HospitalInspections.org

Based on observation, document review, and staff interview it was determined for 2 of 10 (Pt #31, Pt #32) patients observed with a indwelling urinary catheter, the hospital failed to ensure the urinary catheter was secured as hospital policy required. This has the potential to affect all patients that have a urinary device.

Findings include:

1. On 1/25/2022 between approximately 11:00 AM and 11:45 AM, a tour of the critical care unit was conducted with the critical care charge nurse (E #5). During the tour it was noted that Pt #31 (room #2211) and Pt #32 (room #2212) failed to have a Stat Loc (a devise used to secure the catheter tubing to the patient's upper thigh).

2. On 1/25/2022 at approximately 3:45 PM, the Hospital policy, "Maintenance of Indwelling Urinary Catheter" (no date) was reviewed. The policy required "Secure catheter to upper thigh to prevent tension."

3. On 1/25/2022 at approximately 11:30 AM, an interview with the critical care charge nurse (E #5) was conducted. E #5 stated that our policy is to have the catheter secured to prevent injury.

Based on document review and interview, it was determined for 1 of 3 (Pt #11) patient records reviewed for patients who received blood transfusions, the Hospital failed to ensure that the administration was completed in accordance with approved policies and procedures and physician order. This has the potential to affect all patients receiving blood transfusions.

Findings include:

1. On 1/26/2022 at approximately 11:45 AM, the clinical record of Pt #11 was reviewed. Pt #11 was admitted to the facility on 1/11/2022 with a diagnosis of encephalopathy and cirrhosis. Pt #11 had a physician order dated 1/13/2022 at 11:59 AM, to transfuse one unit red blood cells, transfuse each unit over 2 to 4 hours. The patients record indicated the blood transfusion was started on 1/13/2022 at 8:33 PM and ended at 1:00 AM. (infused over 4 hours)

2. On 1/26/2022 at approximately 4:00 PM, the Hospital's policy titled, "Administration of Blood and Blood Products", (revised by the facility, 11/10/2021), was reviewed. The policy required, "The Blood/Blood Product must be infused or stopped within four (4) hours of issue."

3. On 1/26/2022 at approximately 12:00 PM, an interview was conducted with patient safety specialist (E #6). E #6 agreed with the above finding that the blood exceeded the 4 hour timeline.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Full Survey Due to a Complaint conducted on January 24 & 25, 2022, 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 the Full Survey Due to a Complaint conducted on January 24 & 25 2022, the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

Based on observation, document review and interview, it was determined in 1 of 1 crash carts on the rehabilitation unit, the Hospital failed to ensure emergency carts were checked and maintained per policy. This has the potential to effect all visitors and patients who receive care in the Hospital.-current census-115.

Findings include:

1. The policy titled "Restocking Code Blue Carts, SSM Health Southern IL Region", (revised by facility, 3/11/2020) was reviewed on 1/24/22 at approximately 1:40 PM. The policy noted "Process: 1. Crash carts are checked every shift by designated staff, using crash cart check list. This includes a battery check of the defibrillator ......"

2. During a tour of the inpatient rehabilitation unit on 1/24/22 at approximately 1:35 PM, with the director of ambulatory services/PPS (perspective payment system)(E#1) and the regional CNO (E#2) the crash cart check logs were reviewed. The logs lacked documentation of the required daily checks:

a) January 7, 2022 lacked a dayshift check of the crash cart
b) January 12, 2022 lacked a nightshift check of the crash cart
c) January 22, 2022 lacked a nightshift check of the crash cart

3. During an interview on 1/24/22 at approximately 1:45 PM, E#1 verbally confirmed the crash cart wasn't checked daily. E#2 stated, "the crash carts are to be checked every shift."

Based on observation, document review and interview, it was determined the Hospital failed to ensure a clean and sanitary environment to prevent the transmission of infectious diseases. This has the potential to effect all patients who receive care by the Hospital. Current census-115.

Findings include:

1. The policy titled "Instruments: Cleaning, Decontamination, Disinfection Assembly, and Storage", (revised by facility, 1/12/2022) was reviewed on 1/25/2022 at approximately 4:10 PM. The Policy notes "E. Wrappers: 1.[d] All wrappers must be intact and free of holes" and "H. Storage of Sterile Supplies: 1.[J] It is the responsibility of all staff to ensure that the integrity of all sterile items stored is maintained ......"


2. During a tour of the cardiac catheterization procedure laboratory (cath lab) on 1/25/22 at approximately 9:45 AM, Cath Lab #2 was noted to have a set of sterile gloves that were open in the STEMI (segment elevation myocardial infarction) box used for STEMI cases that present emergently.

3. During an interview on 1/25/22 at approximately 9:50 AM with cath lab lead technician (E#3) and director of ambulatory services/cath lab (E#4), E#3 verbally confirmed that "the open sterile gloves should have been discarded and replaced."