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Based on interview, employee file and job description reviews, the hospital CEO, responsible for the day to day function of the hospital, failed to ensure that 2 of 13 hospital services (Food/Dietetic and Emergency Services) were managed in a way to ensure regulatory compliance. This affects all patients presenting to this hospital for any of the identified services.

Findings include:

At this hospital thirteen (13) services were identified based on the Conditions of Participations:

Nursing, Medical Record, Pharmacy, Radiology, Laboratory, Food/Dietetic, Surgical, Anesthesia, Nuclear Medicine, Out-Patient Services, Emergency, Rehabilitation and Respiratory.

On 05/30/12 at 11:45 AM during a telephone interview with RD LL who identified her role as an RD as working for "the system". RD LL confirmed her primary location is West Allis.

On 05/30/12 at 9:45 AM during an interview and job description review of the Dietary Managers job position, HR MM provided surveyor with 2 job descriptions.
#1 Entitled "Regional Manager of Food & Nutritional Services" Job Code: #1160, date: January, 2007
#2 Entitled "Mgr Food Nutrition Svc" Job Code: #1158 created 4/1/2009 revised 5/3/2012.

HR MM explained to Surveyor #22198 that the Job description #1 was no longer valid as of April 2012, when the Aurora System updated all their job description.

Surveyor #22198 asked HR MM for the job documentation and competencies based off the documentation from job description #2 information.

Surveyor #22198 asked HR MM for the competencies and dietitian's (LL and QQ) registration and certification.

MM told Surveyor it might take a while to gather the information because LL and QQ were employee's of the Aurora System so their complete employee files were not kept at this hospital but at another Aurora hospital that was identified as their primary employment.

On 05/30/12 at 11:45 AM HR MM during an interview and job description review, HR MM provided Surveyor #22198 with 2 different job descriptions for the Dietary Managers.
#1 Entitled: "Manager Food Service" Job Code: #1428, dated August 1998 with no revisions.
#2 Entitled: "Mgr Food Nutrition Svc AMCWC" Job Code: 1160, created 4/1/2009 date revised: 5/3/2012.

HR MM provided the same explanation to Surveyor #22198, that the Job description #1 was no longer valid as of April 2012, when the Aurora System updated all their job descriptions and that the manager would be working from job description #2.

Surveyor #22198, noted discrepancies in the 2 job requirements provided at 9:45 AM to the 2 job descriptions provided at 11:45 AM. Job requirement noted in the 9:45 AM that Surveyor asked for, were no longer required in the either of the 2 job descriptions provided at 11:45 AM.

HR MM could not account for why one staff (Manager of Food and Nutritional Services) had 4 different job descriptions or why the job description had changed on 05/30/12 from 9:45 AM to 11:45 AM.

HR MM provided Surveyor with a log to verify when the 2 job descriptions provided at 11:45 AM were new and provided a log to show surveyor that the food service manager had her employee file and job description updated in April 2012 to reflect the 11:45 AM job description (#1160).

Surveyor #22198 pointed out discrepancy in the log to HR MM. The log was suppose to verify in April 2012 that Manager of Food Services job description updated to "Mgr Food Nutrition Svc AMCWC" Job Code: 1160, created 4/1/2009 date revised: 5/3/2012. HR MM could not explain how the log could validate receiving a job description in April 2012 not revised until May 2012.

On 05/31/12 at 8:05 AM Surveyors #22198 & #29963 interviewed System Admin VP Food Services NN, System Clinical Nutrition OO, System Compliance PP, Director of Quality A and CCSO BB, regarding the 4 job descriptions for the manager of food services, discrepancies in the Dietitians job position (system or hospital employees), as well as system versus hospital regarding compliance.

System Admin VP Food Services NN, told Surveyors that the 9:45 AM job description #1 Entitled: "Regional Manager of Food & Nutritional Services" . Job Code: #1160 date: January 2007 was the job description currently in the Manager of Food Services (L) employee file.

System Admin VP Food Services NN, System Clinical Nutrition OO, System Compliance PP, Director of Quality A and CCSO BB could not clear up why there were 4 job descriptions for 1 job in the hospital.

System Admin VP Food Services NN, told Surveyors, Aurora healthcare system is working on standardization across the system, and job description, and standards are currently being worked on, the job description for Food Service Manager L had not been reviewed since 2007.

At 8:30 AM HR MM returned with partial employee files for Registered Dieticians LL and QQ, confirming their employee files are kept at their primary place of employment.

System Admin VP Food Services NN, System Clinical Nutrition OO, System Compliance PP, told Surveyors that the hospital does not contract Dietitians and Dietitians are not "system employees".

System Admin VP Food Services NN, System Clinical Nutrition OO told Surveyors, RD's; LL and QQ are part-time employees here and part time employees at another system hospital.

However, System Admin VP Food Services NN, System Clinical Nutrition OO, System Compliance PP, could not explain why part-time hospital employees failed to complete employee files on site at this hospital.

On 05/31/12 at 12:00 PM Director of Quality A confirmed to Surveyors #29971 and #22198 this hospital does not have any contract, arrangement or agreement between this hospital and the Aurora Grafton hospital or St Luke's. Director of Quality A told Surveyors all contracts, agreements or arrangements between Aurora system hospitals are kept in a "vault" at a system level, that Director of Quality A does not have access to retrieve.

Director of Quality A confirmed to Surveyors #22198 & 29972, that without each hospital knowing what the contracts, arrangements or agreements are, they can not hold each hospital accountable to ensure compliance, or audit quality indicators at this hospital.

During the survey exit 05/31/12 at 2:10 PM System Compliance PP requested feedback and clarification on regulations that define contracted services. System Compliance PP told Surveyors that their Aurora system's legal counsel had informed them system based hospital's do not need to have contracts, agreements or arrangement required under the contracted service regulation, that regulation is not applicable to hospitals within one system.


29972

Findings by surveyor #29972

Per MR review of Pt #14 and Pt #16 on 5/31/2012 beginning at 9:35 AM, both patients were transferred from the facility's emergency department via ambulance to Aurora Grafton Hospital for a Cardiac Catheterization on 2/16/2012 and 11/29/2011 respectively. Per interview with ED RN Manager C on 5/31/2012 beginning at 11:00 AM the hospital does not have a cardiac catheterization lab so all patients who require these services must be transferred. Per ED RN Manager C, these patients are usually transferred to Aurora Grafton Hospital or Aurora St. Luke's Hospital. When surveyor #29972 asked ED RN Manager C if the facility has a contract with these hospitals to transfer patients needing cardiac catheterization, ED RN Manager C responded, "no we just have an understanding".

Based on review of policy and procedures and interview with staff, in 1 of 1 interview (A) the facility failed to ensure the visitation policy included the patient ability to have any visitor they chose without discrimination. This defecient practice has the potential to affect all patients present during the survey (5/29/12- census was 13, 5/30/12- census was 25, and 5/31/12- census was 28).

Findings include:

Per surveyor 18816 review on 5/30/12 at approximately 10:00 AM of the facility policy titled Visiting Policy, dated 2/10, the policy does not include the patient's right to not be denied or restricted visitors based on race, color, national origin, religion, sex, gender identity, sexual orientation, or disability. This is confirmed in interview with Director of Quality A on 5/30/12 at approximately 10:00 AM.

Based on the tour, observation, review of documents and interviews, the hospital's Quality Assurance Process Improvement (QAPI) program failed to include 1 of 13 services (Food/Nutrition) or their contracted services within their Aurora System in their QAPI program. This could affect all patients presenting to this hospital who would have a need for food service.

Findings include:

On 5/29/2012 Foodservice manager L, (FSM-L) and Surveyor #29302 toured and interviewed the dietary staff in kitchen and food storage from 10:00 AM - 2:20 PM. as follows:

On 05/29/12 at 1:00 PM, FSM-L told Surveyor #29302, dietary department employees receive training in proper storage, preparation and serving of food, safety, appropriate personal hygiene and infection control when hired, but not on a yearly basis.

FSM-L acknowledged that there are not regularly scheduled in-services, and information contained in the communication book does not consistently address proper storage, preparation and serving of food, safety, appropriate personal hygiene and infection control.

On 5/29/2012 between 10:00 AM - 10:20 AM, during the tour Foodservice Manager L (FSM-L) and Surveyor #29302 made the following observations:
Items in cooler #1 which did not have labels:
· Container of pesto,
· ½ pan of cooked noodles, and
· Cheese
In cooler #2, items which did not have labels:
· Sheet cake pan of angel food cake slices,
· Sheet cake pan of carrot cake squares, and
· Sheet cake pan of pie slices - Dutch apple and pumpkin.

Also in cooler #2, a container of mushrooms had an expiration date of 5/23/12.
FSM-L acknowledged and confirmed Surveyor #29302's observations that these observations failed to meet the Wisconsin Food Code, 3-501.17 Ready-to-Eat, Potentially Hazardous Food, Date Marking.

On 5/29/2012 at 1:00 PM, foodservice manager L (FSM-L) stated to surveyor 29302, that the professional standard of practice used by the facility's dietary department is the Wisconsin Food Code. According to the Wisconsin Food Code, 4-6 CLEANING OF EQUIPMENT AND UTENSILS, (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.

On 5/29/2012 at 10:27 AM - 10:39 AM, FSM-L and Surveyor #29302 made the following observations in the kitchen: built up grease and dirt on lower right corner ledge of lower double oven, greasy oven hood edge with dust inside hood located above the 4 gas-burner stove and crumbs throughout the inside lower cabinets of the entire cook line. Surveyor #29302 requested FSM-L's kitchen cleaning schedule. FSM-L told Surveyor #29302 there wasn't anything cleaning schedule.

On 5/29/2012 at 11:26 AM, Surveyor #29302 observed Chef K taking temperatures. Chef K inserted thermometer into chicken broth, without sanitizing the thermometer. Chef K then inserted the thermometer into chicken gravy, Chef K then went to sink and rinsed off thermometer, but did not sanitize thermometer. Chef K then inserted thermometer into beef broth, without sanitizing thermometer, Chef K then inserted thermometer into beef gravy.

On 5/29/2012 at 1:00 PM, FSM-L confirmed Chef K's failure to clean the thermometer failed to meet the professional standard of practice used by the facility's dietary department; Wisconsin Food Code states the following at section: 4-602.11 Equipment Food-Contact Surfaces and Utensils. (4) Before using or storing a FOOD TEMPERATURE MEASURING DEVICE; and
(5) At any time during the operation when contamination may have occurred.

Patient census during this survey:
· On 05/29/12 patient census was 13
· 05/30/12 patient census was 25
· 05/31/12 patient census was 28

A dietary service has the potential to affect every patient, staff and visitor that receives food from the hospital's dietary service. On 05/29/12 at 2:20 PM after the review of the daily findings and interview, FSM-L confirmed to Surveyor #29302, the dietary management and food service of the hospital does not participate in the QAPI program.

On 05/30/12 at 8:10 AM during a QAPI interview and review of dietary/food service findings and QAPI documents, Director of Quality A confirmed to Surveyor #22198, that FSM-L does not always attend meeting, and that the hospital's dietary and food is not a part of the QAPI program, that would include oversight, tracking, trending, and improvement projects. Also present during this interview was CCSO BB.

Per Surveyor #29972's interview with ED RN Manager C on 5/31/2012 beginning at 11:00 AM this hospital does not have a cardiac catheterization lab so all patients who require these services must be transferred.

Per ED RN Manager C, these patients transferred to Aurora Grafton Hospital or Aurora St. Luke's Hospital.

Surveyor #29972 asked ED RN Manager C if the facility has a contract, arrangement or agreement with the other hospitals to transfer patients needing cardiac catheterization, ED RN Manager C responded, "no we just have an understanding".

On 05/31/12 at 12:00 PM Director of Quality A confirmed to Surveyors #29971 and #22198 this hospital does not have any contract, arrangement or agreement between this hospital and the Aurora Grafton Hospital or St. Luke's Hospital.

Only one arranged service was identified (Emergency Services). However, surveyors were unable to identify the full scope and universe of all system based contracts, arrangements, or agreements between this hospital and other Aurora System hospital's because the hospital does not maintain the contracts or a list.

Director of Quality A told Surveyors all contracts, agreements or arrangements between Aurora system hospitals are kept in a "vault" at a system level, that Director of Quality A does not have access to retrieve.

Per findings of Surveyor #22198 (Patients #6, 21 & 27)

On 05/31/12 at 9:20 AM a review of Patient #6's medical record and interview with CIE Z confirmed Patient #6 was admitted on 05/28/12 for shortness of breath (SOB) and chest pain. Patient #6 diagnoses was pneumonia. Patient #6 has a history of Methicillin-resistant Staphylococcus aureus (MRSA) and was placed on contact precautions.

Care planning failed to include evidence of family education on "contact" precautions. There was no evidence that the family received appropriate education of personal protective equipment (PPE) while visiting Patient #6.

Education documentation for Patient #6 had a check in the box next to " isolations precautions " . However, when Surveyor #22198 requested to review what documentation was included in the Isolation precautions for a 75 year old patient, CIE Z confirmed education documentation consisted of a series of check boxes. There was no evidence of the content of the education provided.

The care planning failed to address nutritional concerns documented on 05/30/12 by the RD that determined Patient # 6 required an increase of nutritional intake of 75%, and there was no evidence that the family or primary caregiver for Patient #6 had been educated in the additional needs.

On 05/31/12 at 11:00 AM a review of Patient #21's medical record and interview with CIE Z confirmed Patient #21 was admitted on 05/24/12 first in the ER then transferred to the in-patient for fever and diagnosed with sepsis (a severe illness in which the bloodstream is overwhelmed by bacteria).

Multiple tests and cultures completed including MRSA, clostridium difficille (C-diff) and the ER placed Patient #21 in contact and airborne precaution that were implemented in the ER and discontinued in the ER at 10:49 AM. There was no evidence from the ER to the in-patient unit what if any isolation precautions the hospital staff used during transportation.

On 05/24/12 at 12:25 AM once admitted to in-patient, contact and droplet precautions were implemented.

On 05/26/12 at 2:21 PM two days after Patient #21' was admitted with Sepsis and placed on infection precautions, "verbal" education was provided to Patient #21 and family on "Isolation".

05/28/12 at 12:31 PM, 4 days after admission, Patient #21's record documented patient received written and verbal education on "Isolation".

05/30/12 at 3:56 PM, 6 days after Patient #21 was admitted with Sepsis Isolation, education was documented as provided to both family and patient, that included written and explanation.

CIE Z confirmed education documentation consisted of a series of check boxes. There was no evidence of the content of the education provided to the 82 year old patient. CIE Z confirmed the education provided to Patient #21 and family on "isolations precautions" was not available or documented. There was no evidence that the family received appropriate education of personal protective equipment (PPE).

On 05/30/12 at 1:05 PM during an observation of a therapy evaluation Surveyor #22198 observed the following upon entry to Patient #27's room noted as being on contact precautions: 2 family members were in the room sitting at Patient #27's bed side with out any PPE.

At 1:40 PM daughter of Patient #27 came into the room without PPE. Two family members exchanged conversation and one left the room without performing hand hygiene.

At 1:05 PM PT HH initiated a PT evaluation and asked Patient #27's pain level. Patient indicated her pain level was an "8". PT HH asked what a tolerable pain level would be for Patient #27? Patient #27 answered "a 2". No pain medication was offered.

PT HH continued the evaluation and then initiated movement activities that included passive range of motion (ROM).

From 1:05 PM - 2:00 PM, PT HH conducted therapy. At the end of therapy a reassessment of Patient #27's pain level was completed. Patient stated her pain level was still a "6". Also present and confirmed this observation was CCSO BB.

Surveyor #22198 interview with PT HH at 2:00 PM about Patient #27's pain assessment.

PT HH stated HH was aware of Patient #27's back pain as a part of the care plan. PT HH confirmed HH had not thought about pre-medicating prior to therapy.

Surveyors #22198 asked PT HH, what collaboration is done between nursing and PT when therapies need to be done for pain and other care planned problem areas may be affected?

PT HH told Surveyor #22198, there isn't.

On 05/31/12 at 11:30 AM review of Patient #27's medical record and interview with CIE Z confirmed Patient #27 was admitted on 05/30/12 at 12:52 AM just after midnight with a diagnosis of Pneumonia and back pain.

Patient #27's care plan confirmed Patient #27 was placed on "droplet" precautions upon admission.

A check by "Isolation" education indicated Patient #27 received verbal education on 05/30/12 at 12:39 AM. However, CIE Z confirmed there was no evidence or documentation as to content of that education.

On 05/31/12 at 3:07 PM CIE confirmed Pain was a part of Patient #27's care plan, but Patient #27 had not been assessed or premeditated for pain prior to therapy on 05/30/12 based on the times of observation including 2 hours prior to therapy.

One (1) hour and 7 minutes after therapy session, at 3:07 PM after Surveyor #22198 interviewed PT HH about Patient #27's pain level still being a "6" was patient given pain medication.

After Surveyor #22198 conducted observations and interviews on 05/30/12 at 2:00 PM related to failed practice in isolation precautions for Patient #27, was family education documented at 2:41 PM as written and verbal.

On 05/31/12 at 11:50 AM Surveyor #26390 interview Spouse II about "isolation" education. Spouse II told Surveyor #26390, that Patient #27's family was with her all day yesterday and no one told them they needed masks until later. Written education as indicated in the nursing notes was not validated.

On 05/31/12 at 12:00 CIE Z confirmed to Surveyor #22198, there was no evidence or documentation as to content of that isolation education noted on 05/30/12 at 2:41 PM.

CIE Z confirmed to surveyor #22198, checking a box that education would not define the content of the education, or that education was received and understood.











29972

Based on medical record review, review of policy and procedures, and staff interview the facility failed to ensure nursing staff provided appropriate interventions and evaluation of those interventions in 5 of 22 medical records reviewed (Pt # 9, 15, 6, 21, and 27). Failure to implement appropriate interventions and evaluation of patients has the potential to affect all patients present during the survey (5/29/12- census was 13, 5/30/12- census was 25, and 5/31/12- census was 28).


Findings by surveyor #29972

Pain Management Policy #2006: reviewed 5/31/2012 at approximately 11:30 AM.

2a. To evaluate the pharmacological pain interventions, the following guidelines for reassessment are recommended: Reevaluate pain intensity/behavior within 30-60 minutes of administering an oral pain medication and within 15-30 minutes of an IV pain medication.

2b. Compare current pain assessment with established comfort/function goal and consider interventions needed if assessment is not at or below established goal.

Per MR review of Pt #9 on 5/30/2012 beginning at 8:30 AM, pain assessment documented on 5/29/2012 at 9:29 AM. Pt #9 rated pain a 7 out of 10 and Oxycodone 10 mg tablet was documented as given at 9:29 AM. No pain reassessment is documented until 11:45 AM. On 5/29/2012 at 8:41 PM, Oxycodone 5 mg tablet documented as given, pain reassessment not documented until 10:00 PM.

Per MR review of Pt #15 on 5/31/2012 beginning at 10:00 AM: On 1/29/2012 at 7:10 AM Pt #15 presented to the Emergency Department (ED) ambulatory after being involved in a motor vehicle accident. Per nurses note at 7:13 AM Pt #15 states he was driving truck and rolled over. Pt #15 complained of neck pain/bilateral shoulder pain. At 7:16 AM Pt #15's pain assessment is documented as 8 out of 10. Pt #15's pain medication is not documented as given until 8:35 AM. Pt #15 was discharged from ED at 9:25 AM. No pain reassessment is documented.

Review of facility policy and procedure "Expanded Role of the Nurse in the ED" last updated 2/2011, on 5/31/2012 at approximately 11:00 AM, reveals the following: "K. RN Triage to X-ray/Muscular/Skeletal injuries...1. Initiate/maintain Cervical Spine Immobilization."

Per interview with ED RN Manager C on 5/31/2012 at 11:00 AM it is an expectation that patients who present in the ED complaining of head and neck injuries be provided with appropriate head and neck stabilization to prevent further injury. Review of Pt #15's ED record shows no documentation of nursing interventions providing head and neck stabilization.

Per findings of Surveyor #22198 (Patient #5)

On 05/30/12 at 10:45 AM a review of Patient #5's medical record and interview with CIE R confirmed Patient #5 admitted on 05/27/12 for a fall that related to a femoral head fracture required surgical repair of the fracture and was still a current in-patient.
Pt. #5's care plan included pain, skin integrity/pressure ulcer. The care plan failed to include potential complications from the hips surgery (i.e.: infection limitations) or a reassessment of the current pain goals and plan after surgery.

The nutritional consult dated 05/30/12 documented by the hospital RD noted: Inadequate intake related to (r/t) decreased appetite/intake due to (d/t) pain and surgery since admit evidence eating <25% of meals.

The care planning failed to address nutritional concerns documented on 05/30/12 by the RD that determined Patient #5 required and increase of nutritional intake of 75%, and there was no evidence that the family or primary caregiver for Patient #5 had been educated in the additional needs.













29963

Based on Medical Record (MR) review, and staff interview, this facility failed to establish individualized careplans for 2 out of a total of 35 medical records reviewed. Failure to complete a nursing care plan specific to the needs of the patient has the potential to affect all patients present during the survey (5/29/12- census was 13, 5/30/12- census was 25, and 5/31/12- census was 28).

Findings Include:

Per Medical Record review on 5/30/12 at 2:45 PM by Surveyor # 29963, Pt. #22 was admitted to the hospital on 12/24/11 and discharged to Nursing Home on 12/25/12 with a diagnosis of Pneumonia and secondary diagnosis' including chronic right foot ulcer with osteomyelitis (infection in the bones) and peripheral vascular disease. Per review of care plan, problems addressed include: Decreased cardiac output and Pneumonia. Care plan does not address ulcers. Findings verified with CQM B on 5/30/12 at 3:15 PM.

Based on observation and review of policy and procedure, in 2 of 2 observations ( D and H) the facility failed to ensure medication administration and IV (intravenous) starts are performed in an aseptic manner including hand washing per policy. This defecient practice has the potential to affect all inpatients present during the survey (5/29/12- census was 13, 5/30/12- census was 25, and 5/31/12- census was 28).

Findings include:

According to the Centers for Disease Control (CDC), who publish nationally recognized standards of practice and recommendations for health care organizations, the following recommendations regarding handwashing/glove changing were published in the October 2002 Morbidity and Mortality Weekly Report (MMWR): 1. Decontaminate hands before having direct contact with patients, 2. Decontaminate hands after contact with a patient's intact skin (e.g., when taking a pulse or blood pressure, and lifting a patient), 3. Decontaminate hands after contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings if hands are not visibly soiled, 4. Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care, 5. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient, 6. Decontaminate hands after removing gloves.

Occupational Safety and Health Administration Bloodborne Pathogen standards at 29 CFR 1910.1030(d)(3)(ix) requires the following: " Gloves. Gloves shall be worn when it can be reasonably anticipated that the employee may have hand contact with blood, other potentially infectious materials, mucous membranes, and non-intact skin; when performing vascular access procedures except as specified in paragraph (d)(3)(ix)(D); and when handling or touching contaminated items or surfaces. "

Per surveyor 18816 observation of a medication pass on 5/29/12 at 11:50 AM, the following was observed: RN H obtained IV antiemetic Reglan from the Pyxis system without first washing her hands. Upon entering the Patient #1's room 316, washed, gloved and aseptically administered saline to flush the IV line, then the medication. RN H removed the gloves, obtained a new IPA Site Scrub (to clean the IV port), more saline, donned new gloves, and proceeded to administer the saline. RN H removed the gloves and moved the bedside table next to the patient bed, opened apple juice, handled the patient bed/TV/call light control and documented on the computer without the benefit of washing after removing gloves.

Per surveyor 18816 observation of an IV start and medication administration on 5/29/12 at 12:40 PM, the following was observed: RN D already had supplies ready to take into Patient #3's room in the Emergency Department. Upon entering the room RN D washed an aseptically inserted a IV needle for medication administration. RN D secured the IV needle and attached the IV line, left the room entered the supply room, and returned with a tegaderm to protect the needle site, started an antibiotic in the IV line, removed the gloves. RN D proceeded to document on the computer, gather up excess supplies and trash, disposed items in the medication room and touched the computer mouse without the benefit of washing.

Per surveyor 29963 review of facility policies on 6/4/12 at 11:30 PM provided by DQI H, Clinical Nursing Skills and Techniques per Perry and Potter used throughout facility however Perry and Potter does not address the CDC guidelines and recommendations for hand hygiene therefore policies do not reflect current practices for hand hygiene.

Based on review of MR and interview with staff, in 1 of 4 MR (13) the facility failed to ensure the newborn Discharge/Examination Summary is completed on the day of discharge.

Per surveyor 18816 review of Pt #13's MR on 5/30/12 at 3:00 PM revealed Pt 13 was admitted on 8/4/12 as a newborn, and discharged on 8/6/12 to home. The newborn Discharge/Examination Summary is completed by the Medical Doctor on 8/5/12. This is confirmed in interview with RN N on 5/30/12 at 3:00 PM, RN N added the Discharge Summary is to be done on the day of discharge.

Based on MR (medical record) review, review of rules and regulations, and interview with staff, in 3 of 22 (Pt # 22, 23, 34) inpatient closed MR's, the facility failed to ensure MR's are complete within 30 days of discharge. This deficiency potentially affects all 13 inpatients at the facility during survey on 5/29/12, 25 inpatients on 5/30/12 and 28 inpatients on 5/31/12.

Findings include:

The Medical Staff Bylaws/Rules and Regulations, which are reviewed annually and were last reviewed in April of 2011, state:
On page 10 of the Rules and Regulations, 3.3 states, "It is the responsibility of the attending Practitioner to complete all medical records within thirty days of the patient's discharge."

Pt. # 22's MR reviewed by surveyor 29963 on 5/30/12 at 2:45 PM revealed the Pt. was seen by MD on 12/24/11 and discharged from hospital on same date. The MD authentication occurred 2/22/12. This is confirmed with CQM B on 5/30/12 at 3:15 PM.

Pt. # 23's MR reviewed by surveyor 29963 on 5/30/12 at 9:25 AM revealed the Pt. was seen by MD on 2/15/12 and discharged from hospital on same date. The MD authentication occurred 4/11/12. This is confirmed with CQM B on 5/30/12 at 10:40 AM.

Pt. # 34's MR reviewed by surveyor 29963 on 5/30/12 at 2:10 PM revealed the Pt. was seen by MD on 7/10/11 and expired on same date. The MD authentication occurred 5/11/12. This is confirmed with CQM B on 5/30/12 at 2:30 PM.

Based on tour and interview with staff, in 3 of 5 tours the facility failed to ensure crash carts or secured or in constant view to prevent unauthorized access. This deficiency potentially affects all 13 inpatients at the facility during survey on 5/29/12, 25 inpatients on 5/30/12 and 28 inpatients on 5/31/12.

Findings include:

Per surveyor 18816 tour of the Emergency Department at on 5/29/12 at 10:15 AM there is a crash cart next to room NP-8 that has a breakaway lock, is not secured and not in view of staff at all times. This is confirmed in interview with Coordinator of Quality Management B on 5/29/12 at 10:50 AM.

Per surveyor 18816 tour of the third floor medical/surgical unit on 5/29/12 at 11:05 AM the crash cart across from the staff break room has a breakaway lock, is not secured and not in view of staff at all times. This is confirmed with RN E on 5/29/12 at 11:05 AM.


29963


Per Surveyor 29963 tour of the second floor medical/surgical unit on 5/29/12 at 11:45 AM the crash cart located in an alcove across from the elevators has a breakaway lock, is not secured and not in view of staff at all times. This is confirmed with RN N and Coordinator of Quality Management (CQM) B on 5/29/12 at 11:45 AM.

Based on observations, staff interviews and record reviews, the hospital failed to ensure: that employees have received the required training, that food is stored and prepared in a safe manner, that the kitchen is adequately cleaned, that staff is sanitizing thermometers between food items, that staff is checking the internal temperature of the hot water sanitization dish machine to achieved the temperature necessary for sanitization, that staff with facial hair had it covered when working in the kitchen. In addition the facility staff used single-use gloves for multiple tasks that resulted in numerous opportunities for cross-contamination and the facility failed to have policies and procedures specific to facility's dietary department. The totality of these issues had the potential to negatively affect all the 13 inpatients on 5/29/2012.

Findings by surveyor # 29302 include:

REQUIRED TRAINING
On 5/29/2012 from 2:00 PM to 2 :20 PM, in an interview with surveyor 29302 and food service manager L, (FSM-L) it was revealed, employees of facility's dietary department receive training in proper storage, preparation and serving of food, safety, appropriate personal hygiene and infection control when hired, but not on a yearly basis. FSM-L states there is a communication book that employees are to look at daily. If there are any issues/concerns, the communication book is the method used to provide the information to the dietary employees. FSM-L acknowledges that there are not regularly scheduled in-services and information contained in the communication book does not consistently address proper storage, preparation and serving of food, safety, appropriate personal hygiene and infection control.

FOOD STORED AND PREPARED IN A SAFE MANNER
According to the Wisconsin Food Code, 3-501.17 Ready-to-Eat, Potentially Hazardous Food, Date Marking.
(A) Except as specified in ¶¶ (D), (E) and (G), refrigerated, READY-TO-EAT, POTENTIALLY HAZARDOUS
FOOD PREPARED and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold or discarded, based on the temperature and time combination of 5 degrees C (41 degrees F) or less for a maximum of 7 days.

On 5/29/2012 from 10:00 AM to 10:20 AM., during the tour with FSM-L, surveyor 29302 made the following observations: Items in cooler #1 which did not have labels: Container of pesto, ½ pan of cooked noodles, and cheese. In cooler #2, items which did not have labels: sheet cake pan of angel food cake slices, sheet cake pan of carrot cake squares, and sheet cake pan of pie slices - Dutch apple and pumpkin. Also in cooler #2, a container of mushrooms had an expiration date of 5/23/12. FSM-L was in agreement with surveyor's observations.

On 5/29/2012 at 1:00 PM, FSM-L stated to surveyor 29302, that the professional standard of practice used by the facility's dietary department is the Wisconsin Food Code.

On 5/29/2012 at 2:00 PM, FSM-L provided surveyor 29302 with policy no. 5065, revision date 6/11, " Food Preparation and Standards. " Although this policy indicates it is for Aurora Health Care St. Luke's Food Management department, FSM-L stated to surveyor that this is the policy in use for the facility's dietary department. Bullet number 9 states " All items not in their original packaged are covered, dated, and labeled as to contents. "

CLEANING OF EQUIPMENT AND UTENSILS

On 5/29/2012 at 2:00 PM, FSM-L provided surveyor 29302 with policy no. 2020, revision date 6/11, " Safe Food Handling. " Although this policy indicates it is for Aurora St. Luke's and South Shore 's Food Management Department, FSM-L stated to surveyor, that this is the policy in use for the facility's dietary department. Bullet number 9. " CLEANING/SANITIZING EQUIPMENT AND UTENSILS ....D. Equipment is cleaned based on the frequency identified on the cleaning schedule. "

On 5/29/2012 at 1:00 PM, FSM-L stated to surveyor 29302, that the professional standard of practice used by the facility's dietary department is the Wisconsin Food Code. According to the Wisconsin Food Code, 4-6 CLEANING OF EQUIPMENT AND UTENSILS, (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.

On 5/29/2012 at 1:00 PM, FSM-L stated to surveyor 29302, that the professional standard of practice used by the facility's dietary department is the Wisconsin Food Code which states the following at section: 4-602.11 Equipment Food-Contact Surfaces and Utensils. (4) Before using or storing a FOOD TEMPERATURE MEASURING DEVICE; and
(5) At any time during the operation when contamination may have occurred.

On 5/29/2012 from 10:27 AM to 10:39 AM, surveyor 29302 made the following observations in the kitchen: built up grease and dirt on lower right corner ledge of lower double oven, greasy oven hood edge with dust inside hood located above the 4 gas-burner stove and crumbs throughout the inside lower cabinets of the entire cook line. FSM-L was in agreement with surveyor's observations. Surveyor requested from FSM-L a cleaning schedule. FSM-L stated cleaning is part of the employees' job descriptions and there wasn't anything else.

On 5/29/2012 at 11:26 a.m., surveyor 29302 made the following observations of Chef K taking temperatures. Chef K inserted thermometer into chicken broth. Without sanitizing the thermometer, Chef K inserted thermometer into chicken gravy. Chef K then went to sink and rinsed off thermometer, but did not sanitize thermometer. Chef K then inserted thermometer into beef broth. Without sanitizing thermometer, Chef K then inserted thermometer into beef gravy.


MONITORING OF INTERNAL TEMPERATURE OF HOT WATER SANITIZATION DISH MACHINE

On 5/29/2012 at 1:00 PM, FSM-L stated to surveyor 29302, that the professional standard of practice used by the facility's dietary department is the Wisconsin Food Code. On 5/29/2012, 2:00 PM, FSM-L provided surveyor with policy no. 5150, revision date 12/10, " DISHMACHINE TEMPERATURES. " Although this policy indicates it is for Aurora St. Luke's and South Shore's Food Management Department, FSM-L stated to surveyor that this is the policy in use for the facility's dietary department. According to bullet V. 4. " The Dietary Assistant takes a T-stick reading once daily to validate that dishmachine gauges are in working order. A check mark is placed in the T-stick column indicating that temperatures were in the appropriate range .... "

According to the Wisconsin Food Code, 4-7 SANITIZATION OF EQUIPMENT AND UTENSILS, 4-701.10 Food-Contact Surfaces and Utensils.
EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be SANITIZED. (B) Hot water mechanical operations by being cycled through EQUIPMENT that is set up as specified under §§ 4-501.15, 4-501.112, and 4-501.113 and achieving a UTENSIL surface temperature of 71 degrees C (160 degrees F) as measured by an irreversible registering temperature indicator;

On 5/29/2012 at 11:37 AM, surveyor 29302 observed dishwashing procedures performed by dietary aide T (DA-T) using a hot water sanitization mechanical dishwasher. DA-T stated to surveyor logs are kept of the temperatures from the external gauges but doesn't know anything about checking the internal temperature with an irreversible temperature measuring device.

On 5/29/2012 at 2:00 PM, FSM-L stated to surveyor 29302 that EcoLab comes in and services the dishmachine. FSM-L stated EcoLab is a new contract for the facility and initially EcoLab was coming in regularly, however, that has stopped. FSM-L stated when EcoLab did come in, the internal temperature of the dishmachine was checked and staff is not checking the internal temperature of the hot water sanitization dishmachine.

EMPLOYEE HYGIENE

Hair restraints

Surveyor 29302's review of the Wisconsin Food Code states the following: Hair Restraints 2-402.11 Effectiveness.(A) Except as provided in ¶ (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.

On 5/29/2012 at 10:15 AM, surveyor 29302 observed Chef K with his beard uncovered and at 11:18 AM, surveyor observed pm cook J (Cook J) with hair on chin uncovered.

Surveyor 29302 asked FSM-L what the facility's policy is related to facial hair. FSM-L stated to surveyor that staff can have facial hair as long as it isn't any longer than ¼ inch. Surveyor asked FSM-L what professional standard of practice is used for the facility's dietary department, FSM-L responded they use the Wisconsin Food Code.

Single-use glove

3-304.15 Gloves, Use Limitation.
(A) If used, SINGLE-USE gloves shall be used for only one task such as working with READY-EAT FOOD or with raw animal FOOD, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation.

On 5/29/2012 from 11:18 AM to 11:35 AM, surveyor 29302 observed numerous examples of cross contamination by PM Cook J, who was wearing one pair of single-use gloves during the entire observation. Those examples are as follows:
With gloved hands, Cook J opened the reach-in cooler, then opened the walk-in freezer, opened the top steamer, opened the reach-in cooler, placed a pre-cooked chicken breast onto the griddle, opened the reach-in cooler, opened and walked into the freezer, opened the lower oven door, set the timer, opened the microwave, grabbed a hamburger bun, buttered the bun and placed onto the griddle, grabbed a plate from lowerator on the eating surface, went to the dishroom, washed the single-use gloves, grabbed ready-to-eat leaf lettuce, sliced tomatoes, grabbed parsley and two baby carrots, grabbed another plate, touching the eating surface, lifted magnet from front of refrigerator to grab a paper, pushed down onto top of plate to retrieve from lowerator, grabbed bun from griddle, placed bun on plate, placed lettuce and sliced tomato on bud, [heated chicken breast put on bun using spatula] covered chicken breast with bun.

On 5/29/2012 at 1:00 PM, FSM-L stated to surveyor 29302, that the professional standard of practice used by the facility's dietary department is the Wisconsin Food Code. According to the Wisconsin Food Code, single-use gloves shall be used for only one task stated as follows:

POLICIES AND PROCEDURES
On 5/29/2012 at 12:45 PM., per surveyor 29302's request, FSM-L provided the facility's dietary policies and procedures. Surveyor's review of policies and procedures determined that they were identified to be for other facilities, which are as follows: " Dress Code " , policy 8130, revision date 8/11 is for Aurora St. Luke; " Safe Food Handling, " policy 2020, revision 6/11 is for Aurora St. Luke ' s and South Shore ' s Food Management Department; " Standardizing Recipes, " policy 2080, revision 3/12 is for Aurora St. Luke 's and South Shore 's Food Management Department; " General Sanitation, " policy 5015, revision 10/05 is for Aurora St. Luke's and South Shore's Food Management Department; " Food Preparation and Standards, " policy 5065, revision 6/11 is for Aurora St. Luke; " Refrigeration Temperature Recording, " policy 5140, revision 2/12 is for Aurora St. Luke's and South Shore ' s Food Management Department; " Standard Precaution Procedures, " policy 5180, revision 2/12 is for Aurora St. Luke ' s and South Shore ' s Food Management Department; " Vegetable Cleaning/Preparation, " policy 2140, revision 6/11 is for Aurora St. Luke ' s and South Shore ' s Food Management Department; " Dishmachine Temperatures, " policy 5150, revision 12/10 is for Aurora St. Luke's and South Shore's Food Management Department.

Based on observation, staff interviews and review of maintenance documents, the facility failed to construct and maintain the building systems to ensure a safe physical environment due to the cumulative effects of environment deficiencies and resulted in the hospital's inability to ensure a safe environment for the patients, which is a Condition of Participation. This deficiency occurred in 12 of the 21 smoke compartments, and would affect all of the 13 patients in the facility on the day of the survey.

FINDINGS INCLUDE:
It was observed that the facility had the following life safety deficiencies. K11 (common walls), K15 (room finishes), K17 (corridor walls), K18 (corridor doors), K27 (smoke doors), K29 (hazardous room), K38 (exit discharge), K43 (egress locking) , K45 (dual lamps), K62 (fire protection sprinkler maintenance), , K144 (generator) and K211 (ABHR). Please Refer to the full description at the cited K-tags: This observed situation was not compliant with CFR 482.41.

Based on tour and interview with staff, in 1 of 3 tours, the facility failed to ensure emergency call lights are functional. This deficient practice could potentially affect all inpatients (census on 5/29/12 was 13, census on 5/30/12 was 25, and census on 5/31 was 28) and visitors.

Findings include:

Per surveyor 18816 tour of the Emergency Department at 10:15 AM the soiled room is not secure to prevent access by pt.'s or visitors. This is confirmed in interview with RN C on 5/29/12 at 10:15 AM.

Per surveyor 18816 tour of the Birth Day Center on 5/29/12 at 1:30 PM the emergency call light cords in room 324 and public rest room are wrapped around the safety rails preventing the ability to engage the emergency call light if pulled. The emergency call light cord in room 322 is taped on the shower wall preventing access by the Pt., if on the toilet or floor, and the emergency call light cord in room 324 is draped over the shower rail preventing access by the Pt., if on the toilet or floor. This is confirmed in interview with RN N on 5/29/12 at 1:30 PM.

Based on observation, staff interviews and review of maintenance documents, the facility failed to construct and maintain the building systems to ensure a safe physical environment due to the cumulative effects of environment deficiencies and resulted in the hospital's inability to ensure a safe environment for the patients, which is a Condition of Participation. This deficiency occurred in 7 of the 7 smoke compartments, and would affect all of the 28 patients in the facility on the day of the survey.

FINDINGS INCLUDE:
It was observed that the facility had the following life safety deficiencies. K11 (common walls), K15 (room finishes), K17 (corridor walls), K18 (corridor doors), K27 (smoke doors), K29 (hazardous room), K38 (exit discharge), K43 (egress locking) , K45 (dual lamps), K62 (fire protection sprinkler maintenance), , K144 (generator) and K211 (ABHR). Please Refer to the full description at the cited K-tags: This observed situation was not compliant with CFR 482.41.

Based on tour, observation, review of policy and procedures, and interview with staff, in 9 of 9 tours and 9 of 9 observations (I, Q, V, HH, W, EE, CC and U) the facility failed to ensure a sanitary environment, and hand washing is performed per policy. This deficient practice could potentially affect all inpatients (census on 5/29/12 was 13, census on 5/30/12 was 25, and census on 5/31 was 28) and visitors.

Findings include:

Per surveyor 18816 review on 5/29/12 at 3:00 PM of facility laboratory policy titled Personal Protective Equipment: Safe 113.11, dated 9/9/11, it states under C.2. " ...Laboratory coats must be removed before entering designated clean areas and when leaving the laboratory. "

Per surveyor 18816 review on 5/29/12 at 3:00 PM of facility laboratory policy titled Bloodborne Pathogen Exposure Control Plan: Safe 139.10, dated 10/24/10, states under C. 2. " ...Hands are washed between all patient contacts.

Per surveyor 18816 observation of a lab draw on 5/29/12 at 12:25 PM, the following was observed: Lab Technician (LT) I was observed leaving the Lab wearing a lab coat, worn in the lab, entered the Emergency Department to perform a lab draw on Patient #2. LT I washed, donned gloves and after aseptically obtaining blood samples, LT I labeled the tubes, placed them in a baggy and into the lab coat left pocket. LT I removed the gloves, wash not observed to wash, returned to the Lab, removed gloves from the lab coat right pocket, donned the gloves, did not remove or change out the lab coat and proceeded to process the blood samples in the centrifuge and hematology analyzer.

Per surveyor 18816 observation of a dressing change on 5/29/12 at 9:30 AM the following was observed: RN Q entered Pt # 8's room 311, obtained gloves, placed them in her scrub pocket, washed hands, removed the gloves and donned them. RN Q removed the old dressing and discarded the old dressing, donned new gloves over the dirty gloves, and applied the new dressing without the benefit of removing the dirty gloves and washing.

Per surveyor 18816 tour of the Emergency Department at 10:15 AM there is a blue-green substance under the sinks in the Trauma room and rooms 6 and 7. This is confirmed in interview with RN C on 5/29/12 at 10:15 AM.

Per surveyor 18816 tour of the third floor medical/surgical unit at 11:05 AM the stairwell next to room 315 had debris on the floor and cobwebs in the windows. This is confirmed with RN E on 5/29/12 at 11:05 AM.

Per surveyor 18816 tour of the Birth Day Center on 5/29/12 at 1:30 PM there are boxes on the floor in the dirty room. This is confirmed in interview with RN N on 5/29/12 at 1:30 PM.

Per surveyor 29963 review of facility policies on 6/4/12 at 11:30 PM provided by DQI H, Clinical Nursing Skills and Techniques per Perry and Potter used throughout facility however Perry and Potter does not address the CDC guidelines and recommendations for hand hygiene therefore policies do not reflect current practices for hand hygiene.


22198

Per observations, interviews, record and policy reviews by Surveyor #22198 conducted between 05/30/12 and 05/31/12.

Review of the most current policy entitled "Contact Precautions", last reviewed 4/12, a 5 page policy with CCSO BB on 05/30/12 at 3:45 PM identified the following exerts:
Purpose: "Contact Precautions is designed to reduce the risk of transmission of epidemiologically important microorganisms by direct and indirect contact with the patients and their environments. Hands of caregivers are usually cited as the most important contributors to indirect microorganism transmission from patient to patient."
Policy: "All employees will adhere to Contact Precautions and Standard Precautions."
Section B. entitled: "Contact Precautions Personal Protective Equipment", requires staff use of gown and gloves when entering the room and Hand Hygiene before leaving the environment.
Section D: references dedicated items, should remain in room or cleaning between patients.

On 05/31/12 at 11:00 AM Surveyor and CIE Z conducted a record review of Patient #21's medical record. Patient #21 was in contact precautions with additional special precautions for Clostridium difficile (C-diff) for sepsis and a positive C-diff culture.

Patient #21 was an in-patient in Room 208. IC precautions were posted at the entrance of Room # 208 and an IC cart with contact precaution PPE was under the posted IC sign.

On 05/30/12 at 1:20 PM Surveyor #22198 observed PA V entering Patient # 21's room, carrying paper documents and failed to don any PPE. PA V walked around the Patient #21's bed and shifted the privacy curtain.

At 1:25 PM Surveyor #22198 observed PA V coming out of Room 208 again, shifting the privacy curtain and left the room. PA V failed to conduct any form of hand hygiene. Also present in observation was CCSO BB.

On 05/30/12 at 3:15 PM RN W provided Surveyor #22198 with the most current policy entitled "Droplet Precaution" last reviewed 4/12 consisting of 2 pages.

Review of the policy with CCSO BB at 3:45 PM confirmed page 2 under section C. entitled "Masks"
1. Staff and Visitors to wear surgical mask when entering the room. Dispose of mask prior to leaving the room when more than 3 feet from the patient.

Review of the policy with CCSO BB at 3:45 PM confirmed page 2 under section E. entitled "Visitors"
1. Number of visitors should be limited. Check for immunity to Rubella, Mumps, etc. If no history of having disease(s) or immunizations, person cannot visit.
2. Nursing is to instruct visitors in masking technique.

CCSO BB at 3:45 PM confirmed the policy requires visitors to wear a mask and the hospital staff to provide instructions on technique.

On 05/31/12 at 11:30 AM Surveyor and CIE Z conducted a record review of Patient #27's medical record. Patient #27 was in Droplet precautions.

CIE Z confirmed no family or visitor infection control or PPE education was done prior to the observation made by Surveyor on 05/30/12 at 1:05 PM to 2:00 PM. There was no documentation confirming family/visitor immunization or history of disease(s).

On 05/30/12 from 1:05 PM to 2:00 PM Surveyor #22198 and CCSO BB observed a physical therapy (PT) evaluation conducted by PT HH on Patient #27. Patient #27 was on droplet precautions until midnight.

Surveyor #22198 was told that to enter Patient #27's room Surveyor would be required to don a mask to comply with the hospital's droplet precautions policy.

On 05/30/12 at 1:05 PM Surveyor #22198, CCSO BB, PT HH entered Patient #27's room wearing masks at 1:05 PM. Two family members (a spouse and a sibling) were already in the room, neither of them wearing masks. A third family member (daughter) entered the room at 1:40 PM, not wearing a mask.

On 05/30/12 at 2:00 PM during an interview Surveyor #22198 asked RN W (Patient #27's nurse) why the family was in Patient #27's room without a mask?

RN W told Surveyor hospital staff tells families about Infection Control Precautions, but it is up to the families if they follow them; " They have the option to do it or not do it."

On 05/31/12 at 11:50 AM Surveyor #26390 interviewed Spouse (II) of Patient #27. Patient #27's spouse II confirmed the hospital staff had not provided education or information about Infection Control precautions related to Patient #27.

Spouse II told Surveyor #26390 " None of the company yesterday had to wear a mask until later." Spouse II confirmed it was 3:30 PM 05/30/12 after Surveyor #22198's observations, when the hospital staff told them they had to wear a mask.

On 05/30/12 at 1:35 PM, RN W was gloved and masked and observed by Surveyor #22198 removing an intravenous (IV) catheter from Patient # 27's right anticubital. RN W removed the catheter and with RN W's right hand applying pressure to the IV site, reached over to the biohazardous sharps box and reached into the lip of the box allowing the gloved hand to touch the inside of the lip of the biohazardous box.

RN W did not remove the dirty glove or wash hands but proceeded to dress the old IV site with the dirty and potentially contaminated glove.

On 05/29/12 at 2:05 PM to 2:45 PM, Surveyor #22198 and Manager of Rehabilitation (Rehab) Services (MRS) O conducted an onsite tour, observations and interviews at offsite Rehab location. The following was identified:

A dremel located in the clean storage area was dusty and dirty. No preventative maintenance label was identified on the equipment, and the equipment was dusty and dirty.

Ultrasound gel bottles (one time use item) were being cleaned and re-used for bulk massage lotion.

Hydrotrack water therapy equipment is currently tested every 24 hours per MFR. However, testing log documentation does not define the testing or re-testing time(s). An entry on 05/14/12 defined a water chemical imbalance. Chemicals were added, but this caused a pH imbalance that required additional chemical adjustments and testing.
An interview with Physical Therapy Assistant JJ confirmed to Surveyor #22198, there is nothing in the current log that defines the times of chemical testing.
A patient was seen at 9:15 AM on 05/14/12. However Physical Therapy Assistant JJ confirmed they could not confirm testing times or if the test had been completed and water chemical were within acceptable parameters prior to the patient being seen on 05/14/12 at 9:15 AM.

Dexamethasone (a steroid drug) is used in the department in a 4 milligrams (mg) to 1 milliliter (ml) dosage. The topical dexamethasone was in a secondary container prepared at the pharmacy and labeled to identify its expiration date as 06/13/12.
An interview with MRS O at this time confirmed that staff fills the syringes onsite. MRS O confirmed to Surveyor #22198, there is no designated clean area to transfer the medication from one container to another, and the medication transfer happens at a common work area.
A container of 17 syringes observed.

15 syringes had a fill date of 04/02/12. However, no one could confirm the date of the expiration from the bottle is was drawn up from. MRS O talked to 3 different staff and got 3 different answers (30, 60 and 90 days). MRS O confirmed to Surveyor #22198 that not labeling the syringes with the expiration date from the bottle makes it confusing for staff.

2 syringes were empty but laying in with the clean full syringes with dates fill dates of 02/15/12 and 02/06/12.

MRS O had to ask several Rehab staff why staff would place empty dirty syringes in the clean syringe container. MRS O was told by staff that the syringes were sent back to pharmacy to be re-used.
MRS O confirmed to Surveyor #22198 and later confirmed in additional interviews, that ICP JJ and Director of Pharmacy prohibit the re-use of any syringes.

During a respiratory therapy (RT) observation and interview on 05/30/12 at 3:05 PM the following occurred:

RT U completed hand hygiene prior to entering Pt. #37's room.

Ungloved and without hand hygiene between tasks the following took place:

RT U listened to Pt. #37's lung and took a pulse.
RT U removed a used nebulizer mask from a bag hanging on the wall, unscrewed the medication chamber and filled it with DuoNeb solution.
RTU turned on the Oxygen and placed the mask on Pt. #37's face.
RT U monitored Pt. #37's pulse during the procedure.
RT U documented on the computer in Pt. #37's room, used by all staff.
After the treatment was complete, RT U removed the treatment mask from Pt. #37's face and placed the mask back into the bag on the wall. Fluid was visible inside the medication chamber.
RT U performed hand hygiene after all tasks were completed.

After this observation was completed Surveyor #22198 asked RT U about the used mask hanging on the wall, and RTU stated the mask were changed out 3 times per week but not cleaned in-between treatments.

Surveyor #22198 asked RT U why U did not use gloves while performing respiratory therapy treatments, RT U stated gloves are not always necessary and it depends on the patient. Also present during this observation was CCSO BB.

Surveyor #22198 requested the RT policy for cleaning RT equipment and Infection Control policies.

CCSO BB did not have a policy but provided Surveyor #22198 with a page copied from the American Association of Respiratory Care (AARC). Page #621 section ADS: 14.0 entitled; "Infection Control" was reviewed:

14.1 "Standard precautions and measure to limit the transmission of airborne pathogens must be adhered to at all times"
14.2.1 "Jet nebulizers are for single patient use and to should be changed every 24 hours, or at a frequency determined in collaboration with infection control, based on local data, when used in a hospital."
14.2.2 "Jet nebulizers should be cleaned, rinsed with sterile water, and air dried between treatments on the same patient."

CCSO BB provided no additional policies or infection control information to Surveyor.

An interview and review of the copied AARC document and observation, CCSO BB confirmed to Surveyor #22198, that at minimum standard precautions should be used during respiratory treatment.


26390



Findings by surveyor #26390 include:

On 5/31/2012 at 11:58 AM a review of P/P titled, Hand Hygiene/Surgical Hand Antisepsis, was reviewed. The P/P states in part, "2. Hand rub (alcohol-based waterless hand sanitizer) c. Before and after patient contact. h. After removing gloves. K. Gloves 2. Single use gloves should never be washed or reused."

On 5/29/2012 at 1:10 PM a observation with CNO AA was made of RN EE caring for pt. #10 in the Wound Care Clinic of the hospital. RN EE donned gloves, without any hand hygiene, and removed the dressing from pt. #10's left heel. RN EE disposed of the dirty dressing and proceeded to cleanse pt. #10's lower leg and heel with a wash cloth and warm water. RN EE removed the gloves, (no hand hygiene) and proceeded to use a mirror to observe the wound, donned a new pair of gloves and measured the wound. RN EE removed the gloves (no hand hygiene) documented wound measurements. RN EE left the room without hand hygiene and confirmed being finished with pt. #10 and was going to the next patient.
The observation was confirmed with CNO AA, hand hygiene was not performed prior to treatment, after treatment, between glove changes or after touching the patient.

On 5/30/2012 at 9:56 AM a observation with Surgery Director AA was made of Central Processing Technician (CPT), CC. CPT CC explained the process for removing bioburden from surgical instruments. CPT CC preceded to show surveyor 3 pumps of Enzol is used in the sink. When asked how much water is used CPT CC, shrugged shoulders and stated whatever she thinks. CPT CC placed instruments in the sink and began scrubbing immediately and placing instruments on counter for sterilization. When asked how long the instruments should soak in the cleaner CPT CC, responded, "no specific time." Surveyor showed the bottle directions to CPT CC, the bottle states in part, "2 ounces to 1 gallon water", instruments should soak, "a minimum of 1 minute".
Surgery Director AA confirmed the above findings immediately after the observation.


29972

Findings by Surveyor #29972

On 5/30/2012 at 10:30 AM, in the clean linen storage area, observed bath towels, wash cloths, bed sheets, pillow cases, and patient gowns uncovered on shelving unit, exposing clean patient items to potential cross contamination of dust and debris. Observed dust and debris and yellow residue on the floor under the shelving units.

On 5/30/2012 at 10:40 AM, in the Laundry room, observed empty cart containing dirt and debris. Per interview with Environmental Services Manager X during tour, dirty mop heads are kept here prior to being washed in the washing machine. Observed additional area in the laundry room where the dryer is located and observed clean mop heads, laundered curtains, and clean linen in large containers. These containers of clean items must pass by the container of dirty mop heads in order to exit the room, potentially leading to cross contamination of clean items.

On 5/30/2012 at 10:45 AM, in the Biohazard Storage room, observed line down the wall with written words "clean" on one side and "dirty" on the other. Surveyor #29972 observed 2 clean red biohazard containers sitting next to large container storing "dirty" red biohazard containers on the "dirty" side of the room, and "dirty" biohazard container placed next to clean red biohazard container on the "clean" side of the room, potentially leading to cross contamination of the clean biohazard containers. Environmental Services Manager X confirmed these findings at the time of the tour.

On 5/30/2012 at 10:50 am, in the clean utility room, observed 2 Baxter Pumps located directly on the floor. Per interview with Environmental Services Manager X at the time of the tour, the equipment in this room is considered clean and ready for use by patients.

Based on record review and interviews the hospital failed to complete 2 of 22 (# 6 and 23) discharge plans for patients being discharged. Failure to complete discharge plans specific to the needs of the patient has the potential to affect all patients present during the survey (5/29/12- census was 13, 5/30/12- census was 25, and 5/31/12- census was 28).

Findings include:

Per surveyor #22198
Surveyor and CIE Z reviewed the medical record for Patient #6 on 05/31/12 at 9:55 AM.

Patient #6 was admitted on 05/28/12 for shortness of breath and chest pain, and was diagnosed with pneumonia and was in MRSA contact precautions.

Therapy note dated 05/29/12 stated, Patient # 6 as benefiting from home therapy. Patient and family education was completed for stair mobility, therapeutic exercise and gait training.

Nutritional Consult dated 05/30/12, identified Patient # 6 as needing to "increase intake 75%". No discharge education was documented for the patient or the primary caregiver on how to achieve this goal.

On 05/30/12 Pt. was discharged home with a referral for home therapy, and therapy and physician visits were set up prior to discharge. Discharge documentation failed to include home infection control precautions, or nutritional discharge needs.


29963


Findings Include:

Per Medical record review on 5/30/12 at 9:25 AM by Surveyor 29963 of Pt. # 23 MR, revealed pt. was admitted to hospital on 1/31/12 with a diagnosis of Diverticulitis and peritonitis requiring surgery for the placement of a colostomy and a wound VAC (a technique using a machine that applies a vacuum dressing to promote healing in a wound) to promote healing of a surgical wound. Pt. was discharged home on 2/15/12.

Ostomy Nurse Note dated 2/8/12 states, "I will see client again on 1/10/12 for further teaching and appliance change. He will need home care for VAC change as well as continued teaching regarding ostomy care."

Ostomy Nurse Note dated 2/13/12 states, "Ready for discharge from stoma standpoint." No mention of teaching supplied regarding wound VAC treatment.

Discharge Instructions provided by nursing staff do not address care for wound VAC. No instructions provided to Pt. # 23 for wound VAC dressing care or troubleshooting if alarm sounds from would VAC. Findings verified by CQM B on 5/30/12 at 10:40 AM.

Per Surveyor #22198

Record review conducted with Surveyor #22198 and CIE R on 05/30/12 at 10:45 AM confirmed Patient #5 had surgery on 05/29/12. The time out completed at 3:15 PM failed to include dry time for alcohol based prep.

Record reviews conducted with Surveyor #22198 and CIE R on 05/31/12 from 10:30 AM confirmed Patient #1 had survey on 05/28/12. The time out completed 3:31 PM failed to include the alcohol based skin prep dry time.

Record reviews conducted with Surveyor #22198 and CIE R on 05/31/12 from 10:10 AM confirmed Patient #8 had survey on 05/29/12. The time out completed at 3:31 PM failed to include the alcohol based skin prep dry time.

Three (3) questions are asked and documented in the "time out" section in the electronic EPIC EHR section. Two (2) boxes appear after each question that have yes or no. Staff are required to click on the correct response for a time out. This is identified by the box appearing highlighted to indicate yes or no answer.
Q#1 Pre-procedure Verification per policy
Q#2 Physician/LIP reassessed Patient Prior to Sedation
Q#3 (illegible on copies received)
In Patient #8's record Q#2 Physician/LIP reassessed Patient Prior to Sedation was marked "no" (indicated by the "no" box being highlighted).
No additional documentation clarified when the physician was ready.

During an interview and policy review on 05/31/12 at 11:45 AM, Surgical Director DD told Surveyor #22198, that Q#2 was a "time out" question specific to conscious sedation patients and was not applicable to Patient #8 because the surgery was done under general anesthesia.

On 05/31/12 at 11:55 AM Surgical Director DD provided and reviewed the most current policy entitled "Minimal and Moderate Sedation" #2026 effective date 11/11 was 16 pages.

Surgical Director DD confirmed page #8, VIII. "Patient Assessment, Monitoring and Documentation " section F. entitled " Time out and Site Marking" reference policy #149.

During the policy review of the most current " time out " policy #149 entitled, "Wrong Site, Wrong Procedure and Wrong Person Surgery (Universal Protocol For Prevention)" , last revised 08/10 was a 3 pages, Surgical Director DD confirmed with Surveyor #22198 policy #149 did not include protocol for "Physician/LIP reassessed Patient Prior to Sedation" as a part of the hospital's "time out" policy and protocol.



26390

Based on interview, record review, P/P review and Professional Standards Review the hospital failed to follow standards for fire prevention related to the use of Alcohol Based Skin Preparations in the operating room as evidenced in 8 of 8 surgical records reviewed (pt.s #1, 5, 8, 9, 23, 28, 29,30 & 31) out of a total sample of 31. This practice had the potential to effect 9 surgical patients on 5/29/2012 and 11 patients on 5/30/2012.

Findings include:

1. The Association for Operating Room Nurses (AORN) Perioperative Standards and Recommendations, 2008 Edition indicate:
IX.d.1. Waterless, brushless, surgical-scrub solutions should be allowed to dry completely to decrease the potential to produce ignition by static electricity or sparks.
IX.d.3. Provide adequate time for the flammable surgical prep solution to dry completely and any fumes to dissipate before applying surgical drapes, using an active electrode or laser, or activating a fiber-optic light cable.
IX.d.5. Drapes should not be applied until prep solutions are dry, to prevent the accumulation of volatile fumes beneath them.

On 5/30/2012 at 8:12 AM an interview with Chief Nursing Officer, AA and Surgery Director DD was completed. When asked if the hospital had a policy & procedure for a pt. catching fire in the OR both AA and DD responding they did not have such a policy & procedure. Chief Nursing Officer, AA explained the time out documentation does not include a check that the alcohol based skin prep (ABSP) is dry.

On 5/30/12 from 1:49 PM to 3:25 PM records for patients #9, 28, 29, 30 and 31 were completed with CIE R. The Intra Operative documentation in the electronic records shows ABSP was used for patients #9, 28, 29, 30 and 31 but there is no documentation to show the ABSP was dry by the time surgery was commenced. This finding was confirmed by CIE R at the time of review.

On 5/31/2012 at 11:46 AM a review of P/P titled, "Wrong Site, Wrong Procedure, and Wrong Person Surgery" was completed. The P/P states in part, "E. Standardized Time Out 3. During the time-out, the team members address and agree on: a. Correct Patient Identity, b. The correct site, c. The procedure to be done. 4. The time-out is documented in the medical record."


29963

Findings include:

On 5/30/2012 at 9:25 AM, a review of medical records by Surveyor 29963 for pt. # 23 was completed with CQM B and RN E. The Intra Operative documentation in the electronic records shows ABSP was used for pt. but there is no documentation to show the ABSP was dry by the time surgery was commenced. This finding was confirmed by CQM B and RN E at the time of review.