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.

UNIVERSITY OF ILLINOIS HOSPITAL 1740 WEST TAYLOR ST SUITE 1400 CHICAGO, IL 60612 May 10, 2018
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


A. Based on document review and interview, it was determined for 1 of 4 (Pt. #3) clinical records reviewed for patients receiving Phototherapy (light treatment to lower bilirubin levels in babies), the Hospital failed to ensure a physician's order was in place, as required.

Findings include:

1. On 5/8/18 at approximately 11:00 AM, the clinical record of Pt. #3 was reviewed. Pt. #3 was a 10 day old female born on 4/28/18 with diagnoses of [DIAGNOSES REDACTED]#3 was placed on Phototherapy from 5/6/2018 at 11:00 AM until 5/8/2018 at 9:45 AM. However, the clinical record did not include a physician's order for the Phototherapy.

2. On 5/8/18 at approximately 1:00 PM, the Hospital's guidelines titled, "[DIAGNOSES REDACTED] (high level of bilirubin/orange-yellow pigment in the body) in Term and Late Pre-term Infants," (dated 12/2015) was reviewed and required, "... F. Initiation of Phototherapy: 1. Phototherapy is the primary therapy for [DIAGNOSES REDACTED]..."

3. On 5/8/18 at approximately 1:30 PM, the Hospital's document titled, "Nursing Services 2017, Newborn RN (Registered Nurse) Obstetrical Orientation Check List" (dated 7/11/2017) was reviewed and required, "...Page 11 Newborn Phototherapy, check provider orders..."

4. On 5/8/18 at approximately 2:00 PM, the Hospital's job description titled, "Staff Nurse I" and "Staff Nurse II" (revision date 1/30/17) was reviewed and required, "...Verifies and implements orders from physician, physician assistant, and/or advance practice nurse..."

5. On 5/8/18 at approximately 2:20 PM, findings were discussed with E #4 (Associate Chief Nursing Officer of Maternal and Child Health). E #4 stated that there should have been an order for the Phototherapy. E #4 added that she could not find the physician's order for the Phototherapy.

B. Based on document review and interview, it was determined for 4 of 4 (Pt. #1, #2, #3, and #4) clinical records reviewed for patients that received Phototherapy (light treatment to lower bilirubin levels in babies), , the Hospital failed to ensure nursing interventions, regarding the use of the Bilirubin light, were implemented, as required.

Findings include:

1. On 5/8/18 at approximately 1:00 PM, the Hospital's guidelines titled, "[DIAGNOSES REDACTED] (high level of bilirubin/orange-yellow pigment in the body) in Term and Late Pre-term Infants" (dated 12/2015) was reviewed and required, "... F. Initiation of Phototherapy: 1. Phototherapy is the primary therapy for [DIAGNOSES REDACTED]...7.a. Eye shields should be used whenever an infant is receiving overhead phototherapy..."

2. On 5/8/18 at approximately 1:30 PM, the Hospital's document titled, "Nursing Services 2017, Newborn RN Obstetrical Orientation Check list (dated 7/11/2017) was reviewed and required, "...Newborn Phototherapy... Check light intensity...Protect infant eyes..."

3. On 5/9/18 at approximately 10:00 AM, the Hospital's policy titled, "Physical Assessment and Monitoring of Newborns in the Intensive Care and Intermediate Care Nurseries" (dated 7/2017) was reviewed and required, "...Procedure... 2. Physical Assessment...ii. Routine care (diaper change, position change)... should not have intervals that exceed 6 hours."

4. On 5/8/18 at approximately 11:00 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 5 week old female born on 4/1/18 with diagnoses of [DIAGNOSES REDACTED]#1 was repositioned every 6 hours: from 8:00 AM to 5:00 PM (9 hours).

5. On 5/8/18 at approximately 10:45 AM, the clinical record of Pt. #2 was reviewed. Pt. #2 was a 5 day old male born on 5/2/2018 with diagnoses of [DIAGNOSES REDACTED]. The clinical record lacked daily documentation of the bili-meter reading (measures the intensity of the Phototherapy light) from 5/4/2018 to 5/7/2018.

6. On 5/8/18 at approximately 11:00 AM, the clinical record of Pt. #3 was reviewed. Pt. #3 was a 10 day old female born on 4/28/18 with diagnoses of [DIAGNOSES REDACTED]#3 was placed on Phototherapy from 5/6/2018 at 11:00 AM until 5/8/2018 at 9:45 AM. The clinical record lacked daily documentation of the bili-meter reading from 5/6/2018 to 5/8/2018.

7. On 5/8/18 at approximately 11:15 AM, the clinical record of Pt. #4 was reviewed. Pt. #4 was a 4 day old male born on 5/3/18 with a diagnosis of [DIAGNOSES REDACTED]#4 was receiving Phototherapy from 5/7/18 at 9:00 AM until 5/8/18 at 9:00 AM. However, the clinical record lacked every 3 hour documentation that the eye mask (to protect the infant's eyes) was on, from 10:00 AM to 4:00 PM on 5/7/18 (6 hours).

8. On 5/8/18, at approximately 11:30 AM and at 2:20 PM, the findings were discussed with E #2 (Clinical Nurse Specialist) and E #4 (Associate Chief Nursing Officer of Maternal and Child Health). E #2 and E #4 stated that the Hospital's required practice, while babies receive the phototherapy includes daily documentation of bili-meter reading and every 3 hour documentation that the eye mask is in place.

9. On 5/9/18 at approximately 10:30 AM, another interview was conducted with E #2. E #2 stated that position changes (including while babies receive Phototherapy) should be documented in the clinical record every 6 hours.





C. Based on document review and interview, it was determined that for 1 of 4 (Pt #8) clinical records reviewed on the 7 East Unit, the Hospital failed to ensure physicians' orders were followed, as required.

Findings include:

1. The clinical record of Pt #8 was reviewed on 5/8/18 at approximately 10:35 AM. Pt #8 was a [AGE] year old female who was admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]'s order dated 5/2/18 that required, "Please resume free water flush 300 cc's (cubic centimeters) q (every) 6 hours." Pt #8's clinical record lacked documentation that Pt #8 received the required 300 cc's water from 5/5/18 at 6:00 AM to 5/8/18 at 5:59 AM (72 hours).

2. The Associate Chief Nursing Officer (E #3) stated during an interview on 5/9/18 at approximately 10:30 AM, that there was only one documented time the patient received the required 300 cc's of fluid.

D. Based on document review and interview, it was determined that for 1 of 4 (Pt # 8) clinical records reviewed on the 7 East Unit, the Hospital failed to ensure the patient was turned and repositioned, as required, to prevent skin breakdown.

Findings include:

1. The Hospital's policy entitled, "University of Illinois Hospital Clinics Clinical Care Guideline," (dated July 2016) required, "Addendum 1: Medical/Surgical Units...Q2h (every 2 hours)...pt repositioning..."

2. The clinical record of Pt #8 was reviewed on 5/8/18 at approximately 10:35 AM. Pt #8 was a [AGE] year old female who was admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]#8 was on bedrest, requiring passive range of motion (the therapist or equipment moves the joint with no effort from the patient). Pt #8's clinical record lacked documentation that Pt #8 was repositioned every 2 hours as required from: 2:13 AM to 9:01 AM on 5/5/2018 (8 hours and 48 minutes); on 5/5/18 from 9:01 AM until 8:00 AM on 5/6/2018 (22 hours and 59 minutes); and 5/6/2018 from 12:28 PM until 5/8/2018 at 4:50 AM (40 hours and 22 minutes).

3. The Associate Chief Nursing Officer (E #3) stated, during an interview on 5/9/18 at approximately 10:30 AM, that the patient was not turned every 2 hours, as required.





E. Based on document review and interview, it was determined for 1 of 2 (Pt. #6) clinical records reviewed of patients with documented pain, the Hospital failed to ensure that a pain reassessment was done, as required.

Findings include:

1. The Hospital's policy titled, "Inpatient Guidelines For Adult Documentation (effective 8/11/2016)" reviewed on 5/8/18, required, "Addendum 1: Medical/Surgical Units...PCA, every 4 hours."

2. The clinical record of Pt #6 was reviewed on 5/8/18. Pt #6 was a [AGE] year old female admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED].

3. The Chief Nursing Officer E #3 was interviewed on 5/8/18 at approximately 1:30 PM. E #3 stated, "Pain assessments should be done every shift or every 4 hours."

F. Based on document review and interview it was determined that for 1 of 1 (Pt. #1) clinical record reviewed with a documented wound, the Hospital failed to ensure that the patient was free of injury/skin breakdown.

Findings include:

1. On 5/8/18 at approximately 11:00 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 5 week old female born on 4/1/18 with diagnoses of [DIAGNOSES REDACTED].

The nursing assessment sheet indicated that an abrasion on the patient's foot was first identified on 04/03/2018 at 8:00 PM. The physician's progress note, dated 04/04/18 indicated, "Left lower leg abrasion likely 2/2 [secondary to] ID band, no acute signs of infection-wound care. R [right] foot abrasion, likely trauma or pressure induced no acute signs of infection-wound care ..."

The discharge addendum note dated, 4/8/18 at 10:58 PM, included "Skin - On day of life 4, a left lower leg abrasion (thought to be likely secondary to ID band) and a right foot abrasion (thought to secondary to pressure/trauma) was identified ..." Pt. #1 was discharged home on 4/8/18 with an order of Bacitracin [antibiotic ointment] to be applied twice a day.

2. On 5/8/18 at approximately 3:50 PM an interview was conducted with (Registered Nurse) E #1. E #1 stated, "I cannot recall how this scab came on, it was an old injury when I came on. This is not a common injury."

3. On 5/9/18 at approximately 8:58 AM, an interview was conducted with Pt. #1's Attending Neonatologist (MD #1). MD #1 stated, " ...the nurse told me the skin findings. We discussed types of diagnoses. No diagnosis was made, just this finding. The clinical picture [DIAGNOSES REDACTED]"
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, it was determined that for 1 of 1 (Pt #7) clinical record reviewed, of a patient requiring subcutaneous medications, the Hospital failed to ensure the medication was administered and documented, as required.

Findings include:

1. The Hospital's policy requiring medication administration for injectable medications, was requested on 5/9/18. The Associate Chief Nursing Officer (E #3) stated, "The Hospital does not have a policy for medication administration that required site rotation."

2. The clinical record for Pt #7 was reviewed on 5/8/18. Pt #7 was a [AGE] year old male who was admitted on [DATE], with a diagnosis of fluid overload. The clinical record for Pt #7 contained a physician's order dated 5/8/18, that required, "Insulin Aspart 13 units subcutaneous 3 times a day, and Insulin Glargine 40 units subcutaneous every 12 hours." The clinical record indicated that Pt #7 received the prescribed insulin in the same site (right upper arm) on 5/7/18, at 11:51 PM, 5/8/18 at 9:52 AM, and 5/8/18 at 1:00 PM.

3. The Associate Chief Nursing Officer (E #3) was interviewed on 5/9/18 at approximately 10:45 AM. E #3 stated, "The patient told the nurse he only wanted to use his right arm. When we hire a new nurse, they are expected to have the knowledge of rotation of injection sites when administering injections."
VIOLATION: BLOOD TRANSFUSIONS AND IV MEDICATIONS Tag No: A0409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, it was determined that for 1 of 3 (Pt #10) clinical records reviewed for blood transfusions, the Hospital failed to ensure the blood was infused, as required.

Findings include:

1. The Hospital's policy entitled, "Blood Component Therapy," (effective August 18, 2017) required, "...Initiation of Blood...2. Verify physician order for transfusion...."

2. The clinical record of Pt #10 was reviewed on 5/10/2018 at approximately 11:45 AM. Pt #10 was a newborn male admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]'s order dated 8/14/17, which required that Pt #10 receive 37 cc's of blood over 2 hours. However, Pt #10's clinical record contained documentation that the blood was transfused from 4:02 PM on 8/14/17 to 7:05 PM on 8/14/17 (3 hours), not the required 2 hours.

3. The Associated Chief Nursing Officer (E #3) stated, during an interview on 5/10/18 at 11:45 AM, that the patient received the blood over 3 hours and not the required 2 hours.