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.

LORETTO HOSPITAL 645 SOUTH CENTRAL AVE CHICAGO, IL 60644 Jan. 31, 2018
VIOLATION: NURSING SERVICES Tag No: A0385
Based on document review and interview, it was determined that the Hospital failed to ensure well organized nursing services to include adequate staffing, proper certifications and competencies, and evaluations as required. This potentially affected all patients presenting to the Hospital. As a result, the Condition of Participation 42 CFR 482.23, Nursing Services, was not met.

Findings include:

1. The Hospital failed to ensure the Emergency Department (ED) and Critical Care Unit (CCU) were staffed according to the department standard of operating procedures. See deficiency cited at A-392 A.

2. The Hospital failed to ensure all staff completed yearly competencies and certification requirements according to the job description. See deficiency cited at A-392 B.

3. The Hospital failed to ensure all yearly staff performance evaluations were conducted. See deficiency cited at A-392 C.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
A. Based on document review and interview, it was determined that for 2 of 2 patient care units sampled, (Emergency Department and Critical Care Unit), the Hospital failed to ensure the units were staffed according to the department standard of operating procedures, staffing requirement and stated practice. This potentially affected all patients presenting to these areas.

Findings include:

1. The Hospital's "Emergency Services Standard Operating Procedures and Scope of Practices" (12/17), required, "F. Staffing Structure...Emergency Services is staffed in accordance with the staffing plan...Staffing plan as follows: 7a-7p: 4 RN, 2 PCT; 7p-7a: 4RN, 2 PCT." (For both AM and PM shifts)

2. The staffing for the Emergency Department (ED) for 12/10/17-12/23/17 day and night shifts was reviewed and the following shifts were not fully staffed:

-On 12/11/17, for the 7:00 PM to 7:00 AM night shift, 3 RN's (Registered Nurse) started at 7:00 PM and the 4th RN did not start until 1:30 AM on 12/12/17 (short staffed by 1 RN for 5 and 1/2 hours, from 7:00 PM to 1:30 AM).

-On 12/13/17, for the 7:00 PM to 7:00 AM night shift, the 4th RN did not start until 11:00 PM (short staffed by 1 RN for 4 hours).

3. The above findings were discussed with the Director of Emergency Services, during an interview on 1/26/18, at approximately 11:48 AM, who stated that the standard staffing for the Emergency Department is 4 registered nurses for each day and night shift.

4. The Staffing grid and acuity tools for the CCU was requested on 1/30/18` at approximately 11:30 AM. The Director of CCU/Telemetry (E #16) stated that there were no staffing grids or acuity tools for the CCU. E #16 stated that the practice for staffing the CCU is 2 patients to 1 RN.

5. The Critical Care Unit (CCU) Staffing for 12/10/17-12/25/17 and 1/21/18-1/30/18 were reviewed on 1/30/18 and the following shift staff shortages were found:

-12/11/17 and 12/13/17, day shift, - 7 patients- 2 CCU registered nurses (RNs) with one of the nurses assigned as a charge Nurse (a ratio of 3.56 patients to 1 RN).
-12/17/17, day shift - 9 patients, 2 CCU RNs and one (1) Medical Surgical/Telemetry RN (a ratio of 3 patients to 1 RN).
-12/22/17, day shift - 8 patients, 3 RNs (a ratio of 2.66 patients to 1 RN)
-1/23/18, day shift - 8 patients, 2 CCU RNs (a ratio of 4 patients to 1 RN); night shift, 8 patients, 3 RNs (a ratio of 2.66 patients to 1 RN).

6. The Director of CCU/Telemetry (E #16) was interviewed on 1/30/18 at approximately 11:30 AM. E #16 stated that the unit should be staffed with 1 nurse for 2 patients. E #16 stated that a ratio of 2 patients to 1 RN is desirable and if the patient needs more care it could be increased to 1 patient to 1 RN. However, E #16 stated there is no staffing grid or acuity tool to base the staffing for the unit. E #16 stated that there have been many days when the unit was short staffed.

7. The Director of Quality (E #4) was interviewed on 1/30/18 at approximately 2:00 PM. E #4 stated that CCU should be staffed with 1 nurse to 2 patients.

8. The Chief Nursing Officer (E #8) was interviewed on 1/30/18 at approximately 3:00 PM. E #8 stated she has only been with the Hospital for 2 weeks and identified that the various departments including CCU, did not have staffing grids and acuity tools to determine appropriate staffing. E #8 stated that she has met with the various department heads and is creating staffing grids and acuity tools to determine appropriate staffing for each department.


B. Based on document review and interview, it was determined that for 8 of 8 (E #1, 2, 3, 5, 6, 7, 9, &10) sampled ED registered nurses' (RN) personnel files reviewed, the Hospital failed to ensure staff completed all yearly competencies and certification requirements according to the job description. This potentially affected all patients to which these nurses were assigned.

Findings include:

1. The Job Description for the Emergency Services, Registered Nurse (created 9/23/16), required, "Essential Duties and Responsibilities...Demonstrates ongoing competency in clinical skills and complete the ED competency skills on an annual basis... Job requirements: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirement listed must be representative of the knowledge, skills, minimum education, training, licensure, experience, and/or ability required...CPR (cardiopulmonary resuscitation), ACLS (Advance Cardiac Life Support), PALS (Pediatric Advanced Life Support) certification required... CPI (Crisis Prevention Institute), Team Restraints certification within 6 months of hire...."

2. Eight (8) ED registered nurses' personnel files were reviewed on 1/26/18 with the Chief of Human Resource Officer (E #15), between 2:00 PM and 3:00 PM and the following was found:

-Six (6) of 8 (E #1, 2, 3, 5, 6, & 7) RN personnel files lacked Emergency Department specific competencies.
-One RN file (E #5) lacked current CPR, ACLS and PALS certification and training.
-RN's (E #9 and #10) lacked documentation of CPI training.
-RN's (E # 3 and #7) had no current CPI training. The last certification expired in August 2017.

3. The above findings were discussed with the Director of Quality (E #4) and the Chief Human Resource Officer (E #15) during an interview on 1/26/18 at approximately 3:00 PM. E #4 stated that the ED specific competency is "fractured" indicating that parts of the competency such as EKG (electrocardiogram) and blood transfusion may be done but that there was no comprehensive ED competency. E #15 stated that current CPR, ACLS, PALS, and CPI training are required for all ED nurses.

C. Based on document review and interview, it was determined that for 6 of 11 (E #1, 2, 5, 7, 17, & 18) mixed personnel files reviewed (8 RNs and 3 PCTs), the Hospital failed to ensure all yearly staff performance evaluations were conducted as required.

Findings include:

1. The Hospital policy titled, "Performance Evaluations" (rev 12/16) required, "Employees shall receive an evaluation on job performance on a regular and a consistent basis, but not less than annually."

2. The personnel files for 11 staff (8 RNs and 3 PCTs) were reviewed on 1/26/18. There were no performance evaluations for 4 RNs (E #1, 2, 7, and 5) and 2 PCTs (E#17 and 18) for 2017, and the last evaluations were as follows:

-E #1 a RN, was last evaluated on 11/2016
-E #2 a RN, #7 a RN, and # 18 a PCT, were last evaluated in June 2016.
-E #17, a PCT was last evaluated in 2015.
-E #5's file, a RN, did not contain an evaluation.

3. The above findings were discussed with the Chief Human Resource Officer (E #15) during an interview on 1/26/18 at approximately 3:00 PM. E #15 stated all staff should have a yearly performance evaluation, but E #15 could not find current evaluations for the above staff.
VIOLATION: EMERGENCY SERVICES Tag No: A1100
Based on document review and interview, it was determined that for 1 of 1 (Pt. #1) clinical record reviewed of a pregnant patient with a stat (immediately) ultrasound order, the Hospital failed to ensure the ultrasound was completed in a timely manner. Subsequently, the patient died . As a result, it was determined that the Condition of Participation for Emergency Services was not met. This potentially affects all patients presenting to the ED, needing stat ultrasound.

Findings include:

The Hospital failed to ensure that a patient's stat ultrasound order was completed in a timely manner. Subsequently, the patient died . (Refer to deficiency at A-1103)

The immediate jeopardy (IJ) began on 12/12/17 when Pt. #1 was admitted for pregnancy and vomiting. The Hospital failed to complete a stat ultrasound in a timely manner. Pt. #1's clinical record included the following: the stat ultrasound order was written at 3:37 AM; the ultrasound technician was at the bedside preparing to do the ultrasound at 7:25 AM; and the ultrasound results were transcribed 12/12/17 at 9:16 AM (approximately 5 hours 45 minutes after ordered). Subsequently, Pt. #1 died . In addition, the Hospital failed to fully investigate, fully implement corrective actions, and evaluate corrective actions in a timely manner.

An IJ was identified and announced on 1/31/18 at 9:15 AM, during a meeting, with the Chief Executive Officer (CEO), Chief Experience Officer, Chief Nursing Officer, Director of Quality, and Family Nurse Practitioner. The immediate jeopardy was not removed by the survey exit date of 1/31/18. No corrective actions were initiated until 1/24/18.
VIOLATION: INTEGRATION OF EMERGENCY SERVICES Tag No: A1103
**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. #1) clinical record reviewed of a pregnant patient with a stat ultrasound ordered, the Hospital failed to ensure the ultrasound was completed in a timely manner.

Findings include:

1. On 1/26/18 at approximately 2:00 PM, the Hospital's Memorandum from E #13 (Director of Diagnostic Imaging) dated 1/17/12 was reviewed and indicated, "...Ultrasound and Nuclear Medicine Procedures: The ED will call the department to inform the appropriate staff members of the required exams..."

2. On 1/26/18 at approximately 4:00 PM, the Hospital's "Diagnostic Imaging Department Guidelines" dated 8/10/11 were reviewed and indicated, "STAT/ED Procedures: In order to appropriately respond to critical patient situations, the Radiology staff will respond to all STAT exams within 30 minutes: The Nursing units are being reminded to call Radiology when STAT/ED exams are ordered. (The guideline did not include a timeline for physician notification of results).

3. On 1/25/18 at approximately 12:00 PM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a [AGE] year old female who came to the ED on 12/12/17 at 12:37 AM for pregnancy, vomiting and abdominal pain. The clinical record indicated that Pt. #1 was seen by MD #1 (ED Attending Physician) at 12: 50 AM, and had an order for a stat ultrasound written at 3:37 AM. At 4:15 AM, the ED nurse (E#1) documented that the ultrasound technician was contacted. At 7:25 AM, it was documented that the ultrasound technician was at the bedside preparing to do the ultrasound. The ultrasound results with a transcribed date of 12/12/17 at 9:16 AM indicated, "...Impression: live right-sided [DIAGNOSES REDACTED] [fertilized egg implants outside of uterus], gestational age approximately 14 weeks and 6 days and Hemoperitoneum [blood in the space that lines the abdominal-pelvic cavity] ... spoke with (MD #1/ED Attending Physician) in the emergency room notifying her of the findings at the time of the examination report." On 12/12/17 between 8:30 AM and 11:26 AM, Pt. #1 received 4 units of packed red blood cells and a unit of fresh frozen plasma for a hemoglobin (oxygen carrying pigment of red blood cell) of 5.6 mg/dL [normal hemoglobin in pregnancy is above 10.5 mg/dL). At 1:10 PM, Pt. #1 was taken to the OR, Pre-op Diagnosis R (right) [DIAGNOSES REDACTED], Post-op Diagnosis: R (right) ... [DIAGNOSES REDACTED]. Procedures: 1. Laparotomy, removal of Hemoperitoneum, 2. Removal R [DIAGNOSES REDACTED]. Pt. #1 was transferred to CCU, and expired at 3:10 PM.

4. On 1/25/18 at approximately 2:16 PM and 1/26/18 between 10:00 AM and 3:00 PM, intermittent interviews were conducted with E #4 (Director of Quality). E #4 stated that a root-cause analysis was started on 12/13/17, and based on their investigation, found there was a delay in the patient care regarding completion of the ultrasound. E #4 explained that on 12/12/17, an ultrasound was ordered at approximately 3:39 AM; however, the on-call technologist was not notified until 5:56 AM and that the ultrasound was not completed until 7:30 AM. (1.5 hours response time instead of 30 minutes as required by the Guidelines). E #4 said that as of 1/25/18, the Hospital has a "STAT Policy", which includes the Diagnostic Imaging Hospital Guidelines procedure on ultrasound orders.

5. On 1/25/18 at approximately 5:12 PM, 1/26/18 between 12:00 PM and 3:00 PM, and on 1/31/18 at approximately 9:00 AM, intermittent interviews were conducted with E #11 (Director of Emergency Department). E #11 said, "The ED staff were calling the on-call ultrasound technicians rather than the radiology department to notify the on-call technician, and were not following the guidelines for ultrasound orders. At the time of Pt. #1's incident, E #11 said that the Hospital did not really have a policy and procedure for staff to follow regarding ultrasound orders. In regards to reconciliation of the discrepancy between E#1's (Pt. #1's ED RN) documentation that the on-call technician was contacted (4:15 AM) and the ED phone log that indicated the on-call technologist was contacted at (5:56 AM), E #11 stated that the Hospital has not completed its full investigation. Regarding the STAT policy, it included a signature date of 01/25/18, and the E #11 said that the staff education for this policy was started on 1/25/18 (day of the survey).

6. On 1/26/18 at approximately 7:15 AM, an interview was conducted with E #1 (Pt. #1's ED RN). When asked regarding his documentation on 12/12/17 at 4:15 AM and the stat ultrasound order, E #1 said, "I talked to (E #12) and told him that he needed to come as soon as possible ... I was expecting within an hour ..." When asked if he (E #1) called the Radiology Department, E#1 stated that he did not call the Radiology Department.

7. On 1/26/18 at approximately 10:30 AM, an interview was conducted with E #13 (Director of Diagnostic Imaging). E #13 presented and explained the ED call logs that were made from the ED to the on-call ultrasound technician (E #12) on 12/12/17. E #13 said that based on the ED call log, the call was made to E #12 at 5:56 AM. (2.5 hours after the stat ultrasound was ordered). A technician did not respond until almost 1.5 hours after being notified of the stat request. E #13 stated that there is no current data for January 2018, to track if there's any delay in the completion of Radiology Department's tests ordered in the ED. E #13 said, "I usually look at the data at the end of the month."