HospitalInspections.org

Based on MR review and interview with staff, in 5 out of 5 MR reviewed of Medicare beneficiaries (Pt. #3, 4, 5, 6, 11 ) out of a total of 31 MR reviewed, the facility failed to ensure that each Medicare beneficiary is informed of his/her right to appeal discharge from the facility according to the guidelines set by the Centers for Medicare and Medicaid Services (within 48 hours of admission and 48 hours of discharge).

Findings by Surveyor #26711 include:

In an interview with Mgr A, HIM, on 11/15/2011 during MR reviews (between 7:30 a.m. and 9:00 a.m.), Mgr A stated that patients receive the initial Medicare discharge appeal form upon admission from the admitting clerk. The second signature on the notice, if a patient was in the facility long enough to qualify for this, would be obtained by the case management department.

During an interview with RN B, Interim CNO, and RN Z, Case Manager, by Surveyor #26390 on 11/15/2011 at 8:14 a.m., it was discovered that the facility does not have a transfer/discharge notice specific to Swing Bed patients (see tag C-379). In lieu of this notice the facility was using the Medicare Discharge Appeal Notice form.

On 11/17/2011 Dir. A informed Surveyor #26711 that the facility does not have a policy for the Medicare Discharge Appeal notice.

A MR review was completed on Pt. #3's closed MR on 11/15/2011 at 8:36 a.m. in the presence of Mgr. A. Pt. #3, 80 years old, was admitted on 7/16/2011 and discharged on 7/20/2011. There was no Medicare Discharge Appeal form in Pt. #3's MR.

A MR review was completed on Pt. #4's closed MR on 11/15/2011 at 2:15 p.m. in the presence of Mgr. A. Pt. #4, 81 years old, was admitted on 8/19/2011 and discharged on 8/23/2011. There was one Medicare Discharge Appeal form in Pt. #4's MR, and Pt. #4 qualified for the second notice.

A MR review was completed on Pt. #5's closed Swing Bed MR on 11/15/2011 at 2:47 p.m. in the presence of Mgr. A. Pt. #5, 79 years old, was admitted on 10/7/2011 and discharged on 10/14/2011. There was no Medicare Discharge Appeal form in Pt. #5's MR that the facility uses in lieu of the Swing Bed transfer/discharge notice.

A MR review was completed on Pt. #6's closed Swing Bed MR on 11/16/2011 at 11:40 a.m. in the presence of Mgr. A. Pt. #6, 66 years old, was admitted on 9/9/2011 and discharged on 9/16/2011. There was one Medicare Discharge Appeal form in Pt. #6's MR that the facility used in lieu of the Swing Bed transfer/discharge notice. Pt. #6 qualified for for the second notice with the length of stay of 7 days.

A MR review was completed on Pt. #11's closed MR on 11/16/2011 at 3:11 p.m. in the presence of Mgr. A. Pt. #11, 91 years old, was admitted on 9/29/2011 and discharged on 10/3/2011. There was one Medicare Discharge Appeal form in Pt. #11's MR, and Pt. #11 qualified for the second notice.

These findings were confirmed at the time of discovery by Mgr. A, Health Information Management.

Based on observations of 1 of 1 surgical procedure (Pt. #1), MR review in 2 of 2 MR reviewed of patients who had alcohol based skin preparations (Pt.'s #7 and 11), staff interviews, and review of policy and procedures, the facility failed to ensure policies are in place to ensure the safety of all patients from fire during surgical procedures.

Findings include:

Per policy review the facility failed to ensure the policy includes alcohol based skin preparations are dry prior to starting surgery. See tag C231.

In 2 of 2 surgical MR the facility failed to ensure there is documentation the alcohol based skin prep is dry prior to draping. See tag C231.

Per observation of Pt. #1's surgical procedure the facility failed to ensure an alcohol based skin preparation was dry prior to starting surgery. See tag C231.

The cumulative effect of these environmental deficiencies results in the hospital's inability to ensure a safe environment for all patients, staff and visitors.



18107

Based on observation, staff interviews and review of maintenance records, the facility did not provide for emergency gas and water supply. The facility did not have appropriate preventive maintenance of emergency equipment. This deficiency occurred in 18 of the 18 smoke compartments, and had the potential to affect 8 of the 25 in-patients and 547 out-patients that the facility was licensed to serve, as well as 154 staff employed by the hospital during the survey on those days present and an unknown number of visitors and staff not employed by the hospital. These deficiencies occurred in Building #1 (Hospital), Building #2 (Ambulatory Care Center), Building #3 (East Connector), Building #4 (Clinical Laboratory & Materials Management), and Building #5 (Rehabilitation Services) all part of the Federal ID number.

FINDINGS INCLUDE:
1. On 11/14/2011 at 5:00 pm surveyor #18107 observed in the Document Review the smoke compartment on the 1st floor in the Hospital & other attached clinics, that during a review of maintenance documents the facility did not have a comprehensive system to provide for the quantity of emergency water that would be needed to provide care to inpatients and outpatients and back-up water to the sprinkler system in the event the municipal water source failed. The reviewed documents did not include provisions to:
(a) protect these limited emergency supplies,
(b) prioritize their use until adequate supplies are available,
(c) address the event of a disruption in supply (e.g., disruption to the entire surrounding community),
(d) determine the quantity of supply readily available at the hospital,
(e) determine the quantity needed within a short time through additional deliveries.
This observed situation was not compliant with 42 CFR 486.623. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facilities Director), staff E (Corporate Safety Officer) and staff F (AMC Facility Supervisor).

2. During the survey on 11/14/2011 through 11/17/2011 surveyor #18107 observed that the facility failed to have a properly functioning exhaust system. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facilities Director), staff E (Corporate Safety Officer) and staff F (AMC Facility Supervisor).
See C221.

3. During the survey on 11/14/2011 through 11/17/2011 surveyor #18107 observed that the facility failed to comply with provisions of life safety in the following areas. These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff D (Facilities Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).
See C231 for details:
K-11 (Common Wall), K-12 (Building Construction Type), K-17 (Corridor Walls), K-18 (Corridor Doors), K-20 (Vertical Shafts/Floor Penetrations), K-22 (Exit Signs), K-25 (Smoke Barriers), K-27 (Smoke Barrier Doors), K-29 (Hazardous Spaces), K-38 (Exit Access), K-43 (Special Door Locking Arrangements), K-46 (Emergency Lighting), K-50 (Fire Drills), K-51 (Fire Alarm System), K-56 (Installation of a Automatic Sprinkler System), K-62 (Maintenance & Inspection of Sprinkler System), K-64 (Portable Fire Extinguishers), K-67 (Heating, Ventilating & Air Conditioning Systems), K-69 (Maintenance of Kitchen Extinguishing System), K-77 (Piped-in Medical Gas Systems), K-130 (Miscellaneous), K-144 (Inspections & Exercised Emergency Generators), K-147 (Electrical Wiring) and K-154 (Sprinkler System is Out-of-Service for Greater than 4 hours).

Based on observation, staff interviews and review of maintenance records, the CAH facility did not provide a building that was constructed, arranged, and maintained in accordance with Federal, State and local laws, regulations and guidelines, and safety to the patients. The facility did not have a building that complied with state regulations that were in effect when the space was built, a building that complied with state regulations that were in effect when the space was built, and construction after plan review and approval by the Wisconsin Department of Health Services. This deficiency occurred in 3 of the 18 smoke compartments, and had the potential to affect 20 of the 25 In-Patients & all Out-Patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 11/15/2011 at 7:51 am surveyor #18107 observed in the SC-02 smoke compartment on the Basement floor in the Paint Storage Room, that during the tour and follow-up review of facility documents, the facility failed to install an exhaust system for storage of paint creating noxious odors. The Paint Storage Room should have been designed with the appropriate exhaust system to remove noxious odors and dangerous gases. The Paint Storage Room was not maintained in accordance with federal, state and local laws that were in effect at the time of construction. The room had over 50 cans of different types of paint, paint thinner and paint remover. This observed situation was not compliant with 42 CFR 485.623(a). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facilities Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

2. On 11/15/2011 at 3:21 pm surveyor #18107 observed in the SC-06 smoke compartment on the 1st floor in the Surgery Corridor & South Corridor where it intersects at SC-05 (smoke compartment), that during the tour and follow-up review of facility documents, the facility failed to install a 'balanced' Heating, Ventilating and Air Conditioning System. This observed situation was not compliant with 42 CFR 485.623(a). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facilities Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

3. On 11/15/2011 at 5:30 pm surveyor #18107 observed in the SC-06 smoke compartment on the 1st floor in the Surgery Decontamination & Endoscopy Procedure Rooms), that during the tour and follow-up review of facility documents, the facility failed to install a 'balanced' Heating, Ventilating and Air Conditioning System. These spaces are required to be negative to surrounding spaces and were observed to be positive at time of survey tour. This observed situation was not compliant with 42 CFR 485.623(a). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facilities Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

4. On 11/16/2011 at 12:00 pm surveyor #18107 observed in the SC-15 smoke compartment on the Basement floor in the Basement Floor Plans, that the construction plans for work that created this space were not submitted to the Department of Quality Assurance as required by Wisconsin Administrative Code to ensure the design and installation was in accordance with Federal and State local laws that were in effect at the time of construction. This is specific to the Clinical Laboratory area that was renovated recently and I was told that this space is run through the Hospital's Federal ID number. This observed situation was not compliant with 42 CFR 485.623(a). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Facilities Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

During the survey on 11/14/2011 through 11/17/2011 surveyor #18107 observed that the facility failed to comply with provisions of life safety in the following areas. These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff D (Facilities Director), staff E (Corporate Safety Officer) and staff F (AMC Facilities Supervisor).

Findings include:
See C231 for details:
K-11 (Common Wall), K-12 (Building Construction Type), K-17 (Corridor Walls), K-18 (Corridor Doors), K-20 (Vertical Shafts/Floor Penetrations), K-22 (Exit Signs), K-25 (Smoke Barriers), K-27 (Smoke Barrier Doors), K-29 (Hazardous Spaces), K-38 (Exit Access), K-43 (Special Door Locking Arrangements), K-46 (Emergency Lighting), K-50 (Fire Drills), K-51 (Fire Alarm System), K-56 (Installation of a Automatic Sprinkler System), K-62 (Maintenance & Inspection of Sprinkler System), K-64 (Portable Fire Extinguishers), K-67 (Heating, Ventilating & Air Conditioning Systems), K-69 (Maintenance of Kitchen Extinguishing System), K-77 (Piped-in Medical Gas Systems), K-130 (Miscellaneous), K-144 (Inspections & Exercised Emergency Generators), K-147 (Electrical Wiring) and K-154 (Sprinkler System is Out-of-Service for Greater than 4 hours).









26711

Based on MR review, policy and procedure review, staff interview and observation the hospital failed to ensure the safety from fire in the OR (operating room) by not ensuring the alcohol based skin preparation (prep) is dry prior to draping the patient and not documenting this in the MR. This occurred in 2 of 2 records reviewed where alcohol based skin preparations were used (Pt.'s #7 and 11), and 1 of 1 surgical observation (Pt. #1).

Findings include:

The facility's policy titled, "Fire Prevention in the Operating Room," dated 8/1/2011, was reviewed on 11/16/2011 at 1:17 p.m. On page 2, section C, Steps taken to minimize risk, #1 states, "Fuel Risks: Prep solutions-Alcohol based preps are flammable. a. Allow flammable liquid preps to dry fully before draping. b. Avoid pooling, spilling or wicking of flammable preps. Spilled or pooled agent should be soaked up and removed from the patient. c. Remove towels used to catch dripped flammable prep before draping.
The policy does not address that the prepped area must be dry prior to commencing surgery and that this must be documented in the MR.

Manufacturer's recommendations for elapsed time between the completion of Chloraprep application and draping of the surgical site is 3 minutes.

On 11/15/2011 at 12:00 p.m. Surveyor #26711 observed a surgical procedure on Pt. #1 where Chloroprep (an alcohol based skin prep) was used to cleanse the surgical arm. The prep was started by RN T at 12:35 p.m. and at 12:37 p.m. the patient's right arm was draped with sterile drapes prior to the surgical incision.

There was not enough time between completion of the prep and draping to allow for drying of the prep and escape of any vapors prior to surgery starting.

In an interview with RN T at 1:02 p.m. on 11/16/2011, RN T stated, "We usually do wait for 3 minutes for the Chloroprep to dry but because the block [anesthetic into the surgical arm for pain management for surgery] takes 20 minutes to take effect we didn't." RN T also said the confirmation of the prep being dry is not documented in the MR.

MR reviews were completed on 11/16/2011 between 2:15 p.m. and 3:10 p.m. on Pt. #7 and 11's closed surgical records in the presence of Mgr. A.

Pt.s #7 and 11 both had Chlorhexadine/alcohol (an alcohol based skin prep) as the prep for their surgical procedures.

There is no documentation in the MR of confirmation that the prep was dry prior to draping for surgery.

These findings were discussed and confirmed on 11/16/2011 in the presence of Mgr. A, RN B, and CEO C.

Based on observations, accepted standards of practice for injection safety, and staff interviews, the hospital failed to ensure that drugs and biologicals are: 1. Kept secure from unauthorized use in 2 of 7 crash carts in the hospital, 2. Are properly disposed of and/or labeled after preparation in 1 of 1 Anesthesia Carts, and 3. Are prepared in an acceptable manner during 1 of 1 surgical procedures (Pt. #1).

Findings by Surveyor #26390 include:

CDC recommendations for safe injection practices, found on line at: http://www.cdc.gov/injectionsafety/IP07_standardPrecaution.html state, "IV.H.7. Do not keep multidose vials in the immediate patient treatment area and store in accordance with the manufacturer's recommendations; discard if sterility is compromised or questionable 453, 1003. Category IA."

On 11-14-2011 at 2:08 PM a tour was competed with RT Mgr G, and Dir HIM, A. A crash cart was observed in the CST hallway. RT Mgr G, explained the cart is in this location for use during Methacomium Challenge Tests. The cart has a plastic breakaway tie and is unattended and out of the staff's view. The cart does not have a permanent locking device to ensure unauthorized access by patient, families and visitors. The cart was observed to be unattended by staff for approximately 30 minutes during this tour. This was confirmed by RT Mgr G, and Mgr. HIM, A at the time of discovery.

On 11-14-2011 at 1:45 PM a tour was completed of the Cardiac Rehab area with Dir HIM, A and RN/Cardiac Rehab H. A crash cart was observed in the treatment area. The cart had an intact plastic breakaway tie on the cart yet surveyor #26390 was able to open and close the top drawer of drugs repeatedly without breaking the plastic tie. As a result, the crash cart, could be accessed without staff knowledge resulting in tampering, destruction, or removal of crash cart contents. This was confirmed at the time of discovery by Mgr HIM, A and RN/Cardiac Rehab H.





26711

Findings by Surveyor #26711:

An observation of a surgical procedure for Pt. #1 was conducted on 11/15/2011 between 12:12 p.m. through 12:57 p.m.

CRNA U was observed, at 12:42 p.m. to take a vial of previously opened Lidocaine 2% from a medication drawer in U's anesthesia cart and remove some of the contents into a syringe. CRNA U then returned the vial of Lidocaine to the same drawer.
CRNA U then opened a new vial of Propofol and withdrew some of that contents with the same syringe that contained the Lidocaine 2% and returned the Propofol and the syringe, which was re-capped by CRNA U, to the medication drawer indicated for narcotics.

In an interview at 12:59 p.m. on 11/15/2011, and upon inspection of CRNA U's anesthesia cart, CRNA U indicated that the syringe with the Lidocaine and Propofol was prepared for the next case (scheduled after Pt. #1) and that the Lidocaine 2% was opened for use on Pt. #1, however it was not dated. The medication from these multi-dose vials was prepared in a patient care area.

Also upon inspection of CRNA U's anesthesia cart the following was noted:
--The vial of Lidocaine 2% was not dated for when it was opened or would expire.
--There were two vials of Atropine that were opened and not dated for when they were opened or would expire.
--The two vials of Atropine each had a syringe inserted in them with some of the medication drawn into the syringe. CRNA U stated they were from the previous Endoscopy case. In the event an emergency would have happened in the previous case the medication would have been drawn up saving time. This medication was not discarded after it was not needed for its intended use.

These findings were discussed and confirmed at the end of the day conference with Mgr. A, CNO B, and CEO C on 11/15/2011 at 4:30 p.m.

Based on observations, staff interviews, policy review, and nationally recognized standards of practice for the Association of Professionals for Infection Control (APIC) and the Centers for Disease Control (CDC) guidelines, this facility failed to ensure measures were taken to control and prevent infections and avoid cross contamination of patients during cares in 1 of 1 Surgery observation (Pt. #1); failed to maintain separation of clean and dirty in 2 of 6 janitor closets observed (Medical /Surgical-Med/Surg and Obstetrics-OB); failed to safe guard patients and visitors from harmful chemicals kept in janitor closets and soiled utility rooms in 4 of 6 departments (Med/Surg, Intensive Care Unit-ICU, ED, and OB); failed to maintain the integrity of smooth surfaces for infection control purposes in 2 of 6 departments (Med/Surg and Surgery); and failed to take precautions to protect surgical maternity patients and newborns from cross contamination while traveling through the med/surg corridor enroute to the operating room and then back to maternity in one of one maternity units. Failure to follow infection control practices affected all 16 patients in the facility during the time of the survey.

Findings by Surveyor #26711 include:

According to a publication from APIC on 7/22/2004 regarding glove use for healthcare providers, APIC states, "Wear gloves when there is a reasonable likelihood of hand contact with blood or other potentially infectious materials, mucous membranes or nonintact skin; and when handling contaminated items or surfaces. Change disposable gloves when they become contaminated, torn or punctured. Wash hands before donning AND after removing gloves."

According to the CDC website (www.cdc.gov) the guidelines for glove changing and hand hygiene state in part: Hand Hygiene:
IV.A.3.a. Before having direct contact with patients.
IV.A.3.e. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient .
IV.A.3.f. After removing gloves.
IV.B.2.c. Remove gloves after contact with a patient and/or the surrounding environment (including medical equipment) using proper technique to prevent hand contamination. Do not wear the same pair of gloves for the care of more than one patient. Do not wash gloves for the purpose of reuse since this practice has been associated with transmission of pathogens.
IV.B.2.d. Change gloves during patient care if the hands will move from a contaminated body-site (e.g., perineal area) to a clean body-site (e.g., face).

Regarding flash sterilization, the CDC states in its Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008: Do not use flash sterilization for convenience, as an alternative to purchasing additional instrument sets, or to save time. Category II. 817, 962. Also, when necessary, use flash sterilization for patient-care items that will be used immediately (e.g., to reprocess an inadvertently dropped instrument). Category IB. 812, 817, 819, 845.

The facility policy titled, "Hand Hygiene," dated 3/18/2011, was reviewed on 11/17/2011 at 10:55 a.m. Page 1 of the policy, under the section "When to Practice Hand Hygiene" states, "Whenever hands are visibly dirty or contaminated; Before: having contact with patients, putting on gloves, inserting an invasive device, manipulating and invasive device; After: having contact with patient's skin, having contact with bodily fluids or secretions, non-intact skin, wound dressings, contaminated items, having contact with inanimate objects near a patient, removing gloves.

An interview with ICP X was conducted on 11/16/2011 at 10:30 a.m. ICP X informed Surveyor #26711 that the facility follows both the CDC and APIC recommendations for hand hygiene and glove use. ICP X also stated that the expectation for intravenous (IV) access with a needle or a needless system is to clean hands, apply gloves and scrub the hub of the IV for 15 seconds with an alcohol wipe no matter what department you are working in.

Med/Surg
A tour of the Med/Surg department was conducted on 11/14/2011 at 3:05 p.m. accompanied by RN B, Interim CNO. The following infection control violations were noted:
--The Soiled Utility Room was not locked. Patients and visitors could have access to the Crew Clinging Toilet Bowl Cleaner, Virex, and Sani-Cloths (all chemical based cleaning agents).
--Breaches in the integrity of the walls in room 112. There was a hole left uncovered and unpainted.
--A lounge chair in room 126 had the metal handle covered in a foam covering and secured with electrical tape. The vinyl of the chair was also tearing and not intact.
--In the nourishment center, the coils behind the water/ice dispenser had a build up of dust on them and there was hard water deposits staining the cabinet behind the dispenser.
--The janitor closet was unlocked and contained cleaning chemicals that were unsecured from patients and visitors. There were also clean paper products being stored in a dirty area.

These findings were confirmed by RN B at the time of discovery.

ICU
A tour of the ICU department was conducted on 11/14/2011 at 3:45 p.m. accompanied by RN B, Interim CNO, and Dir. A, HIM . The following infection control violations were noted:
--The Soiled Utility Room was not locked. Patients and visitors could have access to the bottle of Cavicide on the counter, a chemical based cleaning agent. There was also an open undated bottle of Peroxide found in a cabinet.
--The Nurses desk, on the hall side where patients and visitors pass by, had breaches in the integrity of the laminate exposing the wood underneath.
--Room 140 had breaches in the integrity of the painted wall surface.

These findings were confirmed at the time of discovery by RN B and Mgr. A.

Surgery
On 11/15/2011 at 12:00 p.m. an observation of Pt. #1's surgical procedure was conducted by Surveyor #26711.

CRNA U was observed on 4 occasions (12:24 p.m., 12:26 p.m. (two times with different medications), and 12:31 p.m.) to access Pt. #1's IV without wearing gloves or cleansing the hub for the purpose of administering medications for surgery.

At 12:44 p.m. RN T dropped the tube of Betadine ointment on the floor. With gloved hands RN T picked up the tube and placed it on the counter, removed gloves and did not perform hand hygiene. At 12:47 p.m. RN T put on a new pair of gloves for more tasks. There is potential for contamination of the counter from the tube that fell on the floor, and potential for cross contamination from the RN not washing hands after glove removal.

These findings were discussed on 11/15/2011 at 4:10 p.m. in the presence of RN B, Mgr. A.

On 11/16/2011 at 9:05 a.m. a tour of the Surgical Suite, to include Central Supply and the Post Anesthesia Care Unit (PACU) was conducted accompanied by RN Y, Surgery Manager.

The following infection control violations were noted:
--The Soiled Utility room had breaches in the integrity of the walls.
--The door to OR 1 was missing laminate exposing porous wood underneath.
--There are breaches in the integrity of the walls exposing porous dry wall in the sterile hallway, the Procedure room, and OR 2.
--The inside edge of the door for OR 3 has missing laminate along the spine of the door exposing porous wood underneath.
--The doors to the equipment room, which houses sterile and clean surgical supplies, were propped open with a cart of supplies to the sterile corridor.
--In the sterile hallway across from OR I there is a Flash sterilizer. Per interview with Surgery Manager, RN Y during the tour, the facility "flashes", or rapid cycle sterilizes the surgical equipment for eye surgeries routinely as they have 4 sets of eye instruments but can do 10-12 cases per day when eye case are scheduled. The use of flash sterilization is not recommended by the CDC except in emergent cases, for instance when an instrument is dropped and required to continue surgery (see 2008 guidelines provided).

These findings were confirmed at the time of discovery by RN Y, Surgery Manager.


26390

Findings by Surveyor #26390:

On 11-16-2011 at 9:30 am a tour of the ED was completed with Mgr HIM, A, Surgery Mgr, Y, RN/ED, S and RN/ED, R. At 10:07 am the triage room was noted to have cleaning chemicals in a unlocked lower cabinet. Surgery Mgr, Y confirmed this could be a safety issue as pt.s could be left alone in that room for an undetermined amount of time. At 10:16 a janitor's closet containing cleaning chemicals was unlocked. Surgery Mgr, Y confirmed that during the hours that housekeeping is working the door is unlocked, " they are in and out of there all day. "

On 11-16-2011 at 11:38 am a tour of the maternity/nursery was completed with RN/OB Mgr. Q, and Quality Mgr. W. At 11:44 the housekeeping closet and soiled utility room on the unit were noted to be unlocked. Both rooms contained cleaning chemicals. This observation was confirmed by RN/OB Mgr. Q at the time of discovery.

On 11-16-11 at 10:32 am an interview with RN\OB Mgr, Q was completed. RN\OB Mgr, Q explained that when a Cesarean section is performed the pt. will go to the surgery department for the procedure.

The route the pt.s take to and from the surgery department to the Maternity unit/nursery passes through a section of pt. rooms (#125,126,128,129) down a corridor that can be used for maternity or medical surgical patients.

RN\OB Mgr, Q stated that any of these rooms could have isolation pt.s in them. One of the rooms is a negative pressure room.

This could expose the newborn and mom to infectious diseases.

Based on observation, interview, policy and procedure review and review of recognized dietary practices, the hospital failed to ensure dietary staff practice proper hand hygiene or had appropriately contained their hair in 3 of 3 staff observations (Staff L, K, and J). These practices affected all 16 patients in the facility at the time of the survey.

Findings include:

On 11-17-2011 at 9:45 am review of the hospital policy titled, "Nutrition services dress code-personal hygiene-health" was completed. The policy states in part, "hair nets are to be worn at all times." P&P titled, "Nutrition services infection control" states in part "proper handwashing is required and emphasized as the most important factor in infection control. Proper handwashing with a bacteriostatic or bacteriocidal soap is a must between patients, before handling equipment, before washing equipment, before and after treating a patient in isolation, after going to the bathroom and after handling dirty or contaminated equipment."

On 11-17-2011 at 4:00 p.m. food code research revealed the following. The U.S. Food Code at http://www.fda.gov/Food/FoodSafety/RetailFoodProtection/ComplianceEnforcement/ucm106613.htm>, states in part, " Hand washing sinks shall be of sufficient number and conveniently located for use by all employees in food preparation and utensil washing areas. Hand washing sinks shall be easily accessible and may not be used for purposes other than hand washing. It is suggested that a hand washing sink be located within 25 feet of a work station. "

The WI Food code at , states in part the following regarding disposable glove use, " Hands are to be washed and dried before putting on
new gloves. "

On 11-15-2011 at 7:42 am the breakfast tray line was observed. Cook Assistant L was observed preparing breakfast trays for pt.s. Cook Assistant L was observed handling toast with gloved hands, moved across the kitchen to the refrigerator, reached in a box and removed a handful of coffee creamers, returned to the food prep station, removed gloves and donned a new pair of gloves without washing hands before putting on new gloves. Cook Assistant L, Cook K, and Cook Assistant J were observed preparing the breakfast trays with hair nets partially covering and containing the hair on their heads.

On 11-17-2011 at 9:45 am RD/Dietary Mgr., I stated the following in regards to Cook Assistant L not washing hands before donning new gloves while serving and handling food. "we are not set up for staff to wash their hands when serving food on the tray line." RD/Dietary Mgr., I explained the expectation for staff is to remove gloves and put on new gloves and wash hands only if visibly soiled. RD/Dietary Mgr., I also explained, "we follow both food codes but the WI food code supercedes."

Based on MR review, policy and procedure review, review of Medical Staff Rules and Regulations, and staff interview this facility failed to have complete and accurate medical records by:
1. Failing to show documentation of discharge planning in 4 of 5 out of a total of 5 discharge MR records reviewed (Pt.s # 2, 3, 5, and 6);
2. Failing to indicate the time the general consent for care form was signed in 26 out of 26 MR reviewed (Pt.s # 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 17, 18, 19, 20, 21, 23, 24, 25, 26, 27, 28, and 29); and
3. Failing to document the disposition of 2 out of 3 newborns upon discharge (Pt.s #31 and 32).

Findings by Surveyor #26711:

The facility's policy titled, "Case Management Discharge Planning Process," dated 11/1/2010 was reviewed on 11/17/2011 at 10:55 a.m. On page 1, the policy states in part, "Case Management arranged services may include, but are not limited to: ...long term care facilities, to include durable medical equipment.
On page 2 of this same policy it states, "The discharge plan is documented in case management navigator."

The facility's policy titled, "Skilled Nursing Bed Program," dated 1/25/2010, was reviewed on 11/17/2011 at 11:00 a.m. On page 1 the policy states, "Case Management will be an integral part of the program. Primary focus will be on returning the Skilled Nursing Bed patient to the community as soon as he/she is able." The Skilled Nursing Bed program is also referred to as the Swing Bed program.

The facility's Medical Staff Rules and Regulations, dated 3/2011, were reviewed on 11/17/2011 at 7:30 a.m. On page 9, section D. General Conduct of Care, #2 states in part, "Consent for admission and treatment must be signed by or on behalf of every patient admitted to the hospital and must be obtained at the time of admission."

Discharge Planning
In an interview with RN Z, Case Manager on 11/14/2011 at 1:00 p.m., RN Z relayed that all patients in the hospital are reviewed by case management, discharge planning starts on admission, and documentation is in the computer in the case management section.

A MR review was completed on 11/15/2011 at 7:32 a.m. on Pt. #2's closed MR in the presence of Mgr. A. Pt. #2, a 76 year old was admitted 5/9/2011 and discharged 5/12/2011 to a Skilled Nursing Facility (SNF). There is no documentation in the MR indicating that the case management department was involved in the discharge planning process for Pt. #2.

A MR review was completed on 11/15/2011 at 8:36 a.m. on Pt. #3's closed MR in the presence of Mgr. A. Pt. #3, a 80 year old was admitted 7/16/2011 and discharged 7/20/2011 to a Skilled Nursing Facility (SNF). There is no documentation in the MR indicating that the case management department was involved in the discharge planning process for Pt. #3.

A MR review was completed on 11/15/2011 at 2:47 p.m. on Pt. #5's closed Swing Bed MR in the presence of Mgr. A. Pt. #5, a 79 year old was admitted 10/7/2011 and discharged 10/14/2011 to an Assisted Living facility. Pt. #5's MR shows a Swing Bed assessment being completed by the case management department on 10/10/2011 however there is no documentation in the MR indicating that the case management department was involved in the discharge planning process for Pt. #5.

A MR review was completed on 11/16/2011 at 11:40 a.m. on Pt. #6's closed Swing Bed MR in the presence of Mgr. A. Pt. #6, a 66 year old was admitted 9/9/2011 and discharged 9/16/2011. The discharge disposition of Pt. #6 is not documented. There is one note on this Swing Bed patient from the case management department dated 9/16/2011-the day of discharge, however there is no documentation in the MR indicating that the case management department was involved in the discharge planning process for Pt. #6.

These findings were confirmed by Mgr. A at the time of their discovery in the MR review.

Consents
During MR reviews of Pt.s 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 17, 18, 19, 20, 21, 23, 24, 25, 26, 27, 28, and 29 throughout the days of 11/15/2011-11/17/2011 by Surveyor's #26711 and 26390 it was discovered that the facility does not obtain the time their general consent for care form for admissions to their facility was signed.

This was discussed with and confirmed by Mgr. A and RN B at the time of MR record reviews and again at the end the day on 11/15/2011 and 11/16/2011 at the daily exit conferences (4:30 p.m.).



26390

Findings by Surveyor #26390 include:

Newborn discharge disposition
On 11-15-2011 at 2:24 p.m. a record review of pt. #31's MR was completed with RN/OB AA. The section of the electronic medical record (EMR) titled Discharge Disposition, was not completed. This was confirmed by RN/OB AA at the time of discovery.

On 11-15-2011 at 2:57 p.m. a record review of pt. #32's MR was completed with RN/OB AA. The section of the electronic medical record (EMR) titled Discharge Disposition, was not completed. This was confirmed by RN/OB AA at the time of discovery

Based on interview and record review the hospital failed to maintain medical records that indicate the time a physician assessed pt.s in the Emergency Department (ED) in 4 out of 8 records reviewed (pt.s#17, 19, 23, 26) out of a total of 31 MR reviewed.

Findings include:

On 11-15-2011 at 3:15 PM a review of pt. #23 was completed with RN\OB AA. The record shows pt. #23 was triaged by nursing staff at 6:55 p.m.. The record does not show what time the patient was seen and assessed by the physician. This was confirmed by RN\OB AA, at the time of discovery.

On 11-16-2011 at 8:30 AM a review of pt. #26 was completed with Dir HIM, A. The record shows pt. #26 was triaged by nursing staff at 1:59 p.m.. The record does not show what time the patient was seen and assessed by the physician. This was confirmed by Dir HIM A, at the time of discovery.


On 11-17-2011 at 7:46 AM a review of pt. #17 was completed with RN/Interim CNO B. The record shows pt. #17 was triaged by nursing staff at 8:46 PM. The record does not show what time the patient was seen and assessed by the physician. This was confirmed by RN/Interim CNO B, at the time of discovery.

On 11-17-2011 at 8:20 AM a review of pt. #19 was completed with RN/Interim CNO B. The record shows pt. #19 was triaged by nursing staff at 11:22 PM. The record does not show what time the patient was seen and assessed by the physician. This was confirmed by RN/Interim CNO B, at the time of discovery.

On 11-16-11 at 9:30 AM an interview was conducted with Mgr HIM, A, RN/ED, R, RN/ED, S and RN/Surgery Mgr, Y. RN/ED, R, and RN/ED, S explained the procedure for a pt. presenting to the ED. After the pt. is triaged by nursing staff the pt. is taken to an exam room and they wait to see the physician. The physician will access the medical record information in the computer for reviewing and that time is logged by the computer. The time the physician goes to the room and physically examines the pt. is not documented. If a record has the time documented it is because a staff person did that on their own, there is no system or procedure in place to document the time the physician saw the pt. in the ED.

Based on MR review, review of the facility's Medical Staff Rules and Regulations, and staff interview this facility fails to ensure that MD (Medical Doctor) History and Physical (H&P) reports are updated and properly authenticated prior to surgery by the responsible professional in 3 out of 5 closed surgical records out of a total of 31 MRs reviewed (Pts. #8, 9, and 10).

Findings include:

The facilities Medical Staff Rules and Regulations, dated 3/2011, were reviewed on 11/17/2011 at 7:30 a.m. On page 6, Section C, Medical Records, #2 states in part that if a previously recorded H&P (within a 30 day window) is used in lieu of a new H&P then, "An interval admission note that includes all additions to the history and any subsequent changes in the physical findings must always be recorded."

On page 7 of the same section of the Rules and Regulations, #4 states, "For outpatient operative or invasive procedures, the history and physical must be dated within thirty (30) days of the surgical date, and updated with an interval note prior to the procedure. An interval note is a statement entered into the medical record that an H&P has been reviewed and that there are either no significant changes to the findings contained in the H&P since performed, or if there are significant changes, those changes are documented in the medical record.

Also on page 7, #11 states, "All clinical entries in the patients's medical record shall be accurately dated and authenticated."

MR reviews were completed on Pt.s 8, 9, and 10's closed surgical MR on 11/16/2011 between 2:30 p.m. through 3:58 p.m. in the presence of Mgr. A, Health Information Management.

Pt. #8 had an H&P completed by 8's family MD on 6/1/2011. Pt. #8 had foot surgery on 6/7/2011. The Surgeon initialed the H&P indicating it was reviewed but did not date or time the initials thereby failing to establish a timeline prior to the procedure. There is also no evidence of an interval note as stated in the Rules and Regulations.

Pt. #9 had an H&P completed on 4/29/2011 for a 5/5/2011 surgery. A pre-operative assessment was documented by the MD, however there is no date or time for the signature, thereby failing to establish a timeline prior to the procedure.

Pt. #10 had an H&P completed by 10's family MD on 5/27/2011 for a 6/6/2011 bladder surgery. The Surgeon initialed the H&P indicating it was reviewed but did not date or time the initials thereby failing to establish a timeline prior to the procedure. There is also no evidence of an interval note as stated in the Rules and Regulations.

These findings were confirmed by Mgr A in interviews regarding the findings at the time of discovery for each MR.

Based on observations of 1 of 1 surgical procedure (Pt. #1), MR review in 2 of 2 MR reviewed of patients who had alcohol based skin preparations (Pt.'s #7 and 11), staff interviews, recommendations from the Association of Operating Room Nurses (AORN), and review of policy and procedures, the facility failed to ensure policies are in place to ensure the safety of all patients from fire during surgical procedures.

Findings include:

Per policy review the facility failed to ensure the policy includes alcohol based skin preparations are dry prior to starting surgery.

In 2 of 2 surgical MR the facility failed to ensure there is documentation the alcohol based skin prep is dry prior to draping.

Per observation of Pt. #1's surgical procedure the facility failed to ensure an alcohol based skin preparation was dry prior to starting surgery.

The cumulative effect of these environmental deficiencies results in the hospital's inability to ensure a safe environment for all patients, staff and visitors.

Findings by Surveyor #26711:

The facility's policy titled, "Fire Prevention in the Operating Room," dated 8/1/2011, was reviewed on 11/16/2011 at 1:17 p.m. On page 2, section C, Steps taken to minimize risk, #1 states, "Fuel Risks: Prep solutions-Alcohol based preps are flammable. a. Allow flammable liquid preps to dry fully before draping. b. Avoid pooling, spilling or wicking of flammable preps. Spilled or pooled agent should be soaked up and removed from the patient. c. Remove towels used to catch dripped flammable prep before draping.
The policy does not address that the prepped area must be dry prior to commencing surgery and that this must be documented in the MR.

Manufacturer's recommendations for elapsed time between the completion of Chloraprep application and draping of the surgical site is 3 minutes.

The Association for Operating Room Nurses (AORN) Perioperative Standards and Recommendations, 2008 Edition indicate:
IX.d.1. Waterless, brushless, surgical-scrub solutions should be allowed to dry completely to decrease the potential to produce ignition by static electricity or sparks.
IX.d.3. Provide adequate time for the flammable surgical prep solution to dry completely and any fumes to dissipate before applying surgical drapes, using an active electrode or laser, or activating a fiber-optic light cable.
IX.d.5. Drapes should not be applied until prep solutions are dry, to prevent the accumulation of volatile fumes beneath them.

On 11/15/2011 at 12:00 p.m. Surveyor #26711 observed a surgical procedure on Pt. #1 where Chloroprep (an alcohol based skin prep) was used to cleanse the surgical arm. The prep was started by RN T at 12:35 p.m. and at 12:37 p.m. the patient's right arm was draped with sterile drapes prior to the surgical incision.

There was not enough time between completion of the prep and draping to allow for drying of the prep and escape of any vapors prior to surgery starting.

In an interview with RN T at 1:02 p.m. on 11/16/2011, RN T stated, "We usually do wait for 3 minutes for the Chloroprep to dry but because the block [anesthetic into the surgical arm for pain management for surgery] takes 20 minutes to take effect we didn't." RN T also said the confirmation of the prep being dry is not documented in the MR.

MR reviews were completed on 11/16/2011 between 2:15 p.m. and 3:10 p.m. on Pt. #7 and 11's closed surgical records in the presence of Mgr. A.

Pt.s #7 and 11 both had Chlorhexadine/alcohol (an alcohol based skin prep) as the prep for their surgical procedures.

There is no documentation in the MR of confirmation that the prep was dry prior to draping for surgery.

These findings were discussed and confirmed on 11/16/2011 at 4:30 p.m. in the presence of Mgr. A, RN B, and CEO C.

Based on MR review, staff interview, policy and procedure (P&P) review, and review of the Medical Staff Rules and Regulations, this facility failed to ensure proper evaluations for anesthesia recovery were completed in 4 of 5 Pt.s who received anesthesia (Pt.'s #7, 9, 10 and 11) out of a total of 31 MR reviewed.

Findings include:

The facilities Medical Staff Rules and Regulations, dated 3/2011, were reviewed on 11/17/2011 at 7:30 a.m. On page 12, E. Surgical Care, 5. states in part, "The anesthetist is responsible for writing a post-anesthetic note after the patient has completed post-anesthesia recovery care to include at least a description of the presence or absence of anesthesia-related complications."

This requirement in the Rules and Regulations does not meet minimum expectations of post-anesthesia recovery documentation to include cardiopulmonary status, level of consciousness, any needed follow-up care and/or observations, and any complications occurring during the post-anesthesia recovery period.

In the same Rules and Regulations, in the same section, page 13, #10 states, "The anesthetist shall maintain a complete anesthesia record to include evidence of pre-anesthetic evaluation and post-anesthetic follow-up of the patient's condition."

The facility policy titled, "Protocol for Anesthesia Care," dated 12/1/2006, was reviewed on 11/17/2011 at 10:55 a.m. On page 2, section D. Post Anesthesia Care, #6 states, "Post anesthetic evaluation is recorded on anesthesia record or progress notes. Time observation recorded will be noted."

An interview was completed on 11/16/2011 at 9:10 a.m. with CRNA V, accompanied by RN Y, Surgery Manager. In response to the question regarding post-anesthesia evaluations on patients, CRNA V responded, "I try to get to everyone that needs one to do them, sometimes someone might get missed."

MR reviews were completed on Pt.s #7, 8, 9, 10, and 11 on 11/16/2011 between 2:15 p.m. and 3:10 p.m. in the presence of Mgr. A, Health Information Management.

Pt. #7 had a surgical procedure (removal of appendix) on 6/27/2011 which required general anesthetic. Pt. #7 arrived in the Post Anesthesia Recovery Unit (PACU) at 2:26 a.m. There is no evidence that a post-anesthesia evaluation was completed.

Pt. #11 had a surgical procedure (repair of a hip fracture) on 9/30/2011 which required general anesthetic. Pt. #11 arrived in the PACU at 8:39 a.m. There is no evidence that a post-anesthesia evaluation was completed.

Pt. #9 had a surgical procedure (pelvic cyst removal) on 5/5/2011 which required general anesthetic. Pt. #9 arrived in the PACU at 8:28 a.m. The post-anesthesia evaluation is incomplete and only indicates there were no post-anesthesia complications.

Pt. #10 had a surgical procedure (scope of the bladder with some tissue removal) on 6/6/2011 which required general anesthetic. Pt. #10 arrived in the PACU at 8:59 a.m. and was discharged on 6/6/2011. The post-anesthesia evaluation is not documented until 6/7/2011.

Mgr. A confirmed the above findings at the time of discovery on 11/16/2011.

Based on MR review, staff interview, review of the hospital agreement with the OPO (Organ Procurement Organization) and 2 of 2 policy and procedure reviews the hospital failed to include a definition of imminent death in the policy and failed to include notification to the OPO as part of the procedure in 4 out of 5 MR records reviewed where imminent death could have been reported (Pt. 12, 13, 14, and 15).

Findings by Surveyor #26390 include:

On 11-16-2011 at 1:35 pm an interview with Interim CNO, B and RN/ED, R was completed. A review of the facility policy titled, "Donation after cardiac death," dated 12/1/ 2010 and " Inquiry for organ tissue donation " dated 11/1/2005 were reviewed at this time as well. Interim CNO, B and RN/ED, R explained the procedure for calling the OPO after a death has occurred. RN/ED, R explained staff can call for imminent death but was not certain that was part of the procedure.

On 11-16-2011 at 1:30 pm a review of the Letter of agreement between the OPO and Hospital was reviewed. The agreement states in part, " Hospital shall notify UWHC-OPO by telephone of any individual whose death is imminent or who has died at the hospital, " and "Hospital shall accept the definition of " imminent death " established by the UWHC-OPO."

At 2:06 pm Interim CNO, B explained the hospital policy and procedures do not include a definition of imminent death and do not direct staff to notify the OPO of imminent death.





26711

Findings by Surveyor #26711:

A MR review was completed on 11/17/2011 at 7:40 a.m. on Pt. #12's closed death record in the presence of Mgr. A. Pt. #12 was admitted to the facility on 4/17/2011 at 8:30 p.m. and passed away on 4/18/2011 at 11:50 a.m. The OPO was notified of death at 11:55 a.m. and was not notified prior to this time that death was imminent.

A MR review was completed on 11/17/2011 at 7:50 a.m. on Pt. #13's closed death record in the presence of Mgr. A. Pt. #13 was admitted to the facility on 3/18/2011 and passed away on 3/20/2011 at 10:35 p.m.. There is no documentation as to when the OPO was notified of death and the OPO was not notified prior to death that it was imminent.

A MR review was completed on 11/17/2011 at 8:00 a.m. on Pt. #14's closed death record in the presence of Mgr. A. Pt. #14 was admitted to the facility on 6/17/2011 and passed away on 6/22/2011 at 3:05 a.m. The OPO was notified of death at 3:25 a.m. and was not notified prior to this time that death was imminent.

A MR review was completed on 11/17/2011 at 8:05 a.m. on Pt. #15's closed death record in the presence of Mgr. A. Pt. #15 was admitted to the facility on 4/5/2011 and passed away on 4/12/2011 at 8:55 a.m.. There is no documentation as to when the OPO was notified of death and the OPO was not notified prior to death that it was imminent.

These findings were confirmed by Mgr A at the time of discovery.

Based on interview, Policy & Procedure review, and record review the hospital failed to include a complete discharge in the transfer and discharge process in 2 of swing bed discharge records (Pt. #5 and 6).

Findings by Surveyor #26390 include:

On 11-15-11 at 8:14 AM an interview was completed with RN/Case Mgr, Z and RN/Interim CNO, B. RN/Case Mgr, Z explained the discharge process in that the physician completes a discharge summary and RN/Case Mgr, Z will assist when needed with placement or any other pt. needs for post care. RN/Case Mgr, Z also explained they do not have a procedure in place for notifying pt.'s of their transfer and discharge rights in a written notice.

On 11-15-11 at 9:00 AM a review of the hospital P&P titled, "Skilled Nursing Bed Program" was completed. The policy states the following related to discharge, "The patient will be discharged from the Medicare Skilled Nursing Bed when he/she no longer meets the criteria for skilled care as the patients goals have been met." "The physician shall discharge the patient from the SNB if the continued stay review does not indicate the need for this program".




26711

Findings by Surveyor #26711:

A MR review was completed on Pt. #5's closed Swing Bed MR on 11/15/2011 at 2:47 p.m. in the presence of Mgr. A. Pt. #5, 79 years old, was admitted on 10/7/2011 and discharged on 10/14/2011. There was no Swing Bed transfer/discharge notice.

A MR review was completed on Pt. #6's closed Swing Bed MR on 11/16/2011 at 11:40 a.m. in the presence of Mgr. A. Pt. #6, 66 years old, was admitted on 9/9/2011 and discharged on 9/16/2011. There was no Swing Bed transfer/discharge notice.

These findings were confirmed at the time of discovery by Mgr. A, HIM.

Based on staff interview the hospital failed to provide an ongoing program of activities for swing bed patients. Failure to provide an activity program for Swing Bed patients affects all patients to be admitted to the program.

Findings include:

On 11-15-11 at 8:14 AM an interview with RN/Case Mgr, Z and RN/Interim CNO, B was completed. RN/Case Mgr. Z explained that Occupational therapy takes care of that. RN/Case Mgr. Z also stated that they do not have an activity schedule.

On 11-15-11 at 10:34 AM an interview was completed with Rehab Mgr BB. Rehab Mgr BB explained that the Occupational Therapists (OT) conducts an assessment for swing bed pt.'s. They do not use an ongoing program or a calender for ongoing activities; but rather do individualized activities per patient need.