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Based on medical record review and interview the facility failed to provide patients with the second copy of the "Important Message from Medicare" (IMM), prior to discharge for 6 of 6 patients (#19, 21, 24, 30, 36, 42), which could potentially deny patients of the information necessary to exercise their rights. Findings include:

A review of the medical records on 05/01/2013 between 4:00-6:00 PM revealed the following:

Patient #19 was admitted on 11/24/2012 and was an inpatient for three days. The initial IMM was signed by the patient's wife at the time of admission. The medical record did not contain an additional copy of the IMM at the time of the patient's discharge.

Patient #21 was admitted on 11/29/2012 and was an inpatient for five days. The medical record did not contain an additional copy of the IMM at the time of the patient's discharge.

Patient #24 was admitted on 02/13/2013 and was an inpatient for 16 days. The medical record did not contain an additional copy of the IMM at the time of the patient's discharge.

Patient #30 was admitted on 02/23/2013 and was an inpatient for six days. The medical record did not contain an additional copy of the IMM at the time of the patient's discharge.

Patient #36 was admitted on 04/16/2013 and was an inpatient for three days. The medical record did not contain an additional copy of the IMM at the time of the patient's discharge.

Patient #42 was admitted on 03/25/2013 and was an inpatient for 23 days. The medical record did not contain an additional copy of the IMM at the time of the patient's discharge.

On 05/02/2013 at 1045 AM, during an interview with staff S (Director of Admitting), she stated "We do not give patient's a second copy of the IMM. We have them initial the first copy every couple of days and sometimes everyday, but the patients are not given a second copy."

A request was made during the interview for a copy of the policy in regards to the facility processes' and who's responsibility it was for completing the IMMs. Staff S at 12:00 PM stated that she "was unable to locate a policy/procedure for the IMM in their system." At the time of exit (1:00 PM) from the facility, no facility staff members were able to produce a policy/procedure outlining processes for completing the IMM.

Based on Quality Assessment and Performance Improvement (QAPI) document review and interview, the facility's governing body failed to ensure that the QAPI program involves all hospital departments. Findings include:
On 5/1/13 at approximately 1330 during review of the previous three months of QAPI meeting minutes revealed that there was no QAPI project or reporting being completed by the dietary department or the infusion clinic.
On 4/30/13 at approximately 1415 during an interview with staff D and E when asked what the current QAPI projects are within the dietary department the reply by staff E was, "None".
On 4/30/13 at approximately 1550 during an interview with staff F when asked what the current QAPI projects were being conducted in the infusion clinic at the time of survey, the reply was, "I don't know".

Based on records review, and interview the facility failed to have a system in place to ensure that all practitioners appointed to the medical staff/granted medical staff privileges were reappraised at least every 24 months to determine if the practitioners privileges should be continued, discontinued, revised or otherwise changed in one (Staff U) of 15 medical staff reviewed. This failure resulted in the potential to have medical staff/practitioners practicing outside their scope of practice or privileges for all patients admitted to this facility.

Findings include:

On 5/1/13 at approximately 4:00 PM during the review of medical staff credentialing records, the record for Staff U, a nurse midwife was not current. Her appointment letter was dated 2/9/11 and stated "appointment will begin 2/4/11 and will expire 2/4/13" No documentation was found requesting reappointment or granting continued privileges. Staff T stated "There is no current document, the reappointment was totally missed, there is no system to trigger a reminder to reappraise all practitioners."

Based on document review, interview and review of the medical staff bylaws, the facility failed to ensure that all patient medical records were completed within 30 days of discharge of the patient. Findings include:

On 05/01/13 at approximately 11:00 AM, during an interview with the Director of Health Information and review of documentation provided by her, it was determined that the facility had 64 medical records that had remained open, greater than 30 days post discharge, requiring completion by the physicians.

On 05/01/13 at 1:00 PM, during review of the "Chippewa County War Memorial Hospital Medical Staff Rules and Regulations", dated January 13, 2012 on page three it stated in section "C. MEDICAL RECORDS
The attending physician shall be held responsible for the preparation of the complete medical record for each patient. This record shall include but not be limited to identification data complaint, a complete History and Physical (H&P) per Medical Records standard format, accepted by the Medical Staff, consultation(s), laboratory and diagnostic studies, special reports, provisional diagnosis, condition on discharge, follow-up and autopsy report when appropriate. Abbreviations on the 'DO NOT USE' list shall not be used in the medical record. The final diagnosis shall be entered on the face sheet without abbreviations or symbols. No medical record shall be filed until it is complete, except on order of the Medical Executive Committee. The Medical Record shall be completed in all respects within 30 days following discharge. "

Based on observation, record review, staff interview, and policy review, the facility failed to provide proper storage for refrigerated medications in three of three medication refrigerators observed, resulting in the potential for ineffective vaccines and medications. The failure to provide proper storage for refrigerated vaccines and medications has the potential to impact all patients admitted to this hospital who require vaccines or medications that require refrigeration. Findings include:

On 4/30/13 at approximately 11:45 am, during a tour of the Obstetrical Birthing unit (OB) the document titled "Quarterly Refrigerator Log" located at the nursing desk was reviewed. The documented temperature was found to be out of the stated range of "34 degrees F-41 degrees F" on 13 of 30 days (1,3,4,5,6,7,8,10,13,22,23,27,& 28) in April. On three (3,23, & 28) of the 13 days, there is documented corrective action but no recheck of the temperature level after adjustment was documented. On six (1,4,5,6,10, & 27) of the 13 days there was documented corrective action with a single recheck that remained out of range with no further corrective action documented.

Staff R, (OB director) was interviewed and stated "the staff is expected to check the temperature of the refrigerator, adjust the temperature and recheck the temperature and document follow up. We just wrote a new policy 4/23/13 for Vaccine storage"

Review of the policy titled "Refrigeration Temperatures" dated March 2006 states "#4) If the unit is out of temperature range, adjust the thermostat in the appropriate direction and recheck in one hour; 5) If you adjust the thermostat place a note prominently on the unit telling how many degrees and up or down; 6) If adjusting the thermostat does not correct the situation, empty the refrigerator of all medications and alert the maintenance department; and 7) In emergencies, the lab has refrigerators that may be used for either refrigerated or frozen medications.



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On 04/30/2013 at 11:00 AM during observation of the Intensive Care Unit (ICU) with staff O (Director of ICU), it was noted that the medication refrigerator log contained several temperatures that were out of the identified range for storing medications. The document titled "Quarterly Refrigerator Log" contained documentation for the full 30 days of the month of April. The documentation refers to the "Refrigerator Temperature Range 34 degrees F - 41 degrees F/ 1 degree C - 5 degrees C." For the week of April 24 th through April 30 th, the recorded temperatures in Farenheit were between 41.3 to 60.7. The document contains a column for "Corrective action (who notified and how or what action taken)". Of the 7 days of recording the temperatures, only one day, the 25 th showed a second recording (41 degrees) of the temperature within the above stated range.

At the time of the observation with the Director of ICU, when queried about the temperature log and the out of range temperatures she stated "it is because we have this little suction cup thing that attaches to the side of the refrigerator and it falls off and falls down and then the reading is not accurate." When asked about rechecking the temperature if it is out of range or contacting pharmacy or maintenance to get something done to fix the issue, Staff O replied "they are supposed to recheck the temperature, if it is still out of range, they should put in a work order for maintenance to check the refrigerator."

On 04/30/2013 at 3:00 PM a review of the pharmacy department with staff L (Director of Pharmacy), revealed a medication refrigerator temperature log for the month of April with the last seven days of the month's documentation showing temperatures out of the specified ranges for four of the seven days, with only one of the four days showing a re-check of the out of range temperature.

When queried about ensuring that medications are stored safely she stated "I guess we are going to need to look at these closer and maybe change our practice. We need to look at something different for the refrigerators on the units if they are having problems with the thermometers." She also stated "staff are supposed to recheck the temperature, if it is out of range and notify maintenance if it is incorrect, after turning it up or down."

A request was made on 05/02/1013 at 10:00 AM to staff A (Director of Quality) for a policy regarding the monitoring of medication refrigerator temperatures, who checks them, when checked and what to do if out of range. At the time of exit on 05/02/2013 at 1:00 PM a policy was produced that read "Department: Pharmacy, Subject Refrigerator/Freezer Temperature Monitoring" with a written and approval date of 05/01/2013. Request was made at this time for the old policy that would have been in effect for the month of April. Staff A stated "That is all that we have."

Based on observation and interview, the facility failed to provide and maintain a safe environment for patients and staff. This is evidenced by the Life Safety Code deficiencies identified. See K-tags for results.

Based upon observation the facility failed to maintain the hospital environment to ensure the safety of patients.

Findings include:
On 5/1/13 at approximately 10:30 AM, the flooring cove base was observed detached from the wall in OR # 15.
On 5/1/13 at approximately 10:55 AM a chemical dispensing system was observed directly connected, downstream from a built-in atmospheric vacuum breaker, to the mop sink faucet in the housekeeping room in the surgery department.
On 5/1/13 at approximately 10:50AM the scope washers in the central sterile department were observed with no backflow prevention devices on the water inlet lines.
On 5/1/13 at approximately 11:15 AM the Neptune fluid collection docking station was observed directly connected via a garden hose connection to the mop sink faucet in the soiled side of the central sterile department. There were no backflow prevention devices observed on the water connection.
On 5/1/13 at approximately 11:20 AM the 1-compartment prep sink in the kitchen was observed without an unobstructed air gap between the drain line and sewer.
On 5/1/13 at approximately 11:30 a broken atmospheric vacuum breaker cap was observed at the 2-compartment prep sink in the kitchen.

Based upon observation and interview the facility failed to provide a sanitary environment in patient care areas and to have a active program for the control of communicable diseases.

Findings include:
On 5/1/13 at approximately 8:50AM while touring the first floor hospital staff was asked about the airflow of the airborne infection isolation (AII) rooms. Staff M and Staff N were not sure if nursing staff or maintenance staff are responsible for monitoring the airflow in the AII room while in use. Staff N indicated that the mechanical monitor on the wall to the room is monitored by maintenance staff but not a visual check.
On 5/1/13 at approximately 9:10 AM, a room labeled as "soiled utility" in the OB department was being used as storage for housekeeping supplies and formula and breastfeeding take-home bags for new mothers. These bags contain infant formula and an ice pack to be used with breastmilk, respectively. These bags were observed stored adjacent to cleaning chemicals and supplies.
On 5/1/13 at approximately 1:30 PM based upon observation it was discovered that there are clean supplies and patient single-use cups stored below bulk containers of soap.

Based on document review and interview, the facility failed to disclose it's financial interest in the Long Term Care facility when presenting patients and/or the patient's family with choices for post hospital care. Findings include:

On 05/01/2013 at 10:00 AM, during interview with staff I (Social Worker) and staff J (Discharge Coordinator) a request was made for the list of Home Health Care Agency's, Nursing Home Facilities and Assisted Living Facilities that are given to patients and/or patients family members who require further medical care after discharge. A 2 page list was produced by staff J that contained all the facilities in the area including Community Services and Medical Equipment Providers. When asked if this was the list given to patients and/or the patient's family staff J replied "Yes." When queried as to if any of the facilities are owned by the hospital staff J replied "Yes, they own the long term care facility."When asked if the patient's are informed during discharge planning that the hospital has a financial interest in the facility staff J replied "We do not specifically inform them of that; I was not aware that we needed to tell them." When asked if financial disclosure was documented in the medical record staff J stated "No."

A review of the list presented of the available facilities did not contain a disclosure of financial interest statement on it. The list did contain the hospital's long term care facility.

Based on Operating Room (OR) log review and interview the facility failed to ensure that the OR log contained the required information. Findings include:
On 5/1/13 at approximately 0900 during review of the OR log for the previous six months it was found that the OR log didn't contain the Registered Nurse name, Pre/Post operative diagnosis or age of the patient.
On 5/1/13 at approximately 1000 during an interview with staff P, it was confirmed that the logs needed to have the above mentioned information added.