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 24, 2021|
|VIOLATION: EMERGENCY SERVICES POLICIES||Tag No: A1104|
|A. Based on observation, document review and interview, it was determined that for 3 of 3 crash carts (2 adult and 1 pediatric) in the Emergency Department (ED), the Hospital failed to ensure that the crash carts and defibrillator checks were completed and documented, as required per policy.
1. On 06/23/2021, between 9:30 AM - 11:45 AM, during the observational tour of the ED, the following were observed:
- The adult crash cart #1: On 06/20/2021, the day shift (7:00 AM - 7:00 PM) check lacked the RN's (Registered Nurse) signature documenting the adult crash cart #1, had been checked as required. The defibrillator check strips were missing for the following dates: 05/19/2021, 06/17/2021, 06/18/2021, 06/19/2021, and 06/20/2021.
- The adult crash cart #2: On 06/20/2021, the day shift check lacked the RN's signature documenting the adult crash cart #1, had been checked as required. The defibrillator check strips were missing for the following dates: 06/19/2021, 06/20/2021, and 06/21/2021.
- The Pediatric Crash Cart: On 05/25/2021, and 06/20/2021, the day shift check lacked the RN's signature documenting the pediatric crash cart had been checked as required.
2. On 06/23/2021, at approximately 1:30 PM, the Hospital's policy titled, "Code Blue/Yellow Crash Cart" (revised 07/2020), was reviewed and required, "...1. The crash cart will be checked at the beginning of every shift by an assigned nurse or designee ...The Nurse Manager/Charge Nurse or designee is responsible for seeing that each crash cart is checked as directed ..."
3. On 06/23/2021, at approximately 2:00 PM, the Hospital's document titled, "Emergency Department - Daily Watch List" (date unknown) was reviewed and included, "...Daily...Equipment checks completed; Crash Cart, defibrillator checked ..."
4. On 06/23/2021, at approximately 10:00 AM, the Charge Nurse (E #2) and ED Nurse Manager (E #3) were interviewed. E #2 stated that the nurse assigned to check the crash carts should have signed the crash cart log and placed the defibrillator strips to make sure its functioning on the days in question. E #3 stated that if the crash cart is not checked, then during an emergency situation if non-functional it would be difficult.
B. Based on observation, document review and interview, it was determined that for 9 of 9 (Pt. #11, 12, 13, 14, 15, 16, 17, 18, and 19) electronic clinical records, the Hospital failed to logoff the computer to ensure that the clinical records were secured and not visible to anyone, as required per policy.
1. On 06/23/2021, between 9:30 AM - 11:45 AM, during the observational tour of the ED the following was observed:
- The triage room by the front registration station, was left open with no patients and no staff in the room. The computer monitor was left open with nine (9) patient information clearly visible to anyone on the screen along with patient names, age, and arrival date.
2. On 06/23/2021 at approximately 1:00 PM, the Hospital's policy used by the ED titled, "HIPAA [Health Insurance Portability and Accountability Act] Sanctions" (dated 06/2020) was reviewed and required, "...Procedure: 1. Violation of (the Hospital) privacy policies and procedures...3. Failing to logoff or leaving a computer monitor on and unsecured ..."
3. On 06/23/2021 at approximately 10:30 AM, the Traige Nurse (E #1) was interviewed. E #1 stated that the computer monitor should have been minimized or closed, it is an error from her end.
4. On 06/23/2021 at approximately 10:45 AM, the ED Nurse Manager (E #3) was interviewed. E #3 stated that it is not acceptable to leave patient information open on the computer while leaving the care area.