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Based on record review and interview, staff failed to ensure that the Important Message from Medicare informing Medicare recipients of their discharge appeal rights was given to eligible patients within 48 hours of admission and/or discharge in 1 out of 4 (Patient #15) Medicare eligible medical records reviewed out of a total of 22.

Findings include:

Review of policy, "An Important Message from Medicare" policy #2, revealed, "On (IP) In Patient admission to the hospital, all patients with Medicare or a Medicare supplemental insurance either as primary, secondary or tertiary will be given "An Important Message for Medicare" form within 24 hours of their admission. The patient is required to sign two copies of the "Important Message from Medicare". One signed copy is given to the patient. The second copy becomes part of the patient's medical record and given to the nursing unit. 2. The Registration clerk that does the admission is responsible for obtaining the signature of the patient. On weekends and holidays when there are limited Registration associates on duty the unit PCA will get the Important Message from Medicare signed. The registrar will go into the encounter on the summary tab and note the form was signed and by who or mailed."

Review of Patient #15's medical record on 1/9/2019 at 8:00 AM revealed an admission date of 10/11/2018 and was discharged on 10/14/2018. Patient #15 received the first IMM on 10/11/2018, a second IMM was not given.

Interview on 1/9/2019 at 1:50 PM, Clinical Informatics EE stated, "[Patient #15] should have received a second copy of the Important Message from Medicare."

A Validation Survey for Life Safety Code compliance was conducted by the Wisconsin Division of Quality Assurance on 01/07 & 08/2019. Waupan Memorial Hospital was found to be NOT in substantial compliance with the requirements of the following applicable regulations for participation in Medicare- Medicaid:

42 CFR Subpart 482.41 - Condition of Participation: Physical Environment was NOT MET


FINDINGS INCLUDE:
The Hospital was found to not have a safe environment, properly constructed and maintained to protect the health and safety of patients based on the following.

K 133 (Multiple Occupancies - Fire Wall)
K 351 (Sprinkler Systems- Installation)
K 372 (Subdivision Building Spaces - Smoke Wall
K 712 (Fire Drills)

Please refer to the full description at the cited K-tags. Due to the accumulative effect of these citations safety of the patients, visitors, and staff was maintained in accordance with the Life Safety Code (NFPA 101-2012).

Based on observation and interview, staff at this facility failed to maintain an environment that reduces potential contamination to patients and staff in 3 of 14 departments observed (Operating Room, Post Anesthesia Care Unit, Emergency Room).

Findings include:

On 1/08/2019 at 7:40 AM observed, in Operating Room 2, a chip in porcelain tile which revealed porous material of the tile which is not cleanable. Surgery Supervisor BB confirmed this finding in an interview at the time of discovery.

On 1/08/2019 at 7:50 AM observed, in Post Anesthesia Care Unit, a large tear (approximately 3 inches wide by 6 inches long) in the paper covering of the drywall exposing the porous gypsum board underneath, which was not cleanable. Surgery Supervisor BB confirmed this finding in an interview at the time of discovery and stated, "Someone probably pulled something off the wall."

On 1/09/2019 at 8:25 AM during a walk through the Emergency Department accompanied by Director of Outpatient Services C, observed the following in 3 of 6 Emergency Department rooms:
Exam room 3-missing laminate on the counter top edges and cabinet doors exposing porous material underneath.
Exam room 4-missing laminate on the counter top edges by the sink area.
Exam room 5-laminate chipped and loose on the cabinet doors.
Director C confirmed these findings in an interview at the time of discovery.

Based on observation, record review and interview, staff failed to ensure emergency carts are secured from unauthorized access in 4 of 14 departments observed (Maternal Health, Intensive Care Unit, Medical Surgical Inpatient Unit and Infusion).

Findings include:

The facility policy titled, "Medication Storage and Handling," dated 4/2014, revealed "All Medications stored outside the Pharmacy, including those in non-automated medication carts, must be stored in a secured, locked cabinet or in an ADC (automated dispensing cabinet)."

On 1/07/2019 at 10:45 AM during tour of the Maternal Health Department with Director of Inpatient Services B and Clinical Inpatient Supervisor G, observed the emergency cart was in an alcove down the hall from the nurses station, not visible from the nurses station, with only break away locks for security. The cart contained medications for emergency purposes and needles and syringes. During an interview at the time of discovery Supervisor G stated that the cart would not be visible from the desk and during discussion regarding cart security with a more permanent type device or change in location, Director B stated, "Sure, I understand."


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On 1/07/2019 at 12:40 PM observed the Intensive Care Unit with Inpatient Clinical Supervisor G, there was no patients or staff present in the area. The code cart was stored in an unsupervised area with a break away lock used for security. The cart contained medications for emergency purposes including needles and syringes.

On 1/07/2019 at 12:50 PM observed the Medical/Surgical Inpatient Area with Inpatient Clinical Supervisor G, noted an emergency crash cart in alcove around the corner down a side hallway from the nurses station. The cart is stored in an area that is not visible from the nurses station and is closed with a break away lock.

On 1/08/2019 at 1:10 PM observed the Infusion area with Supervisor of Outpatient Services M, noted an emergency code cart stored in the nurses station area sealed with a break away lock. The infusion area is staffed Monday through Friday. Supervisor of Outpatient Services M was asked if cart is placed in a locked area when the infusion area is not staffed on the weekends or the evenings, Supervisor of Outpatient Services M stated, "no".

On 1/07/2019 at 4:20 PM during an interview at the daily exit conference regarding emergency cart security, President and Chief Operating Officer A stated, "For mitigation purposes we don't feel it is a risk. We've never had a problem."

A Validation Survey for Life Safety Code compliance was conducted by the Wisconsin Division of Quality Assurance on 01/07 & 08/2019. Waupan Memorial Hospital was found to not be in substantial compliance with the requirements of the following applicable regulations for participation in Medicare-Medicaid:


42 CFR Subpart 482.41(b - Standard: Life Safety from Fire was NOT MET


FINDINGS INCLUDE:
K 133 (Multiple Occupancies - Fire Wall)
K 351 (Sprinkler Systems- Installation)
K 372 (Subdivision Building Spaces - Smoke Wall
K 712 (Fire Drills)

Please refer to the full description at the cited K-tags. Due to the accumulative effect of these citations safety of the patients, visitors, and staff was Not maintained in accordance with the Life Safety Code (NFPA 101-2012).

Based on observation, record review, and interview, staff failed to develop policies that give clear guidance to staff for surgical attire practices in 1 of 1 surgical attire policy reviewed.

Findings include:

On 1/8/2019 at 8:27 AM during an interview with Director of Outpatient Services C regarding standards of practice for surgical services, Director C stated, "We follow AORN (Association of peri-Operative Registered Nurses) and AAMI (Association for Advancement in Medical Instrumentation)."

On 1/08/2019 at 1:10 PM during an interview with Infection Preventionist DD regarding standards of practice followed in the operating room area, Preventionist DD stated, "AORN and AAMI."

In statement by AORN in May of 2017, the following was published: "Publish Date: May 30, 2017, There is a common belief that AORN has urged the elimination of surgeon's skull caps and mandated the use of bouffant caps. This misrepresentation continues to be perpetuated in recently published studies, expert opinion pieces, and media reports. Thus, AORN wishes to correct this misinformation. The AORN guideline makes no reference to "skull caps," and there is no recommendation that bouffant caps should be worn. The AORN guideline simply recommends, "A clean surgical head cover or hood that confines all hair and completely covers the ears, scalp skin, sideburns, and nape of the neck should be worn." This recommendation is supported by a number of studies showing that hair can be a source of bacterial organisms and potential surgical site infection."

On 1/08/2019 at 12:31 PM, policy "Surgical Attire and Donning Techniques," which is undated, revealed "Guidelines will be established for donning surgical attire in the semi-restricted and restricted areas in accordance with guiding principles from both AORN and the American College of Surgeons." Regarding head covering the policy revealed, "Head covering should be clean, low-lint and confine hair. Large sideburns and ponytails should be covered or contained."

On 1/8/2019 between 8:00 AM and 9:00 AM in Operating Room 1, observed surgical personnel (Surgical Technician V, Registered Nurse W, Certified Registered Nurse Anesthetist X and Doctor Z) with exposed ears, and/or facial hair and hair on the back of the head.

On 1/8/2019 at 11:00 AM during an interview with Director C and Surgical Services Supervisor BB, discussed observations made during Patient #7's surgical procedure, specifically, surgical head covering. BB and C referenced a discussion between several surgical field experts (AORN, Association for Professionals in Epidemiology and Infection Control [APIC], Centers for Disease Control [CDC], and American College of Surgeons [ACS]) that took place in the 2nd quarter of the year in 2018. During this discussion the ACS disputed the necessity of ensuring surgical personnel's ears were covered during surgical procedures.

Record review of an e-mail from Risk Management Coordintor KK dated 1/08/2019 at 3:08 PM (found on-line at https://www.facs.org on 1/8/2019 at 7:00 PM) revealed "In a, "Statement on Operating Room Attire," dated August 4, 2016, by the Board of Regents of the American College of Surgeons, the statement revealed, "The guidelines for appropriate attire are based on professionalism, common sense, decorum, and the available evidence. They are as follows...During invasive procedures, the mouth, nose, and hair (skull and face) should be covered to avoid potential wound contamination. Large Sideburns and ponytails should be covered or contained. There is no evidence that leaving ears, a limited amount of hair on the nape of the neck or a modest sideburn uncovered contributes to wound infections."

On 1/8/2019 at 4:00 PM during an interview with Director of Outpatient Services C, Director of Inpatient Services B, and Risk Management KK, in response to what staff are supposed to follow if the policy references two standards of practice with conflicting guidance, Director C stated, "Our policy doesn't state ear covering so we thought we were good there." No clear guidance for surgical attire practices was given to the surgical staff.



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37419


Based on observation, record review and interview, staff failed to adhere to policy and procedures to maintain an environment free from potential contamination in 6 of 14 departments observed (Maternal Health, Surgical Area, Endoscopy, Medical/Surgical floor, Emergency Department, and Infusion Area,) involving 5 of 5 patients observed (Patient #7, 10, 20, 5, 6) with a total patient census of 38 during survey.

Findings include:

Hand Hygiene:
On 1/08/2019 at 12:17 PM policy titled, "Hand Hygiene," dated 5/2015, revealed, "Decontaminate hands before having direct contact with patients; Decontaminate hands after contact with patient's intact skin; Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient; Decontaminate hands after removing gloves that are not visibly soiled."

On 1/08/2019 at 9:00 AM observed colonoscope cleaning. After washing the scope and putting it in the automated scope cleaner, Surgical Technician AA removed gloves, failed to complete hand hygiene, then programmed the automated machine, donned new gloves, and used a sanitizing wipe to clean the bin used to transport the dirty scope.

On 1/08/2019 at 8:32 AM observed Doctor Y enter the operating room, failed to perform hand hygiene, donned clean gloves, and prepared syringes for Patient #7's local anesthesia injections. At 8:39 AM Doctor Y removed the gloves, failed to perform hand


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Emergency Department Area:
Observation on 1/7/2019 at 10:50 AM, Patient #5 was brought in the unit following symptoms of a stroke and was taken directly to have a CT scan of the head. Radiation Technician F put on gloves, without completing hand hygiene, inserted intravenous access, and removed gloves. Radiation Technician F did not complete hand hygiene with removal of gloves. Phlebotomist E was observed drawing blood and then removed gloves (did not complete hand hygiene). Findings were shared with Director of Outpatient Services C at time of observation.

Interview on 1/7/2019 at 10:50 AM, Director of Outpatient Services C stated staff should be completing hand hygiene when entering and leaving a room, before and after patient contact, and when gloves are removed.

Infusion Area:
Observation on 1/7/2019 at 1:36 PM, Registered Nurse L completed a dressing change and intravenous access flushes on Patient #6. Registered Nurse L completed a saline flush on patient #6's intravenous access, removed gloves and did not complete hand hygiene. Findings were shared with Supervisor of Outpatient Services M at time of observation.

Based on record review and interview, the facility failed to complete pain reassessments after giving pain medication for 4 of 6 in-patient medical records (Patients #12, 14, 15, 10) reviewed in a total of 22 records.

Findings include:

Review of facility policy titled, "Pain Assessment and Management", reviewed 5/18/2018 revealed, "10) Patients will have pain re-assessed as to the effectiveness of the methodologies implemented to alleviate or reduce pain...PO (by mouth)- pain reassessment requirements- Within 60 minutes of administration."

Review of Patient #12's closed medical record on 1/08/2019 at 10:05 AM revealed Patient #12 was admitted to the hospital on 10/26/18 through 10/29/2018 following a fall resulting in fractures. On 10/29/2018 at 7:48 AM, Patient #12 received an oral pain medication for complaint of pain. A re-assessment of effectiveness of medication was not competed.

Review of Patient #14's closed medical record on 1/08/2019 at 11:52 AM revealed patient #14 was admitted to the hospital on 12/03/2018 through 12/5/2018 following irrigation and debridement of his/her right knee. On 12/03/2018 at 8:46 PM, Patient #14 received an oral pain medication for complaint of pain. A re-assessment of effectiveness of medication was not completed.

Review of Patient #15's closed medical record on 1/09/2019 at 8:00 AM revealed Patient #15 was admitted to the hospital on 10/11/2018 through 10/14/2018 following bleeding from left knee incision. On 10/12/2018 at 8:09 AM, Patient #15 received an oral pain medication for complaint of pain. A re-assessment of effectiveness of medication was not completed.

Review of Patient #10's open medical record on 1/09/2019 at 9:40 AM revealed Patient #10 was admitted to the hospital on 1/07/2019 for surgery on the right knee. On 1/07/2019 at 12:50 PM, Patient #10 received an oral pain medication for complaint of pain. A re-assessment of effectiveness of medication was not completed.

Interview on 1/09/2019 at 10:00 AM, Clinical Informatics EE stated, "Oral pain medication should be re-evaluated within an hour of the medication being given and intravenous pain medication should have pain levels re-assessed within 1 hour."

Based on record review and interview staff failed to obtain physician signature on verbal orders in 1 of 1 outpatient surgery record where paper orders were used (Patient #9) out of a total of 22 records.

Findings include:

Review of the "Medical Staff Rules and Regulation" pertaining to verbal orders revealed "The attending physician shall sign such orders within twenty-four (24) hours."

On 1/08/2019 at 10:31 AM Patient #9's closed outpatient surgical medical record was reviewed with Surgery Supervisor BB who confirmed the following finding: Patient #9 had a colonoscopy on 12/19/2018. The physician orders were on a paper format, dated by nursing as checked on 12/19/2018 and verbal orders for conscious sedation were also entered on the paper form by nursing, there was not date, time, or physician authentication of the verbal order in the electronical record. Review of the electronic medical record for Patient #9 revealed, a form that indicated the orders were signed off by the physician on 12/27/2018, 8 days after the verbal order was given.

On 1/08/2019 at 10:45 AM during an interview with Supervisor BB regarding the physician authentication of verbal orders, Supervisor BB confirmed that the physician did not sign the physician orders, and that medical records staff discovered the omission during record review.

Based on record review and interview, the facility staff failed to individualize care plans for 4 of 6 in-patients (Patient #12, 13, 15, and 20) in a total of 22 records reviewed.

Findings include:

Review of facility policy titled, "Interdisciplinary Plan of Care and Patient Education," policy is not dated, revealed, "3. The IPOC (Interdisciplinary Plan of Care) can/will be individualized based on documentation of clinical findings, additional diagnosis, and clinical progress toward reaching outcomes."

Review on 1/08/2019 at 10:05 AM of Patient #12's closed medical record revealed admission to the hospital on 10/26/2018 through 10/29/2018 following a fall with fractures. Patient #12 was diagnosed with a urinary tract infection and a foley catheter was inserted. The care plan does not address infection or use of foley catheter. During an interview Clinical Informatics EE stated, "There should be a problem on the care plan addressing the foley and the urinary tract infection."

Review on 1/08/2019 at 11:09 AM of Patient #13's closed medical record revealed admission to the hospital on 12/4/2018 through 12/5/2018 for an infection of the left foot. The care plan does not address infection. During an interview Clinical Informatics EE stated, "There should be a problem on the care plan addressing the infection."

Review on 1/09/2019 at 8:00 AM of Patient #15's closed medical record revealed admission to the hospital on 10/11/2018 through 10/14/2018 for surgical site bleeding. Patient #15 had left knee surgery 3 days prior to re-admission to the hospital. The care plan does not address infection. During an interview, Clinical Informatics EE stated, "There should be a problem on the care plan addressing risk for infection on post surgical patients."





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Review on 1/09/2019 at 11:35 AM of Patient #20's open medical record revealed admission to the hospital on 01/07/2019 for acute exacerbation (sudden worsening) of chronic obstructive pulmonary (lung) disease, diagnosed with left upper lobe pneumonia (infection in the lungs) admitted for antibiotics. The care plan does not address infection. During an interview, Director of Inpatient Services B stated "there should be a IPOC (integrated plan of care) for infection."

37419

Based on record review and interview, the facility failed to ensure consent forms were complete in 3 of 4 consent forms completed (Patient #13, 14, and 21) and failed to accurately document in 1 of 4 time out procedures performed (Patient #24) out of 22 records.

Findings include:

Review of policy "Informed Consent" last revised 2/2014, under Obtaining Informed Consent Signatures - "assure that the patient's informed consent is obtained prior to the performance of any of these procedures."

Review of Patient #13's medical record "Consent to Surgical/Medical Procedure(s)" revealed, on line titled SIGNATURE OF PATIENT OR LEGAL GUARDIAN DATE/TIME, the time or date was not documented.

Review of Patient #14's medical record "Consent to Surgical/Medical Procedure(s)" revealed, on line titled SIGNATURE OF PATIENT OR LEGAL GUARDIAN DATE/TIME, the time or date was not documented.

Review of Patient #21's medical record "Consent to Surgical/Medical Procedure(s)" revealed, on line titled PROVIDER SIGNATURE DATE/TIME, the time or date was not documented.

On 1/08/2019 at 1:27 PM during an interview with Clinical Inpatient Supervisor G and Director of Inpatient Services B, B stated the expectation is that the time and date are documented.

Record review of "Universal Protocol for Invasive/Operative Procedures" last revised date 7/24/2018, revealed Pre-procedure verification process Procedure: "e) The circulator RN [Registered Nurse]/primary RN is responsible for documenting the components and time of this procedure in the medical record."

Review of Patient #24's medical record "OR [Operating Room] Nursing Record" dated 1/08/2019 6:37 PM, documented by circulator RN LL revealed, under "Skin Prep Prep Agents "chloraprep" (a flammable skin prep used to clean the skin to prevent infection), under "Fire Risk Assessment," "Alcohol-based prep solution" "n/a" (not applicable) was documented.

On 1/08/2019 at 1:27 PM during an interview with Clinical Inpatient Supervisor G and Director of Inpatient Services B, G stated n/a was not an appropriate entry, chloraprep has alcohol in it warranting a risk for fire.

Based on record review and interview, this facilty failed to ensure a pre-operative anesthesia evaluation was performed prior to surgery on 1 of 4 surgical patients (Patient #24) in 22 records.

Findings include:

Record review of policy titled "Documenation of Anesthesia Care" # ANES-18, revised date February 2007, revealed under III "The Anesthesia record includes pre-anesthesia evaluation."

Patient #24's medical record was reviewed and revealed Patient #24 was a 24-year-old admitted 1/05/2019 for removal of foreign body from gastrointestinal tract. Patient #24's Operating Room Nursing Record dated 1/05/19 revealed under Case Times "Surgery Incision Time 01/05/19 18:36" [6:36 PM], "Anesthesia Record" documented by Certified Registered Nurse Anesthesis MM "Final Report" was completed "January 05, 2019 19:41" [7:41 PM], after the surgery was started.

On 1/08/2019 at 1:27 PM during an interview with Clinical Inpatient Supervisor G and Director of Inpatient Services B, when asked when the pre-anesthesia note was completed, Supervisor G stated "it looks like it was done after" the surgical procedure started.

Based on record review and interview, staff failed to ensure that Swing Bed patients had the required information needed at the time of transfer or discharge in 1 of 1 swing bed transfer/discharge notice reviewed.

Findings include:

Review of facility's notice given to Swing Bed patients upon transfer/discharge on 1/07/2019 at 4 PM revealed Medicare Notice of Non-Coverage form did not include language that would inform the patient of the right to know where they would be discharged or transferred to should this occur or information regarding who to contact for patients with developmental disabilities and/or mental illness.

On 1/07/2019 at 2:30 PM during interview with Care Management Social Worker O and Director of Care Management N , Director O stated, "No, that information is not on the form."