HospitalInspections.org

Based on document review and interview it was determined for 1 of 2 (Pt. #15) patient medical records reviewed on the adolescent behavioral health unit, the Hospital failed to ensure a comprehensive treatment plan was developed and updated to include changes in patient status.

Findings include:

1. The Hospital's policy entitled, "Charting: Daily Patient Assessment/Nursing Plan of Care" (revised 9/14) was reviewed and required, "...2 During hospitalization new diagnosis\focus may be identified and initiated based on patient care needs...4. The Plan of Care is updated on a daily basis based on ongoing assessment of the patient's needs and response to intervention..."

2. On 5/11/15 at approximately 1:00 PM, the medical record of Pt. #15 was reviewed. Pt #15 was a 17 year old male admitted on 4/22/15 with a diagnosis of Bipolar disorder. On admission, Pt. #15 was placed on suicide and aggression precaution and observation requiring every 15 minute observation. A physician order dated 4/24/15 required safety precaution for sexual acting out. A physician order dated 5/6/15 placed Pt. #15 on 1:1 observation with a sitter. On 5/10/15 a physician order required Pt. #15 to be placed on line-of-sight (LOS) observation.

3. On 5/11/15 the Treatment Plan for Pt. #15 dated 4/22/15 was reviewed. The treatment plan lacked documentation of Pt. #15's diagnosis, status, changes in status,as well as documentation of goals, intervention and responses to intervention. The treatment plan also lacked updates to include the additional precaution for sexual acting out and 1:1 observation.

4. During an interview with the Director of Nursing for Behavioral Health (E#3) on 5/11/15 at approximately 1:25 PM, E #3 stated that the changes in status should have been included in the treatment plan.

Based on observation and interview, it was determined for one of one medical records department, the Hospital failed to ensure medical records were stored in a location to protect from potential damage.

Findings include:

1. On 5/13/15 at approximately 1:45PM, an observational tour was conducted of the Medical Records department. There were several metal shelves against the wall of the permanent file area, and in the clerical staff area where medical records were stored. On the ceiling near theses shelves are water sprinklers. These medical record were not stored in a manner to protect them from potential fire or water damage

2. On 5/14/15 at approximately 1:50PM the Manager of Clerical Services stated the shelves used in these areas do not include a device to maintain the integrity of the medical record in case of fire or if the water sprinklers were activated.

3. On 5/14/15 at approximately 11:30AM the Director of Quality stated there is no hospital policy in reference to the protection of the medical records from fire or water damage.

Based on document review and staff interview, it was determined 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: Regulations" (Revised 1/13/14) required, "11. A medical record is considered delinquent when it has not been completed 30 days after patient's discharge."

2. On 5/14/15 at approximately 8:50AM the Hospital's Director of Quality presented the surveyor with a letter of attestation dated 5/13/15 which included the Hospital had a total of 363 delinquent records past 30 days.

3. On 5/14/15 at approximately 9:00 AM, E #** stated the medical records are considered delinquent 30 days following discharge.

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 May 11-14, 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.

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 May 11-14, 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 on the associated K-tags.

A. Based on document review, observational tour, and interview, it was determined for 3 of 5 staff (E #1, MD #2, & MD #3) in operating room (OR) 7, the Hospital failed to ensure staff decontaminate their hands each time gloves were removed in accordance with policy.

Findings included:

1. On 5/13/15 at 1:30 PM, Hospital policy titled, "Routine Handwashing", revised on 3/2015, was reviewed. The policy required, "1. Indications for handwashing and hand antisepsis... h. Decontaminate hands after removing gloves."

2. On 5/13/15, between 8:30 AM and 10:00 AM, a tour was conducted in OR suite 7. A circulating nurse (E #1), scrub technician (E #2), anesthesiologist (MD #2), and surgeon (MD #3) were preparing for and conducting Pt. #36's excision of a sebaceous cyst of the upper back. The following was observed when Pt. #36 was in the room and sterile supplies were open:

- At 9:06 AM, after Pt. #36 was positioned and secured on the table, the staff removed their gloves. However, MD #2 and MD #3 did not perform hand hygiene.

- At 9:08 AM, E #1 completed the skin preparation and removed her gloves without performing hand hygiene.

- At 9:15 AM, MD #2 raised the table height, removed gloves, but did not perform hand hygiene.

- At 9:43 AM, MD #2 suctioned Pt. # 36, removed gloves, but did not perform hand hygiene.

- At 9:47 AM, MD #2 removed Pt. # 36's endotracheal tube, removed his gloves, but did not perform hand hygiene.

4. On 5/13/15 at 10:10 AM, an interview was conducted with the OR Director (E #6). E #6 stated hands should be disinfected after removing gloves.

B. Based on document review, observational tour, and interview, it was determined, for 1 of 1 "Fluidotherapy" machine at the Ingalls Care Center at 16246 Prince Drive, South Holland, IL, used for 2 of approximately 15 occupational therapy (OT) patients currently on census, the Hospital failed to ensure equipment linen was laundered each week, as required by manufacture's guidelines, to potentially reduce patient contamination.

Findings included:

1. On 5/14/15 at 8:50 AM, the "Fluidotherapy" dry heat therapy unit manufacture's guidelines were reviewed. The guidelines required (pg. 23), "Required maintenance, Weekly maintenance, Each week all sleeves of the Fluidotherapy unit should be laundered in a mild antibacterial detergent..."

2. On 5/14/15, between 8:30 AM and 9:00 AM, a tour was conducted in the Ingalls Care Center. A "Fluidotherapy" dry heat therapy unit was present. The unit is used to apply therapeutic dry heat to OT patient's hands and wrists by inserting bare hands and arms into webbed fabric material (sleeves) and then into a dry heated substance, with the consistency of saw dust, heated to approximately 104 degrees. The sleeves were discolored and dirty.

3. The "Fluidotherapy" cleaning/disinfection log was reviewed on 5/14/15 at 8:50 AM. The log included cleaning every 6 months, last performed in March 2015.

4. On 5/14/15 at 8:50 AM, an interview was conducted with an occupational therapist (E #5). E #5 stated the Fluidotherapy sleeves are laundered when the machine is disinfected, every 6 months.

Based on document review, observational tour, and interview, it was determined, for 4 of 9 staff (MD #1,2 & 3, E #7) in the surgical suites, the hospital failed to ensure adherence to the hospital policy regarding surgical attire.

Findings include:

1. On 5/13/15 the Hospital's policy titled, "Aseptic Practices in Surgery, Infection Control Guidelines" (revised 4/1/14), was reviewed and required, "...9. O. R. (operating room) personnel shall wear protective head covering so as to cover all possible head and facial hair...10. Masks that properly cover the nose and mouth will be used. The mask is to be secured in a manner that prevents venting. Persons should wear masks in the center core and in operating rooms where sterile supplies are opened... Used masks should not be saved by hanging around the neck or tucked into pockets for further use."

2. On 5/13/15 at approximately 8:40 AM the surgeon (MD #1) entered operating room (OR #4) wearing a surgical cap. MD #1 had hair exposed below the cap on the back of the head for approximately 3 inches, and approximately 2 inches on the sides.

3. On 5/13/15, between 8:30 AM and 10:00 AM, a tour was conducted in OR suite 7, where sterile instruments were open. The following was observed during this tour:

- 8:37 AM, an anesthesiologist (MD #2) entered the room tying on his unsecured face mask.

- 9:00 AM, a surgeon (MD #3) entered the room tying on his unsecured face mask.

- 9:55 AM, an OR technician/aide (E #7), entered OR # 7 to clean the room. E#7 had face mask strings dangling from her pocket.

4. During an interview with the OR Nurse Manager (E #4) on 5/13/15 at approximately 9:30 AM, E #4 stated MD #1's hair should have been covered.

5. On 5/13/15 at 10:10 AM, an interview was conducted with the OR Director (E #6). E #6 stated masks should be secure when entering the restricted area, and masks are easy to change (rather than kept in the pocket).