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.

ADVOCATE BROMENN MEDICAL CENTER 1304 FRANKLIN AVENUE NORMAL, IL 61761 Aug. 31, 2017
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on document review, interview and stated practice, it was determined in 1 of 10 (Pt. #8) patient's records reviewed, the Hospital failed to ensure a code sepsis and septic shock flow sheet were documented. This has the potential to affect all patients with sepsis admitted in the Emergency Department.

Findings include:

1. The clinical record for Pt #8 was reviewed on 8/29/17 at 2:30 PM. Pt #8 was admitted on [DATE] with a Diagnosis of Cellulitis in Lower Legs. The code sepsis log was reviewed on 8/29/17 at 1:00 PM. Pt. #8 was listed on the log on 8/1/17 at 2230 (10:30 PM) for code sepsis in the ED. The nurses note dated 8/1/17 at 2229 (10:29 PM) included sepsis screen, actions taken-provider notified and treatment in progress. The record lacked documentation of the septic code being done and lacked the flowsheet "Severe Sepsis/ Septic Shock Flowsheet."

2. During an interview with E#2 (Director of Critical Care) on 8/31/17 at approximately 2:30 PM, it was verified that there was no documentation of the code sepsis in the record and no documentation of the severe sepsis/shock flowsheet and there should have been. E#2 included the practice/process is whenever there is code sepsis done it should be documented in the record and on the flowsheet. E#2 stated the flowsheet is new and was initiated on 7/5/17 and staff may not be used to using it yet. E#2 verified that the "Severe Sepsis/ Septic Shock Flowsheet" hasn't been incorporated into the policy.