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405 STAGELINE ROAD

HUDSON, WI 54016

No Description Available

Tag No.: C0220

Based on tour of the facility with several of the facility staff between August 4th to August 5th, 2014; this surveyor observed that the hospital failed to be constructed, arranged, or maintained to ensure the safety of the patients. The cumulative effects of these environmental problems resulted in the hospital's inability to ensure a safe environment for the patients in 7 of 7 smoke compartments. The Existing Health Care Occupancy chapter of the Life Safety Code (2000 Edition) [NFPA 101] was used for this survey.

The facility was found to contain the following deficiencies:
K-18: Corridor doors smoke-tight
K-27: Smoke barrier openings smoke-tight
K-29: Hazardous areas built as one-hour
K-50: Fire Drills conducted randomly
K-51: Fire alarm system installed per NFPA 72
K-56: Sprinkler system installed per NFPA 13
K-130: Miscellaneous items
K-144: Generator transfer time records
K-147: Electrical system installed per NFPA 70

These deficient practices were confirmed by observation and interview with Staff E (Facilities Director), Staff D (Infection Control Director) at the time of discovery.

Refer to the the full description at the cited K tags.

No Description Available

Tag No.: C0231

Based on tour of the facility with several of the facility staff between August 4th to August 5th, 2014; this surveyor observed that the hospital failed to be constructed, arranged, or maintained to ensure the safety of the patients. The cumulative effects of these environmental problems resulted in the hospital's inability to ensure a safe environment for the patients in 7 of 7 smoke compartments. The Existing Health Care Occupancy chapter of the Life Safety Code (2000 Edition) [NFPA 101] was used for this survey.

The facility was found to contain the following deficiencies:
K-18: Corridor doors smoke-tight
K-27: Smoke barrier openings smoke-tight
K-29: Hazardous areas built as one-hour
K-50: Fire Drills conducted randomly
K-51: Fire alarm system installed per NFPA 72
K-56: Sprinkler system installed per NFPA 13
K-130: Miscellaneous items
K-144: Generator transfer time records
K-147: Electrical system installed per NFPA 70

These deficient practices were confirmed by observation and interview with Staff E (Facilities Director), Staff D (Infection Control Director) at the time of discovery.

Refer to the the full description at the cited K tags.

No Description Available

Tag No.: C0276

29963

Based on observation and interview the facility failed to ensure that medications were secured properly in 1 of 8 areas (Emergency Department) where emergency carts were stored and 2 of 7 pt. care rooms (#1 and 2) in the Emergency Department. The facility failed to ensure medical supplies were monitored for expiration date in 2 of 8 areas observed (medical/surgical area and Specialty Clinic). This deficiency potentially affects all patients and visitors at this facility.

Findings include:

Per review of facility policy on 8/5/14 at 12:00 PM, titled Crash Cart Maintenance, policy #0303.06, dated 4/5/11, the policy stated in part, "12. Monthly inventory of crash carts is done on the first Monday of each month... 13. All supplies that have expiration dates are checked with monthly inventory."
On 8/4/14 at 4:15 PM noted an emergency cart containing medications stored in patient treatment room #1. This emergency cart has a breakaway lock. Patient treatment room #1 is located across from the nursing station, visible from nursing station but has a privacy curtain that could obstruct the view.

Per interview with Emergency Department Interim Manager (EDIM) R at time of observation, EDIM R stated the emergency carts are always in view of the staff to observe the integrity of the cart contents.

Per observation on 8/4/14 at 4:20 PM, a family member was sitting in Emergency Trauma room #2; the privacy curtain was preventing view of family member and emergency cart. At time of observation, EDIM R did agree that the emergency cart in room #2 was not in view of the staff and could potentially leave patients and visitors with unauthorized access to medications.

On 8/5/14 at 11:20 AM during a tour with Manager of Quality A of the Procedure Center, 6 tubes used to collect blood samples were found to be expired 7/14.

On 8/5/14 at 8:00 AM during a tour with Manager of Medical/Surgical U a set of pediatric Heart start pads were noted to be expired 7/14.

Per interview on 8/6 14 at 10: 50 am with Infection Preventionist (IP) D stated "staff is to discard supplies that are expired."

PATIENT CARE POLICIES

Tag No.: C0278

Based on observation, record review and interview the facility failed to ensure proper infection control practices were followed in 1 of 1 surgery observation, 1 of 1 high level disinfection observation and failed to ensure a sanitary environment to prevent potential cross contamination in 1 of 1 laundry storage room. This failure has the potential to affect all patients receiving services at this facility.


Findings include:

On 8-5-2014 at 2:15 pm a review of the P&P #302 titled Surgical Attire, approved 4/2002 was completed. The P&P states in part, "3. Hair covering is worn in the semi restricted and restricted areas. a. Hair covering covers all hair."

On 8-6-2014 at 8:00 am a review of P&P #0382.02 titled Peripheral Intravenous Therapy, effective 4-18-2008 was completed. The P&P states in part, "D. Scrub the hub 1. A friction scrub for 15 seconds to the needleless IV connector with alcohol or chlorhexadine/alcohol solution will be used to disinfect the surface prior to accessing the line to adminster medications".

On 8-5-2014 at 9:58 am CST V was observed in OR #2 setting up the sterile field for pt. #1's surgery. CST V's skull cap did not cover all of CST V's hair.

On 8-5-2014 at 10:29 am in OR #2 CRNA B was observed with pt. #1. CRNA B assisted with bringing pt. #1 into the room and positioning on the table. CRNA B was observed to remove two syringes out of scrub pocket and administer the medication into the IV line without cleaning the port. CRNA B administered another medication without cleaning the IV line port.
On 8-6-2014 at 8:12 am CST S was observed in the high level disinfection room processing a colonoscopy scope. CST S demonstrated how the combination cleaning brush is used and explained it is used approximately four times before disposed of. CST S also explained the brush goes into the Steris machine after use. Observation of the Olympus combination cleaning brush showed the product is single use only.



29963


Per observation on 8/5/14 at 1:45 PM with Manager of Housekeeping Q of clean laundry storage, noted 2 large plastic bags of dirty laundry located on the floor next to clean linen. Manager of Housekeeping Q confirmed that the bags of laundry were dirty and did not belong in the same room of the clean linen storage.
Per observation on 8/5/14 at 1:45 PM with Manager of Housekeeping Q of clean laundry storage, noted 6 racks of clean linen to be uncovered and at risk for potential cross contamination.
Per interview with IP D on 8/6/14 at 10:50 AM, IP D stated " mixing clean and dirty laundry is not usually done and is not allowed in this facility. "

No Description Available

Tag No.: C0279

Based on observation, record review and staff interview, the facility staff failed to wear hair nets appropriately in 3 of 5 staff (N, O, and P) observed working in the kitchen. This deficiency potentially affects all patients, staff and visitors who eat at this facility.

Findings include:

Per review of facility policy on 8/5/14 at 12:00 PM titled Dress Code, policy #786, dated 10/2/13, stated in part under " 3b. Certain work areas may require that hair be under a hair net, cap, or tied back from the face. "

Per observation on 8/5/14 at 8:50 PM of staff working in the dietary kitchen accompanied by RD N, noted the following staff were noted to have hair which was not covered by a net or cap, RD N, Cook O, and Dietary Supervisor P.

Per interview with IP D on 8/6/14 at 10:50 PM, IP D stated " staff working in the kitchen is expected to wear a hair net that covers all hair. "

No Description Available

Tag No.: C0302

Based on record review and interview, the facility staff failed to ensure patients receive effective pain management control in 1 of 7 inpatient (pt. #17) medical records reviewed out of a total sample of 20. This deficiency has the potential to affect all patients.



Findings include:

Per review on 8/6/14 at 10:00 AM of facility policy titled Pain Management, policy #0204.08, dated 7/29/14 stated in part under " II. A. Pain is reassessed at a minimum of every four hours and within an hour after any pain intervention. "

Per review on 8/6/14 at 8:30 AM with RN T of medical record for pt. # 17 revealed oxycodone (pain medication) being given on 8/6/14 at 06:48 AM and re-assessment of pain being completed at 8:01 AM.

On 8/5/14 at 05:44 AM pain medication was given and re-assessment of pain occurred at 08:55 AM.

On 8/4/14 at 11:35 PM pain medication was given and re-assessment of pain occurred at 05:44 AM.

On 8/2/14 at 4:51 PM pain medication was given and re-assessment of pain occurred at 8:26 PM. At 12:52 PM pain medication was given and re-assessment of pain was completed at 4:05 PM. At 03:04 AM pain medication was given and re-assessment of pain was completed at 04:55 AM.

On 8/1/14 at 08:13 AM pain medication was given and re-assessment of pain occurred at 2:05 PM. At 04:20 AM pain medication was given and re-assessment of pain was completed at 06:12 AM. At 12:41 AM pain medication was given and re-assessment of pain was completed at 04:20 AM.

On 8/1/14 at 11:42 PM Hydromorphone (pain medication) was given and re-assessment of pain occurred at 3:07 AM. On 8/1/14 at 06:12 AM pain medication was given and re-assessment of pain occurred at 08:12 AM.

On 7/31/14 at 10:59 PM pain medication was given and re-assessment of pain occurred at 12:41 AM. On 7/31/14 at 05:09 AM pain medication was given and re-assessment of pain occurred at 07:04 AM. On 7/30/14 at 9:13 PM pain medication was given and re-assessment of pain occurred at 10:40 PM.

Per interview with RN T on 8/6/14 at 10:00 AM, RN T stated " staff is expected to re-assess pain within 1 hour of the pain medication being given. "

PATIENT ACTIVITIES

Tag No.: C0385

Based on record review and interview the facility failed to provide activities to meet each patients interests and physical/mental well being for 1 of 2 (pt. #18) swing bed patients reviewed. This had the potential to effect all swing bed patients in the facility during the survey. 8-4-2014 = 3, 8-5-2014 = 4, and 8-7-2014 = 4.


Findings include:

On 8-6-2014 at 9:33 am a review of pt. #18's record was started. A swing bed activity assessment dated 7-30-2014 states in part under Goals - "to be able to spend at least 15 minutes outside per day while on swing bed weather permitting. To be engaged in a leisure activity at least 30 minutes of everyday in between medical cares while on swing bed." "Leisure Interest : Playing solitaire on the computer at home, mowing lawn and taking care of grass." The next swing bed activity note dated 8-5-2014 states in part, "Assessment: pt. has had lots of visits from nephew, nursing is helping pt. engage in leisure time by providing movies and videos to watch in room. Plan: continue movies or magazines." IP D reviewed the record and stated there was no additional documentation or update to the activity goal.

On 8-6-2014 at 10:35 am a interview with pt. #18 was conducted. Pt. #18 expressed happiness to be going home the next day. Pt. #18 was asked if going outside for 15 minutes a day and if spending at least 30 minutes a day on leisure activities. Pt. #18 explained has not gone outside at all and doesn't watch TV in room, "it's too small" or play solitaire on computer. Results of interview were shared with IP D, who stated, "I'm aware its a problem."

On 8-6-2014 at 10:41 am Director Rehab Services (DRS) W produced nursing documentation from the plan of care that stated in part, 8-2-2014 "patient up in chair majority of shift. Reports SOB with too much activity." 8-3-2014, "SOB with wheezes. Pt. has improved strength since admission."