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Based on observation, record review and staff interviews, the facility failed to construct, install and maintain the building systems to ensure a physical environment that was safe for patients and staff. The cumulative effects of the environment deficiencies result in the hospital's inability to ensure a safe environment for all patients and staff.

Findings include:

The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags

K-0131 Occupancy Separation
K-0321 Hazardous Areas - Enclosure
K-0372 Smoke Barrier Construction
K-0918 EES Maintenance and Testing
K-0919 Electrical Equipment - Panels

As a result of these deficiencies, 42 CFR 485.623 Condition of Participation: Physical Plant and Environment was NOT MET.

Based on observation, record review and interview, the facility failed to monitor refrigerator/freezer temperature control per policy in 3 of 3 departments (Emergency, Medical/Surgical and Pharmacy) with refrigerators, facility failed to ensure patient preventative maintenance on patient equipment (automated blood pressure machine) to assure it is maintained in a safe operating condition in 1 of 11 patient care departments (Emergency Department) in a total sample of 15 departments observed and facility failed to ensure that the oxygen and liquid nitrogen tanks were in working order in 1 (South Clinic) of 1 clinics observed in a total sample of 3 clinics.

Findings Include:

A review of the facility policy titled, "Medication Refrigerator and Freezer Temperature", last reviewed 02/10/2022, revealed: "I. POLICY: All medications requiring temperature/freezing will be stored in a refrigerator or freezer capable of maintaining proper temperature requirements. II. PROCEDURE/GUIDELINES: "...Med/Surg, ER & Pharmacy medication refrigerator/freezers will be monitored twice daily for temperature and documented in the book located by the refrigerator ..."

During a tour of the Emergency Department and Medical/Surgical Department with Charge Registered Nurse E on 09/20/2022 at 9:10 AM, observed three automated blood pressure machines in the Emergency Department, one medication refrigerator in the Emergency Department and one medication refrigerator in the Medical/Surgical Department.

A review of the 2022 Emergency Department "Refrigerator Temperature Log" revealed, refrigerator temperature readings were not documented on the following dates: 01/08/2022, 02/27/2022, 03/19/2022, 03/20/2022 and 05/30/2022.

A review of the 2022 Medical/Surgical Department "Refrigerator Temperature Log" revealed, refrigerator temperature readings were not documented on the following dates: 01/02/2022, 02/04/2022, 02/27/2022, 03/06/2022, 03/26/2022 and 03/27/2022.

A review of the Preventative Maintenance stickers on the three automated blood pressure machines in the Emergency Department revealed, one blood pressure machine was overdue on maintenance per the Preventative Maintenance sticker on the machine, maintenance was due on "5/22" and last maintenance was done on "7/21." Charge Registered Nurse E confirmed that maintenance was overdue and took the automated blood pressure machine out of service in the Emergency Department.

During an interview with Charge Registered Nurse E on 09/20/2022 at 9:56 AM, when asked who checks and documents the medication refrigerator temperatures for the Emergency Department and the Medical/Surgical Department, Charge Registered Nurse E stated that "Nursing staff" do the checks and Pharmacy keeps the forms. Charge Registered Nurse E confirmed there should be documented refrigerator temperature checks done twice daily on the temperature logs.

During an interview with Chief Nursing Officer A on 09/22/2022 at 10:15 AM, when asked about the overdue preventative maintenance on the automated blood pressure machine in the Emergency Department, Chief Nursing Officer A stated "Biomed does the checks, it should have been checked but he [Biomed Technician] didn't check it."

During a tour of the Pharmacy Department with Pharmacy Technician/RN Lead I and Pharmacy Technician/RN Lead J on 09/20/2022 at 11:42 AM, observed one medication refrigerator and freezer in the Pharmacy Department.

A review of the 2022 Pharmacy Department "Refrigerator/Freezer Temperature Log" revealed, refrigerator temperature readings were not documented on the following dates: 01/08/2022, 01/15/2022, 01/29/2022, 02/27/2022 and 03/19/2022; and freezer temperature readings were not documented on the following dates: 01/08/2022, 01/15/2022, 01/29/2022, 02/27/2022 and 03/19/2022.

During an interview with Pharmacy Technician/RN Lead I and Pharmacy Technician/RN Lead J on 09/20/2022 at 11:43 AM, when asked about missing refrigerator and freezer temperature checks, Pharmacy Technician/RN Lead J stated that missed temperature readings sometime happen on the weekends or holidays due to staffing.


37419


On 9/20/2022 at 2:37 PM during tour of the South Clinic with Office Manager P, observed 2 large green tanks of oxygen (O2). One 02 tank was empty and one was half full. Also observed one large and one smaller tank of liquid Nitrogen, the large one was empty and the smaller one was half full. When asked how frequently these tanks are checked, Office manager P stated Respiratory Therapy comes monthly to refill the tanks. Office Manager P stated s/he could not recall when the tanks were filled last.

On 9/21/2022 at 2:17 PM during interview with Respiratory Therapy Manager X, RT Manager X stated s/he keeps track of the monthly tank checks at the clinic on his/her calendar. When asked the last time the tanks were checked and filled, RT Manager X stated "I write it on my calendar," last month's calendar was thrown away, and s/he could not recall. RT Manager X stated there was no policy to monitor the 02 or liquid nitrogen tanks at the Outpatient Clinics.

Based on observation, record review and staff interviews, the facility failed to construct, install and maintain the building systems to ensure a physical environment that was safe for patients and staff. The cumulative effects of the Life Safety deficiencies result in the hospital's inability to ensure a safe environment for all patients and staff.

Findings include:

The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags

K-0131 Occupancy Separation
K-0321 Hazardous Areas - Enclosure
K-0372 Smoke Barrier Construction
K-0918 EES Maintenance and Testing
K-0919 Electrical Equipment - Panels


As a result of these deficiencies, 42 CFR 485.623(c) Life Safety from Fire was NOT MET.

Based on observation, record review, and interview the facility failed to receive and dispense sample medications according to their policies and procedures to ensure medications are administered according Wisconsin Chapter Medical Examining Board (Med) 17 (Standards for Dispensing & Prescribing Drugs) in 1 of 1 sample medication administration areas observed (South Clinic) in a total of 1 of 3 outpatient clinics.

Findings include:

Standards for Dispensing & Prescribing Drugs, Med 17.05 Recordkeeping.
(1) Prescription drugs. (a) A practitioner shall maintain complete and accurate records of each prescription drug received, dispensed or disposed of in any other manner.

Record review of policy "Sample Medications" last review date 4/2015 revealed "All sample medications will be recorded in the Received Log upon being put on the self (sic) in the med (medication) room... When dispensing sample medications will be recorded in the Dispense Medication Log... Sample medications will be checked for outdates once a month."

On 9/20/2022 at 2:37 PM during interview with Office Manger P and Licensed Practical Nurse (LPN) Q, when asked what the yellow stickers indicated on the sample medication boxes, LPN Q stated that means they were logged in the Sample Medication Log as received. When asked who enters them into the log, LPN Q stated the drug reps from the drug companies log them. When asked how they were dispensed, LPN Q stated the physician tells the staff when to dispense them and they are logged in the Sample Medication Log as dispensed. When asked who checks to make sure none of the medications are expired, LPN Q stated they take turns checking for "outdates," a "monthly check" is done, but the monthly checks are not documented.

On 9/20/2022 at 2:37 PM with Office Manager P, observed sample medications on two large wire shelving units. At least 75% of the sample boxes did not have yellow stickers on them indicating the samples were written into their Received Log binder.

On 9/20/2022 at 3:22 PM with Licensed Practical Nurse (LPN) Q and Office Manager P, observed there were 13 boxes of Jardiance 25 mg (7 tablets per box) (oral diabetic medication) with no yellow stickers on them, 2 boxes of Synjardy 12.5/1000 mg (14 tablets per box) (helps improve blood sugar) with no yellow stickers, and 6 boxes of Eliques 2.5 mg (14 tablets per box) (used to prevent blood clots) with no yellow stickers.

Record review of log titled "Sample Medication Log RECEIVED" revealed 8 columns titled Pharmaceutical Co./Manufacturer, Medication, Dose/Strength, Lot #, Exp. [expiration] date, Quantity Received, Date Received and Initials. Six months of hand written log entries included:
Under Medication "Jardiance" Dose/Strength "25 mg", Quantity Received "14" Received " " " (sic)(9-15 written above); Quantity Received "14", Date Received "8/17"; Quantity Received "12", Date Received "5/11"; Quantity Received "16", Date Received "4/14/22." A total of 56 boxes of Jardiance 25 mg boxes were received in the last 6 months.

Under Medication "Synjardy" Dose/Strength "12.5/1000 mg" Quantity Received "15", Date Received " " " (sic)(9-15 written above). A total of 15 boxes of Synjardy 12.5/1000 mg were received in the last 6 months.

Under Medication "Eliques" Dose/Strength "2.5 mg" Quantity Received "10", Date Received "8/22"; Quantity Received "20", Date Received "8/01"; "Quantity Received "20", Date Received "5/26"; Quantity Received "10", Date Received "4/19/22"; Quantity Received "10", Date Received "4/28." A total of 70 boxes of Eliques 2.5 mg were received in the last 6 months.

Record review of log titled "Sample Medication Log DISPENSED" revealed 10 columns titled Patient's Name, Dispensing Practitioner's Name, Pharmaceutical Co./ Manufacturer, Medication, Dose/Strength/ Lot #, Exp. Date, Quantity Dispensed, Date Dispensed, Initials. A total of two pages were in the log binder. The hand written log entries included:
Under Medication "Jardiance" Dose/Strength "25 mg" Quantity Dispensed "4 bottles" Date Dispensed "12/2/21"; Quantity Dispensed "6 bottles" Date Dispensed "12/02/21." A total of 10 "bottles" were dispensed. There were 56 boxes of Jardiance 25 mg logged in the Received Sample Medication Log within the last 6 months and there were 10 "bottles" listed in the Dispensed Sample Medication Log. 46 medications listed as Jardiance 25 mg were not listed in the Dispensed Sample Medication Log.

There were no entries for Synjardy 12.5/1000mg. There were 15 boxes of Synjardy 12.5/1000 mg brought in within the last 6 months and there were only 2 on the shelf. 13 boxes were not listed in the Dispensed Sample Medication Log.

There were no entries for Eliques 2.5 mg. There were 70 boxes Eliques 2.5 mg logged in the Received Sample Medication Log within the last 6 months and there were only 6 boxes on the shelf.

On 9/20/2022 at 4:45 PM during interview with LPN Q and Office Manager P, when asked if there were more current pages of the Dispensed Sample Medication Log, Office Manager P stated there were not, that's all they had. When asked who logs the sample medications when they are given out, LPN Q stated "we do." When asked to clarify who we was, LPN Q stated "the nurses." When asked who else would give out sample medications, LPN Q stated the providers do. When asked if I could speak to one of the providers, Office Manager P stated they had all left for the day.

Based on record review and interview the facility failed to ensure that dietary consults were documented per physicians orders in 1 of 20 patient (Patient #7) records reviewed out of a total universe of 20 open and closed records.

Findings include:

A review of the facility policy titled, "EMR Charting Guidelines & Responsibilities" last reviewed 03/01/2022, revealed: "...II. PROCEDURE/GUIDELINES:...4. Each discipline is responsible for initiating, maintaining and completing appropriate forms in the medical records...OMISSIONS: 1. Documentation should occur as soon as possible after care is rendered or events occur..."

Review of Patient (Pt.) #7's medical record revealed Pt. #7 was admitted to the Medical/Surgical unit 09/09/2022-09/16/2022 for treatment of "cellulitis both lower extremities, congestive failure (congestive heart failure)." Pt. #7 was then transferred to Swing bed status on 09/16/2022-09/21/2022 for continued therapies to assist with ambulation prior to discharge. Dietician consults were ordered by Physician Y on 09/09/2022 and 09/16/2022 for "Cardiovascular Diet"; there was no documented evidence of Pt. #7 being seen by a Dietician during hospitalization (09/09/2022-09/21/2022) per chart review.

During an interview with Dietician V on 09/21/2022 at 1:45 PM, when asked if he/she saw Pt. #7 for Dietary consult/s ordered, Dietician V stated, "I did do it." When asked where the consultation documentation was in the chart, Dietician V confirmed that he/she "didn't document" the consult.

Based on record review and interview the facility failed to follow their policies and procedures to ensure an operative report was dictated within the designated time frame in 1 of 6 surgical records reviewed (Patient #18) in a total of 30 medical records reviewed.

Findings included:

Record review of "Medical Staff Bylaws Rules and Regulations" not dated, page 26 under Operative Reports revealed " An operative report ... will be written or dictated immediately following surgery."

Record review of Patient #18's medical record revealed Patient #18 was an 85-year-old who presented 8/11/2022 at 7:55 AM for an open left inguinal hernia under monitored anesthesia care (MAC) and discharged 8/11/2022 at 1:33 PM. The operative report was dictated 8/13/2022 (2 days after the procedure) at 12:45 PM and signed 9/01/2022 (21 days after the procedure).

On 9/22/2022 at 9:30 AM during interview with Operating Room Manager B during review of Patient #18's operative report review, Manager B stated the operative report was not dictated until 2 days after his/her procedure.

On 9/22/2022 at 10:05 AM during interview with Heath Information Manager C, Manager C stated "I called [his/] office and spoke to [his/her] receptionist shortly after the procedure that day" and confirmed it took 2 days to dictate Patient #18 operative report and 21 days for him/her to sign it.

Based on observation, record review, and interview the facility failed to ensure confidentiality of their medical records by failing to secure their outpatient clinic records in 1 of 2 storage areas in 1 (South clinic) of 3 outpatient clinics observed.

Findings include:

Record review of policy "Storage of Medical Records" South Clinic, revealed the Medical Records will be stored in filing cabinets in the clinic office. The clinic office will be staffed at all times and when not the filing cabinets will be locked to prevent patient/visitors and employees from having acess to the medical records."

On 9/20/2022 at 3:35 PM in the nursing station observed a file on the desk containing papers clipped together stacked in the paper holder. When asked what these papers were and if they remained there overnight, Licensed Practical Nurse (LPN) (R) turned them over revealing 10 clipped together medical record charts with lab results. LPN (R) stated they were charts with lab results waiting to be scanned. On the second level of the file, were 34 sheets clipped together. LPN (R) stated they were referrals that were sent and kept there to refer to if there were any questions. LPN (R) stated they would eventually be scanned and shredded.

On 9/20/2022 at 3:35 PM during interview with Office Manager P, when asked if housekeeping cleans after hours, Manager P stated they come in the evenings. When asked if the medical records on the file on the desk were put into the locked storage cabinet at night, Manager P stated "no, we will need to do that."

Based on observation, record review and interview, the facility failed to maintain a clean and sanitary environment to avoid sources and transmission of infection in 7 of 15 departments (Emergency Room, Medical/Surgical, Laboratory, Dietary, Environmental Services, Operating Room, and Cardiac Rehab) observed; the facility failed to follow their hospital-wide infection surveillance and prevention program that adhered to Centers for Disease Control (CDC) nationally recognized, "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the COVID-19 Pandemic Infection Control Guidelines" in 1 of 1 infection control programs reviewed. The failure of these deficient Infection Control practices has the potential to adversely affect all patients, visitors and staff.

Findings include:

The facility failed to designate a qualified person that is responsible for the infection prevention and control program. See Tag 1204

The facility failed to maintain a clean and sanitary environment to avoid sources and transmission of infection, including: inappropriate storage of dirty instruments and disposal of expired nourishment/food. See Tag 1208

The facility failed to ensure systems are in place and operational for infection prevention and control for COVID-19, including: failed to ensure screening for COVID-19 exposure and symptoms, and failed to post COVID-19 infection prevention and control signs/visual alerts to help prevent the transmission of COVID-19. See Tag 1225

The faciilty failed to develop and implement a facility-wide antibiotic stewardship program. See Tag 1244

Based on record review and interview the facility failed to ensure that the individual assigned to the Infection Prevention and Control position is qualified in infection prevention and control in 1 of 1 Infection Prevention Control Program.

Findings include:

During an interview on 9/20/22 at 2:00 PM, Medical Lab Technician (MLT)/Infection Preventionist (IP) K stated, "I've been in this role since March 2020 and then COVID-19 hit. I've had very little training in this role. I do walk around audits, but I don't have documentation of them." When asked about the facilities Infection Prevention and Control Plan, IP K presented a facility document titled, "2018 Infection Prevention and Control Plan", MLT/IP K stated, "I haven't had time to update this plan."

During personnel file record review on 9/21/2022 at 1:30 PM, review of MLT/IP K employee file did not reveal a IP job description or education/certification specific to the IP role.

During an interview on 9/20/2022 at 4:00 PM, Chief Nursing Officer A stated, "We don't have a job description for the Infection Preventionist role."

Based on observation, record review and interview, the facility failed to maintain a clean and sanitary environment free from potential sources of contamination for 7 of 15 departments (Emergency, Medical/Surgical, Labratory, Dietary, Evironmental Services, Operating Room and Cardiac Rehab), the facility failed to adhere to infection prevention and control Personal Protective Equipment (PPE) policies in 1 of 11 patient care areas (Laboratory) in a total sample of 15 departments observed.

Findings include:

A review of the facility policy titled, "Patient-Resident Rights & Responsibilities", last reviewed 03/02/2022 revealed: "...Will promote your right to receive care and treatment in a manner and in an environment that maintains or enhances your dignity and respect..."

Emergency Department

During a tour of the Emergency Department (ED) with Charge Registered Nurse E on 09/20/2022 at 9:10 AM, observed peeling paint on the wall by the patient bathroom.

Medical/Surgical Department

During a tour of the Medical/Surgical (Med/Surg) Department with Charge Registered Nurse E on 09/20/2022 at 9:56 AM, observed water dripping with black staining under the sink in the medication room.

During an interview on 09/22/2022 at 9:30 AM with Plant Maintenance T, when asked about environmental rounding and maintenance work orders, Plant Maintenance T stated, "There is no policy on environmental rounding, if we are down on census we do more frequent rounding; I rely on nurses to put in maintenance orders for things that need to be fixed." Plant Maintenance T confirmed that no orders were placed to maintenance for peeling paint in the ED or the leaking sink in the medication room in the Medical/Surgical Department.

A review of the facility policy titled, "Personal Protective Equipment Guidance for Novel Respiratory Virus, COVID-19", last reviewed 03/04/2021 revealed: "...C. Eye Protection Eye protection (face shield or goggles) will be used by all team members and providers providing patient care regardless of patient's COVID-19 status in communities with moderate to substantial COVID-19 transmission..."

A review of the CDC COVID-19 Data Tracker dated 09/15/2022 through 09/21/2022 identifies High (Red) Community COVID-19 Transmission for Pepin County (where the facility is located).

Laboratory Department

During a tour of the Laboratory Department on 09/21/2022 at 9:24 AM with Laboratory Manager U, observed Medical Laboratory Technician (MLT)/Infection Preventionist K collecting a nasal swab on two scheduled patients in the COVID-19 drive-up testing area; MLT/Infection Preventionist K was not wearing eye protection (face shield or goggles) while collecting COVID-19 nasal swabs for both patients.

During an interview on 09/22/2022 at 10:00 AM with Medical Laboratory Technician (MLT)/Infection Preventionist K, when asked about eye protection while collecting COVID-19 nasal swabs on patients, Medical Laboratory Technician (MLT)/Infection Preventionist K stated, "I thought wearing eye glasses were good, but I probably should have something covering the sides of the eyes."

During an interview on 09/22/2022 at 10:05 AM with Laboratory Manager U, when asked if Laboratory staff collecting COVID-19 nasal swabs should be wearing a face shield or goggles-or are eye glasses sufficient, Manager U stated "Yes, [he/she] normally wears a face shield when [he/she] swabs patients; I told them eye glasses are not enough." When asked if Laboratory staff have been trained on PPE while collecting COVID-19 swab specimens in the drive-through testing area, Laboratory Manager U stated "Yes, they've all had training and they know."



37419


Dietary Services

Record review of policy "Food Dating #NT-124, dated 01/28/2021 under Procedures/Guidelines revealed "Date all items with month, day and year." Rotate using FIFO (First In, First Out). Freezer items - Date outside of box unless removed from box. Dry storage items that are left in boxes - Date outside of box. All attempt will be made to eliminate corrugated cardboard boxes. If the box has the expiration date and the items being removed do not, employee will write expiration date on the packages."

Record review of policy "Storage & Labeling of Foods for Later Use" #NT 142, dated 01/28/2021 revealed all containers containing PHF (potentially hazardous foods) "will be labeled with the contents and the date the PHF was opened or prepared... will be used or discarded after 72 hours (3 days)." Commercially produced foods "will be used or discarded within 7 days of opening or by the "use by date." Whichever date comes first."

Record review of policy "Frozen & Freezer Food Storage" #NT141, dated 01/27/2022 under procedure revealed "All items placed in freezer will be in properly sealed/resealed packages, dated in the original packaging or logged on the log sheets. 6. Log sheet must state, date placed in freezer, name of the item, and date it went out of the freezer... 8. All items placed in freezer may be stored for maximum of 4 months."

On 9/20/2022 from 11:03 AM to 12:15 PM, during tour with Dietary Manager N, observed:

In the walk-in refrigerator 1 bag of cabbage with no date sticker, expiration date 9/16/2022 on package; 1 bag of cut celery pieces with sticker date 9/07, no expiration date (greater than 7 days); 1 bag of carrots, sticker date 9/05 and "best by" date 9/14; 3 peppers and 1 soft cucumber with no date stickers; 1 large bag and one l/2 bag of shredded lettuce with no date stickers or expiration dates.

In the dry storage room 1 small bag of almonds with no sticker date, expiration date 9/14/2022; 1 jar cocktail peanuts expiration date 5/17/22; 1 can sweetened condensed milk with expiration date 8/2022; 14 bags of powdered sugar with no date stickers or expiration dates; 4 bags 8 ounce toffee bits with no sticker date or expiration dates; 1 bag labeled cinnamon & sugar sticker date 7/26/2022 with no expiration date; 1 large container [classic roast coffee] expiration date 2/10/2022, 1 large container [decaffeinated coffee] with expiration date 3/04/2022; 1 box pancake and baking mix date sticker 2/15 and expiration date 10/08/2021; 1 opened box cream of wheat in plastic bag with small holes in bottom of bag with expiration date of 1/13/2022; 1 one gallon plastic container of mayonnaise with sticker date 6/08 with no expiration date; 2 large 1 gallon containers Miracle Whip with date stickers 7/13 with no expiration date; 1 four quart container of canola oil with no date sticker; 1 container Ranch buttermilk dressing with no date sticker, expiration date 7/19/22; 2 six ounce cans of tomatoe paste with no date sticker, expiration date 4/18/22; 8 large cans cream of mushroom soup with sticker dates 9/16, with expiration dates 7/31/2022.

In the walk-in freezer 1 twelve pack of potato rolls with no date sticker, expiration date of 8/12/2022; 5 large bags of baby carrots with no date stickers or expiration date; 7 large bags of broccoli with no date stickers or expiration date; 3 large bags of peas with no date stickers or expiration date; 1 large bag of mixed vegetables with no date stickers or expiration date; 13 small Styrofoam containers labeled "Prune power" dated 11/16/2021 (greater than 4 months old).

In stand-up refrigerator 1 bag hand written "Turkey/Ham" with date sticker 7/28. Manager N stated it was recently taken out of the freezer. Log on clipboard titled "Walk-In Freezer: Leftovers Can Be Held for 4 Months" on row 10, under columns Date In: "7-28-22," under Item "Turkey Ham pcs" (pieces) and under Amount "1 bag" hand-written in. Manager N stated there should have been a date sticker on the turkey/ham indicating when it was put in the refrigerator and the turkey/ham should have been marked off the log on the clipboard.

In freezer on top of stand-up refrigerator with 1 bag labeled Turkey Ham pieces with date sticker 9/13, 1 bag labeled Bacon pieces date sticker 9/13, 1 bag labeled sausage with date sticker 9/13, and 1 bag labeled turkey with date sticker 7/28. All items not listed on freezer log sheet.

Upright freezer on the right of the entrance door with plastic bin labeled "M & M cookies" with 5 cookies inside with date sticker 4-15-2022 (greater than 4 months); 2 bags of cranberries with no date stickers, no expiration dates; 9 loaves of bread with no date stickers and expiration date of 5/26/2022; one bag with bag of yeast with expiration date 10/2014.

Shelf by the customer window across from the grill an open bag of pancake mix had two date stickers on bag "9/16" and "11/17" in a plastic container.

On 9/20/2022 at 11:42 AM during an interview with Cook O, when asked what the date stickers indicated, Cook O pointed to the 9/16 sticker and stated that was "the open date." When asked what the 11/17 date sticker indicated, Cook O stated "The expired date, the received date? I'm not sure." When asked how their sticker system works, Cook O stated one sticker is placed on the food item "when it comes in" and another sticker is placed on the food item "when it is opened."

On 9/20/2022 at 12:15 PM during interview with Dietary Manager N, when asked if all food is marked with the date when it was received, Manager N stated "they should be, yes." Manager N stated s/he has not been here that long, is still "figuring out" the processes, and determining priorities. Manager N confirmed the foods that were expired should have been "thrown out."

Operating Room

Record review of policy "Surgical Attire" last reviewed 02/2022, revealed "All head and facial hair is to be covered while in the restricted areas."

On 9/21/2022 at 8:45 AM during observation of a cystoscopy procedure on Patient # 17, observed Doctor (Dr.) Y walk into procedure room, sign the surgical consent, and don sterile surgical gloves, without completing hand hygiene. Observed Dr. Y with sideburns and facial hair not covered.

On 9/20/2022 at 9:02 AM during interview with Operating Room Manager B, Manager B stated they follow the AORN (Association of periOpertive Registered Nurses) standards of practice. The AORN recommends hand hygiene before and after donning gloves.

On 9/21/2022 at 9:05 AM during interview with Operating Room (OR) Manager B, when asked what their policy was on covering facial hair, OR Manager B stated "they should be using beard guards" and it should be "covered." When asked if s/he saw Dr. Y complete hand hygiene prior to donning gloves before the procedure, OR Manager B stated "they usually use [hand sanitizer]" and confirmed it was not done.

On 9/21/2022 at 9:32 AM during tour with Certified Registered Nurse Anesthesist (CRNA) AA, opened anesthesia supply cart and observed one large bag of normal saline with expiration date 11/2021 and one package blood tubing with expiration date 11/2021.

On 9/21/2022 at 9:32 AM during interview with CRNA AA, CRNA AA stated, "I'll get rid of those."

Environmental Services

Record review of policy "Hospital Patient Rooms" last review date 11/05/2020 revealed Cubicle curtains will be taken down and washed twice a year and/or replaced whenever soiled."

On 9/21/2022 at 1:21 PM during observation with Environmental Service (EVS)/Dietary Manager N, of Housekeeper BB doing a terminal cleaning of Room 104 after a patient was discharged, observed one curtain hanging in the middle of the room as a divider, a curtain topper above the window, and a shower curtain in the bathroom. When questioned when the last time the curtains were cleaned, EVS Manager N stated "what do you say, every other month or so?" Housekeeper BB stated "I don't believe so, we used to." EVS Manager N stated they would check with maintenance for the cleaning log.

On 9/21/2022 at 3:50 PM during interview with EVS Manager N, EVS Manager N stated the policy stated the curtains are cleaned twice a year but there is "no cleaning log." EVS Manager N stated "I could not say" when the curtains were cleaned last or when they were due to be cleaned next.

Cardiac Rehab

On 9/22/2022 at 7:32 AM during observation of accucheck test completed by Cardiac Rehabilitation Coordinator W, Coordinator W completed the test and put the glucose machine back on the charger without cleaning it.

On 9/22/2022 at 7:32 AM during interview with Coordinator W, when asked if s/he routinely cleans the glucose machine after use, Coordinator W picked up the glucose machine, cleaned it with a sani-wipe, replaced it back on the charger and stated "I could" When asked if they had a policy on cleaning of the glucose machine, Coordinator W stated that s/he was not aware of one.

Based on interview and record review the facility failed to develop and implement a facililty-wide antibiotic stewardship program, based on nationally recognized guidelines in 1 of 1 Infection Prevention and Control programs reviewed.

Findings include:

A review of the facility policy titled, "RX 108 Duties of Pharmacist", dated 1/20/2021, revealed: "I. Policy: 1. Work under the direction of the P (Pharmacy) & T (Therapeutics) Committee and be responsible for meeting specifications of quality and quantity on all drugs in the drug room. 2. Be responsible to the Hospital for developing, supervising, and coordinating activities of the pharmacy. 3. Part-time Consultant Pharmacist is on duty in the pharmacy every Monday, Wednesday, and Friday for 1 - 2 1/2 hours and as necessary to refill pyxis or check refilling of pyxis done by tech and complete other duties as necessary to meet the needs of the Pharmacy Dept."

During an interview on 9/22/2022 at 9:35 AM, Pharmacist H stated, "We really don't have an antibiotic stewardship program here. Patients are started on a broad spectrum antibiotic and are usually discharged home before culture results are in. When they are doing better, they are changed to oral antibiotics."

Based on observation, interview and record review, the facility failed to ensure COVID-19 visual alerts were placed in strategic places with the current recommendations for infection prevention and control practices in 2 of 2 public areas (Waiting room and cafeteria) and 2 of 2 public entrances, in a total universe of 4 public areas.

Findings:

Review of CDC Nationally recognized, "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, last updated September 23, 2022, revealed: "Ensure everyone is aware of recommended IPC [infection prevention control] practices in the facility. -Post visual alert (e.g., signs, posters) at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias) with instructions about current IPC recommendations (e.g., when to use source control and perform hand hygiene). Dating these alerts can help ensure people know that they reflect current recommendations. Establish a process to identify anyone entering the facility, regardless of their vaccination status, who has any of the following three criteria so that they can be properly managed:
1) a positive viral test for SARS-CoV-2
2) symptoms of COVID-19
3) close contact with someone with SARS-CoV-2 infection (for patients and visitors).."

A review of the CDC COVID-19 Data Tracker dated 09/15/2022 through 09/21/2022 identifies High (Red) Community COVID-19 Transmission for Pepin County (where the facility is located).

A review of the facility document titled, "2018 Infection Prevention and Control Plan", revealed: "Program Organization Structure and Authority: [facility name] will maintain an ongoing Infection Prevention and Control program designed to prevent, control, and investigate infections and commuicable diseases among patients, healthcare workers, and visitors."

On 9/20/2022 at 8:30 AM, entered the facility through the main entrance and did not observe any visual alerts with the recommended IPC [infection prevention control] practices in the facility.

On 9/20/2022 at 12:30 PM, entered the facility cafeteria and did not observe any visual alerts with the recommended IPC practices in the facility.

During an interview on 9/21/2022 at 11:45 AM, when asked when did the facility removed the COVID-19 Infection Prevention posters through out the facility, Chief Nursing Officer (CNO) A stated, "I don't remember."