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.

RUSH UNIVERSITY MEDICAL CENTER 1653 WEST CONGRESS PARKWAY CHICAGO, IL 60612 Aug. 7, 2015
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, it was determined that in 1 of 10 (Pt #1) clinical records reviewed, the Hospital failed to ensure the physicians' orders were followed as written.

Findings include:

1. The clinical record of Pt #1 was reviewed on 8/7/15. Pt #1 was a [AGE] year old female admitted on [DATE] with a diagnosis of spinal stenosis/kyphoscoliosis. Pt #1's clinical record contained a physician's order dated 6/15/15 at 8:07 PM to "avoid prolonged sitting (greater than 45 minutes." Nursing documentation dated 6/16/15 included that Pt #1 was in the chair from 2:58 PM to 5:24 (2 hours and 26 minutes).

2. On 8/7/15 at approximately 12:50 PM the Orthopedics Clinical Nurse Specialist (E #13) stated during an interview that the patient was up in the chair for 2 hours and not 45 minutes as ordered by the physician.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation, document review and interview, it was determined that for 3 of 3 staff observed with facial hair (E #7, 8, and 9) in the surgical department, the Hospital failed to ensure staff adherence to the OR dress code policy.

Findings include:

1. During observational tour of the surgical department on 8/5/15 between 9:00 AM and 10:30 AM, a clinical engineer (E #7) was in OR room 19 at 9:00 AM with his facial hair uncovered, Registered Nurse (E #8) was in the central core at 9:25 AM with his facial hair uncovered, and an environmental worker (E #9) was cleaning OR 16 at 10:30 AM with his facial hair uncovered.

2. The Hospital policy entitled, "Attire for Personnel - Operating Room/Post Anesthesia Care Unit/ Ambulatory Surgery Unit/Rush..." (approval Date 9/20/2012) required, "Policy: Dress Code Regulations...2. Personnel must cover head and facial hair completely when entering the semi-restricted and restricted areas."

3. The above findings were discussed with the Infection Preventionist (E #10) during an interview on 8/7/15 at approximately 10:15 AM. E #10 stated the staff should have been wearing beard covers.