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||Oct. 5, 2017|
|VIOLATION: QUALIFIED REHABILITATION SERVICES STAFF||Tag No: A1126|
|Based on document review and interview, it was determined that the Hospital failed to ensure a qualified physical therapist was available to provide the required services,which potentially affects 8 patients receiving physical therapy services.
1. On 10/4/17, the "Mission and Scope of Services and Operational Functions of the Physical Therapy and Speech Therapy Programs" (rev. 1/2010) was reviewed and indicated " Physical Therapy:...Inpatients evaluations are normally completed within 24 hours of receipt of the physician order (except on some Saturdays, Sundays and holidays) and treatment is on-going daily until discharge..."
2. On 10/4/17 at approximately 1:30 PM, the Physical Therapist (E #12) was interviewed. E #12 stated that the Rehabilitation Department hours of operation are from 8:00 AM to 5:00 PM Monday through Friday. E #12 stated that she is the only physical therapist at the Hospital and works Monday thru Friday from 8:30 AM to 5:00 PM. Patients are not seen on weekends. E #12 stated that if she is on vacation or absent, the Hospital does not have a Physical Therapist to cover her absence. E #12 also stated that acute patients should be seen on a daily basis.
|VIOLATION: PHYSICAL ENVIRONMENT||Tag No: A0700|
|Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Full Survey Due to a Complaint conducted on October 3 & 4, 2017, the surveyors find that the facility failed to provide and maintain a safe environment for patients and staff.
This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.
|VIOLATION: LIFE SAFETY FROM FIRE||Tag No: A0710|
|Based on observation during the survey walk-through, staff interview, and document review during the Life Safety code portion of the Full Survey Due to a Complaint conducted on October 3 & 4, 2017, the surveyors find that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags.
|VIOLATION: DIRECTOR OF DIETARY SERVICES||Tag No: A0620|
|Based on document review, observation and interview, it was determined that the Hospital failed to ensure that open food in the refrigerator and freezer was wrapped and dated. This failure has the potential to affect all 35 patients on the Hospital census on 10/3/17.
1. On 10/3/17 at 1:00 PM, the Hospital's policy titled, "Food Handling and Storage" (reviewed 11/16) was reviewed. The policy required "... Procedure... All food containers are labeled and dated with date it was opened or prepared as well as the product."
2. On 10/3/17 at 11:30 AM, a tour was conducted of the dietary services food storage refrigerator and freezer with the Nutrition Director (E#7). On 10/3/17 at 11:35 AM, the Hospital's freezer contained a frozen pork roast wrapped in undated plastic and 2 bags of green beans in an undated plastic bag. On 10/3/17 at 11:40 AM, the Hospital's refrigerator contained undated, unwrapped open boxes of brownish lettuce and mushrooms.
3. On 10/3/17 at 11:40 AM, E#7 stated that all food in the freezer and refrigerator should be wrapped with plastic wrap and dated.
|VIOLATION: RN SUPERVISION OF NURSING CARE||Tag No: A0395|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
A. Based on document review and interview, it was determined that for 1 of 4 (Pt. #9) patients reviewed for admission skin assessments, the Hospital failed to ensure that a skin assessment using the Braden scale for skin assessment was done.
1. On 10/2/17 at 1:45 PM, the Hospital's policy titled "Pressure Ulcer Prevention and Management" (revised Mar. 2016) was reviewed. The policy required "Procedure:... I. Assessment ... A. Skin assessment of all patients shall be initiated by a nurse upon admission using the Braden Scale, and shall be completed within 8 hours of admission.
2. On 10/2/17 at 10:30 AM, Pt.#9's clinical record was reviewed. Pt. #9 was an [AGE] year old female admitted on [DATE] with the diagnosis of lung mass, generalized weakness. Pt. #9's clinical record lacked documentation or an admission skin assessment using the Braden scale.
3. On 10/2/17 at 10:55 AM, the Chief Nursing Officer (E#2) stated that Pt. #9 should have had an admission skin assessment using the Braden scale.
B. Based on document review and interview, it was determined that for 1 of 4 clinical records reviewed (Pt. #6) for patients with pressure ulcers, the Hospital failed to ensure that physician orders for pressure ulcer treatment were ordered.
1. On 10/2/17 at 1:45 PM, the Hospital's policy titled "Pressure Ulcer Prevention and Management," (revised [DATE]) was reviewed. The policy required "Explanation... A multidisciplinary team approach involving the physician, nursing...shall be utilized in the prevention and management of pressure ulcers."
2. On 10/2/17 at 10:30 AM, Pt. #6's clinical record was reviewed. Pt. #6 was a [AGE] year old female admitted on [DATE] with the diagnoses of large bowel obstruction and clinical sepsis. Pt.#6"s nursing wound assessment documentation dated 10/1/17 included "...Pressure ulcer 1 cm in length x 0.5 cm in width x 0.1 cm in depth...primary dressing aquacel [sterile dressing]." Pt. #6's clinical record lacked a physician order for aquacel.
3. On 10/2/17 at 10:55 AM, the Chief Nursing Officer (E#2) stated that Pt. #6 should have a physician order for the pressure ulcer treatment.
|VIOLATION: NURSING CARE PLAN||Tag No: A0396|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on document review and interview, it was determined that for 1 (Pt. #13) of 3 clinical records reviewed on the Mother/Baby unit for care plans, the Hospital failed to ensure a care plan was developed as required.
1. On 10/3/17 at approximately 11:00 AM, the policy entitled "Plan of Care Multidisciplinary Treatment Plan" (rev 1/2017), was reviewed and required "Procedure...2. The admitting nurse caring for the patient will start the multidisciplinary treatment plan by initiating the nursing plan of care within eight hours of admission to the unit... The plan of care should include goals, expected outcomes, interventions, evaluation and patient/family education relevant to the patient's problems..."
2. On 10/3/17 at approximately 10:00 AM, the clinical record for Pt. #13 was reviewed. Pt. #13 was a [AGE] year old female admitted on [DATE] with a diagnosis of planned cesarean. The clinical record lacked a plan of care.
3. On 10/3/17 at approximately 10:15 AM, the Charge Nurse (E #8) of the Mother/Baby unit was interviewed. E #8 stated, "The plan of care should be initiated on day of admission and updated as needed."