HospitalInspections.org

On September 3rd, 2013; observation revealed that the facility had the following deficiencies:

K-18 (smoke-tight openings into corridors),
K-29 (hazardous areas),
K-56 (sprinkler system),
K-147 (electrical system).

Please refer to the full description of the deficient practice at the individual K-tags. These observations are not compliant with 42 CFR 485.623. These deficiencies were confirmed at the time of discovery by a concurrent observation and interview with Staff BB.

Based on observations and staff interview (Staff J, S), this facility failed to ensure the environment is well maintained and safe for all patients, staff and visitors in 4 out of 11 departments visited (Medical/Surgical [Med/Surg] floor, ED, Radiology, OR Procedure Room). Failure to ensure a well maintained environment that is safe has the potential to affect all patients, staff and visitors who enter the facility.

Findings include:

During an observation of care for Pt. #20 on the Med/Surg floor in room 1523 on 8/27/2013 at 7:40 a.m., it was noted that the outer edge of the floor to ceiling wardrobe in the room had broken/chipped laminate about half way up from the floor making for a porous, non-cleanable surface.
This was confirmed by CNO A on 8/27/2013 at 8:00 a.m.

In the tub/shower room on the Med/Surg floor the walls and inside of the door had numerous gouges and dings making for a porous, non-cleanable surface. This was confirmed by CNO A on 8/27/2013 at 8:05 a.m.

In the Radiology department there were broken tiles on the floor behind the CT machine making for a porous, non-cleanable surface. This was observed on 8/27/2013 at 2:15 p.m. and confirmed by Radiology Mgr J at the time of the observation who, in an interview at this same time stated that J had never noticed that before.

In the ED there were 3 sizes of containers partially filled with formalin (a toxic tissue preservative) on the supply cart in the hallway. This was observed during a tour of the ED with Lead ED RN S and CNO A on 8/28/2013 at 9:00 a.m. RN S confirmed in an interview during this same time that there was no formalin spill kit in the event of a spill.



26390

During a tour and observation of surgery, procedure room, sterile supply and sterile processing on 8/27/2013 from 8:00 a.m.-10:25 a.m., accompanied by OR Coord. N, the following observations related to a well maintained environment were noted and confirmed at the time of discovery.
**Holes and gouges in the drywall of the procedure room.

On September 3rd, 2013; observation revealed that the facility had the following deficiencies:

K-18 (smoke-tight openings into corridors),
K-29 (hazardous areas),
K-56 (sprinkler system),
K-147 (electrical system).

Please refer to the full description of the deficient practice at the individual K-tags. These observations are not compliant with 42 CFR 485.623. These deficiencies were confirmed at the time of discovery by a concurrent observation and interview with Staff BB.

Based on observation, 1 of 1 staff interview (Staff M) and document review the hospital failed to ensure narcotic medications are handled in a secure manner by staff (OR Coord. N) in 1 of 1 procedure observations (Pt. #5) and that medications are appropriately stored in 1 of 2 medication refrigerators on the Medical/Surgcial floor. This failure had the potential to affect all pt.'s served by the hospital. During the survey the average daily census was 2.6 pt.s'.
Findings include:
On 8/27/2013 at 9:33 AM OR Coord. N was observed in the procedure room preparing injectable medications for pt. #5 ' s colonoscopy (Versed and Fentanyl). OR Coord. N placed the syringes on the bedside table and asked ST O to not leave the room. OR Coord. N then left the procedure room to get pt. #5. OR Coord. N returned at 9:40 AM with pt. #5.
On 8/27/2013 at 2:00 PM an interview was completed with RPh M. The observation of OR Coord. N leaving the medications unsecured in the procedure room with ST O was presented to RPh M and asked if this is how medications should be handled. RPh M stated the nurse should be in control over medications at all times and not left with another staff person.
On 8/28/2013 at 4:00 PM a review of the P/P titled Anesthesia Medication Security and Utilization was completed. The P/P dated 9/29/2010 states on page 2, D. " Narcotics drawn up for use during a case are kept in a secure location. "


26711

During a tour of the Medical/Surgical department on 8/27/2013 from 7:40 a.m.-8:45 am. accompanied by CNO A the following observations related to proper medication storage were noted and confirmed by CNO A at the time of discovery:

**In the Omni Cell (electronic medication dispensing unit) refrigerator the freezer portion of the dorm size refrigerator was over-frosted and there was significant build up of frozen condensation in and around the small freezer section. In the refrigerator were the following items:
--insulin (situated right next to the freezer section)
--flu vaccine
--pneumonia vaccine
--Tuberculosis serum for testing purposes
--Diltiazem

Insulin, Diltiazem, and vaccines must be protected from freezing. With the current state of the freezer section (being over frosted) the integrity of these medications cannot be guaranteed.

Based on observations, review records (1 out of 21 MR, Pt. #13), P/P review, nationally accepted standards of practice from the CDC, manufacturer recommendations for surgical wrap for instruments, and staff interview (Staff G), this facility failed to ensure a safe and sanitary environment that would prevent and control the potential spread of infection and also failed to have an effective system for investigating infections that are identified. This deficiency potentially affects the 2.6 (averaged) inpatients treated at this facility during the survey.

Findings include:

Interviews were conducted with IP G on 8/26/2013 from 1:35 p.m.-2:20 p.m. and again on 8/28/2013 from 11:30 a.m.-12:00 p.m. IP G stated that the facility follows the nationally accepted standard of practice recommendations of the CDC and that G has been a member of APIC for 8 years.

IP G stated that hospital surveillance rounds are done in conjunction with safety rounds with EVS and that cleanliness and "If things are sitting out that shouldn't be," are looked at. IP G was unable to provide documentation of these safety rounds. IP G stated G has not gone to the OR during a procedure to watch the technique of any of the employees as part of these safety rounds or any other surveillance rounds G completes.

The CDC recommendations for Hand Hygiene and personal protective equipment are as follows(CDC.gov; October 12, 2007):
IV. Standard Precautions
Perform hand hygiene:
IV.A.3.a. Before having direct contact with patients.
IV.A.3.b. After contact with blood, body fluids or excretions, mucous membranes, nonintact skin, or wound dressings.
IV.A.3.c. After contact with a patient's intact skin (e.g., when taking a pulse or blood pressure or lifting a patient).
IV.A.3.d. If hands will be moving from a contaminated-body site to a clean-body site during patient care.
IV.A.3.e. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient .
IV.A.3.f. After removing gloves.
IV.A.4. Wash hands with non-antimicrobial soap and water or with antimicrobial soap and water if contact with spores (e.g., C. difficile or Bacillus anthracis) is likely to have occurred. The physical action of washing and rinsing hands under such circumstances is recommended because alcohols, chlorhexidine, iodophors, and other antiseptic agents have poor activity against spores.


IV.B.3. Gowns
IV.B.3.a. Wear a gown, that is appropriate to the task, to protect skin and prevent soiling or contamination of clothing during procedures and patient-care activities when contact with blood, body fluids, secretions, or excretions is anticipated.
IV.B.3.a.i. Wear a gown for direct patient contact if the patient has uncontained secretions or excretions.

IV.B.4. Mouth, nose, eye protection
IV.B.4.a. Use PPE to protect the mucous membranes of the eyes, nose and mouth during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions and excretions. Select masks, goggles, face shields, and combinations of each according to the need anticipated by the task performed.


In reviewing policies for infection control/hand hygiene it was noted there were three separate policies for hand hygiene.

The facility's policy titled, "Hand Hygiene," dated 5/13/2013 was reviewed on 8/28/2013 at 12:15 p.m. The policy lists indications for hand hygiene to be as follows:
"1. Before having contact with patients.
2. Before donning sterile gloves for a sterile procedure.
3. Before inserting indwelling catheters or other invasive devices that do not require a surgical procedure.
4. After contact with body fluids or excretions, mucous membranes, or non-intact skin and wound dressings if hands are not visibly soiled.
5. When moving from a contaminated body site to a clean body site during patient care.
6. After contact with inanimate objects in the immediate vicinity of the patient."

This policy also addresses fingernails and artificial nails:
"1. HCWs [health care workers] should not wear artificial nails or extenders when having direct contact with patients and nails should be kept short (<0.5 cm [centimeters] long or approximately 1/4 inch long)."
In review of nursing meeting minutes dated June 5, 2013, IP G's Infection Prevention update section indicates that, "Effective 7/5/13 all direct care staff will no longer be allowed to wear acrylic or gel nails per the Hand Hygiene policy."
The policy does not reflect this stated change.

Infection Control Program:
In interviews conducted with IP G on 8/26/2013 from 1:35 p.m.-2:20 p.m. and again on 8/28/2013 from 11:30 a.m.-12:00 p.m. (CNO A was also present at the 8/28/2013 interview) the following findings regarding the Infection Control Program at this facility were determined:

The infection control tracking log from September 2012 through the date of the survey in August 2013 indicated that there were 7 hospital acquired infections (HAI) and 1 entry that was not classified as hospital or community acquired. After the interview on 8/26/2013, IP G stated that G entered 6 of the 7 as HAI in error, that these 6 patients acquired their infections as a result of a different facility not this facility.
On 8/28/2013 at 3:30 p.m., IP G was unable to provide documentation of the investigations that led to these conclusions except for the patient identified in August as having a HAI and that investigation was dated 8/27/2013. IP G stated G does not document findings or keep notes that lead to these conclusions.

A MR review for Pt. #13 was conducted on 8/28/2013 at 1:30 p.m. assisted by RN W. Pt. #13 was a maternity patient who had Cesarean Section delivery on 7/2/2013, developed phlebitis (inflammation of the vein due to the IV) and was on antibiotics. Pt. #13 is not on the infection control tracking log.

On 8/28/2013 at 12:15 p.m. a review of the hand hygiene audit data was conducted. IP G stated that G has been doing hand hygiene observations for "a long time." The data for June, July, and August 2013 was provided. June had 1 RN observation, July had 2 RN observations, and August had 2 observations, one RN and one LPN. There were no negative findings for any of the audits.
IP G stated G was unable to find any other data of hand hygiene audits.

Surgical Site Infection (SSI) follow up is done by IP G by using the computer to follow discharged patients at follow up physician appointments. IP G stated there are no surgeons outside the facility's computer system. Information that is sent to the physicians regarding SSIs is a generated letter that indicates how many procedures that provider has performed at the facility and how many resulted in SSIs. In review of the Infection Prevention and Control Meeting minutes for the first quarter of 2013 the SSI rate was 1.39%, for the fourth quarter of 2012 it was 2.68%.
IP G was unable to produce documentation of investigations that led to these conclusions.


Unit observations:
During a tour of the Medical/Surgical/Obstetrics departments on 8/27/2013 from 7:40 a.m.-8:45 am. accompanied by CNO A and RN K, the following observations related to infection control were noted and confirmed at the time of discovery:
**On the OB unit, in the nursery, 34 bottles of glucose water for infants were noted to have expired August 1, 2013.
**On the Medical/Surgical unit the gastroccult developer (used to check for blood in the stomach contents) had an expiration date of 4/2013.

During a tour of the ED on 8/28/2013 from 8:25 a.m.-9:30 a.m., accompanied by CNO A and Lead ED RN S, the following observations related to infection control were noted and confirmed at the time of discovery:
**A bottle of sterile water in a clean supply room was noted to expire in June of 2012.
**2 bottles of gastroccult developer had an expiration date of 4/2013.
**The portable x-ray machine in the back hallway had a build up of dust on the flat surfaces. Rad Tech T was interviewed during the tour regarding this and explained that after use this machine has the high touch surfaces wiped down with an approved cleaning wipe and agreed that the areas that had the dust build up were not routinely cleaned.
**A unused viral culture tube for H1N1 (type of virus) collection was in the bottom drawer of a food refrigerator in the break room area. This culture tube had an expiration date of 3/2013.
**A basket with equipment for IV starts was on the cabinet in the breakroom area.

During a tour of the kitchen on 8/27/2013 at 12:00 p.m. accompanied by Dietary Mgr I the following observations related to infection control were noted and confirmed at the time of discovery:
**On a back counter in the kitchen there was a radio that had a significant amount of dust and greasy build up covering the whole surface of the radio that faced the kitchen.
**In a small work area off the kitchen a computer keyboard and the base of the computer monitor had a build up of dust around it.



26390

During a tour and observation of surgery procedure room, sterile supply and sterile processing on 8/27/2013 from 8:00 a.m.-10:25 a.m., accompanied by OR Coord. N, the following observations related to infection control were noted and confirmed at the time of discovery:
**29 sterile packs wrapped in KimGuard (surgical wrap for instruments prior to sterilization) were stored stacked on top of each other.
On 8/27/2013 at 3:00 PM a review of KimGuard one-step manufacturers instructions for use was completed. Under the section titled,"Sterility Maintenance" states "Caution: Do not stack trays. Stacking trays can result in damage to the wrap caused by undue pressure from the weight."
** ST O was observed retrieving a scope for a colonoscopy. ST O explained the scopes are not numbered, the scopes have colored tape on them and ST O knows which one they started with that day.
Without a log with tracking numbers for the scopes that could be linked back to a patient in the event of a problem (infection, scope malfunction, etc.) the facility would not be able to look back if the colored tape would come off. On 8/27/2013 at 4:30 PM a P/P for Endoscopy recall (how are scopes tracked and recalled for infection control) was requested. On 8/28/2013 at 3:43 PM CNO A explained the hospital doesn't have a P/P for recalling scopes.
** After administering medications OR Coord. N donned gloves without washing hands first.
** ST O retracted the scope from pt. #5, removed soiled gloves and donned a new pair without hand washing
** Physician X was observed during a colonoscopy without eye protection, gown, or mask.
** ST O was observed during the colonoscopy without eye protection.
On 8/27/2013 at 3:20 PM a review of the hospital P/P titled, Attire in the Operating Room dated 8/14/2012 was completed. The P/P states in part, "Masks: Masks will be worn at all times in the operating rooms and sub-steriles." "Eye Protective: Protective eyewear, mask or face shields must be worn when splashing or spraying is likely."
** CSR Q was observed in sterile processing explained for pre cleaning of instruments 1 pump of Endozyme is mixed with 3 gallons of water. A measurement of one pump was found to equal ? ounce. The directions on the bottle state ? ounce to 1 gallon of water. OR Coord. N and CSR Q both confirmed the correct amount of Endozyme was not being used.
In an interview with Housekeeping Staff L 8/27/2013 at 8:02 a.m., L stated that limited in-house laundry is still being done at the facility. These items include the privacy curtains, MD scrubs and physician sleep room bedding, OB/nursery bedding and blankets, and clothes for babies.
On 8/28/2013 at 7:55 AM a tour of the laundry was completed with CSR Q. CSR Q explained most laundry is sent out but they do wash the beds sheets for OB and the ER, surgical scrubs, skilled nursing side resident laundry (including isolation laundry) and the physician lounge sheets. CSR Q was asked if water temperatures are monitored and documented. CSR Q explained they do not check that, the water temperature is set.
On 8/28/2013 at 8:27 AM a review of the hospital P/P titled IC Laundry was reviewed, the P/P is dated 9/12/2012. The P/P states under procedure, " Ensure that all wash room formulas are followed. Hot water must be a minimum of 180 degrees F, or follow the recommendations of the chemical manufacturer for optimum temperature.
In an interview conducted with IP G on 8/28/2013 from 11:30 a.m.-12:00 p.m. (CNO A was also present at the interview) IP G was unable to provide approval documentation from the infection prevention committee regarding detergent, water temperature, and appropriate handling of items that continue to be processed in the in-house laundry. At 12:15 p.m. IP G reported they do not have any documentation of monitoring the water temperature for washing machines and dryer temperatures.

Based on MR review, Medical Staff Rules and Regulations, and staff interview (Staff D), this facility failed to ensure that telephone/verbal (TO/VO) orders are properly authenticated with signature, date, and time within a 24-hour period of being written in 2 out of 15 out of a total of 21 MRs reviewed (Pt.s #13, 16). Failure to have properly authenticated TO/VO has the potential to affect all patients receiving care in this facility, including the 2.6 (averaged) patients present during the course of the survey.

Findings include:

The Medical Staff Rules and Regulations (R/Rs), dated 3/1/2012, were reviewed on 8/26/2013 at 11:30 a.m. On page 6 the R/Rs state, "Verbal and telephone orders will be signed, dated, and timed by the Practitioner within twenty-four (24) hours of receipt."

A MR review on Pt. #13's closed OB MR was conducted on 8/28/2013 at 1:30 p.m. assisted by RN W. Pt. #13 was admitted on 7/2/2013 and discharged on 7/4/2013. There is 1 TO/VO from 7/2/2013 and 1 TO/VO from 7/3/2013 that are not properly authenticated by the MD (missing date and time); and 2 TO/VO from 7/1/2013 (prior to Pt. #13 even being admitted to the facility) that are not authenticated by an MD at all. These findings were confirmed by RN W during the MR review.

A MR review on Pt. #16's closed MR was conducted on 8/28/2013 at 3:30 p.m. assisted by HIM Mgr D. Pt. #16 was admitted on 7/12/2013 and passed away on 7/14/2013. There is 1 TO/VO from 7/12/2013 that is not authenticated by the MD. This finding was confirmed by HIM Mgr D during the MR review.

Based on MR review, 2 of 2 staff interviews (Staff A, V), and review of facility's Nursing Scope of Practice guidelines this facility failed to 1. Individualize care plans, and 2. Failed to complete pain assessments per the care plan on 9 of 15 MRs reviewed of patients who had care plans out of a total of 21 MRs reviewed (Pt.s #2, 11, 12, 13, 14, 16, 17, 18 and 21 ). Failure to develop individualized patient plans of care has the potential to affect all patients receiving care in this facility, including the 2.6 (averaged) patients present during the course of the survey.


Findings include:

In an interview with CNO A on 8/26/2013 at 9:10 a.m. regarding Nursing Services, CNO A stated that the expectation is to individualize the care plan to reflect the needs of the specific patient.

A document identified as the Nursing Scope of Practice for this facility was provided on 8/28/2013 at 3:30 p.m. by CNO A. The document addresses patient care planning and regarding patient-related goals states, "Use all available resources to develop a specific plan of care that includes planning goals and interventions designed to help the patient achieve these goals."

This facility does not have a policy regarding nursing care plans (also known as POCs).

In an interview with RN V on 8/27/2013 at 2:55 p.m. regarding the ability of staff to individualize patient care plans, RN V stated that it is possible to type in what individual criteria should be on the care plan.

A MR review for Pt. #11 was conducted on 8/27/2013 at 3:30 p.m. assisted by HIM Mgr D. Pt. #11 was a maternity patient who hemorrhaged after giving birth. Pt. #11 has a standard computerized care plan for imbalanced fluid volume that is not individualized to Pt. #11's specific needs. This finding is confirmed by HIM Mgr D during the MR review.

A MR review for Pt. #12 was conducted on 8/28/2013 at 2:40 p.m. assisted by HIM Mgr D. Pt. #12 was a newborn who was born to a mom who admitted to using methamphetamines during the pregnancy. Pt. #12 has a standard computerized care plan for newborns that is not individualized to Pt. #12's specific needs. This finding is confirmed by HIM Mgr D during the MR review.

A MR review for Pt. #13 was conducted on 8/28/2013 at 1:30 p.m. assisted by RN W. Pt. #13 was a maternity patient who had Cesarean Section delivery, developed phlebitis (inflammation of the vein due to the IV) and was on antibiotics. Pt. #13 has a standard computerized care plan for pain that is not individualized to Pt. #13's specific needs. There is no care plan that addresses the cesarean section, phlebitis or antibiotic. These findings were confirmed by RN W during the MR review.

A MR review for Pt. #14 was conducted on 8/27/2013 at 2:50 p.m. assisted by HIM Mgr D. Pt. #14 is a newborn who has a standard computerized care plan for newborns that is not individualized to Pt. #14's specific needs. This finding is confirmed by HIM Mgr D during the MR review.

A MR review for Pt. #16 was conducted on 8/28/2013 at 3:30 p.m. assisted by HIM Mgr D. Pt. #16 was admitted with pneumonia. Pt. #16 had a standard computerized care plan for ineffective airway clearance that was not individualized to Pt. #16's specific needs. This finding is confirmed by HIM Mgr D during the MR review.



26390

On 8/27/2013 at 1:28 PM a review of pt. #21's record was completed with HIM Mgr. D. Pt. #21 was admitted on 8/26/2013 for a total right hip replacement. The nursing POC has activity intolerance listed as a problem with pain management and perform a comprehensive assessment of pain to include location, characteristics, onset/duration, frequency, quality, intensity or severity of pain, and precipitating factors as approaches. A review of all assessments shows no assessment for pain was completed. This was confirmed by HIM Mgr. D at the time of review.
On 8/28/2013 at 2:47 PM a review of pt. #2's record was completed with HIM Mgr. D. Pt. #2 was admitted on 6/16/2013 for a perforated appendix. The nursing POC has acute pain listed as a problem with pain management and perform a comprehensive assessment of pain to include location, characteristics, onset/duration, frequency, quality, intensity or severity of pain, and precipitating factors as approaches. A review of all assessments shows no assessment for pain was completed. This was confirmed by HIM Mgr. D at the time of review.
On 8/28/2013 at 3:55 PM a review of pt. #17's record was completed with HIM Mgr. D. Pt. #17 was admitted on 5/28/2013 for with a status post colostomy. The nursing POC has Alteration in comfort/pain related to abdominal wound listed as a problem. The record does not show that any assessment of pain was ever completed. This was confirmed by HIM Mgr. D at the time of review.
On 8/28/2013 at 4:20 PM a review of pt. #18's record was completed with HIM Mgr. D. Pt. #18 was admitted on 7/1/2013 with aseptic meningitis. The nursing POC has pain listed as a problem with pain management and perform a comprehensive assessment of pain to include location, characteristics, onset/duration, frequency, quality, intensity or severity of pain, and precipitating factors as approaches. A review of all assessments shows no assessment for pain was completed. This was confirmed by HIM Mgr. D at the time of review.

Based on 2 out of 2 SANE MRs (Pt. #6 and 7) and 1 out of 2 closed OB records (Pt. #13) out of a total of 21 MR reviews, P/P review, and 3 of 3 staff interviews (Staff D, W, Y), this facility failed to ensure that MRs are complete and accurate by 1. Not including discharge information in the MR (Pt.s #6, 7), 2. Not having discharge instructions signed (Pt. #6) or in the MR at all (Pt. #7), 3. Having an incomplete SANE exam in the MR (Pt. #7), 4. Having CRNAs pre-sign the anesthesia record before a procedure (Pt. #13). Failure to keep complete and accurate records has the potential to affect all patients receiving care in this facility, including the 2.6 (averaged) patients present during the course of the survey.

Findings include:

The facility's policy titled, "Care of Sexual Assault Survivors," dated 5/13, was reviewed on 8/26/2013 at 10:30 a.m. The policy states in part, "Provide for follow-up services, a. Provide discharge instructions...)."

A MR review was conducted on Pt. #6's closed ED record on 8/26/2013 at 2:42 p.m. with the assistance of HIM Mgr D, who confirmed the following findings: Pt. #6's discharge instruction form is not signed by the patient or a SANE nurse or an MD and there is no evidence in the MR regarding what discharge information Pt. #6 received regarding the treatment and care of sexual assault victims. HIM Mgr D agreed that this information should be part of the MR.

In an interview with RN Y on 8/28/2013 at 1:20 p.m., RN Y explained that the educational information for emergency contraception is in "Exit Care" (this facilities electronic data base for educational material which is based on discharge instruction criteria) and any ED nurse can print it out and give it to the patient.

A MR review was conducted on Pt. #7s closed ED record on 8/26/2013 at 3:10 p.m. with the assistance of HIM Mgr D, who confirmed the following findings: Pt. #7's discharge instruction form is not in the MR and there is no evidence in the MR regarding what discharge information Pt. #7 received regarding the treatment and care of sexual assault victims. The SANE Sexual Assault Record (form the SANE nurse documents the exam on) is not signed, dated or timed by the SANE nurse on page 5 and the diagram of a human body does not indicate that there were abrasions on Pt. #7's thighs (as indicated in the police report in the MR). HIM Mgr D agreed that this information should be part of the MR.

A MR review was conducted on Pt. #13's closed OB record on 8/28/2013 at 1:30 p.m. with the assistance of RN W who confirmed the following findings: Pt. #13 was scheduled for a Cesarean Section on 7/2/2013. On 7/1/2013 CRNA P conducted a pre-anesthesia review of Pt. #13's medical history. CRNA P pre-signed the Anesthesia Record which is a record of the patient's status during surgery from an anesthesia provider. CRNA P did not administer the anesthesia on 7/2/2013, CRNA Z did.
In an interview with RN W at the time of the record review, W stated that the CRNA should not have pre-signed the anesthesia record.

Based on 2 of 3 closed ED records out of a total of 21 MR reviews and 1 of 1 staff interviews (Staff D) this facility failed to maintain a MR that, 1. Has a properly completed general consent for care (Pt. #7), and 2. Has a properly completed consent to transfer to an acute facility (Pt. #8). Failure to obtain properly completed consents has the potential to affect all patients receiving care in this facility including the 2.6 (averaged) patients present during the time of the survey.

Findings include:

A MR review was conducted on Pt. #7s closed ED record on 8/26/2013 at 3:10 p.m. with the assistance of HIM Mgr D who confirmed the following finding: Pt. #7's general consent for care form is not signed by the patient or a witness. HIM Mgr D agreed that this information should be part of the MR.

A MR review was conducted on Pt. #8's closed ED record on 8/26/2013 at 3:40 p.m. with the assistance of HIM Mgr D who confirmed the following finding: Pt. #8 was transferred to an acute care facility for a higher level of care on 8/22/2013. Pt. #8's transfer consent form (titled Important Legal Notice) does not have the time Pt. #8 signed the form. Under section 1, Patient Condition the boxes for no likelihood of deterioration and may be at risk for deterioration are both checked. There is no MD co-signature for the Nurse Practitioner (required by the facility within 24 hours). Under section 6, Mode of Transport, the box for Advanced Life Support Ambulance is checked but who was contacted, by whom, the time contacted and the estimated time of arrival is not filled in.
In an interview with HIM Mgr D during the record review D agreed that the form was incomplete.

Based on MR review, P/P review, Medical Staff Rules and Regulations, and staff interview, this facility failed to maintain MRs that contain completed physical examinations/medical screening examinations on 2 of 2 closed SANE MRs out of a total of 21 MRs reviewed (Pt. #6, 7). Failure to complete physical exams on patients has the potential to affect all patients receiving care in this facility including the 2.6 (averaged) patients present during the course of the survey.

Findings include:

The Medical Staff Rules and Regulations (R/Rs), dated 3/1/2012, were reviewed on 8/26/2013 at 11:30 a.m. Regarding Medical Screening Examinations on page 13 they state in part, "When an individual on Hospital property requests examination or treatment for a medical condition, or such a request is made on his or her behalf, the Hospital will, through a physician Member of its Medical Staff or a nurse practitioner, physician assistant, or certified nurse midwife, provide an appropriate medical screening examination to determine whether or not the individual has an emergency medical condition."

The facility's policy titled, "Care of Sexual Assault Survivors," dated 5/13, was reviewed on 8/26/2013 at 10:30 a.m. The policy states in part on page 2, "c. Assist the SANE Nurse: ...2. Patient should be place in gown prior to physician taking medical history."

A MR review was conducted on Pt. #6 and 7's closed ED records on 8/26/2013 from 2:42 p.m.-3:30 p.m. with the assistance of HIM Mgr D, who confirmed the following findings: Neither Pt. #6 or 7 received the services of a provider who was qualified, by Medical Staff R/Rs, to perform a medical screening exam.

In an interview with CNO A on 8/26/2013 at 4:30 p.m., CNO A stated that the facility did not follow their policy in the case of Pt. 6 and 7 and these patients should, according to their policy, have had a medical screening examination.

Based on 1 of 2 SANE MRs out of a total of 21 MRs review, P/P review, and staff interview (Staff Y) this facility failed to ensure that there were MD orders for all tests and procedures performed on patients (Pt. #6). Failure to obtain MD orders for tests and/or procedures has the potential to affect all patients receiving care in this facility, including the 2.6 (averaged) patients present during the course of the survey.

Findings include:

The facility's policy titled, "Care of Sexual Assault Survivors," dated 5/13, was reviewed on 8/26/2013 at 10:30 a.m. There are no pre-established orders/standing orders for any laboratory (lab) tests or cultures to be done as part of a protocol for a sexual assault survivor identified within the policy.

A MR review was conducted on Pt. #6's closed ED record on 8/26/2013 at 2:42 p.m. with the assistance of HIM Mgr D, who confirmed the following findings: Pt. #6 had the following lab tests completed in the ED by the SANE nurse and/or a lab technician: urinalysis, pregnancy test, cultures and general probe (unknown what this test is, it was written as gen probe). An MD or other qualified provider to write orders in this facility did not see the patient and therefore did not write an order for these tests.

In an interview with RN Y on 8/28/2013 at 1:20 p.m. regarding who is ordering the tests for the sexual assault patients if an MD or other qualified provider is not, RN Y stated that there is a conversation that takes place in the ED with the provider that is there but this is not documented and the orders are not written as verbal orders.

Based on 1 of 1 procedure observation (Pt. #5), 2 of 2 staff interviews (Staff A, N) and document review the hospital failed to ensure all staff performing procedures in the surgical department have gone through the credentialing process (ST O). This failure had the potential to affect all patients receiving services at the hospital, average daily census during survey was 2.6.


Findings include:

On 8/27/2013 at 9:50 AM Physician X and ST O were observed in the procedure room with pt. #5 for a colonoscopy. From 9:50 AM to 10:15 AM ST O advanced and retracted the scope during the colonoscopy.
On 8/27/2013 at 10:50 AM OR Coord. N was interviewed regarding the observation of ST O advancing and retracting the scope for the colonoscopy for pt. #5. OR Coord. N agreed that was rare and only physician X is the only MD that allows the ST to do this. OR Coord. N was asked for ST O's credentialing file and proof of training that would allow ST O to perform that procedure.
On 8/27/2013 at 3:21 PM OR Coord. N presented the file on ST O. The file contained a copy of ST O's Wisconsin Nurse Aide Registry, and Certified Surgical Technologist certificate which expired on 5/11/2013.
On 8/27/2013 at 4:30 PM the above findings were discussed in an interview with CNO A and CEO H. CNO A explained they do not have a credentialing file for ST O and no record of training for ST O to operate the scope during a colonoscopy.

Based on review of Quality program data and interviews with 5 of 5 staff (Staff B, C, E, H, J), this facility failed to include all services affecting patient care are evaluated and included in the overall Quality plan for the facility. Failure to evaluate all services for quality of care has the potential to affect all patients receiving care in this facility. The average daily census during the survey was 2.6.

Findings include:

On 8/26/2013 at 9:30 AM an interview with CD B and QI/UR Coord. C was completed. When asked if all contracted services were part of the QI program CD B and QI/UR Coord. C explained that they do not have a list of all of the contracted services and therefore they are not included in the hospitals QI.

On 8/26/2013 at 3:03 PM a interview with Main. E revealed currently the housekeeping/laundry departments are not participating in the hospital QI. Main. E stated it has been talked about E is not really involved however the hospital should include the contracted laundry service in the QI program.


26711

In an interview with CEO H on 8/27/2013 at 8:40 a.m. regarding Governing Body involvement to ensure contracted services are being provided in a safe and effective manner, CEO H stated that the Governing Body has delegated this to the departments that use the contracted services to ensure that the services are sound.

In an interview with Radiology Mgr J on 8/27/2013 at 2:10 p.m. regarding the contracted nuclear medicine service which J oversees, it was determined that this contracted service does do tracking and trending of QI data and Mgr J receives a quarterly report from them.

Mgr J does not, however submit this data to the QI program manager for inclusion in the overall QI program.

Based on P/P review, review of the OPO program data, and 1 of 1 staff interviews (Staff A) this facility failed to incorporate into its policy and practice for Organ and Tissue Donation the definition of imminent death and timely notification. Failure to have a current and updated policy on Organ and Tissue Donation for staff to follow has the potential to affect all patients who wish to donate organs, tissue, and/or eyes at this facility.

Findings include:

The facility's policy titled, "Organ and Tissue Donation," with at review date of 8/14/2012, was reviewed on 8/27/2013 at 11:40 a.m. The policy states, "All patients who have died will be evaluated for Organ/Tissue donation."
In this same policy under the Action section for the MD/Nursing staff nurse or designee #1 states to, "Pronounce death. Document in the medical record using Charge the Record of Death Checklist."

There is no definition of imminent death in the policy, or a provision for staff to contact the OPO regarding an imminent death, when the patient still has a pulse and is breathing.

There is no definition of timely notification of the OPO after a patient does pass away other than to notify the OPO "as soon as possible."

In an interview on 8/27/2013 at 1:30 p.m. with CNO A, who is new to the CNO role in the facility and to the overseer of the OPO program, CNO A agreed that the policy is missing some information and definitions and needs to be updated.

Based on document review and 1 of 1 staff interview (Staff U) the hospital failed to have necessary transfer documents for swing bed patients. This failure has the potential to affect all swing bed patients receiving services at this facility including the 1 swing bed pt. during the course of the survey.

Findings include:

On 8/26/2013 at 8:00 AM a review of the hospital's swing bed program and admission packet was completed. A transfer form that includes reason for transfer, location pt. is transferred to, name, address and phone number of the State ombudsman was not found in the admission packet.
On 8/28/2013 at 11:00 AM an interview with SW U regarding the hospital swing bed program was completed. SW U was asked for a copy of the transfer form used for pt's. leaving the hospital. SW U provided a copy of the Notice of Medicare Non-Coverage form.
This form does not contain reason for transfer, location pt. is transferred to, name address and phone number of the State ombudsman. SW U agreed the hospital doesn't have such a form for the swing bed Pt.s