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Based on record review and interview the facility failed to renew restraint orders daily for 3 of 4 patients (#9, 10, and 13) with non-violent behaviors, out of a total universe of 30 records reviewed. This deficient practice had the potential to affect all172 patients served by the facility at the time of survey.

Findings include:

Facility policy titled "Restraint/Seclusion" dated 7/2013 states "Restraints for non-violent/non-destructive behavior, orders are in effect for up to one calendar day, which includes the day the order was obtained. If the patient remains in restraints for more than one calendar day, then a new order must be obtained by midnight the following day."

Review of Pt #9's MR revealed Pt #9 had restraints starting on 7/2/15 and continued to have at the time of survey on 7/7/15. No orders were written for the continuation of the restraints on 7/3/15 and 7/4/15.

Review of Pt # 10's MR revealed Pt #10 had restraints starting on 6/25/15 and continued to have restraints at the time of survey on 7/7/15. No orders were written for the continuation of the restraints on 6/27/15, 6/28/15, 7/2/15 and 7/3/15.

Review of Pt #13's MR revealed Pt #13 had restraints starting on 6/27/15 and continued to have restraints at the time of survey on 7/7/15. No orders were written for the continuation of the restraints on 6/29/15 and 7/3/15.

Per interview with RN J on 7/7/15 at 9:15 AM, restraint orders need to be reordered every calendar day and should be done via a sticker placed in the paper chart and signed by the ordering practitioner daily. RN J confirmed the findings at the time of the interview.

Based on record review and interview the hospital failed to ensure entries in medical records were complete for 5 of 30 MR's reviewed (#3, 4, 7, 17 and 18). This deficient practice had the potential to affect all 172 patients served by the hospital at the time of survey.

Findings include:

Hospital policy entitled; "Documentation: Medical Record Standards" dated June 2015, states: "All entries must be legible and complete, and must be authenticated, timed and dated promptly by the person (identified by name and discipline) who is responsible for ordering, providing, or evaluating the service furnished."

Per review of pt. #3's MR on 07/06/15 at 1:00 PM patient discharge instructions for an admission on 12/26/2014 were not signed or dated by the RN or the patient.

Per interview with Staff F on 07/07/15 at 10:30 AM it is the expectation of the medical records department that all dictated H&P's be signed within 24 hours.

Per review of pt. #4's MR on 07/06/15 at 1:30 PM an H&P dictated 03/07/15 was not authenticated by the physician until 03/28/15.

Per review of pt. #7's MR on 07/06/15 at 2:30 PM a H&P dictated 03/09/15 was not authenticated by the physician until 03/13/15.



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Per review of pt.#17's MR on 7/7/2015 at 2:00 PM, patient progress note reveals an entry written by a physician on 7/7/15, the entry does not include the time the note was written. Patient progress note dated 6/26/15 does not include a time. The findings were shared and confirmed with CNS U at the time of the findings.

Per review of pt.#18's MR on 7/7/2015 at 2:10 PM, patient progress note reveals an entry written by a physician on 6/30/15, the entry does not include the time the note was written. Patient progress note dated 7/1/15 does not include a time. The findings were shared and confirmed with CNS U at the time of the findings.

Based on record review and interview the facility failed to ensure telephone and verbal orders are authenticated promptly in 7 of 30 (#10, 13, 14,17,18, 20 and 35) records reviewed. These deficiencies had to potential to affect all 172 patients served by the hospital at the time of survey.

Findings include:

Hospital Rules and Regulations, dated 12/5/2014 state "... all verbal orders and telephone orders shall be authenticated by the prescribing practitioner in writing within forty eight hours of receipt, pursuant to a waiver granted by the State of Wisconsin."

Telephone orders dated 6/19/15, 6/20/15, 6/26/15 and 7/5/15 for Pt #10 were not authenticated by the prescribing physician.

Telephone orders dated 6/27/15 for Pt #13 were not authenticated by the prescribing physician.

Telephone orders dated 7/1/15 for Pt #14 were not authenticated by the prescribing physician.

Telephone orders dated 7/2/15 for Pt #20 and were not authenticated by the prescribing physician.

Per interview with CNS L on 7/7/15 at 1:35 PM, the physician should be authenticating all telephone orders within the 48 hour time frame.


Per review of pt. #35's MR on 7/7/2015 at 2:20 PM, physician order sheet revealed a telephone order taken on 6/29/2015 AT 2:35 PM, the order was not signed by a physician. The findings were shared and confirmed with VP of Operations AA at time of record review.


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Per review of pt. #17's MR on 7/7/2015 at 2:00 PM, physician order sheet revealed a verbal order taken on 7/4/2015, the order was not signed by a physician. Noted a verbal taken on 6/30/15, which was not signed by the physician. Physician orders written for TPN (total parental nutrition) was noted, the order was signed but there was no date or time indicating when the order was written. The findings were shared and confirmed with CNS U at time of record review.

Per review of pt. #18's MR on 7/7/2015 at 2:10 PM, physician order sheet revealed a verbal order taken on 6/27/2015, the order was not signed by a physician. The findings were shared and confirmed with CNS U at time of record review.




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Based on observation and interview the hospital failed to ensure expired drugs and bilogicals were not available for use in 3 of 6 areas toured (Dialysis unit, rehab gym and cardiac rehab unit). This deficient practice had the potential to affect all 172 patients served by the hospital at the time of survey.

Findings include:

During a tour of the dialysis unit on 07/07/2015 at 11:30 AM, 3 expired vaccutubes (used for the drawing and preservation of blood samples) were found in a drawer in the patient care area. Per interview with Dialysis Director B at the time of the observation the tubes were expired.

During a tour of the Rehab gym on 07/07/2015 at 8:30 AM, an expired (05/15) bottle of hydrogen peroxide was found in a cabinet in the gym area. Per interview with Rehab Dir. A at the time of the observation the bottle was expired.

During a tour of the cardiac rehab unit on 07/07/2015 at 8:45 AM, a 250 ml bottle of expired (06/15) injectable nitroglycerine was found in the crash cart. Per interview with Rehab Dir. A at the time of the observation the bottle was expired.

Based on observation, interview and review of record documents the hospital failed to be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for hospital services appropriate to the needs of the community. These deficiencies would affect all of the 172 current inpatients, out of a potential 300 beds, outpatients, staff and visitors within the facility.

Findings include:

A-700: The facility failed to maintain a safe environment from fire based on the following twenty-three (23) K-tags:

K-11 (building separation barriers)
K-12 (construction type)
K-18 (corridor doors)
K-20 (vertical openings)
K-22 (exit signs)
K-24 (smoke compartment size)
K-25 (smoke wall)
K-27 (smoke doors)
K-29 (hazardous rooms)
K-30 ( gift shop)
K-32 ( two exits)
K-34 (stair doors)
K-38 (egress)
K-40 (corridor doors)
K-46 (emergency lighting)
K-45 (exit lighting)
K-51 (fire alarm smoke detectors)
K-56 (sprinkler installation)
K-62 (sprinkler tests)
K-64 (portable extinguishers)
K-69 (K-77 (piped medical gas)
K-143 (oxygen transfer)
K-147 (electrical code)

Based on observation, interview and review of record documents the hospital failed to be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for hospital services appropriate to the needs of the community. These deficiencies would affect all of the 172 current inpatients, out of a potential 300 beds, outpatients, staff and visitors within the facility.

Findings include:

A-700: The facility failed to maintain a safe environment from fire based on the following twenty-three (23) K-tags:

K-11 (building separation barriers)
K-12 (construction type)
K-18 (corridor doors)
K-20 (vertical openings)
K-22 (exit signs)
K-24 (smoke compartment size)
K-25 (smoke wall)
K-27 (smoke doors)
K-29 (hazardous rooms)
K-30 ( gift shop)
K-32 ( two exits)
K-34 (stair doors)
K-38 (egress)
K-40 (corridor doors)
K-46 (emergency lighting)
K-45 (exit lighting)
K-51 (fire alarm smoke detectors)
K-56 (sprinkler installation)
K-62 (sprinkler tests)
K-64 (portable extinguishers)
K-69 (K-77 (piped medical gas)
K-143 (oxygen transfer)
K-147 (electrical code)

Based on observation and staff interview, the facility did not provide proper ventilation due to (i) lack of proper pressure relationships of clean and dirty rooms relative to adjacent spaces, and (ii) not maintaining negative pressure in four air-borne infectious isolation patient sleeping rooms in accordance with CDC and AIA guidelines. This deficient practice had a potential of cross-contamination of air with undesirable contaminants, and causing possible infection for all patients receiving services at this hospital.

The CDC guidelines can be found in the website



Findings include

During a tour of the facility with Staff M1 (quality improvement manager), Staff M2 (architect, Eppstein Uhen Architects), and Staff HH (maintenance group leader) on 7/13/15, and with Staff KK (project manager), Staff F (director of Women and Infant services), Staff M3 (manager of Women and Infant services), Staff M1, Staff M2 and Staff HH on 7/14/15, surveyor observed the following deficient practice.

1. On 7/13/15 at 12 pm, the Pump Room W2146 in the smoke compartment 2Q on the 2nd Floor cardiovascular surgery unit of the CVI building was not under positive pressure relative to adjacent spaces to cause airflow from the room into corridor;

2. On 7/14/15 between 9:15 am and 10:30 am, the Clean Supplies Room 2304 in the smoke compartment 2C on the 2nd Floor C-wing of Main Hospital building was not under positive pressure. The space was instead under negative pressure causing airflow in the wrong direction from corridor (dirty environment) to Room 2304 (clean environment).

3. On 7/14/15 between 9:15 am and 10:30 am, the air-borne infectious isolation patient rooms 252 and 253 in the Main Hospital building were not maintained to provide a negative pressure differential of 0.01 inch of water column. The pressure readings indicated in the monitors mounted on corridor walls just outside of the rooms 252 and 253 were 0.0044 and 0.003 inch of water column respectively, and not at least 0.01 inch as required. Furthermore, the pressure monitor of Room 252 indicated positive normal instead of negative normal in the display panel, and did not cause low pressure alarm when tested with doors kept open allowing negative pressure to drop to near zero.

4. On 7/14/15 between 9:15 am and 10:30 am, the air-borne infectious isolation patient rooms 269 and 270 in the Main Hospital building were not maintained to provide a negative pressure differential of at least 0.01 inch of water column. The pressure readings indicated in pressure monitors of both rooms were 0.003 inch of water column.

5. On 7/14/15 between 10:30 am and 11:40 am, the Clean Supplies Room E2690 in the smoke compartment 2Y on the 2nd Floor LDR unit of the St. Luke's Health Pavilion building was not under positive pressure. The space was instead under negative pressure causing airflow in the wrong direction.

6. On 7/14/15 between 10:30 am and 11:40 am, the Soiled Utility Room E2245 in the smoke compartment 2Z on the 2nd Floor Nursery unit of the St. Luke's Health Pavilion building was not under negative pressure. Instead, the space was under positive pressure causing airflow in the wrong direction.

7. On 7/14/15 between 10:30 am and 11:40 am, the Soiled Utility Room E2256 in the smoke compartment 2Z on the 2nd Floor of the St. Luke ' s Health Pavilion was not under negative pressure.

Item 1 of the deficient practice stated above was acknowledged at the time of discovery by a concurrent observation and interview with the quality improvement manager, the architect of Eppstein Uhen Architects, and maintenance group leader, and Items 2 through 7 of the deficient practice stated above were acknowledged at the time of discovery by a concurrent observation and interview with the quality improvement manager, the architect of Eppstein Uhen Architects, the maintenance group leader, and the project manager.

Based on observation, record review and interview the hospital failed to demonstrate effective infection control standards in 7 of 12 observations ( staff D,E, P, Q, V, W and Y) and 5 of 14 areas (Admission Search Room, 3rd floor dayroom, PACU, OB Dept. and Endoscopy Dept.). These deficiencies had the potential to affect all 181 patients served by the hospital at the time of survey.

Findings include:

1. Per review of facility policy entitled; "IV Therapy" dated 5/15, (no number) on 7-6-2015. The policy states in part, "C. Skin prep: Disinfect site with chlorhexidine preperation using friction for 30 seconds. Allow disinfectant to air dry."

2. Per review of the policy entitled; "SE Wisconsin Region Point of Care Xceed Pro Blood Glucose Monitoring PC1124", effective April 2014 (no number), on 7-6-2015. The policy states in part on page 2 of 8, "III Safety Precautions B. Instruments used at patient bedside must be cleared between each use with the approved wipes and allowed to air dry as specified on the container."

3. Per observation of Nursing Assistant E with pt. #1 on 7-6-2015 at 11:00 AM, Nursing Assistant E used a blood glucose meter to check pt. #1's blood sugar level and placed the meter on the pt.'s bedside table, then on the counter outside the pt.'s room. Nursing Assistant E returned the blood glucose meter to the holder outside the nurses station without disinfecting the machine.
Observation shared and confirmed with Director of Clinical Services C at the time of the observation.

4. Per observation of RN D with pt. #2 on 7-6-2015 at 3:20 PM, during a PICC line dressing change RN D used a chloraprep swab to wipe around the insertion site once, then the second swab to go around the insertion site twice and then applied the clean dressing without letting the site dry.
Observation shared and confirmed with Director of Clinical Services C at the time of the observation.

Wisconsin Avenue location -

5. Per observation on 7-7-2015 at 11:26 AM gouged drywall and chipping paint was observed outside door #3158 (Admission Search Room).

6. Per observation on 7-7-2015 at 11:37 AM, gouged drywall and peeling paint was observed outside the dayroom on the 3rd floor.


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7. Per review of facility policy titled Hand Washing, Hand Hygiene, and Hand Care, no policy number, dated 5/2015 stated in part under A. Hand hygiene program complies with the World Health Operations hand hygiene guidelines. 2. Hand rub (alcohol based waterless hand sanitizer) h. after removing gloves.

8. Per interview with Clinical Director of Surgical Services (CDSS) N on 7/7/2015 at 9:55 AM, CDSS N stated "Hand hygiene needs to be completed every time gloves are removed."

9. Per observation in operating room labeled "LS2" on 7/8/2015 at 9:20 AM, Anesthesia Monitoring Technician (AMT) V was observed to remove gloves after intubation of patient #36 and apply a new pair of gloves without hand hygiene. At 9:25 AM, AMT V removed gloves again, grabbed syringe out of anesthesia cart and put on gloves without hand hygiene. At 9:37 AM, AMT V removed gloves, removed supplies from anesthesia care and put on new gloves without hand hygiene. Observations were confirmed and discussed with CDSS N and Administrator Director of Surgical Services (ADSS) M at time of observation and CDSS N agreed that the same findings were noted during the observation.

10. Per observation in operating room labeled "LS2" on 7/8/2015 at 9:20 AM, Anesthesiologist W was observed to remove gloves after intubation of patient #36 and apply a new pair of gloves without hand hygiene. Observation was confirmed and discussed with CDSS N and Administrator Director of Surgical Services (ADSS) M at time of observation and CDSS N agreed that the same findings were noted during the observation.


PACU:

11. Per review of facility policy titled Ceiling Tile Removal Management, no policy number, dated 5/2015 stated B. All Ceiling tiles in any high risk patient sleeping/treatment area will be replaced with washable tiles.

12. Per observation in PACU on 7/7/2015 at 10:30 AM, one-half of the ceiling tiles in the PACU were unwashable tiles. One-half of the room had washable tiles. These findings were confirmed with Director of EVS G at time of observation.



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13. Facility policy "Cleaning, Disinfection & Sanitation of Reusable Patient Care Items & Medical Equipment" dated October 2009 states in part: "A. Reusable Patient Care Items...b. Semi-critical items (devices that contact mucous membranes) are to be sterilized or receive high level disinfection before reuse...d. Non-critical items (devices that have contact with only intact skin, not mucous membranes) may undergo low level disinfection and are to be disinfected between patients...B. 11. General environmental cleaning of floors, walls, ceilings, cubicle curtains and countertops are cleaned and disinfected according to the Environmental Services Department policy and procedure."

14. Facility policy "Handwashing, Hand Hygiene & Hand Care" dated May 2015 states in part: "E. Hand Hygiene...c. before and after patient contact..."

15. In the OB department on 7/6/2015 at 10:45 AM, a layer of dust was observed on the ice machine and refrigerator in nourishment rooms #1 and #3. During an interview with EVS assistant Z and EVS Director G on 7/8/2015 at 8:45 AM, Z and G stated nourishment rooms on the nursing units are to be cleaned "daily" including "high dusting of the ice machine and refrigerators."

16. On 7/6/2015 at 2:15 PM, RN P inserted Pt. #31's IV. Following the procedure, RN P removed a phone and pen from P's pocket while wearing contaminated gloves. RN P did not remove gloves or disinfect the phone or pen prior to placing the phone and pen back into pocket.

17. On 7/6/2015 at 2:45 PM, Lab Tech Q obtained a blood sample from Pt. #32. While donning contaminated gloves, Q removed a phone from Q's pocket.

18. These findings were confirmed with Dir F and Dir O on 7/6/2015 at 3:00 PM. Dir O stated staff "should not" answer phones while donning contaminated gloves without disinfecting after use.

19. In the Endoscopy department on 7/7/2015 at 9:00 AM the scope storage cabinet contained endoscopy scopes for patient use. During an interview with Mgr S and Endo Tech T at the time of the observation, S and T stated the scopes are disinfected after every patient use. Mgr S stated that, at a minimum, scopes would need to be re-disinfected prior to patient use "or at least every 5 days." Mgr S and Tech T stated that due to the high volume of endoscopy procedures "there aren't any scopes that aren't being used at least every 5 days." Mgr S and Tech T stated that there was not a system in place to monitor when a scope was last used and there was no data to confirm that each scopes was in fact used within each 5 day timeframe.

20. On 7/8/2015 at 8:15 AM, RN Y assessed Pt. #33 using a personal stethoscope. After the assessment, RN Y placed the stethoscope around Y's neck and left Pt. #33's room without disinfecting the stethoscope. This observation was confirmed with Dir O and Dir F on 7/8/2015 at 8:25 AM. Dir F stated nursing staff is expected to disinfect stethoscopes between each patient use.