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 LUTHERAN GENERAL HOSPITAL 1775 DEMPSTER ST PARK RIDGE, IL 60068 July 24, 2015
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
A. Based on observation, document review and interview, it was determined that for 1 of 1 (PCT E #1) patient care technician observed, the Facility failed to ensure the PCT cleaned the point of care device prior to returning the device to its charger.

Findings include:

1. On 7/21/15 between 9:30 AM and 11:00 AM an observational tour was conducted on the 14 west unit. At approximately 10:30 AM The PCT (E #1) was observed performing a finger stick blood glucose check. Following the procedure the glucose monitor was replaced onto its holder (charger) without being cleaned.

2. Hospital policy entitled, "Disinfectant Guidelines and Cleaning of Patient Care Equipment," (last reviewed 11/19/14) required, "...IV, Procedure: A. Process: 1. Clinical and support associates(e.g...Technicians...) ...c) Associates who use any equipment are responsible for its cleaning and disinfection between patient uses."

3. The Assistant Clinical Manager of the 14 west unit confirmed during an interview at approximately 10:30 AM on 7/21/15 that the PCT failed to clean the glucose monitor prior to replacing on the charger.






B. Based on observation, document review and interview, it was determined that for 3 of 3 staff (E #2, 3, and 4) and 1 of 1 (MD #1) physician observed in operating room (OR) 9, the Hospital failed to ensure staff adhered to the OR dress code policy.

Findings include:

1. During observation of the OR 9 on 7/21/15 between 1:30 PM and 2:45 PM, a scrub technician (E #2), Registered Nurse orientee (E #3), and a Nurse (E #4) had hair exposed around the temple, ear and neckline. The Anesthesiologist (MD #1) had sideburns that were exposed and was not covered by a mask or head covering.

2. The Hospital policy titled, "Dress Code for Associates" (rev 4/15/14) required, "...D. Attire for Restricted and Semi-restricted Areas: Hair Covering, a.) All possible head and facial hair must be covered with clean protective headwear adequate in size to extend beyond the hairline, in restricted and semi-restricted areas, hoods and bouffant styles only."

2. The above findings were discussed with the Vice President of Surgical Services on 7/21/15 at approximately 2:45 PM, who stated that all hair should be covered while in the surgical suite.





C. Based on observation, document review, and interview it was determined that 1 of 1 employee (E #6) performing central line care and 1 of 1 (E #8) observed inserting a Foley catheter, the Hospital failed to ensure infection control practices were followed.

Findings include,

1. Policy entitled, "Hand Hygiene," (Reviewed 1/28/14) indicated "...III. Definitions/Abbreviations C. Hand hygiene: A general term that applies to hand washing...antiseptic hand rub...IV. Indications for Hand Hygiene a.) Hands shall be washed with soap and water (1) When hands or gloves are visibly soiled (3) For specialty areas, see unit specific guidelines 2.) Use soap and water or alcohol-based hand rub: a.) Upon entering a patient room: Before direct contact with patients or their environment. Including but not limited to: a. Patient care procedures (i.e. urinary catheter placement, ...non surgical procedures) 2.) After every contact with a patient or the patient's environment."

2. Policy entitled, "Central Venous Catheter (Adult): Non tunnel Central Venous Catheters (Single-Lumen, Double-Lumen, Triple-Lumen, Quad- Lumen, Dialysis Catheters)", (Template Date 5/15/14) indicated "...IV. Procedure: A. Prior to all aspects of non-tunneled CVC care: 1. Hand hygiene is done according to Advocate policy...I. Dressing Change (non-tunneled CVC)...5. Perform hand hygiene...12. Remove clean gloves and foam strip if securement device was removed, or sterile gloves if foam strip was not used with securement device. 13. Perform Hand Hygiene. 14. Put on sterile gloves."

3. On 7/21/15 at approximately 11:40 AM the registered nurse (E #6), was observed changing the dressing of Pt #15's right arm peripherally inserted central venous catheter (PICC). While gloved, E #6 removed Pt #15's PICC dressing and disposed of it, removed her gloves, however failed to perform hand hygiene. E #6 then put on sterile gloves, cleaned the exit site, and applied a sterile dressing. E#6 then reached in her pocket with the same gloves and took two (2) 10 ml syringes of normal saline and primed the caps, without changing gloves and/or performing hand hygiene, she then cleaned the ports of the PICC with disinfecting pads and placed the primed caps on the hubs of the CVC.

4. On 7/21/15 at approximately 12:00 PM the findings were presented to the Manager and the Nurse Educator (E#7) of the 12 west unit. E #7 stated E #6 should have performed hand hygiene when she discarded used gloves and before applying sterile gloves.

5. On 7/21/15 at approximately 2:30 PM a tour was conducted in the Hospital's surgical department. In Operating Room (OR) #9, a registered nurse (E#8) was observed inserting an indwelling catheter in Pt #19. E #8 removed her gloves after prepping Pt #19 for the catheter insertion and discarded the used gloves. E #8 cleaned her hands with a disinfecting wipe and applied one sterile glove to the left hand and immediately removed and discarded the pair of sterile gloves. E#8 then obtained a new pair of sterile gloves and put them on and proceeded to insert the Foley catheter without performing hand hygiene.

6. On 7/21/15 at approximately 3:00 PM the finding was discussed with the Vice President of Surgical Services (E #9). E #9 stated its unrealistic for E #8 to have left the patient alone to go wash her hands. E #9 stated E #8 washed her hands prior to entering the OR and that should have been sufficient. E #9 stated E #8 could have used a disinfecting wipe. E #9 stated that its different inserting a catheter in the OR than in the Hospital.

7. On 7/23/15 at approximately 11:00 AM the Director of Clinical Excellence and Patient Safety (E #10) stated the Hospital does not have a specific policy for the insertion of an indwelling catheter in the OR.