HospitalInspections.org

Based on medical record reviews and staff interviews, the facility failed to ensure that physician orders were dated, timed, and authenticated for 10 of 33 patients sampled (Patients #2, 5, 8, 9, 16, 21, 22, 23, 25, 31)
Findings include:
The hospital's policy on "Medical records, Documentation requirements" dated 11/1/2009 states; "Each entry in medical records shall be dated, timed and authenticated by the person responsible for the entry."
Per medical record review of Patient #2 by Surveyor #05409 from 2:36 p.m. to 3:25 p.m. on 2/8/10, the following was noted: authentication was lacking from telephone orders written on the following dates: 8:15 p.m. order on 2/4/10; 6:00 a.m. order on 2/5/10; 2:55 p.m. order on 2/5/10; and 6:45 a.m. order on 2/6/10. The 4 page written orders for admission on 2/4/10 were not timed when authenticated.
These findings were verified per interview with Quality Manager " C " from 2:05 p.m. to 2:07 p.m. on 2/10/10.
Per medical record review of Patient #5 by Surveyor #05409 from 12:50 p.m. to 12:53 p.m. on 2/9/10: The verbal order at 11:30 a.m. on 2/4/10 was not authenticated. The verbal order written at 8:42 a.m. on 2/5/10 was not dated or timed when it was authenticated. A written order on 2/6/10 was not timed. A telephone order written at 3:15 p.m. on 2/6/10 was authenticated on 2/7/10, but time when authenticated was lacking.
The findings were verified per interview with Quality Manager " C " from 2:00 p.m. to 2:02 p.m. on 2/10/10.
Per medical record review of Patient #9 by Surveyor #05409 from 12:55 p.m. to 1:25 p.m. on 2/9/10, the following was noted:
Verbal orders written at 2:00 p.m. on 1/31/10, at 10:30 a.m. on 2/1/10,at 8:30 a.m. on 2/4/10, and at 3:30 p.m. on 2/5/10 were not authenticated. Two written orders on 2/4/10 were not timed when authenticated. A telephone order written at 9:05 a.m. on 2/5/09 was not authenticated.
These findings were verified per interview with Quality Manager " C " from 1:07 p.m. to 1:15 p.m. on 2/10/10.
Per medical record review of Patient #16 by Surveyor #05409 from 8:30 a.m. to 9:22 a.m. on 2/10/10, the verbal telephone orders on the following dates were not authenticated: An, order written at 6:40 p.m. on 2/2/10, an order written at 9:45 p.m. on 2/4/10, and an order written at 10:15 p.m. on 2/4/10.
These findings were verified per interview with Quality Manager " C " from 2:07 p.m. to 2:10 p.m. on 2/10/10.
Per medical record review of Patient #21 by Surveyor #05409 from 10:58 a.m. to 11:15 a.m. on 2/10/10, the following was noted: Orders on the following dates were stamped rather than signed by the physician and no date or time was documented when stamped: emergency room orders prior to admission on 1/15/10, two verbal orders at 5:30 p.m. on 1/15/10, verbal orders written at 4:30 p.m. and 5:55 p.m. on 1/16/10, a telephone order written at 6:28 a.m. on 1/17/10. An order written by a physician on 1/16/10 was not timed when authenticated.
These findings were verified per interview with Optimization Specialist " E " from 11:00 a.m. to 11:05 a.m. on 2/10/10.
Per medical record review of Patient #25 by Surveyor #05409 from 2:10 p.m. to 3:10 p.m. on 2/9/10 Telephone orders written on the following dates lacked the time and date the orders were authenticated: 3:15 p.m. on 11/25/09; 3:20 a.m., 4:30 a.m., and 5:20 a.m. on 11/26/09. Times were lacking for when admission orders were written on 2/24/09 were authenticated.
These findings were verified per interview with Optimization Specialist " F " at 4:00 p.m. on 2/9/10.
Review of Patient (Pt.) #31 ' s medical record on 2/10/10 at 1:50 PM by Surveyor #27383 revealed that telephone orders taken by a Registered Nurse on 1/27/10 at 1330 and 1/27/10 at 2:06PM were signed by the physician but not dated or timed.
On 2/10/10 at 3:45 PM Surveyor #27383 reviewed with Program Coordinator A, Quality Manager B, and Quality Manager C the findings in the medical record of Pt. #31. Coordinator A, Quality Manager B, and Quality Manager C acknowledged the need for physician orders to be signed (authenticated), dated and timed

The review of the following records by surveyor #20878 on 02/09 and 02/10/10 indicated deficiencies in dating and timing of orders;

Pt. #8's record contained an order from 02/06/10 which was not timed by the physician. A verbal order written by a nurse on 02/03 was not co-signed by the physician. An order written by a physician on 02/03/10 was not timed.

Pt. #22's record contained two orders written by a physician which were neither dated or timed and were taken off by nurses on 01/22/10.

Pt. #23's record contained an order written on 12/4 which was not timed by the physician. The co-signature on a telephone order written 12/2/09 was not timed or dated. Orders written on 12/1/09 were not timed.

These findings were confirmed per interview with Program coordinator A at 3:00 PM on 02/10/10.

Based on medical record reviews and staff interviews, all verbal orders were not authenticated within 48 hours for 5 of 33 patients sampled (Patients #1, #2, #5, #16 and #21).
Findings include:
Hospital policy #521 states; "Verbal orders of authorized individuals are transcribed by qualified personnel. The ordering practitioner must authenticate (verify, sign, date and time) the order within the time frame defined by State of Wisconsin regulations (within 48 hours)."
Per medical record review of Patient #2 by Surveyor #05409 from 2:36 p.m. to 3:25 p.m. on 2/8/10, the following was noted: authentication was lacking from verbal telephone orders written on the following dates: 8:15 p.m. order on 2/4/10; 6:00 a.m. order on 2/5/10; 2:55 p.m. order on 2/5/10; and 6:45 a.m. order on 2/6/10.
These findings were verified per interview with Quality Manager " C " from 2:05 p.m. to 2:07 p.m. on 2/10/10.
Per medical record review of Patient #5 by Surveyor #05409 from 12:50 p.m. to 12:53 p.m. on 2/9/10: The verbal order at 11:30 a.m. on 2/4/10 was not authenticated.
The findings were verified per interview with Quality Manager " C " from 2:00 p.m. to 2:02 p.m. on 2/10/10.
Per medical record review of Patient #9 by Surveyor #05409 from 12:55 p.m. to 1:25 p.m. on 2/9/10, the following was noted: Verbal orders written at 2:00 p.m. on 1/31/10, at 10:30 a.m. on 2/1/10, at 8:30 a.m. on 2/4/10, and at 3:30 p.m. on 2/5/10 were not authenticated. A verbal telephone order written at 9:05 a.m. on 2/5/09 was not authenticated.
These findings were verified per interview with Quality Manager " C " from 1:07 p.m. to 1:15 p.m. on 2/10/10.
Per medical record review of Patient #16 by Surveyor #05409 from 8:30 a.m. to 9:22 a.m. on 2/10/10, the verbal telephone orders on the following dates were not authenticated: An, order written at 6:40 p.m. on 2/2/10, an order written at 9:45 p.m. on 2/4/10, and an order written at 10:15 p.m. on 2/4/10.
These findings were verified per interview with Quality Manager " C " from 2:07 p.m. to 2:10 p.m. on 2/10/10.
Per medical record review of Patient #21 by Surveyor #05409 from 10:58 a.m. to 11:15 a.m. on 2/10/10, the following was noted: Orders on the following dates were stamped rather than signed by the physician: Two verbal orders at 5:30 p.m. on 1/15/10, verbal orders written at 4:30 p.m. and 5:55 p.m. on 1/16/10, a verbal telephone order written at 6:28 a.m. on 1/17/10.
Per review of pt.#1's medical record on 02/10/2010 by surveyor #20878 there were two verbal orders written by the nurse on 02/06/2010 which were not co-signed by the physician.

Based on observation, staff interview and review of maintenance records between 2/9-2/12/2010, the facility failed to construct, install, and maintain the building system due to (i) failure to maintain a 2-hr fire-rated occupancy separation between the hospital and Medical Office Building; (ii) two open spaces not separated from corridors, nor provided with smoke detector coverage; (iii) lack of automatic flush bolts in the double leaf corridor doors; (iv) two doors in hazardous areas mechanically held open; (v) one smoke barrier not extended to the roof deck above; (vi) failure of one fire-rated smoke barrier door to fully close; (vii) failure to protect openings in four hazardous areas with properly functioning doors; (viii) one non-latching fire-rated door in one hazardous area; (ix) failure of one fire-rated door to fully close and latch in an exit passageway on the 1st Floor; (x) failure to maintain one exit access to exits readily accessible and lack of required headroom in the Medical Records Room and adjacent corridor; (xi) one Mechanical Room not protected with sprinkler heads of ordinary temperature rating required for light-hazard occupancy; (xii) failure to maintain a minimum of 18 inch vertical clearance below the sprinkler deflectors and above the top of storage; (xiii) lack of a floor drain in an emergency shower located in the Laboratory; (xiv) failure to identify emergency electrical wall outlets in two locations in the ICU Suite, and maintain working clearance in front of electrical switches in one location; and (xv) dirty exhaust grilles in the Sterile Processing Room and deposit of lint with possible dirt in the gap around the thru-the-wall Washer and opening on the Sterile Processing side of the Washer, and failure to maintain negative pressure in a soiled utility room on the 3rd Floor 1963 Center building.

The cumulative effect of these environment problems resulted in the hospital's inability to ensure a safe environment for the patients.

Refer to K-tags K-11, K-17, K-18, K-21, K-25, K-27, K-29, K-30, K-33, K-38, K-56, K-62, K-76, K-134, K-147, and tag A-726 for detail.

Based on observation, staff interview and review of maintenance records, the facility failed to ensure 'life safety from fire' to patients.

Findings include

1. Failed to protect the life safety of patients from fire due to failure to maintain a 2-hr fire-rated occupancy separation between the hospital and Medical Office Building;
2. Failed to protect the life safety of patients from fire due to two open spaces not separated from corridors, nor provided with smoke detector coverage;
3. Failed to protect the life safety of patients from fire due to lack of automatic flush bolts in the double leaf corridor doors;
4. Failed to protect the life safety of patients from fire due to two doors in hazardous areas mechanically held open; (v) one smoke barrier not extended to the roof deck above;

5. Failed to protect the life safety of patients from fire due to one smoke barrier not extended to the roof deck above;
6. Failed to protect the life safety of patients from fire due to one fire-rated smoke barrier door not closing fully to prevent smoke transfer from one smoke compartment into another;
7. Failed to protect the life safety of patients from fire due to failure to protect openings in four hazardous areas with properly functioning doors;
8. Failed to protect the life safety of patients from fire due to one non-latching fire-rated door in one hazardous area;
9. Failed to protect the life safety of patients from fire due to failure of one fire-rated door to fully close and latch in an exit passageway on the 1st Floor;
10. Failed to protect the life safety of patients from fire due to failure to maintain one exit access to exits readily accessible and lack of required headroom in the Medical Records Room and adjacent corridor;
11. Failed to protect the life safety of patients from fire due to one Mechanical Room not protected with sprinkler heads of ordinary temperature rating required for light-hazard occupancy;
12. Failed to protect the life safety of patients from fire due to failure to maintain a minimum of 18 inch vertical clearance below the sprinkler deflectors and above the top of storage;
13. Failed to protect the life safety of patients from fire due to lack of a floor drain in an emergency shower located in the Laboratory; and
14. Failed to protect the life safety of patients from fire due to failure to identify emergency electrical wall outlets in two locations in the ICU Suite, and maintain working clearance in front of electrical switches in one location.

Refer to K-tags K-11, K-17, K-18, K-21, K-25, K-27, K-29, K-30, K-33, K-38, K-56, K-62, K-76, K-134, K-147 for detail.

Based on observation and interview, the facility failed to (i) maintain exhaust grilles clean in the Sterile Processing Room; (ii) maintain negative pressure in one soiled utility room in patient sleeping/use area; and (iii) install air filter of 90% or more filtration efficiency in one patient treatment area in accordance with the recommendations in CDC and the American Institute of Architects (AIA) guidelines. This had a potential of affecting indeterminable number of patients.

Findings include

During a tour of the facility with Staff C (facility management supervisor), Staff D (security supervisor), and Staff E (environmental safety officer) between 2/9 and 2/12/2010, Surveyor 12316 observed spaces in the following locations that did not either have properly maintained exhaust system, or adequate negative pressure, or HVAC units with proper filtration efficiency.

1. 1st Floor: On 2/9/2010 at 3:12 pm, the Sterile Processing Room in the Surgery Department had three exhaust grilles dirty, and an accumulation of lint with possible dirt was observed along the small gap around the thru-the-wall Washer Unit in the Sterile Processing Room;
2. 3rd Floor: On 2/11/2010 at 1:45 pm, the Soiled Utility room on the 3rd Floor 1963/69 building did not have negative pressure in relation to the corridor as recommended by CDC and AIA guidelines. The airflow was not in the right direction i.e. from adjacent corridors into the Soiled Utility room; and
3. 2nd Floor: On 2/11/2010 at 2:30 pm, the ceiling plenum return air from the Nuclear Medicine and Pulmonary Suite in the 1948 building was not properly treated with a primary air filter of at least 90% filtration efficiency by the HVAC units serving these spaces before recirculation as recommended by AIA guidelines.

The above deficient practice had a potential of contaminating air in clean spaces with undesirable contaminants, and causing possible infection.

The above deficiency was acknowledged by the facility management supervisor, security supervisor, and environmental safety officer at the time of discovery, and confirmed with the facility management manager, Staff A (quality manager) and Staff F (compliance coordinator) at the exit conference on 2/12/2010 at 4:15 pm.

Based on observations and interviews, the facility failed to follow CDC guidelines regarding proper infection control techniques for 3 of 4 patient observations (Patients #27, 32, and 33)
Findings include:
Per observation of RN " G " providing a dressing change to Patient #33 from 8:40 a.m. to 8:55 a.m. on 2/10/10, the following was noted: RN " G " removed the soiled dressing from #33 ' s hip, doffed her gloves, pushed the control on the bed to raise the bed and then donned a new pair of gloves without cleansing her hands.
During the daily exit interview with Program Coordinator " A " and Quality Managers " B " and " C " , the observation was discussed and " C " verified that RN " G " should have cleansed her hands prior to donning a new pair of gloves after removing the soiled dressing as it is expected that staff follow CDC guidelines with glove changes.
Per observation of RN " H " from 8:55 a.m. to 9:00 a.m. on 2/10/10, the following was noted: RN " H " with gloved hands, administered eye drops into the eyes of Patient #32, put the drops back into the medication drawer began putting medications into cup, used a mouse and key board with soiled gloves, then doffed the gloves. RN " H " donned new gloves, applied a nitro patch to #32 ' s Right arm, then doffed gloves without cleansing her hands and logged out of the computer.
During the daily exit interview with Program Director " A " and Quality managers " B " and " C " , " A " , " B " , and " C " agreed that RN " H " did not follow CDC guidelines for cleansing hands between glove changes and use of the computer.

On 2/9/10 (8:40 am - 12:10 PM) Surveyor #27383 observed a Laparoscopic Hysterectomy performed on Patient (Pt.) #27 in the surgical department. Surveyor #27383 observed (8:40 am -9:20) the surgical preparation of Pt. #27 including intubation, positioning of Pt. #27 in stirrups, draping of the patient, and the abdominal preparation (wash) with Betadine. At this time, Surveyor #27383 observed a surgical staff member pick up a blue cloth/pad, which had fallen to the floor with positioning of the patient, and place it under Pt. #27 ' s right hand.

On 2/10/10 at 3:45 PM Surveyor #27383 reviewed the above observation with Program Coordinator A, Quality Manager B, and Quality Manager C. The observation was acknowledged by Coordinator A, Quality Manager B, and Quality Manager C.