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 GOOD SAMARITAN HOSPITAL 3815 HIGHLAND AVENUE DOWNERS GROVE, IL 60515 April 18, 2013
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on document reviews, and staff interview, it was determined that for 1 of 5 (Pt #1) clinical records reviewed with a positive MRSA (Methicillin Resistant Staphylococcus Aureus) screen, the hospital failed to patient did not acquire MRSA while hospitalised ensure contact isolation was initiated in a timely manner as required by Hospital practice and policy.

Findings include:

1. The Hospital policy titled, " Methicillin resistant Staphylococcus Aureus Screening for the NICU,"
(originated 4/18/08) reviewed on 4/16/13 required, "...all NICU infants will be screened for MRSA upon admission and every Monday... Polymerase Chain Reaction (PCR) -Laboratory technique used for raid identification of bacteria through genetic testing... Precaution/isolation: ...PCR positive: a. contact Isolation.

2. The clinical record of Pt. #1 was reviewed on 4/16/13. Pt. #1 was admitted to the Neonatal Intensive Care Unit (NICU) at birth on 2/8/13 for monitoring for withdrawal due to maternal history of heroin use treated with Methodone. Laboratory results for MRSA (Methicillin Resistant Staphylococcus Aureus) screen from the nares on 2/8/13 and 2/11/13 were negative, however on 2/18/13 MRSA was PCR positive. The clinical record included a physician order dated 2/18/13 for "contact isolation". However, the record lacked documentation of contact isolation being initiated timely, with the first isolation documentation beginning on 2/21/13, 3 days after the order for isolation was written.

3. The above findings were confirmed with the Nurse Manager on 4/17/13 at approximately 2:00 PM, who stated isolation should have been documented beginning on 2/18/13.