HospitalInspections.org

Based on MR review and 5 of 5 interviews with facility staff, in 23 of 30 MR reviewed (#3, 4, 8, 9, 10, 11, 12, 18, 20, 27, 15, 16, 14, 6, 24, 23, 21, 19, 25, 22, 26, 29, 28), the hospital failed to ensure that patient discharge summaries, social service progress notes, social services substantiated diagnosis sheet and social services after care plans are completed by trained and licensed staff in the state of Wisconsin and authorized by the medical staff. The use of CNA's, SW, and LPN's to complete physician and social worker medical record documentation affected all 14 patients in the facility at the time of the survey and 23 of 30 MR reviewed.

Findings include:
Per review of CNA (R) personnel file and the state of Wisconsin CNA Registry information on the morning of 4/6/11 CNA (R) is in good standing as a CNA in the state of Wisconsin. Per review of his personnel file he holds no other training, certifications or licenses.

Per interview with RN (D) on 4/6/11 at 8:00 AM CNA (R) has worked for many years as a "Social Worker Assistant" in the hospital. Per (D), CNA (R) is doing physician discharge summaries, Social Worker progress notes, Social Worker Treatment Plan - Substantiated Diagnosis Sheet, and the patient After Care Plan for Social Services. See examples below.

Per review of CNA (R) job description on the morning of 4/6/11 his job responsibilities include the following: "III. A. 3. Dictate discharge summaries insuring timely completion." CNA (R) is not licensed to perform a physician discharge summary.

Per interview, with CNA (R) who was wearing a name tag that identified him as a "Social Worker Assistant", Administrator (J), DON (A) and Social Worker (X) on 4/6/11 at 10:00 AM, it was revealed that CNA (R) has worked for many years as a "Social Worker Assistant" in the hospital. Per CNA (R), he is doing physician discharge summaries, Social Worker progress notes, Social Worker Treatment Plan - Substantiated Diagnosis Sheet, and the patient After Care Plan for Social Services. Per CNA (R) he does not hold any other training, certifications or licenses with the state of Wisconsin that would allow him to perform as a physician or social worker.

Review of MR throughout the survey also revealed that an LPN and Social Workers are also completing physician discharge summaries without training or licenses to do so. See examples below. Review of the LPN and Social Worker job descriptions the morning of 4/6/11 did not reveal evidence that this task is assigned to them.

Review of the medical staff rules and regulations dated 4/2/08 directs the following: "B. Medical records 1. Responsibility for completing the medical record: The attending Practitioner shall be responsible for recording the discharge summary." 9. Discharge Summary: A discharge clinical summary shall be recorded on all medical records of patients."
The medical staff rules and regulations do not delegate this task to the LPN, CNA or Social Worker.

The CNA, LPN and Social Worker are working outside of their training, certification and licenses, job descriptions and medical staff rules and regulations.


18816


Examples by surveyor #18816:
Pt #3's MR reviewed by surveyor 18816 on 4/6/11 at 9:45 AM revealed Staff R completed SSPNs between 2/6/11 to 4/4/11 signing with the titled SWA. Staff R is a CNA and not licensed or qualified to chart in the SSPN. This is confirmed in interview with RN D on 4/6/11 at 11:45 AM.

Pt #4's MR reviewed by surveyor 18816 on 4/6/11 at 10:45 AM revealed Staff R completed the SDS signing with the titled SWA. Staff R completed the ACP signing with the title SWA. Staff R completed an SSPN on 4/4/11 signing with the title SWA. Staff R is a CNA and not licensed or qualified to complete a SDS, ACP or chart on the SSPN. This is confirmed in interview with RN D on 4/6/11 at 11:45 AM.

Pt #8's MR reviewed by surveyor 18816 on 4/5/11 at 10:45 AM revealed the DCS is dictated and signed by Staff R as a SWA, the ACP was competed and signed by Staff R as a SWA. Staff R completed a SSPN on dated 9/8/10, signing with the title SWA. Staff R is a CNA and not licensed or qualified to complete a DCS, ACP or chart in the SSPN. This is confirmed in interview with RN D on 4/6/11 at 8:00 AM.

Pt #9's MR reviewed by surveyor 18816 on 4/5/11 at 1:20 PM revealed the DCS is dictated by an LPN and authenticated by the DON. The ACP was competed and signed by Staff R as a SWA. Staff R completed a SDS signing with the title SWA. Staff R is a CNA and not licensed or qualified to complete an ACP or SDS. The DON and LPN are not licensed to complete a DCS. This is confirmed in interview with RN D on 4/6/11 at 8:00 AM.

Pt #10's MR reviewed by surveyor 18816 on 4/5/11 at 2:00 PM revealed the DCS is dictated by an LPN and authenticated by the DON. Staff R completed a SSPN on 9/10/10 signing with the title SWA. Staff R is a CNA and not licensed or qualified to chart in the SSPN. This is confirmed in interview with RN D on 4/6/11 at 8:00 PM.

Pt #11's MR reviewed by surveyor 18816 on 4/5/11 at 2:15 PM revealed Staff R completed a SDS signing with the title SWA. Staff R completed SSPNs on 9/20/10 signing with the title SWA. Staff R is a CNA and not licensed or qualified to chart in the SSPN. This is confirmed in interview with RN D on 4/6/11 at 8:00 PM.

Pt #12's MR reviewed by surveyor 18816 on 4/5/11 at 2:25 PM revealed the DSC is dictated by Staff R as a SWA. Staff R completed a SDS and SSPN dated 10/6/10 signing with the title SWA. Staff R is a CNA and not licensed or qualified to complete a SDS. This is confirmed in interview with RN D on 4/6/11 at 8:00 PM.

Pt #18's MR reviewed by surveyor 18816 on 4/6/11 at 11:30 AM revealed the DCS is dictated by a SW. The SW is not licensed or qualified to to complete a DCS. This is confirmed in interview with RN D on 4/6/11 at 8:00 PM.

Pt #20's MR reviewed by surveyor 18816 on 4/6/11 at 1:30 PM revealed the DCS is dictated by a SW. The ACP was competed and signed by Staff R as a SWA. Staff R completed a SSPN on 1/3/11 at 10:40 AM, signing with the title SWA. Staff R is a CNA and not licensed or qualified to complete ACP or chart in the SSPN. The SW is not licensed or qualified to complete a DCS. This is confirmed in interview with RN D on 4/6/11 at 2:15 PM.

Pt #27's MR reviewed by surveyor 18816 on 4/6/11 at 1:40 PM revealed the DSC is dictated and signed by Staff R as a SWA, the ACP was competed and signed by Staff R as a SWA. Staff R completed a SSPN on date "1010" and 11/30/10, signing with the title SWA. Staff R completed a SDS signing with the title SWA. Staff R is a CNA and not licensed or qualified to complete a DCS, ACP or chart in SSPN. This is confirmed in interview with RN D on 4/6/11 at 2:15 PM.

Examples by surveyor #29972:
Pt #15 MR reviewed by surveyor 29972 on 4/5/11 at 1:20 pm revealed the following: DCS was completed and signed by Staff R as a SWA. Staff R is a CNA and not licensed or qualified to complete a DCS. The treatment Plan-- substantiated diagnosis sheet was signed by Staff R as a SWA. The instructions on the top of the sheet state Social Worker will complete the document and Staff R is a CNA. This is confirmed in interview with RN D on 4/6/11 at 11:30 am.

Pt #16 MR reviewed by surveyor 29972 on 4/5/11 at 2:15 pm revealed the following: DCS was completed and signed by Staff R as a SWA. Treatment Plan-substantiated diagnosis sheet was signed by Staff R as a SWA. Instructions on sheet state Social Worker will complete and Staff R is a CNA. This is confirmed in interview with RN D on 4/6/11 at 11:30 am.

Pt #14 MR reviewed by surveyor 29972 on 4/5/11 at 3:30 pm revealed the following: DCS was completed and signed by Staff R as a SWA. Treatment Plan-substantiated diagnosis sheet was signed by Staff R as a SWA. Instructions on sheet state Social Worker will complete and Staff R is a CNA. After Care Plan completed and signed by Staff R as a SWA. This is confirmed in interview with RN D on 4/6/11 at 11:30 am.

Pt #6 MR reviewed by surveyor 29972 on 4/6/11 at 10:30 am revealed the following: Treatment Plan-substantiated diagnosis sheet was signed by Staff R as a SWA, instructions on sheet state Social Worker will complete and Staff R is a CNA. Discharge planning care plan signed by Staff R as a SWA, Staff R is listed as the responsible staff member.

Pt #24 ' s MR reviewed by surveyor 29972 on 4/6/11 at 1:30 pm revealed the following: DCS was completed and signed by Staff R as a SWA. Treatment Plan-substantiated diagnosis sheet was signed by Staff R as a SWA, instruction on the sheet state Social Worker will complete and Staff R is a CNA. After Care Plan completed and signed by Staff R as a SWA. This is confirmed in interview with RN D on 4/6/11 at 2:45pm.

Pt # 23 ' s MR reviewed by surveyor 29972 on 4/6/11 at 1:50 pm revealed the following: DCS completed and signed by Staff R as SWA. Treatment Plan-substantiated diagnosis sheet signed by Staff R as a SWA, instructions on sheet state Social Worker will complete and Staff R is a CNA. After Care Plan completed and signed by Staff R as a SWA. Staff R completed Social Service Progress note on 1/14, 1/17, and 1/18. This is confirmed in interview with RN D on 4/6/11 at 2:45 pm.

Examples by surveyor #29963:
Pt # 21 ' s MR reviewed by surveyor 29963 on 4/6/11 at 9:00 a.m. revealed the treatment plan diagnosis sheet was completed by Staff R as a SWA. Staff R is a CNA and not licensed or qualified to complete the diagnosis sheet. This was confirmed in interview with RN D on 4/6/11 at 11:35 p.m.

Pt # 19 ' s MR reviewed by surveyor 29963 on 4/6/11 at 10:00 a.m. revealed the treatment plan diagnosis sheet was completed by Staff R as a SWA. Staff R is a CNA and not licensed or qualified to complete the diagnosis sheet. This was confirmed in interview with RN D on 4/6/11 at 11:35 p.m.

Pt # 25 ' s MR reviewed by surveyor 29963 on 4/6/11 at 10:30 a.m. revealed the treatment plan diagnosis sheet was completed by Staff R as a SWA. Staff R is a CNA and not licensed or qualified to complete the diagnosis sheet. This was confirmed in interview with RN D on 4/6/11 at 11:35 p.m.

Pt # 22 ' 2 MR reviewed by surveyor 29963 on 4/6/11 at 10:45 a.m. revealed the After Care Plan was completed and signed by Staff R as a SWA. Staff R is a CNA and not licensed or qualified to complete the diagnosis sheet. This was confirmed in interview with RN D on 4/6/11 at 11:35 p.m.

Pt # 26 ' s MR reviewed by surveyor 29963 on 4/6/11 at 11:15 a.m. revealed the treatment plan diagnosis sheet was completed by Staff R as a SWA. Staff R is a CNA and not licensed or qualified to complete the diagnosis sheet. This was confirmed in interview with RN D on 4/6/11 at 11:35 p.m.

Pt # 29 ' s MR reviewed by surveyor 29963 on 4/6/11 at 1:15 p.m. revealed the treatment plan diagnosis sheet was completed by Staff R as a SWA. Staff R is a CNA and not licensed or qualified to complete the diagnosis sheet. This was confirmed in interview with RN D on 4/6/11 at 2:40 p.m.

Pt # 28 ' s MR reviewed by surveyor 29963 on 4/6/11 at 1:45 p.m. revealed the treatment plan diagnosis sheet was completed by Staff R as a SWA. The After Care Plan was completed and signed by Staff R as a SWA. Staff R is a CNA and not licensed or qualified to complete the diagnosis sheet. This was confirmed in interview with RN D on 4/6/11 at 2:40 p.m.

Based on 1 of 1 staff (A) interviews, record review, P&P review, and observations, it was determined that the hospital failed to be managed by an effective governing body (GB).

Findings include:

A. The pharmacy condition is not met as evidenced by:
1. The GB failed to ensure that medications are stored in a manner that provides for safety and immediate access. See Tag A-491

2. The GB failed to ensure that a pharmacist maintain overall responsibility for the pharmacy service. See Tag A-492

3. The GB failed to ensure that current and accurate records are kept of the receipt and distribution of all scheduled drugs. See Tag A-494

4. The GB failed to ensure open single use medications do not remain available for patient use. See Tag A-505

5. The GB failed to ensure that medication administration errors are reported to the patient's MD and that the medical record contains documentation related to the incident. See Tag A-508

6. The GB failed to ensure that a drug formulary with P&P for it's use is established and approved by the medical staff. See Tag A-511

The cumulative effect of these systemic pharmacy problems can lead to unsafe storage, use, administration, control and disposal of medications within the facility and result in the facility's inability to ensure that patient safety and well-being is ensured

B. The medical records condition is not met as evidenced by:
1. The GB failed to ensure that medical records are protected from possible loss or destruction. See Tag A-438

2. The GB failed to ensure that all entries into the medical record are complete, timed, dated and authenticated. See Tag A-450

3. The GB failed to ensure that orders are timed and dated and that all telephone, verbal and standing orders are authenticated within 48 hours of receipt. See Tag A-457

4. The GB failed to ensure that patient discharge summaries are completed by trained and licensed staff in the state of Wisconsin and authorized by the medical staff. See Tag A-468

5. The GB failed to ensure that all parts of the MR are completed within 30 days of discharge per medical staff rules and regulations. See Tag A-469

The cumulative effect of these systemic medical records problems resulted in the hospitals inability to ensure that all MR are complete, protected, and accurately reflect treatment rendered at the facility.


18816


C. The Quality Assurance and Performance Improvement Program condition is not met as evidenced by :
1. In 1 of 1 interviews, the Governing Body failed to ensure the QAPI program is functioning to provide tracking, trending, interventions and reevaluation of measurable indictors to promote quality care at the facility. See Tag 310.

2. In 1 of 1 interviews, the Governing Body failed to ensure the QAPI program is functioning to provide tracking, trending, interventions and reevaluation of measurable indictors related to medical errors. See Tag 311.

3. In 1 of 1 interviews, the Governing Body failed to ensure the QAPI program is functioning to provide set priorities for improvement and there is reevaluation of the indictors to promote quality care at the facility. See Tag 312.

4. In 1 of 1 interviews, the Governing Body failed to ensure the QAPI program is functioning to provide tracking, interventions and reevaluation of safety at the facility. See Tag 313.

5. In 1 of 1 interviews, the Governing Body failed to ensure the QAPI program is functioning to provide expectations for safety at the facility. See Tag 314.

The cumulative effect of failures to develop, implement, maintain, and evaluate an effective, data-driven, quality assessment and performance improvement program, resulted in the facility's inability to provide safe and optimal patient care.

D. The emergency services standard is not met as evidenced by:
1. The GB failed to ensure that the hospital is prepared to handle medical emergencies related to children as young as 12, failed to have medical protocols established by the medical staff to handle emergencies for both adults and children, and failed to have adequate staff trained to handle medical emergencies. (See Tag A093)

The lack of preparedness for medical emergencies could deny patients safe and adequate initial treatment of an emergency medical condition.

Based on record review and 2 of 2 staff (A, D) interviews, the hospital failed to be prepared to handle medical emergencies related to children as young as 12, failed to have medical protocols established by the medical staff to handle emergencies for both adults and children, and failed to have adequate staff trained to handle medical emergencies. The lack of preparedness for medical emergencies could deny patients safe and adequate initial treatment of an emergency medical condition.

Findings include:
1. Interview with RN D by surveyor 29972 on 4/6/11 at 8:15 revealed the following: the facility treats patients 12 years old and up. RN D confirmed there is no specialized pediatric training or competencies for staff related to the care of the child as young as 12 years old. An interview with RN A on 4/6/11 at 1:20pm confirmed there are no children's care manual, reference books, or policy and procedures in place on providing care to children.

RN A also confirmed in interview there is no child ambu bag on site for treatment in case of an emergency.

2. Per interview, with DON (A) on 4/6/11 at 10:15 AM, the facility only has a couple of protocols established for medical emergencies. The hospital nursing staff are trained in cardio-pulmonary resuscitation and to just call 911. Per (A), the hospital does not have protocols established by the medical staff with staff training for the following examples of medical emergencies: chest pain (incomplete protocol), burns, seizures, congestive heart failure, severe lacerations, anaphylactic shock, deliveries of babies etc.

Per (A), the hospital medical staff have not adopted an emergency room manual that would direct staff in the event of a medical emergency.

Based on MR review, review of P&P, and interview with staff, in 9 of 11 Medicare/Medicaid Pts (#8, 11, 18, 27, 16, 13, 14, 24, 23) out of a total of 30 MR reviewed, the facility failed to ensure that the Medicare Beneficiary Notice (MBN) is given to Pts within 48 hours of admission and within 48 hours of discharge. The lack of a notification of these Medicare rights resulted in patient 's #8, 11, 18, 27, 16, 13, 14, 24, 23 inability to appeal discharge from the facility.

Findings include:
Review of the P&P "Medicare Beneficiaries Notice of Their rights, Including Discharge dated 4/4/08, directs the following: "Upon admission , the Medicare patient/guardian will receive The Important Message from Medicare (OMB#0938-0692) CMS-R-193." "The business office staff will give the IM form to the Medicare patient/guardian upon admission or as far as possible in advance, but not more than two calendar days before discharge."


18816

Examples by surveyor #18816:
Per surveyor 18816 interview with DON A on 4/6/11 at approximately 11:30 AM verified that the facility has the "An Important Message from Medicare About Your Rights". Per surveyor interview with RN D on 4/6/11 at 8:00 AM, RN D is unaware the MBN is to be given to the Pts within 48 hours of admission and within 48 hours of discharge.

Pt #8's MR review by surveyor 18816 on 4/5/11 at 10:45 PM revealed the patient was admitted on 8/27/10. There is no evidence Pt #8 received the MBN within 48 hours of admission and within 48 hours of discharge. This is confirmed in interview with RN D on 4/6/11 at 8:00 AM.

Pt #11's MR review by surveyor 18816 on 4/5/11 at 2:15 PM revealed the patient was admitted on 9/29/10. There is no evidence Pt #11 received the MBN within 48 hours of admission and within 48 hours of discharge. This is confirmed in interview with RN D on 4/6/11 at 8:00 AM.

Pt #18's MR review by surveyor 18816 on 4/6/11 at 11:30 AM revealed the patient was admitted on 10/29/10. There is no evidence Pt #18 received the MBN within 48 hours of admission and within 48 hours of discharge. This is confirmed in interview with RN D on 4/6/11 at 11:45 AM.

Pt #27's MR review by surveyor 18816 on 4/6/11 at 1:40 PM revealed the patient was admitted on 11/29/10. There is no evidence Pt #27 received the MBN within 48 hours of admission and within 48 hours of discharge. This is confirmed in interview with RN D on 4/6/11 at 2:15 AM.

Examples by surveyor #29972:
Pt #16 ' s MR reviewed by surveyor 29972 on 4/5/11 at 2:15pm revealed the patient was admitted on 12/27/10. There is no evidence pt #16 received the MBN within 48 hours of admission and within 48 hours of discharge. This is confirmed in interview with RN D on 4/6/11 at 11:30am.

Pt #13 ' s MR reviewed by surveyor 29972 on 4/6/11 at 8:35am revealed the patient was admitted on 11/20/10. There is no evidence pt #13 received the MBN within 48 hours of admission and within 48 hours of discharge. This is confirmed in interview with RN D on 4/6/11 on 11:30am.

Pt #14 ' s MR reviewed by surveyor 29972 on 4/6/11 at 9:30am revealed the patient was admitted on 12/9/10. There is no evidence pt #14 received the MBN within 48 hours of admission and within 48 hours of discharge. This is confirmed in interview with RN D on 4/6/11 at 11:30 am.

Pt # 24 ' s MR reviewed by surveyor 29972 on 4/6/11 at 1:30pm revealed the patient was admitted on 1/25/11. There is no evidence pt #24 received the MBN within 48 hours of admission and within 48 hours of discharge. This is confirmed in interview with RN D on 4/6/11 at 2:45pm.

Pt #23 ' s MR reviewed by surveyor 29972 on 4/6/11 at 1:50pm revealed the patient was admitted on 1/13/11. There is no evidence pt #23 received the MBN within 48 hours of admission and within 48 hours of discharge. This is confirmed in interview with RN D on 4/6/11 at 2:45pm.

Based on review of QAPI minutes, and interview with staff, in 1 of 1 interview (A and V), there is no effective QAPI program that includes tracking, trending, interventions and reevaluation of indicators to monitor and improve safe quality care of patients at the facility. This deficient practice affects all 14 patients in the facility during the survey.

Findings include:

In 1 of 1 interview, there is no tracking of the quality of contracted services. See Tag 267.
In 1 of 1 interview, there is no trending and analysis of data gathered. See Tag 275.
In 1 of 1 interview, there is no improvement plan for data gathered. See Tag 276.
In 1 of 1 interview, there is no analysis of medication error data gathered. See Tag 287.
In 1 of 1 interview, there are no plans and implementation of plans to improve on medication errors. See Tag 288.
In 1 of 1 interview, there is no reevaluation of interventions taken to improve medication errors. See Tag 290.
In 1 of 1 interview, there is no documentation of sustained improvement on medication errors. See Tag 291.
In 1 of 1 interview, there is no identified QAPI projects for various departments in the facility. See Tag 297.
In 1 of 1 interview, the Governing Body failed to ensure the QAPI program is functioning to provide tracking, trending, interventions and reevaluation of measurable indictors to promote quality care at the facility. See Tag 310.
In 1 of 1 interview, the Governing Body failed to ensure the QAPI program is functioning to provide tracking, trending, interventions and reevaluation of measurable indictors related to medical errors. See Tag 311.
In 1 of 1 interview, the Governing Body failed to ensure the QAPI program is functioning to provide set priorities for improvement and there is reevaluation of the indictors to promote quality care at the facility. See Tag 312.
In 1 of 1 interview, the Governing Body failed to ensure the QAPI program is functioning to provide tracking, interventions and reevaluation of safety at the facility. See Tag 313.
In 1 of 1 interview, the Governing Body failed to ensure the QAPI program is functioning to provide expectations for safety at the facility. See Tag 314.

The cumulative effect of failures to develop, implement, maintain, and evaluate an effective, data-driven, quality assessment and performance improvement program, resulted in the facility's inability to provide safe and optimal patient care.

Based on review of QAPI minutes, and interview with staff, in 1 of 1 interview (A and V), there is no tracking of the quality of contracted services. This deficient practice affects all 14 patients in the facility during the survey.

Findings include:
Per surveyor 18816 interview with RN V and DON A, on 4/6/11 at 8:55 AM, they do not gather data on contracted services including radiology, therapy services, laboratory services, pharmacy services, medical staff, AODA and organ donation.

Based on review of QAPI minutes, and interview with staff, in 1 of 1 interview (A and V), there is no trending and analysis of data gathered. This deficient practice affects all 14 patients in the facility during the survey.

Findings include:
Per surveyor 18816 interview with RN V and DON A on 4/6/11 at 8:55 AM, they gather data on medication errors, incidents, restraints, Pt satisfaction and case reviews, but only discuss in meetings. Per RN V, there is no analyzing or trending of this information for determining improvement measures.

Based on review of QAPI minutes, and interview with staff, in 1 of 1 interview (A and V), there is no improvement plan for data gathered. This deficient practice affects all 14 patients in the facility during the survey.

Findings include:
Per surveyor 18816 interview with RN V and DON A on 4/6/11 at 8:55 AM, they gather data on medication errors, incidents, restraints, Pt satisfaction and case reviews, but only discuss in meetings. Per RN V, there is no improvement plan for this information.

Based on review of QAPI minutes, and interview with staff, in 1 of 1 interview (A and V), there is no analysis of medication administration error data gathered. This deficient practice affects all 14 patients in the facility during the survey.

Findings include:
Per surveyor 18816 interview with RN V and DON A on 4/6/11 at 8:55 AM, they gather data on medication errors, but only discuss in meetings. Per RN V, there is no analysis for the cause of the medication errors.

Based on review of QAPI minutes, and interview with staff, in 1 of 1 interview (A and V), there are no plans and implementation of plans to improve on medication administration errors. This deficient practice affects all 14 patients in the facility during the survey.

Findings include:
Per surveyor 18816 interview with RN V and DON A on 4/6/11 at 8:55 AM, they gather data on medication errors, but only discuss in meetings. Per RN V, there is no plan in place to implement for improving medication errors.

Based on review of QAPI minutes, and interview with staff, in 1 of 1 interview (A and V), there is no action taken to improve on medication errors. This deficient practice affects all 14 patients in the facility during the survey.

Findings include:
Per surveyor 18816 interview with RN V and DON A on 4/6/11 at 8:55 AM, they gather data on medication errors, but only discuss in meetings. Per RN V, there is no action taken to improve medication errors.

Based on review of QAPI minutes, and interview with staff, in 1 of 1 interview (A and V), there is no reevaluation of interventions taken to improve medication errors. This deficient practice affects all 14 patients in the facility during the survey.

Findings include:
Per surveyor 18816 interview with RN V and DON A on 4/6/11 at 8:55 AM, they gather data on medication errors, but only discuss in meetings. Per RN V, there is no reevaluation of interventions to improve medication errors.

Based on review of QAPI minutes, and interview with staff, in 1 of 1 interview (A and V), there is no documentation of sustained improvement on medication errors. This deficient practice affects all 14 patients in the facility during the survey.

Findings include:
Per surveyor 18816 interview with RN V and DON A on 4/6/11 at 8:55 AM, they gather data on medication errors, but only discuss in meetings. Per RN V, there is no documentation of ongoing monitoring showing improved results in medication errors.

Based on review of QAPI minutes, and interview with staff, in 1 of 1 interview (A and V), there is no identified QAPI projects for various departments in the facility. This deficient practice affects all 14 patients in the facility during the survey.

Findings include:
Per surveyor 18816 interview with RN V and DON A on 4/6/11 at 8:55 AM, they gather data on medication errors, incidents, restraints, Pt satisfaction and case reviews, but only discuss in meetings. Per RN V, there are no identified QAPI projects that individual departments are working on.

Based on review of QAPI minutes and interview with staff in 1 of 1 interviews (A and V) the Governing Body failed to ensure the QAPI program is functioning to provide tracking, trending, interventions and reevaluation of measurable indictors to promote quality care at the facility. This deficiency affects all 14 patients in the facility during the survey.

Findings include:
Per surveyor 18816 interview on 4/6/11 at 8:55 AM with RN V and DON A, the QAPI meeting minutes are reported to the Governing Body on a quarterly basis. The QAPI meeting minutes include only discussion of incidents, medication errors, restraints, Pt satisfaction and case reviews. There is no data on tracking, trending, interventions and reevaluation of measurable indicators to promote quality care incorporating all departments of the facility.

Based on review of QAPI minutes and interview with staff in 1 of 1 interviews (A and V) the Governing Body failed to ensure the QAPI program is functioning to provide tracking, trending, interventions and reevaluation of measurable indictors related to medical errors. This deficiency affects all 14 patients in the facility during the survey.

Findings include:
Per surveyor 18816 interview on 4/6/11 at 8:55 AM with RN V and DON A, the QAPI meeting minutes are reported to the Governing Body on a quarterly basis. The QAPI meeting minutes include only discussion of incidents, medication errors, restraints, Pt satisfaction and case reviews. There is no data on tracking, trending, interventions and reevaluation of measurable indicators related to medical errors.

Based on review of QAPI minutes and interview with staff in 1 of 1 interviews (A and V) the Governing Body failed to ensure the QAPI program is functioning to provide priorities for improvement and there is reevaluation of the indictors to promote quality care at the facility. This deficiency affects all 14 patients in the facility during the survey.

Findings include:
Per surveyor 18816 interview on 4/6/11 at 8:55 AM with RN V and DON A, the QAPI meeting minutes are reported to the Governing Body on a quarterly basis. The QAPI meeting minutes include only discussion of incidents, medication errors, restraints, Pt satisfaction and case reviews. There is no data indicating priorities are set by the Governing Body for reevaluation of indicators for all departments in the facility.

Based on review of QAPI minutes and interview with staff in 1 of 1 interviews (A and V) the Governing Body failed to ensure the QAPI program is functioning to provide tracking, interventions and reevaluation of safety at the facility. This deficiency affects all 14 patients in the facility during the survey.

Findings include:
Per surveyor 18816 interview on 4/6/11 at 8:55 AM with RN V and DON A, the QAPI meeting minutes are reported to the Governing Body on a quarterly basis. The QAPI meeting minutes include only discussion of Pt satisfaction. There is no data on trending, interventions and reevaluation to improve on patient safety.

Based on review of QAPI minutes and interview with staff in 1 of 1 interviews (A and V) the Governing Body failed to ensure the QAPI program is functioning to provide expectation of patient safety. This deficiency affects all 14 patients in the facility during the survey.

Findings include:
Per surveyor 18816 interview on 4/6/11 at 8:55 AM with RN V and DON A, the QAPI meeting minutes are reported to the Governing Body on a quarterly basis. The QAPI meeting minutes include only discussion of incidents, medication errors, restraints, Pt satisfaction and case reviews. There is no data on tracking, trending, interventions and reevaluation of measurable indicators to promote quality safety measures throughout the facility.

Based on review of QAPI minutes and interview with staff in 1 of 1 interviews (A and V) the Governing Body failed to ensure the QAPI program is functioning to provide how many projects will be included in the QAPI program on an annual basis. This deficiency affects all 14 patients in the facility during the survey.

Findings include:
Per surveyor 18816 interview on 4/6/11 at 8:55 AM with RN V and DON A, the QAPI meeting minutes are reported to the Governing Body on a quarterly basis. The QAPI meeting minutes do not include how many projects will be included in the annual QAPI program.

Based on observation and review of P & P, in 1 of 1 observation (V) the facility failed to ensure medications are administered in a safe and sanitary manner. This deficiency affects all 14 patient at the facility during survey.

Findings include:
Per surveyor 18816 observation of RN V administering medications on 4/6/11 at 7:30 AM, RN V washed her hands and while obtaining the medications, dropped the pills from the blister pack into her hand then into the paper souffle cup to take to the patient. RN V was observed to look at a name bracelet that had only the first name, and not further identify the patient by full name, or other means of identification. This procedure was repeated for 3 consecutive patients.

The above observations were reviewed with DON A at 4:00 PM on 4/6/11.

Based on one of one (D) staffinterview, record review, and P&P review, it was determined that the hospital failed to have an effective medical record management system.

Findings include:

1. The facility failed to ensure that medical records are protected from possible loss or destruction. See Tag A-438
2. The hospital failed to ensure that all entries into the medical record are complete, timed, dated and authenticated. See Tag A-450
3. The hospital failed to ensure that orders are timed and dated and that all telephone, verbal and standing orders are authenticated within 48 hours of receipt. See Tag A-457
4. The hospital failed to ensure that patient discharge summaries are completed by trained and licensed staff in the state of Wisconsin and authorized by the medical staff. See Tag 468
5. The hospital failed to ensure that all parts of the MR are completed within 30 days of discharge per medical staff rules and regulations. See Tag A-469

The cumulative effect of these systemic medical records problems resulted in the hospitals inability to ensure that all MR are complete, protected, and accurately reflect treatment rendered at the facility.

Based on observations of 1 of 3 storage rooms for MR, and 1 of 1 interview with staff by surveyor #13469, the facility failed to ensure that medical records are kept off the floor.
The deficiency allows for possible loss or destruction due to water damage.

Findings include:
Per review, of MR Standards and Management P&P dated 2/25/04 on the morning of 4/6/11, the policy directs the following: " II. Retention/preservation of medical records: Records will be preserved intact and retained indefinitely."

Per observation, while touring the facility medical record storage rooms on 4/5/11 at 8:30 AM with Medical Records Director (B), it was noted that patient medical records stored in the "old morgue" were in boxes resting directly on the floor. In addition, there were several piles of medical records outside boxes resting directly on the floor.

Based on MR review and interviews with facility staff , in 29 of 30 MR reviewed (#1, 3, 4, 5, 7, 8, 9, 10, 11, 12, 18, 20, 27, 30, 15, 16, 17, 13, 14, 6, 24, 23, 21, 19, 25, 22, 26, 29, and 28) the hospital failed to ensure that all entries into the medical record are complete, timed, dated and authenticated. The lack of a complete record to include timing, dating and authenticating entries into the MR does not provide a chronological picture of the patient's progress to delineate the course of treatment.

Findings include:
Per review of the medical staff rules and regulations dated 4/2/08 on the morning of 4/6/11 by surveyor #13469, the rules direct the following:"B Medical Records: 1. Responsibility for Completing the medical record: 6. Clinical entries. b. All clinical entries in the patient's medical record shall be accurately dated, timed, authenticated with the name and title of the person making the entry."


18816

Examples by surveyor #18816:
Pt #1's MR reviewed by surveyor 18816 on 4/4/11 at 3:20 PM revealed the following: The PIE dated 3/28/11 does not include an evaluation of Pt 1's intelligence, orientation, memory and weaknesses. This is confirmed in interview with DON A on 4/5/11 at 7:30 AM.

Pt #3's MR reviewed by surveyor 18816 on 4/6/11 at 9:45 AM revealed the following: The PIE dated 2/16/11 does not include an evaluation of Pt 1's weaknesses, and is not authenticated by the MD with a date and time. The Statement of Patient's Rights, is not timed when signed. This is confirmed in interview with RN D on 4/6/11 at 11:45 AM.

Pt #4's MR reviewed by surveyor 18816 on 4/6/11 at 10:45 AM revealed the following: The PIE dated 3/31/11 does not include an evaluation of Pt 1's weaknesses, and is not authenticated by the MD with a date and time. The consents for the medications Lamictal, Lithium Carbonate, Zolpidem are not timed when signed. The consent to treatment and medication and the Notification of Advance Directives are not timed when signed. This is confirmed in interview with RN D on 4/6/11 at 11:45 AM.

Pt #5's MR reviewed by surveyor 18816 on 4/6/11 at 11:00 AM revealed the following: The PIE dated 4/1/11 does not include an evaluation of Pt 1's weaknesses, and is not authenticated by the MD with a date and time. The consents for the medications Zoloft and Clonazepam are not timed when signed. The Statement of Patient's Rights is not timed when signed. This is confirmed in interview with RN D on 4/6/11 at 11:45 AM.

Pt #7's MR reviewed by surveyor 18816 on 4/6/11 at 1:30 PM revealed the following: The PIE dated 4/3/11 does not include an evaluation of Pt 7's weaknesses, and is not authenticated by the MD with a date and time. This was confirmed in interview with RN D on 4/6/11 at 2:15 PM.

Pt #8's MR reviewed by surveyor 18816 on 4/5/11 at 10:45 AM revealed the following: Pt #8 was discharged on 9/9/10, the DSC is not authenticated with a date and time by the MD. The PIE dated 8/27/10 does not include an evaluation of Pt 7's weaknesses, and is not authenticated with a date and time by the MD. The Conditional Transfer agreement is not timed when signed. There are SSPNs between 8/27/10 and 9/9/10 that are not timed when written. This was confirmed in interview with RN D on 4/6/11 at 8:00 AM.

Pt #9's MR reviewed by surveyor 18816 on 4/5/11 at 1:40 PM revealed the following: The PIE dated 9/8/10 does not include an evaluation of Pt 9's weaknesses, and is not authenticated by the MD with a date and time. The Admissions Unit Statement of Rights on Emergency Detention, the Consent for Treatment and Medication, and the Notification of Advanced Directives are not timed when signed. This is confirmed in interview with RN D on 4/6/11 at 8:00 AM.

Pt #10's MR reviewed by surveyor 18816 on 4/5/11 at 2:00 PM revealed the following: The SSPNs dated 9/10/11 are not timed when written. Admissions Unit Statement of Rights on Emergency Detention, the Consent for Treatment and Medication, the consents for Prozac, Buspar, Clonazepam, Trazodone and Diphenhydramine are not timed when signed. This is confirmed in interview with RN D on 4/6/11 at 8:00 AM.

Pt #11's MR reviewed by surveyor 18816 on 4/5/11 at 2:15 PM revealed the following: The PIE dated 9/30/10 does not include an evaluation of Pt 11's weaknesses, and is not authenticated by the MD with a date and time. The dictated Psychotherapy Narratives for 10/1/10 and 10/4/10 are not authenticated with a date and time. The consents for medication and treatment are not timed when signed. This is confirmed in interview with RN D on 4/6/11 at 8:00 AM.

Pt #12's MR reviewed by surveyor 18816 on 4/5/11 at 2:25 PM revealed the following. The PIE dated 10/5/10 does not include an evaluation of Pt 12' s weaknesses, and is not authenticated by the MD with a date and time. The Statement of Rights on Emergency Detention is not timed when signed. This is confirmed in interview with RN D on 4/6/11 at 8:00 AM.

Pt #18's MR reviewed by surveyor 18816 on 4/6/11 at 11:30 AM revealed the following: Pt #18 was discharged on 1/18/11, the DCS has no date it was dictated or transcribed, and the MD did not date and time when it was authenticated. The PIE dated 4/15/10 does not include an evaluation of Pt 18's intelligence, orientation, memory, and weaknesses; and it is not authenticated with a date and time by the MD. The medication consent forms for Haloperidol and Diphenhydramine are not timed when signed. This was confirmed in interview with RN D on 4/6/11 at 11:45 AM.

Pt #20's MR reviewed by surveyor 18816 on 4/6/11 at 1:30 PM revealed the following: Pt #20 was discharged on 1/3/11, the DCS has no date it was dictated or transcribed, and the MD did not date and time when it was authenticated. The PIE dated 12/29/10 does not include an evaluation of Pt 20's intelligence, orientation, memory, and weaknesses; and it is not authenticated with a date and time by the MD. The medical progress note dated 1/2/11 is not timed by the MD. The medication consent forms for Haloperidol and Celexia are not timed when signed. This was confirmed in interview with RN D on 4/6/11 at 2:15 PM.

Pt #27's MR reviewed by surveyor 18816 on 4/6/11 at 1:40 PM revealed the following: Pt #27 was discharged on 12/1/10, the DCS revealed the MD did not date and time when it was authenticated. The PIE dated 11/29/10 does not include an evaluation of Pt 27's weaknesses; and it is not authenticated with a date and time by the MD. The medication consent form for Seroquel are not timed when signed. This was confirmed in interview with RN D on 4/6/11 at 2:15 PM.

Pt #30's MR reviewed by surveyor 18816 on 4/6/11 at 2:00 PM revealed the following: The PIE dated 2/11/11 does not include an evaluation of Pt 30's weaknesses; and it is not authenticated with a date and time by the MD. The medication consent forms for Carbamazepine, the Authorization for Treatment, and the Notification of Advanced Directives are not timed when signed. This was confirmed in interview with RN D on 4/6/11 at 2:15 PM.

Examples by surveyor #29972:
Pt #15 ' s MR reviewed by surveyor 29972 on 4/5/11 at 1:20 pm revealed the following: Pt #15 was discharged 12/23/10; the MD did not authenticate the DCS with the date and time. The general medical evaluation dated 12/22/10 was not timed by the MD. The progress notes/care plan dated 12/22/10 is not timed. The discharge planning care plan is not completed, dated, or signed by the responsible staff. The PIE does not contain an evaluation of pt #15 ' s weaknesses. This is confirmed in interview with RN D on 4/6/11 at 11:30 am.

Pt # 16 ' s MR reviewed by surveyor 29972 on 4/5/11 at 2:15 pm revealed the following: pt #16 was discharged on 12/28/10; the MD did not authenticate the DCS with the date and time. The statement of patient rights dated 12/27/10 was not timed. The PIE does not include an evaluation of pt #16 ' s weaknesses. This is confirmed in interview with RN D on 4/6/11 at 11:30 am.

Pt #17 ' s MR reviewed by surveyor 29972 on 4/5/11 at 3:30 pm revealed the following: pt #17 was discharged on 12/29/10, the DCS has no dictation or transcription date and time, and the MD did not date and time when it was authenticated. The PIE does not include an evaluation of pt#17 weaknesses. The discharge planning care plan and coping with a break up care plan is not completed, dated or signed by the responsible staff. This is confirmed in interview with RN D on 4/6/11 at 11:30 am.

Pt #13 ' s MR reviewed by surveyor 29972 on 4/6/11 at 8:35 am revealed the following: pt #13 was discharged on 12/9/11, the DCS has no dictation or transcription date and time, and the MD did not date and time when it was authenticated. The PIE does not include an evaluation of pt #13 weaknesses. This is confirmed in interview with RN D on 4/6/11 at 11:30 am.

Pt #14 ' s MR reviewed by surveyor 29972 on 4/6/11 at 9:30 am revealed the following: pt #14 was discharged on 12/13/10, the DCS has no dictation or transcription date and time and the MD did not date and time when it was authenticated. The PIE does not include evaluation of pt #14 weaknesses. The discharge planning care plan and Hallucinations care plan are not completed, dated or signed by the responsible staff. This is confirmed in interview with RN D on 4/6/11 at 11:30 am.

Pt #6 ' s MR reviewed by surveyor 29972 on 4/6/11 at 10:30 am revealed the following: pt #6 ' s discharge planning care plan is not signed and dated. PIE does not include an evaluation of pt #6 ' s weaknesses. This is confirmed in interview with RN D on 4/6/11 at 11:30 am.

Pt #24 ' s MR reviewed by surveyor 29972 on 4/6/11 at 1:30 pm revealed the following: pt #6 was discharged on 1/28/11; the DCS is not authenticated with date and time by the MD. The PIE does not include evaluation of pt #24 ' s weaknesses. The discharge planning care plan is not completed, dated, or signed by responsible staff. This is confirmed in interview with RN D on 4/6/11 at 2:45 pm.

Pt #23 ' s MR reviewed by surveyor 29972 on 4/6/11 at 1:50 pm revealed the following: pt #23 was discharged on 1/18/11; the DCS has no dictation or transcription date, and the MD did not date and time when it was authenticated. The PIE does not include pt #23 ' s weaknesses. Nurses admission intake notes dated 1/13/11 are not timed on pages 3 and 4. Social Services progress notes dated 1/14, 1/17, and 1/18 are not timed. Discharge planning care plan and auditory hallucination and coping with legal charges treatment plans are not completed, dated, and signed by responsible staff. This is confirmed in interview with RN D on 4/6/11 at 2:45 pm.

Examples by surveyor #29963:
Pt #21 ' s MR reviewed by surveyor 29963 on 4/6/10 at 9:00 a.m. revealed the following: Pt # 21 was discharged on 1/11/11; the DCS was dictated on 3/15/11 at 1:55 p.m. and transcribed on 3/16/11 at 10:34 a.m., the MD did not date and time when it was authenticated. The progress note dated 1/10/11 is not timed by the staff. The medication consent form for Olanzapine is not signed, dated or timed by staff. The treatment plan listing strengths is not completed, dated or signed by staff. The statement of patient rights form is not timed by staff. This is confirmed in interview with RN D on 4/6/11 at 11:35 a.m.

Pt #19 ' s MR reviewed by surveyor 29963 on 6/6/11 at 10:00 a.m. revealed the following: Pt # 19 was discharged on 11/10/10; the DCS was dictated on 1/11/11 at 7:27 a.m. and transcribed on 2/1/11 at 10:50 a.m., the MD did not date and time when it was authenticated. The PIE does not include an evaluation of Pt. # 19 ' s weaknesses, and it is not authenticated with a date and time by the MD. The psychotherapy narrative note is not dated or timed by the MD. The physician order dated 11/10/10 is not dated by the MD. This is confirmed in interview with RN D on 4/6/11 at 11:35 a.m.

Pt # 25 ' s MR reviewed by surveyor 29963 on 4/6/11 at 10:30 revealed the following: the DCS was not authenticated with a date and time by the MD. This is confirmed in interview with RN D on 4/6/11 at 11:35 a.m.

Pt # 22 ' s MR reviewed by surveyor 29963 on 4/6/11 at 10:45 a.m. revealed the following: the DCS was not authenticated with a date and time by the MD. This is confirmed in interview with RN D on 4/6/11 at 11:35 p.m.

Pt # 26 " s MR reviewed by surveyor 29963 on 4/6/11 at 11:15 a.m. revealed the following: Pt # 26 was discharged on 3/3/11, no discharge summary noted. This is confirmed in interview with RN D on 4/6/11 at 11:35 a.m.

Pt # 29 ' s MR reviewed by surveyor 29963 on 4/6/11 at 1:15 p.m. revealed the following: Pt # 29 was discharged on 8/9/10; the DCS was dictated on 9/27/10 at 11:35 a.m. and transcribed on 9/30/10 at 1:35 a.m., MD did not date and time when it was authenticated. The notification of advanced directives form is not completed, or timed by staff. This is confirmed in interview with RN D on 4/6/11 at 2:40 p.m.

Pt # 28 ' s MR reviewed by surveyor 29963 on 4/6/11 at 1:45 p.m. revealed the following: Pt # 28 was discharged on 12/20/10; the DCS was dictated on 2/16/11 at 3:09 p.m. and transcribed on 3/2/11 at 1:18 p.m., MD did not date and time when it was authenticated. This is confirmed in interview with RN D on 4/6/11 at 2:40 p.m.

Based on MR review, review of medical staff rules and regulations, and interviews with facility staff, in 20 of 30 MR reviewed, (#1, 3, 4, 5, 7, 8, 9, 10, 11, 12, 18, 20, 27, 30, 23, 26, 19, 22, 26, 29), the hospital failed to ensure that orders are timed and dated and that all telephone, verbal and standing orders are authenticated within 48 hours of receipt. The lack of dating and timing of orders does not provide a chronological picture to delineate the course of treatment. The lack of physician validation of telephone, verbal and standing orders within 48 hours could result in inaccurate and inappropriate medication administration and treatment of patients.

Findings include:
Per review, of the medical staff Rules and Regulations dated 4/2/08 on the morning of 4/6/11, the rules direct the following: "C. General conduct of Care: 2. Verbal and Telephone Orders: C. All verbal and telephone orders shall be dated, timed and authenticated in writing by a practitioner who is authorized to write orders by hospital policy within 48 hours."

Examples by surveyor #18816:
Pt #1's MR reviewed by surveyor 18816 on 4/4/11 at 3:20 PM revealed VOs written on 3/27/11 and 4/2/11 are not authenticated by the MD with a date and time. The exclusion of a date or time with the MD countersignature does not identify if the verbal orders were countersigned within 48 hours. This is confirmed in interview with DON A on 4/5/11 at 7:30 AM.

Pt #3's MR reviewed by surveyor 18816 on 4/6/11 at 9:45 AM revealed VOs written on 2/25/11 and 3/29/11 are not authenticated by the MD with a date and time. The exclusion of a date or time with the MD countersignature does not identify if the verbal orders were countersigned within 48 hours. This is confirmed in interview with RN D on 4/6/11 at 11:45 AM.

Pt #4's MR reviewed by surveyor 18816 on 4/6/11 at 10:45 AM revealed VOs written between 3/31/11 and 4/4/11 are not authenticated by the MD with a date and time.

Pt #5's MR reviewed by surveyor 1886 on 4/6/11 at 11:00 AM revealed a VO written on 3/31/11 is not authenticated by the MD with a date and time. An SO written on 3/31/11 is not dated or timed when written, does not include the MD that ordered the medication and is not authenticated by the MD with a date and time. This is confirmed in interview with RN D on 4/6/11 at 11:45 AM.

Pt #7's MR reviewed by surveyor 18816 on 4/6/11 at 1:15 PM revealed a VO written on 4/3/11, and a SO written on 4/4/11 are not authenticated by the MD with a date and time. This is confirmed in interview with RN D on 4/6/11 at 8:00 AM.

Pt #8's MR reviewed by surveyor 18816 on 4/5/11 at 10:45 AM revealed a VO written on 9/1/10 is not authenticated by the MD with a date and time. This is confirmed in interview with RN D on 4/6/11 at 8:00 AM.

Pt #9's MR reviewed by surveyor 18816 on 4/5/11 at 1:20 AM revealed a VO written on 9/9/10 is not authenticated by the MD with a date and time. This is confirmed in interview with RN D on 4/6/11 at 8:00 AM.

Pt #10's MR reviewed by surveyor 18816 on 4/5/11 at 2:00 PM revealed VOs written on 9/11/10 and 9/13/10, TOs written on 9/12/10, and a SO written on 9/12/10 that are not authenticated by the MD with a date and time. This is confirmed in interview with RN D on 4/6/11 at 8:00 AM.

Pt #11's MR reviewed by surveyor 18816 on 4/5/11 at 2:15 PM revealed the SO written on 10/1/10, and the VO written on 10/4/10 are not authenticated by the MD with a time and/or date. This is confirmed in interview with RN D on 4/6/11 at 8:00 AM.

Pt #12's MR reviewed by surveyor 18816 on 4/6/11 at 2:25 PM revealed VOs written on 10/5/10, 10/8/10 and 10/12/10 are not authenticated by the MD with a date and time. This is confirmed in interview with RN D on 4/6/11 at 8:00 AM.

Pt #18's MR reviewed by surveyor 18816 on 4/5/11 at 11:30 AM revealed TOs written on 1/16/11, a SO written on 1/17/11 and a VO written on 1/17/11 are not authenticated by the MD with a date and time. On 1/16/11 at 2:45 PM a TO stated "physical hold x 20 min", this order does not include a reason for the restraint and is not signed by the MD. On 1/16/11 at 2:00 PM a progress note states Pt #18 was given Geodon via intramuscular injection, there is no documentation of this medication in the MD orders and no documentation it was given in the Medication Administration Record. This is confirmed in interview with DON A at approximately 11:30 AM.

Pt #20's MR reviewed by surveyor 18816 on 4/6/11 at 1:30 PM revealed TOs written on 12/29/10, and VOs written on 1/3/11 are not authenticated by the MD with a date and time. This is confirmed in interview with RN D on 4/6/11 at 2:15 PM.

Pt #27's MR reviewed by surveyor 18816 on 4/6/11 at 1:40 PM revealed TO written on 11/29/10 is not authenticated by the MD with a time. This is confirmed in interview with RN D on 4/6/11 at 2:15 PM.

Pt #30's MR reviewed by surveyor 18816 on 4/6/11 at 2:00 PM revealed and order written on 2/11/11 at 9:30 PM does not include the MD that ordered the medications, the RN that wrote the order, and if it was a TO, SO or VO. A VO written on 2/15/11 at 4:40 PM is not authenticated by the MD with a time. This is confirmed in interview with RN D on 4/6/11 at 2:15 PM.

Example by surveyor #29972:
Pt #23 ' s MR reviewed by surveyor 29972 on 4/6/11 at 1:50pm revealed the following: VO written on 1/13/11 at 4:30 pm is not authenticated by the MD with a date and time. The exclusion of a date or time with the MD countersignature does not identify if the verbal orders were countersigned within 48 hours. This is confirmed in interview with RN D on 4/6/11 at 2:45pm

Examples by surveyor #29963:
Pt # 26 ' s MR reviewed by surveyor 29963 on 4/6/11 at 9:00 a.m. revealed VO ' s written on 1/10/11 and 1/11/11 was not authenticated by the MD with a time. The exclusion of a date or time with the MD countersignature does not identify if the verbal orders were countersigned within 48 hours. This is confirmed in interview with RN D on 4/6/11 at 11:35 a.m.

Pt # 19 ' s MR reviewed by surveyor 29963 on 4/6/11 at 10:00 a.m. revealed VO ' s written on 11/9/10 was not authenticated with a signature, date or time and 11/10/10 was not authenticated by the MD with a time. This is confirmed in interview with RN D on 4/6/11 at 11:35 a.m.

Pt # 22 ' s MR reviewed by surveyor 29963 on 4/6/11 at 10:45 a.m. revealed VO ' s written on 1/10/11 was not authenticated by the MD with a time. This is confirmed in interview with RN D on 4/6/11 at 11:35 a.m.

Pt # 26 ' s MR reviewed by surveyor 29963 on 4/6/11 at 11:15 a.m. revealed (4) VO ' s written on 3/31/11 and 3/7/11 was not authenticated by the MD with a time and 3/8/11 was not authenticated by the MD with a signature, date or a time. This is confirmed in interview with RN D on 4/6/11 at 11:35 a.m.

Pt # 29 ' s MR reviewed by surveyor 29963 on 4/6/11 at 1:15 p.m. revealed (2) TO ' s written on 8/5/10 was not authenticated by the MD with a date and time. This is confirmed in interview with RN D on 4/6/11 at 2:40 p.m.

Based on MR review and 5 of 5 interviews with facility staff, in 19 of 23 closed MR out of a total of 30 MR reviewed (#8, 9, 10, 12, 18, 20, 27, 17, 13, 14, 23, 21, 19, 25, 29, 28, 15, 16, 24), the hospital failed to ensure that patient discharge summaries are completed by trained and licensed staff in the state of Wisconsin and authorized by the medical staff. The use of CNA's, SW, and LPN's to complete physician discharge summary affected 19 of 23 closed patient MR reviewed.

Findings include:
Per review of CNA (R) personnel file and the state of Wisconsin CNA Registry information on the morning of 4/6/11 CNA (R) is in good standing as a CNA in the state of Wisconsin. Per review of his personnel file he holds no other training, certifications or licenses.

Per interview with RN (D) on 4/6/11 at 8:00 AM CNA (R) has worked for many years as a "Social Worker Assistant" in the hospital. Per (D), CNA (R) is doing physician discharge summaries. See examples below.

Per review of CNA (R) job description on the morning of 4/6/11 his job responsibilities include the following: "III. A. 3. Dictate discharge summaries insuring timely completion." CNA (R) is not licensed to perform a physician discharge summary.

Per interview, with CNA (R) who was wearing a name tag that identified him as a "Social Worker Assistant", Administrator (J), DON (A) and Social Worker (X) on 4/6/11 at 10:00 AM, it was revealed that CNA (R) has worked for many years as a "Social Worker Assistant" in the hospital. Per CNA (R), he is doing physician discharge summaries. Per CNA (R) he does not hold any other training, certifications or licenses with the state of Wisconsin that would allow him to perform physician delegated tasks.

Review of MR throughout the survey also revealed that an LPN and Social Workers are also completing physician discharge summaries without training or licenses to do so. The DON is countersigning the LPN patient discharge summaries without the training or license to do so. See examples below. Review of the LPN and Social Worker job descriptions the morning of 4/6/11 did not reveal any evidence that this task is assigned to them.

Review of the medical staff rules and regulations dated 4/2/08 directs the following: "B. Medical records 1. Responsibility for completing the medical record: The attending Practitioner shall be responsible for recording the discharge summary." 9. Discharge Summary: A discharge clinical summary shall be recorded on all medical records of patients."
The medical staff rules and regulations do not delegate this task to the LPN, CNA or Social Worker.

The CNA, LPN and Social Worker are working outside of their training, certification and licenses, job descriptions and medical staff rules and regulations.


18816

Examples by surveyor #18816:
Pt #8's MR reviewed by surveyor 18816 on 4/5/11 at 10:45 AM revealed the DCS is dictated by a SWA who is not a qualified delegated practitioner. This is confirmed in interview with RN D on 4/6/11 at 8:00 AM.

Pt #9's MR reviewed by surveyor 18816 on 4/5/11 at 1:20 PM revealed the DCS is dictated by an LPN and authenticated by the DON. Neither the LPN or DON are qualified delegated practitioners. This is confirmed in interview with RN D on 4/6/11 at 8:00 AM.

Pt #10's MR reviewed by surveyor 18816 on 4/5/11 at 2:00 PM revealed the DCS is dictated by an LPN and authenticated by the DON. Neither the LPN or DON are qualified delegated practitioners. This is confirmed in interview with RN D on 4/6/11 at 8:00 AM.

Pt #12's MR reviewed by surveyor 18816 on 4/5/11 at 2:25 PM revealed the DCS is dictated by a SWA who is not a qualified delegated practitioner. This is confirmed in interview with RN D on 4/6/11 at 8:00 AM.

Pt #18's MR reviewed by surveyor 18816 on 4/6/11 at 11:30 AM revealed the DCS is dictated by a SW who is not a qualified delegated practitioner. This is confirmed in interview with RN D on 4/6/11 at 11:30 AM.

Pt #20's MR reviewed by surveyor 18816 on 4/6/11 at 1:30 PM revealed the DCS is dictated by a SW who is not a qualified delegated practitioner. This is confirmed in interview with RN D on 4/6/11 at 2:15 PM.

Pt #27's MR reviewed by surveyor 18816 on 4/6/11 at 1:40 PM revealed the DCS is dictated by a SWA who is not a qualified delegated practitioner. This is confirmed in interview with RN D on 4/6/11 at 2:15 PM.

Examples by surveyor #29972:
Pt #17 ' s MR reviewed by surveyor 29972 on 4/5/11 at 3:30 pm revealed the following: DCS is completed and signed by SW who is not a qualified delegated practitioner. This is confirmed in interview with RN D on 4/6/11 at 1130 am.

Pt #13 ' s MR reviewed by surveyor 29972 on 4/6/11 at 8:35 am revealed the following: DCS is completed and signed by a SW who is not a qualified delegated practitioner. This is confirmed in interview with RN D on 4/6/11 at 11:30 am

Pt #14 ' s MR reviewed by surveyor 29972 on 4/6/11 at 9:30 am revealed the following: DCS is completed and signed by SW who is not a qualified delegated practitioner. This is confirmed in interview with RN D on 4/6/11 at 11:30 am.

Pt #23 ' s MR reviewed by surveyor 29972 on 4/6/11 at 1:50 pm revealed the following: DCS is completed and signed by SW who is not a qualified delegated practitioner. This is confirmed in interview with RN D on 4/6/11 at 2:45 pm.

Pt #15 MR reviewed by surveyor 29972 on 4/5/11 at 1:20 pm revealed the following: DCS is completed and signed by SWA who is not a qualified delegated practitioner. This is confirmed in interview with RN D on 4/6/11 at 11:30 am.

Pt #16 MR reviewed by surveyor 29972 on 4/5/11 at 2:15 pm revealed the following: DCS is completed and signed by SWA who is not a qualified delegated practitioner. This is confirmed in interview with RN D on 4/6/11 at 11:30 am.

Pt #24 ' s MR reviewed by surveyor 29972 on 4/6/11 at 1:30 pm revealed the following: DCS is completed and signed by SWA who is not a qualified delegated practitioner. This is confirmed in interview with RN D on 4/6/11 at 2:45 pm.

Examples by surveyor #29963:
Pt # 21 ' s MR reviewed by surveyor on 4/6/10 at 9:00 a.m. revealed the DCS is dictated by the SWA who is not a qualified delegated practitioner. This is confirmed in interview with RN D on 4/6/11 at 11:35 p.m.

Pt # 19 ' s MR reviewed by surveyor on 4/6/10 at 10:00 a.m. revealed the DCS is dictated by the SWA who is not a qualified delegated practitioner. This is confirmed in interview with RN D on 4/6/11 at 11:35 p.m.

Pt # 25 ' s MR reviewed by surveyor on 4/6/10 at 10:30 a.m. revealed the DCS is dictated by the SWA who is not a qualified delegated practitioner. This is confirmed in interview with RN D on 4/6/11 at 11:35 p.m.

Pt # 29 ' s MR reviewed by surveyor on 4/6/10 at 1:15 p.m. revealed the DCS is dictated by the SW who is not a qualified delegated practitioner. This is confirmed in interview with RN D on 4/6/11 at 2:40 p.m.

Pt # 28 ' s MR reviewed by surveyor on 4/6/10 at 1:45 p.m. revealed the DCS is dictated by the SW who is not a qualified delegated practitioner. This is confirmed in interview with RN D on 4/6/11 at 2:40 p.m.

Based on MR review, review of medical staff rules and regulations, and interviews with facility staff, in 20 of 23 closed MR reviewed (9, 8, 12, 18, 20, 27, 30, 15, 16, 17, 13, 14, 24, 23, 21, 19, 25, 22, 29, 28) out of a total of 30 MR reviewed, the hospital failed to ensure that all parts of the MR are completed within 30 days of discharge per medical staff rules and regulations. The lack of a completed record within 30 days of discharge affected 20
of 23 closed MR reviewed.

Findings include:
Per review, of the medical staff Rules and Regulations dated 4/2/08 on the morning of 4/6/11, the rules direct the following: "1. Responsibility for completing the Medical Record: 14. Medical Record Completion and Filing: Records shall be completed within 30 days of discharge or death. A medical record shall not be permanently filed until it is completed."

Per interview, with Medical Records Director (B) on 4/5/11 at 8:30 AM, the data collection for late discharge summaries has exceeded the facility expectation of completion within 30 days of discharge. Per (B), she has reported this exception to hospital administration. Per data presented to surveyor #13469 on the AM of 4/6/11 the number of discharges from September 2010 through March 2011 is 289. The number of days over 30 days for the completion of DCS is 233 days. The percentage of discharge summaries completed greater than 30 days after patient discharge was 81%.


18816

Examples by surveyor #18816:
Pt #9's MR reviewed by surveyor 18816 on 4/5/11 at 1:30 PM revealed Pt #9 was discharged on 9/9/10, the DSC, PIE and VO are not dated and/or timed to ensure the record is complete within 30 days of discharge. This is confirmed in interview with RN D on 4/6/11 at 8:00 AM.

Pt #8's MR reviewed by surveyor 18816 on 4/5/11 at 10:45 AM revealed Pt #8 was discharged on 9/9/10 the authentication's by the MD on the DSC and VO are not dated and/or timed to ensure the record is complete within 30 days of discharge. This is confirmed in interview with RN D on 4/6/11 at 8:00 AM.

Pt #12's MR reviewed by surveyor 18816 on 4/5/11 at 2:25 PM revealed Pt #12 was discharged on 10/12/10. The DCS, PIE and VOs that are not authenticated by the MD with a date and time to ensure the record is complete in 30 days. This is confirmed in interview with RN D on 4/6/11/at 8:00 AM.

Pt #18's MR reviewed by surveyor 18817 on 4/6/11 at 11:30 PM revealed Pt #18 was discharged on 1/18/11, the DCS has no dictation date and the authentication's by the MD on the DSC, PIE, and TOs are not authenticated, dated and/or timed to ensure the record is complete within 30 days of discharge. This is confirmed in interview with RN D on 4/6/11 at 2:15 PM.

Pt #20's MR reviewed by surveyor 18817 on 4/6/11 at 1:30 PM revealed Pt #20 was discharged on 1/3/11, the DCS has no dictation date and the authentication's by the MD on the DSC, TOs and VOs are not dated and/or timed to ensure the record is complete within 30 days of discharge. This is confirmed in interview with RN D on 4/6/11 at 2:15 PM.

Pt #27's MR reviewed by surveyor 18816 on 4/6/11 at 1:40 PM revealed Pt #27 was discharged on 12/1/10, the DCS was dictated on 2/4/11. and the authentication's by the MD on the DSC, TOs and VOs are not timed and/or dated to ensure the record is complete within 30 days of discharge. This is confirmed in interview with RN D on 4/6/11 at 2:15 PM.

Pt #30's MR reviewed by surveyor 18816 on 4/6/11 at 2:00 PM revealed Pt #30 was discharged on 2/15/11, the authentication's by the MD on the orders are not timed and/or dated to ensure the record is complete within 30 days of discharge. This is confirmed in interview with RN D on 4/6/11 at 2:15 PM.

Examples by surveyor #29972:
Pt #15 ' s MR reviewed by surveyor 29972 on 4/5/11 at 1:20 revealed the following: Pt #15 was discharged at 12/23/10; DCS not dictated until 2/15/11 and MD did not authenticate DCS with time and date to ensure the record is complete within 30 days of discharge. This is confirmed in interview with RN D on 4/6/11 at 11:30am.

Pt #16 ' s MR reviewed by surveyor 29972 on 4/5/11 at 2:15pm revealed the following: Pt #16 was discharged on 12/28/10; DCS not dictated until 3/24/11 and the MD did not authenticate DCS with time and date to ensure the record is complete within 30 days of discharge. This is confirmed in interview with RN D on 4/6/11 at 11:30am.

Pt #17 ' s MR reviewed by surveyor 29972 on 4/5/11 at 3:30pm revealed the following: pt #17 discharged on 12/29/10; DCS has no dictation or transcription date and time and the MD did not authenticate with date and time to ensure the record is complete within 30 days of discharge. This is confirmed in interview with RN D on 4/6/11 at 11:30am

Pt #13 ' s MR reviewed by surveyor 29972 on 4/6/11 at 8:35 revealed the following: pt #13 was discharged on 12/9/10; DCS has no dictation or transcription date and time, and the MD did not authenticate with date and time to ensure the record is complete within 30 days of discharge. This is confirmed in interview with RN D on 4/6/11 at 11:30am.

Pt #14 ' s MR reviewed by surveyor 29972 on 4/6/11 at 9:30am revealed the following: pt
#14 was discharged on 12/13/10; DCS has no dictation or transcription date and time, and the MD did not authenticate with date and time to ensure the record is complete within 30 days of discharge. This is confirmed in interview with RN D on 4/6/11 at 11:30am.

Pt #24 ' s MR reviewed by surveyor 29972 on 4/6/11 at 1:30pm revealed the following: pt
#24 was discharged on 1/28/11; DCS dictated on 3/16/11 and the MD did not authenticate with date and time to ensure the record is complete within 30 days of discharge. This is confirmed in interview with RN D on 4/6/11 at 2:45pm.

Pt #23 ' s MR reviewed by surveyor 29972 on 4/6/11 at 1:50pm revealed the following: pt
#23 was discharged on 1/18/11, DCS has no dictation or transcription date and time, and the MD did not authenticate with date and time to ensure the record is complete within 30 days of discharge. This is confirmed in interview with RN D on 4/6/11 at 2:45pm.

Examples by surveyor #29963:
Pt # 21 ' s MR reviewed by surveyor 29963 on 4/6/11 at 9:00 a.m. revealed a discharged date of 1/11/1. The DCS was not dictated until 3/5/11 at 13:55. The authentication by the MD is not dated or timed on the DCS to ensure the record is completed within 30 days of discharge. This is confirmed in interview with RN D on 4/6/11 at 11:35 p.m.

Pt # 19 ' s MR reviewed by surveyor 29963 on 4/6/11 at 10:00 a.m. revealed a discharged date of 11/10/10. The DCS was not dictated until 1/11/11. The authentication by the MD is not dated or timed on the DCS to ensure the record is completed within 30 days of discharge. This is confirmed in interview with RN D on 4/6/11 at 11:35 p.m.

Pt # 25 ' s MR reviewed by surveyor 29963 on 4/6/11 at 10:30 a.m. revealed that the DCS has no dictation date and the time to ensure it was complete within 30 days of discharge. Authentication by the MD on the DCS did not include a date or time to ensure the record is completed within 30 days of discharge. This is confirmed in interview with RN D on 4/6/11 at 11:35 p.m.

Pt # 22 ' s MR reviewed by surveyor 29963 on 4/6/11 at 10:45 a.m. revealed the DCS has no dictation date and the time. The authentication by the MD on the DCS did not include a date or time to ensure the record is completed within 30 days of discharge. This is confirmed in interview with RN D on 4/6/11 at 11:35 p.m.

Pt # 29 ' s MR reviewed by surveyor 29963 on 4/6/11 at 1:15 p.m. revealed a discharge date of 8/9/10. The DCS was not dictated until 9/27/10. The authentication by the MD is not dated or timed on the DCS to ensure the record is completed within 30 days of discharge. This is confirmed in interview with RN D on 4/6/11 at 2:40 p.m.

Pt # 28 ' s MR reviewed by surveyor 29963 on 4/6/11 at 1:45 p.m. revealed a discharge date of 12/20/10. The DCS was not dictated until 2/16/11. The authentications by the MD is not dated or timed on the DCS to ensure the record is completed within 30 days of discharge. This is confirmed in interview with RN D on 4/6/11 at 2:40 p.m.

Based on 2 of 2 staff (A, H) interviews, record review, P&P review, and observations, it was determined that the hospital failed to have an effective and safe pharmacy practice.

Findings include:

1. The hospital failed to ensure that medications are stored in a manner that provides for safety and immediate access. See Tag A-491
2. The hospital failed to ensure that a pharmacist maintain overall responsibility for the pharmacy service. See Tag A-492
3. The hospital failed to ensure that current and accurate records are kept of the receipt and distribution of all scheduled drugs. See Tag A-494
4. The facility failed to ensure open single use medications do not remain available for patient use. See Tag A-505
5. The hospital failed to ensure that medication administration errors are reported to the patient's MD and that the medical record contains documentation related to the incident. See Tag A-508
6. The hospital failed to ensure that a drug formulary with P&P for it's use is established and approved by the medical staff. See Tag A-511

The cumulative effect of these systemic pharmacy problems can lead to unsafe storage, use, administration, control and disposal of medications within the facility and result in the facility's inability to ensure that patient safety and well-being is ensured

Based on observation and 1 of 1 interview with staff, the facility failed to ensure that medications are stored in a manner that provides for safety and immediate access. This deficient practice affects all 14 patients in the facility during the survey.

Findings include:
Per surveyor #18816 tour of the facility on 4/4/11 between 11:00 AM and 12:15 PM, with RN D, a respiratory inhaler was in a drawer in the dressings cabinet rather than in the medication cart for safety and access. This was confirmed during the tour with RN D.

Based on 2 of 2 interviews with facility staff and review of hospital P&P by surveyor
#13469, the hospital failed to ensure that a pharmacist maintained overall responsibility for the pharmacy service. The lack of a responsible pharmacist to ensure the development, supervision and coordination of all activities of the hospital wide pharmacy service can lead to unsafe storage, use, administration, control and disposal of medications within the facility.

Findings include:
Review of facility pharmacy P&P the morning of 4/6/11, the policy 12.1 Standards of Practice for Consulting Pharmacist directs the following: 1"1. The consultant pharmacist is responsible to the Administrator of the facility for developing, coordinating and providing general supervision of all pharmaceutical services and regularly visits the facility to carry out these responsibilities. 4. The consultant pharmacist participates in the continuing education programs. 6. The consultant pharmacist is a member of the Quality "Assurance and Assessment committee. 7. The consultant pharmacist or representative makes quarterly inspections of each nursing station and its related medication storage areas and submits a report to the facility. 8. The consultant pharmacist participates in the review of medication error reports and reports to quality improvement."

Per interview, with DON (A) on the morning of 4/5/11 it was revealed that the hospital contracts with a medication distribution vendor to supply medications to the facility. There is a contract with Pharmacist (H) to oversee the pharmacy service in the hospital. In addition, RN (Y) from the contracted medication supplier comes to the facility monthly to do on-site visits to audit the hospital medication system.

When asked, DON (A) was unable to produce evidence of the contracted pharmacist written reports of on-site visits, involvement in the QAPI program, review of medication administration error reports and adverse drug reaction reports, development and review of hospital pharmacy P&P, and staff education related to safe medication practices. In addition, DON (A) was unable to produce any monthly RN (Y) on-site visit reports since July 2010 except one in January 2011.

Per interview, with Consultant Pharmacist (H) on 4/5/11 at 10:00 per telephone, (H) indicated that he was told over a year ago that his services were no longer needed in the hospital. Per (H) he is not doing on-site visits, involvement in the QAPI program, review of medication administration error reports and adverse drug reaction reports, development and review of hospital pharmacy P&P, and staff education related to safe medication practices in the hospital. Per (H), he is not aware of any RN (Y) on-site visits or reports.

Based on record review and 1 of 1 interview with facility staff, the hospital failed to ensure that the wasting of controlled substances by nursing staff follow hospital policy and standards. The lack of current and accurate records of the receipt and distribution of all scheduled drugs allows for the potential loss, diversion and inappropriate use of controlled substances.

Findings include:
Per Surveyor 29963 review on 4/5/11 at 10:30 a.m. of facility policy titled 5.6 Wasted Controlled Substances it states " Wasted controlled substances must be recorded as " wasted " . The reason for wasting the medication should be recorded on the Narcotic Record. This record must be signed by two licensed nurses, including the date, reason and signature."
Controlled Substance records reviewed from 2/22/10 through 4/4/11 revealed that three controlled substances were documented as "destroyed" and initialed by one licensed nurse instead of the two required per facility policy. Examples include: Hydrocodone 5/500- Quantity 6- on 2/22/11, Chlordiazepoxide 25 mg- Quantity 24 on 2/24/11, and Librium 25 mg- quantity 8 -on 3/5/11.

Controlled substance records were signed by two licensed nurses, but the reason for the two signatures was not identified. Examples include: Lorazepam 2 mg- Quantity 6 - on 3/24/11, and Lorazepam 0.5 mg - Quantity 5- on 3/24/11. Per interview with DON A on 4/5/11 at 10:45 a.m the above examples of drugs were actually wasted and it should have been identified on the narcotic sheet but was not clear on the record.

The above examples were confirmed in interview with DON A on 4/5/11 at 10:45 a.m.

Based on tour and interview with staff, in 1 of 1 tour the facility failed to ensure open single use medications do not remain available for patient use. This deficient practice affects all 14 patients in the facility during the survey.

Findings include:
Per surveyor 18816 tour of the facility, on 4/4/11 between 11:00 AM and 1215 PM, with RN D, there was a 250 milliliter bottle of normal saline open in the cabinet in the exam room, and there were 2-250 milliliter bottles of normal saline open in the cabinet in the medication room. Normal saline bottles are one time use bottles. This is confirmed during tour with RN D.

Based on 4 of 4 MR reviewed (#31, 32, 33, 34), review of 11 medication administration error reports, and 1 of 1 interviews with facility staff by surveyor #13469, the hospital failed to ensure that medication administration errors are reported to the patient's MD and that the medical record contains documentation related to the incident. The lack of MD notification of medication administration errors does not allow the practitioner to assess the patient's need for a change in the medical treatment plan. The lack of documentation of the incident in the MR does not provide an accurate and chronological picture of the patient's course of treatment.

Findings include:
Per review of the facility P&P "medication variance report" dated 4/15/08 directs the following: "All medication errors will be reported to the doctor. Date and time and doctor notified will be documented." Policy #10.2 dated 3/1/05 directs that "Every medication incident that occurs, whether by facility staff or by pharmacist, must be documented and the prescriber notified."

Per review of 11 medication administration error reports and 4 of 4 MR on 4/6/11 at 9:00 AM, the following was noted:

1. Patient #31 medication variance report indicated that Buspivane was discontinued at 2:35 on 2/28/11. Additional doses were given at 4:00 PM and 8:00 PM on 2/28/11. Review of patient #31 MR the morning of 4/6/11 did not reveal any evidence that the MD was notified that patient #31 was given two extra doses of Buspivane. This was confirmed in interview with DON (A) at 10:45 AM on 4/6/11.

2. Patient #32 medication variance report indicated that Metoprolol 25 mg was given at 8:00 PM on 2/28/11 without an MD order. Review of patient #32 MR the morning of 4/6/11 did not reveal any evidence that the MD was notified that patient #32 was given Metoprolol without an order. In addition, the MAR (medication administration record) did not contain evidence that the nurse gave this patient Metoprolol on 2/28/11. This example was confirmed in interview with DON (A) on 4/6/11 at 10:30 AM.

3. Patient #33 medication variance report indicated that Geodan IM (intramuscular) was given on 1/16/11 without an MD order. Review of patient #33 MR the morning of 4/6/11 did not reveal any evidence that the MD was notified that patient #33 was given Geodan IM without an MD order. This example was confirmed in interview with DON (A) on 4/6/11 at 10:50 AM.

4. Patient #34 medication variance report indicated that Venlafaxine was ordered to be given in the AM and again at 4:00 PM. The nurse gave the medication at 8:00 PM instead of 4:00 PM as ordered. Review of patient #34 MR the morning of 4/6/11 did not reveal any evidence that the MD was notified that patient #34 was given this medication at the wrong time. This example was confirmed in interview with DON (A) on 4/6/11 at 10:50 AM.

Based on 1 of 1 interview with DON (A) by surveyor #13469, the hospital failed to ensure that a drug formulary with P&P for it's use is established and approved by the medical staff. Failure to establish a list of drugs with P&P approved by the medical staff does not ensure the quality and safe dispensing and administration of drugs to patients in the facility.

Findings include:
Per interview with DON (A) on 4/5/11 at 11:50 AM, the hospital medical staff has not established a drug formulary. Per (A), there is a list of the drugs that are kept in the nursing medication room, but this list was not established by the medical staff. Per (A), Psychiatrist (W) does not know of any drug formulary.

Based on 1 of 1 interview with facility staff (A) by surveyor #13469, the hospital failed to ensure that it's contracted radiology service provides final results of all films, scans or other image records to the hospital to be entered into the MR. The lack of a complete MR to include radiology reports results in the facilities inability to ensure that all MR are complete and accurately reflect treatment rendered at the contracted facility to assist in medical staff diagnosis and treatment of it's patients.

Findings include:
Per review of the hospital contract with the facility performing radiology services on the morning of 4/6/11 the contract stipulates the following: "Part IV - General Provisions 4.01 "The hospital (contracted radiology service) will report to the resident's physician and appropriate facility personnel the results of tests."

Per interview, with DON (A) on 4/5/11 at 9:40 AM, the hospital is not getting the final radiology reports from the contracted service to be included into the hospital MR.

Based on observation of 3 of 5 staff, and 1 of 1 interviews with facility staff, the hospital does not ensure that food handlers in the dietary department cover all of their hair while preparing food trays for patients. The deficient practice could lead to contamination of patient food and affected all 14 patients in the hospital at the time of the survey.

Findings include:
Per review, of facility policy "Employee Health and Hygiene" dated 2/17/04 on the morning of 4/6/11 by surveyor #13469, the policy directs the following to dietary staff: "Hair nets or caps must be worn at all times" to cover hair while working in the kitchen.

Per surveyor #29972 observation of dietary staff preparing patient food trays in the food tray line on 4/5/11 at 11:35 am , 3 of 5 staff observed did not have all their hair contained in a hair net, allowing for potential contamination of food. This is confirmed in interview with Staff C during the observation.

Based on record review, and 1 of 1 staff (C) interviews, the hospital failed to ensure that the current therapeutic diet manual is approved and periodically reviewed by the dietitian and medical staff. The lack of dietitian and medical staff approval and review could lead to the use of an inappropriate or outdated manual. This deficiency affected all 14 patients in the facility at the time of the survey.

Findings include:
Per interview with Dietary Manager (C) on 4/4/11 at 1:00 PM, there is no evidence that the current dietary manual used in the facility has been approved and periodically reviewed by the dietitian and medical staff.

Based on observation, staff interviews, and review of maintenance records, the hospital failed to ensure the physical environment of the building met the minimum requirements of the 2000 Edition of the Life Safety Code for "Existing Healthcare Occupancy" chapter of this code.

The findings include:
Main Hospital Building
K14: The facility did not provide room finishes with rated wall finishes.
K18: Positive latching was not provided on all doors to the corridor
K20: Vertical shafts were not constructed to the proper hourly rating.
K29: Reliable enclosure of hazardous areas was lacking at locations throughout the building.
K38: The facility did not provide egress paths at all times with door hardware that operated with a single release.
K46: The facility did not provide and maintain emergency illumination of the generator area for at least 90 minutes after a power failure with an emergency battery light at the emergency generator.
K56: Sprinkler system did not meet all minimum regulations per NFPA 13.
K67: The facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A.
K73: The facility did not maintain an egress path that was free of highly flammable furnishings/decoration, as with non-combustible decorations.
K75: The facility did not provide and maintain linen/trash collection receptacles in compliance with the codes with properly sized storage containers for soiled/trash.
K144: The facility did not test the emergency electrical generator in accordance with the codes with derangement signals at a continuously monitored location..

The cumulative effect of these deficiencies indicates that the facility failed to provide a safe environment and reliable systems to ensure safety to all occupants, patients and staff of this facility.

Based on observation, staff interviews, and review of maintenance records, the hospital failed to ensure the physical environment of the building met the minimum requirements of the 2000 Edition of the Life Safety Code for "Existing Healthcare Occupancy" chapter of this code.

The findings include:
Main Hospital Building
K14: The facility did not provide room finishes with rated wall finishes.
K18: Positive latching was not provided on all doors to the corridor
K20: Vertical shafts were not constructed to the proper hourly rating.
K29: Reliable enclosure of hazardous areas was lacking at locations throughout the building.
K38: The facility did not provide egress paths at all times with door hardware that operated with a single release.
K46: The facility did not provide and maintain emergency illumination of the generator area for at least 90 minutes after a power failure with an emergency battery light at the emergency generator.
K56: Sprinkler system did not meet all minimum regulations per NFPA 13.
K67: The facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A.
K73: The facility did not maintain an egress path that was free of highly flammable furnishings/decoration, as with non-combustible decorations.
K75: The facility did not provide and maintain linen/trash collection receptacles in compliance with the codes with properly sized storage containers for soiled/trash.
K144: The facility did not test the emergency electrical generator in accordance with the codes with derangement signals at a continuously monitored location..

The cumulative effect of these deficiencies indicates that the facility failed to provide a safe environment and reliable systems to ensure safety to all occupants, patients and staff of this facility.

Based on review of P&P, review of personnel and credential files, observations, and 5 of 5 interview with staff, the facility failed to ensure there is an active infection control surveillance program to protect patients and visitors from the spread of potential sources of infection or communicable diseases. In 9 of 10 personnel (L, N, M, O, P, R, S, T and U), the facility failed to ensure staff was tested for exposure to tuberculosis (TB) or Quantum Ferron test (QFG) annually per policy. This deficient practice affects all 14 patients in the facility during the survey.

Findings include:
1. Per surveyor #18816 tour of the facility on 4/4/11 between 11:00 AM and 12:15 AM, with RN D, the following was observed:

The Soiled Linen room contained 2 wheelchairs, a shower stool and a commode. Per RN D these items were clean.

The linen closets between rooms 215 and 216, and between 225 and 226, had linen and socks on the floor.

The exam room had 2 scissors in the cabinet, out of packaging. Per RN D the scissors should be packaged to keep clean.

The shower room between rooms 219 and 220 had a cup of shampoo and a cup of conditioner on the floor.

In the kitchenette, the refrigerator had staff food and condiments and butter for patient used, allowing for potential cross contamination. There was a knife in the drawer next to the sink, used for cutting patient food per RN D, mixed with several miscellaneous items allowing for potential cross contamination.

The medication room had a diet tea and coffee creamer in the medication refrigerator.

Per tour of the gym on 4/5/11 at 2:40 PM with Maintenance Supervisor I, there was a coffee cup on the weight bench, and a ball on the floor in the closet.

Per tour of the laundry with Laundry Manager E on 4/4/11 at 2:45 PM the washer room had dust and debris on the pipes and vents above the washers and on the floor behind the washers. A bag of dirty linen was sitting on the floor next to the washer. Per staff E, the bag should have been left in the marked staging area. During the tour, Laundry Manager E was not aware if the Infection Control committee approved the laundry detergent.

Per tour of the laundry with Maintenance Supervisior I on 4/5/2011 at 11:15 AM with surveyor 12187, the air flow was observed from the dirty area of the washing machines to the clean area of the clothes driers using a tissue paper to determine air flow under the door.

Per interview with Housekeeper F on 4/5/11 at 9:00 AM, the housekeeping staff are not aware of what type of infectious disease a patient may have, they are only notified the patient was infectious. Per Housekeeper F, the only cleaning product they use is Virex, this product is not capable of disinfecting all infectious diseases. Per surveyor 18816 review on 4/6/11 at approximately 11:30 AM of facility policy titled Infection Control dated 4/27/04, it states under Action "Place sign outside of patient/resident room if indicated-see table of disease specific precautions."

Example by surveyor #13469:
Per observation, while touring the facility medical record storage rooms on 4/5/11 at 8:30 AM with Medical Records Director (B), it was noted that patient medical records stored in the "old morgue" were in boxes resting directly on the floor. In addition, there were several piles of medical records outside boxes resting directly on the floor. The floor in the storage room was dirty, contained lots of debris and dust, and had bugs crawling on the floor. The MR were not protected from dust and debris. Per (B), she is not sure when the last time the floor was cleaned by housekeeping.

Per observation, while touring the dietary department on 4/4/11 at 1:00 PM with Dietary Managaer (C), it was noted that the doors between the food preperation area and cafeteria tray line are always proped open. As a result, dust and debris can enter the food prep area and contaminate the food. This was confirmed in interview with (C) during the tour.

2. Examples of employee health files:
Per surveyor 18816 review on 4/6/11 at 3:00 PM, facility policy titled Tuberculosis Control Program dated 7/6/09 states under I. New employees A. "New employee with a negative Mantoux history will be given a Mantoux (5 UPPD) skin test at the time of hire by qualified nursing staff.. II. Annual A. Employees working with Admissions patients with a negative Mantoux history will be given an annual Mantoux (%UPPD) skin test."

Review of credential and personnel files by surveyor 29963 on 4/5/10 between 8:45 AM. and 2:45 PM. revealed the following:

MA L ' s personnel file did not have an annual TB test since 3/13/09.
LPN M ' s personnel file did not have an annual TB test since 3/11/09.
MD N ' s personnel file did not have an annual QFG test since 8/4/09.
PhD O ' s personnel file did not have an annual QFG test since 8/20/09.
MD P ' s personnel file did not have an annual QFG test since 3/1/10.
SWA/CNA R ' s personnel file did not have an annual TB test since 4/5/09.
CNA S ' s personnel file did not have an annual TB test since 4/6/09.
CNA T ' s personnel file did not have an annual TB test since 3/13/09.
PT U ' s personnel file did not have an annual TB test since 4/05/09.

Per surveyor 29963 interview on 4/5/11 at 3:20 PM, DON A stated that they no longer do annual PPD, this practice was stopped about a year ago but policy was never changed. Per (A), the practice changed but the policy was not changed. Per (A), TB testing is not following current policy.

Per surveyor 29963 interview on 4/6/11 at 2:20 PM. MA L stated the annual PPD practice was changed April 2010. MA L stated the practice was changed to every two years or as designated. Dates of current TB skin tests for all staff were verified at this time with MA L.


18816

Based on interview with staff, in 1 of 1 (A) interview, the facility failed to ensure staff is trained on organ donation procedures. This deficient practice could affect all 14 patients at the facility during the survey.

Findings include:
Per interview with DON A on 4/6/11 at 8:30 AM there is no training program in place for staff to report to the OPO and tissue bank of the death of a patient to ensure that any potential donors are screened appropriately for potential donation. In addition, staff are not trained to include notification of the OPO and tissue bank into the patient's MR.

Based on review of P&P and interview with staff, in 1 of 1 interview (A) the facility failed to ensure there is a means to record deaths at the facility to ensure all deaths are reported to the contracted Organ Procurement Organization (OPO). This deficient practice could affect all 14 patients at the facility during the survey.

Findings include:
Per facility policy titled Organ/Tissue Donation dated 4/28/05, reviewed by surveyor 18816 on 4/6/11 at approximately 7:00 AM, it does not include the number to call for reporting to the OPO and there is no mention of a log to record deaths. The Authorization for Anatomical Gift form does not include calling the OPO, and documenting the contact.

Per interview with DON A on 4/6/11 at 8:30 AM, she confirmed the policy, and there is no record for recording deaths, stating the OPO sends a quarterly documented asking for a list of deaths that she completes and returns.