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.

INGALLS MEMORIAL HOSPITAL 1 INGALLS DRIVE HARVEY, IL 60426 Oct. 30, 2020
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 5 patients' (Pt. #1) clinical records reviewed requiring peritoneal dialysis, the Hospital failed to notify the physician regarding delay in the implementation of the dialysis order, to ensure that a registered nurse supervised and evaluated the patient's care.

Findings include:

1. On 10/29/2020, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted on [DATE] with a diagnosis of end-stage renal disease. The clinical record included:

- MD #2's (Nephrologist) peritoneal dialysis (PD) order dated 9/7/2020 at 5:01 PM included, " ...2.5 L (liters) 2.5% Dianeal (type of dialysis solution) every six hours."

- E #1's (Registered Nurse) progress note on 9/7/2020 at 9:45 PM included, "(Pt. #1) received in ICU ... as a new admission from ER (Emergency Department) ..."

- The clinical record indicated that Pt. #1 needed to start PD during the night shift on 9/7/2020. However, E #3 (ICU Manager) clarified that Pt. #1's dialysis was initiated on 9/8/2020 between 10:00 AM and 11:00 AM (approximately 12 hours after Pt. #1's admission). The clinical record lacked documentation that a physician was notified of the delay in implementing the PD order.

2. On 10/29/2020, the Hospital's Job Description for Registered Nurses (effective 4/18) included, " ...II. The Registered Nurse assumes primary responsibility for the ... implementation and evaluation of nursing care for assigned patients ... III ... Coordinates patient care services with the physician ..."

3. On 10/29/2020, the Hospital's policy titled, "Peritoneal Dialysis" (reviewed by the hospital on [DATE]) included, " ...Documentation ... Unexpected outcomes and related treatment ..."

4. On 10/29/2020 at approximately 1:30 PM, findings were discussed with E #3 (Manager, ICU). E #3 stated that the nurse should have notified the physician regarding the delay in the implementation of the dialysis order. E #3 could not provide documentation that a physician was notified.