HospitalInspections.org

Based on P&P review, 2 of 2 MR reviewed of patients receiving Medicare benefits
(#8, 25) out of a total of 30 MR reviewed, and 1 of 1 staff interviews (X), the hospital failed to ensure that each Medicare beneficiary is informed of his/her right to appeal discharge from the facility which became effective July 13, 2007 per S&C memorandum 07-28.

Findings include:
Per interview, with CO (X) on 6/13/12 in the AM, nursing staff were given information about the Medicare beneficiaries right to appeal discharge from the hospital. Surveyor
#13469 was not given a P&P that outlined how the process was to be accomplished and who was responsible.

Example by surveyor #13469:
Per MR review, on 6/13/12 at 11:55 AM, Pt. #8 was admitted on 4/5/12 and discharged on 4/8/12. There is no Medicare Discharge Appeal Rights form in the MR indicating Pt. #8 was informed of these rights within 48 hours of discharge. This example was confirmed by Compliance Officer (X) on 6/14/12 at 8:50 AM.


26711

Findings by Surveyor #26711:

A MR review was conducted on Pt. #25's open inpatient MR on 6/13/2012 at 8:20 a.m. Pt. #25 is an 88 year old admitted on 6/6/2012. There is no Medicare Discharge Appeal Rights form in the MR indicating Pt. #25 was informed of these rights within 48 hours of admission.

This finding was confirmed by Compliance Officer X on 6/14/2012 at 8:55 a.m.

Based on 5 of 9 personnel files reviewed of PT aides, HUC's, and ER Techs (BB, CC, DD, EE, FF, GG), and 3 of 3 interviews with facility staff (E, HH, R), the hospital does not follow state laws to ensure that non-licensed caregivers providing direct patient care have successfully completed an instructional program for nurse aides and are on the Wisconsin caregiver registry per applicable laws. This had the potential to affect all patients treated in the facility.

Findings include:
State hospital requirement HFS 124.03 Approval by the department (2) To be approved by the department, a hospital shall comply with this chapter and with all other applicable state laws and local ordinances, including all state laws and local ordinances relating to fire protection and safety, reporting of communicable disease, cancer reporting and post-mortem examinations, and professional staff of the hospital shall be licensed or registered, as appropriate, in accordance with applicable laws.

This requirement is not met.

State statue 146.4(2) directs the following: "A hospital, nursing home, intermediate care facility for persons with mental retardation, home health agency, or hospice may not employ or contract for the services of an individual as a nurse aide, regardless of the title under which the individual is employed or contracted for, unless one of the following is true: (a) The individual has successfully completed instruction in an instructional program for nurse aides that is approved under sub. (3) and has successfully completed a competency evaluation program."

Per interview, with HR (human resource) Manager (E) on 6/12/12 at 10:55 AM there are 5 (BB, CC, DD, EE, FF, GG) non-licensed caregivers providing direct patient care who have not successfully completed an instructional program for nurse aides and are not on the Wisconsin caregiver registry.

Examples of non-licensed direct care providers are as follows: PT Technicians who assist with transfers, preparing patients for treatments, applies hot and cold packs, ultrasound, medcosound, pelvic and cervical traction, ambulation training, whirlpool, sterile whirlpool, bandaging, Iontophoresis (which requires the use of medication applied transdermally), electric stimulation, phonophoresis, and assisting therapy staff as needed with patient care per their job description. Emergency Room Technicians who prepares the patient for the nurse and MD exam and assists with the exam as needed, cleans minor lacerations/abrasions, sets up suture trays and assists with suturing procedures, applies cold packs to closed injuries, assists with the collection of specimens as needed, transports patients as needed per job description. ED HUC's who prepares the patient for the nurse and MD exam and assists with the exam as needed, cleans minor lacerations/abrasions, sets up suture trays and assists with suturing procedures, applies cold packs to closed injuries, assists with the collection of specimens as needed, transports patients as needed per job description.

Interview with PT (HH) on 6/14/12 at 10:15 AM validated the above direct care activities completed by the PT aides.

Interview with PT Technician (R) on 6/13/12, in addition to the above examples, PT Technicians do E-Stems.

The PT Technicians, ED Technicians and ED HUC's job descriptions do not require that these direct care staff complete a CNA (certified nurse aide) training program and maintain current Wisconsin Registry status.

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 "New Healthcare Occupancy" and also "Existing Healthcare Occupancy" chapters of this code.

The findings include:
Main Hospital Building
K15: The facility did not provide room finishes that had rated wall finishes.
K17: The facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with sealed wall penetrations, and a smoke-tight corridor ceiling (in a sprinkled smoke zone).
K18: The facility did not provide corridor separation doors that had positive-latching hardware.
K20: The facility did not provide enclosures around multi-floor vertical openings with rated doors, and sealed wall penetrations.
K22: The facility did not ensure the path of egress was clearly identified by appropriate exit signage and with non-egress pathways without exit signs.
K25: The facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls that had sealed wall penetrations, and rated wall construction.
K29: The facility did not enclose hazardous rooms with sealed wall penetrations, and rated doors.
K38: The facility did not provide egress paths at all times with paths and door hardware that operated with a single release motion.
K39: The facility did not provide and maintain corridors and aisles that were at least the minimal clear width required by the code.
K40: The facility did not ensure exit doors had the required width.
K50: The facility did not conduct fire drills as required by the code to ensure that staff are familiar with fire response procedures with the required quantity of drills.
K51: The facility did not provide a fire alarm system that was installed according to NFPA 72
K55: The facility did not provide and maintain every patient sleeping room with an outside window or outside door.
K56: Sprinkler system did not meet all minimum regulations per NFPA 13.
K62: The facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25.
K67: The HVAC system did not meet the minimum standards on NFPA 90A.
K78: The facility did not provide protection of anesthetizing locations that use medical gases, as required by NFPA 99 with smoke removal system.
K103: The facility did not provide interior walls and partitions made of noncombustible or limited-combustible materials with non-combustible wall materials.
K147: Electrical system did not meet the minimum regulations for NFPA 70.
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, and staff interviews, the facility failed to install proper ventilation systems. This deficiency occurred in 1 of the 5 smoke compartments, and had the potential to affect all surgical patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 6/12/2012 at 9:24 am surveyor #12187 observed in the #1 smoke compartment on the 1st floor in O.T. office, that the facility failed to install a ventilation system in the O.T. office. The ventilation requirement is that there be at least 7.5 CFM of outside air. This observed situation was not compliant with CFR 482.41(c). The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

2) On 6/12/2012 at 10:15 AM, surveyor #12187 and surveyor #13469 observed and was informed that the procedure room in the surgery suite was converted from a PACU to endoscopy room about January 1, 2010. About 2 months later, March 1, 2010, this room was being used as a surgery room. No plans or modification to the room were done. The AIA guidelines for a PACU requires 6 air changes per hour of ventilation of which 2 air changes per hour are of outside air. An operating room requires 15 air changes per hour of which 3 air changes per hour is outside air and the air movement relationship to adjacent area is out from the operating room. In addition, the operating room was using nitrous oxide, a gaseous anesthesia. NFPA 99, 1999 edition, requires that an automatic smoke removal system be installed where gaseous anesthesia is used. (See K78)

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 "New Healthcare Occupancy" and also "Existing Healthcare Occupancy" chapters of this code.

The findings include:
Main Hospital Building
K15: The facility did not provide room finishes that had rated wall finishes.
K17: The facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with sealed wall penetrations, and a smoke-tight corridor ceiling (in a sprinkled smoke zone).
K18: The facility did not provide corridor separation doors that had positive-latching hardware.
K20: The facility did not provide enclosures around multi-floor vertical openings with rated doors, and sealed wall penetrations.
K22: The facility did not ensure the path of egress was clearly identified by appropriate exit signage and with non-egress pathways without exit signs.
K25: The facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls that had sealed wall penetrations, and rated wall construction.
K29: The facility did not enclose hazardous rooms with sealed wall penetrations, and rated doors.
K38: The facility did not provide egress paths at all times with paths and door hardware that operated with a single release motion.
K39: The facility did not provide and maintain corridors and aisles that were at least the minimal clear width required by the code.
K40: The facility did not ensure exit doors had the required width.
K50: The facility did not conduct fire drills as required by the code to ensure that staff are familiar with fire response procedures with the required quantity of drills.
K51: The facility did not provide a fire alarm system that was installed according to NFPA 72
K55: The facility did not provide and maintain every patient sleeping room with an outside window or outside door.
K56: Sprinkler system did not meet all minimum regulations per NFPA 13.
K62: The facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25.
K67: The HVAC system did not meet the minimum standards on NFPA 90A.
K78: The facility did not provide protection of anesthetizing locations that use medical gases, as required by NFPA 99 with smoke removal system.
K103: The facility did not provide interior walls and partitions made of noncombustible or limited-combustible materials with non-combustible wall materials.
K147: Electrical system did not meet the minimum regulations for NFPA 70.
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 1 of 1 MR reviewed with mid-level notes (#7) out of 30 MR reviewed, review of medical staff rules and regulations, and 2 of 2 staff interviews (X, BB) by surveyor #13469, the hospital failed to ensure that an MD/DO periodically reviews all mid-level treatment of patients and entries into the MR. These deficiencies had the potential to affect patients treated in the facility during the time of the survey between 6/11/12 and 6/14/12.

Findings include:
Per interview, with CO (X) on 6/14/12 at 10:10 AM, there is a P&P to direct the MD/DO to review all medical records that reflect the cares provided to patients seen in the ED and admitted to the hospital by mid-level practitioners.

The ED note dated 4/4/12 and completed by a PA found in the MR of Pt. #7 on 6/13/12 at 11:40 AM, did not include evidence that a MD/DO reviewed the cares provided by the PA for Pt. #7 to ensure appropriateness.

At 10:30 AM on 6/14/12 20 random mid-level MR were pulled between 5/1/12 and 5/20/12 by CO (X) and Medical Staff Coordinator (BB) to seek evidence that MR of mid-levels were being reviewed by the MD/DO. 20 of 20 MR pulled did not show evidence of a review for appropriate cares. Per interviews with (X) and (BB), all mid-level MR are to be reviewed by the MD/DO per medical staff rules and regulations.

Per medical staff rules and regulations dated 8/2/05, reviewed on 6/14/12 in the AM, they direct the following: "B. Medical Records 4. The attending physician shall countersign (authenticate) the H&P, physical examination, all orders, and pre-operative notes when they have been recorded by a medical affiliate."

Based on 22 of 22 observations, 25 of 25 staff interviews, 9 of 30 MR reviewed, and P&P review, it was determined that the hospital failed to deliver quality patient care. These deficiencies had the potential to affect patients treated in the facility during the time of the survey between 6/11/12 and 6/14/12.


Examples include:

The hospital failed to ensure that drugs and biological's are secure from unauthorized access, that a pharmacist maintain overall responsibility for the pharmacy service in all hospital departments, that outdated medications/biological's are secured from patient use, that refrigerated medications stored in the pharmacy are monitored to the frequency needed to assure medications are maintained within appropriate storage conditions, and that wasted controlled substances are witnessed by two professional staff. See Tag C-276

The hospital failed to provide proper ventilation, maintaining air flow from clean to dirty, ensure that therapy staff are promoting standard universal precautions, ensure that housekeeping perform quality control checks on the automated systems for dispensing cleaning solutions, that cleaning supplies are protected from cross-contamination, that privacy curtains are on a routine cleaning schedule, that soiled linen is removed from the facility timely, that sterile and surgical supplies are stored appropriately, that staff follow safe injection practices, that staff follow safe hand hygiene practices, ensure that patients are protected from cross-contamination of microorganisms during surgical procedures, and ensure that clean and dirty are kept separate. See Tag C-278

The facility failed to follow recognized dietary practices by failing to, 1. Maintain a current diet manual that is approved annually by the Medical Director and Dietician, 2. Failed to maintain appropriate hand hygiene in the kitchen, 3. Failed to appropriately discard expired food from dry storage, and 4. Failed to provide evidence of appropriate staff training in food service. See Tag C-279

The hospital failed to ensure that all departmental P&P are reviewed at least annually. See Tag C-280

The facility failed to ensure that MD orders and reports are properly authenticated by the responsible professional, and that only personnel authorized by the Medical Staff are writing orders for patient care. See Tag C-297

The cumulative effect of these systemic failures resulted in the facility's inability to provide safe and optimal patient care.

Based on 5 of 5 staff interviews (P, II, F, J, D), 7 of 7 observations, the hospital failed to ensure that drugs and biological's are secure from unauthorized access, that a pharmacist maintain overall responsibility for the pharmacy service in all hospital departments, that outdated medications/biological's are secured from patient use, that refrigerated medications stored in the pharmacy are monitored to the frequency needed to assure medications are maintained within appropriate storage conditions, and that wasted controlled substances are witnessed by two professional staff. These deficiencies had the potential to affect patients treated in the facility during the time of the survey between 6/11/12 and 6/14/12.

Findings include:
Examples by surveyor #13469:

1. The facility has not implemented continuous temperature monitoring of medications stored in the refrigerator/freezer of the pharmacy as professional principles require.

During a tour of the pharmacy on 6/13/12 at 1:00 PM with Pharmacy Director (P) the pharmacy was observed to have a household standard refrigerator/freezer which contained medications and vaccines. The pharmacy was observed to have analog thermometers inside the refrigerator and freezer. Per interview with the Pharmacy Director (P), she indicated staff checks the analog thermometers each day and records the temperature on a log. Surveyor #13469 observed the log.

The pharmacy procedure is to verify the temperature of the refrigerator daily. However the pharmacy is open only Monday thru Friday from 7:00 AM to 5:00 PM and 7:00 AM to 12:00 PM on Saturday and Sunday. Per (P), the refrigerator temperatures are not monitored when the pharmacy is closed. Without continuous monitoring and alarms on the refrigerator it is possible that medications/vaccines in the refrigerator could be exposed to temperatures outside of the manufacturer refrigeration requirements when the pharmacy is closed. In addition, it is possible that for shorter multiple periods that medications may be subjected to temperatures outside of the manufacturer guidelines.

In addition to manufacturer guidelines other organizations have accepted professional principles. The Institute of Safe Medication Practices has issued a medication safety alert July 08, Vol 6 Iss 7 specific to vaccines that indicate refrigerator temperatures need to be monitored continuously.

2. The pharmacy manager does not develop, supervise and coordinate all activities of the hospital wide pharmacy service to ensure safe storage, use, administration, control and disposal of medications within the facility.

Per interview, with Pharmacy Director (P) on 6/13/12 at 1:00 PM, it was revealed that she does not have oversight of all the medications and biological's that are stored, used, administered and controlled in the facility. Two examples are the radiology and surgery department.

3. The pharmacy does not secure outdated medications/biological's from potential use.

Per observation and interview, with Pharmacy Director (P) on 6/13/12 at 1:00 PM while touring the pharmacy department, it was noted that a vial of Heparin vaccine was located in the pharmacy refrigerator with an expiration date of 4/1/12. This vaccine was available for patient use at the time of the survey on 6/13/12. In addition, two boxes full of outdated medications were located at the back of the pharmacy and did not have a lid or labels to indicate the medications were not for patient use. Per (P), the outdated narcotics are in a small box in the locked safe and are also not secured in a container with a lid or labeled not for patient use.

4. The wasting of controlled substances is not witnessed by two professional staff.

Per interview, with Pharmacy Director (P) on 6/13/12 at 1:00 PM, it was revealed that she is not aware if the CRNA has a witness when disposing of unused portions of a controlled substance.

Per interview, with DON (II) on 6/13/12 at 2:05 PM, it was revealed that RN (JJ) said in interview to DON (II) that the CRNA does not have a witness when disposing of unused portions of controlled substances used in the OR.

5. Drugs and biological's are not secure from unauthorized access, allowing for potential tampering, use, removal or destruction.

Per observation and interview, while touring the OR with OR Manager (F) on 6/12/12 at 9:00 AM, it was noted that the "extra anesthesia cart" and the malignant hyperthermia cart that contain medications and intravenous solutions are not secured from unauthorized access when the unit is closed. Per (F), maintenance, IT (information technologists), IT, housekeeping and OR staff can access the OR after hours and on weekends. During this same tour, it was noted that the keys to the anesthesia carts and the refrigerated medications in the OR are not secured to prevent access to the medications kept in the anesthesia carts and medications kept in the refrigerator. Per interview, with RN (J) during the tour, the keys to the refrigerator are kept in a drawer at the nurses station. The keys to the anesthesia carts are tucked behind some 4X4's on the top of each cart. As a result, maintenance, housekeeping and OR staff can access the OR and the medications and intravenous solutions after hours and on weekends.

Per observation and interview, with Pharmacist (P) while touring the ED on 6/13/12 at 3:30 PM, bags of intravenous solutions kept in a cupboard in the pediatric ED room and in bins on the wall in the cardiac ED room are not secured from unauthorized access. Patient's and visitors would have access to the intravenous solutions when ED staff are not in the rooms.


26711

Findings by Surveyor #26711:

Per observation, while touring the facility's off-site physical therapy clinic was conducted on 6/12/2012 at 2:30 p.m. accompanied by Patient Financial Services Manager (PFS Mgr) D. In the therapist's office a bottle of Dexamethasone (liquid steroid used during electrical stimulation of muscles in therapy) was found to be sitting out on top of the desk. The office is unsecured. PFS Mgr D stated (after calling an off duty therapist to inquire about the medication) that the medication is normally kept in a drawer in the desk. This drawer is not able to be locked securely. The Dexamethasone is not secured from unauthorized personnel or patients who might enter the office. These finding were confirmed by PFS Mgr D at the time of discovery.

Based on 14 of 14 observations, 8 of 8 staff interviews (Q, L, N, A, F, G, K, V), the hospital failed to: provide proper ventilation, maintaining air flow from clean to dirty, ensure that therapy staff are promoting standard universal precautions, ensure that housekeeping perform quality control checks on the automated systems for dispensing cleaning solutions, that cleaning supplies are protected from cross-contamination, that privacy curtains are on a routine cleaning schedule, that soiled linen is removed from the facility timely, that sterile and surgical supplies are stored appropriately, ensure that staff follow safe injection practices, that staff follow safe hand hygiene practices, ensure that patients are protected from cross-contamination of microorganisms during surgical procedures, and ensure that clean and dirty are kept separate. These deficiencies had the potential to affect patients treated in the facility during the time of the survey between 6/11/12 and 6/14/12.

Findings include:
Findings by surveyor #13469:
1. Per interview, while touring the O.T. department with Rehabilitation Manager/O.T. (Q) on 6/13/12 at 2:30 AM, it was revealed that in-patients and out-patients treated in the O.T. department are not directed to disinfect their hands before touching the equipment. While staff clean the equipment after use, many pieces have surfaces that are porous and difficult to ensure that microorganisms are removed to prevent cross-contamination.

2. Per interview, with ESS (environmental services supervisor) (L) on 6/12/12 at 1:00 p.m., it was revealed that the company they purchase the cleaning solutions from comes quarterly to the hospital and does quality control checks of the automated dispensing systems. Per (L), she does not ensure that the automated dispensing systems are functioning properly after each new container of solution is placed into a dispensing system. As a result. the facility cannot ensure appropriate mixtures of solution and water for proper cleaning throughout the facility.

While touring the housekeeping storage room at 1:45 p.m. on 6/12/12 with (L), it was observed that wheelchairs are also cleaned in this room. A shower head in the wall is used for this purpose. The area is not in a containment system to prevent splash and spray from the surfaces of housekeeping carts and other supplies in the room when the wheelchairs are cleaned.

3. Per interview, with ESS (L) on 6/12/12 at 1:00 p.m., it was revealed that privacy curtains located throughout the facility are not on a routine cleaning schedule. Per (L), she is not sure when the curtains were last cleaned. Per (L), they do pull the privacy curtains from isolations rooms after each patient.

Per interview, while touring the laundry department with (L) at 1:30 PM, it was revealed that dirty linen is placed in non-permeable plastic bags, placed in carts, and then taken to the linen holding area to await pickup by the contracted service. Per observation, it was noted that in the dirty linen holding room there were two carts (60 inches high by 48 inches wide) and one cart 22 inches high by 32 inches wide) that held linen that was not contained in non-permeable plastic bags per hospital practice. Per (L), the linen in the three carts, that was not contained in non-permeable plastic bags per hospital practice, is left over from a previous contracted service. Per (L), this soiled "linen has been in the holding room for years." Per (L), she does not think the infection control officer knows about the old soiled linen.

Per interview, with Safety Officer (N) at 1:50 PM, (N) was not aware that this soiled linen was held in the hospital for this long. Per interview, with Facilities Director (A) at 2:10 PM, it was revealed that the "Unifirst" linen company contract was terminated in May of 2004. The carts with the soiled unprotected linen has been in various parts of the facility since that time. Facility staff were directed by this surveyor to remove the linen from the facility wearing protective suits, masks, and gloves. This was accomplished the afternoon of 6/12/12.

4. On 6/12/2012 at 10:00 AM surveyors #12187 and surveyor #13469 observed that the sterile storage room in the surgery suite, did not have any ventilation in the room. The temperature in the room at the time of the observation was 84 degrees. Per interview, with OR Manager (F), this room used to be an office and was converted into additional storage for sterile surgical packs and supplies. After investigation of supplies kept in the room, it was determined that Bone Cement and Orthoglass casting products were not being stored per manufacturers directions in the overheated room. In addition, the high temperature with any addition of humidity could affect the sterile surgical packs integrity.

5. Per observation, during the preparation and surgical procedure for patient #18 on 6/12/12, it was noted that:

At 7:45 a.m. ST (G) was passing sterile supplies and instruments to another ST when she dropped a surgical instrument (still in it's sterile package) to the floor. She then picked it up from the floor and placed the now contaminated package onto the cart with other sterile supplies and instruments that she was opening and passing to the second ST. OR Manager (F), who observed the instrument being dropped with surveyor #13469, said that ST (G) should not have picked it up from the floor for use. Per (F), anything that falls to the floor is to be considered contaminated and not for patient use.

Per observation at 7:50 a.m., CRNA (I) failed to appropriately supervise anesthesia student (H) while she prepared for spinal anesthesia to be administered to Pt. #18. After drawing up 1% Lidocaine anesthesia student (H) recapped the needle using both hands holding the cap in her left hand and the syringe with the needle in the right. Recapping needles in the hospital could result in needle sticks and staff exposure to blood borne pathogens.

Per OSHA guidelines 1910.1030(d)(2)(vii) "Contaminated needles and other contaminated sharps shall not be bent, recapped or removed except as noted in paragraphs (d)(2)(vii)(A and (B)

(A) = Contaminated needles and other contaminated sharps shall not be bent, recapped or removed unless the employer can demonstrate that no alternative is feasible or that such action is required by a specific medical or dental procedure.

(B) = Such bending, recapping or needle removal must be accomplished through the use of a mechanical device or a one-handed technique."

Per OSHA guidelines "Needleless systems means a device that does not use needles for the collection of bodily fluids for withdrawal of body fluids after initial venous or arterial access is established."

Per OSHA guidelines: "Sharps with engineered sharps injury protections means a nonneedle sharp or a needle device used for withdrawing body fluids, accessing a vein or artery, or administering medications or other fluids, with a built-in safety feature or mechanism that effectively reduces the risk of an exposure incident."

Per interview, with OR Manager (F) following the observation, (F) said staff, including those supervised by hospital staff, should not recap needles and are to use syringes with needle guards.

Per observation at 8:05 a.m., under the direct supervision of CRNA (I), anesthesia student (H) removed her gloves after prepping Pt. #18 skin for a spinal without disinfecting her hands. At 8:15 a.m., CRNA (I) removed his bloody gloves from assisting with the spinal for Pt. #18, and without disinfecting his hands, he donned another pair of gloves. OR Manager (F) confirmed in interview after the observation that hands should be disinfected each time before applying gloves and after removing gloves.

Per CDC "Guideline for Hand Hygiene in Health-Care Settings" (MMWR 10/25/02) recommendations for glove use, page 33 #6 states, in pert: "Change gloves if moving from a contaminated body site to a clean body site. Decontaminate hands after removing gloves. Decontaminate hands after contact with inanimate objects." http:www.cdc.gov/mmwr/PDF/rr/rr5116.pdf.

Per CDC Guidelines for preventing transmission of infectious agents in healthcare settings 2007: IV. Standard Precautions: washing/gloving standards are as follows: " IV.A.3.a Before having direct contact with patients. IV.A.3.b After contact with blood, body fluids or excretions, mucous membranes, non-intact skin, or wound dressings. IV.A.3.c After contact with a patient's intact skin (e.g; when taking a pulse or blood pressure or lifting a patient). IV.A.3.d If hands will be moving from a contaminated-body site to a clean-body site during patient care. IV.A.3.e After contact with inanimate objects (including medical equipment in the immediate vicinity of the patient. IV.A.3.f After removing gloves.

6. Per observation and interview, while touring the OR and disinfection and sterilization department with OR Manager (F) and SPT (sterile processing technician) (K) on 6/12/12 at 9:30 a.m., it was revealed that the OR has two rooms. One of the rooms used to be a PACU and was converted to an endoscopy suite in January of 2010, In March of 2010 sterile surgeries were also begun in this room. Per (F) and (K), at the completion of an endoscopy the scopes are wiped down, suctioned of waste, tested for leaks, and then taken to the sink in the room to be soaked in an enzymatic cleaner to remove bioburden before being taken for high-level disinfection. Human waste is also flushed down a hopper in this room. Cleaned endoscopes are also stored in this room. This room is also used to do sterile surgical procedures such as carpel tunnels, hand procedures foot surgeries, excisions of lesions and cysts and to place ear tubes. As a result, there is potential for cross-contamination from the cleaning of endoscopes and disposal of human waste, to patients undergoing sterile surgical procedures. Per OR Manager (F), she knew this was a problem when she took over the job as manager recently.

Per SPT (K), after soaking the scopes, they are removed from the enzymatic cleaner, rinsed, and then with gloved hands are walked to the sub-sterile core (the room between the two OR's containing sterile supplies) and placed in a large metal container to soak in "Resert" which is a high-level disinfectant solution. Per (K), the endoscopes are not placed in a closed container for transport to the sub-sterile core and could drip contaminated material onto the surgery department floors. Allowing the contaminated scopes used for colonoscopies and esophagogastroduodenoscopies to be carried through the hallways of the surgery department and into the core allows for the potential of cross-contamination of microorganisms to surgical supplies, patients and staff. Per OR Manager (F), she knew this was a problem when she took over the job as manager recently. Per (F), endoscopes should not be carried in this manner, nor should they be taken into the core.

Per observation, while touring the endoscope room, it was noted that a surgical hand disinfectant "Avaguard" dispenser was in the OR instead of outside of the OR to allow for the surgical hand scrub to take place before entering the room. In addition, the dispenser was located above a surgical supply cart which contained supplies to be used during procedures. There were drips from the Avaguard container running down the wall. The location of the Avaguard dispenser allows for cross-contamination to occur when staff are reaching over the supply cart to obtain Avaguard from the dispenser to disinfect their hands. This observation was confirmed by OR Manager (F) during the observation.


26711

Findings by Surveyor #26711:

On 6/11/2012 at 2:00 p.m. Surveyor #12187 identified a breech in the separation of clean and dirty in the Respiratory Therapy (RT) office and brought this to Surveyor
#26711's attention. In the RT office a toilet room was being used as a storage room for medical gases and paper products. During an interview with Respiratory Therapist Supervisor (RT Supvr) V on 6/13/2012 at 3:05 p.m., it was noted that this toilet room, with a toilet without a lid, housed 3 oxygen tanks (E size), 1 helium tank, and 1 air tank with oxygen and carbon monoxide. These tanks are used to hook to the diagnostic machine to do RT tests on patients. Also, hanging on the door were two bags of dirty circuits used during the testing with the diagnostic machine. RT Supvr V agreed that this does not demonstrate a separation of clean and dirty.

Surveyor: Wallace, Lynn
Findings by Surveyor #12187

On 6/12/2012 at 10:00 AM surveyors #12187 and surveyor #13469 observed that the sterile storage room in the surgery suite, did not have any ventilation in the room. The 2006 Guidelines for Design and Construction of Health Care Facilities requires the sterile storage to have 4 air changes of air per hour and the pressure to be out of the room. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff A (Director of Environmental Services), Staff (F)Surgery Manager) and Staff K (sterile processing tech).

On 6/12/2012 at 10:10 AM surveyor #12187 observed that surgery room (former PACU room) air is coming into the room. The 2006 Guidelines for Design and Construction of Health Care Facilities requires surgery rooms to have a positive pressure. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff A (Director of Environmental Services).

On 6/12/2012 at 10:20 AM surveyor #12187 observed that surgery suite air is coming into the suite from the corridor. The suite is in the sterile zone. The 2006 Guidelines for Design and Construction of Health Care Facilities requires sterile zones to have a positive pressure with relationship to other zones. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff A (Director of Environmental Services).

On 6/12/2012 at 10:40 AM surveyor #12187 observed that central supply (CS) suite air is coming into the central supply. The central supply is in the sterile zone. The 2006 Guidelines for Design and Construction of Health Care Facilities requires sterile zones to have a positive pressure with relationship to other zones. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff A (Director of Environmental Services).

On 6/12/2012 at 1:40 PM surveyor #12187 observed that medication preparation room in the ED air is coming into the medication preparation room. The 2006 Guidelines for Design and Construction of Health Care Facilities requires medication preparation rooms to have a positive pressure with relationship to other zones. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff A (Director of Environmental Services).

Based on 1 of 1 observations (staff M), recommendations by the Food and Drug Administration (FDA), and 3 of 3 staff interviews (L, Y, M), this facility failed to follow recognized dietary practices by failing to, 1. Maintain a current diet manual that is approved annually by the Medical Director and Dietician, 2. Failed to maintain appropriate hand hygiene in the kitchen, 3. Failed to appropriately discard expired food from dry storage, and 4. Failed to provide evidence of appropriate staff training in food service. Failure to follow recognized dietary practices affects all patients, staff, and visitors who eat in the hospital, including the 14 patients present during the survey (6/11/12-6/14/12).

Findings include:

Diet Manual
An interview with Food Services Manager (FS Mgr) L was conducted on 6/12/2012 at 10:30 a.m. FS Mgr L picked up the diet manual used by the facility (Twin Cities) dated 1994 to show Surveyor. The front page had some sporadic signatures from the Medical Director, the most current was 2003, and no signatures from the Dietician. According to FS Mgr L, there was another sheet with signatures from the Medical Director but L was unable to locate it.

In an interview with Dietician Y on 6/14/2012 at 9:04 a.m., Dietician Y stated, "There is no diet manual anywhere, they are an outdated thing in the nutrition world and they are expensive to replace."

Regarding Recommended Daily Allowances (RDAs) in the diets (which changed in 2010 for calcium and Vitamin D according to Wisconsin Department of Health Services Dietician), Dietician Y stated, "RDAs are out, there are certain standards I use like for Diabetes, but diets are constantly changing."

Hand Hygiene
According to the 2009 FDA Food Code, hands are to be washed before engaging in food preparation including working with exposed food, clean equipment and utensils and
? After handling soiled equipment or utensils
? After coughing or sneezing
? After engaging in other activities that contaminate the hands.

FS Mgr L stated, during the above identified interview, that the expectation in the kitchen for handwashing was prior to applying gloves and after removing them and staff are to stay in their area with their gloves on. If staff leave the area the expectation is to perform hand washing and change their gloves.

An observation of Dietary Aide M was conducted on 6/12/2012 at 11:10 a.m. accompanied by FS Mgr L. Aide M was in the tray line at the head, preparing trays with utensils and napkins. Aide M left the tray line, went to a freezer to remove 3 boxes of ice cream for a cart, went to a counter to document on a tray tag with a pen from a box on the counter, touched M's face, and returned to the tray line to continue prepping trays without washing hands between any of these tasks. FS Mgr L confirmed that Aide M should have washed hands before returning to the tray line.

Food Discard
In the interview on 6/12/2012 at 10:30 a.m. with FS Mgr L, Mgr L stated that foods are dated with the dates they are opened and are to be discarded after 7 days, unless it is a prepared meat then it is to be discarded in 3 days.

During the tour of the kitchen on 6/12/2012 at 10:55 a.m. accompanied by FS Mgr L, in the dry storage area several boxes of chocolate muffin mix were noted to be expired.

One box was expired as of July 1, 2011 and two boxes were expired as of May 23, 2012. FS Mgr L confirmed there were no dates on these boxes and stated, "We don't use that anymore anyway."

Training
In the interview on 6/12/2012 at 10:30 a.m. with FS Mgr L, Mgr L stated that staff meet every other month and also receive jobs specific training at these meetings. Mgr L was unable to produce meeting minutes or training content for these meetings other than one meeting in 2009 and one in 2011.

Mgr L admitted that L could not produce the content of the inservices or proof of attendance to show ongoing staff training related to food service.

Based on P&P review and 7 of 7 staff interviews (B, P, Z, C, U, V, T), the hospital failed to ensure that all departmental P&P are reviewed at least annually. These deficiencies had the potential to affect patients treated in the facility during the time of the survey between 6/11/12 and 6/14/12.

Findings include:
P&P review by surveyors #13469 and #26711 during the survey between 6/11/12 and 6/14/12 revealed that hospital departmental P&P are not reviewed annually.

Per interview, with Pt. Care Services Manager (B) on 6/12/12 at 10:30 AM, the hospital P&P are not being reviewed at least annually. Per (B), the last time the ED P&P were reviewed was in 2007.

Per interview, with Pharmacy Manager (P) on 6/13/12 at 1:00 PM, the last time the pharmacy P&P were reviewed was in 2002.


26711

Findings by Surveyor #26711:

The following departments do not have updated policies:

Radiology: per interview with Radiology Director Z on 6/12/2012 at 8:15 a.m. the department has access to organization policies and Director Z will look at some occasionally but Administration is responsible for them. Director Z was unable to state when the last time the Radiology policies were updated.

Dietary: per interview with Dietary Manager L on 6/12/2012 at 10:30 a.m., Manager L looks at the policies, "As needed, but we don't have many." Manager L stated L has no time to do this and was unable to state when the last time the Dietary policies were updated.

Discharge Planning: per interview with Patient Care Services Manager (PCS Mgr) B and Social Services Representative T on 6/13/2012 at 1:30 p.m., policies for Discharge Planning have not been reviewed since 2009.

Organ Donation: per interview with PCS Mgr B on 6/13/2012 at 2:00 p.m., policies for the Organ Donation program have not been reviewed since 2007.

Medical Records: per interview with Health Information Services Manager U on 6/13/2012 at 2:10 p.m., Manager U stated that policies for the Medical Record department are not reviewed annually.

Respiratory Therapy: per interview with Respiratory Therapy Supervisor V on 6/13/2012 at 3:05 p.m., Supervisor V stated that policies for the Respiratory Therapy department have not been reviewed since 2005.

Based on MR review, review of the facility's Medical Staff Rules and Regulations, and 2 of 2 staff interviews (U, X), this facility fails to ensure that MD orders and reports are properly authenticated by the responsible professional in 9 out of 30 MRs reviewed (Pts. #14, 15, 16, 23, 25, 30, 8, 3, 13), and that only personnel authorized by the Medical Staff are writing orders for patient care in 1 out of 30 MR reviewed (Pt. #14). Failure to have properly authenticated orders, and have approved personnel writing orders, has the potential to affect all patients in the facility including the 14 patients during the time of the survey (6/11/2012-6/14/2012).

Findings by Surveyor #26711:
Per review, of the medical staff rules and regulations (dated 8/2/05) on 6/14/12 in the AM, they direct the following related to V.O/T.O: "C. General Conduct of Care: 2. These orders shall be authenticated by the responsible practitioner within 48 hours of their writing."

An interview with Health Information Services Manager (Mgr) U was conducted on 6/13/2012 at 2:10 p.m. Mgr. U stated that physician's have 48 hours to sign verbal orders and 30 days to complete the records after a patient is discharged. Mgr. U stated the attempt to limit the amount of verbal orders in the facility has not proved to be effective.

A MR review was conducted on Pt. #14's closed Swing Bed MR on 6/12/2012 at 1:26 p.m. Pt. #14 was admitted on 5/18/2012 and discharged on 5/25/2012. On 5/22/2012 a Physical Therapy Assistant wrote an order for nursing to follow. Physical Therapy Assistants are not approved by the Medical Staff to write orders in this facility. This order was also not signed, dated, or timed by the MD within 48 hours. Further telephone/verbal (TO/VO) orders not properly authenticated in Pt. #14's MR include: On 5/19/2012 and 5/20/2012 there is one TO each day not dated, timed, or signed by the MD. On 5/18/2012 there is one TO not dated or timed when the MD signed. On 5/19/2012 there are two TOs not dated or timed by the MD. These findings were confirmed by Compliance Officer (CO) X on 6/14/2012 between 8:30 a.m. and 8:45 a.m.

A MR review was conducted on Pt. #15's closed Swing Bed MR on 6/12/2012 at 7:10 a.m. Pt. #15 was admitted on 4/13/2012 and discharged on 5/13/2012. The following TOs were not signed by the MD within 48 hours: TOs written 4/13/12 and 4/14/12 were not signed until 4/18/12; TO written 4/15/12 not signed until 5/4/12; two TOs written 4/17/12 not signed until 4/23/12; TO written 4/22/12 does not indicate a date or time the order was signed by the MD; TO written 4/23/12 not signed until 4/28/12; TO written 4/28/12 not signed until 5/25/12; and TOs written 4/30/12 and 5/3/12 not signed until 5/10/12. These findings were confirmed by CO X on 6/14/2012 between 8:30 a.m. and 8:45 a.m.

A MR review was conducted on Pt. #16's closed Swing Bed MR on 6/12/2012 at 1:00 p.m. Pt. #16 was admitted on 3/15/2012 and discharged on 4/10/2012. The following TOs were not signed by the MD within 48 hours: TO written on 3/18/12 not signed until 3/22/12; and TO written on 3/23/12 not signed until 3/28/12. These findings were confirmed by CO X on 6/14/2012 between 8:30 a.m. and 8:45 a.m.

A MR review was conducted on Pt. #23's closed Obstetrics (OB) MR on 6/13/2012 at 11:05 a.m. Pt. #23 was admitted on 4/13/2012 and discharged on 4/15/2012. The following TO was not signed by the MD within 48 hours: TO written 4/14/2012 remains unsigned, timed or dated by the MD. These findings were confirmed by CO X on 6/14/2012 between 8:30 a.m. and 8:45 a.m.

A MR review was conducted on Pt. #25's open inpatient MR on 6/13/2012 at 8:20 a.m. Pt. #25 was admitted on 6/6/2012. The following TOs were not signed by the MD within 48 hours: One written on 6/6/12 and one written on 6/10/12 were not signed, dated or timed by the MD. These findings were confirmed by CO X on 6/14/2012 at 8:55 a.m.

A MR review was conducted on Pt. 30's closed MR on 6/13/2012 at 12:50 p.m. Pt. #30 was admitted on 11/17/2011 and passed away on 12/1/2011. The following TOs were not signed by the MD within 48 hours: four TOs written on 11/18/2011, one on 11/19/11, one on 11/20/11 and one on 11/25/11 were not signed by the MD until 1/24/2012. These findings were confirmed by CO X on 6/14/2012 between 8:30 a.m. and 8:45 a.m.



13469

Examples by surveyor #13469:
V.O.'s dated 4/6/12 and 4/7/12 found in the MR of patient #8 on 6/13/12 at 11:55 AM, do not identify the date or the time the MD countersigned the orders. The exclusion of a date or time with the MD countersignature does not identify if the verbal and telephone orders were countersigned within 48 hours.

T.O.'s found in the MR of Pt. #3 on 6/13/12 at 11:10 AM were written by the RN on 3/5/12. The MD did not countersign the orders until 4/18/12. Countersigning these orders greater than 48 hours after they were received does not ensure the accuracy of the orders and the provision of safe patient care.

T.O. dated 5/10/12 found in the MR of patient #13 on 6/14/12 at 9:35 AM, do not identify the date or the time the MD countersigned the orders. The exclusion of a date or time with the MD countersignature does not identify if the verbal and telephone orders were countersigned within 48 hours.

T.O.'s found in the MR of Pt. #13 were written by the RN on 5/9/12. The MD did not countersign the orders until 5/22/12. Countersigning these orders greater than 48 hours after they were received does not ensure the accuracy of the orders and the provision of safe patient care.

Examples found in MR #3 and #8 were confirmed by CO (X) on 6/14/12 at 8:50 AM. Examples found in MR #13 were confirmed by CO (X) on 6/14/12 at 11:20 AM.

Based on 1 of 1 observation, 1 of 1 MR reviewed (#3) Medical Staff By Laws and Rules and Regulations, and staff interview of 4 of 4 staff (Staff U, AA, X, C), this facility does not hold the Medical Staff accountable for timely completion of patient's medical records. Failure to complete medical records and hold Medical Staff accountable has the potential to affect all patients receiving care in this facility including the 14 patients during the course of the survey (6/11/12-6/14/12).

Findings include:
Per review, of the medical staff R&R (dated 8/2/05) on 6/13/12 in the AM, the medical staff are directed to do the following: "B. Medical Records: 11. All records of discharged patients shall be completed within a reasonable period of time, not to exceed 30 days."

Per medical staff by-laws: "Article VII - Corrective Action: A. Due Process Procedure: 1. Whenever the activities or professional conduct of any practitioner with clinical privileges are considered to be lower than the standards or aims of the medical staff or to be disruptive to the operations of the hospital and/or nursing home or where the physical or mental health of the staff member may be in question, corrective action against such practitioner may be requested by any offer of the medical staff, by the chief of any clinical service, by the chairman of any standing committee of the medical staff, by the administrator, or by the governing body."

Examples by surveyor #26711:
While the Medical Staff By Laws and Rules and Regulations define time lines for completion of medical records, they do not define the consequences for records not completed within the 30 days after discharge.

A tour of the Medical Records department was completed on 6/13/2012 at 2:10 p.m. accompanied by Health Information Services Manager (Mgr) U.

Mgr. U stated that physician's have 48 hours to sign verbal orders and 30 days to complete the records after a patient is discharged. Mgr. U stated that the attempt to limit the amount of verbal orders in the facility has not proved to be effective.

Per observation in the Medical Records department, it was noted that stacks of records were noted on a shelving unit which Mgr U identified as delinquent records, past 30 days after discharge.

Mgr U states data is collected on physicians who are delinquent and this information is passed on to administration however, "There are no consequences for the lack of response."

The most outstanding medical records noted to be on the shelf were 5 patient records from January of 2012, 2 from February of 2012, and 1 from April of 2012.

Per discussion at the daily exit conference on 6/13/2012 at 4:30 p.m., Chief Financial Officer (CFO) AA stated that AA was aware of the delinquent records and agreed that although the Medical Staff is accountable to complete their work, there are no consequences for not doing so.

It was determined by CFO AA, Compliance Officer X, and Chief Executive Officer C at the daily conference on 6/13/2012 at 4:30 p.m. that the Medical Director is ultimately responsible to follow through on the accountability of the Medical Staff.

Examples by surveyor #13469:
Per MR review, on 6/13/12 at 11:10 AM. Pt. #3 was discharged on 3/6/12. The discharge summary was not dictated until 4/17/12 and countersigned by the MD on 4/20/12. This discharge summary was not completed within 30 days of discharge. T.O dated 3/5/12 were not countersigned by the MD until 4/18/12. These examples were confirmed by Compliance Officer (X) on 6/14/12 at 8:50 AM.

Based on 15 of 30 MR review (11, 12, 13, 18, 15, 16, 19, 21, 22, 23, 24, 25, 26, 27, 29), and 2 of 2 staff interviews (X, B), the hospital failed to ensure that MR documentation is complete and accurate. These deficiencies had the potential to affect patients treated in the facility during the time of the survey between 6/11/12 and 6/14/12.

Findings include:
Examples by surveyor #13469:

Per MR review, on 6/14/12 at 9:30 AM, Pt. #11 had a hernia repair on 3/1/12 with general anesthesia. The Anesthesia record for Pt. #11 does not include the time Anesthesia started or stopped. The MD operative report dictated 3/1/12 does not include the type of anesthesia delivered to Pt. #11. These findings were discussed and confirmed with CO X on 6/14/12 at 11:20 AM.

Per MR review, on 6/14/12 at 9:00 AM, Pt. #12 had a breast biopsy on 3/7/12 with general anesthesia. The Anesthesia record for Pt. #12 does not include the time Anesthesia started or stopped. The MD operative report dictated 3/7/12 does not include the type of anesthesia delivered to Pt. #12. The nursing intra-operative notes dated 3/7/12 do not include evidence that the ABSP Duraprep was allowed to dry before draping. These findings were discussed and confirmed with CO X on 6/14/12 at 11:20 AM. Per interview and review of P&P for ABSP with CO (X), staff are following the hospital P&P and allowing any ABSP used to completely dry before draping, but it is not documented in the patient MR.

Per MR review, on 6/14/12 at 9:35 AM, Pt. #13 had an appendectomy on 5/7/12 with general anesthesia. The Anesthesia record for Pt. #13 does not include the time Anesthesia started or stopped. The MD operative report dictated 5/7/12 does not include the type of anesthesia delivered to Pt. #13. The nursing intra-operative notes dated 5/7/12 do not include evidence that the ABSP Duraprep was allowed to dry before draping. These findings were discussed and confirmed with CO X on 6/14/12 at 11:20 AM.

Per MR review, on 6/12/12 at 8:00 AM, Pt. #18 had a hernia repair on 6/12/12 with general anesthesia. The Anesthesia record for Pt. #18 does not include the time Anesthesia started or stopped. These findings were discussed and confirmed with Pt. Care Services Manager (B) on 6/13/12 at 10:30 AM.


26711

Findings by Surveyor #26711:

A MR review was conducted on Pt. #15's closed Swing Bed MR on 6/12/2012 at 7:10 a.m. Pt. #15 was admitted for Swing Bed services on 4/13/2012. There are several blank lines in Pt. #15's H&P report making this document incomplete. There is a physician progress note on 5/10/2012 that does not include the date or time the physician wrote it. These findings were discussed and confirmed with Compliance Officer (CO) X on 6/14/2012 between 8:30 a.m.-8:45 a.m.

A MR review was conducted on Pt. #16's closed Swing Bed MR on 6/12/2012 at 1:00 p.m. Pt. #16 was admitted for Swing Bed services on 3/15/2012. The Nursing Care Plan has blank lines in the Impaired Mobility care plan making this an incomplete document. These findings were discussed and confirmed with CO X on 6/14/2012 between 8:30 a.m.-8:45 a.m.

A MR review was conducted on Pt. #19's closed Obstetrics (OB) MR on 6/13/2012 at 7:10 a.m. Pt. #19 had a Cesarean Section (C-Section) on 5/23/2012 and DuraPrep was used to prep the abdomen prior to the incision. There is no documentation that this alcohol based skin preparation was dry prior to the incision being made. The Anesthesia record for Pt. #19 does not include the time Anesthesia started or stopped for spinal anesthesia. These findings were discussed and confirmed with CO X on 6/14/2012 between 8:30 a.m.-8:45 a.m.

A MR review was conducted on Pt. #21's closed OB MR on 6/13/2012 at 10:30 a.m. Pt. #21 had spinal anesthesia for a vaginal delivery on 2/26/2012. The Anesthesia record for Pt. #21 does not include the time Anesthesia started or stopped for spinal anesthesia. These findings were discussed and confirmed with CO X on 6/14/2012 between 8:30 a.m.-8:45 a.m.

A MR review was conducted on Pt. #22's closed New Born MR on 6/13/2012 at 10:50 a.m. On the MD Discharge Assessment form, the MD failed to include the time the assessment was completed. These findings were discussed and confirmed with CO X on 6/14/2012 between 8:30 a.m.-8:45 a.m.

A MR review was conducted on Pt. #23's closed OB MR on 6/13/2012 at 11:05 a.m. Pt. #23 had a C-Section on 4/13/2012 and DuraPrep was used to prep the abdomen prior to the incision. There is no documentation that this alcohol based skin preparation was dry prior to the incision being made. The Anesthesia record for Pt. #23 does not include the time Anesthesia started or stopped for spinal anesthesia. These findings were discussed and confirmed with CO X on 6/14/2012 between 8:30 a.m.-8:45 a.m.

A MR review was conducted on Pt. #24's closed New Born MR on 6/13/2012 at 11:27 a.m. On the MD Discharge Assessment form, the MD failed to include the time the assessment was completed. These findings were discussed and confirmed with CO X on 6/14/2012 between 8:30 a.m.-8:45 a.m.

A MR review was conducted on Pt. #25's open inpatient MR on 6/13/2012 at 8:20 a.m. Pt. #25 was admitted on 6/6/2012 with Clostridium Difficile (a contagious bacterial infection in the intestine) and Diabetes, among other medical conditions. The Nursing Care Plan for the Diabetes does not indicate a high parameter to keep Pt. #25 below, making this care plan incomplete. The Nursing Care Plan for the C-Diff indicates Pt. #25 is on droplet precautions, when contact precautions are indicated for C-diff , making this care plan inaccurate. These findings were discussed and confirmed with CO X on 6/14/2012 at 8:55 a.m.

A MR review was conducted on Pt. #26's closed OB MR on 6/13/2012 at 11:33 a.m. Pt. #26 had spinal anesthesia for a vaginal delivery on 5/31/2012. The Anesthesia record for Pt. #26 does not include the time Anesthesia started or stopped for spinal anesthesia. These findings were verified by Compliance Officer X on 6/14/2012 between 8:30 a.m.-8:45 a.m.

A MR review was conducted on Pt. #27's closed New Born Death MR on 6/13/2012 at 11:40 a.m. The Mandatory Death Reporting Log form is not filled out on the lower portion to indicate whether the Organ Procurement Organization determined medical suitability for organ donation. According to CO X at 8:43 a.m. on 6/14/2012, it is an expectation that this form be completed in its entirety.

A MR review was conducted on Pt. #29's closed Emergency Room (ER) Death MR on 6/13/2012 at 12:40 p.m. The dictated ER note does not include a time the MD signed the form. These findings were discussed and confirmed with CO X on 6/14/2012 between 8:30 a.m.-8:45 a.m.

Based on 9 of 26 MR reviewed requiring consents (#1, 6, 8, 9, 11, 12, 13, 23, 24) out of a total of 30 MR reviewed, and 2 of 2 staff interviews (B, X), the hospital failed to ensure that consents for treatment are properly executed to include the witness full name and title and the time the consents were signed by the patient/representative. These deficiencies had the potential to affect patients treated in the facility during the time of the survey between 6/11/12 and 6/14/12.

Findings include:
Examples by surveyor #13469:
The following MR of patients treated in the facility were reviewed between 3:30 PM on 6/11/12 and 9:35 AM on 6/14/12: Pt. #1 treated on 3/2/12, Pt. #8 on 4/5/12, Pt. #9 on 5/2/12, Pt. #6 on 4/1/12, Pt. #11 on 3/1/12, Pt. #12 on 3/7/12 and Pt. #13 on 5/7/12.

Pt. #1, 6, 8, 9, 11, 12, and #13, Admission Agreements/Consents for Care do not include a complete signature and title for the witness, only initials are present.

Pt. #9 and Pt. #13, Admission Agreements/Consents for Care do not include the time they were signed.

Examples found in MR #1, 3, 7, and 8 were confirmed by Compliance Officer (X) on 6/14/12 at 8:50 AM. Examples found in MR #9, 18 and 6 were confirmed by Pt. Care Services Manager (B) on 6/13/12 at 10:30 AM. Examples found in MR #11, 12, and 13 were confirmed by Compliance Officer (X) on 6/14/12 at 11:20 AM.


26711

Findings by Surveyor #26711:

A MR review was conducted on Pt. #23's closed Obstetrics (OB) MR on 6/13/2012 at 11:05 a.m. Pt. #23 was admitted on 4/13/2012 and discharged on 4/15/2012. Pt. #23's Admission Agreement/Consent for Care does not include a complete signature and title for the witness, only initials are present. These findings were confirmed by CO X on 6/14/2012 between 8:30 a.m. and 8:45 a.m.

A MR review was conducted on Pt. #24's closed New Born MR on 6/13/2012 at 11:27 a.m. Pt. #24 was admitted after birth on 4/13/2012 and discharged on 4/15/2012. Pt.
#24's Admission Agreement/Consent for Care, signed by a family member, does not include a complete signature and title for the witness, only initials are present. These findings were confirmed by CO X on 6/14/2012 between 8:30 a.m. and 8:45 a.m.

Based on review of the facility QAPI program, and 3 of 3 staff interview (X, KK, L) by surveyor #13469, the hospital failed to ensure that 36 of 36 contracted services reviewed are evaluated for their effectiveness and delivery of care on an annual basis. These deficiencies had the potential to affect patients treated in the facility during the time of the survey between 6/11/12 and 6/14/12.

Findings include:
Per interview, with CO (X) on 6/14/12 at 10:00 AM, the hospitals contracted services are not evaluated on an annual basis as part of the QAPI program.

Per interview, with Governing Body Chairperson (KK) at 3:00 p.m. on 6/12/12, it was revealed that the hospital does not present evidence to the hospital board that it evaluates contracted services on an annual basis.

Per interview, with Environmental Services Supervisor (L) on 6/12/12 at 1:00 p.m., it was revealed that she does not evaluate the contracted service who provides the laundry service to the facility.

Based on review of the facility's Swing Bed Rights and Responsibilities, 3 of 4 Swing Bed MR (Pt. #14, 15, and 16) out of a total of 30 MR reviewed, and 2 of 2 staff interviews (Staff B and T), this facility does not ensure that Swing Bed patients have the required information needed at the time of transfer or discharge. This deficiency will affect all Swing Bed patients that enter this facility, including the 1 Swing Bed patient present during the time of the survey (6/11/2012-6/14/2012).

Findings include:

The facility's Swing Bed Rights and Responsibilities, which is undated, were reviewed on 6/11/2012 at 1:00 p.m.

The facility has not developed a notice for transfer or discharge that contains language that would inform the patient of the right to know the reason, effective date, or where they would be discharged or transferred should this occur.

The facility also does not give the patient information about the Long Term Care Ombudsman, or include information regarding who to contact for patients with developmental disabilities or mental illness, since this would be located on the transfer/discharge notice.

MR review were done on the closed Swing Bed MR for Pt.s #14, 15, and 16 on 6/12/2012 between 7:10 a.m. and 1:40 p.m. There were no transfer/discharge notices on file in their MRs.

These findings were confirmed by Patient Care Services Manager B and Social Services Representative T on 6/13/2012 at 12:56 p.m. who agree this form would not be in the MR because the facility does not have a form for transfer/discharge.

Based on MR review and 4 of 4 patient and staff interviews (Pt. #17, B, T, X), this facility failed to demonstrate that Swing Bed patients have an ongoing activity program and that the patients are actively engaged to join the activities in 4 out of 4 Swing Bed Pt. MRs (Pt. #14, 15, 16, and 17) out of a total of 30 MR reviewed. Failure to demonstrate ongoing activities in the Swing Bed program has the potential to affect all Swing Bed patients, including the one Swing Bed patient present during the survey (6/11/12-6/14/12).

Findings include:
An interview with Pt. #17 was conducted on 6/13/2012 at 8:30 a.m. Pt. #17 was admitted to Swing Bed status on 6/8/2012 and was able to accurately state that this was for a heart condition and was able to speak to rehabilitation efforts in therapy. Pt. #17 does not recall being asked about activities while in Swing Bed.

An interview regarding the Swing Bed program was conducted with Patient Care Services Manager (PCS Mgr) B and Social Services Representative (SSR) T on 6/13/2012 at 12:56 p.m. SSR T stated that the activity program for the Swing Bed patients is often combined with the affiliated assisted living facility and/or nursing home and patients are approached daily and have a calendar of daily activities to choose from.

SSR T also stated that there is no documentation in the MR that Swing Bed patients have been offered activities daily.

A MR review for Pt. #14 was conducted on 6/12/2012 at 1:26 p.m.; A MR review for Pt. #15 was conducted on 6/12/2012 at 7:10 a.m.; A MR review for Pt. # 16 was conducted on 6/12/2012 at 1:00 p.m.; and a MR review was conducted for Pt. #17 on 6/13/2012 at 8:00 a.m. There is no evidence in any of these Swing Bed MRs that ongoing activities are offered. These findings were discussed with and confirmed by Compliance Officer X on 6/14/2012 between 8:30 a.m.-8:45 a.m.