HospitalInspections.org

Based on review of medical records (MR), review of policy and procedure and interview with staff, in 4 of 14 medicare eligible patient (Pt) records (#4, 22, 26 and 27) out of a total of 38 records, the facility failed to ensure the patients received their discharge appeal rights upon admission and discharge.

Findings include:

Facility policy titled Important Message from Medicare states "The IM (Important Message from Medicare About Your Rights Form) shall be delivered to inpatients within two calendar days of admission. The follow-up copy of the IM shall be delivered as far in advance as possible before discharge, but no more than two calendar days before the day of discharge."

Example by surveyor #13469:
Per MR review, on 1/6/10 at 9:15 AM, Pt #27 was admitted to the hospital on 11/15/09 and discharged on 12/1/09. The MR of Pt #27 contained a Medicare discharge appeal rights form dated 11/20/09. This Pt did not receive the notice within two days of admission and within two days of discharge.


18816

Examples by surveyor 18816:

Pt #22 MR reviewed by surveyor 18816 on 1/5/10 at 7:50 AM revealed he was admitted on 12/8/09 and discharged on 12/10/09. The MR does not include documentation the Medicare Discharge notice given upon admission or discharge. This is confirmed in interview with Director of Nursing (CNO) V on 1/7/09 at 8:30 AM.

Pt #26 MR reviewed by surveyor 18816 on 1/6/10 at 8:25 AM revealed he was admitted on 11/13/09 and discharged on 12/10/09. The Medicare Discharge notices were given 11/20/09, 11/23/09 and 12/2/09. This patient did not receive the notice within two days of admission and within two days of discharge. This is confirmed in interview with CNO V on 1/7/09 at 8:30 AM.


26711

Findings by Surveyor #26711:

A clinical record review of Pt #4's open Rehabilitation clinical record was completed on 1/5/2010 at 7:00 AM. Pt #4 was admitted to the Rehabilitation unit on 12/21/09. The Important Message from Medicare notice regarding discharge appeal rights was given to the patient and signed on 12/25/09. The Pt did not receive the notice within two days of admission. This finding was confirmed by Manager S and Director G during the clinical record review on 1/5/10 at 7:00 AM.

Based on tour and staff interview, this hospital failed to secure potentially harmful items and substances, allowing a potentially unsafe environment for patients.

Findings include:

Examples by surveyor 18816:
Per surveyor 18816 tour of the off site clinic at 1 Main St. Racine with Site Manager (M) MM on 1/6/09 at 1:00 PM, the environmental services closets containing cleaning chemicals and biohazard storage room were unsecured allowing access by patients and/or visitors.

Per surveyor 18816 tour of the off site Behavior Health units at 1320 Wisconsin Ave, Racine, with Clinical Manager DD, Vice President (VP) KK and Registered Nurse (RN) QQ on 1/6/09 at 2:00 PM, the door to the nurses station in the children's unit was propped open with a waste basket. The RN on duty (RR) was in a patient room across from the nursing station with her back to the door, a child from a room two doors down was unattended, and another sleeping on the couch was unattended allowing for access to potentially dangerous supplies, including sharp objects such as pens and an oxygen tank.

RN RR stated during the tour that she often props the door open so she can call for help if needed on the unit.

Continuing the tour to the adolescent unit, the nursing station was unattended and the door was propped open with a waste basket allowing access by four students that were in the hall.

The two nursing stations are connected with a report room, no staff was present in the report room.

Per VP KK, during the tour, the nursing station doors are to be left closed if no one is in the room.


26711

Examples by Surveyor #26711:

A tour of the facility was completed by surveyor 26711, Director (D) C, G, D E, Manager (M) D and M S on 1/4/10 between 2:00 PM and 2:45 PM, and it was noted that two kitchenettes in the Surgical Unit had unsecured chemical solutions under the sinks (One Step Disinfectant, Virex, and Good Sense Deodorizer) allowing access to patients and visitors.

Based on clinical record review, review of policy and procedure and staff interview, in 3 of 3 psychiatric records (Patients # 32, 33, and 34) out of a total of 38 records reviewed, the facility failed to develop both long and short term goals with the psychiatric treatment plans.

Findings include:

Facility policy titled Interdisciplinary Treatment Plan states under C. "Each problem to be addressed will be stated on the form along with short and long term goals and target dates. Interventions to achieve the goals are listed with the start date and persons responsible for the intervention..."

Record reviews for Patients #32, 33, and 34 were conducted by surveyor #26711 on 1/6/10 between 2:30 PM and 3:20 PM. Per review of the treatment plans there are no short and long term goals developed with the patients.

These findings were confirmed in interview with Director AA and Registered Nurse Educator BB on 1/6/10 at 3:20 PM.

Based on tour, observation, review of policy and procedures and interview with staff, the facility failed to ensure patient medical records (MR) were confidential and secured from unauthorized access.

Findings include:

Facility policy titled Uses & Disclosures of Health Information states under I. "Minimum Necessary: It is the policy of WFH (Wheaton Franciscan Healthcare) to protect the privacy of health information."

Example by surveyor #13469:
Per observation and interview, while touring the Cardiac Rehabilitation Department with Cardiac Rehabilitation Manager (RM) Q on 1/4/10 at 2:00 PM, surveyor 13469 noted department MR are kept in metal cabinets that are locked at the end of each business day. Per RM Q, the keys to the metal cabinets are then placed in an unsecured drawer next to the cabinets containing the MR. RM Q stated housekeeping, maintenance and security have access to the department after business hours.


26390


On 1/6/10 in the PM surveyor 26390 tour of the Sleep Medicine Center with Vice President B, Coordinator for Sleep Medicine Center (C) II, and Director of Respiratory FF, revealed the front desk is open to the back room that contains unsecured medical record file cabinets and 9 cardboard boxes of closed medical records.

Based on clinical record review, review of policy and procedures and staff interview, in 1 of 1 patients with ordered dressing changes (#4) out of a total of 38 records reviewed, the facility failed to ensure complete physician orders for dressing changes.

Findings include:

Facility Medical Staff By Laws under Medical Records states U. "All orders for treatment shall be in writing..."

A clinical record review was completed by surveyor 26711 on 1/5/10 at 7:30 AM on Patient (Pt) #4's open Rehabilitation record. Physician (MD) X's order, written on 12/21/09 states "daily dressing change R BK stump [right below the knee amputated leg]." This is an incomplete order with no indication from MD X as to the type of dressing change, confirmed by Director (D) G on 1/5/10 at 8:15 AM.

The transcribed computer orders, by a Health Unit Clerk (HUC) on 12/21/09 stated "Apply Meilax and a rigid stump protector to R BK stump". D G was unable to state where the HUC would have taken the direction for these orders as the MD did not write them.

In interview with MD X on 1/5/10 at 8:15 AM, he stated "When I write daily dressing changes and the area is a below the knee amputation, the dressing change is Meilax with a rigid stump protector, and that is what it will be."

Based on tour, review of policy and procedures and interview with staff, the facility failed to ensure all samples medications are controlled and monitored.

Findings include:

Facility policy titled WFMG (Wheaton Franciscan Medical Group): Prescribed and Over the Counter Sample Medications states under Control and Responsibility "...In addition, an approved mechanism is in place to separately track and balance the sample medications. The practitioner accepting the sample medication is responsible for monitoring, documenting required information, checking expiration dates, security, and control of samples...the Pharmacy Liaison is ultimately responsible for control and storage of sample medications throughout the facility, including facility-based clinics...The department or clinic manager, Pharmacy Liaison, or designee is responsible for the monthly review of the sample medication stock."

Per surveyor 18816 tour of the Women's Center Clinic with Site Manager (M) PP on 1/7/10 at 8:40 AM the sample medication log sheet for Angelica (estrogen replacement) listed a quantity of 20 boxes. The number of boxes in the sample medication room had 18, the log sheet did not have evidence who received the two boxes. This was confirmed during tour with M PP.

Based on tour, observation, review of policy and procedures and staff interview, this hospital failed to ensure medications are secure and not accessible to unauthorized staff, patients and visitors.

Findings include:

Facility policy titled Crash Cart states under B. Security 1. "The crash cart must be kept secured with a tamper evident device. 2. Crash cart tamper evident devices will be issued by the Pharmacy to re-secure the cart after each event or monthly checks." The policy does not address having the cart monitored at all times or secured in a locked area to prevent unauthorized access.

Example by surveyor #13469:
Per observation and interview, while touring the Cardiac Rehabilitation Department with Cardiac Rehabilitation Manager (RM) Q on 1/4/10 at 2:00 PM, it was noted that the crash cart located by a desk in the department is secured with a break-away lock. Per RM Q, the crash cart is not locked with a permanent locking device and secured from unauthorized access at the end of the business day. Per RM Q, housekeeping, maintenance and security have access to the department after business hours.


18816

Examples by surveyor 18816:

Per surveyor 18816 tour of the Post-partum Unit on 1/4/09 at 1:45 PM with Director J, Manager H and Clinical Nurse Specialist I the crash cart located in the corridor off to the side of the nursing station has a breakaway tag and is not always in view of staff.

Per surveyor 18816 tour of the Women's Center Clinic with Site Supervisor PP on 1/7/10 at 8:40 AM the following was observed:

Rooms 20, 21 and 22 had unsecured Sodium Chloride, Potassium Hydroxide, and Peroxide in cupboards, allowing for potential access to patients and/or visitors.

Rooms 6, 7, 8, 26 and 27 contained unsecured formalin and Paptest Prep (poisonous fixatives) allowing for potential access to patients and/or visitors.


26390

Example by surveyor 26390:

Per surveyor 26390 tour of the housekeeping and laundry areas on 1/6/10 in the PM with Vice President (VP) B, Housekeeping Manager (HM) GG and Director of Housekeeping (DHM) Z revealed two bulk storage rooms around the corner from the exit to the outdoor biohazard holding trailer. The bulk storage area that contains drugs and biologicals occupies two rooms adjacent to each other. Both are equipped with badge recognition, self closing mechanisms. When fully closed, the room closest to the exit door does not lock. HM GG confirmed the door leading to the outside is not locked during regular business hours and is not monitored for unauthorized persons entering the hospital. VP B confirmed the door is not operational.


26711

Examples by surveyor 26711:

During a tour of the Surgical floor (3rd floor, 3D) on 1/4/2010 at 2:15 PM with Director (D)E, the emergency cart was observed at the end of a hallway. Per D E it is possible that the emergency cart is unmonitored at times and unauthorized access by patients/visitors is possible. This cart was equipped with a breakaway lock making tampering possible.

During a tour of the Pediatric floor (3rd floor) on 1/4/2010 at 2:45 PM with D J, the emergency cart was observed behind the nurses station. Per D J it is possible that the emergency cart is unmonitored at times, if both nurses are in patient rooms, and unauthorized access by patients/visitors is possible. This cart was equipped with a breakaway lock making tampering possible.

During a tour of the Medical floor (2nd floor) on 1/5/2010 at 9:30 AM with D E, the emergency cart was observed at the end of the hallway. Per D E it is possible that the emergency cart is unmonitored at times, and unauthorized access by patients/visitors is possible. This cart was equipped with a breakaway lock making tampering possible.

During a tour of the Surgical floor (3rd floor) on 1/4/2010 at 2:30 PM with D G, surveyor observed a box of unsecured sodium chloride in small vials on the counter top at the entrance of room 376.

Based on tour, review of policy and procedures and interview with staff, the facility failed to ensure all medications are labeled and dated when open, discarded per policy, and stored to maintain effectiveness.

Findings include:

Facility policy titled Expiration Dating of Multi-Dose and Single-Dose Vials state under Multi-Dose Vials b. "When opened inside or outside of the Department of Pharmacy, they will have the date opened on the label and be initialed by the user. c. Multi-Dose vials may be used up to 28 days from the date of original use after which they must be discarded."

Facility policy titled Parenteral Therapy states under II.C "IV (intravenous) infusion solutions and medication syringes are clearly labeled with drug name, date and time of preparation, date and time of expiration if less than 24 hours, and warnings and precautions if indicated. 1. IV solution containers are changed every 24 hours if no other expirations dates are indicated."

Facility policy titled Refrigerator Maintenance and Monitoring states under L. "Cleaning and defrosting of all refrigerators and freezers is the responsibility of the department/unit/clinic in which they are located and used."

Examples by surveyor 18816:

Per surveyor 18816 tour of the Labor/Delivery Operating Rooms (L/DOR) on 1/4/09 at 1:45 PM with Clinical Nurse Supervisor H, there were two spiked Intravenous (IV) bags of Sodium Chloride set up for rapid infusion with a date of 1/8/10. There were no dates indicating when the bags were spiked, and no patient identifiers.

Per interview with Pharmacist OO on 1/7/10 at 9:40 AM he confirmed IV bags are not to be spiked for potential use, only for planned procedures, and then discarded after 24 hours.

The medication refrigerator in the L/DOR freezer door was frozen shut allowing for potential irregularities in temperature affecting the stability of the medications.

Per surveyor 18816 tour of the Women's Center Clinic with Site Supervisor PP on 1/7/10 at 8:40 AM the following was observed:

1) Exam room #8 cupboard had an unlabeled bottle of unidentified clear liquid with a date 1/3.

2) Exam rooms #20, 21, 22 and 27 cupboards had open undated bottles of peroxide.

3) Exam room #26 cupboard had an open undated bottle of alcohol.

4) Procedure room #1 cupboard had a bottle of Sodium Chloride open with no date.


26711

Example by surveyor 26711:

During a tour of the Surgical Area on 1/6/2010 at 9:00 AM with Director Y, surveyor observed two saline bags in the Anesthesia cart of Operating Room 3 which had "2/5",with no year indicated, written on the removable pull tab that protected the spike port.

Based on observation, staff interviews and review of maintenance records on January 4-13, 2010, the facility failed to construct, install and maintain the building systems to ensure a physical environment that was safe for patients and staff.

The facility was found to contain the following physical environment deficiencies. Refer to the full description at the cited K-tags:
1. Spring Street Main Hospital: K11, K12, K17, K18, K20, K25, K27, K29, K35, K38, K43, K47, K56, K62, K76, and K147.
2. St. Luke's Health Pavilion: K17, K18, K25, K29, K38, K43, K47, K62, and K147.
3. Cardiovascular Institute: K12, K17, K18, K25, K27, K29, K33, K47, K56, K62, K75, and K143.
4. Wisconsin Avenue Hospital: K11, K20, K27, K29, K33, K38, K45, K46, K56, and K62.
5. One Main Clinic: K130

The cumulative effects of the environment deficiencies result in the hospital's inability to ensure a safe environment for the patients and staff.

Based on observation and interview, staff interviews and review of maintenance records, the facility failed to maintain the condition of the physical plant and overall hospital environment in a manner to ensure the safety and well being of patients.

FINDINGS INCLUDE:
1.It was observed in the Spring Street main hospital in the 3A smoke compartment in the 3100-Corridor near patient room 305 that a portion of the flooring was damaged and in need of repair. This condition was observed in two locations, 1" square in area. This observed situation was not compliant with CFR 482.41(a). This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 1352 hours on Jan 4, 2010.

2. It was observed in the Spring Street main hospital in the LD smoke compartment in the 424-Communications Closet that the facility did not implement and follow a routine preventive maintenance and testing program, in accordance with Federal and State laws, regulations, and guidelines and manufacturer's recommendations; The communications closet was full of significant dust and debris on the floor, door frame and equipment rack. This observed situation was not compliant with CFR 482.41(a). This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 0835 hours on Jan 7, 2010.

3. It was observed in the Spring Street main hospital in the LD smoke compartment in the 624-Kitchen Middle Store Room that a portion of a wall was damaged and in need of repair. Three white fiberglass reinforced plastic panels were not securely anchored to the east wall so several 9' high vertical joints on were open and did not provide a washable surface in this food storage space. This observed situation was not compliant with CFR 482.41(a). This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 0912 hours on Jan 7, 2010.

4. It was observed in the St Lukes Health Pavilion in the 2Z smoke compartment in the E2406 Corridor that a portion of a wall was damaged and in need of repair. Vinyl wall covering was pealing from the wall near the window that was outside of Room E2268. This observed situation was not compliant with CFR 482.41(a). This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager), Staff XX (Womens and Childrens Clinical Mngr) at 1218 hours on Jan 7, 2010.

5.It was observed in the Spring Street main hospital in the 3A smoke compartment in the 3100-Corridor near patient room 305 that a portion of the flooring was damaged and in need of repair. This condition was observed in two locations, 1" square in area. This observed situation was not compliant with CFR 482.41(a). This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 1352 hours on Jan 4, 2010.

6. It was observed in the Spring Street main hospital in the LD smoke compartment in the 424-Communications Closet that the facility did not implement and follow a routine preventive maintenance and testing program, in accordance with Federal and State laws, regulations, and guidelines and manufacturer's recommendations; The communications closet was full of significant dust and debris on the floor, door frame and equipment rack. This observed situation was not compliant with CFR 482.41(a). This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 0835 hours on Jan 7, 2010.

7. It was observed in the Spring Street main hospital in the LD smoke compartment in the 624-Kitchen Middle Store Room that a portion of a wall was damaged and in need of repair. Three white fiberglass reinforced plastic panels were not securely anchored to the east wall so several 9' high vertical joints on were open and did not provide a washable surface in this food storage space. This observed situation was not compliant with CFR 482.41(a). This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 9:12 am on Jan 7, 2010.

8. It was observed in the St Lukes Health Pavilion in the 2Z smoke compartment in the E2406 Corridor that a portion of a wall was damaged and in need of repair. Vinyl wall covering was pealing from the wall near the window that was outside of Room E2268. This observed situation was not compliant with CFR 482.41(a). This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager), Staff XX (Womens and Childrens Clinical Mngr) at 12:18 pm on Jan 7, 2010.

Based on observation and MR (medical record) review, policy and procedure review, and interviews with facility staff, in 8 of 8 surgery MR reviewed (7, 10, 11, 13, 15, 19, 22 and 25) out of total of 38 MR reviewed, the hospital failed to ensure that surgical patients are protected from fire, and failed to construct, install and maintain the building systems to ensure the life safety protection of patients and staff from fire.
.

Findings Include:

Facility policy titled Procedural Site/Patient Skin Antisepsis effective October 2009 does not direct surgery staff to ensure that the alcohol based skin prep is dry during the time-out process or that this step is documented in the patient's MR.

The hospital policy does not include the following guidelines which became effective 1/12/07 per Medicare S&C memo 07-11: "D. Verifying that all of the above has occurred prior to initiating the surgical procedure. This can be done, for example, as part of the standardized pre-operative "time-out" used to verify other essential information to minimize the risk of medical errors during the procedure."

In addition, the facility failed to document the implementation of these policies and procedures in the patient's MR.

Per interview, with Surgery Nurse (RN) T on 1/5/10 at 2:00 PM by surveyor 13469, the surgery staff does ensure that the alcohol based skin preps are dry before draping. Per RN T it is not however part of the time-out nor is it documented in the intra-operative notes. Per RN T, the surgery department uses Dura-prep, and Betasept which are alcohol based skin preps.

Patient (Pt) #7's MR review by surveyor 13469 on 1/5/10 at 1:45 PM revealed he was admitted for surgery on 1/5/10. Per intra-operative note dated 1/5/10 Dura-prep was used as a skin prep. The intra-operative note does not identify if the staff ensured that this alcohol-based skin prep was dry during the time-out process. This was confirmed by RN T on 1/5/10 at 2:00 PM.

Pt #25's MR review by surveyor #13469 on 1/6/10 at 8:45 AM revealed she was admitted for surgery on 12/16/09. Per intra-operative note dated 12/16/09 Betasept was used as the skin prep. The intra-operative note does not identify if the staff ensured that this alcohol based skin prep was dry during the time-out process. This was confirmed by Director of Operations G on 1/6/10 at 11:10 AM.


18816

Examples by surveyor 18816:

Pt #13 MR reviewed by surveyor 18816 on 1/5/10 at 8:25 AM revealed he had surgery on 3/12/09. Per intra-operative note dated 3/12/09 BETADINE (an alcohol based skin prep) was used as the skin prep. The intra-operative note does not identify if the staff ensured that this alcohol based skin prep was dry during the time-out process. This is confirmed in interview with CNO V on 1/7/09 at 8:30 AM.

Pt #15 MR reviewed by surveyor 18816 on 1/5/10 at 10:00 AM revealed he had a central line (catheter in the jugular) placed on 9/8/09. The Operative Report dated 9/8/09 does not include documentation of a "time out" or that the alcohol based skin preparation, Chlora-prep, is dry prior to draping. This is confirmed in interview with CNO V on 1/7/09 at 8:30 AM.

Pt #19 MR reviewed by surveyor 18816 on 1/6/10 at 11:35 AM revealed she had a cesarean section on 7/28/09. The Delivery Room Record dated 7/28/09 the "time out" procedure does not include documentation of the alcohol based skin prep, Chlora-prep, is dry prior to draping. This is confirmed in interview with CNO V 1/7/09 at 8:30 AM.

Pt #22 MR reviewed by surveyor 18816 on 1/6/10 at 7:50 AM revealed he had Pacemaker Implant on 12/9/09. Per intra-operative note dated 12/9/09 does not state what was used as the skin prep, nor if it was dry, if alcohol based, with the time out. This is confirmed in interview with CNO V on 1/7/09 at 8:30 AM.


26711

Findings by Surveyor #26711:

Pt #10's MR review by surveyor 26711 on 1/5/10 at 2:15 PM revealed he had a Colon Resection on 1/4/10. Per intra-operative note dated 1/4/10 Chlora-prep was used as a skin prep. The intra-operative note does not identify if the staff ensured that this alcohol-based skin prep was dry during the time-out process. This was confirmed in interview with Clinical Nurse Specialist (CNS) W on 1/5/10 at 2:15 PM.

Pt #11's MR review by surveyor 26711 on 1/5/10 at 2:45 PM revealed he had surgery on 1/4/09. Per intra-operative note dated 1/4/10 Betasept was used as a skin prep. The intra-operative note does not identify if the staff ensured that this alcohol-based skin prep was dry during the time-out process. This was confirmed in interview with

In a phone interview with Director (D) Yon 1/5/2010 at 2:45 PM, she stated that the policy for the hospital is very explicit but due to the hospitals way of charting (charting by exception, a system for documenting exceptions to normal patient indicators as determined by the facility) the information about the prepped site being dry is not included in the "time out" documentation.

Per surveyor 26711 observation on 1/6/2010 at 8:50 AM, Pt #28 was prepped for ureteral stent placement using Betasept. Surveyor observed a sterile drape being used to blot the scrubbed area. A "time out" on the procedure was called when the physician entered the surgical suite, the "time out" did not include confirming the prepped area was completely dry.

Findings by Surveyor: 22219:

1. The facility was found to contain the following physical environment deficiencies. Refer to the full description at the cited K-tags:

Spring Street Main Hospital: K11, K12, K17, K18, K20, K25, K27, K29, K35, K38, K43, K47, K56, K62, K76, and K147.

St. Luke's Health Pavilion: K17, K18, K25, K29, K38, K43, K47, K62, and K147.

Cardiovascular Institute: K12, K17, K18, K25, K27, K29, K33, K47, K56, K62, K75, and K143.

Wisconsin Avenue Hospital: K11, K20, K27, K29, K33, K38, K45, K46, K56, and K62.

One Main Clinic: K130

Based on observation and interview, staff interviews and review of maintenance records, the facility failed to construct, install and maintain a proper ventilation and temperature control system in pharmaceutical, food preparation, and other appropriate areas.

Findings Include:

It was observed in the Spring Street main hospital in the 3C smoke compartment in the 3302-Electrical Room that the space was not constructed and maintained to ensure proper lighting. The light in three out of the first four electrical closets toured was burnt out. This observed situation was not compliant with CFR 482.41(c)(4). This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 2:24 pm on Jan 4, 2010.

Based on a tour, observation, review of policy and procedures and interview with staff, the facility failed to ensure patients and visitors are protected from the spread of potential sources of infections.

Findings include:

Facility Cardiac Rehabilitation policy titled Infection Control states "All participants should wash their hands prior to their exercise session and when done. Participants will be told to wash their hands prior to the exercise session and before leaving the department during their orientation session. They should be encouraged to use waterless sanitizer during exercise."

Facility policy title Movement of Trash and Linen states under Clean Linen "All clean linen shall be covered during transportation throughout the facility."

Examples by surveyor #13469:
Per interview, with Physical Therapist (PT) A while touring the Rehabilitation Department on 1/4/10 at 2:00 PM, the therapy department does not have a policy and procedure for all in-patients and out-patients to wash their hands prior to using therapy equipment. As a result, patients and staff are potentially exposed to communicable diseases.

Per observation, while touring the Rehabilitation Department with PT A on 1/4/10 at 2:00 PM, the following patient equipment was resting directly on the floor exposed to dust and debris and not allowing for proper cleaning of floor surfaces: large wedge and mat stored under a bed, and approximately 40 large foam pieces.

Per observation, while touring the ED (emergency department) with ED Manager (R) on 1/5/10 at 9:00 AM, it was noted that both x-ray rooms had oxygen tubing hanging from the wall exposed to dust and debris. It was unclear how long the tubing had been attached to the wall oxygen.

Per interview, with Cardiac Rehabilitation Manager (Q) on 1/4/10 at 2:00 PM, the department does expect all out-patients to wash their hands prior to the use of therapy equipment. Two of three patients interviewed during the tour by surveyor #13469 revealed that they did not wash their hands prior to using the department equipment. As a result, patients and staff are potentially exposed to communicable diseases.


18816

Examples by surveyor 18816:

Per surveyor 18816 tour of the Post-partum and Labor/Delivery units on 1/4/10 at 1:45 PM with Director J, Manager H, and Clinical Nurse Specialist I the following was noted:

The refrigerator in the Post-Partum unit kitchen contained unlabeled ice cream belonging to patients.

Two bottles of Betasept (surgical skin prep) were open with no date in a storage room, in the Post-partum unit.

The refrigerator in the Labor/Delivery unit kitchen contained a bowl of jello without an expiration date, an uncovered bowl of jello without an expiration date, open carton of mild with an expiration date of 12/27/09, a package of sour cream with an expiration date of 12/1/09, and a can of soda unlabeled.

Per surveyor 18816 tour of the off site clinic at 1 Main St, Racine with Site Supervisor MM the laboratory blood draw chairs had wear and tear on the arms of the chairs preventing the ability to clean appropriately and allowing for potential contamination of patients.


26711

Examples by Surveyor #26711:

A tour of the facility was completed by surveyor 26711, Directors (D) C, G, D E, Manager (M) D and M S on 1/4/10 between 2:00 PM and 2:45 PM, the following was noted:

1) Two kitchenettes in the Surgical Unit had unsecured chemical solutions under the sinks (One Step Disinfectant, Virex, and Good Sense Deodorizer) allowing access to patients and visitors.

2) In the Rehabilitation Unit kitchen cabinet, a container of Thicket (substance used to thicken liquids for patients with swallowing disorders) was opened and undated. Also, a plastic container of noodles and a plastic container of flour was found in the cabinet. These containers were unlabeled and undated.

3) In the hallway of the Rehabilitation unit, outside of room 305, two floor tiles were broken with pieces missing from the corners, preventing the ability to completely clean the floor.

During a tour of the kitchen facilities with D Z and Vice President (VP) L on 1/5/10 at 11:05 AM, surveyor 26711 discovered a green pureed (liquefied food) substance dated 12/31/09 and a container of diced ham dated 1/1/10 in refrigerators. D Z stated that these items expired 48 hours after the date written on the container and should have been discarded at that time.

In the Pediatric unit, toured with D G and J, on 1/4/10 at 3:00 PM, an opened kit with a breast pump was found in a cabinet with a note on the paper that stated "use for parts." The pump was not covered to prevent contamination.

In the clean supply room on the Medical floor (2nd floor-Pulmonary wing), toured with D E on 1/5/10 at 9:00 AM, an air vent in the ceiling was full of lint. This room also houses a computer server area for the telemetry units. Outside the elevators on the Medical floor, laundry staff were observed transporting a cart with clean laundry off of the unit that had not been covered. D E stated this cart should have been covered.

Surveyor 26711 tour of the Surgical area on 1/6/10 at 8:00 AM with D Y and Chief Nursing Officer (CNO) V, the following was noted:

1) A clean supply room wall, around the phone, there were holes in the dry wall making this area impossible to clean and a potential source of microorganisms.
2) The Post Anesthesia Care Unit isolation room had tears in the wall (missing paint areas) that exposed the brown paper of the drywall underneath, making this area impossible to clean and a potential source of microorganisms.
3) The Operating Room (OR), during surgery on Patient #28, it was observed that a fluid drainage container was on the floor under the OR table. This container had tubing to be connected to another tube that would be placed inside the patient during surgery. This tubing was lying on the floor with the end exposed, making it unclean and unsafe to attach to the tubing that would be entering the patient. Also in this OR suite, the OR table's "dust shield" (plastic part of the table that covers the inner workings of the mechanical table) was broken and cracked with pieces missing.

At the 1 Main Clinic, Racine site, Phlebotomist (P) CC was observed obtaining a blood sample from a patient. After obtaining the sample, with gloved hands, P CC entered a drawer of clean supplies with the dirty gloves, thereby contaminating all clean supplies that might have come into contact with the gloves.
These findings were confirmed by Site Supervisor MM on 1/6/10 at 1:30 PM