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Based on record review and interview, the facility failed to offer advance directives to 4 of 4 outpatients (#13, 14, 16, 17) in a total of 20 medical records reviewed.

Findings include:

A record review of policy RCM-HIM-13 titled, "Advance Directives - Patient Self Determination Policy - Wisconsin," last revision date 08/13/2021 revealed, "Each patient, upon registration to a HSHS hospital has... the right to establish an Advance Directive. Communication with Patients about Advance Directives revealed, "For the purpose of this policy it is expanded to include observation patients, day surgery patients, and all other outpatients."

A review of Patient #13's medical record revealed Patient #13 was a 78-year-old who presented to the Surgical Department for outpatient right eye cataract surgery 09/19/2023 at 7:57 AM and was discharged 09/19/2023 at 10:05 AM. There was no documentation that the pre-op staff addressed advance directives with Patient #13.

A review of Patient #14's medical record revealed Patient #14 was a 67-year-old who presented to the Surgical Department for outpatient left eye cataract surgery 09/19/2023 at 9:59 AM and was discharged 09/19/2023 at 12:47 PM. There was no documentation that the pre-op staff addressed advance directives with Patient #13.

A review of Patient #16's medical record revealed Patient #16 was a 55-year-old who presented to the Surgical Department for outpatient right total knee arthroplasty on 06/07/2023 at 08:00 AM and was discharged 06/07/2023 at 3:53 PM. There was no documentation that the pre-op staff addressed advance directives with Patient #16.

A review of Patient #17's medical record revealed Patient #17 was a 77-year-old who presented to the Surgical Department for outpatient right total right hip arthroplasty on 06/14/2023 at 05:56 AM and was discharged 06/14/2023 at 5:00 PM. There was no documentation that the pre-op staff addressed advance directives with Patient #17.

During an interview on 9/20/2023 begining at 9:00 AM, when asked if advance directives were addressed with Patients #13, #14, #16 and #17, Manager P stated they "did not chart that."

During an interivew on 9/20/2023 at 11:41 AM with Medical Surgical Manager C, when asked if outpatients are asked about their advance directives, Manager C confirmed staff did not document that advance directives were discussed with Patients #13, #14, #16 and #17.

Based on observation, staff interview and review of maintenance records on 09/19/2023, HSHS St. Clare Memorial Hospital 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.

1. K223 Doors with Self-Closing Devices
2. K321 Hazardous Areas- Enclosure

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 09/19/2023, HSHS St. Clare Memorial Hospital 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.

1. K223 Doors with Self-Closing Devices
2. K321 Hazardous Areas- Enclosure

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

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Based on record review, observation and interview staff failed to provide safe storage of blood drawing kits with needles attached away from patient access in 1 of 1 EDs (Emergency Department), failed to remove expired supplies from stock and failed to label multi use solutions and medications when opened in 2 departments (ED and Wound Clinic) in a total of 10 departments observed.

Findings:

Review of facility policy #PH-015 titled, "Medication Management and Reconciliation" undated, revealed, "E. Multi-Dose Vials...4. IF multi-dose vials must be used for more than one patient the following apply: a. The vial will be assigned an expiration date (28 days from the initial access or manufacturers expiration date if sooner)..."

On 9/19/2023 at 10:10 AM during a tour of the ED accompanied by ED Manager C the following was observed; two 16 ounce bottles of iodine (antiseptic used for skin disinfection) opened with approximately 1/3 of each bottle used, not dated with opened dates and a 1000 milliliter bottle of sterile water with an expiration date of December 2022. Also observed in ED Room 4 an unsecured drawer with 4 kits for drawing arterial blood gases. The kits contained needles.

During an interview with ED Manager C on 9/19/2023 at 10:10 AM, Manager C confirmed the findings and stated, "The solutions should have an open date and the sterile water should have been discarded. I understand that those kits with the needles should be secured as well."

On 9/19/2023 at 1:45 PM during a tour of the Wound Clinic accompanied by RN (Registered Nurse) I the following was observed; a 500 milligram vial of Lidocaine (a local anesthetic) half used, with an expiration date of September 1, 2023, a 2 ounce bottle of gentian violet (an antiseptic dye) opened and half used with no open date and a 8.5 ounce bottle of Vashe Wound Solution (a washing solution) opened with approximately 1/3 used, with no open date on the container.

During an interview on 9/19/2023 at 1:50 PM with RN I, RN I confirmed the findings and stated, "The bottles should have open dates on them and the Lidocaine should have been discarded."

Based on observation, record review, and interview, the facility failed to maintain a sanitary environment free of potential contamination to patients and failed to ensure appropriate infection precautions were taken when transporting used instruments in 1 of 10 departments (Emergency Department) observed.

Findings:

Review of facility policy titled, "EWD (Eastern Wisconsin Division) Instructions for Point of Use Cleaning and Transportation of Instruments" undated, revealed, "...5. Place all instruments in a single layer in the transport container"

On 9/19/2023 at 10:15 AM during a tour of the ED (Emergency Department) accompanied by ED Manager C, in an interview when Manager C was asked about transporting used instruments from a ED room to the dirty utility room stated, "We would just put gloves on and then carry them to the dirty utility room and place them in the container for sterilizing." When asked if a covered container was used to transport from the room to the dirty utility room Manager C stated, "No, I didn't know we should do that."

During an interview on 9/20/2023 at 1:00 PM with Infection Preventionist R when asked about transporting used instruments in the ED, Infection Preventionist R stated, "It is my expectation that the instruments be taken from the room in a covered rigid container labeled with a biohazard sticker. This is what I teach every department."

During a tour of the ED on 9/19/2023 at 10:15 AM accompanied by ED Manager C, the Emergency Obstetric cart was observed in room 6. The top of the cart had a sticky residue covering a third of the surface.

During an interview with ED Manager C on 9/19/2023 at 10:20 AM Manager C stated, "We recently removed some papers that we had taped to the top of the cart. I can see we need to remove the leftover adhesive."