and facial hair... Masks shall be worn at all times in the restricted areas and shall cover nose and mouth completely...Jewelry is not allowed in restricted and semi-restricted areas of the OR."

2. A tour of Operating Room #4 was completed on survey date 2/29/08 between 8:00 AM and 9:00 AM. During the tour, sterile supplies were opened and it was observed that E. #1 entered the room without a mask and was wearing a gold colored ring.


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This was found in OR suite 10.

3. On 2/20/08 during a tour of the OR suite 10 between 8:00 and 9:00 AM, the following was observed:
-1-2 inches of hair was observed below head covers on an OR Tech (E #3) and the CRNA (E #4)
- With open packs in the room, E #4 entered with mask held by hand and not secured.

4. The above findings were conveyed to the Director of Surgical Services during interviews on 2/20/08 at 9:05 AM and 9:30 AM.