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.

JACKSON PARK HOSPITAL 7531 S STONY ISLAND AVE CHICAGO, IL 60649 June 7, 2018
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

A. Based on document review and interview, it was determined that for 2 of 2 (Pt #1 and Pt #2) patients on the 3 East Medical Unit (3 East) with indwelling urinary catheters (Foleys), the Hospital failed to ensure there were physicians' orders for the catheters; documentation of the date and time of Foley insertion; and the ongoing need for the catheters were reviewed daily to ensure removal of the Foleys as soon as possible.

Findings include:

1. The Hospital's policy titled, "Indwelling Foley Catheterization" (revised 06/2006) was reviewed on 6/6/18 and required, "...A physician order must be obtained before catheterization is done..."

2. The Daily Surveillance - Prevention of CAUTI's (Catheter Acquired Urinary Tract Infections) sheet, dated 6/5/18, was reviewed on 6/5/18 at approximately 1:00 PM and lacked documentation of the indication and ongoing need for the Foleys for Pt #1 and Pt #2.

3. The clinical record for Pt #1 was reviewed on 6/5/18 at approximately 11:30 AM. Pt #1 was a [AGE] year old female, admitted on [DATE], with diagnoses of hematuria (blood in the urine) and altered mental status. The physician's order, dated 6/1/18, included, "Insert Foley Catheter". The order did not include the indication for the Foley. Pt #1's daily assessment, dated and timed 6/2/18 at 8:58 PM, included, "Uninary Elimination: Continent; Urine Appearance: Clear; Urine Color: Yellow to Amber." Pt #1's daily assessments, dated and timed 6/3/18 at 7:00 AM and 6/4/18 at 8:00 PM, included, "Urinary Devices: Foley Catheter; Urine Appearance: Clear; Urine color: Yellow to Amber." The nurses' notes did not include documentation of the Foley insertion date and time, or the indication for the catheter insertion. Pt #1's clinical record also lacked documentation of the review of the continuing need for the catheter to ensure catheter removal at the earliest time indicated.

4. The clinical record for Pt #2 was reviewed on 6/5/18 at approximately 11:40 AM. Pt #2 was a [AGE] year old female, admitted on [DATE], with a diagnosis of altered mental status. The nurse's progress note on admission, at 6:19 AM, included, "A [AGE] year old female was brought into the unit from the ER [emergency room ]...Pt is ambulatory with assist, incontinent of bladder (has foley)..." The emergency room Report Form, dated 6/5/18, lacked documentation of the insertion or presence of a Foley catheter in Pt #2 at the time of transfer from the ER to Pt #2's admission on 3 East. Pt #2's clinical record lacked a physician's order for a Foley. Pt #2's clinical record lacked documentation of the review of the need for the catheter to ensure catheter removal at the earliest time indicated.

5. On 6/5/18 at approximately 11:50 AM, an interview was conducted with the Registered Nurse (RN) (E #6) who was assigned to both Pt #1 and Pt #2 on 6/5/18 from 7:00 AM-3:00 PM. E #6 stated that he did not know why Pt #1 or Pt #2 had Foley catheters. E #6 stated that the need for catheters was not reviewed during shift report from previous shift RN. E #6 stated that he did not know the Foley insertion date, time, or person who inserted the Foley for Pt #1 or Pt #2.

6. During an interview with the Infection Control Nurse (E #3) on 6/5/18 at approximately 12:00 PM, E #3 stated that there should be a physician's order for a Foley, and the indication for continued need for the Foley should be documented and reviewed daily.

B. Based on document review, observation, and interview, it was determined that for 2 of 2 (E #4 and E #5) staff observed performing point-of-care blood glucose testing, the Hospital failed to ensure the the blood glucose meters were cleaned and disinfected after every use.

Findings include:

1. On 6/5/18 at approximately 2:25 PM, the Hospital's policy titled, "Bedside Blood Glucose Precision Xceed Pro Blood Glucose and Ketone Monitoring" (revised 12/2013) was reviewed and required, "...Whenever contaminated the glucometer is to be cleaned with an antiseptic wipe...Between patients the glucometer meter is to be cleaned with an antiseptic wipe..."

2. On 6/5/18 between approximately 11:00 AM and 11:30 AM, tours were conducted of the 3 South Medical Unit and the 3 East Medical Unit. At 11:00 AM, on the 3 South Medical Unit, E #4 (RN-Registered Nurse) was observed checking the blood sugar of Pt #3. Pt #3 was a [AGE] year old male, admitted on [DATE], with diagnoses of acute asthma and hyperglycemia due to diabetes melitus. After using the glucometer to check Pt #3's blood sugar, E #2 returned the glucometer to its storage case, which holds the glucometer and other testing supplies, without disinfecting the glucometer. E #2 then returned the storage case to the nurses' station where the glucometer was available for use on other patients. At 11:10 AM, on the 3 East Medical Unit, E #5 (RN) was observed checking the blood sugar of Pt #4. Pt #4 was a [AGE] year old male, admitted on [DATE] with diagnoses of aggressive behavior and right knee pain. After using the glucometer to check Pt #4's blood suger, E #5 failed to disinfect the glucometer prior to returning it to its storage case.

3. On 6/5/18 at approximately 11:20 AM, an interview was conducted with the Infection Control Nurse (E #3). E #3 stated that the glucometers should have been disinfected after use and before returning the glucometers to their storage cases.