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Based on document review and interview it was determined for 1 of 1 (Pt #5) records reviewed for PICC (Peripherally Inserted Central Catheter) care the Hospital failed to ensure PICC line care was performed as required by policy. This has the potential to affect all patients receiving care at the Hospital with a current census of 6 patients.

Findings include:

1. On 11/30/22 at approximately 9:00 AM, the procedure for "Central Line Maintenance" (revised April 2018) was reviewed. The policy required, "Measure and document external length of catheter daily. Measure and document lower arm circumference (PICC's only) daily."

2. On 11/30/22 at approximately 10:00 AM, Pt #5's record was reviewed. Pt #5 was admitted for Infection of the 3rd toe and was to receive antibiotic therapy. Pt #5's medical record lacked documentation that PICC line care was provided 11/16/2022 through 11/30/2022.

3. On 11/30/22 at approximately 2:30 PM, an interview was conducted with the Quality System Analysis (E#11). E#11 reviewed Pt #5's record and agreed there was no documentation indicating the required measurements of external length of catheter and lower arm circumference were done daily as required by policy.

A. Based on observation, staff interview, and document review, it was determined the Hospital failed to ensure that all mechanical, electrical, and patient-care equipment is maintained in safe operating condition. This has the potential to affect all patients receiving care at the Hospital with a current census of 6 patients.

Findings include:

1. On 11/29/22 at approximately 11:00 AM, a tour of the Emergency Department was conducted with the Director of Nursing (E #5). During the tour the following items lacked the required preventative maintenance (pm) checks:

a) 3 Bair Hugger - last pm was due 9/22
b) Maxi Air (specialty air mattress pump) - last pm completed 05/06/21

2. The Maxi Air directions for use was reviewed on 12/01/22 at approximately 8:30 AM. The instructions stated, on page 16-17, "Care and Preventative Maintenance... Qualified Personnel action/check.. change the air filter every year, perform functionality test every year."

3. An interview was conducted with the Quality Manager (E #1) on 11/29/22 at approximately 3:30 PM. E #1 stated, "We contacted biomed and those items were missed when they were here in September."




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B. Based on document review, observation, and interview it was determined the Hospital failed to ensure expired items were not available for use. This has the potential to affect all patients receiving care at the Hospital with a current census of 6 patients.

Findings include:

1. The policy "Stock Rotation and Monitoring of Storage Rooms" (revised July 2022) was reviewed on 12/1/22 at approximately 1:00 PM. The policy noted, "All stock items will be stored using the rotation system and the oldest products...this prevents stock deterioration and/or expiration of sterile products."

2. An observational tour of Environmental Services was conducted 11/29/22 at approximately 2:00 PM. On a shelf in the supply room was 4 bottles of Avert Sporicidal Disinfectant (2 expired 8/23/22 and 2 expired 11/8/22).

3. An interview was conducted on 11/29/22 at approximately 2:15 PM with the Manager of Environmental Services (E #12). E #12 agreed the bottles of cleaner were expired and should not be available for use.

Based on document review, observation, and interview, it was determined that for 1 of 1 registered nurses (E #9) observed performing an IV (intravenous) insertion the Hospital failed to ensure staff followed infection control policies and procedures. This has the potential to affect all patients receiving care at the Hospital with a current census of 6 patients.

Findings include:

1. On 12/1/22 at approximately 2:30 PM the policy titled "Hand Hygiene" (no revision date) was reviewed. The policy noted, "B. Opportunities when to perform Hand Hygiene...D. Before applying gloves...F. After coming in contact with patient's intact skin."

2. On 11/30/22 at approximately 10:45 AM, E# 9 was observed starting an intravenous needle. E #9 palpated the left forearm for a vein, applied gloves without performing hand hygiene as required by policy.

3. On 11/30/22 at approximately 11:00 AM the above was confirmed with the Operation Manager (E#7). E #7 stated, "Hospital policy of infection control was not being followed."

Based on observation, document review, and staff interview it was determined the Hospital failed to ensure proper storage of 1 disposable laryngoscopes (blade and handle) on the airway supply cart in operating room. This has the potential to affect all patients receiving surgical services at the Hospital with a current census of 6 patients.

Findings include:

1. An observational tour of the Surgery Department was conducted on 11/29/22 at approximately 1:00 PM. A disposable laryngoscope, in open sterile packaging. was located sitting in the airway cart in Operating Room One.

2. A policy regarding sterile packaging of supplies was requested on 12/1/22 at approximately 1:00 PM. No policy recieved.

3. An interview was conducted on 11/29/22 at approximately 1:30 PM with the Director of Surgery (E #10). E #10 agreed the open sterile packaging should not be on the cart and available for patient use.

Based on document review and interview, it was determined, the Hospital failed to provide 24 hour respiratory services to adequately meet the needs of patients requiring respiratory care services. Therefore, the Condition of Participation, 42 CFR 482.57, Respiratory Services is out of compliance. This has the potential to affect all inpatients and outpatients serviced by the Hospital.

Findings include:

1. The Hospital failed to ensure adequate respiratory care staffing, available 24 hours a day. See A-1154.

Based on document review and staff interview it was determined the Hospital failed to ensure adequate respiratory staff were available 24 hours a day, 7 days a week to provide respiratory care to all patients. This has the potential to affect all inpatients and outpatients who would require respiratory care.

Findings include:

1. On 11/29/22 at approximately 2:00 PM, the respiratory therapy (RT) staffing schedule was reviewed from September 2022 through December 2022. Documentation indicated two (2) full time, one (1) prn (as needed), and one (1) float RT's on staff. The following was noted:

11/01/22 - 1st RT (E #14) developed COVID symptoms and completed an at home test which was positive. E #14 was on- call 11/5/22 (Saturday) from 6:30 AM through 11/7/22 (Monday) at 6:30 AM. There was no other RT available/on the schedule.
12/8/22 - E #14 is scheduled for Cardiac Rehab with patients scheduled from 7:00 AM until approximately 2:15 PM with no other RT available/on the schedule.
12/12/22 - Director of RT (E #13) is on PTO (Paid Time Off) and E #14 is off. There is no RT coverage from 6:30 AM until 4:30 PM.

2. The policy "Colleague COVID 19 Prevention Program HSHS Illinois Hospitals" (version 03/22/22) was reviewed on 12/01/22 at approximately 12:45 PM. On Page 7, the policy stated, "Return to Work.. Criteria for returning to work after testing positive for COVID-19 is in accordance with guidance from a licensed health care provider or CDC's "Isolation Guidance" and "Return to Work Healthcare Guidance".... Colleagues who tested positive and had symptoms can return to work when: At least 5 days have passed since symptoms began...."

3. On 12/01/22 at approximately 1:00 PM, an interview was conducted with the Director of Respiratory (E #13). E #13 reviewed the schedules and stated, "The highlighted persons are the on-call person. Through the week on-call is from 4:30 PM until 6:30 AM. On weekends on-call is for the whole day. (E #14) had started not feeling well on 11/01/22 and developed symptoms later in the evening. (E #14) took an at home test which was positive. She took call on 11/5/22. On 12/8/22, I am off and (E #14) is in cardiac rehab. (E #14) would not be available for any emergent respiratory needs within the hospital as (E #14) would be the only person taking care of the rehab patients. On 12/12/22, myself and (E #14) have the day off. As it is scheduled there is no day time coverage for Respiratory."

4. The Policy "Code Blue Response (dated 11/2022)" was reviewed on 12/01/22 at approximately 1:45 PM. The policy stated, " II. PURPOSE: To provide a plan of response to care for patients experiencing cardiac arrest so they might have the best possible outcome.... B. Cardiac Arrest Response Team will include:.... 3. Cardiopulmonary/Respiratory Therapist, when on duty, will be called in if on-call."

5. On 12/01/22 at approximately 2:30 PM, an interview was conducted with the Operations Manager (E #2). E #2 stated, (E #14) had been cleared to return to work on 11/05 and took call.. I have not looked at the December schedule so I am unaware of any openings."