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.
|OSF SAINT ANTHONY MEDICAL CENTER||5666 EAST STATE STREET ROCKFORD, IL 61108||July 3, 2018|
|VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES||Tag No: A0749|
|A. Based on document review, observation and interview, it was determined that for 1 of 1 Physician (MD #1) and 1 of 1 visitor (Z #3) reviewed for PPE (personal protective equipment), the Hospital failed to ensure that PPE was worn in contact isolation rooms. This failure has the potential to cause cross contamination with the 14 patients on the Neurological Trauma Intensive Care Unit (NTICU) and 37 patients on the 3 East (3E) Telemetry Unit.
1. The Facility's policy entitled, "[Name of Facility] Isolation and Transmission-Based Precautions" (revised 3/18) was reviewed and included "...Visitors, including family, are expected to follow the isolation and transmission-based precautions before entering the room..."
2. The Facility's policy entitled, "[Name of Facility] Contact Precautions" (revised 8/17) was reviewed and included "...Put on gown and gloves before entering the patient's room to comply with contact precautions. Instruct visitors to do the same..."
3. On 7/2/18 between 10:20 AM and 10:50 AM, an observational tour was conducted on the NTICU. On 7/2/18 at approximately 10:30 AM, a visitor (Z #3) was observed sitting in Pt #3's isolation room without wearing any PPE. Pt #3 was in contact isolation for MRSA (methicillin resistant staphylococcus aureus) infection.
4. On 7/2/18 between 11:10 and 11:30 AM, an observational tour was conducted on the 3E Telemetry Unit. MD #1 was observed carrying an isolation gown into Pt # 2's isolation room. MD #1 put the isolation gown on after he entered Pt #2's room as he stood at the foot of Pt #2's bed. Pt #2 was in contact isolation for MRSA.
5. On 7/2/18 at approximately 10:55 AM, an interview was conducted with the NTICU Unit Manager ( E #6). E #6 stated that visitors need to wear PPE in Pt #3's isolation room.
6. On 7/2/18 at approximately 11:40 AM, an interview was conducted with the Chief Medical Officer (MD #2). MD #2 said that MD #1 should have put the isolation gown on prior to entering the isolation room.
B. Based on document review, observation and interview, it was determined that for 1 of 1 Registered Nurse ( E#1) observed for cleaning the multiple patient use blood glucose monitor (BGM) machine, the Hospital failed to ensure that the multiple patient use BGM machine was cleaned and disinfected according to policy. This failure has the potential to affect 37 patients on the 3E telemetry unit by causing cross contamination of microorganisms from the BGM machine.
1. The Facility's policy entitled, "[Name of Facility] Glucose in Whole Blood Accu-Check Inform II System" (revised 1/18) was reviewed and included "...Allow bleach to dry for 3 minutes on the glucose monitor...Super sani cloth solution needs to remain wet for 2 minutes..."
2. On 7/2/18 between 11:10 AM and 11:30 AM, an observational tour was conducted on the 3E telemetry unit. On 7/2/18 at approximately 11:25 AM, E #1 was observed cleaning a multiple patient use BGM. E #1 cleaned the BGM and placed the BGM in the container immediately after wiping the BGM for 20 seconds.
3. On 7/2/18 at approximately 11:45 AM, an interview was conducted with the Registered Nurse ( E #2). E #2 stated that the process of cleaning/disinfecting the BGM is to wipe the machine for 30 seconds and allow the BGM to sit and dry for 1 minute.
|VIOLATION: RN SUPERVISION OF NURSING CARE||Tag No: A0395|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on document review and interview, it was determined that for 1 of 2 patients (Pt. #4) reviewed for blood glucose monitoring, the Hospital failed to ensure that blood glucose monitoring was performed as ordered by the Physician. This failure potentially put Pt. #4 at risk for severe [DIAGNOSES REDACTED] (low blood glucose).
1. The Hospital's policy titled, "Lippincott Procedures - Blood Glucose Monitoring" (revised May 18, 2018) was reviewed on 7/3/18 at 10:17 AM. The policy included, " ...Introduction ...The American diabetes Association now defines clinically ...severe [DIAGNOSES REDACTED] as glucose values less than 54 mg/dl [milligrams/deciliter] accompanied by severe cognitive impairment. A plan for preventing and treating [DIAGNOSES REDACTED] should be established for each patient ...Implementation [*]Verify the practitioner's order ..."
2. On 7/2/18 at approximately 11:39 AM, Pt #4's medical record was reviewed. Pt. #4 was a [AGE] year old female admitted with the diagnoses of [DIAGNOSES REDACTED]] ulcer of [the] calf. Pt. #4's Physician order dated 7/2/18 at 6:36 AM included, "Perform POC [point of care] blood glucose ...Routine, every hour, first occurrence on Mon [Monday] 7/2/18 at 0700 [7:00 AM] ..." Pt. #4's laboratory testing records dated 7/2/18 included blood glucose monitoring on 7/2/18 at 7:08 AM with results of 98 mg/dl and 7/2/18 at 9:44 AM with results of 45 mg/dl. Pt. #4's blood glucose monitoring was performed 2 hours and 36 minutes apart and not every hour as ordered.
3. An interview was conducted on 7/2/18 at approximately 11:45 AM, with the Critical Care Clinical Nurse Manager (E #3). E #3 stated that Pt. #4's blood glucose should have been monitored every hour as ordered.
|VIOLATION: INFECTION CONTROL||Tag No: A0747|
|Based on document review, observation, and interview, it was determined that the Hospital failed to ensure adherence to infection control practices, to help prevent cross contamination and spread of diseases. As a result, it was determined that the Condition of Participation, 42 CFR 482.42, Infection Control, was not in compliance.
1. The Hospital failed to ensure adherence to infection control practices (A 749-A).
2. The Hospital failed to ensure the multiple patient use BGM machine was cleaned and disinfected according to policy (A 749-B).