The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

ABRAHAM LINCOLN MEMORIAL HOSPITAL 200 STAHLHUT DRIVE LINCOLN, IL 62656 May 5, 2017
VIOLATION: PATIENT CARE POLICIES Tag No: C0271
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

A. Based on observation, document review, and interview, it was determined the Facility failed to ensure therapy patient care equipment was maintained in accordance with its policy and/or manufacturer guidelines to assure safety. This has the potential to affect all patients utilizing therapy services equipment.

Findings include:

1. An observational tour of the therapy department was conducted on 5/2/17 at approximately 3:20 PM with the Therapy Manager (E#10) with the Director of Nursing (E#1) present. The therapy gym was observed to have various types of patient care equipment available for use. Equipment examples included: one Tuff Stuff Leg Press/Hack Squat, one Tuff Stuff Leg Extension, and one Tuff Stuff Prone Leg Curl machines. The machines were observed to have a manufacturer sticker on each which stated daily, weekly, monthly, six month, and nine month maintenance recommendations, such as monthly cleaning and lubrication of various items and a full inspection by an Authorized Dealer every nine months.

2. An interview was conducted with E#10 on 5/2/17 at approximately 3:30 PM. E#10 stated "I didn't realize these machines were to have those things done. We aren't doing it at this time. The only thing we've had the equipment checked for would be electrical function of the ones that have electrical parts (such as the treadmill)."

3. The Facility policy titled "Medical Equipment Management Plan Policy #600.033" (last revised 9/18/14) was reviewed on 5/3/17 at approximate 9:50 AM. The policy stated all hospital owned equipment would be inspected and included in the maintenance schedule based on the manufacturer's recommendations and risk category of the device.

4. A follow up interview was conducted with E#10 on 5/3/17 at approximately 9:50 AM. E#10 stated the therapy equipment was not on the maintenance schedule, except for the electrical checks (such as the treadmill)."

B. Based on document review and interview, it was determined the Facility failed the Cold Pack Machine and Hydrocollator temperatures were checked daily when the Therapy Department is open to assure safe functioning. This has the potential to affect all patients utilizing these therapy modalities in the Therapy Department.

Findings include:

1. The "Temperature Monitoring Event Log" for both the Cold Pack Machine and the Hydrocollator, dated April 2017 thru May 2, 2017, were reviewed on 5/2/17 at approximately 3:40 PM. The logs lacked temperatures for April 28, 2017, May 1, 2017, and May 2, 2017.

2. An interview was conducted with the Therapy Manager (E#10) with the Director of Nursing (E#1) present. E#10 reviewed the logs and stated temperatures were to be taken each morning the Therapy Department is open. E#10 further stated "The person who usually takes the temperatures was off on those days and someone else should have documented them."

C. Based on observation, interview, and document review, it was determined the Facility failed to ensure the pool lift was maintained in accordance with manufacturer guidelines. This has the potential to affect all patients who utilize the pool lift.

Findings include:

1. An observational tour was conducted on 5/2/17 at approximately 3:20 PM with the Therapy Manager (E#10) and the Director of Nursing (E#1). A pool lift was observed available for patient use. There were no policy or manufacturer guidelines for the care and maintenance of the pool lift observed.

2. An interview was conducted E#10 on 5/2/17 at approximately 3:20 PM. E#10 stated the pool lift is used sporadically throughout the year. E#10 stated "We have a checklist that the staff do on a daily and monthly basis to clean it and check the seat and bolts and such." When asked how often preventive maintenance is performed, E#10 stated the pool lift was not on the preventive maintenance cycle.

3. The manufacturer guidelines were (MDS) dated [DATE] at approximately 9:50 AM. The guidelines stated "Perform a more thorough inspection of the lift every three months if the unit is in use all year around." and proceeded to state what factors were to be addressed.

4. A follow up interview with E#10 was conducted on 5/3/17 at approximately 9:50 AM. E#10 stated "We haven't been doing this (the every three month inspection) and we should have been."
VIOLATION: POLICIES - INFECTION CONTROL Tag No: C0278
A. Based on document review and interview, it was determined the Facility failed to ensure outlying dishwasher temperatures were followed up to assure disinfection of dishes to prevent potential cross contamination. This has the potential to affect all patients, visitors, and staff who may utilize the Dietary services.

Findings include:

1. The Facility policy titled "Temperatures Policy #: 500.019" was reviewed on 5/3/17 at approximately 3:00 PM. The policy stated "II. PROCEDURE: A. Dishwashing - Hobart Flight Type Dish Washer Wash Temperature 150 (degrees Fahrenheit-F) Rinse Temperature 160 F... " The policy lacked what staff were to do when the Dishwasher temperature did not reach the proper temperature during the respective cycle.

2. The "Dish machine Temps (temperatures) logs for April 2017 for breakfast, lunch, and supper were reviewed on 5/3/17 at approximately 1:15 PM. The logs stated the dishwasher was run a total of ninety times. Four out of ninety wash temperatures did not reach 150 F, with a range of 136 F to 148 F. Five out of ninety rinse temperatures did not reach 160 F, with a range of 154 F to 159 F. The log had an area titled "Action Documentation" in which the "Date... Problem...Person Reported Issue... Action follow up" which was blank on each log.

3. An interview was conducted with the Dietary Manager (E#8) and the Dietician (E#9) on 5/3/17 at approximately 1:15 PM. The Director of Nursing (E#1) was present. E#8 and E#9 reviewed the dishwasher logs. E#8 stated that when the dishwasher doesn't reach the proper temperature for the cycle it is in, Plant Operations is notified and a work order is placed. There were no work orders for April.

B. Based on document review and interview, it was determined the Facility failed to ensure the Paraffin Bath was sanitized and cleaned in accordance with manufacturer guidelines. This has the potential to affect all patients who require the use of the Paraffin Bath.

Findings include:

1. The manufacturer guidelines titled "Instructions for Operation and Care of Dickson Paraffin Baths" was reviewed on 5/2/17 at approximately 3:20 PM. The guidelines stated "To sanitize the bath, turn the high heat switch on for a full 55 minutes. The temperature will rise to about 212 F (Fahrenheit) (100 C- Celsius). The bath should in this manner, be sanitized after each day's use. Again, the bath will automatically return to the operating temperature... Therefore, periodically, the Bath should be drained completely of the paraffin solution and the bottom of the Bath and the plexiglas slats cleaned thoroughly." There was no documentation to indicate when the Paraffin Bath was used, whether it was sanitized, and/or whether the Paraffin Bath was drained and cleaned.

2. An interview was conducted with the Therapy Manager (E#10) on 5/2/17 at approximately 3:20 PM. E#10 stated the Paraffin Bath is used "regularly, but I'm not sure how often. I'm not sure how they sanitize it and would have no way to show that it's been done after each use or if it's been drained and cleaned."

C. Based on document review and interview, it was determined the Facility failed to ensure its laundry service provider was monitored to assure the infection control measures of time, temperature, and disinfection were maintained to prevent the potential for cross-contamination. This has the potential to affect all patients serviced by the Facility.

Findings include:

1. The Facility policy titled "Infection Control/Isolation Linens Policy #: 602.004" (last reviewed 8/12/16) was reviewed on 5/5/17 at approximately 10:15 AM. The policy stated "II. Procedure E. The Manager of Environmental Services is a member of the Infection Control Committee to insure (spelled this way) correct laundry procedures and effective disease control in linen usage." The Facility lacked a current contract for linen services.

2. An interview was conducted with the Director Hospitality (E#12- also over linen services) on 5/4/17 at approximately 8:45 AM. E#12 stated there was no process in place to monitor and/or assure the contracted service was meeting time, temperature, and disinfection of linen to prevent the potential of cross contamination. E#12 stated the linen services contract had expired in May of 2015.