HospitalInspections.org

Based on document review and interviews, it was determined that for 1 of 1(Pt # 15) patient requiring safety monitoring, the Hospital failed to ensure the patients safety. The cumulative effect of this systemic practice resulted in the Hospital's inability to adequately protect the patient's rights. Therefore, the Condition of Patients Rights remains out of compliance.

1. The Hospital failed to ensure the patient on 1:1 monitoring did not commit self harm. See deficiency at A 144.

Based on document review and interview, it was determined that for 1 of 1 (Pt # 15) patient on 1:1 safety monitoring, the Hospital failed to ensure the patient did not commit self harm.

Finding include:

1. Hospital policy entitled, "One-To-One Supervision," (reviewed 9/10) required, "Policy: It is the policy of Nursing Services to institute One-To-One Supervision of patient when: 2. When the patient's psychosis or level of confusion and disorganization makes him/her an imminent danger to him/herself or others."

2. On 05/21/13 an observation tour was conducted on the third floor telemetry unit from approximately 9:45 AM until 11:20 AM with the Quality Manager Documentation Specialist (E#1) in attendance. Pt. #15 was observed in room 312-bed 1 at approximately 9:45 AM, covered with a sheet and slightly moving about in the bed. One sitter (E# 3) was in the room. The sitter provided documentation of every 15 minute safety checks which were up to date, and noted Pt. #15 was withdrawn and quiet. At approximately 11:30 AM (approximately 10 minutes after the initial tour), the survey team was informed that Pt. #15 jumped out of a window on the third floor. The third floor was toured again and the window in room 312 was shattered with chards of glass on the floor. No patient was in the room. E# 3 was crying in the hallway and being assisted by administrative staff.

3. The clinical record for Pt. #15 was reviewed on 5/22/13 at approximately 9:00 AM, Pt. #15, a 34 year old male, was brought to the Hospital's Emergency Department (ED) by the Chicago Police Department on 5/20/13 for a psychiatric evaluation due to a Suicide Attempt. The Pt. was triaged as emergent and a triage note dated 5/20/13 at 6:40 PM included, "He walked along the catwalk in the L train red line and tried to jump to the street..." The triage suicide risk score was documented as 4 (suicide risk degree 0-13 low risk). Pt #15's medical screening exam dated 5/20/13 at 6:50 PM included, "neurological assessment, oriented times three, Pt. inappropriate at times." Laboratory tests indicated an elevated creatinine phosphokinase and Pt. #15 received intravenous fluid. Pt. #15 was transferred to the third floor telemetry unit on 5/21/13 at 1:45 AM.

The admitting diagnosis was Altered Mental Status/Rule Out Acute Psychosis. Physician orders included, "place in a yellow gown, suicide prevention with 1:1 monitoring document the suicide risk assessment daily, Haldol 5 mgs every 4 hrs for aggressive behavior." The admission telemetry nursing note dated 5/21/13 at 2:44 AM included that Pt. #15 had a 1:1 sitter. An admission suicide risk assessment score dated 5/21/13 at 8:58 AM listed a score of 14 (14-28 moderate) A psychiatrist (E#5) saw Pt. #15 on 05/21/13 at approximately 10:00 AM while on the telemetry unit. E#5 recommended to continue the sitter, start psychiatric medication and transfer to psychiatry when medically stable.

The observational record contained documentation of safety checks every 15 minutes. A nurse's note (late entry) dated 5/21/13 at 2:11 PM included,"about 11:35 AM...monitor tech came to room 312-1 to check patient's heart monitor. Pt. noted exiting the bathroom and abruptly picked up his IV pole and charged at the window, repeatedly striking it until it was shattered. We tied to talk to him but patient became aggressive and swinging the IV pole at staff, code called at 11:43 AM, security team and Chicago fire department arrived on the scene."

4. On 5/22/13 at approximately 11:30 AM the Chief Quality Office (E #2) was interviewed. E #2 stated that Pt. #15 rushed passed the sitter and a monitor technician after exiting the bathroom and proceeded to take his IV pole and shatter the room window. A code was called. Pt.#15 injured several staff members during their attempt to prevent Pt #15 from jumping out of the shattered window. Pt. #15 fell to the ground landing on several mattresses to prevent his demise. Pt. #15 was transferred to a trauma Hospital by ambulance.

A. Based on document review and interview, it was determined for 1 of 3 (Pt. #7) clinical records reviewed of patients receiving insulin, the Hospital failed to ensure blood sugars were monitored as ordered.

Findings include:

1. The clinical record of Pt. #7 included that Pt. #7 was a 53 year old male admitted on 5/13/13 with the diagnosis of uncontrolled diabetes. A physician's order dated 5/13/13 at 8:53 AM included, "accucheck AC & HS (blood sugars before meals and at bedtime). The following bedtime blood sugars were not documented as being completed: 5/18, 5/19 and 5/20/13.

2. During an interview on 5/21/13 at 10:30 AM, the Manager of 1 West Nursing Unit stated the record did not include documentation of the blood sugars being monitored as ordered.

B. Based on document review and interview, it was determined for 1 of 3 (Pt. #7) clinical records reviewed of patients receiving insulin, the Hospital failed to ensure the insulin was administered as ordered.

Findings include:

1. Hospital policy titled, "Medication Administration Record (revised 10/06)" required, "After the Physician's order for medications has been written, ... All medications are administered by or under the supervision of a Licensed Registered Nurse."

2. The clinical record of Pt. #7 included that Pt. #7 was a 53 year old male admitted on 5/13/13 with the diagnosis of uncontrolled diabetes. A physician's order dated 5/13/13 at 8:53 AM included, "accucheck AC & HS (blood sugars before meals and at bedtime)with sliding scale insulin - moderate dose". The moderate dose orders started with insulin administration for a blood sugar of 150 or greater. The following dates included blood sugars greater than 150 with lack of documentation of insulin being administered:
5/13/13 at 9:33 PM - 358;
5/17/13 at 12:39 PM - 217, 9:03 PM - 235;
5/18/13 at 5:16 AM - 201, 11:49 AM - 205. 4:48 PM - 221;
5/19/13 at 11:38 AM - 191;
5/20/13 at 10:36 AM - 185.

3. During an interview on 5/21/13 at 10:30 AM, the Manager of the Emergency Department stated the record did not include documentation of insulin being administered.

Based on document review and interview, it was determined that for 2 of 2 (Pt. #6 and #7) clinical records reviewed on the 1 West (medical/surgical) nursing unit, the Hospital failed to ensure care plans were individualized for each patient.

Findings include:

1. Hospital policy titled, "Patient Care Plan, (revised 9/94)" required, "Nursing Care Plan will also be selected for the individual patient's needs. ... will be updated on a regular basis ... as the needs and/or condition of the patient dictates."

2. Pt. #6 was a 55 year old male admitted on 5/9/13 with the diagnosis of intertrochanteric fracture of the right hip. Clinical documentation included Pt. #6 had surgery on the right hip on 5/15/13. Pt #6's care plan dated 5/9/13 lacked an update to include the surgery and post operative care required.

3. Pt. #7 was a 53 year old male admitted on 5/13/13 with the diagnosis of uncontrolled diabetes. Pt #7's nursing admission, dated 5/13/13 included documentation that Pt #7 had a right foot ulcer upon admission that was evaluated by the wound nurse. The plan of care dated 5/13/13 lacked documentation of Pt #7's foot ulcer and care ordered.

4. During an interview on 5/21/13 at 10:30 AM, The Manager of 1 West Nursing Unit verified that the care plans were incomplete.

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

Findings include:

1. The Hospital's "Medical Staff Rules and Regulations" (approved 6/19/09) page 12 required, "...The patient's medical record shall be completed at the time of discharge...If, after thirty (30) days following discharge, medical records are still incomplete, Administration will notify the attending physician that his admission privileges have been suspended until the delinquent records have been completed...".

2. On 5/23/13 at approximately 10:00 AM, the Supervisor of Health Information Management (HIM) presented the surveyor with a letter of attestation which documented, "Supervisor of the HIM Department...attest that as of 5/23/13 there are a total of 637 delinquent records."

3. The above findings were confirmed with the CNO on 5/23/13 at approximately 1:30 PM.

Based on document review, observational tour, and interview, it was determined for 1 of 3 Anesthesiologists (E #8), the Hospital failed to ensure Anesthesiologists stored narcotics in a secure place, according to policy.

Findings include:

1. On 5/23/13 at 11:00 AM, Pharmacy policy #405.07, titled, "Dispensing Narcotics to Nursing Units", revised 2/12, was reviewed. The policy required, "... To ensure proper handling of narcotic substances... There are two boxes assigned to each of the three anesthesiologists... [and] a set of two boxes is reserved and labeled for other on call anesthesiologists... There are total 8 narcotic boxes, four boxes stored in Narcotic room in pharmacy and other four are stored in narcotic cabinet in the department of Anesthesia."

2. On 5/23/13 at 8:40 AM, an interview was conducted with an Anesthesiologist (E #8), during an observational tour in the perioperative area. E #8 was asked how narcotics were dispensed and stored. E #8 stated he exchanged his narcotic box with pharmacy for a refill and his full narcotic box was in his locker.

3. During the observation tour on 5/23/13 at 8:45 AM, E #8's narcotic box was seen in his locker in the men's changing room. The drug box contained, 1 - 10 ml vial Ketamine 50 mg/ml, 10 - 2 ml Fentanyl 100 mg/ml, 10 - 2 ml Midazolam 2 mg/2 ml, 10 - 5 ml Midazolam 5 mg/5 ml.

4. On 5/23/13, during the tour the Director of Anesthesia was not working and therefore unavailable for interview. At 8:50 AM, an interview was conducted with the Surgery Manager. The Manager stated Anesthesia received their medications directly from the Pharmacy and nursing was not involved.

Based on observational tour and interview, it was determined, for 2 of 2 Dextrose syringes and 9 of 12 blood tubes on the Behavioral Unit, the Hospital failed to ensure medications and blood tubes had not expired, potentially affecting the safety of 31 patients on the Behavioral Unit.

Findings include:

1. On 5/21/13 between 9:10 AM and 11:15 AM, an observational tour was conducted on the Behavioral Unit. The following expired medications/blood tubes were found:

- on the women's unit - 2 of 2 50% Dextrose syringes 50 ml - expired on 3/1/13.

- on the men's unit - Blood tubes -
4 of 5 green top - expired on 9/12
2 of 4 purple top - expired on 3/13
1 of 3 blue top - expired on 5/12.

2. The Director of Behavioral Health and the Nursing Manager were present when the syringes and blood tubes were found and an interview was conducted on 5/21/13 at 9:45 AM. The Nursing Manager stated she was not aware the items had expired.

Based on document review, observational tour, and interview, it was determined, for 3 of 3 food containers in the patient refrigerator on the Behavioral Unit, the Hospital failed to ensure, containers were labeled, potentially affecting the health of 31 patients on the Behavioral Unit.

Findings include:

1. On 5/22/13 at 9:00 AM, Food and Nutrition Services policy #1.2.5.1, titled, "Floor Stock", revised 7/20/12, was reviewed. The policy required, "2. e. Label and date all perishable items with expiration for appropriate disposal."

2. On 5/21/13 between 9:10 AM and 11:15 AM, an observational tour was conducted on the Behavioral Unit. The patient food refrigerator in the activity room included:

- two full foam containers of food, without a label to identify the food or the expiration date.

- one half full foam container of food, without a label to identify the food or the expiration date.

3. The Director of Behavioral Health was present when the unlabeled food was found. During an interview on 5/21/13 at 9:45 AM, the Director stated he did not know what the food was or when it had been prepared.

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 Validation Survey due to Complaint conducted on 05/21/2013 through 05/23/2013, 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.

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 aValidation Survey due to Complaint conducted on 05/21/2013 through 05/23/2013, 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, dated 05/23/13.

A. Based on observation and interview, it was determined that for 2 of 4 surgical suites (OR #3 and OR #4), the Hospital failed to ensure equipment was maintained. This potentially affected all patients in the surgical suite on 5/23/13.

Findings include:

1. On 05/23/13 an observational tour was conducted between 7:55 AM and 9:00 AM and the following was observed:

a) OR # 3 contained one of two IV poles with an accumulation of tape rendering the IV pole unclean.

b) OR #4 contained one suction canister holder with a heavy accumulation of rust.

2. The Quality Management Documentation Specialist (E#1) verified the above finding during an interview on 5/23/13 at approximately 9:15 AM.

B. Based on document review, observational tour, and interview, it was determined, for 1 of 1 hydrocollator (hot pack) machines, the Hospital failed to ensure staff properly maintain the machine.

Findings include:

1. A Physical Therapy policy, titled, "Equipment Specific Infection-Control Care, implemented in 10/97, was reviewed on 5/22/13 at 2:15 PM. The policy required, "F. Hot Pack Unit... should be cleaned once a month depending on usage..."

2. An observational tour of the Physical Therapy area was conducted on 5/22/13 at 1:55 PM. The hot pack machine (hydrocollator), where hot packs are heated by water, contained a filmy brown substance on the inside walls of the machine, below the water level.

3. An interview was conducted with the Director of Physical Therapy on 5/22/13 at 2:00 PM. The Director stated the hydrocollator is cleaned every quarter however there is no log to document the cleaning.

Based on document review and interview, it was determined for 1 of 2 thermometers,2 of 7 knives and 1 of 14 cutting boards, the Hospital failed to ensure equipment was sanitized, potentially affecting the dietary safety of 94 patients on census on 5/23/13.

Findings include:

1. On 05/23/13 Hospital policy titled, "Thermometers" (updated 4/2006) included, "Sanitizing Thermometers: Antibacterial Probe Wipes: tear off edge of packet, slide thermometer stem through the packet. Wipe back and forth to sanitize entire stem."

2. On 05/23/13 at approximately 10:20 AM, an observational tour of the Dietary Department was conducted with a Dietitian (E #12), Dietary Director and the Vice President of Ancillary Support Services (E #10) in attendance. The Dietary Manager (E#9) inserted the stem of a food thermometer into a bowl of pasta. After checking the temperature of the pasta, E#9 failed to sanitize the thermometer prior to inserting the thermometer back into the thermometer sheath resulting in contamination of the interior of the protective sheath with food substance.

3. The Hospital's HACCP/Food Safety Program (revised 8/09) required, "A. HACCP Program for the Food Service Industry: HACCP (Hazard Analysis Critical Control Point) is a concept first used by...to ensure the safety of food...The major factors in mishandling food are...not using ...sanitized utensils..."

4. Two (2) of seven (7) knives identifies as "clean" contained a dried substance. One (1) of 14 cutting boards identified as "clean" contained a loose dried substance.

5. On 05/23/13 the Vice President of Ancillary and Support Services (E#10) was interviewed and asked when the Infection Control Preventionist last made rounds in the Dietary Department. E#10 stated rounds were conducted last week but not documented. The above findings were verified with the Director of Dietary during an interview on 05/23/13 at approximately 11:15
AM.

A. Based on document review, observation and interview, it was determined for 1 of 3 (E #7) staff observed in Operating Room (OR) 1, the Hospital failed to ensure staff did not wear exposed jewelry in the OR, as required by Hospital policy.

Findings included:

1. Hospital policy titled, "Attire in the Operating Room (revised 10/01)" required, "All jewelry (rings and watches) is to be removed prior to handwashing/scrubbing; all other jewelry shall be totally confined within scrub attire or removed".

2. An observation of OR 1 was conducted 5/23/13 between 8:00 AM and 9:00 AM. E #1 entered OR 1 with post earrings exposed below the surgical cap.

3. The above finding was discussed with the Manager of Surgical Services, during interview on 5/23/13 at approximately 9:00 AM.

B. Based on document review, observation and interview, it was determined for 1 of 1 staff (E#7) observed in OR room 1, the hospital failed to ensure open sterile supplies were not left unattended.

Findings include:

1. Hospital policy titled,"Basic Operating Room Set Up (revised 2/05)" required, "Open up sterile items: ... f. Do not leave unattended".

2. An observation of OR 1 was conducted 5/23/13 between 8:00 AM and 9:00 AM. Upon entering the room, sterile instrument trays had been opened and the room was unattended. E#1 entered the room at 8:04 AM. After all of the sterile packages had been opened, E#1 left the room at 8:32 AM (leaving the room unattended for approximately 6 minutes) and returned at 8:38 AM.

3. The above finding was discussed with the Manager of Surgical Services, during interview on 5/23/13 at approximately 9:00 AM.