HospitalInspections.org

Based on observation and interview, the hospital failed to ensure privacy while providing treatment. In 1 of 1 aquatic therapy areas (YMCA pool) the hospital failed to provide a private area for treatment. This deficiency has the potential to affect all 36 patients served by the hospital at the time of the survey.

Findings include:

During a tour of the YMCA pool on 02/02/2016 at 3:30 PM the area in which hospital outpatient therapy is provided was observed. Per interview with Rehab Dir. AA at the time of observation the pool is open to the general public during the times that therapy is being performed. Per AA there are no privacy screens or other devices to ensure the privacy of patients receiving care.

Based on record review and interview, the facility failed to ensure care plans were individualized for 8 of 23 (pt. #1, 2, 3, 6, 8, 10, 11, 17) patients who required a plan of care. Total records reviewed 30. This deficiency has the potential to affect all 36 patients served by the facility at the time of the survey.

Findings include:

The hospital's "Standards of Professional Practice Inpatient Services" (no date), states under "Standard 6. Evaluation The nurse evaluates progress toward attainment of outcomes."....."3. Evaluates, revises and documents on plan of care every 12 hours within the last 2 hours of your shift."

The following MR's were reviewed on 02/03/2016 between the hours of 9:00 AM and 2:30 PM with Coach of Inpatient Services G.

Pt. #1 was hospitalized from 10/26 through 11/03/2015 with a diagnosis of Sepsis . Pt. #1's MR did not contain documentation defining all outcomes related to nursing goals for this admission.

Pt. #2 was hospitalized from 11/12 through 11/15/2015 with a diagnosis of COPD (Chronic Obstructive Pulmonary Disease). Pt. #1's MR did not contain documentation defining all outcomes related to nursing goals for this admission.

Pt. #3 was hospitalized from 01/14 through 01/17/2016 with a diagnosis of Cellulitis. Pt. #1's MR did not contain documentation defining all outcomes related to nursing goals for this admission.

Pt. #6 was admitted to the hospital on 01/16/2016 with a chief complaint of abdominal pain. Pt. #6's MR did not contain documentation defining specific outcomes related to nursing goals for the PM shift of 02/01/2016.

Pt. #8 was admitted to the hospital on 01/31/2016 with a chief complaint of abdominal pain. Pt. #8's MR did not contain documentation defining specific outcomes related to nursing goals for the PM shift of 02/01/2016 or the AM shift of 02/02/2016.

Pt. #10 was admitted to the hospital on 02/01/2016 with a chief complaint of abdominal pain. Pt. #6's MR did not contain documentation defining specific outcomes related to nursing goals for the AM or PM shifts of 02/02/2016 or the AM shift of 02/03/2016.

Per interview with RN G on 02/03/16 at 1:30 PM nurses are expected to document on nursing care plans and goals every shift. A review of nursing care plans in records 1 - 10 indicated documentation was incomplete, G stated that not all nursing staff were documenting on outcomes of goals as defined by the nursing care plan.


32670



Review of Pt # 11's MR on 12/2/16 at 12:00 PM revealed Pt #11 is diabetic and receiving blood glucose checks. Pt #11's care plan does not reflect any problems, goals or interventions for blood glucose monitoring.

Review of Pt # 17's MR on 12/2/16 at 12:45 PM revealed Pt # 17 has been treated for pain during this hospitalization. Pt #17's care plan does not reflect any problems, goals or interventions for pain control.

Based on observation, record review, and interview, the facility failed to ensure patient records are secure and protected from unauthorized access in 3 of 4 departments in which medical records are stored (Medical records department, Clinic lab and Clinic basement). This deficiency has the potential to affect all 36 patients being served by the hospital at the time of the survey.

Findings:


32670


Facility policy "Security-Medical Records" # IM-040-HIM dated 6/17/14 states "Medical records are accessible to the Medical Staff and allied personnel as required for patient care or sanctioned organizational quality improvement activities only."

The Medical Records department was observed to contain unsecured patient medical record files stored on open shelves on 2/1/16 at 1:00 PM. Per interview with HIPPA officer L at the time of the observation, housekeeping cleans the medical records department after business hours when medical record staff are not present.

The basement of the off-site eye clinic was observed on 02/02/16 at 1:20 PM, old medical records in cardboard file boxes (approx. 20) were stored unsecured. Per interview with Clinic manager L at the time of the observation the landlord of the building and non-clinic staff have access to the area where the unsecured medical records are stored.

The laboratory area of the off-site family clinic was observed on 02/02/2016 at 2:00 PM. Old lab slips with patient identifying information were stored in an unlocked cabinet. Per interview with clinic manager K at the time of the observation patient records should be stored in a locked area. Cleaning staff and other non-clinic staff have access to the lab area.

Based on observation, interview and record review the hospital failed to secure drugs and biologicals from unauthorized use. In 1 of 7 areas (clinic med room) medications and supplies were not secured from unauthorized staff. This deficiency has the potential to affect all 36 patients served by the hospital at the time of the survey.

Findings include:

Hospital policy "Medication Management - Floor Stock" (#MM-203-PHARM) dated 06/14 states;

" 2. All floor stock shall be stored in a locked environment to include a locked cabinet or a locked medication room.

3. Access to floor stock shall be restricted to authorized personnel."

Authorized personnel are defined per policy MM-605-PHARM dated 06/14 as "Personnel Authorized to Administer Medications".

Observation of an off-site clinic was made on 02/02/2016 at 2:45 PM. The medication room door was secured with a lock requiring a code on a numerical keypad. Per interview with Director of Facilities X at the time of the observation there is a master code which allows access by maintenance personnel through all doors using this type of lock, including medication rooms. The medication room observed contained medications and supplies on open shelves. According to X maintenance personnel have access to this med room as well as others. In total there are 7 med rooms with this type of lock and accompanying code.

Based on observation, interview and record review, the hospital failed to store food properly, in 1 of 3 food storage areas observed (dry storage). This has the potential to affect 36 patients served by the hospital at the time of the survey.

Findings include:

The 2/4/16, 10:00 AM record review of Policy " IC-015-QM, Nutritional Services-Infection Prevention" dated 04/14, under "2.B" stated "Procedures for the handling , preparation, and serving of food shall meet the standards of all regulatory bodies". ServSafe guidelines for prevention food storage cross-contamination under "The flow of food: Storage" stated Wrap or cover all food correctly. Leaving food uncovered can lead to cross-contamination."

The 2/2/16 at 12:22 AM observation of the dry food storage storage area reveals dried green peas in an open cardboard box. This cardboard box had no lid. A cardboard box containing a bag of rice and grains of couscous at it's bottom had no lid. The bag of rice had a small hole in the bottom of the bag and spilled rice was in the bottom of this cardboard box.

During the 2/2/16 interview with Operations Coordinator Y at 12:25 AM, Y stated "we could use plastic containers with lids".

A standard Verification Survey for Life Safety Code compliance was conducted by the Wisconsin Division of Quality Assurance on February 1-3, 2016. The Monroe Clinic was found to be NOT in compliance with the following applicable regulations for hospital participation in Medicare-Medicaid:

42 CFR 482.41 Condition of Participation: Physical Environment was NOT MET
42 CFR 482.41(b) Standard: Safety from Fire was NOT MET
NFPA 101 (2000 edition)-Life Safety Code (Chapter 18-New Healthcare) was NOT MET

The Monroe Clinic {Hospital} was a 4-story structure built in 2011, with Type (2,2,2) construction. The building also had a business occupancy Administrative offices, pharmacy clinic and other outpatient clinics that was attached to the health care occupancy via a building connector but it is separated with 2-hour rated construction. The facility was fully sprinkled. The facility had an emergency generator that provided power to the emergency loads. The facility contained thirteen smoke compartments. The Monroe Clinic is licensed for 95 beds, with a census of 34, 39 and 36 inpatients at the time of the survey. Fourteen federal deficiencies of the Life Safety Code were cited for this building. There are six other medical office buildings that were surveyed out a total of 13 sites.

The cumulative effect of these deficiencies has the potential to affect the safety of all patients receiving services at the hospital.

The facility was found to contain the following deficiencies.

K14: Corridor finishes
K18: Positive latching
K22: Access to exits without readily visible signs.
K27: Smoke barrier doors without vision panels
K29: Hazardous areas without rated wall, door closers and rated doors
K39: Corridor width not maintained.
K46: Lacking emergency lighting reliability.
K50: Fire drills not done correctly.
K56: Sprinkler system was not compliant to NFPA 13 minimum standards.
K62. Sprinkler system was not properly maintained.
K69: Kitchen was not properly protected per NFPA 96.
K75: Proper storage and handling of rubbish and soiled materials.
K130: (At the Outpatient buildings) exiting, exit signage, fire dampers, improper vertical enclosures, hazardous rooms, sprinklers, sprinkler maintenance,electrical, dead end corridors, locked doors and room wall finishes
K144: Generators were not inspected or tested in accordance with NFPA 110.
K147: Electrical system not to NFPA 70 minimum standards.

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

A standard Verification Survey for Life Safety Code compliance was conducted by the Wisconsin Division of Quality Assurance on February 1-3, 2016. The Monroe Clinic was found to be NOT in compliance with the following applicable regulations for hospital participation in Medicare-Medicaid:

42 CFR 482.41 Condition of Participation: Physical Environment was NOT MET
42 CFR 482.41(b) Standard: Safety from Fire was NOT MET
NFPA 101 (2000 edition)-Life Safety Code (Chapter 18-New Healthcare) was NOT MET

The Monroe Clinic {Hospital} was a 4-story structure built in 2011, with Type (2,2,2) construction. The building also had a business occupancy Administrative offices, pharmacy clinic and other outpatient clinics that was attached to the health care occupancy via a building connector but it is separated with 2-hour rated construction. The facility was fully sprinkled. The facility had an emergency generator that provided power to the emergency loads. The facility contained thirteen smoke compartments. The Monroe Clinic is licensed for 95 beds, with a census of 34, 39 and 36 inpatients at the time of the survey. Fourteen federal deficiencies of the Life Safety Code were cited for this building. There are six other medical office buildings that were surveyed out of a total of 13 sites.

The cumulative effect of these deficiencies has the potential to affect the safety of all patients receiving services at the hospital.

The facility was found to contain the following deficiencies.

K14: Corridor finishes
K18: Positive latching
K22: Access to exits without readily visible signs.
K27: Smoke barrier doors without vision panels
K29: Hazardous areas without rated wall, door closers and rated doors
K39: Corridor width not maintained.
K46: Lacking emergency lighting reliability.
K50: Fire drills not done correctly.
K56: Sprinkler system was not compliant to NFPA 13 minimum standards.
K62. Sprinkler system was not properly maintained.
K69: Kitchen was not properly protected per NFPA 96.
K75: Proper storage and handling of rubbish and soiled materials.
K130: (At the Outpatient buildings) exiting, exit signage, fire dampers, improper vertical enclosures, hazardous rooms, sprinklers, sprinkler maintenance,electrical, dead end corridors, locked doors and room wall finishes
K144: Generators were not inspected or tested in accordance with NFPA 110.
K147: Electrical system not to NFPA 70 minimum standards.

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

Based on observation, interview and policy review the hospital failed to ensure availability of spill kits for hazardous waste. in 2 of 4 areas (Family Practice clinic, Women's Health Clinic). This has the potential to affect all 36 patients served at the facility during this survey.

Findings include:

Hospital policy "Hazardous Materials Management" (#EC-116-FAC) dated 08/00, states under; "Spills and Accidents": "In a health care setting, the chance of an emergency chemical spill and/or accident of some sort is possible. The risk involved with working with chemical and physical hazards can be greatly reduced through proper utilization of all protective apparel and equipment and assurance that personnel are properly qualified and trained,"

The MSDS (material safety data sheet) for 10% Neutral Buffered formalin states;

"EMERGENCY OVERVIEW
Warning! May cause respiratory tract irritation. Harmful if inhaled. Harmful if absorbed through the skin. May cause lung damage. May cause pulmonary edema. May cause eye irritation and transient injury. May cause severe skin irritation. May cause reproductive and fetal effects. Contains formaldehyde which can cause cancer. May cause allergic respiratory and skin reaction."

Per observation of the Women's Health clinic on 02/02/2016 at 11:30 AM, in the lab area were specimen containers pre-filled with 10 ml of 10% Buffered Formalin (approx. 30). Clinic Dir. BB stated at the time of the observation that there were no formalin spill kits available in the clinic.

Per observation of the Freeport Clinic on 02/02/2016 at 2:00 PM, 10 ml specimen containers of formalin were kept in the lab and procedure rooms. Per interview with Clinic Manager K at the time of the observations there are no formalin spill kits available in the clinic.

Based on observation and staff interviews, the facility did not construct, install and maintain a proper ventilation control system in the clean sterile storage supply area. The facility did not have a ventilation system that was installed and maintained in accordance with state regulations and manufacturer recommendations. This deficiency occurred in 1 of the 13 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 02/01/2016 at 4:10 PM, observation revealed on the Lobby level floor in the the Central clean sterile supply storage room in the OR area, that the ventilation to the space could not be confirmed to be compliant with accepted standards. The central clean sterile supply storage room had negative ventilation. Air was flowing from two sub-sterile rooms into the central clean sterile supply storage room. Clean sterile supply storage room is required to have 2 outside air changes, 4 air changes total and be positive air pressure to the corridor per Guidelines for Design and Construction of Health Care Facilities (FGI Guidelines) and American Society of Heating Refrigeration, and Air Conditioning Engineers (ASHRAE) 170. This observed situation was not compliant with 42 CFR 482.41(c)(4)This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach), staff B (Maintenance Coach), staff W (Facilities Engineer), and staff X (Director of Facilities & Operations Effectiveness).

Based on observations, interview and record review, the hospital failed to ensure a sanitary environment. In 2 of 8 areas observed (OR and off-site clinic) the hospital failed to perform adequate cleaning, maintain clean areas and failed to ensure that 2 of 4 staff (T and V) observed, hand washed after contaminated glove removal. This had the potential to affect 36 patients served by the hospital at the time of the survey.

Findings include:

1) During observations of care for Patient #20 in emergency room 15 on 2/2/16 at 3:25 PM Registered Nurse (RN) T performed intravenous (IV) line venipuncture on Patient #20. After this unsuccessful attempt to start the IV line, RN T removed gloves and applied clean gloves without benefit of hand washing for the second venipuncture attempt.

2) During observations of spinal injection procedure in the Outpatient Department on 2/2/16 at 1 PM, Physician V was observed to remove clean gloves after applying Betadine scrub to the surgical site of Patient #23, and without benefit of hand washing Physician V put on sterile gloves to perform procedure.

During conference room daily exit, on 2/2/16 at 4:15 PM, these hand washing observations were shared with Chief Nursing Officer D, without comment.

The 2/3/16, 2:00 PM policy review of "IC-045-QM, Infection Control- Hand Hygiene" dated 07/14, stated under "3. All staff shall use the hand hygiene techniques, as set forth in the following procedure. The CDC (Centers for Disease Control) has recommended guidelines on when to use non-antimicrobial soap and water, an antimicrobial soap and water or an alcohol based hand rub...D. Before applying sterile gloves...G. After working on a contaminated body site and then moving to a clean body site on the same patient.".


32670


Example of Cleaning in the OR:

On 2/2/16 at 11:25 AM reviewed the manufacturers instructions for "3M HB Quat Disinfectant Cleaner Concentrate 25L". It states "Treated surfaces must remain wet for 10 minutes."

On 2/2/16 at 11:30 AM reviewed of document titled "Standard Work Document - Cleaning between cases" dated June 2015. It states "4. Using a clean microfiber cloth and 25L wipe down holders...6. Using a clean microfiber cloth and 25L wipe down all tables and stands working from top to bottom...7. Using a clean microfiber cloth and 25L wipe down yellow fins, bear hugger, suction canister stands...8. Using a clean microfiber cloth and 25L wipe off light handles...9. Using a clean microfiber cloth and 25L wipe off the bed mattress and base of bed.

Observation on 2/2/16 at 8:53 AM of cleaning of OR 2 accompanied by Director of Surgical Services O. Observed EVS Tech J begin cleaning by wiping down tables and stands. At 8:58 AM EVS Tech J wiped down a pillow and the bed mattress and base of bed using the same rag. At 8:59 AM the top of the bed mattress was already dry. EVS Tech J wiped the light handles after cleaning the bed.

During interview with EVS tech J at 8:59 AM, EVS Tech J stated the cleaning product used to clean the OR was 25L. EVS Tech J stated the contact time was 3 minutes for 25L.

During interview 2/2/16 at 12:10 PM, EVS Coach I stated the wet contact time for 25L should be 10 minutes. EVS Coach I stated a new rag should be used for cleaning each new item as stated in the standard work document and that the lights about the OR bed should be cleaned before the bed mattress.

Based on record review and interview this facility failed to provide a post anesthesia evaluation after the patient has recovered from the anesthesia is 3 of 5 (# 12, 13 and 15) anesthesia medical records reviewed. This deficiency has the potential to affect all patients receiving anesthesia at the facility at the time of the survey.

Findings include:

Review of Pt # 12's MR on 2/2/16 at 12:25 PM, revealed Pt # 12 had surgery on 12/31/15 that required the use of anesthesia. The anesthesia stop time was 12:34 PM and the post anesthesia evaluation occurred at the same time of 12:34 PM.

Review of Pt # 13's MR on 2/2/16 at 12:35 PM, revealed Pt #13 had surgery on 1/5/16 that required the use of anesthesia. The anesthesia stop time was 12:00 PM and the post anesthesia evaluation occurred at the same time of 12:00 PM.

Review of Pt # 15's MR on 2/2/16 at 1:05 PM, revealed Pt #15 had surgery on 1/5/16 that required the use of anesthesia. The anesthesia stop time was 8:03 AM. The post anesthesia evaluation was timed prior to the end of the administration of anesthesia at 7:05 AM.