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 | Aug. 6, 2021 |
| VIOLATION: IC PROFESSIONAL ADHERENCE TO POLICIES | Tag No: A0776 | |
| Based on observation, document review and interview, it was determined that for 3 of 3 ventilators stationed in the hallway, the Hospital failed to ensure staff adherence to prevention of spread of nosocomial infection as required. Findings include: 1. On 08/04/2021, at approximately 11:30 AM - 12:30 PM, an observational tour of the Respiratory Services was conducted. During the tour, the following was observed: - Three (3) adult ventilators stationed in the hallway with sticker labeled "CDS [cleaned with disinfectant solution] -07/30/2021" - Three (3) adult ventilators were not covered with plastic bag after the disinfection of the machines. 2. On 08/04/2021, at approximately 1:30 PM, the Hospital's policy titled, "Infection Control" dated 05/2021, was reviewed and indicated, "...the surface of the ventilator is wiped down by the midnight shift on a nightly basis when in use. When not in use, it is covered with a plastic bag to keep dust particles off." 3. On 08/04/2021, at approximately 11:45 AM, the Liscensed Respiratory Practitioner (E #29) was interviewed. E #29 stated that he had disinfected the three ventilators on 07/30/2021, all the three ventilators should have been covered with a plastic cover to avoid dust and cross infection. |
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| VIOLATION: SECURE STORAGE | Tag No: A0502 | |
| Based on observation, document review, and interview, it was determined that the Hospital failed to ensure that medication was kept in a secured area. This potentially affect the safety of approximately six patients on census at 3 West Medical-Surgical/Telemetry unit. Findings include: 1. On 8/3/2021 at approximately 11:00 AM, an observational tour of the 3 West Medical-Surgical/Telemetry Unit was conducted. During the tour, one unattended vial of heparin (blood thinner) was on the table of the nurse's station. 2. On 8/4/2021, the Hospital's policy titled, "Medication Storage and Security" (reviewed by the Hospital on 5/2021) was reviewed and included, "... Storage Conditions: Drugs shall be stored under the proper conditions of sanitation... safety, and security..." 3. On 8/3/2021 at approximately 11:00 AM, findings were discussed with E #10 (Unit Manager). E #10 stated that medications should be secured in a locked storage area and not be left unattended at the nurse's station. |
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| 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 August 3 & 4, 2021, 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. |
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| VIOLATION: INFECTION CONTROL | Tag No: A0747 | |
| Based on document review, observation, and interview, it was determined that the Hospital failed to ensure a Hospital-wide program for the surveillance, prevention, and control of HAI's (hospital acquired infections) and other infectious diseases. This has the potiential to affect the health and safety of current and future patients treated at the Hospital. As a result, it was determined that the Condition of Infection Control, CFR 482.42, Infection Prevention Control Abx Stewardship, was not in compliance. Findings include: 1. The Hospital failed to ensure the infection control committee held meetings to employ methods for preventing and controlling the transmission of infections within the Hospital. See deficiency at A-749 A. 2. The Hospital failed to ensure sterile instruments were safely stored for usage. See deficiency at A-749 A, and B. 3. The Hospital failed to ensure staff adherence to prevention of spread of nosocomial infection as required by not properly covering three (3) adult ventilators with plastic bag after the disinfection of the machines. See Deficiency at A-776. |
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| VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES | Tag No: A0749 | |
| A. Based on document review and interview, it was determined that the Hospital failed to ensure the infection control committee held meetings to employ methods for preventing and controlling the transmission of infections within the Hospital, potentially affecting the health and safety of approximately 54 patients treated each day. Findings include: 1. On 8/4/2021, the Professional Staff Bylaws & Rules and Regulations, revised 2/6/2020, were reviewed. The Rules and Regulations required (page 41), "... Infection Control Committee... This committee shall meet bi-monthly and at any time designated by its Chair..." 2. On 8/4/2021, the Hospital's policy titled, "Organization and Authority of the Infection Control Committee," revised May 2020, was reviewed. The policy required, "It is the policy of... [the Hospital] that there be an effective hospital-wide infection control program for the surveillance and control of infections... The committee meets quarterly or at any time that the chairman finds necessary..." The policy requirement for meeting frequency varied from the Rules and Regulations requirement. 3. On 8/4/2021, the Infection Control Meeting Minutes dated 2/26/2021, was reviewed. The Minutes included, "Motion by... [the Laboratory Medical Director] to approve the minutes from 2/25/2019..." There was a two year gap between the Infection Control Meetings. 4. On 8/4/2021 at 9:20 AM and at 1:20 PM, interviews were conducted with the Infection Control Preventionist (E #17). E #17 stated that she was hired in February 2021, and does not know why there were no meeting between Feb. 2019 and Feb. 2021. There has not been a quarterly meeting since February 2021 because E #17 needed time to review policies and organize infection control procedures. An Infection Control Meeting is scheduled for Monday, 8/9/2021. B. Based on document review, observation, and interview, it was determined that for 1 of 7 drawers in a sterile instrument cabinet in the sterilizer room, the Hospital failed to ensure sterile instruments were safely stored, potentially contaminating the sterile surgical field of 20 to 25 patients receiving surgical procedures each month. Findings include: 1. On 8/5/2021, the Hospital's policy titled, "Instrument Care," (reviewed by the Hospital June 2020), was reviewed. The policy required, "Instruments in wrappers are considered sterile until open or damaged..." The policy did not provide information on where to store sterile instruments. 2. On 8/4/2021 at 2:30 PM, an observational tour was conducted in the sterilizer room. The surface of 1 of 7 drawers in a sterile instrument cabinet was coated with a brown substance with the appearance of rust. Approximately 20 instrument packages were placed on the brown substance surface. Three of the instrument packages contained the brown substance, which potentially could contaminate an operative sterile field upon opening the package. 3. On 8/4/2021 at 2:35 PM, an interview was conducted with the Infection Control Preventionist (E #17). E #17 stated that the sterile instrument drawer should not contain rust. C. Based on document review, observation, and interview, it was determined that for 2 of 30 sterile instruments, the Hospital failed to ensure sterile instruments were safe, potentially contaminating the surgical site of approximately 20 to 25 patients receiving surgical procedures each month. Findings include: 1. On 8/5/2021, the Hospital policy titled, "Instrument Care," (reviewed by the Hospital 6/2020), was reviewed. The policy required, "Instruments in wrappers are considered sterile until open or damaged..." 2. On 8/4/2021 at 2:30 PM, an observational tour was conducted in the sterilization room. In a sterile instrument cabinet the following was found: - One package, containing a large nail clipper, was torn in 2 places, approximately 1/4 inch each tear. The nail clipper's hinge was discolored with a brown material with the appearance of rust. - One package, containing a small forceps, included a light yellow circular stain, approximately 1/4 inch in diameter which potentially had soaked through the packaging and contaminated the instrument. 3. On 8/5/2021 at 10:45 AM, an interview was conducted with a Surgical Technician (E #22). E #22 stated that the nail clipper contained rust and did not know what the stain was from. |
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| VIOLATION: ADEQUATE RESPIRATORY CARE STAFFING | Tag No: A1154 | |
| Based on document review and staff interview it was determined that, the Hospital failed to ensure adequate respiratory staff were available in-house to provide respiratory care to all patients. This has the potential to affect all 27 airway management patients on census 08/04/2021. Findings include: 1. On 08/04/2021, at approximately 11:45 AM, the Hospital's Respiratory Care Staffing Schedule from 06/01/2021 to 08/05/2021 (eight weeks) was reviewed. The Respiratory Care Staffing Schedule included: - On 06/20/2021, during the day shift (7:00 AM - 7:00 PM) there were two (2) Respiratory Therapists (RTs) in the Hospital with eight (2) ventilator patients, one (1) patient on Bipap, and twenty-one (21) nebulizer treatments. 2-RTs providing coverage for Emergency Department and Intensive Care Unit. No RT was assigned to Medical/Surgical Telemetry Unit. - On 06/30/2021, during the night shift (7:00 AM - 7:00 PM) there were two (2) Respiratory Therapists (RTs) in the Hospital with eight (2) ventilator patients, four (4) patients on Bipap, and twenty-eight (28) nebulizer treatments. 2- RTs providing coverage for Emergency Department and Intensive Care Unit. No RT was assigned to Medical/Surgical Telemetry Unit. - On 07/04/2021 and 07/18/2021, during the day shift, there was one (1) Respiratory Therapist in the Hospital with two (2) ventilator patients, five (5) patients on Bipap, and thirty-six (36) nebulizer treatments. 1 - RT providing coverage for Emergency Department and Intensive Care Unit. No RT was assigned to Medical/Surgical Telemetry Unit. 2. The eight-weeks Respiratory Care Daily Staffing Schedule indicated 1-2 RT staff shortage during both day and night shifts. 3. The Hospital's Respiratory Care Staffing policy was requested, the Hospital staff was unable to provide policy for respiratory care staffing. 4. On 08/04/2021, at approximately 1:00 PM, the Liscensed Respiratory Practitioner (E #29) was interviewed. E #29 stated that there should be at least minimum of three (3) Respiratory Therapists during day shifts and two (2) during night shifts.E #29 stated that there is no Respiratory Therapist staffing policy. E #29 stated that the staffing sheet does not indicate on 07/04/2021 and on 07/18/2021, if there was agency RT to support the staff. |
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| VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING | Tag No: A0144 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on document review and interview, it was determined that for 1 of 3 (Pt. #18) clinical records reviewed for patients with suicide precautions, the Hospital failed to conduct a suicide risk assessment, as required, to ensure care was provided in a safe setting. Findings include: 1. On 8/3/2021, the Hospital's policy titled, "Suicide Risk Assessment" (revised 7/24/2020) was reviewed and included, " ...1. A risk assessment is processed for all referrals to ( Name of Hospital) Intake Department to verify that the patient is referred to the most appropriate level of care ...The Risk Assessment specifically addresses clinical indicators directly and indirectly related to suicidal ideation's and related potential risk factors ..." 2. On 08/03/2021, the clinical record of Pt. #18 was reviewed. Pt. #18 was admitted on [DATE] with a diagnosis of Schizoaffective disorder (mental health disorder). The clinical record lacked documentation of a suicide risk assessment from 07/21/2021 through 08/03/2021. 3. Psychosocial assessment dated [DATE] included, "Psychiatric History of Suicidal Homicidal behavior." 4. Physician's progress note dated 07/23/2021 included, "(Pt. #18)... is refusing medications, is agitated and angry, irritable, is delusional, paranoid with high risk of acting out on paranoia ...Patient (Pt. #18) is a safety risk and high risk for self-harm..." 5. The clinical record of Pt. #18 indicated that Pt. #18 was on the following safety precautions and monitored: Assault precautions, Elopement precautions, and Suicide precautions. 6. On 08/03/2021 at approximately 11:36 AM, an interview was conducted with E #2 (Director of Behavioral Health Unit). E #2 stated that if a patient is actively suicidal, they should have a suicide risk assessment every shift. |
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| VIOLATION: RN SUPERVISION OF NURSING CARE | Tag No: A0395 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Based on observation, document review, and interview, it was determined that for 3 of 3 crash carts (crash carts in 3 East medication room, 3 East central hallway, and 3 West nurse's station) in the Medical-Surgical/Telemetry Unit, and 1 of 1 adult crash cart in the Mother Baby Unit, the Hospital failed to ensure that the crash carts were checked, as required, to ensure a registered nurse supervised the nursing care for all patients. This potentially affects approximately 27 patients in the Medical-Surgical/Telemetry Unit and one patient in the Mother Baby Unit. Findings include: 1. On 8/3/2021 between 9:45 AM through 11:30 AM, an observational tour of the 3rd floor Medical-Surgical/Telemetry Units were conducted. The following were observed: - The crash cart located at the 3 East central hallway was not checked on 7/24/2021 AM shift (7 AM through 7 PM), 7/30/2021 AM and PM shift (7 PM through from 7 AM), 7/31/2021 PM shift, and on 8/1/2021 PM shift. - The crash cart located at the 3 East medication room was not checked on 7/29/2021 PM shift, 7/30/2021 AM and PM shift, 7/31/2021 AM and PM shift, and 8/1/2021 PM shift. - The crash cart located at the 3 West nurse's station was not checked on 7/24/2021 AM shift, 7/29/2021 AM shift, 7/31/2021 AM and PM shift, and 8/1/2021 PM shift. 2. On 8/3/2021 at approximately 11:00 AM, findings were discussed with E #9 (Charge Nurse) and E #10 (Unit Manager, 3 Medical-Surgical/Telemetry Unit). E #9 and E #10 stated that the crash carts should be checked every shift by the nurse. E #10 stated that it is important to check the crash cart to make sure that emergency equipment and supplies are ready and functional to attend patients with medical emergencies. 3. On 08/03/2021, between 9:30 AM - 11:00 AM, an observational tour of the Mother Baby Unit was conducted. During the tour the following was observed: - Adult crash cart lacked the defibrillator checks on 07/24/2021: 7:00 AM - 7:00 PM shift; 07/25/2021: 7:00 PM -7:00 AM shift; 08/02/2021: 7:00 PM - 7:00 AM shift. 4. On 08/03/2021, the Hospital's policy titled, "Code Blue/Yellow Crash Cart" (revised 05/2021) was reviewed and included, "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." 5. On 08/03/2021, at approximately 10:00 AM, the Registered Nurse (E #7) was interviewed. E #7 stated that she is not sure why the crash cart was not checked on those given days. 6. On 08/03/2021, at approximately 10:10 AM, the Nurse Manager of the Mother Baby Unit (E #8) was interviewed. E #8 stated that the defibrillator should have been checked during daily crash cart checks to ensure it is functional. B. Based on document review and interview, it was determined that for 1 of 3 patient's (Pt #13) clinical records reviewed in 3 East Medical-Surgical/Telemetry Unit, for nursing services the Hospital failed to ensure that the physician's order was followed, to ensure a registered nurse supervised the nursing care for each patient. Findings include: 1. On 8/3/2021, the clinical record of Pt. #13 was reviewed. Pt. #13 was admitted on [DATE] due to hyperglycemia (high blood sugar) and opiate withdrawal. The clinical record included a physician's order dated 7/21/2021, to obtain daily blood sugar checks before each meal and at bedtime. The clinical record indicated that blood sugar check was not done before dinner and at bedtime on 8/1/2021. 2. On 8/3/2021, the Hospital's job description for registered nurse for the adult care unit (undated) was reviewed and included, "General summary... implements, and evaluates delivery of patient care... Essential Job Functions... 4. Supervises all nursing activities related to patient care and sets standards for accurate reporting and recording of patient's symptoms, reactions and progress..." 3. On 8/3/2021 at approximately 10:30 AM, findings were discussed with E #9 (Charge Nurse). E #9 could not provide documentation that the blood sugar reading was done on 8/1/2021. E #9 stated, "That should have been done at 5:00 PM and 9:00 PM." |
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| VIOLATION: ADMINISTRATION OF DRUGS | Tag No: A0405 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on document review and interview, it was determined that for 1 of 3 patients' (Pt. #13) clinical records reviewed in 3 East Medical-Surgical/Telemetry Unit for medication administration, the Hospital failed to ensure that the medication order was given in accordance with the approved medical staff policies and procedure. Findings include: 1. On 8/3/2021, the clinical record of Pt. #13 was reviewed. Pt. #13 was admitted on [DATE] due to hyperglycemia (high blood sugar) and opiate withdrawal. The clinical record included a physician's order to administer lispro insulin (medication to treat diabetes) 7 units SQ (subcutaneous/under the skin) three times a day (9:00 AM, 1:00 PM, and 5:00 PM). The clinical record indicated that lispro was not documented as given on 7/31/2021 at 9:00 AM, 1:00 PM, and 5:00 PM. The clinical record did not include the reason why the medication was not administered as ordered or that the physician was notified. 2. On 8/5/2021, the Hospital's policy titled, "Administration of Medication: General" (revised on 6/2021) was reviewed and included, "Policy: Administration of drugs shall be in accordance with... medical staff rules and regulations... Compliance with Drug Orders: Drugs shall be prepared and administered by or under the supervision of appropriately licensed personnel...shall be administered at the scheduled time or within 30 minutes before or after the scheduled time... Report drug administration errors... immediately to the attending physician..." 3. On 8/3/2021 at approximately 10:30 AM, findings were discussed with E #9 (Charge Nurse). E #9 could not provide documentation that lispro was given on 7/31/2021. E #9 stated that the nurse should have documented if the medication was given or not. If not given, E #9 added that reason for not giving the medication should have been documented. |
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| VIOLATION: UNUSABLE DRUGS NOT USED | Tag No: A0505 | |
| Based on document review, observation, and interview it was determined the Hospital failed to ensure unlabeled medication on the Adult Behavioral Health Unit was available for patient use. Findings include: 1. On 08/05/2021, the Hospital's policy titled, "Multi-Dose Vials" (dated 05/2021) was reviewed and included, " ...The following guidelines are used to determine the expiration dates for Multi-dose medications ...Insulin: After opening, may be kept 28 days, or until the expiration date set by the manufacturer on the vial, whichever comes first...Multiple Dose Vials: On nursing stations and in the IV (Intravenous) room, vials may be kept 28 days ...All medications must be dated and initialed upon opening ..." 2. On 08/03/2021 between approximately 9:45 AM - 11:30 AM, an observational tour of the Adult Behavioral Health Unit was conducted. During the tour, the following was observed: - One (1) Humulin R Insulin (medication to treat diabetes) Multi-Dose vial in the refrigerator open and available for use. The multi-dose vial was not labeled with an open date. 3. On 08/03/2021 at approximately 10:08 AM, the Director of Adult Behavioral Health Unit (E #2) was interviewed. E #2 stated, "The nurse should have dated the vial when it was opened." 4. On 08/05/2021 at approximately 10:20 AM, the Pharmacy Manager (E #21) was interviewed. E #21 stated that, " ...the multi-use vial of insulin is good for 28 days once it's opened, there should be a small sticker on the vial to indicate the open and expiration date..." |
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| VIOLATION: PERIODIC EQUIPMENT MAINTENANCE | Tag No: A0537 | |
| A. Based on observations, document review and interview, it was determined that the Hospital failed to ensure periodic and consistent calibration of equipment. This has the potential to affect all 64 patients on census that may require radiological services. Findings include: 1. On 08/05/2021 at approximately between 11:00 AM-11:35 AM, an observational tour was conducted of the Radiology Department. The following was observed: -Daily Quality Control Calibration logs (6/1/2021 through 8/5/2021) for the Prime-Aquillion CT (Computerized Tomography) machine were reviewed. The Daily Quality Control logs indicated that Quality Control test were not documented for the following dates: 06/08/2021, 06/17/2021, 06/18/2021 and 07/13/2021. 2. On 08/05/2021, the Hospital's policy titled, "Medical Equipment Management Plan (dated 07/15/21)" was reviewed and included, " II. (Name of Hospital) self-performed preventive, emergency maintenance and repairs on its patient care equipment. The Biomed engineer is responsible for adhering to the program requirements and performing test and preventative maintenance services as specified... these criteria address ...Intervals for... testing, and maintaining appropriate equipment on the inventory ..." 3. On 08/06/2021 at 10:30 AM, an interview was conducted with Director of Imaging Services (E # 31). E #31 stated that the CT technician should have completed the quality assurance calibration test daily to ensure consistency of results, and that the machine is functioning properly and image quality is not compromised. |
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| VIOLATION: DIRECTOR OF DIETARY SERVICES | Tag No: A0620 | |
| A. Based on document review, observation, and interview, it was determined that the Hospital failed to manage daily dietary services by not ensuring that foods were labeled with an opened or use-by date. This has the potential to affect 67 patients receiving oral diets on 8/4/2021. Findings include: 1. On 8/4/2021, the Hospital's policy titled, "Food Handling and Storage" (revised 4/2019) was reviewed and required, "...All bulk and dry items will be labeled with an open date...all food items with manufacturer's use by dates will be discarded on the date specified..." 2. A tour of Dietary Services was conducted on 8/4/2021 at 11:15 AM. The following was observed: - The walk in refrigerator #1, contained one open bin of burgers that was not labeled with the date opened or use-by date, one open package of turkey meat that was not labeled with the date opened or use-by date, and one open bin of pickles that was not labeled with the date opened or use-by date. -The walk in refrigerator #2, contained open bins of tomatoes, cucumbers, oranges, pears, apples, romaine lettuce, and onions that were not labeled with the date opened or use-by date. -The storage freezer contained one open bin of polish sausage that was not labeled with the date opened or use-by date, one open bin of hamburgers that was not labeled with the date opened or use-by date, and one open bin of chicken breasts that was not labeled with the date opened or use-by date. 3. On 8/4/2021 at 11:45 AM, an interview was conducted with the Dietary Manager (E #16). E #16 stated that all food items should be labeled with the date opened or use-by date. B. Based on document review, observation, and interview, it was determined that the Hospital failed to manage daily dietary services by not ensuring the foods which had expired were discarded. This had the potential to affect the 67 patients receiving oral diets on 8/4/2021. Findings include: 1. On 8/4/2021, the Hospital's policy titled, "Food Handling and Storage" (revised 4/2019) was reviewed and required, "...All food items...will be discarded on the date specified..." 2. A tour of Dietary Services was conducted on 8/4/2021 at 11:15 AM. The following was observed: - The walk in refrigerator #2 contained approximately 20 turkey sandwiches that were labeled with a use date by 8/3/2021. - The cooler contained approximately 30 chicken breasts in a pan with a use date by 8/3/2021. -The freezer contained one bin of chili with a use date by 6/9/2021. 3. On 8/4/2021 at 11:45 AM, an interview was conducted with the Dietary Manager (E #16). E #16 stated that food should be discarded according to the use date/expiration date. E #16 stated that the expired food will be thrown out. |
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| VIOLATION: PHYSICAL ENVIRONMENT | Tag No: A0700 | |
| 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 August 3 & 4, 2021, 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. |
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