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200 HEALTH CARE DR

GREENVILLE, IL 62246

ORDERS FOR DRUGS AND BIOLOGICALS

Tag No.: A0409

Based on document review and staff interview, it was determined in 1 of 3 (Pt #9) blood transfusion record reviewed, the Hospital failed to ensure vital signs were taken per policy. This has the potential to affect all patients receiving blood transfusions.

Findings include:

1. On 12/30/15, the Hospital policy titled, "Blood/Blood Component transfusion" revised 12/15 was reviewed.. The policy indicated under, "14. For each unit of red blood cells, ...to be administered, vital signs (blood pressure, pulse, respirations and temperature) shall be obtained and documented on the blood transfusion e-form: prior to transfusion, fifteen minutes after initiation of the transfusion...".

2. On 12/29/15 at 2:00 PM, the medical record of Pt #9 was reviewed. Pt #9 was admitted on 12/12/15 with diagnosis of sepsis. On 12/12/15 at 8:43 PM, the physician ordered one unit of packed red blood cells infused over 4 hours. The last documented vital signs before the blood transfusion were on 12/12/15 at 6:00 PM. The first unit of blood was initiated at 9:08 PM. The next vital signs documented were on 12/12/15 at 9:13 PM. Therefore, no vital signs were taken prior to the start of the blood transfusion.

3. On 12/29/15 at 2:30 PM, an interview with the Clinical/Quality/Infection Control Coordinator (E#2) was conducted. E#2 reviewed Pt #9's medical record and stated "The vitals should have been taken 15 minutes before the start of the blood transfusion." E#2 confirmed the above findings.

CONTENT OF RECORD: HISTORY & PHYSICAL

Tag No.: A0458

Based on document review and interview, it was determined for 1 of 30 patient (Pt #1), admitted to the Medical Surgical unit, the Hospital failed to ensure medical records included a History and Physical (H&P) within 24 hours after admission. This has the potential to affect all patients receiving care at the Hospital.

Findings include:

1. On 12/28/15 at 11:10 AM, the medical record of Pt #1 was reviewed. Pt #1 was admitted to the Hospital on 12/24/15 with a diagnosis of aspiration pneumonia. Documentation on the H&P indicated the physician completed it on 12/27/15 (more than 24 hours after admission).

2. On 12/28/15 at 1:00 PM, the Medical Staff Bylaws were reviewed. Under "3.2.22" it reads "A medical history and physical examination must be completed and documented for each patient no more than thirty (30) days before or twenty-four (24) hours after a patient is admitted."

3. On 12/28/15 at 1:30 PM, an interview with the Director of Patient Experience (E #1) was conducted. E #1 verbalized that Pt #1's medical record did not have a H&P completed within 24 hours and should have.

SAFETY FOR PATIENTS AND PERSONNEL

Tag No.: A0536

Based on observation, document review and staff interview, it was determined the Hospital failed to ensure all radiation personal protection equipment was safe, potentially affecting all radiology staff and patients.

Findings include:

1. On 12/27/15 at 11:00 AM, a tour of the Radiology department was conducted with the Radiology Manager (E#4). During the tour it was observed 1 protective apron had a small tear on the lower left region.

2. The Hospital policy revised 12/15 , titled, "Radiation Personal Protection Garments Inspection" was reviewed on 12/30/15. The policy indicated under "PROCEDURE: Yearly inspection of all radiation personal protection garments are performed by the Imaging Director....Any cracks or holes in the lead shielding will be determined to be not adequate...Any garment which does not meet adequate shielding....will be disposed of by returning it to a lead recycling complany."

3. On 12/27/15 at 11:15 AM, E#4 observed the tear in the apron. E#4 stated, "I was getting ready to check all of the aprons, this should be disposed."

DIRECTOR OF DIETARY SERVICES

Tag No.: A0620

Based on observation and staff interview, it was determined the Food Services Director (E#10), failed to ensure all dietary practices are followed per the known policies to ensure food is stored properly and safe food is prepared for all patients and staff.
Findings include:

1. On 12/29/15 at 10:30 AM, a tour of the Dietary department was conducted with the Food Services Supervisor (E #11). During the tour several food items were observed to be stored in either the original package or in plastic wrap with no date of opening or use by date. These items include: sliced yellow cheese wrapped in plastic wrap in the kitchen line refrigerator, with no date; cubed cheese in the original package, opened with no date in the dairy refrigerator; a partial opened bag of cranberries and partial opened bag of broccoli in the fruit and vegetable refrigerator with no date; and an opened bag of french fries with no date.

2. On 12/30/15 at 10:30 AM, an interview with the Food Services Director (E#10) was conducted. E#10 was asked to explain the expectation of staff to label opened food items as policies reviewed did not address this. E#10 stated " yes, I expect any item that has been opened to have the date it is opened. This is not in a written policy but staff have been reeducated on this recently (the past 3 months)." E#10 reported the food services supervisor (E#11) informed her of the items not labeled and E#10 agreed all should have the date they are opened and staff are to refer to the "Product Expiration Dates" chart to dispose of items.

PHYSICAL ENVIRONMENT

Tag No.: A0700

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Sample Validation conducted on December 28, 2015, 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.

LIFE SAFETY FROM FIRE

Tag No.: A0710

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Sample Validation Survey conducted on December 28, 2015, 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 December 28, 2015.

FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE

Tag No.: A0724

Based on observation, document review and staff interview, it was determined the Hospital failed to ensure the reliability of equipment needed for its operations and services in the Infusion Center, potentially affecting all patients receiving care in the Infusion Center.
Findings include:

1. On 12.28/15 at 11:10 AM, a tour of the Medical Surgical unit was conducted. During the tour a whirlpool tub was observed without a sticker or documentation of preventive maintenance/calibration.

2. On 12/28/15 at 11:30 AM, an interview with the Director of Patient Care (E #9) was conducted. E #9 verbalized there was no documentation the whirlpool tub had preventive maintenance/calibration conducted on it and was not aware it needed to be performed.

3. On 12/29/15 at 3:00 PM, Hospital policy "Management of Medical Equipment" approved 9/24/13 was reviewed. Under "POLICY: Director of Facilities will ensure all new medical devices will be inspected by Bio-Medicine...... ."

4. On 12/29/15 at 11:00 AM, a tour of the Infusion Center was conducted. During the tour a mechanical scale (Healthometer) was observed without a sticker or documentation of preventive maintenance/calibration.

5. On 12/29/15 at 11:15 AM, an interview with the Director of Infusion Center (E #8) was conducted. During the interview E #8 verbalized the scale is used to weigh patients for weight based chemotherapy medication and was unable to provide evidence the scale had preventive maintenance/calibration performed on it.

6. On 12/29/15 at 2:00 PM, the Chief Nursing Officer (E #3) provided documentation that preventive maintenance/calibration was performed on the scale and the whirlpool tub on 12/29/15 at 2:00 PM.

INFECTION CONTROL PROGRAM

Tag No.: A0749

Based on observation, document review and staff interview, it was determined for 1 of 3 (Pt #2) patient, the Hospital failed to ensure proper isolation signage was posted outside of patient's room on the Medical Surgical floor.

Findings include:

1. On 12/28/15 at 11:15 AM, a tour of the Medical Surgical floor was conducted. During the tour it was observed outside of Pt #2's room (38B), there was no signage to indicate the type of isolation to be observed. An isolation kit with appropriate personal protective equipment was hanging on the outside door, and the Infection Control Manager (E #2) indicated Pt #2 was on contact isolation.

2. On 12/28/15 at 12:00 PM, the Hospital policy "Standard Precautions" revised August 2015, was reviewed. Under "Contact/Contact Enteric Isolations Precautions 1 c. Affixing an orange "Contact Precautions" sign outside the patient's room."

3. On 12/28/15 at 11:20 AM, a review of Pt #2's medical record was conducted. Pt #2 was admitted on 12/22/15 with diagnosis of cellulitus of right lower extremity, and as a result of a positive nasal swab for methicillin resistant staphylococcus aureus obtained on 12/23/15 was placed on contact isolation.

3. On 12/28/15 at 11:45 AM, an interview with the Infection Control Manager (E #2) was conducted. E #2 verbalized there was no signage on Pt #2's door indicting the type of isolation. E #2 verified with nursing staff that Pt #2 should have had contact isolation sign on door at the time of positive lab results.