HospitalInspections.org

Findings include:

A MR review for Pt #26 was conducted on 1/14/2014 at 9:25 a.m. accompanied by RN TT who confirmed these findings. Pt #26 received the IMM upon admission on 9/24/2013. This form is scanned into the EMR and has been signed and dated by Pt #26. Upon discharge on 10/1/2013, social services did not obtain another signature and date to verify that these rights were again given as per federal regulation (42 CFR 489.27) guidelines.

In an interview with SW JJJ on 1/14/2014 around 10:30 a.m., SW JJJ stated the facility used to get a signed/dated second copy to maintain on the record and stopped that practice about a year ago. The current practice is to give the patient the second copy of the the 3-copy form and then mark off in the social services standards of care section in the EMR that the IMM was given, and this is electronically authenticated at the time of data entry. SW JJJ states, "I'm not sure why we stopped having them sign the second one."

A MR review for Pt #28 was conducted on 1/14/2014 at 9:25 a.m. accompanied by RN TT who confirmed these findings. Pt #28 signed the initial IMM on admission, however there is no indication a follow up IMM was given.

In an interview with Nurse Admin B on 1/15/2014 at 9:30 a.m. regarding maintaining evidence in the EMR pertaining to the IMM given close to the time of discharge, Nurse Admin B acknowledged that the current practice is not able to produce that evidence. There was documentation found in an alternate computer system used by social services staff that the second notice was given, however this is not a permanent part of the chart and this computer system does not interface with the patient EMR.




32670

Based on MR review and interviews (TT, JJJ) in 2 of 2 MR (26, 28) requiring a second IMM notice be given, out of a total universe of 30 MR reviewed, the facility failed to obtain a signed IMM second notice as part of the MR. This deficient practice has the potential to affect all Medicare patients treated at this facility.

Per review of Pt #23's MR on 1/15/2014 at 9:45 AM there is no documentation of Pt #23 having or needing an Advanced Directive. This is confirmed in interview with RN YY and RNSI VV on 1/15/2014 at 9:45 AM.

Per interview with Pt #24 on 1/14/2014 at 3:50 PM, Pt #24 stated there is an Advanced Directive, but did not believe one was provided to the hospital. Pt #24's MR review on 1/15/2014 at 11:45 AM revealed there is no documentation of Pt #24 having or needing an Advanced Directive. This is confirmed in interview with RN XX and Dir MM on 1/15/2014 at 11:45 AM.








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Findings include:

On 1/14/2014 at 11:59 AM the P&P titled, "Advance Directive's" dated 10/1/1991 states in part, " 11. Questions and Information a. Each adult patient admitted to MCHS will be provided with written information about Advance Directives, i.e. distributed by the nursing staff with other patient education information. "

On 1/14/2014 at 8:00 AM a review of Pt # 13's record was started. The record shows Pt # 13 does not have a Advanced Directive. The section that asks if the Pt was offered information on formulating an AD is blank. This was confirmed with RN EEE, VP G and VP H at the time of discovery.


29963

Per review of Pt # 18's open MR on 1/14/2014 beginning at 8:00 AM indicated documentation that upon admission staff asked pt if he had completed AD paperwork and Pt # 18 indicated "no" but staff did not complete documentation on whether patient was asked if he would like assistance in completing AD paperwork.

The above findings were confirmed with RN K at time of MR review.


32670

Based on MR review, P&P review and interviews (G, H, K, VV, XX, YY, EEE, MMM) this facility failed to provide information and/or assistance in formulating an advanced directive in 4 of 19 (13, 18, 23, 24) admitted Pts MRs out of a total universe of 30 MRs reviewed. This deficient practice has the potential to affect all admitted patients at this facility.

Based on MR review, P&P review and interviews (B, K, TT) in 2 of 30 MR's reviewed (# 22, 30) the facility failed to document follow up to pain assessments after pain medication was given. This deficient practice has the potential to affect all patients receiving pain medication at this facility.

Findings include:

The facility's Nursing Patient Care Standard, dated 1/14, was reviewed 1/15/2014 at 12:04 p.m. Regarding pain, the standard indicates that upon initial assessment to the facility staff are to, "Assess for presence of pain upon admission to the hospital. If a patient's response to pain is yes, staff are to complete all questions in the MR related to pain. Staff are to, "Assess and document the pain assessment in the EMR, including as appropriate:...Acceptable intensity."

Regarding reassessment of pain, the above standard states that after each pain management intervention reassessment is to occur, "1. Within one half hour of parenteral (intravenous) medication and document response in the EMR on the MAR and 2. Within one hour of an oral medication and document response in the EMR on the MAR."

A MR review for Pt. #30 was conducted on 1/15/2014 at 10:31 a.m. accompanied by RN TT and Nurse Admin B. Pt #30 was admitted to the facility with acute and chronic respiratory failure and was being monitored and treated for pain.

On 11/22/2013 at 3:50 p.m. and 6:02 p.m. Pt. #30 received IV morphine for pain. No pain reassessments were documented to determine the effectiveness of the interventions. These findings were confirmed by RN TT at the time of discovery.


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Per review of Pt # 22's open MR on 1/14/2014 beginning at 2:45 PM revealed Pt # 22 was admitted to the hospital following a fall with a hip fracture.

On 1/13/2014 at 9:39 AM, Pt # 22 complained of pain, rating pain at a "5", Nurse administered pain medication. Documentation indicated that RN completed a reassessment of pain at 11:35 PM but did not list a numerical number to indicate pain rating.

Above findings were confirmed with RN K at time of record review.

Pt #23's MR review on 1/15/14 at 9:45 AM, revealed Pt #23 had a knee arthroscopy (procedure to view the knee joint and remove tissue) on 1/13/2014. The MR has no RN CP for Pre-op care or Post-op care. Per interview with RN YY and Dir O, during MR review, the facility began using a computer MR system three years ago and has not had CPs for Pts since then for the surgical deptment.

Pt #24's MR review on 1/15/2014 at 11:45 AM revealed Pt #24 delivered an infant on 1/11/2014. The RN admission assessment dated 1/11/2014 at 11:10 AM is incomplete including Advanced Directive information that may affect a CP. The Labor CP, dated 1/11/2014 at 3:00 PM, has all possible problems and interventions initiated that are available in the electronic MR, with nothing initiated unique to the Pt including Preterm labor (delivered 5 weeks early). The PP (Post Partum) CPs dated 1/12/2014 at 12:01 PM, 1/13/14 at 8:00 AM and 1/14/14 at 8:52 AM has all possible problems and interventions that are available in the electronic MR. These CPs were not checked "initiated" and there is nothing initiated unique to the Pt including problems related to the infant admitted to special care nursery or emotional needs. This was confirmed in interview on 1/15/2014 at 11:45 AM with RN XX and Dir MM, adding staff have the ability to add problems as needed, but most labor and PP patients have the same problems.


26390

Based on medical record reviews, staff interviews (B, C, F, G, I, K, O, MM, TT, WW, YY) and review of facility policy the staff failed to individualize patient care plans in 11 of 30 medical records reviewed (15, 16, 17, 18, 20, 21, 22, 23, 24, 26, 30) and staff failed to review care plans daily per policy in 3 of 30 MR's (18, 20, 21) reviewed. This deficient practice could potentially affect all inpatients at this facility.

Findings include:

Per review of facility policy on 1/14/14 at 12:30 PM titled "Core Care" dated 5/18/12 indicated under procedure 2. "Patient identified documentation: a. For each patient the nurse will collect and process information to identify the patients needs/concerns, interventions, determine the appropriate expected outcomes, and discharge plan."

On 1/14/2014 at 2:10 PM a review of Pt #15's record was started. The record shows Pt #15 was admitted on 1/7/2014 with a G-tube and a J-tube, however there are no orders for site care, no evidence of site care and no nursing plan of care for the sites. This was confirmed with RN F, VP G and RN Supervisor C at the time of discovery.

On 1/14/2014 at 2:45 PM a review of Pt #16's record was started. The record shows Pt #16 was admitted on 1/13/2014. An initial nursing assessment was completed on 1/13/2014, the section titled pain does not include Pt #16's acceptable level of pain. The nursing plan of care dated 1/14/2014 states the outcome for pain is, " Pain intensity is acceptable " - " Met " is the result entered. Documentation related to pain does not contain a Pt acceptable level of pain. This was confirmed with RN F, VP G and RN Supervisor C at the time of discovery.


26711


An interview with Nurse Admin B and RN TT took place on 1/14/2014 around 10:30 a.m. regarding care planning and individualizing them to patient needs. RN TT stated that goals are able to be personalized to the patient. Both B and TT agree that the care plans are standardized computer care plans that do not always reflect the individual needs of the patient.

A MR review for Pt #26 was conducted on 1/14/2014 at 9:25 a.m. accompanied by RN TT who confirmed these findings. Pt #26 was admitted to the facility on 9/24/2013 for an abdominal wound infection from a previous surgery. The goal developed, "Free of evidence of infection" does not indicate what type of infection or where the infection is and on 9/24, 9/25, and 9/26 is documented as being met. On 9/27 the goal is documented as not being met due to Clostridium Difficile (an intestinal bacterial infection) and then from 9/28-10/1/2013 it is documented as being met again.
Another goal, "Pain intensity is acceptable," does not identify what the acceptable pain level is.
Another goal says, "Skin - Healing." There are no other descriptors or individualization to personalize this to Pt #26.

A MR review for Pt #30 was conducted on 1/15/2014 at 10:31 a.m. accompanied by RN TT who confirmed these findings. Pt #30 was admitted to the facility on 11/22/2013 with acute and chronic respiratory failure from chronic obstructive pulmonary disease. In Pt #30's respiratory care plan, two of the goals are, "Cough and Deep Breathe, and "Oxygen Saturation Monitoring Frequency" These are tasks for the patient/nursing, not a patient goal.









29963


Per interview on 1/14/2013 at 12:30 CNO I stated that nurses are able and are expected to individualize care plans and documentation should be completed at least daily that care plans were reviewed and should be updated with any changes.

Per review of Pt #17's open MR on 1/14/14 beginning at 11:00 AM revealed Pt was admitted following Bariatric Surgery. Assessment dated 1/13/2014 indicated skin was not intact but a care plan problem was not initiated to address impaired skin integrity.

Per review of Pt # 18's open MR on 1/14/2014 beginning at 8:00 AM revealed pt was admitted to hospital on 1/7/2014 due to weight loss secondary to metastatic small cell carcinoma. Documentation indicated nursing staff did not review care plan on 1/9/2014 or on 1/11/2014.

Per review of Pt # 20's open MR on 1/14/2014 beginning at 10:10 AM revealed pt was admitted to hospital on 1/12/2014 due to anemia and low blood pressures. Documentation indicated nursing staff did not review care plan on 1/13/2014.

Per review of Pt # 21's open MR on 1/14/2014 beginning at 11:05 AM revealed Pt was admitted on 1/9/2014 for nausea and vomiting. Documentation indicated nursing staff did not review entire care plan on 1/13/2014.

Per review of Pt # 21's open MR on 1/14/2014 beginning at 11:05 AM revealed Pt was admitted for nausea and vomiting. Pt is also a diabetic with orders to monitor blood sugars but a care plan problem was not initiated for Diabetes.

Per review of Pt # 22's open MR on 1/1/2014 beginning at 2:45 PM revealed pt was admitted following a fall with a hip fracture. Assessment dated 1/13/2014 indicated skin was not intact but a care plan problem was not initiated to address impaired skin integrity.

Above findings were confirmed with RN K at time of record review.

Based on observation, review of P&P, and interview with staff (CC), 1 of 3 medication administration observations (CC), the facility failed to ensure pre-drawn syringes are labeled with date, time and initials, and prepared in an aseptic manner to prevent contamination. This deficient practice has the potential to affect all patients receiving medication at this facility.

Findings include:

Per review on 1/14/14 in the PM of facility policy titled Medication Administration in the Hospital Setting, dated 7/10, it states under #9 "Prepare the medication at the anticipated time of administration in a designated medication preparation area as defined by the department."

Per review on 1/15/14 in the PM of facility policy titled Medication Labeling,dated 7/11, it states under #2.b. "If the medication or solution is drawn, opened, prepared or poured and is to be administered at a later time or by another person, labeling is required.... 4.a. a. Labels are to include: i. the medication/solution name, ii. dose, strength and/or concentration of the medication or solution, and iii. expiration date if not used in 24 hours."

Per observation on 1/14/14 at 12:00 PM CRNA CC removed six syringes from the Anesthesia Cart in preparation for Pt #23's surgery. The syringes had labels with medication names: Propofol (general anesthetic), Versed (amnesiac), Fentanyl (pain med), 1% lidocaine (numbing agent), Zofran (antiemetic), Rocuromiun (blocking agent) and Succinylcholine (blocking agent). The labels did not include dose, concentration, expiration time, date, time or name/initials of who drew up the medication.

During the surgical procedure for Pt #23, at 12:28 PM, CRNA CC opened and drew Sodium Chloride from a vial and Hydromophone from a carpoject (pre-prepared syringe) into a single syringe. CRNA CC did not clean the septum of either the vial or syringe prior to inserting the needle per policy.

During a tour on 1/13/2014 at 2:03 PM of the Fourth floor in the Wishert building with VP G, Director of Neuro Science D and VP of Quality H, Medical records for patients in room #'s 20-29 were noted to be sitting inside unlocked work stations outside of the patient rooms. It was explained the charts have information including physician progress notes, consents, face sheet with personal information, labels with personal information, EMS reports and outside records.




















29963


Based on observations and staff interviews (D, G, H, M, KKK) the facility failed to ensure that unauthorized individuals are prevented from access to patient medical records in 3 of 7 areas (medical records department, Fourth floor Wishert Building and CCU) toured. This deficiency could potentially effect all patients receiving care at this facility.

Finding include:

During a tour on 1/13/2014 at 2:10 PM of the Critical Care Unit (CCU), Medical record for patient in room # 1511 was noted to be sitting on top of the work station outside of the room. The chart was noted to have information including physician progress notes, consents, and a face sheet with personal information.

Per interview on 1/13/2014 at 2:15 PM with RN KKK, RN KKK stated that RN's will bring the charts to the work station area when they are delivering care to patients. No observation of the nurse in the room where the chart was located outside the door.

During a tour of the medical records department on 1/14/2014 at 1:15 PM, noted blue recycle bins in medical record room containing patient information. HIM M stated in interview that housekeeping comes to the medical record department, empties the small blue recycle bins into a large gray storage bin with a locked top. Housekeeping then transports the locked storage bin to an area where the contracted service shreds the paper. HIM M stated that housekeepers do have potential access to patient information as they carry keys to the locked storage bins.

Based on P&P review, MR review, and staff interview (TT) this facility failed to properly record TO/VOs in 2 of 2 (# 26 and 27) records reviewed with noted TO/VO, out of a total universe of 30 MRs; failed to ensure that all written orders are signed, dated, and timed in 1 out of 30 MR reviewed (#27); and failed to ensure that TO/VOs are authenticated by a provider within 48 hours (#27 ) in 1 of 2 MRs reviewed with noted TO/VO with a total universe of 30 MRs reviewed.
This deficient practice has the potential to affect all Pts receiving care at this facility.

Findings include:

The facility's policy titled, "Medical Order," dated 8/2011, was reviewed on 1/14/2014 at 4:00 p.m. The policy states in part, "All orders shall be in writing and dated, timed and signed by the ordering individual."
This policy also states, "All orders transmitted by the physician agent must be transcribed with the ordering physician's name first, the agent and the receiver. i. Example: T.O. Dr. Doe/M. Roe, RN/B. Loe, RN." According to the policy the words "read back" should also be indicated on the order.

A MR review for Pt #26 was conducted on 1/14/2014 at 9:25 a.m. accompanied by RN TT who confirmed these findings. Pt. #26 was admitted on 9/24/2013 and discharged on 10/1/2013. Pt #26 has two improperly written orders, one on 9/25/2013 another on 9/26/2013. The nurse writing the order did not indicate it was a TO.

A MR review for Pt #27 was conducted on 1/14/2014 at 3:33 p.m. accompanied by RN TT who confirmed these findings. Pt #27 was admitted on 9/22/2013 and discharged on 10/4/2013. On 9/24/2013 there is an order written for a IV fluid rate change that does not indicate who wrote the order or the provider who gave the order. RN TT confirmed it was not Pt #27's attending physician who wrote the order.
On 9/23/2013 there is a VO written that was not authenticated by the MD until 10/3/2013. This time period exceeds 48 hours.

Based on MR review, review of P&P, and interview with staff (MM, XX) in 1 of 4 MRs requiring consent for a procedure, out of a total universe of 30 MRs reviewed, the facility failed to document who explained risks and benefits to the Pt prior to procedure. This deficient practice has the potential to affect all Pts receiving procedures at this facility.

Findings include:

Per review on 1/15/14 in the PM of facility policy titled Consent-NWWI Procedure, dated 8/12, it states under # 3. "The physician who is going to perform the specific treatment or procedure is responsible for having the informed consent discussion, as well as ensuring that the consent is documented in the medical record. This is a non-delegable duty."

Pt #24's MR review on 1/15/14 at 11:45 AM revealed Pt #24 had an epidural (medication injected into the spinal area) on 1/11/14 to relieve labor pain. The Consent for Epidural Anesthesia states "I have read this consent form and understand the risks involved, and the possibilities of complications have been fully explained to me by Dr. __________. I completely understand the nature and consequences of the procedure." The document is signed by the Pt, dated 1/11/14 at 5:25 PM. This was prior to any MD or Anesth staff present to explain the risks and benefits of the procedure. This was confirmed in interview with RN XX and ND MM on 1/15/14 at 11:45 AM, agreeing the information should be discussed and form should be complete.

Based on tour, review of SOP and interviewS with staff (G, O, P, DDD) in 2 of 12 areas tours that store medication (OR and 3rd floor Luther Building) the facility failed to ensure there are no expired medications available for patient use. This deficient practice has the potential to affect all patients receiving medications at this facility.

Findings include:

AORN SOP and Recommended Practices for Inpatient and Ambulatory Settings, 2013 Edition states under Medication Safety Viii.e.1. "Intravenous solution containers should be punctured as close as possible to time of use. Opened and unused medication vials, solutions bags, bottles, syringes, and compounded sterile preparations should be discarded within one hour of opening."

Per interview on 1/14/14 at 7:45 AM with RN P, the facility follows AORN SOPs.

Per tour of the OR department on 1/14/2014 at 7:45 AM with RN O, there is a spiked bag of intravenous fluid dated 1/14/2014 with no time or initials of who spiked the bag. Per RN O, there should be a complete label on the bag.

At approximately 10:30 AM the room between ORs 15 and 16 had a refrigerator with 2 bags of Normal saline expire 12/13; a freezer with 3 bags of Sodium Chloride Irrigation expired 1/13, 12/12 and 3/12; and a warmer with a large Sodium Chloride Irrigation bag dated 1/4. Per RN P, the expired bags should not be in the room, and the large bag should have been discarded on 1/4.


26390


On 1/14/2014 at 3:30 tour of 3rd floor Luther building, south tower clean supply room. 3 bags of sodium chloride that expired in 2012 were in the medication refrigerator door. RN Supervisor DDD, explained the bags are in there to keep the door open. Finding confirmed with VP G.

A Validation Survey for Life Safety Code compliance was conducted by the Wisconsin Division of Quality Assurance on 01/13/2014 - 01/16/2014. Mayo Clinic Health System-Eau Claire campus was found to be NOT in compliance with the following regulation:

42 CFR 482.41 Condition of Participation: Physical Environment was NOT MET

The cumulative effect of these deficiencies has the potential to affect the safety of all patients, staff, and visitors at the hospital.

Existing Life Safety Code -Building #2:
K17: Corridors doors not smoke tight
K 56: Sprinkler system not compliant to NFPA 13

New Life Safety Code- Buildings #3 and #4:
K43: Two actions to egress through a door--building #3
K18: Paired Corridor doors not smoke tight--building #4
K27: Smoke barrier doors were not smoke tight--building #4
K33: Paired doors at Exit Passageway not smoke tight--building #4
K43: No signage at a delayed locking mechanism--building #4
K56: Sprinkler system not compliant to NFPA 13--building #4
K147: Electrical system not compliant to NFPA 70--building #4

Please refer to the full description and findings within the specific K-tag deficiencies within the appropriate Building found later in this report.

42 CFR 482.41(b) STANDARD: LIFE SAFETY
CODE FROM FIRE IS "NOT" MET.

A Validation Survey for Life Safety Code compliance was conducted by the Wisconsin Division of Quality Assurance on 01/13/2014 - 01/16/2014. Mayo Clinic Health System-Eau Claire campus was found to be NOT in compliance with the following regulation:

42 CFR 482.41(b) STANDARD: Life Safety from Fire is "Not" met.

The cumulative effect of these deficiencies has the potential to affect the safety of all patients, staff, and visitors at the hospital.

Existing Life Safety Code -Building #2:
K17: Corridors doors not smoke tight
K 56: Sprinkler system not compliant to NFPA 13

New Life Safety Code- Buildings #3 and #4:
K43: Two actions to egress through a door--building #3
K18: Paired Corridor doors not smoke tight--building #4
K27: Smoke barrier doors were not smoke tight--building #4
K33: Paired doors at Exit Passageway not smoke tight--building #4
K43: No signage at a delayed locking mechanism--building #4
K56: Sprinkler system not compliant to NFPA 13--building #4
K147: Electrical system not compliant to NFPA 70--building #4

Please refer to the full description and findings within the specific K-tag deficiencies within the appropriate Building found later in this report.

Based on P&P review, observations and interviews with staff in 4 of 4 staff interviews (F, I, NN, LLL) staff did not clearly understand where the Medical gas zone valve boxes were located to control an oxygen fueled fire within their nursing units. This deficiency has the potential to affect all patients visitors and staff at this facility.

Findings include:

Per review on 1/14/2014 in the PM of P&P titled "Guidelines for preventing fires in oxygen enriched atmospheres" it states "All staff members are required to know locations and proper procedure to shut off valves controlling piped oxygen systems in their job duty area."

On January 14th, 2014 at 10:13 AM, when several of the staff attending the Nurse Station on the fourth floor of the Luther building were asked how to close off the Oxygen valves for an oxygen fire in the south wing of this unit. These staff indicated that this was the responsibility of Management or the Lead Nurse on the floor. Those staff were instructed not to close any valves to the medical gas system. These staff members contacted the lead nurse responsible for this task. Staff F (Lead Nurse) was asked to close the valve for the oxygen system for a room located on the east side of the south wing of this unit. Staff F proceeded to the zone valve locations (several zone valve boxes were located in close proximity of the cross-corridor). Once at the location, Staff F walked directly to a valve box marked "For future use-lines are capped". When asked if this was the correct box Staff F hesitated and walked across the hall and pointed to a different valve box. During the conversation with Staff F, staff I was asked about this item; Staff I reiterated that the Staff F (Lead Nurse) for this unit had correctly followed hospital policy for shutting an oxygen valve.

Code concern: Although Staff F understood where the valve boxes were; Staff F was not sure which panel to open to close the proper oxygen valve.

On January 14th, 2014 at 1:30 PM, when asked Staff NN (Lead Nurse) within the North wing of the OB floor (Second floor) where the zone valves were and which one would be close to extinguish a fire on the south side of her unit. Staff NN promptly went to the panels. Staff NN indicated that since she was the lead nurse, in an emergency she would be with the patient and would send a member of her team to close the proper valve. I asked Staff NN which valve box she would direct to be closed. Staff NNs' response was to close all of the zone valves that delivered oxygen to her unit.

Code concern: Unless staff was certain that no one was on oxygen within the unit; why would all of the valves be closed? Again, Staff NN was not sure which specific panel served the room where the fire was located.

On January 15th, 2014 at 9:50 AM, when asked Staff LLL (Lead Nurse) to bring her staff to the medical gas panel to demonstrate how Staff LLL would close the valve for a oxygen based fire in one of the units' recovery rooms. All staff who accompanied Staff LLL knew where the panel was located (they only had one panel for the unit). When instructed to demonstrate closing the valve, the staff were unsure how to open the panel. One staff even remarked that the valve should not be closed since language on the valve stated; "Close only in an emergency".

Code concern: A better understanding was present with these staff within the Ambulatory Surgery Center of the Luther building and more of a team approach for the responsibility to close any medical gas valve was taken by the staff. It was observed that these staff had never closed the oxygen valve. When directed to close the valve (after checking that no patients were on oxygen) staff were very surprised at the difficulty of closing the valve. One thought that it was stuck; even though the valve was stiff from little operation (typical of these valves).

Conclusion: All responsible staff on these three units were aware of what the medical gas panel looked like. No one appeared to know what the inside looked like and how to open the panel. Those staff who did close the valve were surprised at the stiffness of the valve operation. All staff are trained annually by viewing a photo of the medical gas panel. Further training such as opening the panels and exercising the valves would be valuable to insure the safety of any patient served by this system. The panels were properly signed for the rooms served by the valves in the particular panel. But most staff did not look at the signs at the zone valve panel; which would clarify if the room with the fire within it was actually served by this particular panel.

The above findings were discussed with Quality Director A at the time of the findings.

Based on observation, review of P&P, tours and interviews with staff (B, C, G, L, O, P, JJ, MM, QQ, RR, UU, DDD, FFF, GGG) in 4 of 8 staff observation (J, N, QQ, SS) and in 10 of 15 department tours (Family Birthing, Endoscopy, Central Processing, Cath Lab, Wishert building, Luther building, Laundry, CCU, Kitchen, OR) the facility failed to ensure a safe and sanitary environment to prevent and control contamination and/or cross contamination. This deficient practice has the potential to affect all patients and visitors at this facility.

Findings include:

Per review on 1/15/14 in the PM of facility policy titled Infection Control-Cardiac Catheterization Lab/Special Procedures dated 10/11 it states under 3. "When sterile equipment is being used, staff, physicians and approved observers will wear hospital scrub attire while in the procedure room."

Per review on 1/15/14 in the PM of facility policy titled Central Processing Department Attire dated 6/09 it states under 2.a. "Proper attire in the semi-restricted area of Central Processing (processing and sterile storage areas) shall include hospital supplied: i. Disposable bouffant cap ii. Disposable hood for personnel with facial hair..."

Per review on 1/15/14 in the PM of facility policy titled Dress Code-Surgical Attire dated 9/13 states under Surgical Attire: "Protective eyewear is worn by intraoperative staff involved in direct patient care activities or processing of contaminated instruments." Under Head Coverings "A hood is worn where established as standard attire specific to the practice setting, or by anyone who cannot cover and contain all head and facial hair with a head covering or mask."

Per review on 1/15/14 in the PM of facility policy titled Cleaning, Disinfection, and Sterilization of Patient Care Equipment dated 3/13 it states under 3. c. "Disposition of items in patient care areas: Depending upon the item, clean in the immediate environment, deliver to the soiled Utility Room, or return to the designated department."

Per review of facility policy on 1/14/14 at 10:00 AM titled Hand Hygiene dated 10/28/13 indicated under policy statements "1. Indication for hand hygiene a. Alcohol-based hand rub (ABHR) will be used: i. Before having direct contact with patients v. after contact with patient's skin viii. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient environment. ix. After removing gloves.x. After contact with respiratory secretions and contaminated objects."

Per AORN SOP for Inpatient and Ambulatory Setting 2013 edition, under Surgical Attire III.c.2. "The surgical gown back should be considered unsterile. The back of the gown cannot be constantly monitored." Under VII. "Sterile fields should be constantly monitored, it should be monitored continuously. Under Care of Instruments XII.c."Sterilization occurs only on surfaces that have direct contact with the sterilant. Instruments should be kept in the open and unlocked position using instrument stringers, racks, or instrument pegs designed to contain instruments. open to allow all surfaces to be exposed for sterilizing." Under Cleaning and Processing Endoscopes IX.a. "Flexible endoscopes should be stored in a closed cabinet with venting that allows air circulation around the flexible endoscopes..."

Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC), 2003: "Dryer temperatures and cycle times are dictated by the materials in the fabrics. Man-made fibers (i.e., polyester and polyester blends) require shorter times and lower temperatures."

Per interview on 1/14/14 at 7:45 AM with RN P, the facility follows AORN SOPs.

Per review on 4/14/14 at 3:00 PM of policy titled " Food Procurement, Delivery and Storage" it states " 2. All cooked, prepared or ready to eat foods are stored above all raw and uncooked foods."

Per review of Wisconsin Food Code dated 2013 on 4/16/14 at 1:50 PM, it states
"3-305.11 Food Storage.
(A) Except as specified in ¶¶ (B) and (C) of this section, FOOD shall be protected from contamination
by storing the FOOD:
(1) In a clean, dry location;
(2) Where it is not exposed to splash, dust, or other contamination"

Per review of facility policy on 4/14/14 at 3:10 PM, titled "Infection Control - Food and Nutrition Services" it states, "all employees must.... Effectively restrain 100% of one's hair when working in the department."

Examples in Family Birthing Center & Women's Health:

Per tour on 1/13/14 between 2:00 PM and 3:00 PM the following was noted with RN MM:
The soiled room door was open to main hallway. Per RN MM during tour, the door sticks open.

4 vacant L/D (labor and delivery) rooms #'s 21124 & 21126, had one Sani-Wipe and one Pre-Wetted Wipes; and in room #'s 21125 and 21128 had two containers of Sani-Wipe in drawer accessible by Pts and visitors (including children). Both Sani-Wipe and the Pre-Wetted Wipes indicate hazards to humans and to keep out of reach of children. RN MM stated the wipes should not be in the Pt rooms.

Examples in OR:

Per tour on 1/14/14 between 7:45 AM and 12:30 PM with RN P and RN O, the following was noted:

At 8:20 AM the following staff in OR 6 wore a skull cap rather than a bonnet, that allowed for exposed hair: PA Q, RN R, ST S, and MD T.

At 8:25 AM ST U changed gloves after loading the instruments on a case cart without the benefit of washing. Per RN P during at time of observation, staff should wash between glove changes.

At 8:40 AM H X wipes the tubing for a compression pump and coiled the clean tubing onto the dirty pump recontaminating the tubing. And ST U allowed the straps, that stabilize a Pt on the OR table, to drop to the floor recontaminating them. Per RN P at time of observation, the entire pump and tubing should be cleaned, and the straps should not touch the floor.

At approximately 10:25 AM OR rooms 15, 16 and 20 have gouges in the walls making the walls unwashable. Per RN P the at time of observation the walls are damaged.

At 10:35 MD AA did not have eye protection during a procedure in OR 10. Per RN P there should be proper eye protection.

At 10:38 AM in the clean supply room, Perfussionist III dropped supplies on the floor, picked up and continued to the supply room desk. RN P asked Perfussionist III if the supplies are going to be used for a case, and the response was yes. RN P agreed the supplies should not be used.

At 11:30 AM RNA P donned a hood and mask that did not completely cover the sideburns to enter OR 6 at the end of a procedure, and the following staff in OR 6 wore a skull cap rather than a bonnet, that allowed for exposed hair: CRNA CC, MD FF, and FA GG.

At 11:30 AM ST HH touched the trash bin and to move closer to the instrument table and proceeded to assist in the set up opening and handing over sterile equipment to ST II. ST HH did not wash after touching the bin.

Between 11:30 AM and 12:20 PM ST II, gowned and gloved for Pt #23's procedure turned away from the open instrument table a minimum of 9 times prior to the procedure. Per RN P, STs should not turn their back to the open table.

At 11:30 AM brownish splatter was noted on the ceiling of OR 6. Per RN P during observation the splatter should be cleaned.

At 12:22 PM after the surgical site was prepped, MD FF fanned the prepped site to expedite drying, allowing for potential recontamination. Per RN P the MD should not fan the prep site.

Examples in the Endoscopy unit:

At 10:00 AM tour of the Post Endoscopy unit with RN O, revealed holes in the wall outside bay 29, making the wall unwashable. The Pre Endoscopy room 35 has gouges in the wall making the walls unwashable. RN O agreed the walls need to be repaired.

At approximately 10:15 AM, the closets holding endoscopes are not vented. RN O agreed the closeets should be vented.

Examples in Central Processing:

Per observation in Central Processing on 1/14/14 between 11:00 AM and 11:30 AM the T DD prepared four OB trays with instruments for sterilization. The clamps and scissors were placed in an unlocked but closed position, preventing the steam sterilization process to reach all surfaces of the instruments. Per interview with BM JJ during observation, they understood the instruments could not be locked but could be closed. During this observation, Tech JJ and Tech EE had skull caps that allowed for exposed hair rather than bonnets.

Examples in Radiology/Cath lab:

Per tour of the Radiology/Cath Lab unit on 1/14/14 between 2:20 PM and 3:30 PM, with Admin L, the following was observed:

The wooden pull down desk in the ultrasound room has varnish worn off allowing for a porous surface that is not cleanable.

The Bone Density table has a piece of plastic taped down at the foot area, with tape peeling up and slits in the plastic, making it a surface that is not completely washable.

The Cath Lab procedure room 335 had doors open to the corridor and inner halls that had signage to keep the doors closed. Per LT UU during the tour at approximately 3:20 PM, the room is considered sterile and the doors should be closed. The mattress on the OR table in room 335 has several areas taped to repair tears, and the tape is curling up allowing for a surface that is not washable.

Per interview with Admin L and LT UU during the tour, they acknowledged the unwashable surfaces adding they needed to be replaced.


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Examples in the Wishert area/tower:
On 1/14/2014 at 2:03 PM a tour of the 4th floor in the Wishert building was started. There were gouges in the drywall between rooms #4143-4145. Finding confirmed with VP G.
Examples in the Luther area/tower:
A tour of the north and south tower, 4th floor, new building, was conducted on 1/14/2014 from 8:06 a.m. through 8:40 a.m. accompanied by Nurse Admin B. and Supv C. All empty rooms were inspected for integrity (4 on north side-41131, 41133, 41138, 41140; and 8 on the south side-41001, 41002, 41007, 41009, 41010, 41011, 41013, 41014). All of the rooms inspected had breaches in the integrity of the drywall exposing a porous surface, rendering the surface non-cleanable for microorganisms.

The following rooms also had a build up of dust and debris in the corners of the molding at the entrance to the bathrooms: 41131, 41133, 41001, 41007.

These findings were verified at the time of discovery by Nurse Admin B and Supv C.


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Examples in Laundry:

An interview with EVS Dir RR was conducted on 1/14/2014 at 11:00 a.m. regarding housekeeping and laundry services. This facility does their own laundry on site. Dir RR stated that the dryer is steam fed but the facility does not monitor the temperature. Dir RR states, "Staff monitors them so it doesn't get too hot."


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Examples in CCU:

Per tour of Critical Care Unit (CCU) on 1/13/14 at 2:00 PM the following was noted: patient room # 1505- ceiling tiles stained near venting area. The following empty rooms noted to have gouges in the dry wall included: #1511 and 1521. Nutritional Services room on top of ice machine had a layer of dust and water and ice spout area noted to have a white film. Patient room # 1521 had a vinyl recliner noted to have a rip on the arm of the chair.

Findings were shared with ADM L at time of tours.


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Examples in the Kitchen:

During a tour of the food receiving area on 4/14/14 at 12:30 PM, accompanied by VP Admin FFF and Regional Director Food Services GGG, noted large areas of missing and/or cracked tiles on the floor of the connecting corridor near the elevators of the receiving area, making the area non-washable. VP Admin FFF agree the tiles needed to be replaced at the time of discovery.

During a tour of the dry food storage area on 4/14/14 at 12:50 PM, accompanied by VP Admin FFF and Regional Dir Food Services GGG, noted dusty, disassembled metal shelving and railings, a black hose, and various other non-food items stored on the floor, in the corner of the dry food storage room. Regional Director GGG at the time of discovery stated they are old unused items from a kitchen remodel and agreed they should not be stored with the clean food supply.

During a tour of the kitchen on 4/14/14 at 1:30 PM accompanied by Regional Dir Food Services GGG, noted Cook HHH without a hair net/cap covering all hair. Regional Dir Food Services GGG stated at the time of discovery, all hair should be covered per policy.

Examples During Observation of Cares:
On 1/14/2014 at 11:40 AM RN N was observed collecting supplies from the Pyxis machine (a key coded medication despensing machine). RN N removed an IV line set from the cabinet and another line set fell on the floor. RN N picked up the extra line set and put it back in the Pyxis machine. VP G was present for the observation and agreed the dirty item should not have been put back into the clean cabinet.
An observation of respiratory care with Pt. #31 and RT SS was conducted on 1/14/2014 at 10:30 a.m. After completing a nebulizer treatment and respiratory assessment for Pt. #31, with the same gloves used to touch Pt. #31, RT SS used a sanitizing wipe to clean off the hand held scanner, thereby re-contaminating the scanner prior to glove removal.

RT SS also did not clean the stethoscope used during Pt. #31's assessment upon starting or completion of cares and left Pt. #31's room with the stethoscope around SS's neck.

In an interview with IP QQ on 1/14/2014 at 1:10 p.m., regarding the policy and expectation of stethoscopes after patient use and throughout the facility in non-patient care areas, QQ stated that there is no policy on how often the stethoscopes should be cleaned but the expectation is to clean them before leaving the room/between patients.

Per observation of a PICC line dressing change on 1/14/14 at 8:50 AM RN J assisting with dressing change by holding pt. # 32's hand and touching pt's arm, removed the glove from her left hand, put hand in pocket and removed supplies to hand to other RN. RN J then put a new glove on the left hand without the benefit of hand hygiene.

Findings were shared with ADM L on 1/14/13 at 4:00 PM.

Based on observation (Z), interviews (O, Z, MM, VV, XX, and YY), review of P&P and review of MRs, in 2 of 4 MRs requiring Anesthesia Services (23 and 24) the facility failed to ensure there is a complete Pre Anesthesia exam performed and documented, and there are complete Post Anesthesia evaluations performed and documented.

Findings include:

In 1 of 1 observation, the facility failed to ensure medical staff performed their duties per policy including a complete Pre-Anesthesia evaluation prior to surgery. See Tag 1003

In 2 of 4 MR requiring Anesthesia services, the facility failed to ensure there is a Post Anesthesia exam and note after a procedure, to ensure the Pt fully recovered from the anesthesia. See Tag 1005.

The cumulative effect of these deficiencies potentially affect all Pts receiving Anesthesia Services at the facility.

Based on observation, MR review, review of P&P and interview with staff (O and Z), in 1 of 1 observation (Z), the facility failed to ensure medical staff performed their duties per policy including a complete Pre-Anesthesia evaluation prior to surgery.

Findings include:

Per review on 1/15/14 in the PM of facility policy titled Basic Standards for Preanesthetic Care, dated 1/04, it states under 2. "Interviewing and examining the patient to: a. Discuss the medical history, previous anesthetic experienced and drug therapy. b. Assess those aspects of the physical condition that might affect decisions regarding perioperative risk and management...The responsible anesthesiologist shall verify that the above has been properly performed and documented in the patient's record."

On 1/14/14 between 9:25 AM and 9:37 AM Anesth Z was observed visiting Pt #23, the Pre-op unit, for a Pre-Anesthesia evaluation prior to surgery. Anesth Z did not perform lung or heart tone assessment, or look in Pt #23's mouth, or have the Pt move their head. After seeing Pt #23, Anesth Z was observed documenting in the MR. Review of the MR on 1/14/14 at 9:37 AM Anesth Z documented on the Anesthesia Pre-op Physical Exam at 9:34 AM "Airway-Normal neck ROM (range of motion); Normal mouth opening...Oral-Normal teeth (Pt #has dentures)...Cardiovascular(CV)-Normal CV exam; Regular rate, rhythm...Pulmonary-Lungs clear to auscultation."

Per telephone interview with Anesth Z on 1/15/14 at 11:20 AM confirmed there was no heart or lung sound assessment performed in PACU and could not remember if he looked in Pt #23's mouth. Anesth Z confirmed the documentation was done without the exam. NA O was present during the telephone interview, and observation, and confirmed the findings, agreeing Anesth Z did not perform the physical exam and did document the exam as complete.

Based on MR review, review of P&P and interviews with staff (O, Z, MM, TT, VV, XX, YY) in 3 of 4 MR requiring Anesthesia services (23, 24, 28) the facility failed to ensure there is a Post Anesthesia exam and note after a procedure, to ensure the Pt fully recovered from the anesthesia. This deficient practice has the potential to affect all Pts receiving anesthesia at this facility.

Findings include:

Per review on 1/15/14 in the PM of facility policy titled Standards for Post Anesthesia Care, dated 2/10, it states under Standard V "A physician is responsible for the discharge of the patient from the post anesthesia care unit."

Per review on 1/15/14 in the PM of facility policy titled Documentation of Anesthesia Care, dated 2/10, it states under III. A. "Patient evaluation on admission and discharge from the post anesthesia care unit."

Pt #23's MR review on 1/15/14 at 9:45 AM revealed Pt #23 had a knee stereoscopy (procedure to view and remove tissue) on 1/14/15. Pt #23 was discharged from the OR to PACU at 1:11 PM. The Anesth Post-op Evaluation is timed 1:16 PM and states "Awake and alert. No complication, Cardiovascular function stable including Pulse, BP (Blood pressure), Temperature, Respiratory function stable rate. Airway patency, O2 (oxygen) Saturation, Pain control, nausea/vomiting assessed and treated. Post procedure hydration adequate. Return of neurologic function for inpatients receive regional.." This note does not constitute a complete Post Anesth Evaluation including actual value of Pulse, BP, Respiration, and O2 Saturation, if airway is patent, pain level and if there was nausea or vomiting. The timing of the post note does not allow for post anesthesia complications. There are no other notes indicating whether Anesth Z or MD FF saw Pt #23 after being moved to PACU and prior to discharge to home. This is confirmed in interview with RN YY and RNIS VV on 1/15/14 at 9:45 AM, agreeing the note does not have values and an MD and Anesth should see the Pt prior to discharge.

Per telephone interview with Anesth Z on 1/15/14 at 11:20 AM confirmed there was no addition visit with Pt #23 after the note timed 1:16 PM. Anesth Z stated if they can speak and are responsive, they do not see Pt again unless called by PACU. NA O was present during the telephone interview.

Pt #24's MR review on 1/15/14 at 11:45 AM revealed Pt #24 received an epidural (medication injected in the spinal area) to relieve labor pain on 1/11/14 at 5:47 PM. There is no Post Anesth note. The Post-Anesthesia Note: on the back of the Pre-Anesthetic History & Evaluation form has a check box for Stable or Other and does not indicate actual values required for Pulse, BP, Respiration, and O2 Saturation, if airway is patent, pain level and if there was nausea or vomiting. The timing of the post note does not allow for post anesthesia complications. There is no space to document removal of the epidural catheter and if the tip was intact upon removal. This is confirmed during MR review with RN XX and ND MM on 1/15/14 at 11:45 AM, agreeing an Anesth should see the Pt after an epidural.



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A MR review was conducted on Pt. #28's closed MR on 1/15/2014 at 8:56 a.m. accompanied by RN TT who confirmed the findings. Pt. #28 had hip surgery on 10/3/13. The post anesthesia evaluation indicates the vital signs are stable and does not list what they are.