HospitalInspections.org

Based on document review and interview, it was determined for 2 of 2 (Pt #9 and 10) clinical records reviewed on nursing unit 3A, the Hospital failed to ensure the patients were identified as fall risk as required, per policy.

Findings include:

1. Hospital policy titled, "Fall Prevention," (revised 4/14) reviewed on 11/18/14 at approximately 1:30 PM, required, "A patient who is identified as a High Risk Fall Precaution... a. Yellow sticker placed on patient's chart".

2. The clinical record of Pt # 9 was reviewed on 11/18/14. Pt #9 was a 69 year old male admitted on 11/7/14 with a diagnosis of right hip fracture status post fall. Pt #9's clinical record contained an admission nursing assessment that identified Pt #9 as a high risk for falls. A yellow sticker was not placed on Pt #9's clinical record identifying Pt #9 as a high fall risk.

3. The clinical record for Pt #10 was reviewed on 11/18/14. Pt #10 was a 76 year old female admitted on 11/17/14 with a diagnosis of cellulitis of the left face. Pt #10's clinical record contained an admission nursing assessment that identified Pt #10 as a high risk for falls. A yellow fall sticker was not placed on Pt# 10's clinical record identifying Pt #10 as a high fall risk.

4. An interview was conducted with the Facility Educator (E #1) on 11/18/14 at approximately 1:40 PM. E #1 stated there should be a yellow sticker on Pt #9's and Pt #10's clinical charts.

Based on document review and interview it was determined for one of one medical record department, the Hospital failed to ensure medical records were complete within 30 days after discharge.

Findings include:

1. The Medical Staff Rules and Regulations (reviewed September 2014) reviewed on 11/19/14 at approximately 1:00 PM required, "When a medical record has not been completed within thirty (30) days after patient discharge, the record will be considered delinquent. "

2. On 11/19/14 at approximately 1:00 PM, the Manager of Health Information Management (E#5) was interviewed. E #5 stated the Hospital currently has 10 delinquent medical records.

3. On 11/19/14 at approximately 1:40 PM, E #5 presented an attestation letter that included, "This letter certifies that as of November 19, 2014 there are 10 delinquent medical records at Methodist Hospital of Chicago."

Based on document review, observation, and interview, it was determined that for 1 of 4 (E #6) radiology technicians observed, the Hospital failed to ensure a radiation exposure badge was worn by the technician, as required by policy.

Findings include:

1. The Hospital policy titled, "Radiation Safety: Employees and Patients" (revised 8/14), required, "All employees working with or in the immediate vicinity of ionizing radiation and or radiopharmaceuticals shall be required to wear film badges...."

2. During an observational tour of the Radiology department on 11/19/14 at approximately 1:30 PM, a radiology technologist (E #6) was not wearing a radiation exposure (dosimeter) badge.

3. E #6 was interviewed on 11/19/14, at approximately 1:30 PM. E #6 stated she started her employment over 1 month ago and has performed x-rays throughout the month. E #6 stated she currently does not have a dosimeter badge.

4. The Manager of Radiology (E #7) was interviewed on 11/19/14 at approximately 2:00 PM. E #7 stated that E #6 started working at this hospital on October 7, 2014 and should have an exposure badge but has not yet received the ordered badge as of survey date 11/19/14.

Based on document review and interview, it was determined for one of one tray line temperature log book, the Hospital failed to ensure the temperature of food items on the tray line were recorded to ensure they were maintained at the appropriate temperature.

Findings include:

1. The Hospital's policy entitled, "Cafeteria Infection Control", (revised 06/01/11) required, "...The temperature of food items on the cafeteria tray line shall be taken and recorded before the start of serving...Hot foods should be 141 degrees F (Fahrenheit) and above, and the cold foods should be 40 degrees F and below. The temperatures shall be logged..."

2. On 11/20/14 at approximately 11:30 AM, the tray line temperature logs were reviewed for 11/2014. The temperature logs lacked documentation of all food item temperatures. examples included:
- 11/16/14 lunch: beef patties on a bun
- 11/17/14 lunch: pureed green beans, broth soup, corn, french fries, strained cream soup; supper: fries
- 11/18/14 supper: french fries, baked fries, grilled cheese; lunch: fish, salisbury steak, mashed potatoes; breakfast: scrambled eggs, bacon, french toast, fried egg, grilled ham
- 11/20/14 breakfast: scrambled eggs, bacon, pureed sausage

3. On 11/20/14 at approximately 11:45 AM, the Director of Food Services stated that the temperatures should be recorded for all food items prior to the start of the tray line.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Medicare Sample Validation Survey conducted on November 18-19, 2014, 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 random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Medicare Sample Validation Survey conducted on November 18-19, 2014, the surveyors find that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated November 19, 2014.

Based on document review and interview, it was determined that for 5 of 18 steam and gas surgical instrument sterilization loads (6/26, 7/11, 10/7 for steam sterilization and 7/26 & 8/7/14 for gas sterilization), the Hospital failed to ensure biological testing were conducted.

Findings include:

1. The steam and gas sterilization records for 3/1/14-11/14/14 were reviewed on 11/19/14. The records lacked documentation of biological testing on 6/26/14, 7/11/14, & 10/7/14 for steam sterilization; and on 7/26/14 & 8/7/14, for gas sterilization.

2. The Hospital policy titled, "Monitoring Devices for Sterilization" (Rev. 11/1/13) required, "Monitors are used to ensure that complete sterility is attained during the in-house sterilization process....Steam Sterilization... Biological indicators are placed inside a random load once per day...once the sterilization cycle is complete the brown ampule is removed from the pack, cracked and placed inside an incubator along with a control ampule...After 24 hours, the control ampule should turn bright yellow... the ampule exposed to sterilization should have no color change, indicating that spores have been killed...ETO Sterilization (gas)...biological indicators for ETO are placed inside every load...once the sterilization cycle is complete the green ampule is removed from the pack, cracked and placed inside an incubator along with a control ampule...After 24 hours, the control ampule should turn bright yellow... the ampule exposed to sterilization should have no color change, indicating that spores have been killed."

3. The above findings were discussed with the Assistant Administrator for Support Services, on 11/19/14 at approximately 10:00 AM who stated that the 24 hour biological testing results should be documented in the sterilization record.

Based on document review, observational tour, and interview it was determined for 1 of 5 (E #2) surgical staff and 1 of 1 (E #3) sterile processing technician in restricted areas, the Hospital failed to ensure staff adhere to attire policy.

Findings include:

1. Hospital policy titled, "Attire in the Operating Room," (revised 5/14) required, "Disposable, high-filtration efficiency masks must be worn at all times in the O.R. suite. Masks are also worn in sub-sterile area (Restricted Area)... All personnel should cover head and facial hair, including sideburns and nape of the neck, when in the semi-restricted and restricted areas."

2. On 11/19/14 between 8:30 AM and 10:30 AM an observational tour was conducted in the Hospital's surgical area. At 9:00 AM, surgical technician (E #2) entered the restricted area without donning a mask.

3. An interview was conducted with the Nurse Manager (E #4) of surgical services on 11/19/14 at 10:00 AM. E#4 stated, the employee E #2 should have had a mask on when entering any restricted area.


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4. An observational tour of the surgical instrument processing department, a restricted area, was conducted on 11/19/14, at approximately 9:00 AM. The processing technician (E #3) was wearing a surgical cap, however the cap did not cover the back of his head exposing approximately 2 inches of hair, and E #3 had a beard and mustache that was not covered.

5. The Assistant Administrator for Support Services was interviewed on 11/19/14 at approximately 10:00 AM. The Administrator stated that E #3 should have all hair, including facial hair, covered.

A. Based on document review and interview, it was determined that for 1 of 1 crash cart in the Emergency Department (ED), the Hospital failed to ensure the crash cart check was completed and documented, as required by policy.

Findings include:

1. The Hospital policy titled, "Maintenance of Crash Cart" (revised 6/14) , required, "The RN in charge, or designee, will check... every shift. The RN checking the crash cart will document the check by signing the crash cart log. "

2. On 11/20/14 at approximately 9:10 AM the ED crash cart log was reviewed. On 11/13/14, the day shift (7:00 AM-7:00 PM) check lacked the RN's signature documenting the crash cart had been checked as required.

3. The above finding was discussed with the Director of Ambulatory and Emergency Services (E #8) on 11/20/14 at approximately 10:00 AM, who stated that the nurse should have signed the crash cart log on the day in question.

B. Based on observation, interview and stated practice, it was determined that for 1 of 3 (Cabinet #1) cabinets in the psychiatric bay of the Emergency Department (ED), the Hospital failed to ensure all cabinets were locked.

Findings include:

1. During an observational tour of the Emergency Department on 11/20/14 between 9:10 AM and 10:00 AM, Cabinet #1 in the 3 bed psychiatric bay of the ED was unlocked. The cabinets contained clavicle splints, arm slings and elastic bandages.

2. On 11/20/14 at approximately 10:00 AM the Hospital's policy regarding securing medical supplies in the ED was requested. The Director of Ambulatory and Emergency Services (E #8) stated the Hospital does not have a policy relative to locking the cabinet in the psychiatric bay in the ED however, it is the practice that the cabinets should be locked at all times for both patient safety and theft concerns.

3. The above finding was discussed with E #8 on 11/20/14 at approximately 10:00 AM. E #8 stated the cabinet should have been locked.