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Based on facility grievance file review, hospital policy and staff interview (A), the hospital failed to ensure that written decision notice information was provided to 5 of 6 patient complainants (Pts. 1, 2, 3, 4, 5) and that the written notice contained the required notice information. This occurred in a total of 6 grievances reviewed, in a total sample of 18 patients; having the ability to affect the total hospital census of 25 patients.

Findings include:

In the 3/5/14 interview with QA Director A at approx. 11:45 a.m., A was asked to provide resolution timeframes for randomly selected sampled patients filing hospital grievances, documented on the hospital patient complaint log.

Policy No. COL-1019, effective 3/1/07 and revised 1/2014, states under "E. In its resolution of complaints, the hospital provides the individual (complainant) with a written notice of it's decision within 30 days which contains the following: the name of the hospital contact person, the steps taken behalf of the individual to investigate the complaint, the results of the process, and the date of completion of the complaint process."

The 3/5/14 at 1 p.m. review of the above selected complaints for Pts. 1, 2, 3, 4, and 5 show no complaint response letters were written to these complainants after the facility investigations were completed.

In interview with A at 1:15 p.m. on 3/5/14, A stated that the process would have to be changed.

Based on observation, WI (Wisconsin Food Code) standards of practice, facility policy and staff interview (B), the hospital failed to ensure that 3 of 3 total staff observed (C, D, E ) preparing food/ prepping patient meal trays were wearing proper hair restraints in the kitchen. This was observed in 1 of 2 food preparation areas (patient food preparation area), and has the ability to affect 25 hospital patients.

Findings include:

Per 11/12/13 review of the Wisconsin Food Code dated June 2013, "FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES."

Facility policy reviewed on 3/4/14 at 1:30 p.m. titled "Infection Control Policy, Department Dietary, dated 1/2013 states under "2. All employees shall wear a clean uniform daily. Hair nets are to be worn while preparing or serving food while in the kitchen area."

During a observational tour of the kitchen on 3/5/14 at 11:50 a.m. accompanied by Executive Chef B, the following staff were observed in the kitchen and food preparation areas without hair restraints which covered all hairs on their heads: Patient Tray Prep Worker C, and Cooks D and E. Cooks D and E were at the stoves, cooking food; and C was walking through the kitchen, and was noted to have a loose hair on shoulder of kitchen jacket.

Per interview with B, at the time above, B stated that audits of staff to ensure effective hair restraint were conducted.

Based on record reviews and staff interview (F), the anesthesia services failed to ensure 1 of 5 ( Pt. 8) total surgical patients had a pre-operative anesthesia assessment completed prior to surgery. This occurred with a total sample of 18 patients, and has the ability to affect 25 patients.

Findings include:
On 3/5/14 between 1 p.m. and 2 p.m., 5 electronic anesthesia assessment patient records were review with Director of Surgery F. It was identified by F that Patient #8's pre-anesthesia assessment was done after the surgical procedure was completed. Patient #8 had surgery on 3/4/14 requiring general anesthesia, the electronic operative report documents patient in at 7:35 a.m. and patient out at 11:09 a.m. The pre-anesthesia evaluation was documented at 3/4/14 at 11:26 a.m.
Per interview with F, at above date and time. F stated that pre-operative anesthesia evaluation was not done per surgical services rules and regulations.