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Based on document review and interview the hospital failed to follow Wisconsin Administrative Code Chapter DHS 13 that requires entities to report to the Wisconsin Department of Health Services, Office of Caregiver Quality, acts of abuse to a client from a caregiver. This has the potential to affect all patients receiving services at the hospital.


Findings include:

On 7-12-2012 at 8:30 AM a review of abuse, neglect and misappropriation report #12-447 was completed. The report shows on 1-13-2012 RN SSSS was observed by staff to slap a pt across the face.
At 10:10 AM QMC II explained the incident was not reported and there were a number of staff involved in the decision to not report the act to DHS.

The cumulative affect of this systemic failure resulted in the hospitals inability to properly protect pt's.

Based on document review and interview the hospital failed to report an act of abuse to the Department of Health Services.

Findings include:

On 7-12-2012 at 8:30 AM a review of abuse, neglect and misappropriation report #12-447 was completed. The report shows on 1-13-2012 Registered Nurse SSSS was observed by staff to slap a patient across the face.
At 10:10 AM Quality Management Coordinator (QMC) II explained the incident was not reported and there were a number of staff involved in the decision to not report the act to DHS.

Based on P&P, MR review, and staff interview, the facility failed to ensure staff appropriately assessed & met pt care needs and pt's response to interventions in 4 of 41 MR reviewed (pts #30, 31, 33, & 34). This had the potential to affect 462 in-pts on 7-10-12, 455 in-pts on 7-11-12, and 456 in-pt's on 7-12-12.

Facility policy titled, "Routine Daily Care," dated 8/12/2011, was reviewed on 7/12/2012 at 11:40 a.m. The P&P states in part, "B. Pts will be offered the opportunity to bathe or shower daily. Pts will receive assistance as required...D. Oral hygiene will be offered BID [twice per day] and as necessary. Pts who are NPO [nothing by mouth] will be offered oral hygiene more frequently...E. Pts will be offered hygiene and comfort measures at bedtime and as needed."

A MR review was completed on Pt. #34's closed MR in the presence of QMC R on 7/12/2012 at 9:10 a.m. According to Pt. #34's Physical Assessment Flow Sheets, there is no documentation that Pt. #34 was offered, or received, bath care, oral care or skin care on the following dates on day shift or p.m. shift: 6/29/12, 6/30/12, 7/1/12, 7/2/12, 7/3/12, 7/6/12, and 7/7/12.

These findings were confirmed by QMC R at the time of the MR review.

Finding by Surveyor #29972:

Policy: Documentation of NCP revised on 6/1/2011: The NCP plan and outcome management tools should reflect all the interventions that an RN is implementing for the pt's. In addition, the following events must be documented--1. All assessments. Acute care and exceptions are documented on the Physical Assessment Flow Sheet. D. All nursing care provided will be documented in the pt's medical record.

Policy: Pain Management revised on 3/19/2010: G (1). Patient assessment, reassessment, management and documentation in the medical record of pain will include: assessment tool used, pain rating, tolerable pain goal, location, quality, intervention. G (4). Reassessment of pain will occur within or about one hour of interventions

Review on 7/11/2012 beginning at 9:15 am of Pt #30's MR reveals the following: Review of Physical Assessment flow sheet dated 7/6/2012, 7/7/2012, and 7/8/2012 of the "Activities of Daily Living" chart shows no evidence of nursing interventions provided or offered from 7:00 am to 11:00 pm in the following categories listed; bathing, oral care, skin care, perineal/foley care, activity, turning every 2 hours, call light with in reach, side rails up, sequential compression device(SCD).

Review on 7/11/2012 beginning at 1:45 pm of Pt #31's MR reveals the following: Physical Assessment flow sheet with no date reveals the "Activities of Daily Living" chart shows no evidence of nursing interventions provided or offered from the hours of 7:00 am to 3:00 pm and 11:00 pm to 7:00 am the next day in the following categories listed; bathing, oral care, skin care, perineal care/foley care, monitor alarms on, activity, call light with in reach, turning every 2 hours, side rails up, SCD. During the hours of 3:00 pm to 11:00 pm there is no evidence of nursing intervention provided or offered for bathing, oral care, skin care, or foley care.

The "Activities of Daily living" has a column for staff to initial that care was provided from the hours of "7-15" "15-23" and "23-07". This practice does not allow for multiple entries of specific time of interventions, who provided the intervention, and pt's response to the intervention

Per interview on 7/11/2012 with RN SSS at 2:00 pm, and RN TTT at 3:00 pm, they do not routinely document when a pt is turned every 2 hours, or when a Pt is up to chair, up to bathroom, or back to bed. Per RN SSS and RN TTT pt activities of daily living are documented in end of shift progress note and on the Physical Assessment flow sheet, but do not contain each time the activities or interventions were done, who did it, and how the pt responded for each intervention provided or activity performed.

Review on 7/12/2012 beginning at 9:15 am of Pt #33's MR revealed the following: on 7/7/12 at 9:46 am pt #33 was given 20 mg of Oxycodone CR (controlled release), no pain assessment is documented at this time and pain reassessment not done until 2:57 pm. At 2:57 pm Pt #33 rated pain 8 out of 10 and was given Oxycodone 15mg IR (immediate release), pain reassessment not done until 8:14 pm. On 7/8/12 at 11:33 am Pt #33 rated pain 7 out of 10 and was given Oxycodone 15mg IR, pain reassessment not done until 5:30 pm.

The above findings were confirmed at time of review with QC S.

Based on record review, and interview the hospital failed to ensure plans of care including pertinent pt diagnosis, were individualized and updated. This occured in 17 of 41 records reviewed (pts. #3, 4, 29, 30, 31, 32, 33, 36, 37, 43, 44, 45, 46, 47, 48, 49, & 50). This had the potential to affect 462 in-pts on 7-10-12, 455 in-pts on 7-11-12, and 456 in-pts on 7-12-12.

Per Surveyor #18816 interview with RN S on 7/10/12 at 11:50 AM the NCP are "canned" and all interventions for each problem must be selected or once initiated they cannot retrieve new ones if, and when, there are changes in the pt's condition.

Pt #3's and #46 MR review by Surveyor #18816 on 7/10/11 at 10:45 AM revealed the NCP is not individualized to the pt. Pt #3 and #46 had a cesarean section without a prior labor, the NCP included the problem "Impaired Skin Integrity" with two interventions "cleanse incision(s) & chg (change) dressing(s)" and "inspect incision(s) &/or dressing". Per RN S in interview on 7/10/12 at 11:50, those interventions are the only ones available so always checked since they cannot go back and add interventions if needed when developing the NCP. Further, Pt. #3's NCP included the problem "Postpartum Pain" includes interventions for "Provide ice packs for 1st 24 hrs (hours)"and "Provide Perineal Analgesics", there was no vaginal delivery or labor to require ice packs or perineal analgesics. This is confirmed in interview with Mangers QQ and RR on 7/10/12 at 10:45 AM and 2:30 PM.

Pt #43, 44, and 45's MRs reviewed by Surveyor #18816 on 7/10/12 at 1:10 PM and 1:30 PM respectively revealed the Problem "Alteration in Comfort R/T labor" has identical interventions failing to provide interventions unique to the Pts. This is confirmed in interview with Mangers QQ and RR on 7/10/12 at 1:10 PM, 1:30 PM, and 2:00 PM respectively.

Pt #'s 4, 47, 48, and 49 reviewed by Surveyor #18816 on 7/10/12 at 11:00 AM, 1:20 PM, 1:45 PM, and 2:15 PM respectively revealed the NCPs are identical except for Pt #47 not having the intervention to monitor for hypoglycemia (low blood sugar) and for circumcision. This is confirmed in interview with Mangers QQ and RR on 7/10/12 at 11:00 AM, 1:20 PM, 1:45 PM, and 2:15 PM respectively.

Pt #50's MR review by Surveyor #18816 on 7/10/12 at 3:00 PM revealed there is no record of a NCP. Per interview with Manager QQ on 7/10/12 at approximately 3:30 PM there is a glitch in the interface between two computer systems that allowed the NCP for Pt #50 to be dropped and irretrievable once the MR is closed.


26711

Findings by Surveyor #26711:

A MR review was completed on Pt. #36's open MR on 7/11/2012 at 2:20 p.m. in the presence of RN NNN and Dir JJ. Pt. #36 was admitted to the facility on 6/22/2012 with an open wound to the buttocks that required surgical repair. Pt. #36 also is an incomplete quadriplegic (paralyzed partially from the neck down).

The NCP for Pt. #36 does not reflect the paralysis or need for intervention for mobility. RN NNN confirmed a mobility care plan should have been initiated.

A MR review was completed on Pt. #37's open MR on 7/11/2012 at 3:15 p.m. in the presence of RN OOO and Dir. JJ. Pt. #37 was admitted to the facility on 7/4/2012 for surgery for a broken leg. Pt. #37 is also a Diabetic and needs dialysis several times per week.

The NCP for Pt. #37 does not reflect that Pt. #37 is a Diabetic or needs dialysis. RN OOO confirmed that both of these problems probably should have been identified on the care plan for this pt.


29972

Findings by Surveyor #29972:

Review on 7/11/2012 beginning at 9:15 AM of Pt #29's MR reveals the following: Pt #29 was admitted for clotted leg graft on 7/10/2012 and received surgical interventions. Pt #29 is on in-pt dialysis. NCP does not reflect dialysis needs or skin intergrity needs post surgery.

Review on 7/11/2012 beginning at 10:30 am of Pt #30's MR reveals the following:
Pt #30 was admitted on 7/5/2012 and is on a in-pt dialysis. NCP does not reflect dialysis needs.

Review on 7/11/2012 beginning at 1:45 pm of Pt #31's MR reveals the following:
Pt #31was admitted on 7/10/2012 for a Nephrectomy and was on in-pt dialysis. Physician orders include NPO (no food by mouth) and strict I & O's (intake and output) NCP does not reflect dialysis or fluid management needs.

Review on 7/11/2012 beginning at 2:35 pm of Pt #32's MR reveals the following: Pt #32 was admitted on 7/10/2012 for bleeding from dialysis catheter. Pt #32 was on in-pt dialysis and does not speak english. NCP does not reflect catheter proplem, dialysis needs, or communication barriers.

Review on 7/12/2012 beginning at 9:15 am of Pt #33's MR reveals the following: Pt #33 was admitted on 6/1/2012 for poly drug overdose in an attempt to commit suicide. Pt #33 has had an above elbow amputation and lower leg amputation when admitted to hospital and is on in-pt dialysis. Pt #33 was on 15 minute checks for safety. NCP does not reflect fall risk, safety issues, and dialysis needs.

The above findings were confirmed at time of review with QC S.








29302

Findings by Surveyor 29302.

An open medical record review was completed on Pt #40 by Surveyor #29302 on 7/12/2012, from 10:02 AM - 10:45 AM, in the presence of CNS VVVV and NE WWWW. Pt. #40 was admitted to the facility on 6/09/2012 with weakness, fatigue and increased ascites. Diagnoses are Ascites, Leukocytosis and Acute Pancreatitis. According to Pt. #40 ' s Medical Nutrition Therapy, 6/18/12, 0825, nutrition diagnosis is inadequate protein-energy intake related to h/o (history of) poor appetite and overall medical condition as evidenced by reports of poor PO (oral) intake, weight loss, and now NPO (nothing by mouth).

According to " Census Report with Notes, " Pt. #40 began total parenteral nutrition on 7/9/2012 at 10:24. Surveyor #29302's review of the NCP for Pt. #40 indicates there are no nutritional concerns identified. RN UUUU, who was assigned to Pt. #40, stated to Surveyor #29302's that RN UUUU does not know why there is not a NCP for nutrition for Pt. #40. CNS VVVV stated there should be a nutrition plan of care for Pt. #40 and confirms there is not a nutrition plan of care for Pt. #40.

Based on observation, P&P review, and staff interview, this facility failed to properly identify medications upon opening them in two units observed (Out-pt Orthopedic Rehabilitation), and dispose of medications once expired in one unit observed (4 Pavilion). Failure to properly follow protocol for medication safety has the potential to affect all patients receiving care in this facility.

Findings by Surveyor #26711:

The facility policy titled, "Multiple Dose Medication Beyond Use Date," dated 4/12/2012, was reviewed on 7/9/2012 at 4:45 PM. The policy states in part, "2. Multiple-dose parenteral [injectable] medications vials (MDVs) shall be assigned a beyond-use date upon initial use. Assuming that recommended storage conditions have been maintained, parenteral MDVs must be discarded whenever one of the following occur, whichever occurs first....c. Twenty-eight days after initial entry into the vial....e. When the manufacturer's stated expiration date is reached."

Number 3 of this same policy states, "Staff will be responsible for indicating the beyond-use date on the package label of parenteral MDVs upon initial use."

During a tour of the out-pt orthopedic rehabilitation area on 7/9/2012 at 3:03 PM. accompanied by Dir JJ and KKK, a bottle of Dexamethasone (steroid preparation used during treatment in physical therapy) was found in a cupboard. The Dexamethasone was open and not dated.

In an interview with PTA LLL during the tour, LLL was unaware that a date was needed stating that a bottle usually only lasts two days. PTA LLL was reminded of the facility policy of dating the vial for the expiration date when it is opened by Dir JJ during the interview.

This finding was confirmed by Dir's LLL and JJ at the time of discovery.

A tour of 4th floor Pavilion was conducted on 7/9/2012 at 3:50 PM accompanied by Dir JJ and Manager KK. In a clean utility room a locked pharmacy box containing 24 different types of medications (some of these 24 medications had multiple vials) was discovered on a cart. The date on the card adhered to the top of the box was 7/2010. Manager KK stated KK was not aware the box was there and to KKs knowledge it had never been used.

A phone call was made by 4 Pavilion staff to the pharmacy regarding the box and it was discovered the box's purpose was for a back up supply of medications in the event of an emergent cardiac or respiratory event (Code Cart Back Up Box). The contents of the box was reviewed and all of the medications were expired. The expiration dates ranged from July 2010 through October 2011.

These findings were confirmed at the time of discovery by Director JJ and Manager KK.

Based on observations, P&P review, review of "Patient Information" booklet, and staff interviews this facility failed to maintain pt confidentiality with in-pt MRs by placing them in unlocked cabinets accessible to unauthorized personnel, visitors and other pts throughout the units surveyed. Failure to secure MR and maintain confidentiality has the potential to affect all pts receiving care on these units, including all pts present during the course of the survey.

Findings by Surveyor #26711 include:

The facility's policy titled, "Patient Rights and Responsibilities," dated 5/20/2010, was reviewed on 7,/12/2012 at 10:58 a.m. The policy states, in A. #6, "The patient's medical record, including all computerized medical information, shall be kept confidential in accordance with the requirements of state and federal law."

On page 3 of the Pt Information booklet, made available to all in-pts, #6 of the Pt Rights also states that confidential information will be kept confidential. It states in part, "The pt's health record, including all computerized medical information, is kept confidential in according to the requirements of state and federal law."

During a tour of the following units on the 5th floor: 5 SW, 5 NW, 5 NE, and 5 SE, on 7/9/2012 between 10:05 AM and 12:00 PM accompanied by Dir JJ it was noted that the paper portion of pt's MR are placed in cabinets called "nurse servers." These nurse servers are unlocked, can be opened from the hallway, and are accessible to anyone who would wish to access them. Throughout the 5th floor, MRs were present in many of these nurse servers unless they were at the nurses station with new orders.

An example of these findings is at 10:55 AM on 5 NW, staff from the Intravenous (IV) access team was in room #5102 putting in an IV in a pt's arm. The nurse server door was wide open to the hallway, the pt's MR was in the nurse server with the pt name exposed to the open hallway.

Dir JJ confirmed this finding and stated the chart should have been turned so that the name was not exposed to the hallway.



29972

Findings by Surveyor #29977:

On 7/9/2012 at 10:25 AM while touring the GI clinic observed a voided medication prescription for Oxycodone/Acetaminophen written for Pt #42 sitting face up in the garbage. The garbage was located in a hallway containing multiple pt exam rooms.

The above findings were confirmed at time of observation with RN U and Quality Coordinator S.

Based on 7 of 35 medical records reviewed (#3,16, 19, 29, 31, 32, 33), staff interview, and facility policy, the hospital failed to ensure orders were dated, timed, and authenticated.

Findings include:

The hospital's policy on orders entitled; "Orders - Patient Care" (CPM 0172) specifies: "All inpatient orders, when carried out or implemented, must be acknowledged with the individual's initials/name, date and time and should be reviewed for appropriateness."

Examples by surveyor 18816:

Pt #3's MR review by Surveyor #18816 on 7/10/12 at 10:45 AM revealed Anesthesiologist Orders for PACU-Labor and Delivery are signed by the nurse on 7/6 with no year documented, and time "3" with no indication if it is 3:00 AM or 3:00 PM. There is authentication of the orders by the anesthesiologist with a signature, date or time. The Discharge Orders/Physician Plan of Care is signed by the doctor as "7/ /12" with no day indicated and no time. This is confirmed in interview with Manager QQ and RR on 7/10/12 at 10:45 AM.

Findings by Surveyor #20878:

Pt. #19's MR was reviewed on 07/11/12. A verbal order transcribed on 09/30/11 was co-signed by the physician with no time or date.

Pt. #16's MR was reviewed on 07/11/12. A "Recombinant Factor VII Order form" was signed and dated by the physician on 07/02/11 but order was not dated.

These findings were confirmed per interview with QM-RN A on 07/11/12 at 1:30 PM.


29972

Findings by Surveyor #29972:

Review on 7/11/2012 beginning at 9:15 AM of Pt #29's MR revealed the following: Admission history and physical dated 7/10/2012 no time documented; Anesthesiologist Post-Operative order sheet dated 7/10/2012 has no time documented; Operating room summary dated 7/10/2012 has no time documented.

Review on 7/11/2012 beginning at 1:45 PM of Pt #31's MR revealed the following: Anesthesiologist Post-Operative order sheets dated 7/10/2012 have no time documented.

Review on 7/11/2012 beginning at 2:35 pm of Pt #32's MR revealed the following: Hemodialysis Pre-treatment RN assessment and Post-treatment RN assessment dated 7/10/2012 have no time documented. Dialysis Flow sheet dated 7/10/12 has no time documented of report to hospital RN.

Review on 7/12/2012 beginning at 9:15 am of Pt #33's MR revealed the following: Intraoperative orders dated 7/2/2012 not authenticated by physician timed or dated; Physician Operating Room summary not signed, dated, and timed by physician, Blood Transfusion Record dated 6/28/2012 has no time started documented and no date or time completed documented.

The above findings were confirmed at time of MR review with QC S.

Based on 6 of 35 medical records reviewed (#16, 17, 19, 25 34 and 36), interview with staff and review of facility policy, the hospital failed to ensure verbal orders were authenticated within the 24 hours dictated by their policy.

Findings include:

The hospital's policy on orders entitled; "Orders - Patient Care" (CPM 0172) specifies: "Verbal and telephone orders must be authenticated by a Prescribing Provider who is responsible for the care of the patient within 24 hours of receipt (co-signed)."

Findings by Surveyor #26711:

A MR review was completed for Pt. #34's closed MR on 7/12/2012 at 9:10 AM in the presence of QMC R. Pt. #34 has two verbal orders written by an RN from 7/3/2012 that were not signed by a physician; one verbal order from 6/27/2012 that is not timed with the signature and date of the physician; and three verbal orders written by RNs on 7/6/2012 that were not signed until 7/9/2012.

QMC R confirmed these findings at the time of discovery.

A MR review was completed for Pt. #36's open MR on 7/11/2012 at 2:20 PM in the presence of Director JJ. Pt. #36 has one verbal order written by an RN on 7/1/2012 that remains unsigned by a physician.

Director JJ confirmed this finding at the time of discovery.

Findings by Surveyor #20878:

A review was completed for Pt. #16's closed MR on 7/11/2012. Pt. #16 has four telephone orders transcribed by the RN on 7/1/2011 which were not signed by a physician.

QM-RN A confirmed these findings on 07/11/12 at 1:30 PM.

A review was completed for Pt. #17's closed MR on 7/11/2012. Pt. #17 has three verbal orders transcribed by the RN on 08/03/2011 which were not signed by a physician until 09/02/2011.

QM-RN A confirmed these findings on 07/11/12 at 1:30 PM.

A review was completed for Pt. #19's closed MR on 7/11/2012. Pt. #19 has two verbal orders transcribed by the RN on 9/30/2011 which were not signed by a physician until 10/13/2011.

QM-RN A confirmed these findings on 07/11/12 at 1:30 PM.

A review was completed for Pt. #25's open MR on 7/11/2012. Pt. #25 has two telephone orders transcribed by the RN on 7/3 and 7/4/2012 which were not signed by a physician.

QM-RN A confirmed these findings on 07/11/12 at 1:30 PM.

Based on MR review and interview, 2 of 35 (#34 and 36) pt. records did not have appropriate date and time documented on admission agreements. This has the potential to affect all patients admitted to the hospital.

Findings include:

A MR review was completed on Pt. #34's closed MR on 7/12/2012 at 9:10 AM in the presence of QMC R. Pt. #34's Admission Agreement does not include the time it was signed. The date is written over the area where the time should be.

QMC R confirmed this finding at the time of discovery during the MR review.

A MR review was completed on Pt. #36's open MR on 7/11/2012 at 2:20 PM. in the presence of Dir JJ. Pt. #36's Admission Agreement does not include the time it was signed. The date is written over the area where the time should be.

Dir JJ confirmed this finding at the time of discovery during the MR review.

Based on P&P, observations, and staff interview the facility failed to ensure drugs and biologicals are stored in a manner to prevent unauthorized access in 4 of 53 areas toured.

Findings by Surveyor #29972 on 7/9/2012:

Policy: General Statement of Pharmacy Operations last revised 2009:
"Medications on in-pt nursing units and select hospital out-pt departments are stored and secured in automated dispensing cabinets; or refrigerator storage areas as necessitated by individual drugs; or in the locked clean utility room. These areas are kept locked at all times and are note accessible to the public".

At 10:05 AM, during a tour of the GI clinic, a medication refrigerator was observed unlocked in hallway between exam rooms 6,7,8, and 9. Per interview with RN U staff is not always present in hallway.

At 10:35 AM in GI clinic exam room 1, observed an unlocked cabinet containing multiple boxes labeled Demonstration kit Pegintron. Instructions on boxes stated the following, "This kit is not to be left with or given to pt's. The contents of this kit are not to be used for actual injection in humans. Store kit in a locked cabinet as you would do with any materials containing a syringe." Per RN U the teaching is done by a pharmacist and the mediation is used for the treatment of hepatitis C.

The above findings were confirmed during tour with RN U and QC S.

At 10:55 AM in Code 4 room 4962 observed door propped open . Code 4 room contained emergency crash cart with break away lock and a locked medication refrigerator with the key in an unlocked drawer in the code room. Per RN W Code 4 room is left open during the day.

At 11:05 AM in Code 4 room 4962 observed unlocked cabinet containing 4 medication vials of Lidocaine 1%.
The above findings were confirmed during tour with RN W and QC S.

Findings by Surveyor #29972 on 7/10/2012:

At 9:45 AM during tour of the GI lab, observed doors leading into the GI lab propped open from main corridor of hospital. Per interview with RN U doors are left open for in-pts to come down for GI procedures otherwise they would not know when in-pts arrived.

In Procedure room 1, observed med drawer unlocked containing 2 vials of Benadryl, Atropine, Narcan, Flumazenil, and Epinephrine; no staff were present other than staff touring with surveyor.

In hallway of GI Lab observed an unlocked emergency medication cart containing Lidocaine, Morrhuate sodium, and Epinephrine. Per RN U this cart is taken to ICU for emergency GI procedures. Per RN U staff do not lock the medication carts in the GI Lab. RN U stated, "I don't know where the keys are".

The above findings were confirmed during tour with RN U and QC S.


22198

On 7/9/12 between 1:10 PM and 2:50 PM during the tour of the West Operating Room, 2- 20 milliliter (ml) syringes containing 40 milliequivalent per 20 ml of potasium chloride were lying in a bucket unsecured. This was confirmed by DSN E and Interim Dir of West Operating Rooms J.


26390


On 7/9/2012 at 2:00 PM a tour of the 6th floor MICU was completed with QM, A and DON, MMMM. Located at the end of the hallway, away from direct staff supervision crash cart #49 was observed with a plastic breakaway lock.

At 3:20 PM a tour of the Bone Marrow Transplant unit was competed with QM, A and Dir NNNN. Located at the back of the unit, away from direct supervision code cart #40 was observed with a plastic breakaway lock.

Based on observations, staff interviews, record reviews, P&P review and review of the 2009 Food and Drug Administration Food Code used as the facility's professional standards of practice for the food service department, the facility did not prepare and serve food under sanitary conditions.

· Garbage receptacles that were not in use were not covered.
· Numerous food items in cooler and freezer without labels.
· Chemicals stored in same area as food.
· Improper procedure followed for 3-compartment sink warewashing.
· Oven hood dusty and dripping with grease. Convotherm oven dirty.
· Staff not washing hands after removing gloves and putting on new pair.
· Staff using hand antiseptic in place of proper hand washing.

The totality of these concerns has the potential to affect 462 in-pts on 7-10-12, 455 in-pts on 7-11-12, and 456 in-pts on 7-12-12.

Findings include:

COVERING RECEPTACLES
According to the 2009 Food and Drug Administration Food Code, Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered:
(A) Inside the FOOD ESTABLISHMENT if the receptacles and units:
(1) Contain FOOD residue and are not in continuous use; or
(2) After they are filled;

Surveyor #29302 observed the following waste receptacles without covers and which were not currently in use:
7/10/2012, 9:58 AM, receptacle in salad bar prep area;
7/10/2012, 10:47 AM, receptacle outside freezer area;
7/10/2012, 1:32 PM, receptacle next to hand washing sink in main kitchen
7/10/2012, 1:36 PM, receptacle outside dining room door;
7/10/2012, 1:50 PM, two receptacles near tilt braising pan.

Surveyor #29302's observations of uncovered waste receptacles were validated by staff Food Service Director (FSD) ZZZ and QMC JJJJ.

FOOD STORED AND PREPARED IN A SAFE MANNER
According to the 2009 Federal Food Code, 3-501.17 Ready-to-Eat, Potentially Hazardous Food, (Time/Temperature Control for Safety Food), Date Marking.
" (A) ... READY-TO-EAT, POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold or discarded when held at a temperature of 5oC (41oF) or less for a maximum of 7 days. "

On 7/10/12 at 10:33 AM, Chief Clinical Dietitian YYY acknowledged to surveyor 29302 that the professional standard of practice used by the foodservice department is the 2009 Federal Food Code.

On 7/10/12 between 10:07AM -10:19 AM, Surveyor #29302 made the following observations in cooler 1424 of food items without labels:
· Spinach, no label - FSD-ZZZ states is " reasonably certain that item was delivered today, " but acknowledges it is not labeled.
· Two unidentified 6 inch third pans which Chef AAAA acknowledges does not see labels but that one contains a mushroom soup and the other contains a broccoli soup.
· Nineteen containers sitting on a cart that contains what FSD-ZZZ states is for the salad bar - chopped vegetables, and confirms there are no labels on the containers.
· Another cart in cooler 1424 with 9 containers (without labels) of food that includes cherry tomatoes, shredded carrots, cucumbers, fresh mushrooms, eggs and cheese. FSD-ZZZ confirms there are no labels on the containers.

On 7/10/12 between 10:20 AM -10:30 AM, Surveyor #29302 made the following observations in the " Ingredient Control Room " of food items that did not have labels: chicken breasts, ravioli, dessert bars, 8 large bags of chicken quarters, 18 dozen ciabatta breads and 4 bags of bread sticks which Chef AAAA acknowledges there are no dates or labels on these items.

On 7/10/2012 at 2:18 PM, Surveyor #29302's review of facility's " Storage of Food Items" policy number DP8074-904, revised 5/1//2010, bullet number 6. Prep carts, (A). "All prepared items, are to go into sealed or wrapped containers to be labeled, dated, and rotated to the rear of the cart."

STORAGE OF CHEMICALS
According to the 2009 Food and Drug Administration Food Code, 7-201.11 Separation, POISONOUS OR TOXIC MATERIALS shall be stored so they cannot contaminate FOOD, EQUIPMENT, UTENSILS, LINENS, AND SINGLE-SERVICE and SINGLE-USE ARTICLES

On 7/10/12 at 10:30 AM, storage room for "Patio Café", Surveyor #29302 observed chemicals - Ultra Klene, Ultra Dry (sitting directly on floor), 6 bottles of cleaning agent for the oven with 2 having sprayers attached and an aerosol cleaning agent without a cap. All items were identified by Chef- AAAA and who also acknowledges the chemicals were being stored with food items.

On 7/10/12 at 10:31 AM, outside the storage room for the "Patio Café", Surveyor #29302 observed eleven canisters of carbon dioxide sitting directly on the floor and witnessed by FSD ZZZ, Chef AAAA and QMC JJJJ.

Manual Warewashing, Sink Compartment Requirements
According to the 2009 Food and Drug Administration (FDA) Food Code , a quaternary ammonium compound solution shall be used according to manufacturer ' s directions included in the labeling. The dietary department uses Ecolab 146 Multi-Quat Sanitizer. According to surveyor 29302 ' s review of its product specifications, sanitizing requires immersion of all utensils for at least one minute. The FDA Food Code also states the concentration of the sanitizing solution shall be accurately determined by using a test kit or other device.

On 7/10/2012 at 10:40 AM, Surveyor #29302 observed DA BBBB manually washing dishes in a 3-compartment sink. Surveyor 29302 observed DA-BBBB dip container into sanitizing solution and immediately remove without waiting the manufacturer ' s recommendations of one minute. Surveyor
#29302 asked DA-BBBB to check the concentration of the sanitizing solution in the third compartment sink. DA-BBBB left area to find test strips and returned 5 minutes later. At 10:45 AM, DA-BBBB proceeded to take test strip, swish into solution, removed without strip registering concentration. DA-BBBB repeated this three different times.

Surveyor #29302 requested Chef-AAAA to check solution. Chef-AAAA checked solution and reported that it registered at 400 parts per million (ppm). Surveyor #29302 disagreed with Chef-AAAA ' s assessment since one had to look very closely to see that just the very edge of the strip turned green and not the entire portion of the strip that was dipped into the sanitizing solution. Surveyor #29302 requested of Chef AAAA to view the log of the sanitizer solution concentration which Chef AAAA stated, AAAA will need to ask the manager. On 7/10/2012 at 1:04 PM, QMC JJJJ confirmed to Surveyor #29302, the 3-compartment sanitizing solution concentration is not checked.

On 7/10/2012 at 1:04 PM, Surveyor #29302's review of "Pot Washing" policy # DP8072-620, revised 3/30/2012, bullet number 11 states "Check final rinse water for appropriate level of quaternary sanitizer."

CONTAMINATED EQUIPMENT
The 2009 FDA Food Code states that nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris.
The dripping of grease or condensation onto food constitutes adulteration and may involve contamination of the food with pathogenic organisms. Equipment, utensils, linens, and single service and single use articles that are subjected to such drippage are no longer clean.

On 7/10/2012 at 1:37 PM -1:50 PM, Surveyor #29302 observed oven hoods above fryers to be thick with dust and dripping with grease. The griddle was dirty with dust and grease on its back ledge. The Convotherm, an oven that provides convection cooking, steam cooking or the combination of both was dirty on the outside of door and there was a large (at least 24 inches) build-up of what FSD-ZZZ reports to be calcium deposits. All Surveyor #29302's observations were verified by FSD-ZZZ and QMC JJJJ. Surveyor requested cleaning schedules, which FSD ZZZ stated, is part of employee's job description.

HAND HYGIENE
According to the 2009 Food and Drug Administration (FDA) Food Code, food employees shall clean their hands using a cleaning compound in a handwashing sink. Food employees are to wash their hands with soap and water, "before donning gloves for working with FOOD ". Hand antiseptics are applied only to hands that are cleaned (washed with soap and water), immediately before engaging in food preparation, including working with exposed food, clean equipment and utensils, and unwrapped single service and single-use articles. May 2003, " FDA Fact Sheet on Hand Hygiene in Retail & Food Service Establishments Food Service Safety Facts " clarifies that the " CDC Guideline for Hand Hygiene in Healthcare Settings, " were not intended to apply to food establishments.

On 7/10/2012 at 1:55 PM, Surveyor #29302 observed Chef CCCC and Chef DDDD, both remove disposable gloves, then put on a new pair without washing hands with soap and water. Both Chef CCCC and Chef DDDD stated to Surveyor #29302 that their hands were not washed after removing the disposable gloves before putting on new pair. Chief Clinical Dietitian YYY validated Surveyor #29302's observation and spoke with both Chef's CCCC and DDDD.

On 7/11/2012 at 9:22 AM, Surveyor #29302 observed line staff GGGG working on room service trays. When moving from one tray to the other, staff GGGG used hand antiseptic, without washing hands prior to switching tasks. Surveyor #29302's observation was validated by FSD-ZZZ.

On 7/11/2012 at 9:27 AM - 9:33 AM, Surveyor #29302 observed line staff HHHH and line staff IIII repeatedly open refrigerator doors, then back to room service trays without washing hands after becoming contaminated. Surveyor #29302's observation was validated by FSD-ZZZ.

Based on observation, staff interview and review of maintenance records between 7/9/2012-7/17/2012, the facility failed to construct, install, and maintain the building system due to the following deficiencies. The cumulative effect of these deficiencies has the potential to affect the safety of all patients receiving services at the hospital.
Building #01- Pavilion
(a) Lack of 2-hr fire-rated wall separation;
(b) Construction type not compliant due to lack of fire proofing on structural beams on Penthouse Floor, unsealed penetrations of floors, vertical shaft of wood construction in one location;
(c) Corridor door held open with a computer cart;
(d) Vertical shaft penetrations not sealed;
(e) Lack of smoke compartmentation in one floor;
(f) Only one legal exit in corridor due to magnetic locking system on one door;
(g) Improper stair pressurization air;
(h) Lack of proper maintenance of batteries for the main fire alarm panel;
(i) Obstructions to sprinkler water flow from sprinklers;
(j) Lack of maintenance of sprinkler system;
(k) Ventilation system not installed per NFPA 90A;
(l) More than 32 gallon capacity soiled/trash containers not stored in areas protected as hazardous areas;
(m) Medical air system air drawn from a dirty space;
(n) Miscellaneous noncompliant items- in floors of business occupancy; and
(o) Emergency generator not installed in compliance with NFPA 110.

See K11, K12, K18, K20, K23, K32, K33, K52, K56, K62, K67, K75, K77, K130, and K144 for detail.

Building #02- West Hospital and North Tower (Hospital)
(a) Lack of common separation wall with rated wall construction;
(b) Quantity of materials deemed hazardous stored in a corridor and not separated from corridor with a corridor wall, lack of smoke-tight corridor ceiling in a sprinkler protected smoke zone, holes in corridor walls;
(c) Noncompliant corridor doors;
(d) Lack of exit signs in corridors to direct occupants to exits; exit signs located in non-egress pathway;
(e) Smoke barrier with unsealed penetration, or not constructed to ½ hour fire resistance rating due to numerous electrical or medical gas boxes; smoke barrier not extended to the floor deck above;
(f) Lack of self-closing device on smoke barrier door;
(g) Non-latching doors protecting openings to hazardous areas, lack of self-closing devices on doors, lack of smoke-tight ceiling due to gap around escutcheon ring at sprinkler head;
(h) Non-latching stairwell exit door, and exit doors out of one stair not readily opened from the egress side;
(i) Openings to stairs from normally unoccupied mechanical rooms, and ante rooms;
(j) Exit not readily accessible due to more than 50 lbf to set doors in motion, intervening rooms/spaces deemed hazardous, obstructions to swing of breakaway type doors and lack of handle to open such doors;
(k) Obstruction in means of egress corridor;
(l) Horizontal exit not having 1-hour rated walls in a 90 degree corner for 10 feet in each direction;
(m) Battery-powered emergency lighting units in ORs and other locations not tested at least 90 minutes annually;
(n) Exit sign not continuously illuminated and not served by the emergency lighting system;
(o) Overhead paging system used to direct and inform patients, visitors and staff after the initial fire alarm signal is initiated.
(p) Lack of maintenance of fire alarm system battery;
(q) Some spaces lack sprinkler protection, obstruction to sprinkler water discharge;
(r) Lack of maintenance of sprinkler system - five-year inspection;
(s) Ventilation system not installed in accordance with manufacturer specifications and NFPA 90A: Corridor used as return/supply plenum, combustible storage in mechanical room used as a return air plenum;
(t) Kitchen range hood wet chemical suppression system not inspected semi-annually;
(u) More than 32 gallon capacity containers of soiled/trash in areas not protected as hazardous areas;
(v) Empty oxygen cylinders not separated from full, and not marked or tagged empty;
(w) Lack of area alarm panel in one anesthetizing location, and combustible storage within 50 ft of Bulk Oxygen Storage;
(x) Interior walls and partitions made of combustible materials, and not of non-combustible or limited-combustible materials;
(y) Miscellaneous items- in Business occupancy, and travel distances to exit access corridor doors through 2 intervening rooms exceeded the allowable limit of 50 ft in health care occupancy;
(z) Clear spaces not provided in front of electrical panels due to objects stored in front of panels; critical wall receptacles not identified as to the panelboard and circuit number per NFPA 70, the National Electrical Code, and strip plug used to provide power to various pieces of equipment in one operation room; and
(aa) Lack of adequate ventilation to maintain positive pressure in clean spaces, lack of negative pressure in one docontamination room and 2 other dirty spaces, and lack of proper separation of clean linen cart handling area from a dirty bio-hazard handling area, lack of positive pressure in two operating rooms, lack of negative pressure in janitor closet, lack of exhaust in biohazard room for ventilation, and lack of proper filters in one air-handling unit servicing one corridor of hospital.

See K11, K17, K18, K22, K25, K27, K29, K32, K33, K38, K39, K44, K46, K47, K51, K52, K56, K62, K67, K69, K75, K76, K77, K103, K130, K147, A709 and A726 for detail.

Building #3-Specialty Clinics

(a) Vertical shafts were not constructed to the proper hourly rating;
(b) Smoke barrier wall not constructed to ½ hour fire resistance rating;
(c) Smoke barrier doors were not smoke tight;
(d) Fire alarm system to minimum standards;
(e) Lack of proper maintenance of batteries for the main fire alarm panel;
(f) Lack of maintenance of sprinkler system;
(g) Miscellaneous items- in a Business occupancy; and
(h) Electrical system compliance to NFPA 70 Electrical code.

See K20, K25, K27, K51, K52, K62, K130 and K147 for detail.



Building #04- West Clinics
(a) Lack of maintenance of fire alarm system battery; and
(b) Miscellaneous noncompliant items: Smoke isolation dampers not installed on supply and return sides of two air-handling units; exit discharge from one exit runs close to hazards, and not a safe access to public way; lack of proper maintenance of sprinkler system- lacking in monthly inspection, and five-year inspection of check valves and gauges, and gauges of standpipe and hose systems.

See K52 and K130 for detail.


Building #06- Birth Center at Children's Hospital of WI on 6th and 7th Floors

(a) Gap at the meeting edge of elevator double doors sealed with plastic brush seals, and not listed astragals for fire-rated doors;
(b) Smoke barrier walls not constructed/maintained to 1/2-hour fire resistance rating;
(c) Lack of local smoke detectors within 5 ft of door to hazardous area that is held open;
(d) Lack of maintenance of fire alarm system battery;
(e) Obstruction to sprinkler flow discharge by cubicle curtains;
(f) Lack of proper maintenance of sprinkler system - five year inspection; and
(g) Strip plug extension cord (power tap) used; not in compliance with National Electrical Code.

See K20, K25, K29, K52, K56, K62 and K147 for detail.

Building #08- Eye Institute
(a) Lack of maintenance of fire alarm system battery; and
(b) Miscellaneous noncompliant items: Lack of self-closing door to hazardous area, doorway blocked by wheel chair, unsealed floor penetration by cable, lack of ramp at exit discharge, lack of maintenance of sprinkler system, emergency generator battery not installed/located in compliance with NFPA 110, audible and visual derangement trouble signals of generator not located at a continuously monitored location, lack of emergency remote manual stop button.

See K52 and K130 for detail.


Building #10- North Tower (Floors 6-9) Hospital

(a) Corridor doors did not passage of smoke due to a wide gap at meeting edge;
(b) Smoke doors not fully closing;
(c) Sprinkler system (escutcheon plate missing) not properly maintained/installed;
(d) Non-latching stairwell door; and
(e) Objects stored in front of electrical panel; no clear space provided per NFPA 70

See K18, K23, K62, K130 and K147 for detail.


Building #11- Cancer Center

(a) Lack of maintenance of fire alarm system battery; and
(b) Miscellaneous noncompliant items: Stairwell door failed to close and latch, lack of proper maintenance of sprinkler system, emergency generator cooling system not installed in compliance with NFPA 110.

See K52 and K130 for detail.


Building #12 - Sunny Slope Health Center (outpatient off-site clinic)

(a) Travel distance to portable fire extinguisher more than the allowable 75 ft.

See K130 for detail.


Building #13-Specialty Clinics Lower Level, 1st and 3rd Floors; and Pavilion Building Lower Level.

(a) Separation wall between health care and another occupancy not constructed of 2-hr fire resistance rating;
(b) Unsealed penetrations of 3-hr fire-rated floor;
(c) Unsealed holes in the corridor wall separation;
(d) Corridor doors did not have astragals at the meeting edge prevent passage of smoke;
(e) Non-latching fire rated doors, unsealed wall penetrations, and lack of fire dampers at duct penetrations of fire-rated vertical shaft enclosures;
(f) Fire barrier door magnetically held open, but did not have smoke detector within 5 feet;
(g) Lack of appropriate exit signs when the egress path is not readily apparent, and "no-exit" signs on doors that may be confused as exits;
(h) Smoke barrier wall labeled 2 hr-smoke barrier not constructed to proper fire rating;
(i) Smoke compartments not having enough space to accommodate occupants needing to evacuate from adjacent smoke compartments;
(j) Smoke barrier doors did not have astragals at the meeting edges;
(k) Hazardous areas not constructed properly to a one or two-hour rating;
(l) Exit stairwell requirements such as, exit enclosure free of non-exit utilities, fire-rated doors, uninterrupted continuous exit passageway with rated wall construction not met;
(m) Locking system on exit stairwell doors that would prevent reentry from stair sider, door in egress path interfering with another door, dead bolt in the egress side of door;
(n) Clear corridor width not 8 ft wide due to structural column in the middle;
(o) Lack of visual alarms in common spaces, improper location of smoke detectors;
(p) Lack of proper maintenance of batteries for the main fire alarm panel;
(q) Obstructions to sprinkler water discharge, sprinklers of different response time factor in the same smoke compartment, missing escutcheon plates, improperly installed sprinklers, lack of sprinkler coverage in some spaces, electrical closet not sprinkler protected, nor all the exceptions met;
(r) Lack of maintenance of sprinkler system;
(s) Ventilation system not installed in accordance with manufacturer specifications and NFPA 90A;
(t) Lack of information on the type and volume of grease laden vapor and smoke producing cooking activities to not require a Kitchen rangehood system per NFPA 96;
(u) More than 32 gallon capacity containers of soiled/trash in areas not protected as hazardous areas;
(v) Wrong labeling of med gas and vacuum system zone valve box, labeling of vacuum shut-off valves covered;
(w) Miscellaneous items- in Ambulatory Health Care occupancy, and travel distance from a suite in health care occupancy exceeded the allowable limit; and
(x) Electrical raceway not installed per NFPA 70, the National Electrical Code.

See K11, K12, K17, K18, K20, K21, K22, K25, K26, K27, K29, K33, K38, K39, K51, K52, K56, K62, K67, K69, K75, K77, K130, and K147 for detail.


Building #14 - 3rd Floor of Remodeled Existing West Hospital
K130: Dead end corridor of more than allowable 30 feet created due to across corridor doors locked at night.

See K130 for detail.

Based on observation, P&P review and interviews, the hospital and equipment were not maintained in such a manner that the safety and well-being of patients are assured. This potentially affects all patients receiving services at this hospital. In-patient daily census during this Health Service Survey:
7/9/12 = 446
7/10/12 = 462
7/11/12 = 455
7/12/12 = 456

Findings include:

Equipment
On 07/10/12 at 11:25 AM on the 2nd floor Rehabilitation services and at 3:05 PM on the 5th floor Rehabilitation services departments, Ness L300 (functional electric stimulators) were found.

Rehabilitation Staff ZZ and YY stated this equipment was not on the preventative maintenance oversight of the hospital ' s bio-medical review. No company data was provided to ensure preventative maintenance and equipment safety was provided for the NESS L300 electrical stimulators. DSN E or Dir of PI FFF took notes of observations and accompanied surveyor through this on site visit.

On 7/9/2012 between 10:05 AM and 11:15 AM, Surveyor #26711 accompanied by Dir JJ observed and confirmed the following:
The 5th floor nourishment centers had ice/water machines. The coils at the back of these machines had dust build up on them. Water was leaking under the water machines of 5 NE and 5 SE. The electric toaster on 5 NE was sitting in a puddle of water.

Blanket warmers:
ICC D provided the most current policy entitled "Fluid and Blanket Warming" #D82.307 last revised 03/10/2009 and highlighted and confirmed the following:

A. "All fluid warmers will be set a temperature ranging from 98 to 104 degrees Fahrenheit."(F)
B. "All blanket warmers will be set at temperatures ranging from 100 - 110 degree Fahrenheit."
C. "Blanket and fluid warmer temperatures will be monitored and documented every 24 hours on a temperature log."

The policy also notes, "IV fluids are not to be kept at temperatures above 110 degrees Fahrenheit (F)" and "irrigation fluids are not to be kept at temperatures above 104 degrees F". "For better temperature control do not mix fluids and blankets."
ICC D and DSN E confirmed the hospital staff are not following the hospital policy for monitoring or maintaining fluid and blanket warming.

On 07/10/12 at 1:10 PM 3 Blanket warmers found in west operating department contained both blankets and fluids co-mingled. No temperature logs were provided. For 2 of the 3 blanket warmers there was no internal or external thermometer. DSN E and Interim Dir of OR West J confirmed this.

On 07/10/12 at 10:14 AM, in the Breast Cancer Clinic, room #3227 contained a blanket warmer. The external thermometer read, "actual temp" 128 F, "set temp" 130 F. No temperature logs were provided. Administrative Breast Cancer clinic staff WW and XX did not know the policy for blanket temps.

07/09/12 at 10:40 AM on floor 3 NW had a blanket warmer that had no internal or external thermometer. The internal wall had a posting "Do not exceed 125" degree F. No temperature logs were provided. RN G confirmed there was no way to know at what temperature the blankets were.

07/09/12 at 11:05 AM in SICU the blanket warmer had no internal or external thermometer. No caution sign was posted. No temperature logs were provided.

07/10/12 at 8:15 AM in the Day hospital 2 blanket warmers had external thermometers that indicated the set temp was 151 degrees F and 150 degrees F. No temperature logs were provided. Day Hospital Manager UU was not aware of the temperature maintenance.

DSN E and Dir PI FFF took notes of these observations and accompanied surveyor through this on site visit.

On 7/9/2012 at 2:00 PM a tour of the North Tower 9th floor was completed with QM A, and DON MMMM. 2 clean storage rooms were identified to have blanket warmers; one was set at 160 degrees the other at 188 degrees.

At 3:20 PM a tour of the Bone Marrow Transplant unit was completed with QM A, and Dir NNNN. A blanket warmer was identified at the end of the hallway, the warmer was set at 185 degrees.


Biohazardous Waste uncovered and unsecured
On 07/10/12 at 3:00 PM in the Cardiology department, room #3847 dirty utility room contained a biohazardous waste receptacle. The biohazardous waste receptacle cover was not secured. In a common hallway, the Biohazardous room (#3847) was not locked. Cardiology staff HH and DSN E and Surveyor #22198 confirmed this.

07/10/12 at 10:14 AM in the Breast Cancer Clinic room #3219 contained a biohazardous waste receptacle. Room #3219 was not secured. DSN E and Administrative Breast Cancer clinic staff WW and XX and Surveyor 22198 confirmed these findings.

07/09/12 at 10:40 AM in 3 NW room #3167 contained biohazardous waste not secured.

07/09/12 at 11:05 AM in the SICU in an unlocked dirty utility room off a common hallway, 2 biohazardous receptacles were uncovered and a suction canister filled with red fluid was sitting on a shelf.

07/10/12 at 8:15 AM in the Day Hospital area room #3175 and #3131 contained unsecured biohazardous waste. Observation on 3 NW, SICU and the Day Hospital were confirmed by Surveyor #22198 and DSN E.

On 7/10/12 between 9:30 AM and 11:00 AM, Surveyor #18816 observed the following in the Labor and Delivery,and Mom/Baby floors, accompanied and confirmed by Managers QQ and RR, Dir WWW and, QC R:

The soiled rooms #6625, #6658 and next to 7C 141, and EVS Room 7C-140 are not secured allowing pt and visitor access to biohazards and chemical hazards.

On 7/9/2012 at 2:00 PM a tour of the North Tower 9th floor was completed with QM A, and DON MMMM. 2 Soiled Utility rooms were identified as holding areas for biohazard material. Both rooms were unlocked.

On 7/10/2012 at 8:45 AM a tour of the North Tower 4th floor was completed with QMC JJ and NM OOOO. The soiled utility room used to hold biohazard material was unsecured.

At 9:40 AM a tour of North Tower 3rd floor was completed with QMC JJ and NM PPPP. The soiled utility room used to hold biohazard material was unsecured.

At 10:20 AM a tour of North Tower 2nd floor was completed with QMC, JJ and NM, QQQQ. The soiled utility room used to hold biohazard material was unsecured.


Environment
From 07/09/12 at 10:05 AM - 07/12/12 at 9:50 AM, on 3 NW, 3 SW, West Operating Department, SICU, Cardiology/Pulmonary/HTN and EKG clinics, Breast Cancer Clinic, Day Hospital and 2nd and 5th floor Rehabilitation observations identified damaged walls, damaged kickboards, gaps and damaged door frames, damaged floors and ceilings.
Surveyor #22198 toured with DSN E and Dir PI FFF who took notes and confirmed these observations.

On 7/10/12 between 9:30 AM and 11:00 AM, Surveyor #18816 observed the following in the Labor and Delivery,and Mom/Baby floors, accompanied and confirmed by Managers QQ and RR, Dir WWW and, QC R:

Rooms 1, 3, 5, 7 and 19 had an unlocked drawer containing syringes and needles, allowing access to pt's and visitors.

On 7/9/2012 between 10:05 AM and 11:15 AM, Surveyor #26711 accompanied by Dir JJ observed and confirmed the following:
5 SW, 5 NW had unlocked soiled utility rooms had (Cavi-wipes) sitting out on the counters. Cavi-wipes have a warning label to keep out of reach of children. Without the door being locked a visiting child could enter these rooms and handle these wipes potentially causing harm.

In-pt Dialysis Unit: on 7/9/2012 between 10:05 AM and 2:30 PM, near the supply carts were small holes in walls. The water valves behind dialysis stations had broken doors covers. Manager CC, QC S and Surveyor #29972 observed and confirmed these findings.

The following observations were confirmed at the time of discovery by Surveyors #12187 & #29942, concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic):
On 07/09/2012 at 2:58 PM, on the lower level in the clean linen room #l780, that a portion of the ceiling was damaged and in need of repair. The ceiling tiles were not washable or were not maintained in a condition to be used in a clean linen room.
On 07/10/2012 at 9:15 AM, on the lower level positron emission tomography (PET) machine room #L749B, that a portion of the ceiling was damaged and in need of repair. Two ceiling tiles were stained and dirty inside the PET room.
On 07/10/2012 at 9:45 AM, on the lower level rooms #L745A and L745B, that a portion of the ceiling was damaged and in need of repair. The ceiling tiles were not washable or were not maintained to a clean condition.



26390

Based on observation and staff interview, the facility failed to ensure 'life safety from fire' to patients.

Findings include:
Building #01- Pavilion
K11: Lack of 2-hr fire-rated wall separation between health care and business occupancy.
K12: Construction type not compliant due to lack of fire proofing on structural beams on Penthouse Floor, unsealed penetrations of floors, vertical shaft of wood construction in one location.
K18: Corridor door held open with a computer cart.
K20: Vertical shaft penetrations not sealed.
K23: Lack of smoke compartmentation in one floor.
K32: Only one legal exit in corridor due to magnetic locking system on one door.
K33: Improper stair pressurization air.
K52: Lack of proper maintenance of batteries for the main fire alarm panel.
K56: Obstructions to sprinkler water flow from sprinklers
K62: Lack of maintenance of sprinkler system.
K67: Ventilation system not installed per NFPA 90A
K75: More than 32 gallon capacity soiled/trash containers not stored in areas protected as hazardous areas.
K77: Medical air system air drawn from a dirty space.
K130: Miscellaneous items - in floors of business occupancy.
K144: Emergency generator not installed in compliance with NFPA 110.
See K11, K12, K18, K20, K23, K32, K33, K52, K56, K62, K67, K75, K77, K130, and K144 for detail.

Building #02- West Hospital and North Tower (Hospital)
K11: Lack of common separation wall with rated wall construction.
K17: Scrub Ex equipment with quantity of materials deemed hazardous stored in a corridor and not separated from corridor with a corridor wall, lack of smoke-tight corridor ceiling in a sprinkler protected smoke zone, holes in corridor walls
K18: Noncompliant corridor doors.
K22: Lack of exit signs in corridors to direct occupants to exits; exit signs located in non-egress pathway.
K25: Smoke barrier with unsealed penetration, or not constructed to ½ hour fire resistance rating due to numerous electrical or medical gas boxes; smoke barrier not extended to the floor deck above.
K27: Lack of self-closing device on smoke barrier door.
K29: Non-latching doors protecting openings to hazardous areas, lack of self-closing devices on doors, lack of smoke-tight ceiling due to gap around escutcheon ring at sprinkler head.
K32: Non-latching stairwell exit door, and exit doors out of one stair not readily opened from the egress side.
K33: Openings to stairs from normally unoccupied mechanical rooms, and ante rooms.
K38: Exit not readily accessible due to more than 50 lbf to set doors in motion, intervening rooms/spaces deemed hazardous, obstructions to swing of breakaway type doors and lack of handle to open such doors.
K39: Obstruction in corridors.
K44: Horizontal exit did not have 1 hour rated walls in a 90 degree corner for 10 feet in each direction.
K46: Battery-powered emergency lighting units in ORs and other locations not tested at least 90 minutes annually.
K47: Exit sign not continuously illuminated and not served by the emergency lighting system.
K51: Overhead paging system used to direct and inform patients, visitors and staff after the initial fire alarm signal is initiated. Overhead paging system is not a part of the fire alarm system.
K52: Lack of maintenance of fire alarm system battery.
K56: Some spaces lack sprinkler protection, obstruction to sprinkler water discharge
K62: Lack of maintenance of sprinkler system - five-year inspection
K67: Ventilation system not installed in accordance with manufacturer specifications and NFPA 90A: Corridor used as return/supply plenum, combustible storage in mechanical room used as a return air plenum,
K69: Kitchen range hood wet chemical suppression system not inspected semi-annually.
K75: More than 32 gallon capacity containers of soiled/trash in areas not protected as hazardous areas.
K76: Empty oxygen cylinders not separated from full, and not marked or tagged empty.
K77: Lack of area alarm panel in one anesthetizing location, and combustible storage within 50 ft of Bulk Oxygen Storage.
K103: Interior walls and partitions made of combustible materials, and not of non-combustible or limited-combustible materials.
K130: Miscellaneous items- in Business occupancy, and travel distances to exit access corridor doors through 2 intervening rooms exceeded the allowable limit of 50 ft in health care occupancy.
K147: Clear spaces not provided in front of electrical panels due to objects stored in front of panels; critical wall receptacles not identified as to the panelboard and circuit number per NFPA 70, the National Electrical Code, and strip plug used to provide power to various pieces of equipment in one operation room.

See K11, K17, K18, K22, K25, K27, K29, K32, K33, K38, K39, K44, K46, K47, K51, K52, K56, K62, K67, K69, K75, K76, K77, K103, K130 and K144 for detail.

Building #3-Specialty Clinics

K20: Vertical shafts were not constructed to the proper hourly rating.
K25: Smoke barrier wall not constructed to ½ hour fire resistance rating.
K27: Smoke barrier doors were not smoke tight.
K51: Fire alarm system to minimum standards.
K52: Lack of proper maintenance of batteries for the main fire alarm panel.
K62: Lack of maintenance of sprinkler system.
K130: Miscellaneous items- in a Business occupancy.
K147: Electrical system compliance to NFPA 70 Electrical code.


Building #04- West Clinics
K52: Lack of maintenance of fire alarm system battery.
K130: Smoke isolation dampers not installed on supply and return sides of two air-handling units; exit discharge from one exit runs close to hazards, and not a safe access to public way; lack of proper maintenance of sprinkler system- lacking in monthly inspection, and five-year inspection of check valves and gauges, and gauges of standpipe and hose systems.

See K52 and K130 for detail.


Building #06- Birth Center at Children's Hospital of WI on 6th and 7th Floors

K20: Gap at the meeting edge of elevator double doors sealed with plastic brush seals, and not listed astragals for fire-rated doors.
K25: Smoke barrier walls not constructed/maintained to 1/2-hour fire resistance rating.
K29: Lack of local smoke detectors within 5 ft of door to hazardous area that is held open.
K52: Lack of maintenance of fire alarm system battery.
K56: Obstruction to sprinkler flow discharge by cubicle curtains.
K62: Lack of proper maintenance of sprinkler system - five year inspection.
K147: Strip plug extension cord (power tap) used; not in compliance with National Electrical Code.

See K20, K25, K29, K52, K56, K62 and K147 for detail.

Building #08- Eye Institute
K52: Lack of maintenance of fire alarm system battery.
K130: Lack of self-closing door to hazardous area, doorway blocked by wheel chair, unsealed floor penetration by cable, lack of ramp at exit discharge, lack of maintenance of sprinkler system, emergency generator battery not installed/located in compliance with NFPA 110, audible and visual derangement trouble signals of generator not located at a continuously monitored location, lack of emergency remote manual stop button.

See K52 and K130 for detail.


Building #10- North Tower (Floors 6-9) Hospital

K18: Corridor doors did not passage of smoke due to a wide gap at meeting edge.
K23: Smoke doors not fully closing;
K62: Sprinkler system (escutcheon plate missing) not properly maintained/installed.
K130: Non-latching stairwell door.
K147: Objects stored in front of electrical panel; no clear space provided per NFPA 70

See K18, K23, K62, K130 and K147 for detail.


Building #11- Cancer Center

K52: Lack of maintenance of fire alarm system battery.
K130: Stairwell door failed to close and latch, lack of proper maintenance of sprinkler system, emergency generator cooling system not installed in compliance with NFPA 110.
See K52 and K130 for detail.


Building #12 - Sunny Slope Health Center (outpatient off-site clinic)
K130: Travel distance to portable fire extinguisher more than the allowable 75 ft.
See K130 for detail.


Building #13-Specialty Clinics Lower Level, 1st and 3rd Floors; and Pavilion Building Lower Level

K11: Separation wall between health care and another occupancy not constructed of 2-hr fire resistance rating.
K12: Unsealed penetrations of 3-hr fire-rated floor.
K17: Unsealed holes in the corridor wall separation.
K18: Corridor doors did not have astragals at the meeting edge prevent passage of smoke.
K20: Non-latching fire rated doors, unsealed wall penetrations, and lack of fire dampers at duct penetrations of fire-rated vertical shaft enclosures.
K21: Fire barrier door magnetically held open, but did not have smoke detector within 5 feet.
K22: Lack of appropriate exit signs when the egress path is not readily apparent, and "NO EXIT" signs on doors that may be confused as exits.
K25: Smoke barrier wall labeled 2 hr-smoke barrier not constructed to proper fire rating due to drywall screws not covered with joint compound, and butt joints not fully taped and embedded with joint compound, and unsealed conduit penetrations.
K26: Smoke compartments not having enough space to accommodate occupants needing to evacuate from adjacent smoke compartments.
K27: Smoke barrier doors did not have astragals at the meeting edges.
K29: Hazardous areas not constructed properly to a one or two-hour rating.
K33: Exit stairwell requirements such as, exit enclosure free of non-exit utilities, fire-rated doors, uninterrupted continuous exit passageway with rated wall construction not met.
K38: Locking system on exit stairwell doors that would prevent reentry from stair sider, door in egress path interfering with another door, dead bolt in the egress side of door.
K39: Clear corridor width not 8 ft wide due to structural column in the middle,
K51: Lack of visual alarms in common spaces, improper location of smoke detectors.
K52: Lack of proper maintenance of batteries for the main fire alarm panel.
K56: Obstructions to sprinkler water discharge, sprinklers of different response time factor in the same smoke compartment, missing escutcheon plates, improperly installed sprinklers, lack of sprinkler coverage in some spaces, electrical closet not sprinkler protected, nor all the exceptions met.
K62: Lack of maintenance of sprinkler system.
K67: Ventilation system not installed in accordance with manufacturer specifications and NFPA 90A
K69: Lack of information on the type and volume of grease laden vapor and smoke producing cooking activities to not require a Kitchen rangehood system per NFPA 96.
K75: More than 32 gallon capacity containers of soiled/trash in areas not protected as hazardous areas.
K77: Wrong labeling of med gas and vacuum system zone valve box, labeling of vacuum shut-off valves covered.
K130: Miscellaneous items- in Ambulatory Health Care occupancy, and travel distance from a suite in health care occupancy exceeded the allowable limit.
K147: Electrical raceway not installed per NFPA 70, the National Electrical Code.


Building #14 - 3rd Floor of Remodeled Existing West Hospital
K130: Dead end corridor of more than allowable 30 feet created due to across corridor doors locked at night.

See K130 for detail.

_________________________

Based on observation and Staff interview, the facility did not provide adequate ventilation due to (i) lack of positive pressure in 4 clean utility and storage spaces, (ii) lack of negative pressure in two spaces, such as construction/repair and soiled utility closet, (iii) lack of positive pressure in one central sterile processing (supply /assembly) room, and lack of negative pressure in the decontamination room, and (iv) lack of proper separation of the clean linen cart handling area from the dirty space in accordance with CDC and AIA guidelines. This deficient practice had a potential of contaminating air in clean spaces 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

(i) During a tour of the facility with Staff M1 (safety and emergency preparedness director), Staff M3 (project manager) and M8 (senior mechanic), Surveyor 12316 observed on 7/10/12 at between 9:10 am and 9:50 am that the 5th Floor clean storage Room N5119 and clean utility Room N5126 had an airflow occurring from corridor to the room, and hence, not maintained under positive pressure.

(ii) During a tour of the facility with Staff M1, Staff M3 and M8, Surveyor 12316 observed on 7/10/12 at 10:16 am that the 5th Floor SW Patient Room 5151 was undergoing toilet repair, but the air flow direction was from inside the room into corridor, and not from the clean to dirty space (construction area). The room was neither neutral nor negative relative to corridor.

(iii) During a tour of the facility with Staff M1, Staff M3 and M8 on 7/10/12, Surveyor 12316 observed at 2:40 pm that the Clean Utility Room 4124 in the 4th Floor North Tower was not under positive pressure to cause airflow from clean to dirty space.

(iv) During a tour of the facility with Staff NN1 (nurse manager), Staff M3 and M8 on 7/11/12, Surveyor 12316 observed at 9:35 am that the clean equipment storage Room 4244 in the 4th Floor CVICU unit had an airflow from the suite passage into the room, and not under positive pressure to cause airflow from clean to dirty space.

(v) During a tour of the facility with Staff M3 and M8 on 7/12/12, Surveyor 12316 observed at 2 pm that the Closet 2A41A with a rolling shutter accessed from Corridor 2300 was considered a dirty space, but did not have an exhaust to maintain a negative pressure. The closet is located across IR Minor Procedure Room 2428 on the 2nd Floor.

(vi) During a tour of the facility with Staff MM (manager), Staff M3 and M8, Surveyor 12316 observed on 7/13/12 at 8:45 am that the Sterile Processing (assembly) room in the Central Sterilizing Suite in the 1st Floor West Hospital was not under positive pressure relative to adjacent spaces to cause airflow from the clean sterile supply to dirty spaces, because there was no wall between the sterile storage and the adjacent materials distribution storage space. Also observed was that there was no airflow from sterile assembly/supply space into the Decontamination due to the lack of negative pressure in the Decontam and/or lack of positive pressure in the sterile supply room.

Surveyor also observed that three exhaust grilles in the Decontamination Room, and two exhaust grilles in the Sterile processing/assembly room (NE corner) on the discharge side of cart wash were dirty, and one electrical junction box in the ceiling of Sterile assembly room was covered with a cover plate, but had some gap around the junction box.

(vii) While on tour with Staff M3 and M8 on 7/12/12 between 3 pm and 3:15 pm, Surveyor 12316 observed that one loading dock located near Exit #72 on the 1st Floor West Clinics was used to handle both the clean linen carts and biohazard waste bins with a chain-link fence between the two areas. The biohazard waste loading area was in the south side of the dock, and not separated from the clean linen cart unloading area with a wall. Five clean linen carts with clean linens on the loading dock were observed to be zipped wide open. Some biohazard waste bins with lids were on the loading dock, while some were loaded in the truck.

The above deficiency was acknowledged by the project manager and senior mechanic at the time of discovery, and confirmed with Staff M2 (director of plat operations) at the daily exit conference on 7/10, 7/11, 7/12 and 7/16/12 at 4:30 pm.



Surveyor 12187:

Based on observation and Staff interview, the facility did not provide adequate ventilation due to lack of positive pressure in two Operating rooms, and lack of negative pressure in a janitor closets, lack of exhaust in biohazard room, and lack of proper filter in air handling unit servicing one corridor of hospital in accordance with CDC and AIA guidelines. This deficient practice had a potential of contaminating air in clean spaces with undesirable contaminants, and causing possible infection for all patients receiving services at this hospital.

The CDC guidelines can be found in the website


1. On 07/12/2012 at 8:31 am surveyor #12187 observed on the 3rd floor in the OR number 2 & 3, that OR 2 and 3 had air going into the operating room from the adjacent spaces. The 2006 Guidelines for Design and Construction of Health Care Facilities requires Operating rooms to have positive pressure with relationship to other zones. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

2. On 07/12/2012 at 9:45 am surveyor #12187 observed on the 3rd floor in the Janitors closet room 3434, that that janitors closet room 3434 had air going out of the room into corridor. The 2006 Guidelines for Design and Construction of Health Care Facilities requires janitor closets to have a negative pressure with relationship to other zones. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

3. On 7/11/2012 at 12:50 AM surveyor #12187 observed that room 3424B, a biohazard room did not have any ventilation. The 2006 Guidelines for Design and Construction of Health Care Facilities requires biohazard rooms to have ventilation; negative pressure with relationship to other zones and the air to be exhausted. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

4. On 7/12/2012 at 9:31AM surveyor #12187 observed that the filters in the air handler servicing the hospital corridor in the pavilion building did not have a minimum of 30% as required by the AIA guidelines. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

Based on review of IC data, hospital policies, observations and interviews, the hospital's ICC's failed to develop a comprehensive system for identifying or investigating staffs compliance with IC standards of practice and hospital P&P. This had the potential to effect every in-pt and out-pt receiving services.
In-pt daily census during this Health Service Survey:
7/9/12 = 446
7/10/12 = 462
7/11/12 = 455
7/12/12 = 456

Findings include:

On 7/11/12 at 1:00 PM, a review of safety rounds contained multiple IC concerns that paralleled the current surveyor IC findings from 7/9/12 - 7/11/12. Interviews with the ICCs D and MMMM confirmed the hospital staff's non- compliance identified in the hospital's safety rounds was similar to what surveyors were finding.

ICC's D and MMMM told Surveyor #22198, the hospital was down One (1) ICC position and with a hospital this size, D and MMMM could not be everywhere, and relied and floor managers to be monitoring their staff ' s compliance and report to the ICC's.

ICC's D and MMMM confirmed there was no formal plan or program to ensure floor managers were monitoring their staff's day to day IC compliance unless it happened to be a part of their performance measure.

Hand Hygiene
In SICU on 7/11/12 at 11:05 AM during a wound care observation, RN LLLL after washing hands and donning gloves, picked up a covered garbage can and moved it to the other side of the bed to have easy access during the dressing change. RN LLLL then removed the gloves and stated "it's not a sterile procedure, so I am just changing gloves, it is not necessary to wash hands in between". An additional failure to perform hand hygiene between tasks clean and a dirty task was observed. DSN E confirmed these findings with Surveyor #22198.

Additional Hand Hygiene non-compliance observed and interviews:
On 7/10/12 at 11:25 AM in the 2nd floor rehabilitation services:
- The hand washing sink in room #2116 was not accessible for hand washing. Observed and confirmed by Therapy Managers XX, YY, and Surveyor #22198.

On 7/11/12 at 10:35 AM in the SICU:
- RN KKKK after completing a blood sugar check, removed one glove and without hand hygiene and used the computer.
- RN LLLL gave IV medication bare handed.
- RN LLLL touched the pt bare handed and without hand hygiene, donned gloves. DSN E and Surveyor #22198 observed and confirmed these findings.

On 7/9/12 between 11:00 AM and 4:00 PM in the Lower Level Surgical Department:
- ST L removed gloves and did not perform hand hygiene.
- Anesthesiologist M did not perform hand hygiene between glove changes prior to initiating an intravenous line (IV).
- Surgeon O removed gloves without hand hygiene typed on the computer keyboard.
- After using the computer, Surgeon O donned new gloves without hand hygiene.
- With gloves on RN Q handled the trash cart, failed to remove gloves before obtaining tape to secure the dressing on the pt's abdomen.
- RN Q with contaminated gloves, removed the gloves to obtain a warm blanket and answered the phone, without hand hygiene. Surveyor # 18816, RN J and QC R observed and confirmed findings.

On 7/11/2012 at 11:30 AM on the 5th floor:
- After the pt's back and buttocks were washed, PCT MMM failed to wash hands between a glove changes. Dir JJ was present in the room, however behind the curtain for pt privacy purposes, during this observation by Surveyor #26711.
On 7/9/2012 at 1:40 PM:
- PCT DD completed a dialysis catheter dressing change removed gloves, and without washing hands, grabbed a new pair of gloves, placed gloves on the pt's tray table before sanitizing DD's hands. Manager CC, QC S and Surveyor #29972 observed and confirmed the dialysis care findings.

Personal Protective Equipment (PPE)
Day Hospital: On 7/10/12 at 8:52 AM - 9:55 AM, during a bone marrow Biopsy (Bx), Physician EEE refused a mask and face shield to perform this sterile procedure stating his personal glasses were enough. Physician EEE failed to tie the waste tie of his gown. DSN E and Surveyor #22198 observed and confirmed these findings.

Two (2) policies provided and reviewed by Surveyor and E, " Surgical Suite Wearing Attire" #D82.006 last revised 01/20/12, and policy " Personal Protective Equipment" #SP3.004, that defines the standards of practice that states eye and face protection must comply with ANSI Z87.1-1989, noting staff who wear prescription lenses, "eye protectors shall be fitted properly over prescription lenses" .

DSN E confirmed to Surveyor #22198, Physician EEE failed to meet the hospital's policies and current standards of practice for donning the appropriate PPE.

Additional PPE non-compliance observed and interviews:
On 7/11/10:30 AM in the SICU:
- RN EE entered and left a MRSA positive pt's room twice with a gown untied at the neck and waist. Surveyor #22198 along with DSN E and SICU Manger I confirmed this observation.

On 7/9/12 between 1:10 PM and 2:50 PM in the West Operating Room:
- 2 Perfusionists (exited before they were identified by touring hospital staff) were observed leaving the sterile supply area requiring masks, not wearing masks.

Surveyor #22198, DSN E and Interim Dir J observed and confirmed this finding failed to comply with personnel attire sterile process policy #D85.044 or surgical attire policy #D82.006.

On 7/9/12 between 11:00 AM and 4:00 PM in the Lower Level Surgical Department:
- In OR 31Anesthesia Resident K did not have eye protection on during a procedure.
- Five (5) surgical staff present (L, K, M, O and Q) participating in the surgery, did not have hair contained in bonnets or caps. Surveyor #18816, RN J and QC R observed and confirmed these findings.

Textiles
On 7/11/2012 at 11:30 AM, during bed bath observation on the 5th floor, PCT MMM used the same gloves used to remove soiled bedding after the bath to reposition the pt's Depends pad and turn the pt after the cares were completed. PCT MMM handled the cloth (textile) curtain twice with contaminated gloves worn to complete a pt bath and cares. Dir JJ was present in the room, however behind the curtain for pt privacy purposes, during the bath observation by Surveyor #26711.

On 7/9/2012 at 10:50 AM in 5 NW:
- An interview with EVS TC JJJ, stated that there was no set schedule for textile curtain cleaning. JJJ stated some rooms now have vinyl curtains and "they can just be sprayed with a disinfectant" .
- EVS Coordinator III stated that there was no set schedule for cloth curtain cleaning, but if nursing staff called to have textile curtains cleaned, EVS staff would clean them if they were contaminated, for example blood on them, otherwise there is no schedule.
- EVS Coordinator III stated curtains from isolation pt rooms are removed and cleaned upon discharge. Surveyor #26711, Dir JJ, EVS Coordinator III and EVS TC JJJ were present and confirm this interview.

On 07/09/12 at 11:05 AM in the SICU:
- EVS staff H said the curtains may or may not be cleaned or changed. EVS H said EVS staff could possibly spray down the textile curtains with Virex (cleaning product) as an alternative to laundering. Also present was DSN E.

On 07/09/12 at 10:05 AM 3 in the SW Medical/Surgical floor:
- RN I was uncertain about the cleaning routine for the textile privacy curtains for the unit.
- On 7/10/12 at 11:10 AM interview with Dir of EVS QQQ, QQQ said there is no routine cleaning schedule for pt privacy curtains unless curtains are visibly soiled or for special isolation rooms.
-QQQ provided and reviewed with Surveyor #29972 policy #6016 "Cubicle Curtain Changing" that states "Curtains will be changed when visibly soiled and in special isolation rooms".

Environment and Cross Contamination
Day Hospital: On 7/10/12 at 8:52 AM - 9:55 AM, LT DDD was identified as the staff responsible for handling bone marrow. After receiving from Physician EEE the bone marrow Bx specimen, LT DDD's gloves were visibly contaminated with blood and spicule.

LT DDD wiped gloves with gauze and with contaminated gloves touched multiple surfaces including reaching in to a common lab bucket taken from pt to pt rooms. The bucket contained extra specimen slides, pre-drawn up heparin syringes for the next case, filter paper, pens and a pencil and 4 extra fluid filled histology containers.

LT DDD continued wiping off bloody gloves with the bloody gauze. When the gauze was no longer effective, DDD reached into the box of clean gloves with the contaminated gloves on and removed one glove. LT DDD donned the one glove over the contaminated right glove using the dirty glove of the left hand. DSN E observed and confirmed this observation with Surveyor #22198.

On 07/11/12 at 8:25 AM at the Mayfair Center for Diagnostic Imaging (CDI):
- Clean linen and biohazardous materials co-mingled in a storage room just off a secondary pt lounge/waiting area. Staff Manager GGG confirmed the biohazard bags contained contaminated biohazard material collected from the individual rooms where magnetic resonance imaging (MRI), computed tomography (CT) and other radiologic diagnostic tests are completed. Staff GGG indicated the biohazard material is stored in that room and picked up by a contracted company every three months.

According to Guidelines for Environmental Infection Control in Health-Care Facilities
Recommendations of Centers for Disease Control (CDC) and the Healthcare Infection Control Practices Advisory Committee (HICPAC) published June 6, 2003, for linens the guidelines state: "Package, transport, and store clean textiles and fabrics by methods that will ensure their cleanliness and protect them from dust and soil during inter-facility loading, transport, and unloading." Staff Manager GGG and Surveyor #14941 observed and confirmed these findings.

On 07/09/12 between 1:10 PM and 2:50 PM in the West Operating Room:
- Sterile supply storage working areas, desk surfaces and metal sterile supply storage racks were covered in dust and debris.
- A 06/27/12 safety rounds identified 3 holes in a wall and ceiling tiles had damage and had not been fixed as of this date 07/09/12.
- Throughout the department multiple taped up paper signs are used.
- The Biohazardous Room had no ventilation.
Interim Dir J, DSN E and Surveyor #22198 observed and confirmed these findings.

On 07/09/12 at 2:50 PM in the West Operating Pre-op holding:
- The floor by the ice machine outside room #3282 was damaged. The counters laminate facing was gone and bare wood exposed.
- The ice machine had white crusty build up, and the exterior surface was dusty with dust and debris built up underneath the ice machine and on the plumbing. DSN E and Surveyor #22198 observed and confirmed these findings.

On 07/09/12 at 3:00 PM in the Cardiology Clinic:
- Clean storage room (#3887) door was propped open and the linen cart in the clean storage room was uncovered. DSN E, Cardiology staff HH and Surveyor #22198 observed and confirmed these findings.

On 07/10/12 at 10:04 AM in the Breast Cancer Clinic:
- Room #3219 vents in were dusty. Surveyor #22198 and DSN E confirmed this observation.

On 7/9/12 at 10:05 AM 3SW Medical/Surgical floor:
- Holes were in the walls and the computer key board was dusty in a cleaned room (#3192) ready for a pt admission.
- The kitchenette counter drawers were full of debris.
- Coffee grounds were all over inside the drawer and an open packet of coffee was lying in the drawer.
- On 7/12/12 at 9:30 AM, after bathing a pt, PCT XXX emptied the dirty bath water into the sink in the pt's room. 2 staff used this same sink for hand hygiene and DSN E and Surveyor #22198 observed and confirmed these findings. DSN E confirmed the pt and family would potentially use this same sink.

On 7/9/12 at 10:40 AM 3NW in the Cardiology Unit:
- A soiled utility room #3120 vents were dusty and paint was missing exposing the dry wall.
- Clean storage room had 2 pt positioning chairs with tape and tape residue harboring dust and debris.
- 1 of the 2 chairs seat had a large stain.
- A portable computer on wheels had a paper signed taped to the handle. Surveyor #22198, DSN E and ICC D observed and confirmed these findings.

On 07/09/12 at 11:05 AM in the SICU:
-During a review of ventilation rate measurement data sheet with M1 (director of plant operations) on 7/17/12, Surveyor #12316 found that the SICU Pt room #3326 on the 3rd floor had a significant quantity of air (320 cfm) drawn from adjacent areas of the SICU suite, mostly from the suite passage #3303. Pt room #3326, a negative pressure room was confirmed used by SICU pt's when there are no pt's requiring a negative pressure room (i.e.: TB+).
The airflow rate of 320 cfm from the suite passage/corridors into the SICU room #3326, has the potential to cross contaminate the air inside the pt room when used for general (non-isolation) surgical ICU pt's. Related to the amount of air drawn from adjacent areas to supplement the rooms exhaust is high, a negative pressure room, not used as a negative pressure room has a high potential for cross contamination.
On 7/13/12 between 8 AM and 9 AM, Staff M1 stated to Surveyor #12316, that with the exception of immune-compromised pt's, the physicians allow pt's to occupy the negative pressure rooms.
- Large open supply carts full of clean and sterile supplies were uncovered inside each pt's room.
- An observation on 07/11/12 at 11:05 AM, identified cross contamination when SICU Manager I and RN LLLL during pt care, reached inside the clean/sterile supply cart with dirty gloves to remove supplies.
- Ice machine had dust and debris build up underneath.

Found in pt room #4 (#3222) a clean room ready for a pt admission:
- A vinyl reclining chair, vinyl commode top and a vinyl sitting chair surface were not intact.
- The kick board and sink counter laminate surface was not intact and had exposed particle board.

EVS supply room #3224 contained staffs personal belongings including a purse.
- A bag of candy was sitting on a shelf with EVS chemical cleaning supplies.
- 7/11/12 at 11:45 AM, RN LLLL contaminated a pt's tray table by placing contaminated wound cleaning supplies. Sitting on the pt's tray table was the pt's incentive spirometer (a breathing therapy device). The tray table is also used for placement of food trays. The tray table was not cleaned off. DSN E and Surveyor #22198 confirmed these observations.

On 07/10/12 at 11:25 AM in Rehabilitation Services on 2nd and on 07/10/12 from 3:05 PM in Rehabilitation Services on 5th floor, Manager of Neuro Rehab YY observed and confirmed the following observations with Surveyor #22198:
- 3 therapy whirlpools had tape on the handles of the removable jets. PTA AAA said it was to maintain the jet adjustments.
- Therapy Storage areas were dusty, enclosed therapy cabinets dusty.
- Portable therapy equipment had colored tape on it; to identify the equipment belonged to therapy, harboring dust and debris.

An activity of daily living (ADL) bathroom supposed to be used for rehabilitation was used for storage.
- The bath room was dusty and dirty and the toilet had a large gap between the wall tiles and the back of the toilet.
- The bath/shower faucets and handle sprayer were pitted and corroded.
- 3 large vinyl therapy bed covers had tears/damage exposing the foam interior.
- 1 vinyl covered therapy chair had tears/damage exposing the foam interior.
- An electrical wheel chair had tape and tape residue harboring dust and debris.
- An arm trauft had a sticky foam substance that was not fully intact, harboring dust and debris.
- A reflect (mirror) paper not intact, making this surface non-cleanable and visible fingerprints and dust were seen.

On 7/9/12 between 11:00 AM and 4:00 PM in the Lower Level Surgical Department:
- The ice machine near Operating Room (OR) 31 had a scoop buried in the ice allowing for potential contamination.
- Surgical Technician (ST) L turned her back to the instrument table twice after all instruments were open.
- OR 25 there was dust in the air vents, on the walls there were holes, chipped paint, tape residue, dirty smudges to the right of the main door, and an unknown residue to the left of the main door. A computer keyboard at the head of the surgical table was dusty
- The doors for OR ' s 24 and 30 did not latch when closed, and require manual closing.
- A foam heel protector fell on the floor. RN Q picked up the protector and placed on the pt.
- A box of hospital gloves were placed on a pt's legs.
- RN Q picked up gauze off the floor contaminated with body fluids from the pt without wearing gloves and proceeded to don sterile gloves and apply Chlora-prep to the pt's abdomen.
-RN Q removed the gloves and did not wash or use hand gel. RN J, QC R and Surveyor #18816 observed and confirmed these findings.

On 7/10/12 between 9:30 AM and 11:00 AM in the Mom/Baby and Labor and Delivery (L&D):
- There are gouges in the wall next to an isolette and behind the isolette by OR2.
- There were paper towels under the sink in the nursery.
- The microwave was dirty with food residue. Managers QQ, RR, Dir WWW, QC R and Surveyor #18816 observed and confirmed these findings.

On 07/09/2012 from 10:05 AM through 12:00 PM the following 5th Floor in-pt units were toured, 5 SW, 5 NW, NICU, 5 NE, and 5 SE:
- Numerous gouges, scrapes and breeches in the smooth surface integrity of the drywall and wooden doors were noted both in pt rooms and in the hallways throughout the 5th floor.
- Breeches in integrity of the walls/doors render the surface non-cleanable of all microorganisms.
- Nourishment centers on the 5th floor all had ice/water machines. The coils at the back of these machines had dust build up on them.
- Water was leaking under the ice/water machines of 5 NE and 5 SE.
- Nourishment center on 5 SW a gummy substance built up next to the water machine.
- 5 NICU had a carton of open undated milk
- Drawers that held packaged food were dirty.
- 5 NE had brown gelatinous substance under the toaster.
-5 SE there was corrosive build up on the water pipes to the pt water/ice machine.
- An open undated bottle of molasses and an open undated envelope of carnation instant breakfast.
- 5 NW clean toilet paper supplies were stored in a cabinet in the dirty utility room.
- NICU, a slide board was stored on the dirty floor behind wire supply carts in a clean utility room.
- Clean supplies were on the floor and had not been picked up off the dirty floor.
-5 NE bags of trash and linen sitting directly on the floor of a soiled utility room, instead of in the bins they were supposed to be placed in.
- Cardboard shipping containers of Lovenox (medication used for prevention of blood clots) were on the pt care unit in the clean equipment room. Cardboard shipping containers have the potential to harbor microorganisms.
- A bag of restraints, a box of probe covers and sample size deodorant was on the floor in the clean supply room. Dir JJ and Surveyor #26711 observed and confirmed these 5th floor findings.

- On 7/11/2012 at 11:30 AM during an observation of bed bath cares, PCT MMM did not wash between the pt's toes but used a towel to dry between them.
- PCT MMM used a rinse rag on pt's groin and the same rag for the front of the legs. - PCT MMM used the same gloves to wash the groin and then turn the pt, touching the upper extremities and torso.
- PCT MMM used the same wash cloth to wash the pt's buttocks then the pt's back.
- PCT MMM failed to wash the back of the pt's legs.
Upon completion of the bed bath, PCT MMM squeezed out and placed on the vanity next to the sink the wash cloth and bath basin used to rinse the pt's back and buttock areas. The vanity contained the pt's oral care products, for example-toothbrush.
Dir JJ was present in the room, however behind the curtain for pt privacy purposes, during the bath procedure observed by Surveyor #26711.

On 7/11/2012 at 10:40 AM in the 4 Pavilion:
- A house keeping closet contained clean supplies (toilet paper, paper towel, bottles of soap) for distribution to pt and visitor areas.
- Room #408 P, a room identified as clean and ready for a pt admission, had a loose ball of black hair (approximately 5 inches by 3 inches) on the floor.
- Room #408 a large amounts of dust build up was visible on the keyboard and key crevices of the mobile computer kept in each pt's room.
- Numerous gouges, scrapes and breeches in the smooth surface integrity of the drywall and wooden doors were noted in pt's rooms and in the hallways throughout the 4 Pavilion. Dir JJ, Manager KK and Surveyor #26711 observed and confirmed these findings.

On 7/9/2012 at 11:20 AM in the Respiratory Therapy office:
- Cardboard shipping boxes were in the same area as cleaned ventilators machines intended for pt use.
- Cardboard shipping containers can harbor microorganisms. Dir JJ and Surveyor #26711 observed and confirmed these findings.

On 7/9/2012 between 10:05 AM and 2:30 PM in the Gastrointestinal (GI) Clinic:
-gouges were found in the dry wall in exam rooms #1, 2, 4, 7, and 8.
- A ceiling vent of the bathroom in exam room #8, was dust and debris.
- A cabinet of exam room #12 was a tube of used surgical lubricant. Per RN U, surgical lubricant is " one time use only " . RN U and Quality Coordinator S and Surveyor #29972 observed and confirmed these findings.

On 7/9/2012 between 10:05 AM and 2:30 PM in the Dialysis Access/Transplant Clinic:
- In exam room A2, an opened package containing a urinary leg bag.
- Under the sink in exam room A2 was dirt and debris.
- Code Room #4s crash cart had a dusty suction canister
- Yellow residue was found in cabinet under the sink.
- Exam room A4 found under the sink was a green yellowish residue.
- A used band-aid was sitting on the rim of a garbage can.
- Exam room A11under the sink was black debris.
- In a cabinet under the ice machine was brown residue and pt drinking straws were scattered through out.
- Dust was on top of the pt ice machine. RN Manager X, Dir of Transplant Services Y, RN W, QC S and Surveyor #29972 confirmed these findings.

On 7/9/2012 between 10:05 AM and 2:30 PM Infectious Disease (ID) Clinic:
- Exam rooms C7, C8, C10, RM 4920 had gouges in dry wall.
- Near front reception desk gouges were in dry wall.
- Pt restroom #4921 had large dust balls in ceiling vent.
- In clean supply room #4926, dust and debris were in the ceiling vent.
- In exam room C10 was dust and debris in drawers
- Under a sink there was clean storage (glove boxes, urinal, Kleenex box, clean chucks, and napkins).
- Under sink in exam room ' s #C10, C8 and C7 was a yellow brownish residue. ID Manager Z, RN BB, RN AA, Quality Coordinator S and Surveyor #29972 confirmed the ID clinic observations.

On 7/9/2012 between 10:05 AM and 2:30 PM in the In-pt Dialysis Unit:
- Near the supply carts were small holes in walls.
- The water valves behind dialysis stations had broken door covers.
- The closet doors near clean supply carts contained pen markings, sticky tape residue and screw holes.
- Ceiling tiles were damaged above dialysis station 5 and black scuff marks on the floor. - Ceiling lights above the dialysis station contained dust and debris.
- A brown and white residue was found on the metal racks containing clean supplies.
- Rooms #9, 10, and main entrance door had paint chipping exposing the drywall.
- A yellow brownish residue was on the floor near room 10.
- Rooms #9 and 10 the hand washing sinks were visibly soiled.
- Biohazard containers were kept near clean equipment and hand washing sink.
- Shipping boxes were kept near the clean equipment.
- Cracks in laminate counter top at nurse's station.
- Supply carts were dirty and contained sticky tape residue.
- In the storage supply room across from In-pt Dialysis the ceiling vents had dust and debris.
- Wood pallets were visibly soiled and contained supplies.
- In the storage supply room across from In-pt Dialysis were gouges in dry wall.

On 7/9/2012 between 10:05 AM and 2:30 PM in the In-pt Dialysis Water Room:
- Ceiling vents contained dust and debris.
-A black residue was on the floor.
- The dry wall was bubbling and scratched.
- There were visibly soiled tile surrounding floor drain and broken drain cover. Manager CC, Quality Coordinator S and Surveyor #29972 confirmed all Dialysis findings.

On 7/10/2012 between 9:00 AM and 12:00 PM in the GI Lab:
- Observation of a scope cleaning and disinfecting revealed line of red tape in sink and water level was below this line. When asked by Surveyor #29972 how much water is in the sink, GI Tech PP replied "8 gallons". When asked how many pumps of solution were used, GI Tech replied "3 pumps". GI Tech PP was unsure of how many gallons of water would fill the sink to the red line. Per GI Tech PP, does not fill sink to red line because it will overflow. This practice does not follow manufactures guidelines to ensure the proper disinfection of equipment.
Per instructions on the bottle labeled Intercept Solution, one full stroke of hand pump = 1 ounce (oz); 1 oz of solution is needed per 3 gallons of water.
- GI processing room had black residue was on the floor.
- GI Scopes cleaned and ready to use for pt's, were hanging in opened storage closet in Clean Utility room #2335, and card board shipping boxes sitting on cart next to clean GI scopes.
- On the floor under metal racks were dust, debris, and packaging material. Per RN U, storage closet containing clean GI scopes is left open during the day and closed in the evening. This leaves the scopes vulnerable to damage, dust or debris.
- Cleaned GI "scope buttons" ready to use for pt's was uncovered, sitting on white cloth towel in Clean Utility room 2335- the white cloth towel was visibly soiled with yellow stains.
-2 - 60 cc syringes were unpackaged and attached to open-ended tubing sitting in drawer in procedure room #1. This could potentially lead to cross contamination. Per RN U, the 60 cc syringes and tubing are used to suction pt's during GI procedures. RN U, QC S and Surveyor #29972 confirmed the GI Lab findings.

On 7/10/2012 between 9:00 AM and 12:00 PM in Housekeeping:
- Linen storage holding area had gouges in dry wall.
- A Mixing Supply Closet (room 1509) was black residue, dust and debris
Mop heads were dirty.
Dirty cleaning rags were on the floor.
Mixing Supply Closet (room 2204)
Black residue, dust, debris was on the floor.
Empty card board boxes were on the floor. Operations Manager PPP, Dir of EVS QQQ, QC S and Surveyor #29972 confirmed these findings.

On 7/10/2012 at 9:05 AM in the Dialysis Care:
- RN OO while administering Venofer 100mg to Pt #2, dropped the medication scanner on the floor, picked it up and proceeded to scan the medication and the pt's ID bracelet without disinfecting the scanner.

- On 7/10/2012 at 8:25 AM, Dialysis RN OO while preparing Pt #2's fistula site for treatment, RN OO scrubbed the arterial and venous site with a Chlora-prep applicator for less then 10 seconds and waited for less then 30 seconds for the area to dry. This deficient practice did not allow the antiseptic to reach its full bacteriostatic effect. Policy-Cannulation Site Selection and Skin Preparation: when using Chlora-prep, apply 2 minutes prior to use and allow drying. Manager CC, QC S and Surveyor #29972 observed and confirmed the dialysis findings.

- On 7/11/2012 at 11:15 am, Surveyor 12316 accompanied by Staff M3 and Staff M8 observed that the return grille of the Pt room #17 (2NT 17) in the 2nd Floor NT was dirty. Also observed was a dust layer build-up on the inside of flex duct near the return grille of Room 17, which was acknowledged by Staff M3.
On 7/10/12 between 8:30 AM and 9 AM, while on a tour with Staff GG (project manager) and Staff LL (senior mechanic), Surveyor 12316 observed the following:
On the 6th Floor MICU, lint was observed on the floor of Pt room 6NT Room 9;
On the 6th Floor MICU, the Electrical Closet N6145 located across lockers had lint and debris in the floor;
On the 6th Floor MICU, the Pt room 6NT Room 14 had three spots with debris. A little after the above observation, the charge nurse of the unit confirmed that the unoccupied room was ready for next pt;
On the 5th Floor NICU, the Ante Room N5117, adjacent to the Pt room #11 and used for storing equipment at the time of survey, had lint on floor.
On the 4th Floor Transport Storage located across the In-pt Dialysis Unit, lint was behind the corridor door of the room;
- On 7/11/2012 at 3:20 pm, Surveyor 12316 accompanied by Staff GG and Staff LL observed that the return grille of Exam Room 8 (Room 2697) in the Neurophysiology area of the West Clinics was dirty; and
- On 7/12/2012 at 11:25 am, Surveyor 12316 accompanied by Staff GG and Staff LL observed that the Clean Utility Room 2335 in the GI Lab had dust and debris around and behind the room door.

On 7/11/2012 at 10:50 AM surveyor #12187 observed that room operating rooms under construction for a lighting upgrade, that staff and construction workers entered and left the room without changing their shoes or booties. Once one leaves the construction site, a person enters the sterile area. The sticky mat was covered in with construction dust and could be walked on by anyone in the sterile corridor. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

On July 12, 2012 at 9:36 AM, surveyor # 12187 observed a Scrub Ex machine in corridor 2373 on the second floor of the West Hospital, East Addition. Surveyor interview Staff XXXX, a contract environmental services worker. She described how she emptied the Scrub Ex machine. The Scrub Ex machine has a locked metal enclosure (14" X 18" X 48" ) at the bottom of the machine at the floor of the corridor. A door opens on one side. In the corridor, she reaches in and grabs the soiled scrubs in her arms and places them into a soiled bin and takes them away. The soiled scrubs are being moved outside of the containers and contaminating the air in the corridor. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

On July 12, 2012 at 1:44 PM, surveyor # 12187 observed a that two cartons of paper products are stored in the floor sink of the janitors closet, room 3162. With a leak in the facet or water being dumped into the sink, the cartons of paper products could become wet. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Director of Plant Operations), staff M4 (Project Manager) and staff M10 (Senior Mechanic).

Supplies (expired, unlabeled, damaged or storage):
On 07/10/12 between 1:10 PM and 3:00 PM in the West Operating Room:
-ST GG, responsible for supplies, confirmed 3 expired vacuntainer tubes (blue) and had potential to be used.
- Sterile gloves were rubber banded, potentially damaging the packaging.
- Sterile packages of Aortic Perfusion Catheters (20 French (f), 22f and 24f ) were rubber banded. No risk assessment or policy was provided that allowed for rubber banding of sterile packages.
- No department specific risk assessment or hospital policy was provided that defined " event related " sterility for rotation and distribution of supplies that did not have expirations dates that would include manufacturer's validation of package and package content sterility.
- A blue packaging material (Kimguard) used to wrap instruments was re-used to cover equipment. Interim Dir J, DSN E and Surveyor #22198 confirmed these findings.

Additional non-compliance medical supply findings:
On 7/10/12 at 10:04 AM in the Breast Cancer Clinic:
- "Mepilex" (a sterile wound care material) was removed from their original container and did not have an expiration date. Surgical Nursing E and Surveyor #22198 observed and confirmed these findings.

On 7/9/12 at 10:40 AM in the 3NW Cardiology Floor:
- In a bucket (not in their original container), 9 sterile macrobore extension kits had no expiration date.
- Y tubing used for blood transfusions was out of its original container and did not have an expiration date. Distribution Technician F, responsible for stock rotation, confirmed F was not aware of a process for ensuring sterility for product that did not have an expiration date.
No department specific risk assessment or hospital policy was provided that defined " event related " sterility for rotation and di

Based on review of medical records (MR), review of policy and procedures, observation and interview with staff, in 3 of 3 Pt's that had surgery, the facility failed to ensure there is verbal and written confirmation the alcohol based skin preparation is dry prior to draping. This practice could potentially affect all patients receiving surgery at the hospital.

Findings include:

Per review of facility policy titled Operating Room Fire Safety Plan on 7/10/12 at 1:10 PM by surveyor 18816, states under Prevention Practices B "Allow preps to completely evaporate before draping". The policy does not include verbal and documented verification the prep is dry. This is confirmed in interview with QC R on 7/10/12 at 1:10 PM.

Per surveyor 18816 observation of Pt #1 preparation for exploratory surgery on 7/9/12 between 12:16 PM and 1:00 PM revealed after the Surgeon O placed a plastic protective barrier over an ostomy site on right side of Pt #1's abdomen, RN Q began prepping the abdomen with Chloraprep. There was no verbal verification the prep was dry prior to Surgeon O placing a sterile towel on the protective barrier, that was visibly wet, and continued to drape the Pt for surgery. Per interview with RN Q on 7/9/12 at 12:49 AM, RN Q confirmed they do not document the prep is dry, and they do not verbally state the prep is dry. Pt #1's MR review by surveyor 18816 on 7/10/12 at 8:15 AM revealed the Nursing Intraop Record that includes documentation of the verbal "Time Out" to identify the pt, site, procedure does not include documentation the Chloraprep used, that contains alcohol, was dry prior to draping. This is confirmed in interview with QMC R on 7/10/12 at 2:30 AM.

Pt #3's MR review by surveyor 18816 on 7/10/12 at 10:45 AM revealed the Preoperative Assessment that includes documentation of the verbal "Time Out" to identify the pt, site, procedure, equipment, correct implants and position, does not include documentation the Chloraprep used, that contains alcohol, was dry prior to draping. This is confirmed in interview with Manger RR on 7/10/12 at 10:45 AM.

Pt #46's MR review by surveyor 18816 on 7/10/12 at 2:30 AM revealed the Preoperative Assessment that includes documentation of the verbal "Time Out" to identify the pt, site, procedure does not include documentation the Duraprep used, that contains alcohol, was dry prior to draping. This is confirmed in interview with Manger RR on 7/10/12 at 2:30 AM.



26711

Findings by Surveyor #26711:

A MR review was completed on Pt. #34's closed MR on 7/12/2012 at 9:10 a.m. in the presence of QMC R. Pt. #34 had a surgical procedure for bladder cancer during this hospitalization (6/27/12 - 7/10/12) and Chloroprep was used as a skin prep.

There is no documentation in the MR to indicate this alcohol based skin prep was dry prior to draping the surgical area.

QMC R confirmed that this documentation is not in the MR.

A MR review was completed on Pt. #36's open MR on 7/11/2012 at 2:40 p.m. in the presence of Dir JJ. Pt. #36 had a surgical procedure to close an open wound on the buttocks and Chloroprep was used as a skin prep.

There is no documentation in the MR to indicate this alcohol based skin prep was dry prior to draping the surgical area.

Dir JJ confirmed that this documentation is not in the MR.

A MR review was completed on Pt. #37's open MR on 7/11/2012 at 3:15 p.m. in the presence of Dir JJ. Pt. #37 had a surgical procedure to repair a broken leg and Chloroprep was used as a skin prep.

There is no documentation in the MR to indicate this alcohol based skin prep was dry prior to draping the surgical area.

Dir JJ confirmed that this documentation is not in the MR.

Findings by Surveyor #20878:

A review was completed on Pt #25's MR on 7/11/2012. Pt #26 had a surgical procedure for excision of a pelvic mass on 07/02/12, Chloraprep was used as a skin prep.

There is no documentation in the MR to indicate this alcohol based skin prep was dry prior to draping the surgical area.

RN-QM A confirmed that this documentation is not in the MR on 07/11/12 at 1:30 PM.

A review was completed on Pt. #26's MR on 7/11/2012. Pt. #26 had a surgical procedure for femoral arterial bypass on 07/07/12, Exidine was used as a skin prep.

There is no documentation in the MR to indicate this alcohol based skin prep was dry prior to draping the surgical area.

RN-QM A confirmed that this documentation is not in the MR on 07/11/12 at 1:30 PM.





29972

Findings by Surveyor #29972:

Review on 7/11/2012 beginning at 9:15 AM of Pt #29's MR reveals the following: surgical procedure for the removal of clot in leg graft performed under general anesthesia; Chloraprep was used as a skin prep. No documentation in MR of skin prep being dry prior to draping the surgical area.

Review on 7/11/2012 beginning at 1:45 pm of Pt #31's MR reveals the following: surgical procedure for Nephrectomy performed under general anesthesia; Chloraprep was used as a skin prep. No documentation in MR of skin prep being dry prior to draping the surgical area.

Review on 7/12/2012 beginning at 9:15 am of Pt #33's MR reveals the following: Pt #33 admitted as in-pt on 6/1/2012 with multiple surgical procedures performed, per close review of surgical procedures under general anesthesia on 7/2/12, 7/5/12, and 7/9/12, Chloraprep was used as skin prep. No documentation in MR of skin prep being dry prior to draping the surgical area.

The above finding were confirmed at time of review with QC S.