HospitalInspections.org

Based on document review and interview, it was determined for 1 of 2 patient's (Pt #17) clinical records reviewed for Emergency Department (ED) suicide risk interventions, the Hospital failed to ensure interventions were put in place. This has the potential to affect all suicidal patients in the ED.

Findings include:

1. On 05/13/2021 at approximately 12:00 PM, the "SMD Suicide Risk Screening" policy was reviewed. The policy stated, "C. Assessment: Patient answering affirmatively to screening questions for suicide risk will undergo a follow up suicide risk assessment. 1. If the suicide assessment is positive, suicide precautions will be implemented immediately.... a. Patient placed on 1:1 constant observation until evaluation by a physician to determine safety needs and treatment plan. b. Patient will be placed in green scrubs.... c. Personal items will be inventoried.... d. Implement safety measures to create a safe patient environment."

2. On 05/12/2021 at approximately 9:00 AM, the clinical record of Pt #17 was reviewed. Pt #17 presented to the Emergency Department (ED) on 05/06/21 at 8:48 PM with the chief complaint of "Psychiatric Problem." The chart noted:
a. At 9:03 PM, ED Triage notes stated "Pt arrives with issues of feeling suicidal and hearing voices... Wants to be admitted because the voices scare (Pt #17) and are giving (Pt) directions. States (Pt) had a plan to harm (Pt) by jumping off of a bridge but there were nets so (Pt) couldn't do it."
b. At 9:06 PM, a Columbia Suicide Severity Rating Scale stated, "2. Suicidal Thoughts: Yes, 3. Suicidal Thoughts with Method Without Specific Plan or Intent to Act: Yes, 4. Suicidal Intent Without Specific Plan: Yes, Suicide Intent with Specific Plan: Yes."
c. At 2:04 AM on 05/07/2021, the record stated, "Suicide Risk: Do you have suicidal ideation?: Yes, Suicide Risk Assessment: Attempting or threatening suicide/self harm?: Yes, Recent evidence of psychiatric disorder?: Yes, Response to question indicating hopelessness?: Yes, Coping with recent loss/disruption in support system?: Yes".
d. The record lacked documentation of any suicide interventions provided and lacked documentation to indicate the presence of a sitter or continuous observation of Pt #17.

3. An interview was conducted with Chief Nursing Officer of Illinois for (name of hospital corporation) (E #1) and ED Director (E #4) on 05/12/21 at 2:00 PM. E #1 and E #2 reviewed Pt # 17's clinical record. E #2 stated "There are no suicide precaution interventions charted, no documentation of 1:1 observation, and there should have been."

Based on document review and interview, it was determined for 3 of 4 (Pt#19, Pt #20 and Pt #21) Intermediate Care Unit/ Intensive Care Unit (IMC/ICU) patients, the Hospital failed to ensure the registered nurse evaluated the provision of patient care, in accordance with physician orders and/or the patient's care needs. This has the potential to effect all patients receiving care in the Hospital, with a current census 99 patients.

Findings include:

1. On 05/12/2021 at 12:55 PM, the policy "Plan for the Provision of Patient Care Services" (no revision date) was reviewed. The policy noted "G. Definition of Nursing Care... A registered professional nurse provides nursing care emphasizing the importance of the whole and interdependence of its parts through the nursing process to individuals, groups, families, or communities, that includes but is not limited to: (1) the assessment of healthcare needs..."

2. On 05/12/2021 at approximately 11:00 AM, Pt #19's record was reviewed. Pt #19 was admitted to ICU on 04/21/2021 with a diagnosis of Gastric Outlet Obstruction. The record noted the patient had a surgical incision to the abdomen with a dressing. The record lacked a physician order for incision and/or dressing needs.

3. On 05/12/2021 at approximately 11:20 AM, an interview with Intensive Care Registered Nurse (E#5) was conducted. E#5 confirmed theta #19's record lacked a physician order for the dressing and wound to the patient's abdomen and stated, "The patient has a special surgical dressing and we are not supposed to change it until the physician tells us to." There was no order to address the care needs of Pt #19's abdominal surgical incision and dressing.

4. On 5/11/2021 at 1:00 PM, a review of Pt #20's record was completed. Pt #20 was admitted to IMC on 5/10/2021 with the diagnosis of Sickle Cell Crisis. A physician order was entered on 5/11/2020 at 5:00 PM for "Daily Weights". The record lacked documentation of weight on 5/11/2021.

5. On 5/12/2021 at 11:00 PM, a review of Pt #21's record was completed. Pt #21 was admitted to IMC on 5/6/2021 with a diagnosis of Urinary Track Infection. A physician order was entered for 5/7/2021 at 5:00 PM for "Daily Weights". The record lacked documentation of daily weights on 5/8/2021 and 5/10/2021.

6. On 5/12/2021 at 12:00 PM, an interview with the Manager of IMC/ICU (E#13) was conducted. E#13 reviewed Pt #20 and Pt #21's record and verbally agreed the record lacked daily weights, as ordered.

Based on document review and staff interview, it was determined for 1 of 2 (Pt #19) Intensive Care Unit (ICU) patients records reviewed, the Hospital failed to ensure a plan of care was developed and maintained, to meet the patient's needs. This has the potential to affect all patients who receive care in the ICU, with a current census of 10 patients.

Findings include:

1. On 05/12/2021 at 12:55 PM, the policy "Plan for the Provision of Patient Care Services" (no revision date) was reviewed. The policy noted "G. Definition of Nursing Care... A registered professional nurse provides nursing care emphasizing the importance of the whole and interdependence of its parts through the nursing process to individuals, groups, families, or communities, that includes but is not limited to: (1) the assessment of healthcare needs, nursing diagnosis, planning, implementation, and nursing evaluation, the administration of medications and treatments as prescribed by a physician."

2. On 05/12/2021 at approximately 11:00 AM, Pt #19's record was reviewed. Pt #19 was admitted to ICU on 04/21/2021 with a diagnosis of Gastric Outlet Obstruction. The record noted the patient had a surgical incision to the abdomen with a dressing. The record lacked a care plan for the dressing and/or wound care.

3. On 05/12/2021 at approximately 11:20 AM, an interview with Intensive Care Registered Nurse (E#5) was conducted. E#5 confirmed the record lacked a physician order for the dressing and wound to the patient's abdomen and stated, "The patient has a special surgical dressing and we are not supposed to change it until the physician tells us to." There was care plan to address the care needs of Pt #19's abdominal surgical incision and dressing.

Based on document review and interview, it was determined for 1 of 1 (Pt #16) patient record reviewed, the Hospital failed to ensure a LifeVest policy established and implemented for nursing staff to address the care needs of these patients. This has the potential to affect all patients who receive a LifeVest with an average of 12 patients per year.

Findings include:

1. The clinical record was reviewed on 5/12/2021 at approximately 3:00 PM. The record noted Pt #15 was admitted on 5/3/2021 with a diagnosis of supraventricular tachycardia. An order dated 5/4/2021 noted "Wearable Cardiac Defibrillator (Life Vest)... Request start date within 48 hours prior to discharge. Fax Order, H&P (History and Physical), ECHO (echocardiogram), Cath (Catheter) Report, Demographics (FIN Sheet), and Consult/Progress note to... (name/number)." The Case Management Progress Note dated 5/7/2021 noted "Patient also Dc'd (discharged) home with a Cardiac LifeVest." The Physician's Discharge Summary dated 5/7/2021 lacked documentation of the LifeVest. The record lacked documentation the company was notified with the required information, lacked documentation Pt #15 was educated, lacked the level of Pt #16's understanding of the Life Vest and lacked the level of competence to care for the Life Vest post discharge.

2. During an interview on 5/13/2021 at approximately 12:30 PM, E#17 (Director of Medical Services) stated the hospital did not have a LifeVest policy. E#17 demonstrated a "How to Order the LifeVest" document and "When a patient with LifeVest presents" document provided by the manufacturer and stated "This is all I have. I was told... (manufacturer) provides all the education to the patient prior to discharge. We don't have anything to do with it." E#17 reviewed Pt #16's record and verbally agreed it was unable to be determined if the patient was educated, the level of understanding and level of competence to care for the LifeVest post discharge.

Based on document review and staff interview, it was determined for 1 of 2 (Pt #20) Intermediate Care Unit (ICU) patients, the Hospital failed to ensure the patient was re-evaluated after given an opiod medication for pain, per Hospital policy. This has the potential to affect all patients receiving pain management at the Hospital with a current census of 99 patients.

Findings include:

1. On 5/12/2020 at approximately 1:00 PM, the policy "Pain Management" was reviewed. The policy noted "The patient's level of sedation will be monitored before and following the administration of all opoid pain medications that are given in route of Intravenous (IV), Intramuscular (IM)..."

2. On 5/12/2021 at 10:00 AM, a review of Pt #20's chart was completed with the Manager of IMC/ICU (E#13). Pt #20 was admitted to the IMC unit on 5/10/21 with a diagnosis of Sickle Cell Crisis. Pt #20 received Dilaudid (opiod pain medication) 1 milligram intravenously for pain on 5/11/21 at 10:16 AM, on 5/11/21 at 5:10 PM and on 5/11/21 at 8:52 PM. Pt #20's record lacked documentation of the level of sedation after each Dilaudid dose given intravenously.

3. On 5/12/2020 at 11:00 AM, an interview with E#13 was conducted. E#13 reviewed Pt #20's record and verbally agreed the record lacked documentation of the reassessment of the level of sedation after receiving the medication and it should have been documented.

Based on document review and staff interview, the Hospital failed to ensure the Pharmacist properly supervised the accountability of drugs. This has the potential to affect all patients receiving care at a Hospital with a current census of 99 patients.

Findings include:

1. On 05/12/2021 at 9:30 AM, the Hospital policy "Controlled Substance-Hospital Pharmacy" (revised by the Hospital 12/14/2020) was reviewed. The policy noted "d) Pharmacy's Responsibilities: The Pharmacy Director/Manager or designee will monitor and review all discrepancy reports on a weekly basis to ensure appropriate resolution."

2. On 05/11/2021 at 4:00 PM, the "Discrepancy Audit Detail Report" (02/11/2021- 05/10/2021) was reviewed. The report noted the following time frames for medication discrepancy resolutions:

DISCOVERY DATE RESOLUTION DATE REASON

03/03/2021 04/20/2021 user miscounted pocket contents
03/04/2021 04/20/2021 user miscounted pocket contents
03/30/2021 05/02/2021 user miscounted pocket contents
03/26/2021 04/13/2021 drip not removed for patient expired/wasted

3. On 05/12/2021 at 2:30 PM, an interview with the Director of Pharmacy (E#6) was conducted. E#6 confirmed the Narcotic Discrepancy Audit Detail Report was accurate and stated "the discrepancies should have been resolved on the day they were discovered."

A. Based on document review and interview, it was determined for 8 of 8 (E#21, E#22, E#23, E#24, E#25, E#26, E#27, E#28) pharmacy technician's training files reviewed, the hospital failed to ensure the media fill tests were accurately conducted per policy. This has the potential to affect all inpatients and outpatients who receive a compounded intravenous medication at the hospital.

Findings include:

1. The "Pharmacy Colleague Media Fill Test Sample Collection Form" was reviewed on 5/13/2021. The form noted "Employees will complete the test kits... resulting in 3 - 10 ml (milliliter) sample vials... These samples will be transferred to the lab where they will be intubated (misspelled incubated) for 14 days. Samples that remain clear after 14 days denote a pass."

2. The following records noted only 2 samples were obtained and were not incubated for the 14 days:
a) E#21, collected on 4/1/2021, received in laboratory (lab) on 4/2/2021 and were resulted on 4/4/2021, 3 days post collection;
b) E#22, collected on 4/1/2021, received in lab on 4/2/2021 and were resulted on 4/4/2021, 3 days post collection;
c) E#23, collected on 3/16/2020, received in lab on 3/17/2021 and were resulted on 3/18/2021, 2 days post collection;
d) E#24, collected on 8/26/2020, received in lab on 8/27/2021 and the left was resulted on 8/28/2020, 2 days post collection and the right hand was resulted on 9/1/2020, 6 days post collection;
e) E#25, collected on 4/1/2021, received in lab on 4/2/2021 and were resulted on 4/4/2021, 3 days post collection;
f) E#26, collected on 8/20/2020, received in lab on 8/20/2020 and were resulted on 8/22/2020, 2 days post collection;
g) E#27, collected on 3/9/2020, received in lab on 3/9/2020 and were resulted on 3/11/2020, 2 days post collection;
h) E#28, collected on 3/16/2020, received in lab on 3/17/2020 and were resulted on 3/18/2020, 2 days post collection.

3. During an interview on 5/14/2021 at approximately 12:00 PM, E#17 (Director of Medical Services) reviewed E#21, E#22, E#23, E#24, E#25, E#26, E#27 and E#28's Pharmacy Colleague Media Fill Test Sample Collection Form and verbally agreed only 2 samples were obtained (not the required 3 samples) and the tests were not incubated for 14 days and should have been.

B. Based on document review and interview, it was determined for 3 of 8 (E#23, E#27, and E#28) pharmacy technician's training files reviewed, the hospital failed to ensure competencies were conducted annually per policy. This has the potential to affect all inpatients and outpatients who receive a compounded intravenous medication at the hospital.

Findings include:

1. The "Pharmacy Colleague Media Fill Test Sample Collection Form" was reviewed on 5/13/2021. The form noted "Employees will initially complete a medium complexity media fill test kit and then on an annual basis."

2. The following records noted the media fill tests were not conducted annually:
a) E#23, tested on 3/16/2020, greater than one year ago;
b) E#27, tested on 3/9/2020, greater than one year ago; and
c) E#28, tested on 3/16/2020, greater than one year ago.

3. During an interview on 5/14/2021 at approximately 12:00 PM, E#17 (Director of Medical Services) reviewed E#23, E#27 and E#28's Pharmacy Colleague Media Fill Test Sample Collection Form and verbally agreed the competencies were not conducted annually and should have been.

Based on observation, document review and interview, it was determined the Hospital failed to ensure narcotic drugs were properly accounted for. This has the potential to affect all patients receiving care at a Hospital with a current census of 99 patients.

Findings include:

1. On 05/12/2021 at 9:30 AM, the Hospital policy "Controlled Substance-Hospital Pharmacy" revised 12/14/2020 was reviewed. Under "G. Record Keeping-Discrepancies" it reads "Any discrepancies in controlled substance count will be investigated and documented as follows a) Staff Responsibilities: i. When notified by the automatic dispensing machine (ADM) system of a controlled substance discrepancy, the user will initiate an investigation as soon as possible, no later than the end of their shift."

2. On 05/12/2021 at 10:00 AM, the "Discrepancy Audit Detail Report" for 05/11/2021 to 05/10/2021 was reviewed. There was no indication the medication discrepancy for the extra Hydrocodone-Acetaminophen tablet in the ED (Emergency Department) ADM was reported for resolution.

3. On 05/11/2021 at 12:20 PM, a tour of the ED was conducted. It was observed that one automatic dispensing machine (ADM), used to dispense medications, had a narcotic discrepancy. The discrepancy indicated a wrong amount of Hydrocodone-Acetaminophen (5-325 milligram) on hand. When the ADM screen was touched, the screen indicated there were 7 Hydrocodone-Acetaminophen tablets available. When the ADM was opened and inventoried, there were 8 Hydrocodone-Acetaminophen tablets in the drawer (one more than indicated). There was no investigation to clear the discrepancy as of the time of the observation.

4. The Narcotic Discrepancy Audit Detail Report was reviewed on 5/11/2021 and indicated 1 tablet was signed out for a patient on 04/05/2021, but was not taken out of the drawer, which caused the medication discrepancy. The discrepancy had not been cleared until 5/11/2021.

5. On 05/11/2021 at 12:30 PM, an interview with the Director of the Emergency Department (E#4) was conducted. E#4 verbally agreed there was a narcotic drug discrepancy and the discrepancy should have been resolved at the end of the shift on the day that it occurred and it wasn't.

Based on document review and interview, it was determined the surgical department perioperative staff and providers were not monitored for radiation exposure per policy. This has the potential to affect all providers and staff who work in the perioperative surgical department.

Findings include:

1. The policy titled "Radiation Safety and Dose Reduction" (undated) was reviewed on 5/13/2021. The policy noted "2. Personal are to wear whole body badges at collar for measurement of exposure... Exchange badge monthly..."

2. The Radiation Dosimetry Reports dated December 2020, January 2021, February 2021 and March 2021 and the Perioperative Department Radiology List were reviewed on 5/12/2021. The Perioperative Department Radiology List noted the staff and providers in which a dosimetry badge was issued, although lacked all providers who may utilize radiology equipment during a procedure. The reports lacked documentation the dosimetry badges were monitored monthly per policy and noted multiple entries as "unused" or "absent".

3. During a tour of the surgical department on 5/11/2021 at approximately 12:00 PM, E#18 (Surgical Scrub Technician/issues dosimetry badges) was interviewed. E#18 stated "I don't go into the rooms (operating rooms), so I don't know if they (staff) are wearing them (dosimeter badges). Most of the doctors don't even want them (dosimeter badge). I don't know about monitoring and compliance."

4. During an interview on 5/13/2021 at approximately 10:30 AM, E#19 (Radiology Technician) stated "The staff are required to do annual training about radiation exposure and wearing the badges. It's up to them if they want to wear it or not. We can't make them."

5. During an interview on 5/13/2021 at approximately 10:30 AM, E#20 (Director of Surgical Services) was asked to provide documentation of monthly dosimeter badge reports for all perioperative staff and providers. Documentation of monthly dosimeter badge reports for all perioperative staff and providers was not provided as of 5/14/2021 at 3:00 PM. E#20 verbally agreed staff and provider's should wear the dosimeter badges during all procedures that utilize radiology equipment.

Based on observation, document review, and staff interview, it was determined the Hospital failed to ensure expired food items were disposed of per Hospital policy. This has the potential to affect all patients, staff and visitors of the dietary service areas in the Hospital.

Findings include:

1. On 5/11/2021 at approximately 11:00 AM, a tour of the dietary department was conducted. During the tour the following items were observed to be outdated:
-- 2 (two) one gallon jugs of Apple Cider Vinegar was observed in the storage room with an expiration date of 11/1/2020
-- 5 (five) plastic bags of brown rice with a "use by" sticker of 4/24/2021
-- 1 (one) open Half and Half quart of coffee creamer with a "use by" sticker of 5/1/2021

2. On 5/11/2021 at approximately 11:15 AM, an interview with the Dietary Manager (E #12) was conducted. E #12 agreed the items were expired.

3. On 5/12/2021 at approximately 3:00 PM, the Hospital policy "Food and Supply Storage" (revised by the Hospital January 2021) was reviewed. The policy noted, "Discard food past the use by or expiration date".

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 May 11 & 12, 2021, 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 May 11 & 12, 2021, 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 document review and interview, it was determined for 1 of 2 analog scales in the Emergency Department, the Hospital failed to ensure they were maintained to ensure a level of safety and quality. This has the potential to affect all patients receiving care in the Emergency Department which treats approximately 100 patients per day.

Findings include:

1. On 05/11/2021 at 12:20 PM, a tour of the Emergency Department was conducted. It was observed in triage room #2 an analog scale without a preventive maintenance sticker on it, ensuring it had been calibrated.

2. On 05/11/2021 at 1:50 PM, an interview with the Director of the Emergency Department (ED) (E#4) was conducted. E#4 confirmed the scale did not have a calibration sticker on it and stated "I will check to see if it's been calibrated."

3. On 05/12/2021 at 9:00 AM, a review of the "Incoming Inspection Work Order" for the analog scale from triage room #2 was reviewed. It indicated the scale was calibrated on 05/11/2021 at 2:47 PM, after it was discovered it wasn't calibrated.

B. Based on observation, document review and interview, it was determined the Hospital failed to ensure electrical equipment, available for patient use, was inspected and had routine maintenance. This has the potential to affect all patients receiving care in the Hospital. Current census 99 patients.

Findings include:

1. On 5/11/2021 at 10:00 AM, a tour of the IMC (Intermediate Care Unit) was conducted with the IMC Manager (E#13). In the storage room, one Kangaroo Pump (a pump used to deliver nutrition by a tube into the stomach) was observed, available for patient use, and lacked a preventive maintenance sticker or an inspection tag.

2. On 5/13/2021 at 12:30 PM the policy "Incoming Equipment Inspections Procedure" was reviewed. The policy noted "Equipment brought in by a vendor must be inspected for electrical safety before use ..."

3. On 5/13/2021 at 1:00 PM, an interview with the Patient Safety Specialist (E#3) was conducted. E#3 stated "maintenance was unable to provide documentation on the Kangaroo Pump. The pump had not been recorded in the hospital inventory and was taken off the unit."


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C. Based on document review and interview, it was determined daily cleaning was not conducted in the Pharmacy's compounding area to prevent cross contamination. This has the potential to affect all inpatients and outpatients who receive care by the Hospital and required pharmaceutical interventions.

Findings include:

1. The Pharmacy daily cleaning log was reviewed on 5/11/2021 at approximately 3:00 PM. The log lacked documentation the daily buffer room cleaning was conducted on 4/10/2021, 4/25/2021, 5/5/2021, 5/7/2021 and the daily hood cleaning on 4/13/2021.

2. During an interview on 5/13/2021 at approximately 2:30, E#17 (Director of Medical Services) reviewed the Pharmacy's daily cleaning log and verbally agreed the daily cleaning was not conducted daily and should have been.


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D. Based on observation, document review, and staff interview, it was determined the Hospital failed to ensure outdated or expired supplies were not available for patient use. This has the potential to affect all patients receiving care at a Hospital with a current census of 99 patients.

Findings include:

1. On 5/11/2021 at approximately 2:00 PM, a tour of the Rehabilitation Unit was conducted. During the tour, on the crash cart, were 4 (four) defibrillator pads with the following expiration dates: 2 (two) defibrillator pads expired 8/2020, 1 (one) defibrillator pad expired 3/2020, and 1 (one) defibrillator pad expired 4/2019.

2. On 5/11/2021 at approximately 2:30 PM, an interview with the Rehabilitation Unit Manager (E #14) was conducted. E #12 verbally agreed the pads were expired and should not be on the crash cart.

3. On 5/12/2021 at approximately 4:00 PM, a policy on outdated supplies was requested. The Manager of Infection Prevention (E #7) stated the Hospital did not have a policy specific to outdated supplies, but the staff regularly go through supplies on units and replace or discard any expired supplies.

Based on observation, document review, and staff interview, it was determined for 1 of 3 steam sterilizer (sterilizer #6) logs reviewed, the Hospital failed to ensure surgical instruments were sterilized, in accordance with its manufacturer's Instructions for Use (IFU). This has the potential to affect all patients receiving surgical care at a Hospital.

Findings include:

1. On 5/12/2021 at approximately 11:00 AM, a tour of the Sterile Processing Department was conducted. During the tour sterilizer #6 was observed to be actively in service. Sterilizer #6's sterilization log was reviewed for 5/12/2021. The log noted at 8:28 AM an ortho (orthopedic) mallet was sterilized with a sterilization time of 4 minutes and a dry time of 10 minutes.

2. On 5/12/2021 at approximately 11:30 AM, an interview with the Central Processing Educator (E #15) was conducted. E #15 stated, "the load contained an ortho mallet and confirmed the shorter run time for the load".

3. On 5/12/2021 at approximately 3:00 PM the Manufacturer's IFU's were reviewed with the Director of Surgery for (for the Hospital's sister Hospital) (E #16). E #16 confirmed the ortho mallet was to run at least a 4 minute sterilization cycle with a minimum 30 minute dry time, according to the manufacturer's IFU.

4. On 5/12/2021 at approximately 4:00 PM the Hospital policy "Sterilization Standards" (no revision date) was reviewed. The policy noted, "wrapped cycle parameters are 4 minutes exposure... 20 to 40 minutes dry time...as per instrument manufacturer's instructions for use".