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.

GOTTLIEB MEMORIAL HOSPITAL 701 WEST NORTH AVE MELROSE PARK, IL 60160 Sept. 18, 2014
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and staff interview, it was determined for 3 of 4 (Pts #1,2 and 3) clinical records reviewed for patients on mechanical ventilation, the hospital failed to ensure oral care was completed in accordance with hospital policy.

Findings include:

1. The hospital's policy entitled "Infection Control: Oral Care for Ventilated Patients" (effective 8/2012) was reviewed on 9/17/14 at approximately 1:00 pm and required, "...1. The oral cavity is assessed every shift and PRN [as needed] by the registered nurse. 2. Intubated patients are provided oral care using a swab and cleansing agent every four hours and PRN. 3. Brushing of teeth and/or oral cavity, including tongue, with a soft suction toothbrush and subglottic suctioning will be performed twice a day and PRN by the nurse or respiratory therapist ...Use chlorhexidine mouth rinse for oral decontamination twice a day ...Document oral care every four hours in EPIC under Hygiene/ Skin Care ... "

2. The clinical record for Pt #1 was reviewed on 9/17/14 at approximately 10:00 am. Pt #1 was a [AGE] year old male who was admitted to the hospital's ICU (intensive care unit) on 7/28/14 with a diagnoses of cardiac arrest, anoxic brain damage, chronic encephalopathy, hypertension, congestive heart failure, and respiratory failure. Pt #1 had a chronic tracheostomy and was on chronic ventilator support. Nurses ' notes lacked the completion of oral care (teeth brushed and mouth swabbed with Chlorhexidine) on 7/29/14 between 12:03 am and 8:00 am (approximately 8 hours) and between 8:00 am and 11:00 pm (approximately 15 hours).

3. Pt #2 was a [AGE] year old male admitted on [DATE] with diagnoses of pneumonia and hypoxia. The clinical record lacked documentation of completion of oral care on 9/14/14 between 8:00 am and 8:00 pm (12 hours).

4. Pt #3 was a [AGE] year old female admitted to the hospital ' s ICU on 9/9/14 with a diagnosis of respiratory failure. The clinical record for Pt #3 lacked documentation of completion of oral care on 9/15/14 between 9:00 am and 4:00 pm (7 hours).

5. On 9/18/14 at approximately 1:00 pm, the Director of Nursing stated that oral care should have been completed every 4 hours.