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.
|ROSELAND COMMUNITY HOSPITAL||45 W 111TH STREET CHICAGO, IL 60628||June 26, 2019|
|VIOLATION: PATIENT RIGHTS: EXERCISE OF RIGHTS||Tag No: A0129|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on document review and interview, it was determined that for 1 of 2 complaints reviewed, the Hospital failed to ensure that the patient/patient representative had the right to make decisions regarding patient care.
1. The Hospital's policy titled, "Patient Rights/Grievance Process" (revised 03/18), was reviewed on 6/26/19 and required, "...the patient has... the right to participate in the development and implementation of his or her plan of care... Or his or her representative... has the right to make informed decisions regarding his or her care... The patient's rights include... being involved in care planning and treatment, and being able to request or refuse treatment..."
2. The clinical record of Pt. #3 was reviewed on 6/26/19. Pt. #3 was a [AGE] year old female, admitted on [DATE], with diagnoses of acute respiratory failure and pneumonia (infection of the lungs). Pt. #3 expired on [DATE], at approximately 2:12 AM, due to cardiorespiratory failure. Nursing notes and flowsheets indicated that a Registered Nurse (E#6) provided nursing care to Pt. #3 on 5/3/19, 5/4/19, and 5/5/19 from 7:00 AM to 7:00 PM.
3. The Patient Advocate/Navigator Complaint Log Tool for Pt. #3 was reviewed on 6/26/19 and included, "On Friday May 3, 2019 [Pt. #3's] patient's son experience[d] rude treatment from [E#6] ICU [Intensive Care Unit] Nurse that was taking care of his mom [Pt. #3]... [Pt. #3's son] also stated while [E#6] was attending to his mom he noticed that she [E#6] was not gentle with her [Pt. #3] at all... [Pt. #3's son] asked that [E#6] be replaced as his mom's nurse. His request was honored for that day. When [Pt. #3's son] returned on May 4, 2019 [E#6] was again the residing nurse which made [Pt. #3's son] very upset because of his request to have [E#6] removed as his mom's nurse. Charge nurse made changes and provide[d] the patient with a different nurse..."
4. The Intensive Care Unit (ICU) Daily Staff Schedule and Staff Assignments from 4/29/19 to 5/7/19 were reviewed on 6/26/19 and indicated that E#6 was assigned to work with Pt. #3 on 5/3/19, 5/4/19, and 5/5/19 from 7:00 AM to 7:00 PM.
5. A telephone interview was conducted with the Registered Nurse (E#6) on 6/27/19, at approximately 8:05 AM. E#6 stated that she was made aware that Pt. #3's son/primary caregiver had made a complaint about E#6 and had requested a new nurse. E#6 stated that she was asked if she wanted to change assignments but stated that she [E#6] was "confident that she did nothing wrong" and "I wanted to keep my assignment." E#6 stated that she was never taken off Pt. #3's care.
6. An interview was conducted with the ICU Unit Manager (E#12) on 6/27/19, at approximately 9:47 AM. E#12 stated that E#6 should have been taken off the care of Pt. #3, as requested by the patient's son. E#12 stated that typically the Charge Nurse makes the staffing assignments for each shift; however, E#12 stated that in this case the Unit Manager or House Supervisor (when the Unit Manager is not present) should have confirmed that the assignment change was made.
|VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING||Tag No: A0144|
|Based on document review and interview, it was determined that for 1 of 2 Intensive Care Unit (ICU) personnel files (E#20) reviewed, the Hospital failed to ensure that staff working with critical care patients had up-to-date Advanced Cardiac Life Support (ACLS) training as required.
1. The Hospital's policy titled, "Cardiopulmonary Resuscitation (CPR)" (last reviewed by Hospital 04/19), was reviewed on 6/27/19 and required, "Critical Care Nurses (ED [Emergency Department), ICU [Intensive Care Unit] & Telemetry) are required to be ACLS certified within the first year of employment and maintain certification ..."
2. The personnel file of a Registered Nurse (E#20) was reviewed on 6/27/19 and indicated that E#20 was hired to work in the ICU on 9/15/2008. The ACLS certification on file had an expiration date of April 2019.
3. E#20's Timecard report from 5/1/19 to 6/22/19 was reviewed on 6/27/19 and indicated that E#20 worked a total seventeen 12-hour shifts in the ICU on the following dates: 5/3/19-5/5/19, 5/8/19, 5/9/19, 5/13/19, 5/14/19, 5/17/19-5/19/19, 5/22/19, 5/23/19, 5/27/19, 5/28/19, 5/31/19, 6/5/19, and 6/6/19.
4. An interview was conducted with the Manager of the Emergency Department (E#15) on 6/27/19, at approximately 12:45 PM. E#15 stated that a current ACLS certification could not be found for E#20. E#15 stated that E#20 had recently taken time off due to a sick relative and did not have time to complete the ACLS training.