HospitalInspections.org

On February 26, 2020, a follow up visit was conducted to verify corrective actions. All deficienies have been corrected. The requirements of 42 CFR Subpart 482.41 Physical Environment, are MET.


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Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Sample Validation Survey conducted on October 28-29, 2019, the surveyors find that 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 document review, observation, and interview, it was determined that for 3 of 3 patient rooms (Rooms: #102, #103, & #105) in the High Acuity Unit (HAU) at the Chicago campus, the Hospital failed to ensure that the window blinds in each patient room were present and/or functional, to provide personal privacy for patients.

Findings include:

1. On 10/30/19, the Hospital's policy titled, "Work Order System," (revised 2/2011), was reviewed. The policy required, "Individuals requesting work to be performed... submit work requests via the on-line work order system... Facility Operations staff address the work orders in a prompt manner, preferably within 24 hours..."

2. On 10/30/19, the Hospital's policy titled, "Patient Rights and Responsibilities," (revised 9/2015), was reviewed. The policy required, "... 4. The patient has the right to have personal privacy..."

3. On 10/29/19 at 1:45 PM, an observational tour was conducted in the HAU. Three of 3 patient rooms (rooms #102, #103, & #105) had window blinds missing and/or were not functional. The windows provided viewing to the outside as well as viewing from the outside into the patient room.

4. On 10/30/19 at 11:15 AM, the work orders for HAU for September and October 2019 were reviewed. There were no work orders for window blinds in HAU.

5. On 10/29/19 at 2:10 PM, an interview was conducted with an Environmental Service Worker (E #14), who was cleaning room #105. E #14 stated that there should be working window blinds on each window.

6. On 10/30/19 at 9:10 AM, an interview was conducted with the Director of Quality and Patient Safety (E #12). E #12 stated that the HAU window blinds were being installed and repaired today.

Based on document review, observation, and interview, it was determined that for 3 of 4 medical units (2 North, 3 North/South, and 4 North/South) at the Chicago Campus, the Hospital failed to ensure that patient information was secured from unauthorized access, in order to maintain confidentiality of clinical records. This had the potential to affect the privacy of 55 patients on census, on those units, on 10/28/19.

Findings include:

1. The Hospital's policy titled, "Patient Rights & Responsibilities" (revised 09/2015), was reviewed on 10/29/19 and required, "...The patient has the right to confidentiality relating to the medical record..."

2. The Hospital's policy titled, "Overview of HIPPA [Health Insurance Portability and Accountability Act] Compliance Program" (revised 01/2018), was reviewed on 10/29/19 and required, "...[The Hospital] is committed to protecting the privacy of its patients and their Protected Health Information in all forms (i.e., written, electronic, spoken)..."

3. Observational tours of 3 medical units (2 North, 3 North/South, and 4 North/South) at the Chicago Campus were conducted on 10/28/19, between approximately 9:30 AM and 12:25 PM. There were 13 patients on census on 2 North; 15 patients on 3 North/South; and 27 patients on 4 North/South. Each patient's room had a clipboard that was kept on a shelf outside of their room doors (facing the hallway). The clipboard contained the patient's personal and medical information, including: the patient's name; age; gender; admission date; medical record number; weight; current medications; vital signs (pulse, blood pressure, respiration rate, temperature, and blood glucose); intake/output (I/O) records; occult blood test results (tests for blood in the stool); and evaluation/progress notes from respiratory care, physical therapy, occupational therapy, speech language pathology, and a wound clinician. Each clipboard had a cover sheet that included, "Confidential. This is protected health information intended solely for the use of authorized healthcare professionals..." The clipboards/charts were accessible to other patients and visitors and was not supervised by an authorized staff member at all times.

4. An interview was conducted with a Registered Nurse (E#13) on 10/28/19, at approximately 11:58 AM. E#13 stated that each patient has a clipboard on the wall outside of their room which contains current medical information for the past 24 hours, such as vitals, I/O, and medications. E#13 stated that the clipboards are for the doctors, nurses and/or PCTs (patient care technicians) to review.

5. An interview was conducted with the Director of Health Information Management/Medical Records (E#4) on 10/29/19, at approximately 9:15 AM. E#4 stated that patients' medical records should be kept at the nurse's station where it can be supervised 24/7 (24 hours a day, 7 days a week). When asked about keeping a portion of the patient's clinical record in the hallway, E#4 responded that confidentiality of those records was a concern and should be looked into.

Based on document review and interview, it was determined that for 3 of 4 records reviewed (Pts. #22, #23, and #27) for non-violent restraints, the Hospital failed to ensure that the condition of the patient was monitored every 2 hours while in restraints, as required.

Findings include:

1. The Hospital's policy titled, "Restraint Use" (revised 09/2019), was reviewed on 10/29/19 and required, "... The patients' physical status and needs are monitored and assessed by the RN [registered nurse] at a minimum of every two hours... These include but are not limited to: ... g. ... evidence of injury... The RN will document the patient's assessment, safety, care provided, and outcomes in 2-hour increments while the restraint order is in effect... Based upon their assessment and the absence of unsafe patient behaviors, either the nurse may enter an order under the physician per protocol or the physician may enter an order to discontinue the use of restraints... Documentation of Care Provide to the Patient in Restraints [includes] ... d. Discontinue the Restraint problem when restraints are discontinued..."

2. The clinical record of Pt. #22 was reviewed on 10/28/19. Pt. #22 was admitted on 10/16/19, with a diagnosis of acute respiratory failure. There were physicians' orders, dated 10/17/19, 10/18/19, and 10/19/19, for (non-violent) soft limb restraints and 4 siderails. Restraint flowsheets indicated that Pt. #22 was in restraints from 10/17/19 at 12:00 AM to 10/19/19 at 7:54 AM; however, the record did not indicate whether the restraints were removed/discontinued on 10/19/19, following the 7:54 AM assessment. The physician's order for restraints, dated 10/19/19, was not documented as completed/discontinued until 10/19/19 at 8:07 PM (12 hours and 13 minutes after the last documented assessment). The restraint flowsheets lacked documentation of restraint monitoring assessments and care provided on 10/17/19 from 12:00 AM to 3:30 AM (3 hours and 30 minutes); on 10/17/19 from 10:06 AM to 1:09 PM (3 hours and 3 minutes); on 10/17/19 from 3:52 PM to 6:47 PM (2 hours and 55 minutes); on 10/18/19 from 3:30 AM to 6:17 AM (2 hours and 47 minutes); on 10/18/19 from 6:00 PM to 9:41 PM (3 hours and 41 minutes); and on 10/19/19 from 2:43 AM to 5:30 AM (2 hours and 47 minutes).

3. The clinical record of Pt. #23 was reviewed on 10/28/19. Pt. #23 was admitted on 9/18/19, with a diagnosis of acute and chronic respiratory failure.

- There were physicians' orders, dated 10/23/19 and 10/24/19, for (non-violent) soft limb restraints and 4 siderails. Restraint flowsheets indicated that Pt. #23 was in restraints from 10/23/19 at 10:00 PM to 10/24/19 at 8:00 AM. The flowsheets lacked documentation of restraint monitoring assessments and care provided from 10/23/19 at 10:00 PM to 10/24/19 at 3:21 AM (5 hours and 21 minutes).

- There were physicians' orders, dated 10/26/19 through 10/28/19, for (non-violent) vest restraint and 4 siderails. Restraint flowsheets indicated that Pt. #23 was in restraints from 10/26/19 at 10:00 AM to 10/28/19 at 8:09 AM. The flowsheets lacked documentation of restraint monitoring assessments and care provided from 10/26/19 at 8:00 PM to 10/27/19 at 12:00 AM (4 hours) and on 10/28/19 from 3:30 AM to 6:08 AM (2 hours and 38 minutes). Restraint assessments completed on 10/26/19 at 12:00 PM and 6:00 PM lacked documentation of whether or not injuries were present.

4. The clinical record of Pt. #27 was reviewed on 10/28/19. Pt. #27 was admitted on 8/29/19, with the diagnoses of end-stage renal disease and respiratory failure. There were physicians' orders, dated 9/1/19, 9/2/19, 9/3/19, 9/4/19, and 9/5/19, for (non-violent) soft limb restraints and 4 siderails. Restraint flowsheets indicated that Pt. #27 was in restraints from 9/1/19 at 12:00 AM to 9/5/19 at 11:03 AM. The flowsheets lacked documentation of restraint monitoring assessments and care provided on 9/1/19 from 2:00 AM to 5:30 AM (3 hours and 30 minutes); on 9/1/19 from 4:00 PM to 10:00 PM (6 hours); on 9/3/19 from 6:14 AM to 9:02 AM (2 hours and 48 minutes); on 9/3/19 from 5:38 PM to 8:20 PM (2 hours and 42 minutes); on 9/4/19 from 1:34 PM to 4:13 PM (2 hours and 39 minutes); and on 9/5/19 from 11:03 AM to 2:49 PM (3 hours and 46 minutes).

5. An interview was conducted with the Manager of the 4 North/South Unit (E#20) on 10/28/19, at approximately 10:30 AM, and again on 10/30/19, at approximately 12:00 PM. E#20 stated that the expectation is for restraint assessments and monitoring to be completed and documented at minimum every 2 hours. E#20 stated that it was unclear when Pt. #22's restraints were removed on 10/19/19. E#20 stated that the nurse typically documents that restraints are "Not needed, discontinued" under the "Assessment of Need for Restraints" section in the record; however, it was not documented for Pt. #22. E#20 confirmed that on 10/19/19 from 7:54 AM to 8:07 PM, there was no documentation of restraint assessments and/or discontinuation of restraints in the record.

A. Based on document review and interview, it was determined that for 2 of 2 Procedure Nurses (E #18 and E #19) personnel files reviewed for conscious/moderate sedation qualifications, the Hospital failed to ensure that all drugs were administered in accordance with medical staff approved policy and procedures. This failure has the potential to affect Pt. #25 and an average of 14 patients per month receiving conscious/moderate sedation administered by the Procedure Nurse.

Findings include:

1. On 10/30/19, the policy titled , "IV [intravenous] Moderate Sedation", (revised 9/2019) was reviewed. The policy required, IV moderate sedation is provided by qualified members of the medical staff or nursing staff...Registered Nurses who have completed a sedation certification class may also administer moderate sedation...Nursing qualification 1. The Registered Nurse managing the care of patients receiving IV moderate sedation is qualified by: a. completion of IV moderate sedation education class b. ACLS [Advanced Cardiac Life Support] certification c. Bi-annual completion of moderation sedation review with competency assessment."

2. On 10/30/19, the job description entitled, "Procedure Nurse" dated 04/2013, was reviewed. The job description required, "Principle duties and responsibilities...17. Maintains current skills in providing care to patients undergoing special procedures and moderate sedation by attending relevant courses and programs..."

3. On 10/30/19, E #18's (Procedure Nurse at the Chicago campus) personnel records, with education, certification and competencies were reviewed. E #18's personnel record included a continuing education certificate dated October 9, 2006. The certificate included, "The above member [E #18] completed 10 contact hours entitled: Questions and answers in sedation/analgesia...This certificate must be retained for a period of five (5) years after course completion." E #18's competency dated 8/6/19, lacked documentation of a bi-annual moderate sedation review or assessment.

4. On 10/30/19, E #19's (Procedure Nurse at the Chicago campus) personnel records, with education, certification and competencies was reviewed. E #19's personnel record included a continuing education certificate dated July 26, 2010. The certificate included, "[E #19] is credited with successfully completing 10 contact hours entitled: Questions and answers in sedation/analgesia. This certificate must be retained for a period of six (6) years." E #19's competency dated 8/19/19, lacked documentation of a bi-annual moderate sedation review or assessment.

5. On 10/30/19, Pt. #25's clinical record was reviewed. Pt. #25 was admitted on 8/8/19 with the diagnoses of renal failure and coronary artery disease. Pt. #25 had an esophagogastroduodenscopy (EGD - a scope placed down the throat to the stomach)/ percutaneous endoscopic gastrostomy (PEG) tube (feeding tube) insertion. Pt. #25's procedure record dated 10/22/19 indicated that E #18 was the sedation nurse (administers sedation medication during procedures). The procedure record indicated that E #18 administered 1 milligram of versed (sedative) to Pt. #25 during the procedure.

6. On 10/30/19 at approximately 11:15 AM, an interview was conducted with the Director of Education (E #17). E #17 stated that the Hospital recognizes that the procedure nurses are not in compliance with the requirements for conscious/moderate sedation. E #17 stated that E #18 and E #19 are scheduled to attend the conscious/moderate sedation certification course.


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B. Based on document review, observation, and interview, it was determined that for 2 of 3 (Pts. #15, Pt #16) patients observed for drugs and biologicals administration, the Hospital failed to ensure that IV (intravenous-administered through veins) fluids were labeled with a date, and discarded, according to the hospital's policies.

Findings include:

1. The Hospital's policy titled, "Central Venous Catheters [CVC-tube placed in large vein];" (revision date 8/19), was reviewed on 10/29/19, and required, "Purpose. B. To prevent infections and to ensure the optimal functioning of central venous access catheters [intravenous access through large vein]. 3. Infusion of Intermittent IV Piggyback (IVPB) Medications [small amount of intravenous medication administered along with a primary IV bag]. a. Label the 250 cc [cubic centimeters] bag of normal saline with date and patient's name. Change the saline flush bag every 24 hours... 5. Hyperalimentation [a form of nutrition delivered though a vein] and Lipid (Fat) Emulsion Infusion. f. The lipid emulsion tubing and/ or hyperalimentation tubing must be changed minimally every 24 hours."

2. The Hospital's policy titled, "Intravenous Therapy: Peripheral Line" (reviewed by hospital on 10/2010), was reviewed on 10/29/19, and required, "IV solutions are changed at least every 24 hours."

3. The clinical record for Pt #16 was reviewed on 10/29/19. Pt #16 was admitted on 10/24/19, with the diagnosis of Complex Medical Care. Pt #16's Medication Orders included an order (dated 10/26/19) for Total Parental Nutrition (TPN/intravenous nutrition).

4. The clinical record for Pt #15 was reviewed on 10/29/19. Pt #15 was admitted on 9/27/19, with the diagnosis of Respiratory Failure. Pt #15's Medication Orders , dated 9/27/19 and 10/19/19, included an order for peripheral Meropenem (antibiotic) 500 mg (milligrams) IV Piggyback and an order for Sodium Chloride 0.9% 250 ml (milliliters) bag.

5. On 10/28/19 at 9:40 AM, during an observational tour at the Chicago Campus, in Pt #16's room, a TPN IV bag was actively being administered to the patient through the CVC line. The TPN bag did not contain a label with the date and time that it was started.

6. On 10/28/19 at 10:12 AM, during an observational tour at the Chicago Campus, in Pt #15's room, there was an IV antibiotic bag (Meropenem) and Sodium Chloride IV bag hanging at the patient's bedside. The IV bags were dated 10/25/19 (3 days prior).

7. On 10/28/19 at 9:45 AM, an interview was conducted with the 3 South Staff RN (Registered Nurse)/ E #16. E #16 stated, "We [nurses] usually date IV's when we hang them. I don't see a date on Pt #16's IV bag. Once the TPN is hung, then it is only good for 24 hours. [Regarding the expired IV bags], the IV bags are good for 24 hours. We should check the IV's at the beginning of the shift and discard them if needed."

8. On 10/29/19 at 3:15 PM, an interview was conducted with the Staff Educator (E #15). E #15 stated that it is important for the nurses to label and date IV meds (medications) when they are hung. E #15 stated that it is especially important to date the TPN bag when hung, because of the additives that are in the solution. E #15 stated that if the TPN bag is hung for more than 24 hours, then bacteria can begin to grow.

Based on document review and interview, it was determined that for 1 of 3 (Pt. #16) patient records reviewed for procedures, the Hospital failed to ensure that the clinical record included all treatments and care provided necessary to monitor the patient's condition.

Findings include:

1. On 10/30/19, the job description entitled, "Procedure Nurse" dated 04/2013, was reviewed. The job description required, "Principle duties and responsibilities...5. Provides direct patient care prior to, during, and immediately post procedure...Documents all care provided..."

2. On 10/30/19, Pt. #16's clinical record was reviewed. Pt #16 was admitted on 10/24/19, with the diagnosis of Complex Medical Care. Pt. #16's procedure record dated 10/21/19 indicated that Pt. #16 had an esophagogastroduodenscopy (EGD) (tube placed down the throat to the stomach)/ percutaneous endoscopic gastrostomy (PEG) tube insertion (feeding tube). The intra-procedure (during) documentation section of the procedure record was left blank. The intra-procedure section lacked documentation for the following: equipment used during the procedure; the names of individuals present for the procedure (including the physician, and sedation nurse); monitoring type; procedure location; IV (intravenous) fluids; patient position; skin prep; oxygen therapy; scope type; and type, size and location of catheter inserted. The record lacked documentation of who administered versed (sedative) 1 milligram IVP (intravenous push) to Pt. #16 during the procedure.

3. On 10/30/19 at approximately 3:30 PM, an interview was conducted with the Director of Quality and Patient Safety (E #12). E #12 stated that the procedure records should include documentation of the care provided during the procedure.

Based on document review and interview, it was determined that the Hospital's Medical Record Department at the Hinsdale and Chicago campus failed to ensure medical records were completed within 30 days following discharge, as required.

Findings include:

1. On 10/29/19 at 1:00 PM, the Hospital's policy titled, "Incomplete/Delinquent Medical Records," (revised 3/2019), was reviewed and required, "...All medical records of discharged patients shall be completed within thirty (30) calendar days of discharge from the Hospital..."

2. On 10/29/19 at 1:30 PM, the Hospital's letter of attestation, dated 10/29/19, was reviewed. The letter noted that there are currently a total of 7 delinquent medical records at the Hinsdale and Chicago campus. The letter was signed by the Medical Record Director (E #4).

3. On 10/29/19 at 1:45 PM, an interview was conducted with E #4. E #4 stated that medical records should be completed in 30 days. E #4 stated that there are a total of 7 delinquent records from both campuses.

A. Based on document review, observation, and interview, it was determined that the Hospital failed to manage dietary services by discarding expired chlorine test strips to ensure that dishes/trays were adequately disinfected, potentially affecting the average of 70 patients who recieve food trays per day.

Findings include:

1. The Hospital's policy titled, "Temperatures for Equipment/Utensil Wash and Rinse" (revised 09/2019), was reviewed on 10/29/19 and required, "...Patient Dishmachine:... The rinse temperature should be confirmed with a chlorine test strip in which the goal is to reach 100 ppm [parts per million]..."

2. An observational tour of the dietary area at the Chicago Campus was conducted on 10/29/19, at approximately 10:15 AM. At approximately 11:15 AM, the Manager of Food and Nutrition (E#21) demonstrated how to operate the dishmachine. E#21 used a bottle of chlorine test strips to verify if the rinse water had reached 100 ppm. The bottle of test strips had an expiration date of 01/2019 and had a sticker covering the color coded chart (used to determine the level of chlorine by comparing it to the color of the test strip).

3. An interview was conducted with the Manager of Food and Nutrition (E#21) on 10/29/19, at approximately 11:20 AM. E#21 stated that the purpose of the chlorine test is to make sure that the rinse water is able to adequately sanitize the dishes. After asking E#21 how the staff could compare the strip to the color chart if it was covered, E#21 attempted to remove the sticker covering the color coded chart. E#21 stated that staff could see the edge of the color coded box for 100 ppm and stated, "They've been doing this for a while so they know that's the 100 parts per million box." When the expiration date of the strips were brought to the attention of E#21, E#21 responded, "I should have another bottle in my office."

B. Based on document review, observation, and interview, it was determined that the Hospital failed to manage dietary services by labeling opened food products and discarding outdated food products to ensure that they were safe for consumption, potentially affecting the average of 70 patients who recieve food trays per day.

Findings include:

1. The Hospital's policy titled, "Receiving, Storing and Securing of Food and Supplies" (revised 08/2019), was reviewed on 10/29/19 and required, "...B. Storing of Food and Supplies... Prepared food will require a 'use by' date of 7 days... Ensure that all food and nonfood supplies are in containers or packages that are clearly labeled and that all use by dates are current. Frozen food items placed in the cooler for thawing will be dated with an expiration date of 7 days from the day it was placed in the cooler. Expired foods will be thrown out..."

2. An observational tour of the dietary area at the Chicago Campus was conducted on 10/29/19, at approximately 10:15 AM.

- There were approximately 20 ground beef patties thawing in the cooler/refrigerator with a manufacturer's use by date of 10/20/19. The box was not labeled with the date it was placed in the cooler.

- There were 5 bowls of pasta, 4 bowls of salad, 3 bowls of fruit, 1 sandwich, and 1 slice of cake in the cooler that were not labeled with the date prepared.

- There was a box of approximately 80 ground beef patties in the freezer with a use by date of 10/19/19.

- There were 2 cinnamon rolls wrapped in foil, an opened bag of hashbrowns, an opened bag of breakfast sausages, an opened bag of french toast, and an opened bag of unidentified (not labeled) food product in the freezer that were not labeled with the date opened.

3. An interview was conducted with the Manager of Food and Nutrition (E#21) on 10/29/19, at approximately 10:45 AM. E#21 stated, "We don't use food past the printed use by date on the box." After bringing up the use by date of the ground beef patties to the attention of E#21, E#21 responded that in this case it was okay to use the patties after the manufacturer's use by date because it was kept in the freezer beforehand. E#21 stated that she just moved the patties from the freezer to the cooler yesterday but did not write down the date it was thawed. E#21 proceeded to write a use by date of 11/3/19 on the box of patties. E#21 stated that foods are usable past the use by date if kept in the freezer. E#21 stated that for example, if all the corned beef thawing in the cooler (with a use by date of 11/3/19) is not used, it could be refrozen for later use. E#21 stated that opened/prepared food items should be labeled with a use by date within 7 days of opening or preparation. E#21 stated, "The labels may have fallen off." E#21 stated that the undated food items in the cooler were pulled/prepared by the staff this morning for the dinner tray line.


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4. On 10/30/19, between 11:00 AM and 11:30 AM, an observational tour was conducted in the Food Services Department at the Hinsdale campus. The cooling refrigerator contained the following:
- 4 pineapples with green mold on each pineapple (undated)
-1 bag of cilantro with brown cilantro (undated)
-1 box of lettuce with brown lettuce (dated 9/27/19)
- 1 box of red potatoes with soft potatoes (dated 8/23/19)
-1 box of red peppers with wrinkled, soft red peppers (dated 9/27/19)

The freezer refrigerator contained the following:
-1 bag of hamburgers with a label "use by 10/23/19"

5. On 10/30/19 at approximately 11:35 AM, an interview was conducted with the Director of Food/Nutrition (E #5). E #5 stated that produce food items are good for 2 weeks. E #5 stated that the out dated food items and food items that look moldy or brown needed to be thrown out.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Sample Validation Survey conducted on October 28-29, 2019, 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 on the CMS Form 2567, dated 10/29/19.

Based on observation, document review and interview, it was determined that for 2 of 2 visitors on the B-1 Unit at the Hinsdale campus, the Hospital failed to identify a system for controlling infections by not ensuring that PPE (personal protective equipment) was worn in contact isolation rooms.

Findings include:

1. The Hospital's policy titled, "Transmission Based Precautions" (revised 8/19), was reviewed on 10/29/19 and required, "...Procedure...Apply gloves upon entering Contact Precaution Room...Gowns must be worn upon entering the room..."

2. An observational tour of the B-1 Unit was conducted on 10/28/19, at approximately 10:00 AM. The following observations included:
-At approximately 10:10 AM, a visitor in Pt. #6's room was observed not wearing any gloves. Pt #6 was in contact isolation for history of a multi drug resistant organism.
-At approximately 10:15 AM, a visitor in Pt #5's room was observed not wearing a gown or gloves. Pt #5 was in contact isolation for KPC infection (Klebsiella pneumoniae carbapenemase).

3. An interview was conducted with the Manager of the Unit (E #2) on 10/28/19, at approximately 10:25 AM. E#2 stated that the visitors in both rooms should wear a gown and gloves in the contact isolation rooms.