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The surveyors find that COP, A 700, Physical Environment, was NOT MET.

Based on observation during the survey walk-through, staff interview and document review during the Life Safety portion of a Full Validation Survey conducted on 03/12/2012 through 03/14/2012, 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 cited. Also see A710.

A. Based on an observational kitchen tour, review of Sodexho contracted service policy, review of "food safety audit", Infection control audit tools and staff interview, it was determined that for 1 of 2 kitchens inspected, the Hospital failed to ensure staff adherence to a sanitary environment to prevent potential cross contamination of food, potentially affecting all patients on census.

Findings include:

This was identified at the Chicago North Campus

1. For 1 of 2 kitchens, the Hospital failed to ensure staff adherence to a sanitary environment to prevent potential cross contamination of food (A-748).

The cumulative effect of these systemic practices resulted in the Hospital's inability to ensure compliance with the Condition of Infection Control.

A. Based on review of the Hospital's Medical Staff Rules and Regulations, attestation letter of delinquent records from the Medical Record's Department, and staff interview, it was determined that for 1 of 2 Hospitals sites (Northlake), the Hospital failed to ensure medical records were completed within 30 days post discharge, potentially affecting 13 patients from having a complete record.

Findings include:

1. On 3/13/12 at approximately 8:30 AM the Hospital's Rules and Regulations (10/27/11) were reviewed, and included, "16 a.- The patient's medical records shall be complete at the time of discharge. Delinquent records are those that are incomplete, including signatures, after thirty (30) days following discharge of the patient."

2. On 3/13/12 at approximately 9:30 AM, the Medical Records Coordinator provided documentation that indicated "Kindred Hospital Chicago Northlake has 13 medical records that are over 30 days delinquent"

3. On 3/13/12 at approximately 9:30 AM, the above finding was confirmed with the Director of Quality Management.

A. Based on an observational tour, Hospital policy review and staff interview, it was determined that for 50 of 50 tablets (synthroid) and 8 of 8 medication syringes (Sodium Citrate), the Hospital failed to ensure outdated medications were not available for patient use, potentially affecting all patients receiving Synthroid and Sodium Citrate on census.

Findings include:

This was identified at the Chicago North campus.

1. On 3/13/12 at approximately 9:30 AM, an observational tour was conducted in the pharmacy. The main dispensing area contained fifty (50) tablets of synthroid 200mcgs with an expiration date of 1/2012 and eight (8) 3 cc syringes labeled sodium citrate 4% with an expiration date of 3/9/12.

2. Hospital policy #H-MM-40-010 titled,"Medication Management-revised date 11/09", reviewed on 3/14/12 at 1:30 PM included,"All medications shall be removed from pharmacy stock and patient care areas prior to their expiration date"

3. The above findings were confirmed by the Director of Operation (E#1) and a Pharmacy Technician (E#2) during an interview on 3/13/12 at approximately 10:00 AM.

B. Based on Hospital policy review, an observational tour, stated Hospital practice and staff interview, it was determined that for 6 of 6 high alert medications (3 of 3 Potassium Chloride 20 meq IV( intravenous) solutions and 3 of 3 Potassium Chloride 40 meq IV solutions), the Hospital failed to ensure high alert medications were separated and stored to prevent medication errors in accordance with stated practice, potentially affecting all patients receiving potassium chloride on census.

Findings include:

This was identified at the Chicago North campus.

1. On 3/13/12 at approximately 1:30 PM, Hospital policy #H-MM 70-001 &A titled, "High Risk Medications-revised 11/2010" included," Definition: High- Alert medications are those drugs involved in a high percentage of medication errors..look alike/sound alike. Policy: The hospital will determine their list of high alert medications. Sample: Potassium Chloride IV."

2. On 3/13/12 at approximately 10:00 AM, the second floor "After Hours Night Cabinet" medication dispensing room was inspected. Three (3) 50 cc IV solutions that contained 20 meq of Potassium Chloride were stored in the same bin (Labeled High Alert) along with three (3) 100 cc IV solutions that contained 40 Meq of Potassium Chloride. Thus, the potential for a medication error.

3. The Director of Operations was interviewed on 3/13/12 at approximately 10:10 AM. The Director stated that it is a standard of practice to separate High Alert medications such as Potassium Chloride.

4. The above findings were verified with the Director of Quality during an interview on 3/13/12 at approximately 10:10 AM.

A. Based on personnel file review, stated Hospital practice and staff interview, it was determined that for 3 of 9 Pharmacy Technicians (E# 5, 6, and 7), the Hospital failed to ensure staff completed annual competencies in IV preparation and use of Laminar hood, potentially affecting all patients receiving IV therapy on census.

Findings include:

This was identified at the Chicago North campus.

1. The personnel files for E#s 5, 6, and 7 were reviewed on 3/13/12 between 2:00 PM and 3:00 PM. The following employees lacked annual competency training on compounded sterile preparations and use of the laminar airflow hood.

* The personnel file for E#5, dated of hire (doh) 8/8/11 lacked competency for sterile IV preparations and use of the laminar hood.

* The personnel file for E#6,doh 7/11/11, lacked competency for sterile IV preparation and use of the laminar hood.

* The personnel file for E#7, doh 6/4/10, lacked competency for sterile IV preparation and use of the laminar hood.

2. On 3/13/12 at approximately 9:30 AM, the Director of Operations was interviewed. The Director stated that, "it is Hospital practice to have all Pharmacy Technicians complete annual competencies in IV preparation and use of the laminar hood."

3. The above findings were confirmed with the Director of Operations during an interview on 3/13/12 at approximately 3:00 PM.

A. Based on an observational tour, Hospital policy and staff interview, it was determined that for 1 of 3 employees who entered the pharmacy unescorted (E#4), the Hospital failed to ensure that only authorized staff enter the locked Pharmacy, potentially affecting all patients on census.

Findings include:

This was identified at the Chicago North campus.

1. On 3/13/12 at approximately 9:30 AM, the surveyor was touring the Pharmacy in the company of the Director of Operation (E#1) and a Pharmacy Technician (E#2). A Public Safety Officer (E#4) was observed walking through the pharmacy medication dispensing area unescorted. E#4 inspected the fire extinguisher near the IV preparation room, and then left the area by himself.

2. On 3/13/12 at approximately 11:00 AM, Hospital policy titled,"Storage of Medications-revised 11/2010" was reviewed. The policy included," Only hospital staff authorized to stock or administer medications have access to medication storage areas or automated dispensing devices."

3. On 3/12/12 at approximately 2:00 PM, the Director of Operations was interviewed. The Director stated that, "a pharmacist let the Public Safety Officer (E#4) into the pharmacy; however, E#4 was not considered authorized personal and should have been escorted while in the pharmacy."

4. The above finding was confirmed with the Director of Operations and Assistant Administrator during an interview on 3/12/12 at approximately 2:00 PM.

The surveyors find that STANDARD, A 710, Life Safety from Fire, was NOT MET.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Full Validation Survey conducted on 03/12/2012 through 03/14/2012, the surveyors find that the facility does not comply with NFPA 101 - 2000, the Life Safety Cod

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies cited. under K-tags on CMS Forms 2567 for the above survey.

A. Based on observation, review of Hospital policy, and staff interview, it was determined that for 1 of 1 dedicated female bathroom on the Behavioral Health Unit (BHU) and 6 of 13 patient's sink cabinets (S #2, 3, 4, 5, 6, and 8) on the High Acuity Unit (HAU), the Hospital failed to ensure a sanitary and safe patient environment environment was maintained. This potentially affected all female patient's on the BHU and 6 patients in the HAU rooms.

Findings include:

This was identified at the Northlake campus

1. On 3/14/12 between 9:00 AM and 10:30 AM during an observational tour of the Behavioral Health Unit, room 372 (a dedicated female bathroom) contained the following: an overflow waste can, trash on the floor, and what appeared to be a needle shield from a syringe on the floor.

2. On 3/14/12, at approximately 10:00 AM, during the tour, these findings were confirmed with the Chief Clinical Officer (CCO).

This was identified at the Chicago North Campus

3. The Hospital policy entitled, "Quality Control Standards" (revised 7/30/10), was reviewed on 3/15/12 at approximately 8:30 AM and required, "...Environmental Services shall provide a high level of cleanliness and appearance throughout all areas of the hospital...Bathroom Fixtures...Paint and other surface material in good condition...Corners, edges, and underneath clean..."

4. A tour of the HAU Unit was conducted on 3/15/12 between approximately 9:00 AM and 11:00 AM. The patient sink cabinets (S# 2, 3, 4, 5, 6, and 8) contained outer peeling surface on the sides and bottoms with exposed rough surfaces.

5. The above findings were confirmed with the Clinical Nurse Manager during an interview on 3/15/12 at approximately 11:00 AM.

A. Based on an observational kitchen tour, review of Sodexho contracted service policy, review of "food safety audit", Infection control audit tools and staff interview, it was determined that for 1 of 2 kitchens inspected, the Hospital failed to ensure staff adherence to a sanitary environment to prevent potential cross contamination of food, potentially affecting all patients on census.

Findings include:

This was observed at the Chicago North campus.

1. On 3/15/12, a tour of the kitchen was conducted between 9:45 AM and 12:15 PM in the company of the Kitchen Manager, Food Service Manager and General Manager from Sodexho. The following was observed:

* The main preparation area contained an electrical extension cord stored with packaged muffins.

* A wet rag identified as a "cleaning rag" was stored on the counter with a pan of thawed chicken.

* Thirteen (13) metal food trays and 4 of 4 muffin trays in the food preparation area identified by staff as "clean", contained heavy accumulation of grease. The top of the convection oven was greasy. Three (3) of 3 carts were stained and greasy.

* The floor in the entire dietary department was sticky and the base boards contained a heavy accumulation of brown substance.

* A cutting board near the preparation area was stored on a dusty, greasy shelf.

* A pair of tongs were lying on the floor.

* The exterior of the knife holder contained paper stickers rendering the knife holder unclean.

* A bag of croutons were stored on a shelf with office supplies.

* Four (4) ceiling tiles over the cooks area were brown stained.

* Three(3) of 3 thermometers used to check food temperatures were stored in a container that was stained and dusty.

*.The ceiling of the walk in freezer contained an accumulation of ice and two boxes of food items also contained an accumulation of ice.

* An opened garbage receptacle was directly next to a tray of bananas.

* The ice scoop was stored in an opened bucket that contained water. Thus the potential for bacterial growth.

* Eight(8) of approximately 30 spice jars, 3 of 4 flour bins and 22 can food items were dusty.

* Two jackets were stored in the dry goods room.

2. The above findings were verified with the Infection Control Practitioner (ICP) and Sodexho General Manager during an interview on 3/15/12 at approximately 12:15 PM.

3. On 3/15/12 at approximately 1:20 PM, the General Manager from Sedex presented a binder titled, "Cleaning Procedure Manual" The binder contained a routine cleaning schedule for 26 kitchen items such a food carts, grills, ovens, fryer and refrigerators. During an interview with the General Manager on 3/15/12 at approximately 1:15 PM, the Manager stated that there was no documentation that any of the 26 items listed for cleaning had been implemented. The Manager further stated that the floors are cleaned daily, but could not present documentation.

4. On 3/15/12 at approximately 1:30 PM, the "Food Safety Program, revised 8/2009" was reviewed. The Program included, "A food safety self inspection program (using the Food Safety Audit form) must be completed every thirty days, with follow up action recorded and kept on file for 12 months." The food safety audit dated 2/09/12 was reviewed on 3/15/12 at approximately 1:40 PM. The audit included a section titled,"cleaning surfaces and pest control, floors, floor matts, baseboards, wall, ceiling and exhaust fans or vents clean." The February 9, 2012 audit identified that only the walls of the kitchen were not clean. No other cleaning issues were identified in the audits.

5. Infection control audit sheets, dated 5/31/11, 9/18/11, and 1/11/12 were reviewed on 3/15/12 at approximately 2:00 PM. There was documentation that the floors in dietary needed deep cleaning for the last 3 audits with documentation of only one cleaning in January, 2012.

6. The Infection Control Practitioner (ICP) confirmed the above findings during an interview on 3/15/12 at approximately 1:45 PM.

A. Based on review of Association of Operating Room Nurses (AORN) Perioperative Standards, observation, and staff interview, it was determined, that for 5 of approximately 20 sterilized hinged surgical instruments, the Hospital failed to ensure hinged surgical instruments were sterilized in an open position.

Findings include:

This was identified at the North Lake campus.

1. On 3/13/12 at 10:30 AM, the AORN Perioperative Standards and Recommended Practices for Inpatient and Ambulatory Settings, 2012 edition, was reviewed. The Standard required, "Recommendation XII - cleaned surgical instruments should be organized for packaging in a manner to allow the sterilant to contact all exposed surfaces... XII.c. Instruments with hinges should be opened..."

2. On 3/13/12 between 9:30 AM and 10:00 AM, an observational tour was conducted in the surgical area. Five hinged instruments (3 needle holders, 1 Kelly clamp, and 1 drape clamp) were in sterile wrappers in the closed position and available for surgery, creating the potential for non sterile instruments to be used during surgical procedures.

3. An interview was conducted with the North Lake campus HAU Manager on 3/13/12 at 10:30 AM. The Manager stated that the Hospital follows AORN standards. These findings were confirmed during the interview.

B. Based on review of Manufacturer's directions, Biological Monitoring Log, and staff interview, it was determined, that for 23 of 23 biological indicator tests for the steam sterilizer, the Hospital failed to ensure the control biological indicator test results were documented.

Findings include:

This was identified at the North Lake campus.

1. On 3/13/12 at 10:30 AM, the Dual Species Self-Contained Biological Indicator instructions, were reviewed. The instructions included, "Directions for Use... 13.1. Biological controls are performed weekly, preferably each day an SCBI [Self-Contained Biologic Indicator] is used."

2. On 3/13/12 at 4:45 AM, the 2012 Biological Monitoring Log for the steam sterilizer was reviewed. For 23 of 23 days when testing was performed in 2012, the Biological Indicator Control test results were not recorded in the Log.

3. These findings were confirmed during an interview with the North Lake campus HAU Manager on 3/13/12 at 10:30 AM.


C. Based on review of Manufacturer's directions, observational tour, and staff interview, it was determined, that for 2 of 2 biological indicators for the steam sterilizer, the Hospital failed to ensure biological indicator tests were properly performed.

Findings include:

This was identified at the North Lake Campus.

1. On 3/13/12 at 10:30 AM, the Dual Species Self-Contained Biological Indicator instructions, were reviewed. The instructions included, "Directions for Use... 2. Place the Verify Dual Species Self-Contained Biological Indicator (SCBI) in an appropriate challenge pack... 4.1... place the challenge pack in the loaded chamber... 5. Perform the sterilization test... 6... remove the challenge pack... 7. Remove the SCBI from the challenge pack...8... firmly seal the SCBI by using the Activator Set... The indicator is properly sealed when the cap is pushed down to the second black bar on the vial label... 9. To activate the SCBI, push or pull the SCBI completely through the restricted space on the Verify Activator Set... 10. Place the activated SCBI in the Verify Single Temperature or Dual incubator..."

2. On 3/13/12 between 9:30 AM and 10:00 AM, an observational tour was conducted in the surgical area. There was an incubator that contained 2 biological indicators, both dated 3/8/11. Both biological indicator tube tops had not been depressed to the second black bar on the vial to seal the tube before placement in the incubator. The color of both indicators had not changed. It could not be determined which indicator was the "control" and which was the "test". The Verify Activator Set for sealing and activating the SCBI indicator vials was not found.

3. These findings were confirmed during an interview with the North Lake campus HAU Manager on 3/14/12 at 10:00 AM.