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.

PRESENCE SAINT JOSEPH MEDICAL CENTER 333 N MADISON ST JOLIET, IL 60435 Aug. 2, 2012
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review of Hospital policy, clinical record, and staff interview, it was determined that for 1 of 1 surgeons (S1) suspected of being under the influence of alcohol prior to the start of surgery, the Hospital staff failed to report suspicion of the incapacitated surgeon as required per policy, in a timely manner in order help ensure patient safety during the surgical procedure. This potentially affected 1 sampled patient (Pt. #1) who had a surgical procedure on 5/7/12.

Findings include:

1. The Hospital's Medical Staff policy entitled, "Impaired Medical Staff " (revised 1/18/11) required, "...Report and Investigation: If any individual working in the Medical Center, or as otherwise provided in the Bylaws, has a reasonable suspicion that a Medical Staff member is Impaired, the following steps shall be taken: A. A written report shall be given to the President of the Medical staff who shall supply a copy and consult with the Medical Center President or designee. The report shall include a description of the incident(s) or reason(s) that led to the belief that the member may be Impaired. The report shall be as factual as possible. The individual making the report does not need to have proof of the Impairment, but must state the facts and reasons leading to the suspicions."

The Hospital's policy entitled, "Drug and Alcohol Free Work Place" (revised 9/22/10) required, "...Staff members must report suspicious behavior to a supervisor/manager. The supervisor/manager who witnesses the circumstances warranting the test should contact Human Resources or designee during off shift (House Supervisor or Administrator on Call) immediately after the observed behavior."

The Hospital's policy entitled, "Chain of Command" (revised 7/8/10) required, "...Examples of indications for implementing chain of command include but are not limited to: ... In situations where impairment of a practitioner is suspected ... In such instances, the nurse or other health care professional initiates the chain of command indicated below: A. First level: Assistant Patient Care Manager or Charge Person; B. Second level: Patient Care Manager (House Operations Administrator on off-shifts) or Department Manager; C. Third level: Nursing Director or Department Director; D. Fourth level: Vice President, Patient Care Services or Vice President, Clinical Services or Chief Medical Officer; E. Fifth level: Chief Operating Officer; F. Sixth level: President, Chief Executive Officer ..."

2. The clinical record for Pt #3 included that this was a [AGE] year old female who (MDS) dated [DATE] with dizziness. A CT was done in the ED that showed a large hematoma in the right cerebellar hemisphere with mass effect. S1 (neurosurgeon) was notified. Pt #3 received 2 units of fresh frozen plasma and was taken to the OR. Pt #3 underwent a craniotomy performed by S1, start time 11:17 (P.M.) on 5/7/12. The operative report included, "...Despite all the efforts, the patient continued to bleed. It seemed like at least partial decompression was achieved and the cerebellum was no longer bulging out. The oozing seemed to have been at least partially subdued and at this point, decision was made to stop further surgery and start closing the wound." Pt #3's POA/family later decided to withdraw support. Pt #3 expired at 5:59 AM on 5/8/12.

3. A telephone interview was conducted on 8/1/12 at approximately 10:00 AM with the Scrub Technician (E #5) who was on the OR staff list for Pt #3's surgery on 5/7/12. E #5 stated that she smelled alcohol on S1's breath in the OR during surgery in May (date unknown). E #5 stated that others, including the anesthesiologist, asked E #5 if she smelled alcohol on S1 too. This was in the OR after S1 was scrubbed in to do a craniotomy on a woman. E #5 stated that it was an emergency case around 10:30 PM. E #5 stated that the anesthesiologist must have brought it up to the Hospital Board because after the incident the Chief of Surgery called E #5 at home (E #5 works nights, date of call unknown) and told E #5 that if a surgeon is suspected to be under the influence of alcohol, I should tell the anesthesiologist, the House Supervisor, and call the Surgery Department Manager and Director. E #5 stated that he/she did not file a complaint or report this incident to anyone.

A telephone interview was conducted on 8/1/12 at approximately 11:00 AM with the anesthesiologist (E #7) for Pt #3's surgery on 5/7/12. E #7 stated that during Pt #3's surgery, one of the scrub nurses made a hand gesture as if tilting hand to mouth like lifting a bottle to drink, and nodding head toward S1. E #7 stated that he is behind a drape during surgery, and therefore is not near the surgeon. E #7 stated that after surgery, another nurse told him that S1 smelled like alcohol at the scrub sink before surgery. I did not notice any motor skill impairment of S1. E #7 stated that Pt #3 had a very bad bleed, surgery was completed, the family withdrew treatment, and Pt #7 expired. E #7 stated that he reported this incident to his anesthesia partners the next day who took it to the Neurosurgery Partners and the Hospital's Administration. E #7 confirmed (by patient name and date) that this incident took place during the surgery for Pt #3 on 5/7/12.

On 8/1/12 at 2:20 PM, an interview was conducted with the OR Charge Nurse (E #11) who was on duty on 5/7/12, during Pt. #3's surgery. E #11 stated that she was not in the OR room but "over heard a comment while leaving" (shift ended at 11:00 PM) that S1 was intoxicated during surgery. E #11 stated that she did not report the incident "considering the source it came from" and did not indicate the source she referred to. E #11 stated that she was not interviewed regarding the incident and is unaware of any investigation of the alleged intoxicated surgeon.

On 8/1/12 at 2:30 PM, a phone interview was conducted with the Registered Nurse (E #12) who was circulating for Pt. #3's surgery on 5/7/12. E #12 stated that there was "talk" that the Surgeon (S1) was intoxicated, but she did not notice - she was very busy working on the craniotomy case "running around, getting blood ..."

An interview was conducted on 8/2/12 at approximately 9:35 AM with the Director of Surgical Services (E #9). E #9 stated that she just heard about this within the last week (since 7/23/12), from the surgical team. E #9 stated that no one had reported an incident of suspicion that S1 was under the influence of alcohol during surgery to her. E #9 stated, "One person made a comment, but not to me. I think it was before the surgery, that one staff member - a surgical technician- mentioned it to the RN from the neuro team. No one else in the room felt this was the case. I did investigate this and talked to the staff that was there, except the scrub tech (E #5) that suspected this because E #5 works nights and was unable to be reached." E #9 stated that the protocol to follow if a physician is suspected to be under the influence of alcohol would be to go to the charge nurse or anesthesiologist to report suspicions, and then follow the Chain of Command policy.
VIOLATION: OPERATING ROOM POLICIES Tag No: A0951
A. Based on review of the Hospital's housekeeping contractual service procedure, American periOperative Registered Nurses (AORN) 2012 Perioperative Standards and Recommended Practices, observational tour, and staff interview, it was determined, that for 3 of 4 Operating Room (Suites 5, 8, & 12), the Hospital failed to ensure Operating Room (OR) housekeeping procedures and AORN standards were followed, potentially affecting approximately 35 patients on the surgical schedule on 8/1/12.

Finding include:

1. The contractual (Sodexo) housekeeping cleaning procedure, dated 2011, titled "Surgical/Invasive Areas and Delivery Rooms - Between Cases" included, "Procedure... 4. Use a solution-dampened cloth and damp dust... table, mattress cover... damage or worn coverings should be replaced... 14. Inspect the room: Report any needed repairs..."

2. AORN 2012 Standards and Recommended Practices for Maintaining a Sterile Field included, "Recommendation IV All items introduced to a sterile field should be opened, dispensed, and transferred by methods that maintain item sterility and integrity... When solutions are dispensed... the entire contents of the container should be poured... Any remaining fluids should be discarded. The edge of the container is considered contaminated after the contents have been poured, therefore, the sterility of the contents cannot be ensured if the cap is replaced..."

3. On 8/1/12 between 10:10 AM and 11:00 AM, an observational tour was conducted in the OR with the Director of Surgical Services and the OR Patient Care Manager and the following was observed:

- Suite 5 - tape residue on a table and wall damage, preventing thorough disinfection

- Blood bank room - 1 unsecured oxygen tank

- Blood bank room - ice machine - pink and white build up on overflow tray, located less than 2 feet from tissue graft refrigerator.

- Suite 8 - arm board tears, tape residue on mattress, and wall damage, preventing thorough disinfection

- Suite 12 - tape on IV pole, tape residue on table preventing thorough disinfection

4. On 8/1/12 between 10:10 AM and 11:00 AM, during an observational tour in the OR, interviews were conducted with the Director of Surgical Services and the OR Patient Care Manager. The OR Patient Case Manager stated that the unsecured oxygen tank was empty and she had no idea what the substance in the ice machine tray was.

B. Based on request for Hospital policy, review of American periOperative Registered Nurses (AORN) 2012 Perioperative Standards and Recommended Practices, sterilizer log review, and staff interview, it was determined, that for 1 of 1 sterilizer (#4/5), the Hospital failed to ensure sterilized instruments were were properly recorded in the sterilizer log, potentially affecting approximately 35 patients on the surgical schedule on 8/1/12.

Finding include:

1. On 8/1/12 at 11:30 AM, the flash sterilization log policy was requested. There was no flash sterilization log policy.

2. AORN 2012 Standards and Recommended Practices for Sterilization in the Perioperative Practice Setting included, "Recommendation VII Immediate use steam sterilization (IUSS) should be kept to a minimum and should be used only in selected clinical situations and in a controlled manner... Documentation of cycle information and monitoring results should be maintained in a log... Documentation of cycle information provides a means for tracking items that are processed using IUSS to individual patients and for quality monitoring... Immediate use steam sterilization records should include information on each load, including: the items processed, the patient... the date and time the cycle was run, the operator, the reason for the IUSS..."

3. On 8/1/12 at 1:00 PM, the immediate use (flash) steam sterilizer log for sterilizer (4/5) for July 2012 was reviewed. The log did not include the time the loads were run and 9 of 32 entries lacked documentation of the items processed, the patient's name, the date and time the cycle was run, the operator, and/or the reason for the IUSS..."

4. On 8/1/12 at approximately 2:00 PM, the missing documentation was discussed with the Accreditation Manager. The Accreditation Manager stated that there was no hospital policy for the sterilization log, but was able to print the AORN Perioperative Standards and Recommended Practices from the Internet, which the OR follows.
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