HospitalInspections.org

This was an follow-up Verification Visit to the original survey on 7/23/2012. Based on observation, staff interviews and review of maintenance documents, during the original survey tour of the facility on 5/7/12, 5/10/12 and 5/11/12 the facility did not construct and maintain the building systems to the 2000 edition of the Life Safety Code of the National Fire Protection Association (NFPA). Refer to the full description of the deficient practices at the cited K-tags under the appropriate building.

FINDINGS INCLUDE:

The Rogers Memorial Hospital survey consisted of (7) Buildings:

Building #1 is the original structure in 1906 with 5 additions in 1911-12, 1920, 1921, 1939 & 1958 located in Oconomowoc, WI had two (3) outstanding deficiencies still remaining to be complete: K-11 Separation between CBRF and Existing Hospital at 1st Floor, K-33 Exit Components at Ground Floor from Mailroom Stairs and K-130 Miscellaneous including; completion of fire door installations with threshholds to Stairs A at Ground, 1st, 2nd & 3rd Floors.
Building #2 is a 2-story structure originally built in 1988 and Occupied as New Construction in 2000, with a 2-story addition in 2009-2010 located in West Allis, WI. No outstanding deficiencies.
Building #3 is a 3-story structure built in 2005 and occupied in 2006 located in Oconomowoc, WI.
No outstanding deficiencies.
Building #6 is a Storage Occupancy (S-1) located in the Lower Level of the Experimental Therapy (ET) Building and separated by 2-hour construction from the rest of the IP & ET Building located in Oconomowoc, WI.
No outstanding deficiencies.
Building #7 is the Gymnasium (A-1) located on the 1st Floor of the Experimental Therapy (ET) Building and separated by 2-hour construction from the rest of the IP & ET Building located in Oconomowoc, WI.
No outstanding deficiencies.
Building #8 is a 3-story structure and Tunnel / Link built from 2010-2012 and Occupied in 4 Phases. December 2011 (Lower Level of ET), March 7, 2012 (1st Floor ET), April 18, 2012 (Tunnel / Link), May 8, 2012 (Inpatient Sleeping), located in Oconomowoc, WI.
Has one (1) outstanding deficiency: K-18 Corridor Doors (missing fire/smoke documentation of material used for door astragal).
Building "MA" is a 4 story clinic structure built in 1989 with a Type II (000) class of unprotected steel frame construction, located in Madison, WI.
Has one (1) outstanding deficiency: K-130 Miscellaneous

This includes deficiencies cited in: A-709 Life Safety from Fire.

The cumulative effect of these environment deficiencies resulted in the hospitals inability to ensure a safe environment for all patients, staff, and visitors.

THIS WAS A FOLLOW-UP VERIFICATION VISIT on July 23, 2012 to the original survey. Based on observation, staff interviews and review of maintenance documents, during a tour of the facility on 5/7/12, 5/10/12 and 5/11/12 the facility did not construct and maintain the building systems to the 2000 edition of the Life Safety Code of the National Fire Protection Association (NFPA). Refer to the full description of the deficient practices at the cited K-tags under the appropriate building.

FINDINGS INCLUDE:

The Rogers Memorial Hospital survey consisted of (7) Buildings:

Building #1 is the original structure in 1906 with 5 additions in 1911-12, 1920, 1921, 1939 & 1958 located in Oconomowoc, WI had two (3) outstanding deficiencies still remaining to be complete: K-11 Separation between CBRF and Existing Hospital at 1st Floor, K-33 Exit Components at Ground Floor from Mailroom Stairs and K-130 Miscellaneous including; completion of fire door installations with threshholds to Stairs A at Ground, 1st, 2nd & 3rd Floors.
Building #2 is a 2-story structure originally built in 1988 and Occupied as New Construction in 2000, with a 2-story addition in 2009-2010 located in West Allis, WI. No outstanding deficiencies.
Building #3 is a 3-story structure built in 2005 and occupied in 2006 located in Oconomowoc, WI.
No outstanding deficiencies.
Building #6 is a Storage Occupancy (S-1) located in the Lower Level of the Experimental Therapy (ET) Building and separated by 2-hour construction from the rest of the IP & ET Building located in Oconomowoc, WI.
No outstanding deficiencies.
Building #7 is the Gymnasium (A-1) located on the 1st Floor of the Experimental Therapy (ET) Building and separated by 2-hour construction from the rest of the IP & ET Building located in Oconomowoc, WI.
No outstanding deficiencies.
Building #8 is a 3-story structure and Tunnel / Link built from 2010-2012 and Occupied in 4 Phases. December 2011 (Lower Level of ET), March 7, 2012 (1st Floor ET), April 18, 2012 (Tunnel / Link), May 8, 2012 (Inpatient Sleeping), located in Oconomowoc, WI.
Has one (1) outstanding deficiency: K-18 Corridor Doors (missing fire/smoke documentation of material used for door astragal).
Building "MA" is a 4 story clinic structure built in 1989 with a Type II (000) class of unprotected steel frame construction, located in Madison, WI.
Has one (1) outstanding deficiency: K-130 Miscellaneous

The cumulative effect of these LIFE SAFETY FROM FIRE deficiencies resulted in the hospitals inability to ensure a safe environment for all patients, staff, and visitors.

Based on record review and interview, the facility failed to develop Master Treatment Plans (MTPs) that included individualized specific interventions for 10 of 10 active sample patients (A1, A2, A3, A4, B1, B2, B3, B4, B5 and B6). The identified interventions on the MTPs lacked specificity or were routine discipline tasks. This deficient practice results in treatment plans that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment.

Findings include:

A. Record Review

1. Patient A1

The MTP (7/21/12 review) listed the following non-specific and routine discipline functions for the problem "At Risk for Self Harm": "Social Services will give opportunities to express feelings in safe environment"; "Social Services will assist [Patient A1] to process situational emotions and behaviors" and "Social Services will assist [Patient A1] to develop problem solving and conflict resolutions skills."

2. Patient A2

The MTP (7/22/12 review) listed the following non-specific and routine discipline functions for the problem "At Risk for outward aggressive behaviors": "Nursing will positively reinforce all non-agreesive [sic] expressions of difficult emotions." "Experiential Therapy will provide [Patient A2] wil [sic] opportunites [sic] to practice non-aggressive social skills." "Social Services will provide [Patient A2] with the opportunity to develop non-aggressive coping skills."

3. Patient A3

The MTP (7/20/12 review) listed the following non-specific and routine discipline functions for the problem "Poor Impulse Control": "Experiential therapy will provide diversionary techniques." "Social Services will review options with [Patient 3]. "Experiential therapy will provide assignments." "Social Services will discuss what are [sic] appropriate v (versus) inappropriate topics with others." "Experiential therapy will encourage [Patient A3] to express anger."

4. Patient A4

The MTP (7/23/12 review) listed the following non-specific and routine discipline functions for the problem "Altered nutrition related to Eating Disorder Thought Patterns": "Dietitian will provide assignments." "Dietitian will review assignments." "Nursing will provide assignments." "Nursing will review assignments." "Social Services will provide assignments." "Social services will review assignments."

5. Patient B1

The MTP (7/23/12 review) listed the following non-specific and routine discipline functions for the problem "Depressed Mood" : "Nursing will provide assignments." "Nursing will review assignments." "Dietitian will provide assignments." "Dietitian will review assignments." "Physician to order medication."

6. Patient B2

The MTP (7/23/12 review) listed the following non-specific and routine discipline functions for the problem "Safety Maintenance" : "Nursing will monitor [Patient B2] for safety each shift or treatment day." "Nursing will implement prescribed safety level."

7. Patient B3

The MTP (7/23/12 review) listed the following non-specific and routine discipline functions for the problem "At Risk for Outward Aggressive Behaviors": "Nursing will positively reinforce all non-aggressive expressions of difficult emotions." "Social Services will provide [Patient B3] with the opportunity to develop non-aggressive outbursts."

8. Patient B4

The MTP (7/24/12 review) listed the following non-specific and routine discipline functions for the problem "Depressed Mood": "Nursing will reinforce positive statements made by [Patient B4]." "Nursing will provide assignments." "Nursing will review assignments." "Dietician will provide assignments." "Dietician will review assignments." "Physician to order medication."

9. Patient B5

The MTP (7/23/12 review) listed the following non-specific and routine discipline functions for the problem "Altered Thought Process": "RN will assess [Patient B5]'s ability to concentrate, follow instructions, and problem solve." "RN will assess and observe [Patient B5]'s judgment and awareness of safety." "Physician will assess [Patient B5]'s recent and remote memory."

10. Patient B6

The MTP (7/23/12 review) listed the following non-specific and routine discipline functions for the problem "At Risk for Suicide": "Social Sercices [sic] will assist [Patient B6] in ID safe and healthy coping strategies." "Social Services will provide opportunity for [Patient B6] to verbalize and demonstrate positive coping strategies."

B. Interviews

1. In an interview on 7/23/12 at 1:35 p.m., the Vice President of Nursing stated, "It is difficult to manipulate the Electronic Health Record. The interventions are built into the program and the staff have [sic] to 'deselect' every intervention that does not apply to the specific patient. Staff does not have the ability to change the interventions except from writing something in the 'comment section.' The Vice President of Nursing also stated, "We are in the process of changing the electronic record system so that the treatment plan has interventions that reflect what we are really doing."

2. In an interview on 7/24/12 at 9:30 a.m., the Clinical Informatics Manager stated, "Staff must write comments under each intervention in order to individualize the care plan. Each staff should write a comment, but they do not always do so."





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