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301 TROY DR

MADISON, WI 53704

PATIENT RIGHTS: NOTICE OF RIGHTS

Tag No.: A0117

Based on Medical Record (MR) review, and staff interview, this facility failed to obtain a signed Medicare discharge appeal form in 4 out of 14 out of 31 MR reviewed (Patients [Pt.] #3, 4, 17, and 23); also, this facility failed to pursue the Medicare discharge appeal forms that were mailed to guardians in 5 of 14 of 31 MR reviewed (Pt. #2, 13, 18, 23, and 30); and failed to provide another copy of the Medicare Discharge Appeal form within 48 hours of discharge to 10 of 14 of 31 Pt's. who qualified for Medicare (Pt. #1, 2, 3, 4, 13, 17, 18, 20, 23, and 30). Failure to present Medicare recipients with the information needed to appeal their discharge is not fulfilling the facility's responsibility to provide patients with all of their rights.


Finding include:

In an interview with Director (Dir.) C and Medical Information Supervisor (MIS) N on 2/24/2011 by Surveyors #26711 and 26390, MIS N stated that if patients have guardians then the Medicare Discharge Appeal form gets mailed to the guardian. MIS N keeps track of when the form was mailed and to who, but does not follow up on them, just waits for them to be returned. Dir. C stated that the Social Workers (SW) should be the staff who would track this, but it is currently not a priority for them. Dir. C also stated that the SW's are to be obtaining the signatures for the form prior to the discharge.

A MR review was completed on Pt. #1's closed MR on 2/22/2011 at 4:10 p.m. Pt. #1 was admitted on 10/23/2009 and discharged on 12/23/2010 to a nursing home for hospice care. There is no evidence of Pt. #1, or a guardian, receiving the Medicare Discharge Appeal form within 48 hours of discharge.

These findings were discussed with and confirmed by MIS N on 2/24/2011 at 11:50 a.m.

A MR review was completed on Pt. #2's closed MR on 2/23/2011 at 8:10 a.m. Pt. #2 was admitted on 4/16/2009 and discharged on 6/3/2010. The Medicare Discharge Appeal form was mailed to Pt. #2's guardian, however was not returned/obtained throughout the hospitalization of 13 1/2 months. There is no evidence of Pt. #2 or the guardian receiving the Medicare Discharge Appeal form within 48 hours of discharge.

These findings were discussed with and confirmed by MIS N on 2/24/2010 at 11:50 a.m.

A MR review was completed on Pt. #3's closed MR on 2/23/2011 at 3:30 p.m. Pt. #3 was admitted on 4/22/2010 and discharged on 9/22/2010. The Medicare Discharge Appeal form was mailed to Pt. #3's guardian, however was not returned/obtained throughout the hospitalization of 7 months. There is no evidence of Pt. #3 or the guardian receiving the Medicare Discharge Appeal form within 48 hours of discharge.

These findings were discussed with and confirmed by MIS N on 2/24/2010 at 11:50 a.m.

A MR review was completed on Pt. #4's closed MR on 2/23/2011 at 8:10 a.m. Pt. #4 was admitted on 2/1/2010 and discharged on 3/20/2010. There is no evidence of Pt. #4 receiving the Medicare Discharge Appeal form within 48 hours of admission or within 48 hours of discharge.

These findings were discussed with and confirmed by MIS N on 2/24/2010 at 11:50 a.m.

A MR review was completed on Pt. #13's closed MR on 2/23/2011 at 11:04 a.m. Pt. #13 was admitted on 5/18/2010 and discharged on 6/21/2010. The Medicare Discharge Appeal form was mailed to Pt. #13's guardian, however was not returned/obtained throughout the hospitalization of 4 1/2 weeks. There is no evidence of Pt. #13 or the guardian receiving the Medicare Discharge Appeal form within 48 hours of discharge.

These findings were discussed with and confirmed by MIS N on 2/24/2010 at 11:50 a.m.

A MR review was completed on Pt. #17's closed MR 2/24/2011 at 11:16 a.m. Pt. #17 was admitted on 7/30/2010 and discharged on 8/11/2010. There is no evidence of Pt. #17 receiving the Medicare Discharge Appeal form within 48 hours of admission or within 48 hours of discharge.

These findings were discussed with and confirmed by MIS N on 2/24/2010 at 1:45 p.m.

A MR review was completed on Pt. #18's closed MR on 2/24/2011 at 12:33 p.m. Pt. #18 was admitted on 1/10/2011 and discharged on 2/7/2011. The Medicare Discharge Appeal form was mailed to Pt. #18's guardian, however was not returned/obtained throughout the hospitalization of 4 weeks. There is no evidence of Pt. #18 or the guardian receiving the Medicare Discharge Appeal form within 48 hours of discharge.

These findings were discussed with and confirmed by MIS N on 2/24/2010 at 1:46 p.m.

A MR review was completed on Pt. #20's closed MR on 2/22/2011 at 3:53 p.m. Pt. #20 was admitted on 8/29/2010 and discharged on 9/30/2010 to a nursing home. There is no evidence that Pt. #20 or the guardian, received the Medicare Discharge Appeal form within 48 hours of discharge.

These findings were discussed with and confirmed by MIS N on 2/24/2010 at 11:50 a.m.






26390

A MR review was completed on Pt. #30's open MR on 2/23/2011 at 11:45 a.m. Pt. #30 was admitted on 1-29-2011 The Medicare Discharge Appeal form was mailed to Pt. #30's guardian, however was not returned/obtained throughout the hospitalization of 25 days.

These findings were discussed with and confirmed by MIS N on 2/24/2010 at 11:50 a.m.

A MR review was completed on Pt. #23's closed MR on 2/24/2011 at 12:55 p.m. Pt. #23 was admitted on 10/19/2010 and discharged on 11/09/2010 to a hospital. There is no evidence of Pt. #23, or a guardian, receiving the Medicare Discharge Appeal form within 48 hours of admission or discharge.

These findings were discussed with and confirmed by MIS N on 2/24/2010 at 1:50 p.m.

PATIENT RIGHTS: CARE IN SAFE SETTING

Tag No.: A0144

Based on observations on 2 of 2 inpatient units observed (Geriatric Treatment Unit-GTU, and Civil Secure Treatment Unit-CSTU) and staff interview, this facility does not ensure that permanent fixtures are structured in such a manner as to minimize the potential for patient harm and injury. Failure to safeguard the environment poses potential risks to the safety of all patients on these two units.

Findings include:

A tour of the GTU was conducted on 2/23/2011 from 8:50 a.m. -9:30 a.m. and on CSTU from 1:00 p.m.-1:50 p.m. by Surveyors #26711 and 26390 accompanied by Director (Dir.) C, Registered Nurse's G from unit CSTU and Registered Nurse, D from unit GTU. The following findings were observed:

GTU
It was noted that along the three patient care hallways on this unit, loopable, permanently attached hand rails were present. The presence of these non-enclosed horizontal fixtures could allow a patient access to a means to perform self-injury.

In all of the patient bathrooms (11 rooms-124, 127, 128, 131, 134, 144, 147, 155, 157, 162A, 162B) there were exposed plumbing around the toilets and/or hand rails in an area where a patient may not always be under the direct supervision of staff. The presence of these non-enclosed fixtures could allow a patient access to a means to perform self-injury.

These findings were confirmed during the tour by Dir. C and RN D on 2/23/2011.

CSTU
In six bathrooms, it was noted there was exposed plumbing around the toilets (Rooms 235, 237, 241, 244, 246A, 249). The presence of these non-enclosed fixtures could allow a patient access to a means to perform self-injury.

There was an unoccupied multi-toilet bathroom (A255) that was left unlocked during the tour. According to RN G, while interviewed during the tour, all unoccupied rooms are to be locked for patient and staff safety.

These findings were confirmed during the tour by Dir. C and RN G on 2/23/2011.

PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS

Tag No.: A0147

Based on observation and interview the hospital does not ensure medical records are secured from housekeeping after medical record staff leave for the day. This practice does not ensure confidentiality of all patients medical records.

Findings include:

On 2-22-2011 at 2:05 pm an interview with Health Information Supervisor (HIS), N and tour of the medical records office revealed the hospital has housekeeping staff that clean the medical records (MR) office after MR staff have left the office for the day. HIS, N explained that the records are in the office that is locked when staff are not present but are still accessible to everyone that has access to the office.

This was confirmed with Director A, and Director B on the afternoon of 2-23-2011.

MEDICAL RECORD SERVICES

Tag No.: A0450

Based on policy & procedure and record review and interview the Physical Therapy department failed to authenticate documentation in the medical records in 30 of 30 records reviewed (#1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31) by not timing signatures on Physical Therapy assessments and progress notes.

Findings include:

On 2-23-2011 a review of policy and procedure titled, Medical Record Documentation Requirements, revealed section XI. General Guidelines C. states,"all entries must be dated with month, day and year, while utilizing military time."

Interview on 2-24-2011 at 2011 with physical therapist (PT), U revealed the physical therapy department does not time their notes or assessments. PT, U explained the system they use is different from the rest of the therapy department, PT, U expressed being aware of the requirement and agreed it isn't done.

From 2-22-11 through 2-24-11 medical records reviewed by surveyors #26390 and #26711 for patient's #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31) were reviewed and found all Physical Therapy assessments and notes did not have timing by signatures.

This was confirmed on the afternoon of 2-23-2011 with Directors A and B.

PHYSICAL ENVIRONMENT

Tag No.: A0700

Based on observation, staff interviews and review of maintenance documents, the facility did not construct and maintain the building systems to ensure a safe physical environment due to the cumulative effects of environment deficiencies and resulted in the hospital's inability to ensure a safe environment for the patients, which is a Condition of Participation. The facility did not have a facility free of life safety deficiencies. This deficiency occurred in 4 of the 6 smoke compartments, and had the potential to affect all of the 36 residents that the facility was certified to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On February 22, 2011 surveyor #28616 observed in the GTU-1, GTU-3, CSTU-2 and CSTU-3 smoke compartments on the lower and main level floors that the facility had the following deficiencies: K011, K018, K029, K045 and K062 Please refer to the full description of the deficient practice at the cited K-tags: This observed situation was not compliant with CFR 482.41. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff P (Environmental Services Director) and staff Q (Buildings and Grounds Superintendent).

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LIFE SAFETY FROM FIRE

Tag No.: A0709

Based on observation, staff interviews and review of maintenance records, the facility did not construct, install and maintain the building systems to ensure a life safety environment in the building to meet the minimum requirements of the 2000 Edition of the Life Safety Code for "New Healthcare Occupancy" and "Existing Healthcare Occupancy" chapters of this code. The facility did not have a facility free of life safety deficiencies. This deficiency occurred in 4 of the 6 smoke compartments, and had the potential to affect all of the 36 residents that the facility was certified to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On February 22, 2011 surveyor #28616 observed in the GTU-1, GTU-3, CSTU-2 and CSTU-3 smoke compartments on the lower and main level floors that the facility had the following life safety deficiencies: K011, K018, K029, K045 and K062. Please refer to the full description of the deficient practice at the cited K-tags: This observed situation was not compliant with CFR 482.41(b). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff P (Environmental Services Director) and staff Q (Buildings and Grounds Superintendent).

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INFECTION CONTROL PROGRAM

Tag No.: A0749

Based on observations, policy and procedure review, review of professional standards, and staff interview, this facility failed to maintain a sanitary environment ensuring that patients, staff, and visitors are free from potential sources of contamination. In 2 of 2 observations (Patients #19 and 21) with Registered Nurse (RN) D, hand hygiene was not followed. In 2 of 2 units observed (Geriatric Treatment Unit-GTU, and Civil Secure Treatment Unit-CSTU) cleanliness was not maintained. In 3 of 4 patient (Pt.) bathrooms (A155, A157, and A162B) and 2 of 4 housekeeping closets, clean supplies were not stored to protect their integrity. In 1 of 1 ice machines observed in the kitchen, cleanliness was not maintained.
The lack of using appropriate infection control practices allowed for the possible transfer of dust, debris, microorganisms, and communicable diseases to staff, patients, and environmental surfaces. This affects all 36 beds included in the two units.

Findings include:

Facility policy titled, "Hand Hygiene," dated 1/2010, was reviewed on 2/24/2011 at 8:10 a.m. On page 2 of 4, 1. C. addresses when staff are to wash hands. C. 6. states, "Before and after dressing changes," and C. 9. states, "After removing gloves."
On page 3 of 4 II. B. 2. b. also indicates hands are to be washed or decontaminated after removing gloves.

In an interview with Infection Control Officer (ICO) J on 2/22/11 at 2:10 p.m., ICO J stated that the facility follows the recommendations from the Centers of Disease Control (CDC) for its infection control program and hand hygiene expectations.

The following are some of the recommendations from the CDC published in the October 25, 2002 Morbidity and Mortality Weekly Report (MMWR): 1. G. Decontaminate hands after contact with body fluids, or excretions, mucous membranes, non-intact skin, and wound dressings if hands are not visibly soiled; 1. H. Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care; I. J. Decontaminate hands after removing gloves.

Hand hygiene
An observation of insulin administration for Pt. #21 was made by Surveyor #26711 with RN D on 2/23/2011 at 9:30 a.m. RN D was not observed to wash D's hands prior to obtaining insulin from the vial. RN D then applied gloves, gave the injection, removed the gloves, and went on to other tasks before washing hands. This practice is not consistent with the facility policy or CDC recommendations.

An observation of a dressing change on Pt. #19's right elbow was made by Surveyor #26711 with RN D on 2/23/2011 at 10:05 a.m. Pt. #19 has had an open draining wound to the right elbow for 2-3 months. Pt. #19 is also on contact precautions for VRE (Vancomycin Resistant Enterococci, a bacterial strain that is highly resistant to antibiotics), which was found in the genital area.

After washing hands, applying gloves, and then removing the old dressing from Pt. #19's elbow, RN D continued the procedure without removing the now contaminated gloves, or washing hands and reapplying gloves. Items touched with the contaminated gloves were: the clean supply bin, the clean packing that went in to the wound, and the clean dressings used to cover the wound. After removing gloves, RN D checked Pt. #19's left arm for any open areas before washing D's hands. This practice is not consistent with the facility policy or CDC recommendations.

On 2/23/2011 at 4:17 p.m., when Surveyor #26711 asked ICO J what the expectation was for changing gloves during a dressing change procedure, ICO J stated that after removing the old dressing, staff should remove gloves and wash hands before continuing with cares.

These findings were discussed on 2/23/2011 at 4:30 p.m. with Dir. C and Dir. A present.

During the tour of the kitchen on 2-23-2011 at 10:30 am with Food Service Manager H, and Food Service Manager (FSM) I surveyor #26390 made the following observation.

A free standing ice machine was noted to have a build up of white and pink/red hard substance on the inside of the ice machine where the ice drops into the holding bin. FSM I could not say exactly when the last cleaning was done, FSM I explained it was done when the filter wasn't working and needed to be replaced. FSM I explained this ice machine is not on a regular cleaning schedule.

FSM's H and I confirmed the findings during the tour.

During environmental tours of the GTU and CSTU on 2/23/2011 between 8:50 a.m. and 2:00 p.m., Surveyors #26711 and #26390 made the following observations:

GTU
Room (rm) A119, a supply storage room, had ceiling vents thick with dust, and substantial dirt and debris on the floor.
Rm. A141, a shower room, had visible dirt and debris on the floor, and also on horizontal surfaces above eye level on a water filtration device for a bath tub.
Rm. A146, a Pt. room, had previous water damage to the wall under the window causing the paint to bubble and the integrity of the wall to be porous and not cleanable.
Rm. A149, a Pt. room, had a pair of soiled blue rubber gloves that had been placed on top of the Pt.'s wardrobe.
Rms. A155, A157, and A162B all had built in cabinets in the bathrooms that had sliding plexiglass doors. The cabinets held clean supplies for Pt. use. According to RN D, these cabinets are to be closed to keep the supplies inside them free from contamination. In these three rooms, all of these cabinets were open.
Rm. A156, a staff "workroom", had a combination of clean supplies occupying the same space as dirty carts, a mop and bucket cart, and garbage container.
Also noted, in several of the Pt. rooms and in the hallway, breaks in the integrity of the drywall and tiled surfaces revealing porous material, rendering these surfaces uncleanable for microorganisms.

These findings were confirmed by RN D and Director (Dir.) C at the time of the observations.

CSTU
Rm. A237, a Pt. seclusion room, had breaks in the integrity of the drywall, rendering it unable to be cleaned properly.
Rm. A245, a housekeeping closet, had clean paper towels meant for distribution to Pt. rooms and bathrooms occupying the same space as unclean carts and materials used during the cleaning of the unit.

These findings were confirmed by RN G and Dir. C at the time of the observations.

OPO AGREEMENT

Tag No.: A0886

Based on medical record review (MR) of a total of 5 deaths with 1 of 5 deaths occurring at the hospital (Patient #3), policy and procedure review, and staff interview (2 out of 2 staff interviewed, Director [Dir.] A and Dir. B), this facility does not have a complete policy and procedure for notifying the Organ Procurement Organization (OPO) of imminent death.

Findings include:

Facility policy titled, "Organ/Tissue Donations," dated 8/11/2009 was reviewed on 2/24/2011 at 9:05 a.m. by Surveyor #26711 accompanied by Dir. A and Dir. B.

This policy indicates that the OPO must be informed of patient deaths within two hours. The Centers for Medicare and Medicaid (CMS) guidance indicates "timely notification" to be within one (1) hour to the OPO after a patient death.

This policy also does not define imminent death. In an interview on 2/24/2011 at 9:05 a.m., according to Dir. A and Dir. B, since it is rare that a patient actually die from natural causes inside the facility, they have not been reporting for imminent deaths.

A MR review was conducted on 2/23/2011 at 3:30 p.m. by Surveyor #26390 on Pt. #3's closed death record. Pt. #3, who was in hospice at this facility, died at the facility due to a progression of the disease process. There is no indication in the MR that the OPO was contacted regarding this imminent death.

These findings were discussed with Dir. A and Dir. B at the time of the interview on 2/24/2011.