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Based on observation, interview, and record review, the facility failed to ensure safe medication administration practices for 1 of 3 patients receiving medication (Patient #9) out of a total universe of 6 patients on the inpatient unit.

Review of the facility policy titled "Medication Administration" last revised on 12/24/09 revealed in part "Procedure: Medication administration may only be performed by a Registered Nurse or Licensed Practical Nurse. 1. All medications require an M.D. order and are to be given exactly as prescribed...14. The nurse shall read the drug name on the unit dose and compare this with the order in the Medication and Treatment record.

On 2/20/20 at 7:20 AM, Licensed Practical Nurse (LPN) D was observed preparing to administer medications to Patient #9. LPN D called out for Patient #9 utilizing his/her first name. Patient #9 approached the nurse's station and confirmed his/her identity to LPN D. Patient #9 then stated, "I need the rest of my insulin." LPN D was observed to enter the medication room, reviewed Patient #9's orders, and drew up 20 units of Lantus (long-acting) insulin in one syringe and 5 units of Regular insulin in a separate syringe. LPN D was not observed to review Patient #9's medication administration record to determine what insulin had previously been administered.

At 7:25 AM, LPN D instructed Patient #9 to return to his/her room so the insulin could be administered. Upon entering the room, Patient #9 stated to LPN D, "He already gave me my Lantus." LPN D proceeded back to the medication room, discarded the Lantus insulin and syringe, and reviewed Patient #9's medication administration record, which revealed Patient #9's Lantus insulin had been given by the outgoing night nurse. LPN D stated, "The night nurse said in report that he didn't give the Lantus."

During an interview with Unit Coordinator A on 2/20/2020 at 8:30 AM, A stated "The nurse should check the MAR (medication administration record) prior to giving any medication."

Based on observation, interview, and record review staff failed to discard medications that were ordered for patients who had been discharged in 1 of 1 floor stock cabinets.

Findings include:

Review of the facility policy titled "Medication Disposal and Destruction" last revised 5/2012, revealed in part "Policy: Upon discharge or discontinuance, all unused portions of any prescription drug is disposed of... Procedure: 5. Other medications in unit dose format or un-opened containers may be returned to the pharmacy for credit."

During a tour of the medication room behind the nurses station on 2/18/2020 at 9:45 AM with Unit Coordinator A, 6 medications in the floor stock cabinet, (3 liquid Haldol and 3 liquid Prolixin) were observed to have labels of patients who had been discharged placed on the packages.

During an interview with Unit Coordinator A at the time of the observation, A stated, "Medications with patient labels should not be in the floor stock cabinet."

Based on observation, staff interview and review of maintenance records on 02/19/20, the Fond du Lac County Acute Psych Unit failed to construct, install, and maintain the building systems to ensure life safety to patients.

Findings include:

The facility was found to contain the following deficiencies.

K211 Means of Egress - General
K345 Fire Alarm System - Testing and Maintenance
. K914 Electrical Systems - Maintenance and Testing

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.

Based on observation, staff interview and review of maintenance records on 02/19/20, the Fond du Lac County Acute Psych Unit failed to construct, install, and maintain the building systems to ensure life safety to patients.

Findings include:

The facility was found to contain the following deficiencies.

K211 Means of Egress - General
K345 Fire Alarm System - Testing and Maintenance
K914 Electrical Systems - Maintenance and Testing

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.

Based on record review, observation, and record review the facility failed to ensure there is an effective infection prevention and control program to investigate, prevent and control potential infection and cross contamination.

Findings include:

The facility failed to designate a qualified individual responsible for the infection prevention and control program. See tag A748.

The facility failed to maintain and clean and sanitary environment free from potential sources of contamination on 1 of 1 nursing units. See tag A750.

The facility failed to demonstrate the implementation and review of infection prevention and control activities outlined in the infection control plan. See tag A770.

Based on record review and interview, the facility failed to demonstrate that designated infection control officers were qualified by training or experience to develop and maintain a hospital-wide program for infection control and prevention in 1 of 1 infection control programs reviewed.

Findings include:

Review of the document titled, "Bylaws, Rules and Regulations of the Medical Staff" signed 2/3/10 revealed, "...An Infection Control Officer for the hospital will be appointed at the beginning of each year by the Medical Staff. This Officer shall be a registered nurse and will have the responsibility for the investigation, control and prevention of infections within the hospital..."

During an interview with Registered Nurse (RN) I on 2/18/20 at 2:50 PM, RN I stated she had been employed at the facility "since 1980," and confirmed she was the facility's designated Infection Control Officer. RN I stated that she had not received any specialized training, experience, or certification specific to infection control or prevention outside of the facility's mandatory annual blood borne pathogen education and infection control policy review. RN I stated, "I just look at antibiotic use. I count how many patients and staff are on antibiotics and I give that number to [Unit Coordinator A] who reports it at their quarterly meetings."

During an interview with Unit Coordinator A on 2/19/20 at 11:13 AM, Unit Coordinator A confirmed that RN I was the designated Infection Control Officer for the hospital and that RN I did not have any training or education specific to infection control or prevention outside of the facility's mandatory annual education on blood borne pathogens, hand hygiene, and review of the facility's infection control polices. Unit Coordinator A stated, "[RN I] tracks the number of patients and staff on antbiotics. I guess the rest (of infection control activities) will be me." Unit Coordinator A confirmed that A had no specialized training, experience, or certification in infection control and prevention other than the facility's annual training.

Based on observation, record review and interview, facility staff failed to maintain a clean and sanitary environment free from potential sources of contamination on 1 of 1 nursing units observed (inpatient psychiatric unit).

Findings include:

Review of facility policy directive #02-065-27 titled, "Supply and Equipment Storage" effective 8/1/14 and last reviewed 10/25/19 revealed, "Policy: ...A sanitary environment shall be maintained throughout the unit and storage areas to avoid sources and transmission of infection...Procedure: ...3. Supplies may not be stored under sinks...6. Shelving, drawers, and cabinets must be clean..."

During a tour on 2/19/20 at 1:01 PM with Unit Coordinator A, the cabinet under the sink in the room labeled "Soiled Utility" was observed to contain three one-gallon bottles of bleach. Unit Coordinator A stated, "We moved those down there from the cabinet above the sink yesterday."




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During a tour on 2/18/20 at 9:45 AM with Unit Coordinator A, the cabinet under the sink in the room labeled "Medication Room" was observed to contain 1 sharps container and 2 drug busters containers, Unit Coordinator A stated, "yes, those items are stored there."




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Review of facility policy Directive #DTY-080-02 "Food Brought in to the Facility from the Outside for Resident Consumption" effective date 1/29/18 revealed, "Nursing: 2. Ensure all unsealed, perishable food is dated and discarded after three days."

Review of facility policy Directive #02-065-16 "Cleaning Schedules" effective date 2/15/10 last reviewed 10/25/19 revealed, "2. Patient refrigerator ... is cleaned by Acute unit staff on the night shift or as arranged per established schedule."

During a tour with Unit Coordinator A on 2/18/20 at 9:55AM the Acute Care Unit refrigerator was unlocked by Unit Coordinator A and the following was observed: 2 containers of cottage cheese; one dated "Best by 2/14/20" and the other "Best by 2/6/20", 2 opened, undated 1 pound packages of butter that were wrapped such that the butter was exposed, a ziplock bag containing bologna with no date, cellophane wrapped cheese slices without a date. There was a partially eaten, uncovered cake and an uncovered dessert in a 9 x 13 pan. The freezer contained a styrofoam container with rice without a date and an undated, mostly eaten plastic container of ice cream.

In the door of the freezer compartment were 4 blue ice packs in a ziplock bag labeled "Do Not Use - only for lab specimens."

In interview with Unit Coordinator A she stated, "we should be dating everything in this refrigerator and obviously we aren't." When questioned regarding when to discard food items she stated, "I would have to look at the policy." When questioned about the ice packs she stated, "they are reusable, we use them to hold urine specimens for pick up. We wipe them off and place them back in the freezer after use." When questioned regarding infection control with the ice packs and food items she stated, "they are covered, we never saw it as a problem."

In interview with Dietary Manager F when asked about the Acute Unit Refrigerator stated, "it is the responsibility of the unit to keep the refrigerator clean. We [dietary] send requested stock items like bologna and cheese to the unit with their meal trays. We don't actually go onto the unit. These items have an expiration date or best by from the manufacturer but the unit is to date the package when opened and discard weekly. It is not the responsibility of the dietary department."

Based on observation and interview, the facility failed to demonstrate the implementation and review of infection prevention activities outlined in the facility's infection control plan in 1 of 1 infection control programs reviewed.

Findings include:

Review of facility policy directive #01-001-05 titled, "Infection Control" effective date 02/02/10 and last reviewed 10/25/19 revealed, " ...The Infection Control Officer will monitor hospital compliance with the Infection Control Plan and identify, investigate, report, prevent and control infections and communicable diseases. The ICO is responsible for maintaining a sanitary environment, developing and implementing infection control measures for hospital staff, minimizing risks associated with patients who admit with infections and risks contributing to healthcare associated infections, complying with reportable disease requirements, coordinating with local, state, and federal agencies to address communicable disease and bioterrorism threats and maintain active surveillance of infections and communicable diseases for patients and staff. The Infection Control Officer will use the following resources to identify and investigate potential problems: a. Incident Reports; b. Infection Control Logs; c. Customer Satisfaction Surveys; d. Client Grievance Reports; e. Adverse Medical Reports; f. Department Specific Audits; g. Contracted Services Occurrences; h. Input from QAPI Committee; i. Pharmacy and Therapeutics Committee; Department Specific Quality Assurance Studies; k. Department specific screens and audits. Data collected will be analyzed and reported in a manner that will help identify trends and help the facility improve patient care."

Review of the Infection Control quarterly meeting minutes revealed the inclusion of a report of the total number of patients admitted during the previous quarter with diagnosed infections, broken out by type of infection and antibiotic usage. Staff illness symptoms and antibiotic usage were also included in the report. No documentation of additional infection control activities was found.

During an interview on 2/18/20 at 2:50 PM, Registered Nurse (RN) I confirmed that I was the designated infection control officer for the hospital. I stated, "I just look at the antibiotic use for patients and staff. I log the patients that are admitted on antibiotics and what infection they have, and add any patients that are put on antibiotics while they are admitted here. I log any staff that are sick with their symptoms and whether or not they are on antibiotics. I give those numbers to [Unit Coordinator A] to be reported at the quarterly meetings." When asked about reporting communicable diseases or awareness of communicable disease outbreaks in the community that may impact the facility's patient population, RN I stated, "I don't do anything like that. If there is something I will call public health and let them take care of it." When asked about patients with multi-drug resistant organisms, RN I stated, "We probably wouldn't take patients like that. We don't have isolation rooms or anything." When asked about formal surveillance activities, RN I stated, "I don't do any formal surveillance. I do monthly infection control rounds on the unit; making sure things are clean." When asked about tracking and follow up of staff exposures, RN I stated, "That's [Unit Coordinator A]'s responsibility." When asked if an annual risk assessment was completed to prioritize infection control activities or if there was a process for reviewing the infection control plan for effectiveness, RN I stated, "Not that I know of. You would have to ask [Unit Coordinator A]." When asked about I's involvement in infection control policy development, review, or updates and staff education, RN I stated, "I don't do anything with policies. That's [Unit Coordinator A]."

During an interview on 2/19/20 at 11:13 AM, Unit Coordinator A, "All nursing staff are responsible for reporting any evidence of communicable disease. We do surveillance on patient and staff infections and that is reported at the quarterly meetings." When asked about infection control policies, A stated, "I review them all annually; they are not necessarily updated." When asked about the process for reviewing the infection control plan and activities for effectiveness and determining priorities, Unit Coordinator A stated, "I am not aware of any plan assessment or review process." When asked about infection prevention education for staff, A stated, "staff are required to review the Infection Control binder every year." A stated the binder contains the facility's infection control policies and a blood borne pathogen review.

Based on record review and interview, the facility failed to develop a mechanism for ongoing reassessment of the effectiveness of the discharge planning process through review of a representative sample of patients who have been readmitted to the facility in 1 of 1 discharge planning processes reviewed.

Findings include:

On 2/18/20 at 11:48 AM, review of the documents included in the binder titled, "Committee Meeting Minutes" revealed readmission rates were reported in the "Utilization Review" committee meetings held quarterly.

During an interview on 2/20/20 at 8:00 AM, when asked about patients that are readmitted, Unit Coordinator A stated, "If we are seeing that patients are being admitted frequently, we try and work with them to determine any barriers or find alternate resources to help them avoid inpatient treatments. [Medical Records Director B] tracks the readmission rates."

During an interview on 2/20/20 at 12:47 PM, when asked about readmissions, Medical Records Director B stated, "I was able to come up with a way to alphabetize the patient names so I can see if patients have had more than one admission. I count those up and report the number to the board quarterly. There is no other review process that I know of."

During an interview on 2/20/20 at 1:40 PM, when asked about a process for reviewing readmissions, Unit Coordinator A stated, "There is no process for reviewing readmissions. We just look at the number."

An unannounced joint Recertification survey was conducted by two (2) federal surveyors from 02/18/2020 - 02/20/2020. The census at the time of this survey was 16 patients; the sample of active patients was seven (7) patients.

Based on record review and interview the facility failed to provide social work assessments that met professional social work standards, including conclusions and individualized treatment recommendations that described individualized anticipated social work roles in treatment and discharge planning for seven (7) of seven (7) active sample patients (A1, A2 , A3, A4, A5, A6, and A7). This has the potential to result in a lack of professional social work treatment services for those patients and/or lack of input to the treatment team.

Findings Include:

A. Medical Records

1. Patient A1 was admitted on 02/15/2020. The Acute Social History, dated 02/17/2020, failed to include Conclusions and Recommendations for inpatient Social Work treatment and listed only a Clinical Summary and Discharge Plans.

2. Patient A2 was admitted on 02/10/2020. The Acute Social History, dated/ 02/11/2020, failed to include Conclusions and Recommendations for social work inpatient treatment and listed only a Clinical Summary and Discharge Plans.

3.Patient A3 was admitted on 02/15/2020. The Acute Social History, dated 02/15/2020, failed to include Conclusions and Recommendations for social work inpatient treatment and listed only a Clinical Summary and Discharge Plans.

4. Patient A4 was admitted on 01/09/2020. The Acute Social History, dated 02/14/2020, failed to include Conclusions and Recommendations for social work inpatient treatment and listed only a Clinical Summary and Discharge Plans.

5. Patient A5 was admitted on 01/09/2020. The Acute Social History, dated 01/10/2020, failed to include Conclusions and Recommendations for social work inpatient treatment and listed only a Clinical Summary and Discharge Plans.

6. Patient A6 was admitted on 02/24/2020. The Acute Social History, dated 02/17/2020, failed to include Conclusions and Recommendations for social work inpatient treatment and listed only a Clinical Summary and Discharge Plans.

7. Patient A7 was admitted on 02/07/2020. The Acute Social History dated 02/10/2020 failed to include Conclusions and Recommendations for social work inpatient treatment and listed only a Clinical Summary and Discharge Plans.

B. Policy Review

Hospital policy, "Documentation Standards Social Work," updated 06/29/2017, stated, "Standards for the timeliness and content of these documents [Evaluations/Assessments] have been established." There were no standards regarding Conclusions and Recommendations in the policy.

C. Interview

In an interview on 02/19/2020 at 11:20 a.m., the Director of Social Work concurred with the findings regarding the lack of Conclusions and Recommendations within the content of the Acute Social History. She further concurred with the lack of specificity in the policy regarding the content required in an Acute Social History.

Based on medical records review, policy review, and interview the facility failed to provide Master Treatment Plans (MTPs) (facility called IP[Inpatient] Treatment Plan) that identified patient-related short-term (STG) and long-term goals (LTG) stated in observable, measurable, behavioral terms for seven of seven sample patient (A1, A2, A3, A4, A5, and A6, and A7). This failure hinders the ability of the treatment team to measure change in the patient as a result of treatment interventions and may contribute to failure of the team to modify plans in response to patient needs, as well as to increase patient stays beyond the resolution of the behaviors requiring admission.

Findings Include:

A. Medical Records

1. Patient A1 was admitted on 02/15/2020. The MTP, dated 02/19/2020, listed the problem, "SI [Suicidal Ideation] AEB [As Evidenced By] Overdose on Vyvanse and jumping off 2nd story patio." The non-measurable LTG for this problem was, "Will be free from SI by discharge."

2 Patient A2 was admitted on 02/10/2020. The MTP, dated 02/14/2020, listed the problem, "Homicidal ideations." The non-measurable goal for this problem was, "[Patient] will have a decrease in thoughts of wanting to harm others prior to discharge from the acute unit."

3.Patient A3 was admitted on 02/15/2020. The MTP, dated 02/16/2020, listed the problem, "Psychoses [sic]? AEB auditory hallucinations." The non-measurable STGs for this problem were, "Will verbalize reduction in active psychotic symptoms by day 2," and "Demonstrate ability to interact appropriately in group and 1:1 setting by discharge."

4. Patient A4 was admitted on 02/14/2020. The MTP, dated 02/18/2020, listed the problem, "Suicidal thoughts while intoxicated." The non- measurable LTG for this problem was, "Patient will be free from suicidal ideations prior to discharge and verbalize motivation for continued treatment services."

5. Patient A5 was admitted on 01/09/2020. The MTP, updated 02/11/2020, listed the problem, "Impaired Insight." The non-measurable goal for this problem was, "To work on orientation, realistic identification of problems areas [sic] and insight. Educate the patient on their mental health diagnosis, signs and symptoms and triggers that may affect their mental health."

6. Patient A6 was admitted on 2/14/2020. The MTP, dated 02/17/2020, listed the problem, "Suicidal Thoughts." The non-measurable goal for this problem was," [Patient] will be able to develop the ability to recognize, accept, and discuss ways to cope with feelings of depression or hopelessness."

7. Patient A7 was admitted on 02/07/2020. The MTP, dated 02/13/2020, listed the problem, "Psychosis as evidenced by auditory and visual hallucinations." The non-measurable LTG goal for this problem was, "Will demonstrate ability to interact appropriately in group and 1:1 settings by discharge."

B. Policy Review

Hospital Policy, "Treatment Planning Conference," revised 3/99, stated, "Each Plan includes individualized, measurable short- and long-term goals and objectives. The objectives must show specially how the goals will be attained, in what period, and describe the services, activities, programs, expected locations, frequency and staff member responsibility.

C. Interview

1. In an interview on 02/19/2020 at 11:20 a.m., the Director of Social Work concurred with the findings regarding the lack of observable, measurable long- and short-term goals.