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 April 6, 2022
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on document review and interview, it was determined that for 2 of 3 (Pt.#2 and #9) unusual occurrence/patient adverse events reviewed, the Hospital failed to identify these as adverse patient events, and to analyze, track, and ensure clear expectations for safety were established, potentially affecting the safety of all patients presenting to the Emergency Department.

Findings include:

1. The Hospital's Quality and Assessment Performance Improvement Plan (dated 6/2020) was reviewed and included, " ... Purpose: The plan creates a vehicle and process to measure the degree to which it meets its mission and to scientifically affect it's patient outcomes, through objective and systematic monitoring and evaluation of the quality and appropriateness of patient care. The organization endeavors to implement continuous quality assessment and performance improvement measures and processes in the identification and resolution of patient care issues and problems ... VII. Program Scope. The scope will include but not be limited to measurement, analysis, and tracking of the following data ... I. Measure, assess and report to appropriate Medical Staff Department and/or Committees the following required patient care indicators ... Risk Management activities to include adverse patient events ..."

2. The Hospital's policy titled, "Procedure for Reporting Adverse and Sentinel Events" (revised 4/2021) was reviewed and included, " ... Sentinel Event: an unexpected occurrence involving death ... to a patient ... To provide a ... mechanism of identification ... and follow-up of all incidents that pose an actual or potential safety risk to patients, families, visitors and staff ... The following events should be reported using the QMOR (Quality Management Occurrence Report/Unusual Occurrence Report Form) ... 1. Caused harm ... Procedure ... The intent of the QMOR is to improve patient safety by analyzing root causes of events and implementing operational changes to promote patient safety. All patient occurrences will be reported to Risk Management ... Steps to Complete QMOR ... Document the ... patient details, unit the event took place ... Document all related information pertaining to the event i.e. Was the event related to safe, drug or equipment ... Narrative Description of the Occurrence ... State all actions that may prevent reoccurrences ... All department managers must complete an investigation on all submitted Quality Management Occurrence Report. All Managers must complete the Quality Management Investigation Form and submit with the (QMOR). Both forms must be submitted to the Quality Risk Manager within 72 hours of the incident ... Staff involved in discovering or witnessing a reportable event must complete a QMOR ..."

3. The Hospital's Quality Management Occurrence Department Investigation Form (dated 4/2021) included, " ... The ... (QMOR) is a required tool used for reporting occurrences ... Reportable occurrences are defined as any situation which could or did result in physical or psychological harm ... All questions must be answered ... 1. Date and Time notification of incident ... 3. Did the Manager, Director or Assigned Designee complete a department investigation of this incident ... 4. What are the findings of the investigation ... 5. What factors contributed to the incident ... 6. Have all parties involved been interviewed ... What is the plan of correction to prevent reoccurrence of this incident ..."

4. On 4/1/2022, the Hospital's Unusual Occurrence/Incident Report Log from January 1, 2022, through March 31, 2022, was reviewed. The log did not indicate that a QMOR was completed for 2 (Pt.#2, and Pt. #9) 5 clinical records reviewed for Mortality not Expected on Admission.

5. On 3/31/2022, the clinical record of Pt. #2 was reviewed. Pt. #2 was brought to the Hospital's ED (emergency department) by Chicago Fire Department on 1/9/2022 at approximately 7:05 PM, with complaint of AMS (altered mental status). Pt. #2 had a medical history of Diabetes Mellitus (high blood glucose). Pt. #2 was in severe distress tachycardia (rapid heart rate), tachypnea (abnormal rapid breathing). Accu-check (blood glucose monitoring) was high.

The physician's orders dated 1/9/22 at 10:30 PM included, "Insulin Regular Humulin (medication to treat high blood glucose) 100 unit in 100 ml sodium chlorine 0.9% 100 ml IV solution, infuse at rate of 10 units per hour till closing the anion gap" On 1/11/22 at 4:55 PM, "Pt was found to flat lined (no heart rhythm) on monitor and have no pulse at 3:57 PM. Code blue called ... pt expired at 4:15 PM ..."

The Nurses Notes from 1/10/2022 at 4:22 AM to 1/11/2022 at 4:55 PM were reviewed. Insulin drip was started on 1/10/2022 at 5:50 AM (7 hour and 20 minutes from when ordered.) The clinical record lacked documentation of the rationale for the delay of the insulin drip or that the physician was notified about a change in the patient's condition. The DKA (Diabetes Ketoacidosis) protocol was not followed. A Code blue (medical emergency) was called... pt expired at 4:15 PM..."

6. On 4/5/2022 the clinical record of Pt. #9 was reviewed. Pt. #9 was brought to the ED with a chief complaint of "Not feeling well" on 01/12/22 at 2:32 PM. Nurses noted dated 1/12/22 at 5:00 PM, indicated that Pt. #9 was in the waiting room and assessed by physician (MD #1). At that time MD #1 requested the nurse to take Pt. #9 to the treatment area and ordered a CT (computerized tomography) immediately. Pt. #9 returned from CT at 6:00 PM and placed in a wheelchair due to no bed available in the ED. At 7:50 PM, nurse documented, " ...1938 (7:38 PM)- ...pt. in hallway. Unresponsive ...CPR (cardiopulmonary resuscitation) performed ..." At 7:49 PM patient was declared dead. The clinical record lacked documentation of triage assessment and ongoing reassessment of Pt. #9 while in the emergency department.

7. On 4/5/22 at 11:52 AM, an interview was conducted with the Assistant Director of Regulatory and Quality (E#2). E#2 stated that deaths are evaluated and if meets criteria they are forwarded to the medical team for further review. E#2 stated that the case for (Pt.#2) met the criteria for further medical review, and it was sent to the ED Director (MD#1) for Mortality Review. MD#1 determines if the patient adverse event would be deemed a Sentinel Event. As of now, E#2 has not been made aware that this case Pt. #2 and Pt. #9 "case" were deemed as Sentinel Events, there has not been any further investigations done.

8. On 4/5/22 at 12:16 PM, an interview was conducted with the Director of the ED (MD#1). MD #1 stated that he completed a Mortality Review for (Pt.#2, & #9) and did not feel that they met criteria for Sentinel Event and did not recommend further investigation or review. MD#1 stated that during January 2022, the ED was overwhelmed with over 70 patients at one point ... Patients were being monitored as best as possible, not as they should have been.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on document review and interview, it was determined that, the Hospital failed to provide nursing supervision of patient care, by failing to ensure that the required assessments and monitoring were conducted in the Emergency Department. This potentially places any patient requiring assessment and monitoring in the Emergency Department at risk for serious harm or death. As a result, the Condition of Participation, 42 CFR 482.23, Nursing Services, was not in compliance.

Findings include:

1. The Hospital failed to supervise and evaluate nursing care for the patients by providing the required assessments and monitoring. See deficiency at A-395.

The immediate jeopardy was identified on 4/5/2022, due to the Hospital's failure to ensure nursing services were supervised by failing to conduct assessments and monitoring for patients with change in condition in the Emergency Department (ED), as required. Subsequently, 3 patients died . The IJ was identified on 4/5/2022 at 42 CFR 482.23 Nursing Services, and was announced on 4/5/2022 at 2:40 PM, during a meeting with the Chief Executive Officer, the Chief Medical Officer, the Chief Nursing Officer, Cheif Quality Officer and the Assistant Director of Regulatory and Complilance. The IJ was not removed by exit date 4/6/2022.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on document review and interview it was determined that, the Hospital failed to ensure adequate number of registered nurses were available in the emergency department (ED).

Findings include:

1. The Hospital's policy titled, "Mission and Scope of Services of the Department of Emergency Medicine" dated 05/2021 was reviewed. The policy included, " ...Nursing staff: ...staffing levels will be based on our facilities staffing matrix ...Day and evening: Minimum of 5 RN's with additional support staff ...Nights: Minimum 4 RN's with additional support staff ..."

2. The Hospital's document titled, "Emergency Department of Nursing Staffing Schedule" dated 01/01/2022 - 03/31/2022 was reviewed. The schedule included staffing shortages during the morning shift (7:00 AM - 7:00 PM) on the following dates: 01/31/2022 - 4 RNs; 03/20/2022 - 4 RNs. During the night shift the schedule included staffing shortages on the following dates: 01/20/2022 - 3 RNs; 01/29/2022-3 RNS; 01/30/2022 - 3 RNs.

3. On 03/31/2022 at approximately 2:20 PM, the ED Manager (E #1) stated that during the COVID-19 surge around end of December, staffing was difficult. E#1 stated that the average nurse patient ratio is 3 to 4, but can go up to 6.

4. On 04/06/2022 at approximately 9:15 AM, the above findings were discussed with the Chief Nursing Officer (E #9). E #9 stated that the care of the patients in the ED is impacted when staffing is reduced.
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 3 of 5 patients' (Pt. #2, Pt. #8, and Pt. #9) clinical records reviewed for nursing services in the Emergency Department (ED), the Hospital failed to supervise and evaluate nursing care by providing the required assessment and monitoring.

Findings include:

1. The Hospital's job description for the emergency room Staff RN (undated) included, " ... 1. Assesses physical, physiological ... dimensions of patient; applies knowledge of illnesses ... diseases and uses available resources ... 3 ... implements medical plan through passing medications and intervention with physician orders. Documents nursing intervention, patient response, effectiveness, complications, etc, communicates information to peers and physician. 4. Evaluates Nursing Care provided: reviews and evaluates effectiveness of intervention and implementation of plan ..."

2. The Hospital's policy titled, "Documentation Requirements for Nurses" (effective May 2021) included, " ... Accurate and timely documentation is essential for quality care and outcomes ... The purpose of this policy is to outline the nursing responsibilities for documentation of inpatient care ... Procedure ...The frequency of observation and documentation of ongoing assessment is based on patient location, acuity, and severity of illness ... Critical Care: A focused re-assessment and monitoring is performed at least every two hours and as needed with documentation of any changes; vital signs and other physiologic measurements are documented every hour or as ordered by a physician ..."

3. The Hospital's policy titled, "Assessment and Reassessment - Multidisciplinary" (reviewed by the Hospital on 5/2021) was reviewed and included, " ... It is the policy of (Name of the Hospital) that all patients will be assessed and reassessed for their physical, psychological, and social status ...RN (Critical Care) ... (Every) shift or with change of status ..."

4. The Hospital's policy titled "Triage Protocol" (dated 06/2020) was reviewed and included, " ...All patients seeking care ...are subject to specific and appropriate triage processes and procedures ...3. If patient arrives to the ED via EMS [emergency medical services] or law enforcement and appears in distress the EMS/Law enforcement personnel will take the patient directly to the treatment area "station A" for evaluation by the ED Charge Nurse or ED RN designee for evaluation and registration ...4. The triage staff will conduct ER waiting room rounds every 30 minutes, If, there is no triage staff, rounding will be done by Lead RN ...Procedure ...Triage RN-obtain chief complaint via computer, and then follow chief complaint indicator ...Registrar enters the 'stated complaint' on the tracker ...3. Complete the Triage section of the Emergency Department Nursing record, including the PMH (past medical history), the SH (social history) and the pain scale ..."

5. The Hospital's protocol titled, "Diabetes Ketoacidosis (DKA) and Hyperglycemic Hyperosmolar State" (revised 8/2021) was reviewed and required, "A. DKA i. Plasma glucose > [greater] than 250mg/dl (milligrams/deciliter); iii. Anion Gap > 12 ... v. Arterial pH < [less than] 7.30. Laboratory values A. Order 2 hours for 6 hours than every 4 hours until anion gap < 14, Chemistry, Magnesium/Phosphorus, Serum Acetone ... B. Accu-checks (blood glucose monitoring) every 1 hour while patient is on insulin drip. C. Notify prescriber of any abnormal results."

6. The clinical record of Pt.#2 was reviewed on 3/31/2022 at approximately 12:45 PM. Pt.#2 was brought to the Emergency Department via ambulance on 1/9/2022 at 7:05 PM. The clinical record included the following:

-Triage Screening note dated 1/9/22 at 7:05 PM, included, "Condition at Arrival: Serious ... Temperature 98.2, Blood Pressure 134/85 (normal systolic-top number 100-140), Pulse 129 (normal 60-90), Respirations 32 (normal 12-24), ESI (emergency severity index-5 level severity rating scale 1 most urgent, 5 least urgent) 3."
-ED Provider Progress Note (MD#2) dated 1/9/22 at 7:08 PM, included, "Exam Limitations: clinical condition AMS (altered mental status) ... Initial Comments: (Pt#2) was brought to ED by CFD (Chicago Fire Department) ... H/O (history of) Diabetes Mellitus (high blood glucose) and missed doses of his meds (medication), now came in with high blood sugar, AMS, tachypnea (abnormal rapid respirations) and palpitations ... Started IV (intravenous) fluid ... Insulin regular (medication to treat high blood glucose) 10 units IV push ... will be admitted to ICU (intensive care unit)."
-Physician's order dated 1/9/22 at 10:30 PM, included, "Insulin Regular Humulin 100 unit in 100 ml (milliliter) sodium chlorine 0.9% 100 ml IV solution, infuse at rate of 10 units per hour till closing the anion gap.
-Nursing Note (RN/E#7) dated 1/10/22 at 4:22 AM, included, "awaiting insulin gtt (drip) from pharmacy. The clinical record lacked documentation of a reason for delay in administration of the insulin drip or that a physician was notified of delay in medication administration.
-Nursing Note (E#7) dated 1/10/22 at 5:50 AM, included, "mixed and verified insulin gtt with (name of Charge Nurse). Insulin gtt initiated at this time. Accu-check reading Hi. Will check in an hour, at 7:04 AM, and at 9:22 AM reading HI." The clinical record lacked documentation that a serum blood glucose was drawn, or that the physician was notified of the accu-check results as required.
-Nursing Note (RN/E#5) dated 1/10/22 at 8:15 AM, included, "Received (Pt.#2) in hallway in DKA, pt is lethargic and unresponsive to verbal stimuli or painful stimuli, will check bs (blood sugar) and contact NP (Nurse Practitioner). at 9:38 AM, bs reads over 600, NP is contacted, verbal order to give 10 units of regular insulin ivp (intravenous push) ... order is carried out, pt remains lethargic ... at 10:25 AM, Pt is hypotensive (blood pressure at 9:08 AM was 61/39, at 11:10 AM 71/52) ... at 11:28 AM, glucose 1063. The clinical record lacked further documentation by the RN after 10:30 AM of care or interventions provided or that a physician was notified of patient's declining status.
-Nursing Note (RN/E#8) dated 1/10/22 at 7:50 PM, (no previous documentation since 1/10/22 at 10:30 AM from E#5) "Assumed Pt care ... Pt lying in bed. Respiratory distress noted, 02 saturation 88% on room air ... BP 79/35: HR-127, R-38. Comfort measures provided ... next documentation by this RN was at 6:46 AM (11 hours and 54 minutes), "Pt continues lethargic and unresponsive to verbal commands ... comfort measures provided ..." There was no documentation that the nurse notified the physician of the patient's declining status and low blood pressures.
-Nursing Note (RN/E#6) dated 1/11/22 at 4:55 PM, "Pt was found to flat lined (no heart rhythm) on monitor and have no pulse at 3:57 PM. Code blue called ... pt expired at 4:15 PM ..."
- A Certificate of Death dated 1/14/22 at 2:30 PM, for Pt. #2 included, " ... Cause of Death ... Diabetic Ketoacidosis ... Date pronounced: 1/11/2022 ... Time of death: 4:15 PM ..."

7. The clinical record of Pt. #8 was reviewed on 04/05/2022 at approximately 9:30 AM. Pt. #8 was brought to the Emergency Department on 01/12/2022 for altered mental status. The clinical record included:

-emergency room physicians note dated 01/12/2022 at 3:15 PM, included, " ...History and present illness...unknown PMH (past medical history) who presents via EMS after patient was found on the floor at home. Patient ... unable to give history ...
-Physician/nursing communication note dated 01/16/2022 at 10:41 AM, included, "Admit to MICU (Medical Intensive Care Unit) ..."

The Nurses Notes from 1/12/2022 to 1/18/2022 were reviewed. Pt. #8 was unable to respond to question, responsive to painful stimuli only. On 1/18/2022 at 8:59 AM, the nurse documented, " Pt is stable but remains critical." The Nurses Note dated 01/18/2022 at 11:49 AM, included, " ...Nurse noticed Pt's eyes become glaze during cleaning and changing, sternal rub is performed, pt. does not respond, pulse cannot be felt, code called. CPR is started at 11:18, MD is in room to run ode, despite CPR and several med given pt expires at 1131 AM. Police and gift of Hope are notified. Call is placed to mother ..."
The medical record lacked documentation of reassessment and vital sign monitoring from 01/18/2022 at 7:00 AM until 10:53 AM (3 hours 53 minutes). Patient #8 coded and expired on [DATE] at 11:31 AM.

8. The clinical record of Pt. #9 was reviewed on 04/05/2022 at approximately 10:30 AM. Pt. #9 was brought to the Emergency Department on 01/12/2022 at 2:32 PM. The clinical record included the following:
-Nurse note (entered by RN #3) dated 01/12/2022 at 5:00 PM, included, "Pt. in the waiting room area ...MD #1 went to assess the w/r (waiting room) and told me (RN #3) this pt. need to come back ...pt brought in w/c and pt was placed in HW (hallway) in front of room 18 ...MD #1 saw pt. and told me to have Pt. taken to CT STAT (computerized tomography immediately) ..."
-Nurse note dated 01/12/2022 at 6:00 PM, (entered at 8:12 PM) included, " ...Pt. is returned from CT, all ED bays and HW beds are full; Pt. in w/c in front of room 18".
-ED provider note dated 01/12/2022 at 8:10 PM, included, " ...Chief Complaint: Wellness check ...time seen by provider 16:58 (4:58 PM) ... History of Present Illness ...BIBEMS (Brought in by EMS) after not feeling well. Seen by previous physician as medical screening for lethargy. Orders placed. Upon my evaluation, pt found in asystole (absence of heart rhythm). Unresponsive. ACLS (Advanced Cardiac Life Support) initiated at 19:40 (7:40 PM). Pt. intubated by me and ACLS started...Diagnosis: Cardiopulmonary Arrest ...Expired ...Given 4 doses of 1 mg (milligram) of epinephrine. No ROSC (return of spontaneous circulation) ... no brainstem reflexes ...Declared dead at 1949 (7:49 PM). No family to notify at this time."
-Nurse note dated 01/12/2022 at 7:50 PM, included, " ...1938 (7:38 PM) Writer observed pt. in hallway. Unresponsive. Writer checked Pt. Pulse and it was not present. Writer assumed care of Pt. at this time. Pt. wheeled to bed in front of room six when CPR (cardiopulmonary resuscitation) was initiated ...1940 (7:40 PM) Defib (defibrillator) pads attached, IO (interosseous) access to right patella, RT (Respiratory Therapy) engaging in assisted respirations via BVM (bag valve mask), MD ...at the head of the bed preparing for ET (endotracheal) tube insertion ...1942 (7:42 PM) ET tube inserted ...CPR in progress ...1950 (7:50 PM) CPR ceased at this time. Time of death called by MD ..."
The clinical record lacked documentation of triage assessment and ongoing reassessment of Pt. #9 while in the emergency department. Pt. #9 coded and expired on [DATE] at 7:50 PM.

9. On 4/1/22 at 9:07 AM, an interview was conducted with an ED Physician (MD#2). MD#2 stated, "I remember this case (Pt.#2), all rooms were full, and we had patients in the hallway due to high census and no beds on units. For DKA patients on insulin drip blood glucose and accu-check should be done at least every 2 hours, this is the standard, BMP (basic metabolic panel-blood test to measure chemical balance) every 2-4 hours or until anion gap is closed. For continuing high blood sugars or low blood pressures we would treat with fluids, and if bp (blood pressure) is unstable (hypotensive less than 90 systolic blood pressure) we monitor every 10 to 30 minutes due to severe dehydration and can lead to shock."

10. On 4/1/22 at 9:45 AM, an interview was conducted with a Registered Nurse (RN/ED E#7). E#7 stated, " ...For patients in the ED ... their vital signs are monitored every 2 hours, accu-checks are per physician order. When I assumed care for (Pt.#2) he was lethargic but able to speak, with rapid breathing and tachycardic. Labs were ordered when I was assigned, I had about 8-10 patients on this day, there were about 50 patients in ED that day, there were patient beds in the hallway, we had patients waiting for beds because there were no beds available. It was difficult to keep up with patients and documentation. I do not recall the actual time the physician ordered an insulin drip, but I waited for it a long time and eventually the charge nurse alerted me that we had to mix it ourselves. The charge nurse and I went to the medication room, and we mixed the insulin drip.... The accu-checks were being done every hour per insulin drip protocol, and they still read hi. However, they were not documented because I could not get into the computer system." E#7 confirmed that Pt. #2's clinical record lacked documentation of the accu-checks done hourly or that a physician was notified of late administration of insulin drip.

11. On 4/1/22 at 10:50 AM, an interview was conducted with a Physician (MD#3). MD#3 stated, "I do not recall seeing the patient (Pt.#2). I am a kidney specialist but based on my clinical judgement if a patient is in diabetic ketoacidosis (DKA) and on an insulin drip, they should have Accu-checks hourly and vital signs at least every 2 hours if stable. For hypotensive or low blood pressures such as 78/32 vital signs should be done every 15 minutes, and patient should be in the ICU. If the blood pressure is too low the patient will go into shock and cause death due to circulatory collapse."

12. On 4/2/22 at 12:03 PM, an interview was conducted with a RN (E#6). E#6 stated, "(Pt.#2) was very sick and was ICU bound, he was unconscious the entire time I cared for him, I spoke with the physician a few times because I was concerned about his low blood pressure. The physician stated that as long as the MAP (mean arterial pressure, indicator of blood perfusion) was over 65, it was ok and gave no new orders. The map went down to 63, and I called the physician again, and he said as long as MAP over 60, no new orders. I do not recall if (Pt.#2) was on insulin drip, or if we were doing accu-checks. We were pretty busy ..."

13. On 4/2/22 at 12:40 PM, an interview was conducted with a RN (E#5). E#5 stated, "There is a DKA protocol to follow but if we have too many patients we may not be able to get to follow the protocol. If accu-check is done and reads hi, we have to draw blood from patient for bg (blood glucose)." E #5 confirmed that on 1/10/22 during 7AM to 7PM shift, Pt. #2's blood glucose was not checked per DKA protocol.

14. On 4/5/22 at 12:16 PM, an interview was conducted with the Director of the ED (MD#1). MD #1 stated that during this time in January 2022 (when Pt. #2, Pt. #8 and Pt. #9 presented to the ED), the hospital was overwhelmed with over 70 patients at one point. There were only 19 beds available, and not enough monitors available. Patients were being monitored as best as possible, not as they should have been.
VIOLATION: QAPI Tag No: A0263
Based on document review and interview, it was determined that the Hospital failed to identify unusual occurrence/adverse events and to analyze, and track, in accordance with the Quality Assurance and Performance Improvement Plan. This potentially affects all patients that present to the Emergency Department. As a result, the Condition of Participation, 42 CFR 482.21, Quality Assurance, was not in compliance.

Findings include:

1. The Hospital's Quality Committee failed to identify adverse patient events, and to analyze, track, and ensure clear expectations for safety were established, potentially affecting the safety of all patients presenting to the Emergency Department. See deficiency A- 286.