HospitalInspections.org

A. Based on a review of Hospital policy, clinical record review and staff interview, it was determined that the Hospital failed to include patients in the development and implementation of the plan of care (A130); failed to ensure patients had the right to personal privacy (A143); failed to ensure all psychiatric patients receive safe, continuous monitoring (A144). As a result, the Condition of Patient Rights was not met. In addition, an Immediate Jeopardy (IJ) was identified on 6/21/10 at 2:10PM as the Hospital failed to monitor and document safety checks on 4 East for 15 of 34 patients who were on 15 minute safety checks. An immediate jeopardy and serious threat to patient safety was created from the cumulative effect of these systematic practices.

The Hospital President, Executive Vice President, Senior Vice President of Patient Care, and Vice President of Quality was notified of the IJ on 6/21/10 at 2:10PM.

On 6/22/10 at 8:00AM, the Senior Vice President of Patient Care presented a document dated 6/21/10 and titled "Plan of Correction to Address Immediate Safety Concerns 4 East". The document included:

* To ensure the accuracy of the Nurse Tech rounding sheet for patients on precautions the following steps will be taken: Charge Nurse will check Nurse Tech rounding sheet every one hour.

* Clinical Director will check twice a day to ensure what was documented is accurate.

* Director of Quality and Clinical Directors will review this twice a day to ensure that documentation was completed correctly and to demonstrate that observations were actually performed.

* A mandatory inservice will occur for staff on duty 6/21/10 starting at 3:34PM and will continue until all staff have been inserviced.

Documentation provided on 6/22/10 at 8:00AM, evidenced that staff on each of the 4 psychiatric units were inserviced (4 East, 4 Main, 4 South, and 5 Main). On 6/22/10 at 12:00PM, psychiatric units (4 East and 4 South) were inspected. All patients on safety monitoring had documented safety checks every 15 minutes. Charge Nurses documented review of the safety checks to ensure completion and accuracy. As a result, the IJ was removed. However, the Condition of Patient Rights is not met.

B. Based on observational tour, and staff interview, it was determined that, for 4 of 4 psychiatric units oberved, the Hospital failed to maintain the safety of all psychiatric patients by failing to: ensure that safety checks were completed every 15 minutes (A144-A); ensure immediate access to all psychiatric patient rooms (A144-B); ensure that contraband items were not available to suicidal patients (A144-C); ensure psychiatric patients were not placed in patient rooms that lock from the inside and require key access (A144-D). As a result, an additional Immediate Jeopardy (IJ) and serious threat to patient safety was identifed on 6/24/10. The hospital failed to ensure that psychiatric patients did not have the ability to lock themselves in their rooms. An immediate jeopardy and serious threat to patient safety was created from the cumulative effect of these systematic practices

The Hospital President, Executive Vice President, Senior Vice President of Patient Care, and Vice President of Quality was notified of the IJ on 6/24/10 at 3:30pm.
The IJ was not removed at the time of survey exit.



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A. Based on review of Hospital policy, observation and staff interview, it was determined that for 1 of 2 (E # 1) RN's observed, hospital staff failed to ensure patient privacy was maintained during personal care.

Findings include:

1. The Hospital policy titled "Patient Rights" was reviewed on 6/21/10 at 1:45 PM. The policy included "...Respect and Dignity... To expect an environment that preserves dignity...Privacy and Confidential - To receive care which supports the patients privacy".

2. A tour of the Intensive Care Unit (ICU) was conducted on 6/21/10 from 9:15 AM to 10:30 AM. E# 1 was observed providing care to the patient in room #4 at 9:35 AM without the privacy curtain pulled around the bed. The patient's body was exposed (genitalia) while staff and visitors walked past the room. The curtain was pulled after this surveyor brought it to the attention of the staff person involved.

3. The above finding was confirmed by the Clinical Director of ICU on 6/21/10 at 10:30 AM, during an interview.

A. Based on review of Facility policy, observation, clinical record review, and staff interview, it was determined for 15 of 34 patients (Pts. # 21 - 35) on 15 minutes safety checks on the Adult Male Psychiatric Unit (4 East), the Hospital failed to ensure that safety checks were completed every 15 minutes. This failed practice placed 15 patients at risk for elopement, injury, and/or death.

Findings include:

1. Hospital policy No. TX 113, titled: "Precaution" was reviewed on 6/22/10 at 9:10 AM, "based on the clinical needs of each individual patient at a specific time in treatment... the following precautions are utilized at Jackson Park Hospital and monitored by nursing staff... Elopement (EP) Every 15 minutes as order by physician, Suicide (SP) Every 15 minutes... Close Observation (CO) Every 15 minutes..." The policy further required: "orders for precaution are written by the attending physician"

2. On 6/21/10 between 9:15 AM and 11:40 AM, a tour was conducted on the Adult Male Psychiatric Unit (4 East). At 9:15 AM, the Observation Records of 34 patients on 15 minute safety checks were reviewed. Ten patient (Pts. # 21 - 30) had not been checked since 7:45 AM, thus missing checks at 8:00 AM, 8:15 AM, 8:30 AM, 8:45 AM, and 9:00 AM.

At 9:15 AM, the observation records for three patient's (Pts. # 31 - 33) had been completed for the 9:30 AM safety check, prior to the actual time.

At 9:15 AM, two patients (Pts. # 34 & 35) had last been checked at 8:45 AM, thus missing the check at 9:00 AM.

Staffing on 6/21/10 at 9:15 AM, included: 4 Registered Nurses, 1 Mental Health Technician, 3 Patient Care Technicians, 1 Discharge Planner, and 2 Social Workers.

3. On 6/21/10 at 11:30 AM, the Physician orders for safety checks for these 15 patients were reviewed. Four patients (Pts. #21, 25, 33, & 34) were on suicide precautions. Ten patients (Pts. #22, 23, 24, 26, 27, 28, 29, 30, 31, & 32) were on close observation. One patient (Pt. #35) was on elopement precautions.

4. These findings were confirmed by the Clinical Manager of the Male Adult Psychiatric Unit (4 East) on 6/21/10 at 11:30 AM, during an interview.

B. Based on observation and staff interview, it was determined that during a tour of 4 South
the Hospital failed to ensure immediate access to all psychiatric patient rooms.

Findings include:

1. On 6/21/10 from 12:30 PM to 1:30 PM, patient room #440 was observed to be locked. The Director of the unit was requested to open the door and was unable to do so with her key. After several attempts, removing and reinserting the key the Senior Vice President of Patient Services provided her key, which was able to unlock the door. No patient was in the room at the time.

2.The above was confimed by the Senior Vice President of Patient Services during an interview on 6/21/10 at approximately 1:30PM.

C. Based on observation, safety check sheet review, and staff interview, it was determined for 7 of 7 patients on suicide precaution (Pts. 40 - 46) on the Adult Male Psychiatric Unit (4 East), the Hospital failed to ensure that contraband items were not available to suicidal patients. This failed practice placed suicidal patients at risk for injury and death.

Findings include:

1. On 6/23/10 between 3:35 PM and 3:50 PM, a tour was conducted on the Adult Male Psychiatric Unit (4 East). Room 466, a storage room, was unlocked and contained a janitor's cart with a plastic bag liner, 3 boxes containing plastic bags, 1 Television set with detached glass, 1 videc recorder with cord, and 1 CD player with cord. These potential safety hazards were available for suicidal patients.

2. A review on 6/24/10 at 10:30a m revealed that there were 7 patients (Pts. 40 - 46) on suicide precaution according to the safety check sheets for 4 East on 6/23/10 .

3. These findings were confirmed by the Clinical Manager of the Male Adult Psychiatric Unit (4 East) on 6/23/10 at 3:45 PM, during an interview.


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D. Based on a review of Hospital incident analysis, observation, and staff interview, it was determined that, for 4 of 4 Psychiatric Units, (4 East, 4 South, 4 Main, and 5 Main) the Hospital failed to ensure psychiatric patients were not placed in patient rooms that lock from the inside and require key access. This failed practice placed the total 66 psychiatric patients on census, in the above units at risk.

Findings include:

1. On 6/23/10 at approximately 12:00 P.M., the Hospital's incident analyses were reviewed. The analysis dated 5/28/10 included the incident report was about a suicide gesture involving Pt. #47. Documentation in the report revealed that Pt. #47 walked "to her room and closed the door against her 1:1 sitter, they tried to open the door but no one on the unit has the key to her room... Patient had a bedsheet tied in 1 knot around her neck."

2. The clinical record for Pt. #47 was reviewed on 6/23/10 at approximately 3:00PM. The record included documentation that a 32 year old female was admitted on 5/24/10 with a for complaints of suicidal attempt/overdose and depression. A documented nurses's note dated 5/28/10 at 11:00 A.M. included that the nurse was called by the sitter to open Pt. #47's door, and that the patient was standing in the middle of the room with a bedsheet around her neck in 1 knot. The documentation further noted that Pt. #47 was medicated with Haldol (antipsychotic), Ativan (anti-anxiety agent), and Benadryl (antihistamine), and that the patient was in the seclusion room with the 1:1 sitter. Upon examination of the patient by an advanced practice nurse, the plan was to "monitor closely and continue sitter 1:1."

The record also included an earlier progress note dated 5/24/10 at 7:24 P.M. that Pt. #47 was experiencing auditory hallucinations commanding her to"end her life." A "Resident Note" dated 5/25/10 at 2:40 P.M. included that the Resident responded to a Code Blue and Pt. #47 was "found with a bedsheet around her neck in an attempted suicide attempt". The note included that Pt. #47 was laying in bed- nonverbal but responds to painful stimuli. Vital signs: oxygen saturation=99, blood pressure=99/68, respirations=20, heart rate=94. The Resident physician's plan included to transfer Pt. #47 to 2 East Medical Psych Unit, 1:1 sitter, suicide precautions, soft neck collar.

3. In an interview with the Senior Vice President of Patient Care (SVPC), on 6/23/10 at approximately 1:30 P.M., the SVPC stated that the patients do have the ability to lock their doors from the inside of the rooms on the 4 South Unit.

4. Observational tours were conducted on 6/23/10 from approximately 3:30-4:30 P.M. with the following findings:

* 4 East had 19 patient rooms, with a patient census of 33. Of the 33 patients, there were 13 close observations, 7 suicide precautions, 1 assault precaution, 2 seizure precautions, and 25 fall precautions. Some patients were on multiple precaution types. The staffing at the time of the tour was 3 Registered Nurses (RNs), 2 Mental Health Workers (MHWs), and 1 sitter. All 19 patient room doors had a key entry on the outside, in the door knob, and another key tumbler entry on the outside inner surface of the door (this was a door inside a door). On the inside of these doors was one turn switch type lock that patients could use to lock the doors from the inside. No patients were observed behind a locked door at the time of the tour.

* 4 South had 12 patient rooms, with a patient census of 21. Of the 21 patients, there were 7 close observations, 2 suicide precautions, 1 assault precaution, 1 seizure precautions, and 9 fall precautions. Some patients were on multiple precaution types. The staffing at the time of the tour was 2 Registered Nurses (RNs), 2 Mental Health Workers (MHWs), 1 Certified Nursing Assistant (CNA), and 1 sitter. All 12 patient room doors, had a key entry on the outside, in the door knob, and another key tumbler entry on the outside inner surface of the door (this was a door inside a door). On the inside, these rooms have door knobs with a pop in/out, turn button type lock that patients could use to lock the doors from the inside. No patients were observed behind a locked door at the time of the tour.

* 4 Main had 8 patient rooms, with a patient census of 8. Of the 8 patients, there were 4 close observations, 3 suicide precautions, 2 assault precaution, 1 elopement precaution, and 4 seizure precautions. Some patients were on multiple precaution types. The staffing at the time of the tour was 1 Registered Nurse (RN), 2 Mental Health Workers (MHWs). All 8 patient room doors had a key entry on the outside, in the door knob. On the inside, there were door knobs with a pop in/out, turn button type lock that the patients could use to lock the doors from the inside. During the tour, room 424-2 was determined to be locked and occupied. A patient (pt. #48) was locked inside. Administrative staff (SVPC) attempted to unlock the door but the master key did not work. The SVPC knocked and requested that the patient open the door. The patient replied "leave me alone, I'm sleeping". The patient did finally open the door.

The clinical record reviewed on 6/24/10 at approximately 12:00PM included that this was a 32 year old male admitted on 6/20/10 with diagnosis of Schizophrenia. The history and physical included that Pt. #48 was paranoid with aggressive behavior. The physician's admission orders, dated 6/20/10, included close observation precaution which require 15 minute safety checks.

* 5 Main had 8 patient rooms, with a patient census of 4. Of the 4 patients, there were 2 close observations, 2 suicide precautions, 1 assault precaution, and 3 fall precautions. Some patients were on multiple precaution types. The staffing at the time of the tour was 1 Registered Nurse (RN), Mental Health Workers (MHW). All 8 patient room had a key entry on the outside door knob and another key tumbler entry on the outside inner surface of the door (a door inside a door). The inside locks were turn/ switch type locks that the patients could use to lock the doors from the inside. No patients were observed behind a locked door at the time of the tour.

5. The above findings were confirmed during separate interviews with the Senior Vice President of Patient Care, the 4East Clinical Director, and E#14, on 6/23/10 from approximately 3:30-4:30 P.M.

A. Based on observation, review of Monitor Technician job description, review of Hospital policy and staff interview, it was determined that for 1 of 1 (E #3) Telemetry Technicians, the Hospital failed to ensure Telemetry patients were continually monitored. This failed practice placed the 17 monitored patients on census at risk for an adverse outcome.

Findings include:

1. On survey date 6/21/10 at 9:30 AM, the Hospital's Telemetry Monitoring Room (Room #288) on 2 East was observed. There were a total of 17 patients on cardiac monitoring at the time of observation. At 9:35 AM, E #3 left the room, leaving the patients unmonitored until she returned at 9:40 AM ( five minutes later).

2. The Monitor Technician job description reviewed on survey date 6/21/10 at approximately 12:00 PM required, "The Telemetry Technician is responsible for clinical monitoring for normal and abnormal rhythms under the direction of the unit manager and the direct supervision of a registered nurse."

3. The Hospital policy regarding Telemetry Monitoring was requested on survey date 6/21/10 at approximately 10:00 AM, however as of 2:15 PM on survey date 6/21/10, the policy was unavailable for review.

4. The Vice President of Patient Care verified the findings during an interview on survey date 6/21/10 at 9:45 AM. During the interview the Manager stated that when the Technician leaves the monitor room, the charge nurse is required to watch the monitors.

B. Based on review of Hospital policy, clinical record review and staff interview, it was determined that in 3 of 3 (Pt #1, 8, and 9) clinical records reviewed of patients with decubitus ulcers, the Hospital failed to ensure that all decubitus ulcers were assessed in accordance with policy.

Findings include:

1. Hospital policy entitled, "Decubitus Care," reviewed on survey date 6/21/10 at approximately 12:00 PM required, "...II. Policy: C. Assessments are made on admission and every shift. D. Snapshots will be taken of manifested decubiti on admission...III. Procedures:..H. Measure and document size of affected area. I. Measure and document size and stage of decubitus."

The following were identified on the 2 East Nursing Unit:

2. The clinical record of Pt #1 was reviewed on survey date 6/21/10 at approximately 10:00 AM. Pt #1 was a 29 year old male admitted to the Hospital on 6/19/10 with a diagnosis of Infected Decubitus Ulcers. The clinical record contained an Admission Assessment Report dated 6/19/10 at 11:45 PM that contained documentation that Pt #1 had Stage III Pressure Ulcer on his coccyx and right hip. The documentation lacked wound measurements of the documented pressure ulcers.

Nursing documentation dated 6/21/10 at 7:33 AM indicated Pt #1 had a large decubitus to right hip. The documentation lacked the size and measurements as well as coccyx decubitus, as described in the admission assessment.

3. The clinical record of Pt #8 was reviewed on survey date 6/21/10 at approximately 10:15 AM. Pt #2 was a 68 year old male admitted on 6/18/10 with a diagnosis of Chest Pain. The clinical record contained an Admission Assessment Report dated 6/18/10 at 10:45 AM. The Assessment documented that Pt #8 was admitted with Stage II Pressure Ulcers to his Right and Left Upper Arms and Right and Left Lower Anterior Legs. The Assessments lacked sizes of Pt #8's Pressure Ulcers.

The Nursing documentation dated 6/20/10 at 12:36 AM indicated Pt #8 had Stage II pressure ulcers to "lower and upper extremity" and lower right and left anterior leg.

4. The findings were verified by the Vice President of Patient Care during an interview on survey date 6/21/10 at approximately 11:00 AM.



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5. The clinical record review for Pt. #9, on 6/21/10 at approximately 10:00 A.M., included that this was a 39-year-old male, admitted on 6/20/10 with a diagnosis of Medical Stabilization/Detox Heroin. The nursing admission assessment and shift assessment forms dated 6/20/10 included inaccurate documentation that Pt. #9's skin was intact and without wounds. As of survey date 6/21/10, the nurse failed to assess Pt. #9's wounds.

6. Upon interview with the Director of Infection Control on 6/21/10 at approximately 10:45 A.M., the Director stated that after examining Pt. #9, the patient currently has an open wound on the left thigh, and closed wounds on the right interior and right posterior thigh.

7. The above findings were confirmed during an interview with the Senior Vice President of
Patient Care on 6/21/10 at approximately 10:45 A.M.

A. Based on clinical record review, stated Hospital practice, and staff interview, it was determined that for 4 of 4 ( Pt. #2, 3, 4, & 5) clinical records reviewed the Facility failed to ensure a multidisciplinary staffing care plan was completed within 72 hours of admission for all patients.

Findings include:

1. The policy for the 72 hour multidisciplinary staffing was requested for review at 11:00 AM on 6/21/10. As of 3:30 PM on 6/21/10, the policy was not available for review.

2. The clinical record of Pt. #2 was reviewed on 6/21/10 at approximately 9:50 AM. Pt. #2 was a 58 year old female, admitted on 6/14/10, with diagnoses of Psychotic disorder, Suicidal Ideation and Self Mutilation. The clinical record contained a "Multidisciplinary Staffing Report" signed by a nurse, a mental health worker (MHW) and psychiatrist. The report contained the language, "To be completed within 72 hours of admission", however the report was blank lacking the MHW current clinical status; the nurses' medication response assessment; patient problem list with treatment objectives, progress and status; and the psychiatrist summary.

3. The clinical record of Pt. #3 was reviewed on 6/21/10 at approximately 10:10 AM. Pt. #3 was a 43 year old female, admitted on 6/13/10, with diagnoses of Major Depression with Psychotic manifestation and Polydrug Dependence. The clinical record lacked completion of a 72 hour staffing report for Pt. #3.

4. The clinical record of Pt. #4 was reviewed on 6/21/10 at approximately 10:25 AM. Pt. #4 was a 32 year old female, admitted on 6/11/10, with diagnosis of Schizophrenia. The clinical record lacked completion of a 72 hour staffing report for Pt. #4. A weekly Staffing report dated 6/16/10 lacked the nurses' medication response assessment; patient problem list with treatment objectives, progress and status; and the psychiatrist summary.

5. The clinical record of Pt. #5 was reviewed on 6/21/10 at approximately 10:40 AM. Pt. #5 was a 46 year old female, admitted on 6/16/10, with diagnoses of Depression . The clinical record lacked a 72 hour staffing report for Pt. #5.

6. The Clinical Director of the 5 Main unit was interviewed on 6/21/10, at approximately 10:45 AM. The Director stated that it is Hospital practice to complete a multidisciplinary staffing plan for all patients within 72 hours of admission.

7. The above findings were confirmed with the Clinical Director during an interview on 6/21/10 at 10:50 AM.

A. Based on observation and staff interview, it was determined, that for 54 of 54 grey top blood tubes, the Hospital failed to ensure all blood tubes had not expired. These tubes are used for glucose monitoring and created the potential for inaccurate glucose test results.

Findings include:

1. On 6/23/10 between 9:40 AM and 10:25 AM, a tour was conducted in the Laboratory. Fifty four of 54 grey top blood tubes had expired in April 2010. No other grey top tubes were available.

2. These findings were confirmed by the Laboratory Director during an interview on 6/23/10 at 10:20 AM.

A. Based on observation and staff interview, it was determined, that for 1 of 1 men's washroom in the Emergency Department (ED) waiting area, 1 of 1 ceiling vent in the ED trauma room, and 1 of 1 OR Central Supply Over-Flow room, the Hospital failed to ensure supplies and equipment were maintained at an acceptable level of safety and quality.

Findings include:

1. On 6/22/10 between 10:45 AM and 11:40 AM, a tour was conducted in the ED. The following was found:

- Hand washing soap was not available in the men's washroom in the ED, nor was a liquid soap dispenser present.

- 1 of 1 ceiling vent in the Trauma room included an accumulation of dust.

2. These findings were confirmed by the ED Clinical Director during an interview on 6/22/10 at 11:55 AM.

3. On 6/22/10 between 7:25 AM and 8:40 AM, a tour was conducted in the OR Central Supply Area. In the OR Central Supply Over-Flow room, where clean supplies were kept, the ceiling vent contained an accumulation of dust and there were 3 circular patches on the ceiling, each patch approximately 3 inches in diameter, and containing a black substance.

4. The findings were confirmed by the Coordinator of Central Services on 6/22/10 at 8:35 AM, during the tour and the Clinical Director of Perioperative Services was informed of the finding during an interview on 6/22/10 at 8:40 AM.


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B. Based on observation and staff interview it was determined that for 8 of 8 Sheet Pan tray holding carts, the Hospital failed to ensure carts were cleaned and maintained regularly.

Findings include:

1. A tour of the Food and Nutrition Department was conducted on 6/23/10 from 11:00 AM to 12:00 PM. The coolers and freezers were each observed to contain a sheet pan tray holding cart. Each cart held approximately 12 sheet pans and the 8 carts observed contained trays full of juices, vegetables and desserts. The carts had a thick white, crusty substance on the tray holder edges. The substance was able to be removed with wiping of the surface.

2. An interview with the Director of Food and Nutrition was conducted on 6/23/10 at 12:00 PM. The Director indicated that there was not a routine cleaning schedule for the carts in place. The above findings were conveyed during this interview.

A. Based on observation, clinical record review, staff interview, and a review of Hospital policy, it was determined that, for 1 of 2 (Pt. #9) records reviewed on the 3 East Unit, the Hospital failed to ensure a patient with a history of Methicillin Resistant Staphylococcus Aureus, (MRSA) was isolated in accordance with Hospital policy. This failed practice placed the 9 patients on census at risk for cross-contamination and infection.

Findings include:

1. During a tour of the 3 East Medical Stabilization Unit, on 6/21/10 from approximately 9:15-9:55 A.M., Pt. #9 was in private room #354. The room lacked an isolation sign and an isolation cart with personal protective equipment.

2. The clinical record review for Pt. #9, on 6/21/10 at approximately 10:00 A.M., included that this was a 39-year-old male, admitted on 6/20/10 with a diagnosis of Medical Stabilization/Detox Heroin. The record included documentation that Pt. #9 had a history of MRSA in the left thigh as of 4/2010. The record lacked documentation that Pt. #9 was placed in isolation upon admission to rule out current MRSA infection. The record also included documentation on the Emergency Department -Nursing Flow Sheet dated 6/20/10, "Pt.... positive for MRSA, attempted to contact Infection Control Dept., no pager number available."

3. Upon interview with the Director of Infection Control on 6/21/10 at approximately 10:30 A.M., the Director stated that if a patient had a previous history of MRSA in the wound, and the patient is readmitted, a culture of the wound should be done upon readmission if the wound is open, and a nasal swab for MRSA should be obtained. The Director of Infection Control also stated that Pt. #9 currently has an open wound on the left thigh as well as closed ulcers on right interior and posterior thigh, however, a wound culture and nasal swab had not been obtained.

4. Hospital policy #IC 101 entitled, "Isolation Precautions," was reviewed on 6/21/10 at approximately 1:10 P.M. The policy requires, "The Infection Control Coordinator will be informed of every patient known or suspected of having a communicable disease or suspected of being infective... use Contact Precautions for specified patients known or suspected to be infected... with epidemiologically important microorganisms... Examples include... multidrug-resistant bacteria..."

5. Hospital policy #IC 104 entitled, "Methicillin Resistant Staphylococcus Aureus (MRSA): Surveillance and Management," was reviewed on 6/22/10 at approximately 9:38 A.M. The policy requires, "Upon admission to the unit and upon nursing admission, any patient who... Has a history of MRSA at any site... will have nasal swab done MRSA screen... Upon admission to the unit and upon nursing assessment, any patient with: an open wound/decubitus will have a culture and sensitivity done."

6. The above findings were confirmed during an interview with the Senior Vice President of
Patient Care on 6/21/10 at approximately 10:30 A.M.


B. Based on observation, staff interview, and a review of Hospital policy, it was determined that, for 1 of 2 (E#2) staff observed on the 3 East Unit, and 2 of 9 staff/visitors observed in the Operating Room (OR), the Hospital failed to adhere to policy governing hand hygiene. This failed practice placed the 9 patients on census on 3 East, and the 1 patient in OR #2, at risk for cross-contamination and infection.

Findings include:

1. During a tour of the 3 East Medical Stabilization Unit, on 6/21/10 from approximately 9:40-9:50 A.M., E#2 was administering medication to the patients. While observing medication administration to patients in rooms 359-1, 376-2, and 378-3, E#2 failed to perform hand hygiene between patients, even though E#2 handled the drinking cups after the patients used them.

2. The above finding was confirmed during an interview with the Senior Vice President of
Patient Care on 6/21/10 at approximately 9:50 A.M.

3. Hospital policy #IC 101 entitled, "Isolation Precautions," was reviewed on 6/21/10 at approximately 1:10 P.M. The policy requires, "Wash hands after touching... body fluids... and contaminated items... between patient contacts."

4. On 6/22/10 from approximately 7:02-8:55 A.M., during an observational tour of OR #2, the following was observed:

* At approximately 7:11 A.M., E#4 picked up paper from the floor, discarded it, and continued opening sterile packs without performing hand hygiene.

* At approximately 7:20 A.M., E#6 dropped a piece of paper to the floor, retrieved and discarded it; then dropped a packaged stretch bandage, retrieved, opened, and placed it on the sterile field without performing hand hygiene.

5. The above findings were discussed with the Clinical Director of Perioperative Services on 6/22/10 at approximately 9:15 A.M.


C. Based on Hospital policy, observation, and staff interview, it was determined that, for 4 of 9 staff (E# 5, 8, 9, and V#1) observed in Operating Room (OR) #2, the Hospital failed to ensure adherence to Hospital policy governing dress code.

Findings include:

1. Hospital policy #D-11 entitled, "Dress Code: All or Personnel," reviewed 6/21/10 at approximately 2:00 P.M., requires, "The masks must cover the nose and mouth entirely and be tied securely... Disposable scrub hats or hoods that completely cover all possible head and facial hair are to be worn by all... entering the OR restricted and semi-restricted areas."

2. On 6/22/10 from approximately 7:02-8:55 A.M., during an observational tour of OR #2, the following was observed:

* E#5 (OR Tech) had hair exposed at the back of the head
* E#8 (OR Tech) entered OR #2 at approximately 7:49 A.M. without having mask tied securely (sterile packs open)
* E#9 (Radiology Tech) entered OR #2 at approximately 8:02 A.M. with sideburns exposed
* V#1 (Sales Rep) entered OR #2 at approximately 7:42 A.M. with sideburns exposed

3. The above findings were discussed with the Clinical Director of Perioperative Services on 6/22/10 at approximately 9:15 A.M.


D. Based on Hospital policy, observation, and staff interview, it was determined that, for 2 of 3 doors for Operating Room (OR) #2, the Hospital failed to maintain doors closed at all times in accordance with policy.

Findings include:

1. Hospital policy #T-2 entitled, "Traffic Control in the Operating Room," reviewed 6/21/10 at approximately 2:00 P.M., requires, "OR suite doors must be kept closed at all times in order to reduce air turbulence and to restrict air-borne bacterial counts."

2. On 6/22/10 from approximately 7:02-8:55 A.M., during an observational tour of OR #2, the following was observed:

* At approximately 7:00 A.M., 2 of 3 doors to OR#2 were open, although not in use at time. one of the doors in close proximity to the opened sterile packs, remained open from 7:10
-7:15 A.M. and from 7:44 - 7:52 A.M. the other open door remained open throughout observation, from 7:00 A.M. - 8:55 A.M.

3. The above findings were discussed with the Clinical Director of Perioperative Services on 6/22/10 at approximately 9:15 A.M.


E. Based on a review of Hospital stated practice, observation, and staff interview it was determined that for 4 of 9 staff/visitors observed in OR#2, the Hospital failed to ensure the sterile field was maintained free of cross-contamination.

Findings include:

1. Hospital practice as stated by the Clinical Director of Perioperative Services on 6/22/10 at approximately 9:15 A.M., is that individuals who are not scrubbed and properly gowned should maintain a minimum distance of 2 feet from sterile field, so as not to cross contaminate the sterile field.

2. On 6/22/10 from approximately 7:02-8:55 A.M., during an observational tour of OR #2, the following was observed:

* At approximately 7:29 A.M., E#5 (Surgical Assistant- unscrubbed and ungowned) grasped the underside corners of the sterile wrapping under a sterile prep tray that was opened and positioned on a stand, in order to reposition the opened tray. Upon release of the underside corners of the tray wrapper, one of the corners remained folded, exposing the contaminated underside of the wrapper in an upward position. When E#4 (OR Tech, scrubbed, gowned and gloved) approached the tray to prepare it with an iodine solution, the right sleeve and gown front made contact with the folded, contaminated corner of the prep tray wrapper.

* At approximately 7:41 A.M., E#6 (OR Tech) covered a table with a sterile drape and rolled it in front of another smaller table with wrapped sterile supplies. E#6 reached across the sterile draped table to retrieve the "small fragment tray" from the smaller supply table at the back, thereby compromising the sterile field.

* From approximately 7:44-7:55 A.M., V#1 (Sales Representative-unscrubbed, ungowned) was standing less than 2 feet from the sterile field which contained the "small fragment tray" and other sterile equipment. V#1 on multiple occasions, pointed over the sterile field with a silver colored instrument/pointer, while asking E#4 to remove the lids from certain trays, etc., thereby compromising the sterile field.

3. The above findings were discussed with the Clinical Director of Perioperative Services on 6/22/10 at approximately 9:15 A.M.


F. Based on observation and staff interview, it was determined that in OR#2, the staff failed to ensure aseptic technique and environment. This failed practice placed Pt. #18 at risk for cross-contamination and infection.

Findings include:

1. On 6/22/10 at approximately 8:32 A.M., during an observational tour of OR #2, E#7 (Anesthesiologist) disconnected Pt. #18 from the ventilator in order to reposition the patient's bed. Upon disconnection, the corrugated tubing and connector from the ventilator, fell to the floor. E#7 retrieved the tubing and connector from the floor and reattached it to Pt. #18's endotracheal tube.

2. On 6/22/10 from approximately 7:02-8:55 A.M., during an observational tour of OR #2, 2 of 4 intravenous (IV) poles included tape and tape residue, thereby not allowing for proper disinfection of the surfaces.

3. The above findings were discussed with the Clinical Director of Perioperative Services on 6/22/10 at approximately 9:15 A.M.



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G. Based on observation and staff interview, it was determined, that for 1 of 15 surgical packages containing sterilized instruments in the Perioperative Area (OR) Sterile Supply Room on the second floor, the Hospital failed to ensure packaged sterilized instruments were not contaminated.

Findings include:

1. On 6/22/10 between 7:25 AM and 8:40 AM, a tour was conducted in the OR Sterile Supply Room. One sterilized retractor was found inside double packaging and both packages contained holes, which left the retractor contaminated.

2. The finding was confirmed by an Operating Room Technician (E #11) on 6/22/10 at 7:45 AM, during the tour and the Clinical Director of Perioperative Services was informed of the finding during an interview on 6/22/10 at 8:40 AM.

H. Based on observation and staff interview, it was determined, that for 2 of 15 surgical instrument packs in the Perioperative Area, 5 of 5 surgical instrument packs in the Perioperative Decontamination Area, 1 of 1 air conditioning duct in the Pharmacy, 30 of 30 urine samples in the Laboratory, 40 of 40 units of blood in the refrigerator in the Laboratory, 1 of 1 cytotherm bath in the Laboratory, and 20 of 20 preassembled vacutainers in the Laboratory, the Hospital failed to ensure separation of sterile, clean and dirty equipment and supplies was maintained.

Findings include:

1. On 6/22/10 between 7:25 AM and 8:40 AM, a tour was conducted in the Perioperative Area (OR) Sterile Supply Room on the second floor and the OR Central Supply Area. The following was found:

- In the OR Sterile Supply Room, 2 of 15 surgical instrument packages, each containing 1 sterilized biopsy punch were found on top of and next to clean instruments and supplies. This created the potential for contamination of sterile packaging.

- In the OR Central Supply Decontamination area, 5 of 5 brushes, used to clean instrument lumens, contained foreign debris and were placed on a dirty ledge. This created the potential for contamination of surgical instruments.

2. The findings related to the OR Sterile Supply Room were confirmed by an Operating Room Technician (E #11) on 6/22/10 at 7:45 AM, during the tour. The findings related to Central Supply were confirmed by the Coordinator of Central Services on 6/22/10 at 8:35 AM, during the tour. The Clinical Director of Perioperative Services was informed of all the findings during an interview on 6/22/10 at 8:40 AM.

3. On 6/23/10 between 9:00 AM and 9:25 AM, a tour was conducted in the Pharmacy. The air conditioning duct, located over the intravenous bag solutions, contained a thick coating of black material. This failed practice created the potential of contaminating antibiotic intravenous bag solutions shelved below.

4. This finding was confirmed by the Executive Pharmacy Director during an interview on 6/23/10 at 9:20 AM.

5. On 6/23/10 between 9:40 AM and 10:25 AM, a tour was conducted in the Laboratory. The following was found:

- In the Chemistry Room, approximately 30 urine samples were located in a refrigerator which also held clean control reagents for the chemistry analyzer. This failed practice created the potential for contamination of the control reagents.

- In the blood bank room, the inside of the blood refrigerator contained a black substance. Approximately 40 units of blood were held in the refrigerator. This created the potential for contamination of blood packaging.

- In the blood bank room, the log that documented when the water in the cytotherm bath (water bath used to warm blood bags) included: "Cytotherm bath should be cleaned once monthly or sooner as needed. Record date performed". The May log included the date 5/10/10, when the cytotherm bath was last cleaned, over 1 month ago. The log failed to contain documentation that the cytotherm bath was cleaned for the month of June 2010. This created the potential for contamination of blood packaging.

- In the out-patient phlebotomy room, approximately 20 pre-assembled vacutainers (the needle seal was broken and the needle attached to the vacutainer) were contained in 1 phlebotomy case, available for drawing patient's blood. This created the potential for patient infection and contamination of blood draw samples.

6. These findings were confirmed by the Laboratory Director during an interview on 6/23/10 at 10:20 AM.


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A. Based on review of Hospital policy, clinical record review and staff interview, it was determined that or 2 of 2 (Pt. #38 and #39) death records reviewed, the Hospital failed to notify the OPO of deaths that occurred as required.

Findings include:

1. The Hospital policy titled "Organ and Tissue Donation Management" was reviewed on 6/23/10 at 9:00 AM. The policy included "Documentation, Contacting "Gift of Hope" regarding organ/tissue referral and donation is to be documented in the progress note and in the "Organ/Tissue Donation Referral Tracking Form" which should be sent to the Nursing Office."

2. The clinical record of Pt. #38 was reviewed on 6/23/10 at 2:00 PM. Pt. #38 was an 84 year old male admitted on 3/26/10 with the diagnosis of Hypotension. Pt. #38 expired on 3/27/10 with the cause of death listed as Sepsis and Cancer of the Stomach on the death certificate. The clinical record lacked documentation of notification of death to the Gift of Hope in the progress notes or on the tracking form.

3. The clinical record of Pt. #39 was reviewed on 6/23/10 at 2:30 PM. Pt. #39 was a 44 year old female admitted on 3/14/10 with the diagnosis of Decreased Responsiveness. Pt. #39 expired on 3/14/10 with the cause of death listed as Adult Immunodeficiency Disorder Syndrome on the death certificate. The clinical record lacked documentation of notification of death to the Gift of Hope in the progress notes or on the tracking form.

4. The above findings were confirmed with the Senior Vice President of Patient Services on 6/23/10 at approximately 2:45 PM, during an interview.

A. Based on a review of Hospital policy, observation, and staff interview, it was determined that for 1 of 1 (E#7) staff observed between the restricted and unrestricted areas of the Operating Department, the Hospital failed to ensure that the potential for contamination does not exist in the Surgical Department.

Findings include:

1. The Hospital policy # T-2 titled "Traffic Control in the Operating room" was reviewed on 6/21/10 at 2:30 PM. The policy included " Each individual is responsible for maintaining proper OR attire and traffic control. 1. Unrestricted area: Street clothes permitted...b. Pre-operative holding area... Restricted area: full OR attire, cap and mask are required. "

2. The Operating Department was toured from 7:00 AM to 9:15 AM. The pre-operative area had one patient who arrive at approximately 7:45 AM. The anesthesiologist (E#7) exited a restricted area (OR suites) while wearing surgical scrub attire and then entered the pre-operative area (unrestricted) to interview the patient. A family member of the patient was present at bedside wearing street clothes. E#7 then re-entered the restricted area creating a co-mingling situation. The anesthesiologist failed to wear a cover gown when leaving the restricted area.

4. The Clinical Director of the Peri-Operative Services was interviewed on 6/22/10 at 9:15 AM. The Director stated that staff in scrub attire routinely go between the unrestricted and restricted area to talk to patients and families before surgery. The above findings were confirmed during the interview.