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Based on document review and interview, it was determined that for 1 of 1 (E #6) Certified Registered Nurse Anesthesiologist (CRNA) at Location (L#2) employee file reviewed, the Hospital failed to ensure that the CRNA license was updated as required by State or local laws.

The following was observed at Location (L#2):

Findings include:

1. On 09/27/2022 at 12:30 PM, the employee file for the Certified Registered Nurse Anesthesiologist (E #6) who worked in the operating room on 09/27/2022 was reviewed. E #6's employee file included the Registered Nurse license issued by the State of Illinois expired on 08/31/2022.

2. On 09/28/2022 at 10:00 AM, the Hospital's "Medical Staff Bylaws" dated 11/2021 was reviewed and included, "... Section II - APC Practice at Hospital: The Medical Staff shall have oversight of Advanced Practice Clinicians who hold privileges and ensure that all individuals with Privileges provide services only within the scope ...Advance Practice Clinicians shall: ... be subject to all current regulatory standards relevant to the APC ..."

3. On 09/28/2022 at 10:30 AM, the Manager of Human Resources (E #25) at L #2, was interviewed. E #25 stated that the center for verification services at the corporate does monthly web crawl analysis and checks for those personnel that require to update their licenses and certifications. E #25 stated that the web crawl did not show that E #6's (CRNA) license was expired.

Based on observation, document review, and interview, it was determined that for 2 of 2 (Pt. #5 and Pt. #6) patients observed with one-to-one patient safety companions sitting outside by the door of patient rooms in Medical-Surgical Unit, the Hospital failed to ensure the safety for patients were provided as per physician order.

The following was observed at Location (L #2):

Findings include:

1. On 09/26/2022 between 11:45 AM - 1:30 PM, an observational tour of the 2 North-South (Medical Surgical Unit) was conducted along with the Director of Inpatient Services (E #13) and Nurse Manager (E #1) the following was observed:

-At 11:45 AM, the Patient Safety Companion for Room #202 (Pt. #5) was seen sitting outside of room by the door in the hallway and not with clear sight of the patient.

-At 11:50 AM, the Patient Safety Companion (E #2) for Room #206 (Pt. #6) was seen sitting outside of room by the door in the hallway and not with clear sight of the patient.

2. On 09/26/2022 at 11:51 AM, Pt. #5's clinical record was reviewed. Pt. #5 was admitted on 09/22/2022 with a diagnosis of hypercapnia (excessive carbon dioxide in bloodstream). Pt. #5's physician order dated 09/23/2022 at 7:25 PM, included, "Sitter at bedside." The physician's order lacked the documentation for the rationale for sitter at bedside.

3. On 09/26/2022 at 11:52 AM, Pt. #6's clinical record was reviewed. Pt. #6 was admitted on 09/18/2022 with a diagnosis of dementia with behavioral disturbance. Pt. #6's physician order dated 09/18/2022 at 1:56 PM, included, "Sitter at bedside, Comments: Loss prevention standby for patient safety..." Pt. #6's physician order dated 09/22/2022 at 4:47 PM, included, "Discontinue sitter, maintain fall precautions and safety-aide outside of the room."

4. On 09/26/2022, the Hospital's policy titled, "1:1 Safety Intervention (Sitter)" dated 05/13/2022, was reviewed and included, "...Purpose: Establish standard criteria for utilization and accountabilities of the use of 1:1 safety intervention for patients ...Patient Safety Companion - Is a team member who can meet the requirements of the role ...Assess the indications for use of 1:1 safety intervention ...elopement risk, wandering, patient exhibiting unsafe behaviors ...E. Roles and Responsibilities of a Patient Safety Companion: ...1. Ensure that the patient is being continuously observed ...a) maintain 1:1 monitoring with the patient in clear sight ...Always remain in the room. The Patient Safety Companion may not leave the room until another Team member is provided as relief is present in the room ..."

5. On 09/26/2022 at 11:55 AM, the Nurse Manager (E #1) at L #2, was interviewed. E #1 stated that the sitter's are for patient safety. E #1 stated that for Pt. #5 the reason for having sitter was for fall precautions and elopement. E #1 stated that for Pt. #6 the reason for having sitter was for fall precautions and elopement and behavioral issues. E #1 stated that the sitters are called "patient safety companions" and provide safety for patients to avoid falls and elopement.

6. On 09/26/2022 at 11:58 AM, the Patient Safety Companion (E #2) was interviewed. E #2 stated that she was monitoring the patient (Pt. #6) for safety to avoid falls and elopement. E #2 stated that she was told by the nurse manager to sit outside the room by the door.

7. On 09/28/2022 at 11:20 PM, the Director of In-patient Services (E #13) was interviewed. E #13 stated that she wanted to ensure that the policy is corrected and verified between the patient safety companions and the safety aide. E #13 stated that the current policy and protocol addresses the patient safety companions must be sitting inside the patient rooms to ensure patient safety. E #13 stated that the current policy or protocol does not address anything about safety aide or the patient safety companions could be sitting outside the room. E #13 stated that if we have sitters inside the patient rooms it is difficult for them to get placement or discharge a patient.

Based on document review and interview, it was determined that for 1 of 1 patient's (Pt. #38) clinical record reviewed regarding allegation of abuse at Location 2, the Hospital failed to offer an opportunity to file a complaint to local law enforcement, to ensure the patient was free from all forms of abuse.

Findings include:

1. On 9/28/2022, the Hospital's complaint and grievance log for allegation of abuse from 8/4/2022 through 9/28/2022 was reviewed. The log included an investigation report regarding an allegation of abuse by Pt. #38. The report included, "... on 8/14/2022... (Pt. #38) stated she had woken up in the morning to a cool breeze and found her gown was unsnapped and felt like somebody was doing something..." The report did not indicate if Pt. #38 was offered an opportunity to file a complaint to local law enforcement.

2. On 9/28/2022, the Hospital's policy titled, "Detection and Reporting of Patient Abuse" (effective 7/2021) was reviewed and included, "... Abuse means any physical or mental or sexual abuse...V. Procedure... D...5... The opportunity to file a criminal complaint to local law enforcement will be offered... 6. All internal review findings must be documented..."

3. On 9/28/2022 at approximately 10:30 AM, an interview was conducted with E #26 (Manager, Patient Relations). E #26 stated that the investigation concerning Pt. #38 was regarding an allegation of sexual abuse. E #26 could not provide documentation that Pt. #38 was offered an opportunity to contact the local law enforcement.

A. Based on document review and interview, it was determined that for 2 of 6 patients' (Pt. #18 and Pt. #21) clinical records reviewed for nursing assessment at Location #1 (L #1), the Hospital failed to ensure that the nurse supervised and evaluated patients' care by failing to complete the neurological assessments as per physician's orders..

Findings include:

1. On 9/26/2022, Pt. #18's clinical record was reviewed. On 9/21/2022, Pt. #18 was transferred to SICU/surgical intensive care unit due to acute mental status changes. On 9/22/2022, Pt. #18's clinical record included a physician's order for a neurological assessment every two hours. On 9/25/2022, neurological assessments were not performed at 11:00 AM and 3:00 PM.

2. On 9/26/2022, Pt. #21's clinical record was reviewed. On 9/21/2022, Pt. #21 was admitted to 4 North West Unit with a diagnosis of chronic obstructive pulmonary disease. On 9/23/2022, Pt. #21's clinical record included a physician's order for a neurological assessment every four hours. On 9/25/2022, neurological assessments were not conducted at 1:00 PM, 5:00 PM, and 9:00 PM.

3. On 9/29/2022, the Hospital's Job Description for Registered Nurses (revised 1/2021) was reviewed and required, "... Responsible for providing and coordinating comprehensive patient care through the nursing process... Major Responsibilities: Uses the nursing process to assess the needs of the patient, plan and implement individualized interventions and evaluate the effectiveness of the plan of care..."

4. On 9/28/2022 between 1:30 PM and 1:45 PM, findings were discussed with E #16 (SICU Manager) and E #18 (4 North West). E #16 and E #18 stated that the physician's orders remain active as of survey date 9/26/2022, and should have been followed. E #16 and E #18 could not provide documentation that the physician's order was followed.

B. Based on document review and interview, it was determined that for 2 of 6 patients' (Pt. #23 and Pt. #24) clinical records reviewed for nursing assessment at Location #1 (L #1), the Hospital failed to conduct pain reassessments, to ensure a nurse evaluated the patients' care.

Findings include:

1. On 9/26/2022, Pt. #23's clinical record was reviewed. On 9/20/2022, Pt. #23 was admitted to 4 North West with a diagnosis of melena (blood in stool). On 9/22/2022 at 9:44 PM, Pt. #23 was given Morphine Sulfate (intravenous pain medication) for pain. There was no pain reassessment after the medication was administered.

2. On 9/26/2022, Pt. #24's clinical record was reviewed. On 9/19/2022, Pt. #24 was admitted to 4 North West with a diagnosis of altered mental status. On 9/23/2022 at 9:13 AM, Pt. #24 was given Tylenol (oral pain medication) for pain. There was no pain reassessment after the medication was administered.

3. On 9/28/2022, the Hospital's policy titled, "Pain Management" (effective 2/2022) was reviewed and included, "...C. The nurse will use appropriate valid and reliable evidence-based pain assessment tools and techniques... I... Reassessment of pain is ongoing... Reassess after each intervention..."

4. On 9/28/2022 at approximately 1:30 PM, findings were discussed with E #18 (Assistant Manager, 4 North West). E #18 stated that there should be a pain reassessment after the pain medication was administered. E #18 could not provide documentation that pain reassessments were conducted.



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C. Based on document review and interview, it was determined that for 1 of 2 (Pt. #8) patients' records reviewed for glucose monitoring at Location #2, the Hospital failed to ensure the supervision and evaluation of nursing care by failing complete the physician's orders for blood glucose monitoring.

ensure that the nursing staff performed and documented blood sugar checks as ordered.

Findings include:

1. The Hospital's policy titled, "Nursing Documentation (10/29/2021)" was reviewed on 9/26/2022 and included, "Nursing documentation is important for communicating the nursing care delivered."

2. The clinical record of Pt. #8 was reviewed on 9/26/2022. Pt. #8 was admitted on 9/6/2022 with the diagnosis of acute renal failure. A physician's order dated 9/10/2022 at 6:01 PM included, "Blood Glucose every 6 hours". The clinical record lacked documentation of blood sugars on 9/16/2022 at 6:00 PM, 9/17/2022 at 6:00 PM and 9/23/2022 at 12:00 PM.

3. During an interview on 9/26/2022 at 11:20 AM, the nurse manager (E#1) stated that the blood sugars should have been checked every 6 hours as ordered and recorded in the clinical record.

Based on document review and interview, it was determined that for 5 of 5 personnel files of contracted/agency nurses reviewed, the Hospital failed to ensure that the Director of Nursing supervised and evaluated the nursing services provided by all contracted nurses.

The following was observed at Location (L #2):

Findings include:

1. On 09/27/2022, the Hospital's policy titled, "Nursing Agency Personnel" dated 05/15/2014, was reviewed and included, " ...3. The agency appropriately hires and retains candidates that meet site of care criteria for nurses functioning in various areas consistent with job descriptions of the site ...assure compliance with standards set by the site of care ..." The policy did not include evaluations or assessment of the nursing services provided by all the contracted nurses in the hospital.

2. On 09/27/2022 at approximately 10:30 AM, the employee personnel files for five (5) agency/contracted nurses at L #2, were reviewed and included the agency nurses were contracted with the Hospital from 11/01/2021 - 09/26/2022. All of the five (5) agency/contracted nurses' files lacked any type of evaluation by the charge nurse, or nurse manager.

3. On 09/27/2022 at approximately 10:45 AM, the Director of Nursing for Inpatient Services (E #13) at L #2, was interviewed. E #13 stated, "We have never done any type of evaluations for agency or contracted nurses."

4. On 09/27/2022 at approximately 3:15 PM, the Chief Nurse Executive (E #5) at L #2, was interviewed. E #5 stated that the director of nursing oversees the agency nurses program, and she was not sure if evaluations were done for the contracted nurses.

Based on document review and interview, it was determined that for 1 of 2 patients' (Pt. #18) clinical records reviewed for blood transfusion at Location 1 (L #1), the Hospital failed to ensure the assessments for signs and symptoms for delayed reaction were documented in accordance with approves policies and procedures.

Findings include:

1. On 9/26/2022, the clinical record for Pt. #18 was reviewed. Pt. #18 was transferred to SICU/surgical intensive care unit on 9/21/2022 due to acute mental status changes. The clinical record indicated that Pt. #18 had blood transfusion on 9/25/2022 at 11:08 AM and at 3:28 PM. Pt. #18's clinical record did not include the continued assessment to monitor for signs and symptoms of a a delayed blood transfusion reaction.

2. On 9/28/2022, the Hospital's policy titled, "Blood and Blood Product Transfusion/Administration for the Adult and Pediatric/Neonatal Patient" (effective 12/2021) was reviewed and included, "... M. Implementation of the Transfusion... 14. Continue to assess the patient for signs and symptoms of delayed transfusion reaction for at least 30 minutes after the transfusion... 16. Document the procedure as described..."

3. On 9/28/2022 at approximately 1:30 PM, findings were discussed with E #16 (SICU Manager). E #16 stated that there should be a documentation if Pt. #18 had delayed blood transfusion reaction. E #16 could not provide documentation that the assessments for delayed blood transfusion reaction were conducted.

A. Based on observation, document review, and interview, it was determined that the Hospital failed to manage daily dietary services by not ensuring that the 1 of 2 (red buckets) surface cleaning disinfectant solutions were appropriately prepared, as required. This has the potential to affect an average of 140 patients receiving oral diets on 09/27/2022.

The following was observed at Location (L #2):

Findings include:

1. On 09/27/2022 between 11:00 AM and 1:00 PM, and observational tour of the hospital's kitchen and dietary service areas was conducted along with the Kitchen Production Supervisor (E #20) and the following was observed:

-At 11:24 AM, the disinfection sanitizer (red) bucket solution by the patient tray line test strip sample was checked and indicated 100 ppm (parts per million) (normal acceptable range 200 -400 ppm).

2. On 09/27/2022 the Hospital's "Pot and Pan, Sanitizer Dispenser Log" dated 08/17/2022, was reviewed and included, "Product Used: Diversey J-512 Sanitizer. Only use the Diversey J512 Quantanary Sanitizer - Acceptable Range 200 -400 ppm ..."

3. On 09/27/2022 at approximately 11:30 AM, the Production Supervisor (E #20) was interviewed. E #20 stated that the color did not change for the test strip, it should have been between 200 - 400. E #20 stated that an adequate disinfection was not achieved and could cause food borne infections.



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B. Based on observation, document review and interview, it was determined that for the cold food storage area at Location #1, the Hospital failed to manage the dietary services by ensuring that perishable food items were labeled with a use by date or discarded the food items after the use by date. This could potentially affect an average daily patient census of 97 receiving meals from the dietary department.

Findings include:

1. On between 09/28/22 between 11:15 AM through 12:15 PM, an observational tour of the dietary service area at Location #1 was conducted. The following was observed inside the cold food storage area:

- An opened one gallon of mustard approximately half full with an open date of 6/17/22.
- A plastic container with approximately quarter full of cherry tomatoes with no use by date.
- A tray of lettuce with a use by date of 09/26/22.
- A container of guacamole with no preparation or use by date.
- A tray of sliced turkey breasts with no use by date
- A tray of grilled chicken breasts with no preparation or use by date.
- A tray of chicken tenders with no preparation date or use by date.
- A container of beef gravy and a container of poultry gravy with a use by date of 9/20/22
- A tray of sliced pepperoni with a use by date of 9/21/22.
- A tray of sausage with a use by date of 9/26/22.
- A gallon of soup with no preparation date or use by date.
- A quarter gallon of opened buttermilk with no open or use by date.
- A tray of turkey slices with no expiration or use by date.

2. On 09/28/22, the Hospital's policy titled, "Control of Non-Conforming Products" (revised 10/2019) was reviewed and included, "... Non-conforming product: any product that fails to meet the specified requirements of its intended use ... expired, damaged, opened ... include ... Food and dietary products ... Expired food products ... will either be immediately discarded ... any product that is identified in discrepancy ... will be immediately discarded ..."

3. On 09/28/22, the findings were discussed with the Supervisor of Food and Nutrition Production (E #24). E #24 stated that opened and prepared food items should be labeled with a used by date. E #24 stated that the food items should not be used after the use by date due to risk of bacterial growth that can cause illness.

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 September 26-28, 2022, the surveyors find that 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.

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 September 26-28, 2022, the surveyors find that 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, document review, and interview, it was determined that for 3 of 6 inpatient units (SICU/surgical intensive care unit, Hemodialysis, and 4 North West/telemetry/medical-surgical unit) observed at Location #1 (L #1), the Hospital failed to ensure that the crash cart containing supplies and equipment used during medical emergencies were checked, as required.

Findings include:

1. On 9/26/2022 at approximately 10:10 AM, an observational tour of the SICU was conducted. During the tour, there were two crash carts in the unit. The crash cart for patient rooms 1 though 6 was not checked during the day shift (7 AM through 7 PM) on 9/15/2022 and 9/18/2022, and night shift (7 PM through 7 AM) on 9/18/2022. The crash cart for patient rooms 7 through 12 was not checked during the day and night shifts on 9/18/2022.

2. On 9/26/2022 at approximately 12:30 PM, an observational tour of the hemodialysis unit was conducted. During the tour, the crash cart was not checked on 9/10/2022. The dialysis schedule indicated that the unit was open, and ten patients received dialysis treatments on 9/10/2022.

3. On 9/26/2022 at approximately 1:00 PM, an observational tour of the 4 North West unit was observed. During the tour, the crash cart was not checked on 9/24/2022 and 9/25/2022.

4. On 9/28/2022, the Hospital's document titled, "External Contents of the Crash Cart (CC)" (dated 5/2017) was reviewed and required, "... crash carts are checked per shift when the unit is open... The assigned Registered Nurse will check the proper functioning of the equipment on the (crash cart)... Top of CC 1. Suction... 2. Monitor/Defibrillator (equipment used to restore heart function)..."

5. On 9/26/2022 from 10:10 AM through 1:00 PM, findings were discussed with E #16 (SICU Manager), E #17 (Hemodialysis Charge Nurse), and E #18 (4 North West Assistant Manager). E #16 stated that SICU was open and had patients on 9/15/2022 and 9/18/2022. E #17 stated that 4 North West was also open on 9/24/2022 and 9/25/2022. E #16, E #17, E #18 stated that the crash cart should be checked daily to ensure patient safety.



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B. Based on document review, observation, and interview, it was determined that, the Hospital failed to ensure that in the Outpatient Rehabilitation Department at Location #3 (L #3), equipment maintenance, functionality, and cleaning was completed and documented. This has the potential to create a safety risk for patients requiring Outpatient Rehabilitation services.

Findings include:

1. The Hospital provided the user's manual for "Hydrocollator Heating Unit" (dated 2021) and included, "Safety Precautions ... The recommended operating temperature is 160 degrees Fahrenheit (F) to 165 F. The Temperature of the water should be checked with a thermometer after every adjustment, before using the HotPac ... Care and Cleaning ... It is critical to maintain the water level over the top of the HotPac to avoid damage to the heating element ... Water is constantly lost during operation due to evaporation. Therefore it is essential that water be added daily. The tank should also be drained, cleaned, and inspected systematically, at a minimum interval of every two weeks ..."

2. On 09/27/2022 at approximately 11:15 AM, a tour was conducted of the Outpatient Rehabilitation Department along with the Supervisor of Outpatient Department (E#15). There was one Hydrocollator (machine used to heat hot packs using water) in the Occupational Therapy treatment room and another in the Physical Therapy treatment area. There were no temperature logs, or maintenance logs to indicate that staff check temperature, maintain, or clean the Hydrocollators. Cleaning/Maintenance and Temperature Logs for the previous 3 to 6 months were requested during the tour from the Supervisor of Outpatient Rehabilitation Department (E#15).

3. On 09/27/22 at approximately 11:30 AM, an interview was conducted with the Supervisor of Outpatient Rehabilitation Department (E#15). E #15 stated that she did not know where the temperature and maintenance/cleaning logs for the Hydrocollators were stored, after asking several staff in the department E#15 stated she would have to continue to look for the logs. E#15 stated she was not aware of how often the Hydrocollator's temperature is checked or how often they are cleaned. E#15 stated that equipment should be maintained including checking the temperature and cleaning of the equipment to ensure proper functionality.

4. On 9/29/22 at approximately 9:15 AM, the Hospital provided Temperature Logs for the Hydrocollator in the Occupational Therapy treatment room for 7/1/2022 through 9/27/22, and Temperature log for the Hydrocollator in the Physical Therapy Treatment room for 8/25/22 through 9/27/22. There were no Temperature logs for the previous months, and the Hospital was not able to provide documentation of cleaning of the Hydrocollators.

Based on observation and document review, it was determined that for 1 of 2 personnel (MD #4/anesthesiologist) observed administering intravenous medications at Location 1 (L #1), the Hospital failed to ensure that the method for preventing and controlling the transmission of infection was followed during administration of intravenous (IV) medication.

Findings include:

1. On 9/27/2022 between 9:30 AM through 11:30 AM, an observational tour of the operating room was conducted. At approximately 11:15 AM, in OR #3, MD #4 administered intravenous medication to Pt. #38 without disinfecting the IV port with an antiseptic swab. Pt. #38's clinical record included:

- On 9/27/2022, Pt. #38 was in the OR/operating room for a hysteroscopy (examination of uterus) with placement of intrauterine device. The clinical record indicated that Pt. #38 received intravenous medication for sedation (e.g., midazolam and fentanyl) at approximately 11:15 AM.

2. On 9/29/2022, the Hospital's document titled, "Administering IV Bolus or IV Push Medication" (undated) was reviewed and included, "Purpose: Delivering medication by IV push... Use... to prevent contamination of solution or IV catheter, which could result in catheter-related bloodstream infection. Procedure... 7. Administer medication. A. Disinfect IV port... using new antiseptic swab..."

3. On 9/27/2022 at approximately 11:30 AM, findings were discussed with E #19 (OR Manager). E #19 stated that the IV port should have been wiped with antiseptic solution to prevent infection.

Based on observation, document review and interview, it was determined that for 1 of 2 (Pt. #2) blood glucose monitoring observed, the Hospital failed to ensure the staff adherence to prevention of spread of nosocomial infection as required.

The following was observed at Location (L #2):

Findings include:

1. On 09/26/2022 between 10:00 AM to 11:30 AM, an observational tour of the Intensive Care Unit (ICU) was conducted along with Nurse Manager (E #3) and the following was observed:

- At 11:15 AM, the Certified Nurse Assistant (E #4) completed the blood glucose testing for Pt. #2, and placed the glucometer under her armpit while washing hands.

2. On 09/26/2022 the Hospital's policy titled, "Glucose, Whole Blood Monitoring - Nova Statsstrip Express" dated 11/14/2021 was reviewed and included, "...Disinfecting the Meter: ...meter must be disinfected after every patient test ..."

3. On 09/26/2022 at 11:30 AM, the Nurse Manager (E #3) of ICU was interviewed. E #3 stated that she (E #4) should not have placed the glucometer under her armpit, it is totally not acceptable.

Based on observation, document review and interview, it was determined that for 1 of 3 operating room personnel (MD #4/anesthesiologist) observed in the operating room/OR at Location #1, the Hospital failed to ensure that the policy regarding surgical attire was followed.

Findings include:

1. On 9/27/2022 between 9:30 AM through 11:30 AM, an observational tour of the OR was conducted. At approximately 11:00 AM, in OR #3, MD #4 had approximately four to six inches of hair on the back and left side of MD #4's head was exposed, while sterile supplies were open.

2. On 9/28/2022, the Hospital's policy titled, "Operative and Procedure Attire" (effective 1/2022) was reviewed and required, "I... to promote patient and team member safety... III. Restricted area: The surgical clean core areas including operating (rooms). Surgical attire and hair covering are required... V... Head-Hair Coverings: A. Cover the scalp and hair when entering the semi-restricted and restricted areas..."

3. On 9/27/2022 at approximately 11:30 AM, findings were discussed with E #19 (OR Manager). E #19 stated that MD #4's hair should be covered.