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 8, 2020
VIOLATION: INFECTION CONTROL Tag No: A0747
Based on document review, observation, and interview, it was determined that the Hospital failed to prevent and/or contain COVID-19 by implementing an exposure surveillance plan for contracted employees and by following isolation guidelines to control the spread of COVID-19. This has the potential to affect the health and safety of 96 patients on census as of 6/2/2020.

As a result, it was determined that the Condition of Infection Control, CFR 482.42, for COVID-19 was not in compliance.

Findings include:

1. The Hospital failed to prevent and/or contain COVID-19 by ensuring that contracted employees were monitored and tracked for exposure as part of the infection prevention and control program. See deficiency at A-749 A.

2. The Hospital failed to ensure that isolation guidelines were followed to prevent and/or contain COVID-19 as part of the infection prevention and control program. See deficiency at A-749 B & C.
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
Based on document review, observation, and interview, it was determined that the Hospital failed to ensure confidentiality while disclosing a patient's (Pt #13) personal health information. This has the potential to affect the average 100 patients tested for COVID-19 daily at the Hospital.

Findings include:

1. The Hospital's Patients Rights and Responsibilities Statement (undated) was reviewed on 6/4/2020 and required, "...While you are a patient at the [Hospital], you have: E. The right to personal privacy. H. The right to the confidentiality of his or her clinical records..."

2. On 6/2/2020 at approximately 9:20 AM, a Registered Nurse (E#22) was observed giving positive COVID-19 results verbally to a patient (Pt #13) that was seated in the hallway, where the Hospital entrance screening was performed. There were 4 other patients nearby and other staff members walking past, within earshot.

3. On 6/3/2020 at 10:00 AM, an interview was conducted with the Assistant Director of Regulatory and Quality (E #17). E #17 stated that the nurse should not have given the patient test results in a non-private setting.
VIOLATION: INFECTION CONTROL OFFICER(S) Tag No: A0748
Based on document review and interview, it was determined that the Hospital failed to report patients with COVID-19 positive test results, to the local health department, which is required to ensure compliance with the infection prevention and control program for COVID-19.

Findings include:

1. The Hospital's policy titled, "Clinical Guidance for Managing COVID-19-Interim Guidelines" (dated 3/20/2020), was reviewed on 6/3/2020 and required, "...Reporting Persons with Suspected or Confirmed COVID-19 to Public Health: IDPH [Illinois Department of Public Health] receives positive test results directly from laboratories performing testing. However, providers should immediately report to the Illinois Department of Public Health..."

2. On 6/3/2020 at approximately 11:50 AM, the Infection Preventionist (E #4) provided email communication, dated 4/24/2020, that indicated the requirements for reporting COVID-19 results. The email included, "... send a cumulative file of positive/negative results for molecular/serology tests each day with all fields in the attached file..."

3. The Public Health Submissions Report (COVID-19 cases) was reviewed from 5/1/2020-6/2/2020. The Report lacked daily submission of COVID-19 results on 14 of 31 days in May 2020: (5/2, 5/3, 5/4, 5/9, 5/10, 5/11, 5/16, 5/17, 5/21, 5/23, 5/24, 5/25, 5/30, and 5/31).

4. On 6/2/2020 at approximately 1:40 PM, an interview was conducted with E #4. E #4 stated that COVID-19 test results should be reported daily to the health department. E #4 stated that E #4 is the only Infection Control Nurse, therefore on her days off, there is no one that is in the Hospital to report them.

5. On 6/4/2020 at approximately 1:30 PM, the Chief Nursing Officer (E #1) stated that it is a requirement that the COVID-19 test results are reported daily. E #1 stated there has to be a system put into place now that will allow for reporting when E #4 is off work.
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 the Hospital failed to prevent and/or contain COVID-19 by ensuring that contracted employees were monitored and tracked for exposure as part of the infection prevention and control program for COVID-19. This has potential to expose and infect all 96 patients on census with COVID-19, as of 6/2/2020.

Findings include:

1. The Hospital's Policy titled, "COVID-19 - Interim Guidelines for Employee Health Services" (effective 3/27/2020), was reviewed on 6/3/2020 and required, "Persons staying at home because of confirmed or presumed COVID-19 infection should not attend work ... This guidance applies to any person, regardless of whether they have received a laboratory confirmed COVID-19 diagnosis, including healthcare workers. Employees of the [Hospital] must contact Employee Health Services before returning to work ... Return to Work Criteria for HCP [healthcare provider] with Confirmed or Suspected COVID-19. Use one of the below strategies to determine when HCP may return to work in healthcare settings: 1. Test-based strategy... [or]... 2. Non-test-based strategy ..."

2. The clinical record of an Anesthesiologist (MD#4), who was working at the hospital on [DATE], was reviewed on 6/3/2020. MD#4 presented to the ED (emergency department) on 4/1/2020 at 4:41 PM for weakness and syncope (sudden loss of consciousness). An ED Note on 4/1/2020 at 8:00 PM included, "Patient has labs resulting and denies any c/o [complaints] of pain or distress. Patient is trying to return to surgery and resume working." MD#4 was discharged home on 4/1/2020 at 10:30 PM. A note dated 4/5/2020 included, "Spoke to patient [MD#4], notified of positive COVID-19 test result, advised to quarantine for 14 days, and to follow up with his physician. BOH [Board of Health] notified."

3. The Hospital's 2020 Staff Surveillance Lists for COVID-19 Exposure were reviewed on 6/3/2020. The lists did not include the name of MD#4 who tested positive for COVID-19.

4. An interview was conducted with the Employee Health Nurse (E#3) on 6/2/2020, at approximately 2:38 PM, and again on 6/3/2020, at approximately 1:30 PM. E#3 stated that Hospital employees are tracked on a spreadsheet to indicate when they tested positive for COVID-19 and when they were cleared to return to work. E#3 stated that any employee that tests positive or is exhibiting symptoms of COVID-19 shall be taken off work and asked to stay home. E#3 was not familiar with MD#4. E#3 stated that she does not track physicians or other independent contractors. E#3 stated that the tracking lists provided only included staff who were directly employed by the Hospital. When asked how contracted employees were monitored, E#3 stated, "That's a good question ... I don't know the answer to that." E#3 stated that there are only 2 Employee Health Nurses, including herself and a back-up if E#3 is not available.

5. An interview was conducted with the Director of Quality (MD#3) on 6/3/2020, at approximately 1:37 PM. When asked about MD#4, MD#3 stated that MD#4 was an elderly physician who had collapsed about an hour after a procedure on 4/1/2020. MD#4 had tested positive for COVID-19. When asked how the Hospital tracks physicians and other independent contractors who test positive or exhibit signs and symptoms of COVID-19, MD#3 stated, "They should have been tracked by Employee Health."


B. Based on document review, observation, and interview, it was determined that for 2 of 4 COVID-19 positive patients (Pts. #9 and #10) on Intensive Care Unit/ICU, the Hospital failed to ensure that isolation signs were posted and that precautions orders were placed immediately to prevent and/or contain COVID-19 as part of the infection prevention and control program, potentially affecting the health of the 8 patients on the unit.

Findings include:

1. 1. The Hospital's policy titled, "Clinical Guidance for Managing COVID-19 - Interim Guidelines" (effective 3/20/2020), was reviewed on 6/2/2020 and required, "...per the newest CDC [Centers for Disease Control and Prevention] guidance, patients can be managed with droplet/contact precautions..."

2. The Hospital's policy titled, "Categories of Isolation" (last reviewed by Hospital 4/2017), was reviewed on 6/3/2020 and required, "...DROPLET PRECAUTIONS. E. SPECIFIC REQUIREMENTS: ... e. Door Signs... When isolation is initiated, the appropriate isolation sign shall be placed on the patient's door... Orders to initiate and discontinue isolation shall be given by a physician. In the event that isolation orders are not obtained upon admission, and the patient's signs and symptoms indicate a potentially contagious disease process, isolation may be initiated by the Chief Nursing Officer, House supervisor/administrator, charge nurse, team leader, or Infection Preventionist while waiting for orders from the attending physician..."

3. An observational tour of the Intensive Care Unit was conducted on 6/2/2020, at approximately 10:45 AM. There were 4 COVID-19 positive patients (Pts. #9-#12) on census in rooms #7-#10. At approximately 10:45 AM, the door of room #10 lacked a sign for droplet precautions.

4. The clinical records of Pts. #9-#12 were reviewed on 6/3/2020 at approximately 10:15 AM.

- Pt. #9 was admitted on [DATE] at 9:42 PM, with a diagnosis of unspecified pneumonia (lung infection), septicemia (bloodstream infection), and PUI (persons under investigation for COVID-19). Lab results, dated 5/29/2020, indicated that Pt. #9 had high levels of antibodies for COVID-19 (greater than 1 AU [Absorbance units] per milliliter), which indicated a high likelihood that Pt. #9 was positive/contagious for COVID-19. Pt. #9 did not have orders entered for contact or droplet precautions until 6/2/2020 at 11:41 AM (over 72 hours/3 days after admission).

- Pt. #10 was admitted on [DATE] at 9:18 PM, with a diagnosis of COVID-19 and pneumonia. Lab results, dated 5/31/2020, indicated that Pt. #10 was positive for COVID-19. The record lacked orders for contact or droplet precautions related to COVID-19.

5. An interview was conducted with the ICU Nurse Manager (E#5) on 6/2/2020, at approximately 10:45 AM. E#5 stated that all COVID-19 patients are on droplet and contact precautions. E#5 stated that the droplet sign must've fallen off room #10's door. E#5 was not able to find the sign.

6. An interview was conducted with the Acute Care Unit Charge Nurse (E#9) on 6/3/2020, at approximately 10:50 AM. E#9 stated that if COVID-19 is suspected or confirmed, isolation orders for droplet and contact precautions should be placed immediately. E#9 could not find COVID-19 isolation orders for Pt. #10 in the medical record.


C. Based on document review, observation, and interview, it was determined that for 1 of 1 Environmental Services (EVS) staff (E#6) observed, the Hospital failed to ensure that personal protective equipment (PPE) were changed and hand hygiene performed to prevent and/or contain COVID-19 as part of the infection prevention and control program, potentially affecting the health of all 96 patients on the Hospital's census on 6/2/2020.

Findings include:

1. The Hospital's policy titled, "Clinical Guidance for Managing COVID-19 - Interim Guidelines" (effective 3/20/2020), was reviewed on 6/2/2020 and required, "...per the newest CDC [Centers for Disease Control and Prevention] guidance, patients can be managed with droplet/contact precautions. PPE [personal protective equipment] includes facemask (procedure or surgical mask) AND gown AND gloves AND eye protection (goggles or face shield)... EVS [Environmental Services] personnel will wear all recommended PPE when in the room. PPE should be removed upon leaving the room, immediately followed by performance of hand hygiene."

2. An observational tour of the Intensive Care Unit was conducted on 6/2/2020, at approximately 10:45 AM. There were 4 COVID-19 positive patients on census in rooms #7-#10. At approximately 10:55 AM, a Housekeeper (E#6) entered each of the 4 COVID positive patient rooms to remove the garbage bags with the same gown and gloves. After E#6 left the COVID-19 positive patients' rooms, E#6 went into the common soiled utility room then walked through the whole unit. E#6 did not remove her gown until she exited the unit at approximately 11:00 AM. E#6 did not remove her gloves upon leaving the unit. No hand hygiene was performed by E#6.

3. An interview was conducted with the Infection Preventionist (E#4) on 6/2/2020, at approximately 1:56 PM. E#4 stated that staff should not be going in and out of isolation rooms, from patient to patient, with the same gown and gloves.


D. Based on document review, observation, and interview, it was determined that for 1 of 1 staff (E#8) observed performing a blood glucose check, the Hospital failed to ensure that equipment used on a patient was disinfected prior to returning it to a clean area as part of the infection control and prevention program.

Findings include:

1. The Hospital's policy titled, "Glucose Monitoring: Accu-Chek Inform II System" (revised 2/16/17), was reviewed on 6/3/2020 and required, "...The surface of the Accu-Chek Inform II screen and meter, including the communication window is cleaned with disinfectant wipes after each patient..."

2. An observational tour of the Intensive Care Unit was conducted on 6/2/2020, at approximately 10:45 AM. At approximately 11:30 AM, a Certified Nursing Assistant/CNA (E#8) checked the blood glucose of a patient in room #3. E#8 returned the blood glucose machine to the docking station without disinfecting it.

3. An interview was conducted with E#8 on 6/2/2020, at approximately 12:20 PM. E#8 stated that she usually disinfects the Accu-chek monitor with a PDI [alcohol] wipe after use, but she was in a hurry and wasn't sure if she did this time.
VIOLATION: EMERGENCY SERVICES Tag No: A1100
Based on record review and interview, it was determined that for 1 of 1 clinical record reviewed (Pt #1) for a pregnant patient who presented to the emergency department, the Hospital failed to provide a timely assessment and treatment to prevent serious harm or death. As a result, The Condition of Participation 42 CFR 482.55, Emergency Services, was not in compliance.


Findings include:

1. The Hospital failed to ensure that patients are assessed in triage upon arrival, and a MSE (medical screening exam) is conducted, to protect patients from serious harm or death. See deficiency at (A-1104).

The Immediate Jeopardy (IJ) was identified on 6/4/2020, at 42 CFR 482.55, Emergency Services, due to the Hospital's failure to ensure that a pregnant patient greater than 20 weeks gestation, was assessed, triaged, and provided a medical screening exam. Subsequently, Pt #1 died . The IJ was announced on 6/4/2020 at 3:20 PM during a meeting with the Chief Executive Officer, Chief Nursing Officer, Medical Staff President, Director of Quality, and the Director of Operations. The IJ was not removed by the survey exit date of 6/8/2020.
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
Based on document review and interview, it was determined that for 1 of 1 clinical record reviewed (Pt. #1) for a pregnant patient who presented to the Hospital's emergency department and expired on the Obstetrics and Gynecological Unit, the Hospital failed to ensure that the patient was triaged upon arrival and a MSE (medical screening exam) was conducted, to protect the patient from serious harm or death.

Findings include:

1. On 6/3/2020, the policy and procedure titled, "Triage Protocol." (revised 4/2017), was reviewed. The policy required, "Patient Sign-In ... 3. EMT [Emergency Medical Technician] ... will take the patient directly to the treatment area or to the triage area ... Triage ... 1. The triage staff will be notified of a patient arrival by ... the EMT ... 2. The triage staff will check all patients as soon as possible, obtain the chief complaint ..."

2. The Hospital's policy titled, "Medical Screening of OB Patients in the ED" (reviewed by Hospital on 4/17), was reviewed on 6/3/2020, and required, "Any pregnant patient that is equal to or greater than 20 weeks gestation that presents to the Emergency Department with a pregnancy related complaint including possible labor and/or a non-pregnancy related condition would have a medical screening in the Emergency Department..."

3. On 6/2/2020 at 11:45 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 arrived via ambulance to the ED on 5/15/2020, with a complaint of abdominal pain. The Chicago Fire Department (CFD) Record, dated 5/15/2020, indicated that the CFD was "called to the scene for the 30 week pregnant female [Pt. #1] complaining of feeling sick ... Patient was alert and oriented, ambulatory... ... At destination: 5/15/2020, 11:44 AM ... Transfer: 11:46 AM ..."

- Pt. #1 ' s triage note, dated 5/15/2020 at 2:54 PM, more than 3 hours after arrival, included, " ... Condition on arrival: Stable ... Stated complaint: Patient states she is 30 weeks pregnant. Complains of abdominal pain and states she feels dehydrated and general malaise [weakness]. Denies any bleeding or discharge ... Temperature 98.1 F, Blood Pressure 146/79 mm Hg, Pulse Rate 90, Respiratory Rate 18, and Oxygen Saturation 100%... Expected date of delivery 7/25/2020, Gravida 7, Para 3, Abortions 3 ... Triage Acuity Level: ESI 3 [emergency severity index urgent]"

- Pt #1's clinical record lacked an ED Medical Screening exam or subsequent ED documentation.

4. On 6/4/2020 at 9:50 AM, a phone interview was conducted with the Triage Nurse (E #14). E #14 stated that Pt. #1 was in the waiting room and E #14 did not know that Pt. #1 was transported by CFD or that Pt. #1 was pregnant. Pt. #1 was listed a having abdominal pain and there were patients with chest pain to be triaged before Pt. #1. "It was very busy." (The ED Log on 5/15/2020, lists 6 patients that arrived between 11:00 AM and 12:00 PM; including 1 with chest pain). E #14 stated Pt. #1 was not in distress, had no shortness of breath, and stable vital signs when Pt. #1 was triaged. E #14 transferred Pt. #1 to the Obstetric Unit, as per protocol.

5. On 6/4/2020 at 10:05 AM, a phone interview was conducted with the Charge Nurse (E #15). E #15 stated that EMS (Emergency Medical Services/CFD) told E #15 that Pt. #1 was approximately 30 weeks pregnant and complained of abdominal pain. The protocol required patients over 20 weeks pregnant to be sent to triage and E #15 told EMS to take Pt. #1 to triage. E #15 had no more encounters with Pt. #1.

6. Pt #1's clinical record included a nursing note, dated 5/15/2020 at 5:00 PM, in the Obstetrics Unit, which included, "Received Patient from the ER with complaint of abdominal pain, G7, P3, (3 AB) [7 pregnancies, 3 births, 3 abortions]. Intrauterine pregnancy at 30 weeks ... Denies previous medical or surgical history per ER report. Patient instructed to ambulate to the bathroom once contraction over to void and change clothing. Patient receptive/assisted to bathroom. Patient unable to void, complain of feeling pressure. Assisted with removing clothing/ gown on. Patient assisted back to bed. EFM [electronic fetal monitor] with first reading of fetal heart rate 124 bpm [beats per minute]. Trying to take Patient ' s blood pressure, heart rate, and pulse oxygenation, but unable to obtain reading via EFM and portable blood pressure machine. Patient complained of shortness of breath/ wanting ice chips. Oxygen at 10 liters/face mask applied. Rapid response called. MD at bedside. Code Blue called. See Code sheet for further details."

- Pt. #1 ' s Code Blue sheet dated 5/15/2020 at 4:11 PM, included CPR (cardiopulmonary resuscitation) was started at 4:13 PM and ended unsuccessfully at 4:28 PM.

7. On 6/3/2020 at 9:20 AM, an interview was conducted with the Chief Nursing Officer (E #1). E #1 stated when the CFD brought Pt. #1 to the ED, they went into the treatment area and met the Charge Nurse to give report. The Charge Nurse received the verbal report and directed the CFD to take Pt. #1 to triage. The CFD took Pt. #1 to the ED waiting room sometime between 11:00 AM and 12:00 PM, "It' s on the run sheet." Pt. #1 ' s complaint only indicated "abdominal pain" and did not include that (Pt#1) was 30 weeks pregnant. Due to having only abdominal pain, Pt. #1 was on the "tracking board" as a less urgent patient. The triage nurse called more urgent cases before Pt. #1 was seen.

8. On 6/3/2020 at 12:50 PM, an interview was conducted with the ED Manager (E #2). E #2 stated that, "the average waiting time depends on how busy the ER is". When the ER is busy it may take as long as 1 hours to get to triage. Patients with emergency and urgent needs are taken directly in the treatment area.