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 April 12, 2019
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 (Pt. #4) patients reviewed for long waiting time in the Emergency Department, the Hospital failed to ensure the reassessment of patient was done while the patient was in the triage waiting area.

Findings include:

1. The clinical record of Pt #4 was reviewed on 04/09/19. Pt #4 was a [AGE] year old male who (MDS) dated [DATE] at 5:38 PM, with chief complaints of headache, dizziness and chest pain. Pt #4 signed out Against Medical Advice (AMA) while waiting in the Triage area on 12/05/18 at 10:59 PM.

-The Triage Plan notes dated 12/05/18 at 5:33 PM included, "ESI (Emergency Service Index) (triage categorization) score of 3 (ESI Scoring: 1-Resuscitative; 2-Immediate; 3-Urgent; 4-Stable; 5-Non-Urgent). Pain score: 0 (zero)."

-The vital signs notes by Registered Nurse (E #4) dated 12/05/18, included, "Blood pressure at 5:32 PM: 211/111 (normal 120/80); at 9:34 PM: 166/93; and at 9:35 PM: 180/92." The total duration lapsed from re-assessing Pt. #4's condition is 4 hours and 2 minutes.

2. On 04/09/19 at approximately 12:30 PM, the Hospital policy titled, "Triage and Admission to the Emergency Department" (effective 10/25/18) was reviewed. The policy included, "There will be a trained Triage Nurse assigned 24-hours a day ...Patients in the waiting room will be reassessed as conditions warrants or a minimum of at least once every 120 minutes. Reassessments will be documented on the patient's medical record."

3. On 04/09/19 at approximately 3:00 PM, an interview was conducted with the Registered Nurse (E #4). E #4 stated, "Patient (Pt. #4) was in the waiting area. We did all of his laboratory work up and was waiting for the results. We did not administer any blood pressure medications for him (Pt. #4) while waiting in the Triage area. I did not check his vital signs every 2 hours. Initial vital signs were obtained at 5:32 PM and later at 9:34 PM." Upon asking the reason for not administering blood pressure medications, E #4 stated, "Probably, we were busy and did not have any ED beds. Normally, when patients are in the waiting area we do not administer any medications. His (Pt. #4's) ESI level was 3. He (Pt. #4) signed out AMA at 10:59 PM."

4. On 04/11/19 at approximately 8:45 AM, an interview was conducted with ED - Nurse Supervisor (E #12). E #12 stated, "Patient's (Pt. #4's) wife was upset that, he did not have an ED bed. I am not sure who told her that it could cause a stroke. There were lots of patients in the ED with higher acuity." Upon asking about the reassessment of patients in the Triage waiting area, E #12 stated, "This patient (Pt. #4) should have been reassessed for his vital signs in two hours. Because, we want to make sure about the condition of the patient (Pt. #4) especially with his blood pressure being high."
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, document review and interview it was determined for 1 of 1 (Pt. #9) patient reviewed for wound management with a suction drain, the Hospital failed to ensure that the infection control practices were followed.

Findings include:

1. On 04/09/19 between 2:00 PM - 3:00 PM, an observational tour of 3 Main Telemetry Unit was conducted. During the tour the wound negative pressure drainage was seen left on the floor in the Room #378 (Pt. #9).

2. The clinical record of Pt. #9 was reviewed on 04/10/19. Pt. #9 was [AGE] year old male admitted on [DATE] at 7:56 PM with a diagnosis of lethargy. Pt. #9 was admitted from ED to Room #378 and was on contact isolation for MRSA (Methicillin Resistant Staphylococcus Aureus) wound to right leg. The right leg wound was connected to the wound negative pressure drainage.

3. On 04/10/19 at approximately 2:10 PM an interview was conducted with the Charge Nurse (E #14). E #14 stated, "The wound negative pressure drainage should not be left on the floor. I am not sure who left it on the floor. Patient (Pt. #9) is ambulatory."

4. On 04/10/19 at approximately 2:15 PM, an interview was conducted with the Wound Care Nurse (E #13). E #13 stated, "I am so sorry, this wound vacuum negative pressure drainage machine should have been hooked to the pole. If it is on the floor it causes contamination, also if patient walks to the bathroom it can cause trip hazard."