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Based on record review and interview, the hospital failed to document daily checks of emergency equipment located on the inpatient nursing unit in 5 of 6 months (02/01/2019-07/22/2019) reviewed. Between 02/01/2019 and 07/22/2019, there were 16 checks left blank out of a total of 141 expected checks. The hospital failed to document twice daily checks of the medication refrigerator temperature log located in the medication room in 4 of 22 days. Between 07/10/2019 and 07/22/2019, there were 7 checks left blank out of a total of 44 expected checks.

Findings include:

Inpatient nursing unit

Review of Hospital Crash Cart checks document dated, "Feb 2019" revealed 3 out of 28 days had no initials.

Review of Hospital Crash Cart checks document dated, "April 2019" revealed 6 out of 30 days had no initials.

Review of Hospital Crash Cart checks document dated, "May 2019" revealed 1 out of 31 days had no initials.

Review of Hospital Crash Cart checks document dated, "June 2019" revealed 4 out of 30 days had no initials.

Review of Hospital Crash Cart checks document dated, "July 2019" revealed 2 out of 22 days had no initials.

Medication room on the Inpatient nursing unit

Review of Medication Refrigerator Temperature Log document dated, "July 2019" revealed 3 out of 22 days had no initials and 1 out of 22 days had no initials for the PM check.

During an interview with RN G on 7/23/2019 at 9:15 AM RN G stated, "The crash cart checks and medication refrigerator temperature logs are missing initials for checks."

Based on observation, staff interviews, and review of maintenance records between July 23 and July 24, 2019, the facility did not construct, install and maintain the building systems to ensure life safety to patients.

42 CFR 485.623 Condition of Participation: Physical Environment was NOT MET

Findings include:

K 0222 Egress Doors
K 0281 Illumination of Means of Egress
K 0311 Vertical Openings-Enclosure
K 0321 Hazardous Areas-Enclosures
K 0323 Anesthetizing Locations
K 0353 Sprinklers Systems- Testing and Maintenance
K 0355 Portable Fire Extinguishers
K 0361 Corridors - Area Open to the Corridor
K 0911 Electrical Systems - Other
Refer to the full description at the cited K tags.

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.

Based on observation and interview the facility failed to ensure that the building is maintained to ensure patients are unable to have unsecured access to dirty utility rooms (biohazard waste) in 3 of 9 areas surveyed (Emergency Room, Medical Surgical Unit and Recycling Room).

Findings include:

On 7/23/2019 during tour of Medical/Surgical unit dirty utility room door was unlocked, on 7/24/2019 on tour of Emergency Room and Recycling room dirty utility room doors were unlocked. All 3 dirty utility rooms contained bio-hazard material. An interview was conducted on 7/24/2019 with Infection Preventionist G who stated "Yes, they don't have locks."

Based on record review and interview, facility staff failed to ensure room temperatures and humidity levels were within range for 3 of 3 surgical suite rooms (Operating Room A, Operating Room B, and Recovery) in 4 of 4 months reviewed. Room temperatures were out of range in 171 out of a total of 215 room temperature checks and humidity levels were out of range in 17 out of a total of 215 humidity level checks.

Findings include:

Review of the facility document titled, "Gundersen Tri-County Hospital and Clinics Humidity/Temperature Record Chart - Room" created 6/16/16 revealed, "Operating Room temperatures in room A and B are to be between 68 degrees Fahrenheit -75 degrees Fahrenheit. Relative humidity is to be between 20% - 60%. The recovery room is to be between 70 degrees Fahrenheit - 75 degrees Fahrenheit with a relative humidity of 20% - 60%."

Review of the temperature and humidity charts titled, "Room A...June 2019 and July 2019" on 7/24/19 at 8:29 AM revealed documentation of room temperatures below 68 degrees Fahrenheit for 16 of 32 days reviewed.

Review of the temperature and humidity charts titled, "Room A...May 2019" on 7/24/19 at 8:29 AM revealed documentation of room temperatures below 68 degrees Fahrenheit for 20 of 23 days reviewed.

Review of the temperature and humidity charts titled, "Room A...April 2019" on 7/24/19 at 8:29 AM revealed documentation of room temperatures below 68 degrees Fahrenheit for 17 of 17 days reviewed.

Review of the temperature and humidity charts titled, "Room B...June 2019 and July 2019" on 7/24/19 at 8:29 AM revealed documentation of room temperatures below 68 degrees Fahrenheit for 33 of 33 days reviewed, and humidity levels higher than 60% for 6 of 33 days reviewed.

Review of the temperature and humidity charts titled, "Room B...May 2019" on 7/24/19 at 8:29 AM revealed documentation of room temperatures below 68 degrees Fahrenheit for 22 of 22 days reviewed, and humidity levels higher than 60% for 1 of 22 days reviewed.

Review of the temperature and humidity charts titled, "Room B...April 2019" on 7/24/19 at 8:29 AM revealed documentation of room temperatures below 68 degrees Fahrenheit for 18 of 19 days reviewed.

Review of the temperature and humidity charts titled, "Recovery Room...June 2019 and July 2019" on 7/24/19 at 8:29 AM revealed documentation of room temperatures below 70 degrees Fahrenheit for 23 of 30 days reviewed, and humidity levels higher than 60% for 10 of 30 days reviewed.

Review of the temperature and humidity charts titled, "Recovery Room...May 2019" on 7/24/19 at 8:29 AM revealed documentation of room temperatures below 70 degrees Fahrenheit for 16 of 21 days reviewed.

Review of the temperature and humidity charts titled, "Recovery Room...April 2019" on 7/24/19 at 8:29 AM revealed documentation of room temperatures below 70 degrees Fahrenheit for 6 of 18 days reviewed.

During an interview on 7/24/19 at 9:50 AM, when asked about the expectations for corrective actions to be taken when temperatures or humidity are out of range, Surgery Manager K stated, "We contact maintenance." When asked about the follow up process for ensuring temperatures and humidity levels are back in range after contacting maintenance, Surgery Manager K stated, "We do not currently document that. We write down on the sheet when we contact maintenance, but we don't document follow up temperatures, no."

Based on observation, staff interviews, and review of maintenance records between July 23 and July 24, 2019, the facility did not construct, install and maintain the building systems to ensure life safety to patients.

42 CFR 485.623(d)(1) Standard: Life Safety from Fire was NOT MET

Findings include:

K 0222 Egress Doors
K 0281 Illumination of Means of Egress
K 0311 Vertical Openings-Enclosure
K 0321 Hazardous Areas-Enclosures
K 0323 Anesthetizing Locations
K 0353 Sprinklers Systems- Testing and Maintenance
K 0355 Portable Fire Extinguishers
K 0361 Corridors - Area Open to the Corridor
K 0911 Electrical Systems - Other
Refer to the full description at the cited K tags.

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.

Based on observation, record review and interview, staff failed to adhere to policy and procedures to maintain an environment free from potential contamination in 3 of 12 departments observed (Med/Surg unit, Dietary, Endoscope Decontamination and Reprocessing) and failed to isolate Clostridium difficile positive patient in 1 of 3 infectious disease medical records reviewed (Patient #5) out of a total universe of 20 medical records reviewed.

Findings include:

The facility policy titled "Dress Code and Personal Hygiene" index number TCMDi-0125 last revised 10/10/2018 was reviewed on 7/24/2019. This document revealed "6. Hair Restraints: a. 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."

Observations on Medical/Surgical inpatient unit:

A tour of the inpatient Medical/Surgical floor was completed on 7/23/2019 with Infection Control Officer G. On tour there was noted to be areas of exposed dry wall outside of room 213 and 219 and behind the bed in room 219. The wooden doors to patient rooms 205, 213, 214, 215, 216, 217, 219 and the "shower room" had multiple areas of missing pieces of wood and abrasions not promoting a smooth cleanable surface.

Observations in the Endoscope Decontamination and Reprocessing area:

A tour of the Endoscope Decontamination and Reprocessing area (no room numbers) was completed on 7/23/19 with Surgery Manager K and Surgical Tech L. On tour it was noted the wooden doors to the endoscope decontamination room and the endoscope reprocessing room (no room numbers) were chipped and cracked in multiple areas, not promoting a smooth cleanable surface.

Observations in Dietary Department:

An observation of tray preparation line was completed on 7/24/2019 at 7:30 AM. Observed 3 dietary staff (Dietary Aide R, S and T) had hair nets on with hair coming out from under the net at the nape of the neck and above the ears. This observation was confirmed at the time of occurrence with Dietary Manager Q who stated "Yes, I would expect that the hats cover all hair".

Record review of infectious patient findings:

A record review was completed on 7/24/2019 for Patient #5. Patient #5 was seen in the Emergency room (ER) on 4/13/2019 for chief complaint of acute diarrhea, vomiting and abdominal pain and was admitted for observation. On 4/14/2019 Patient #5 was admitted as an inpatient and a stool specimen was sent to lab to be tested for Clostridium difficile and resulted positive on 4/14/2019 at 8:50 AM. There was no documented order for Patient #5 to be placed in contact isolation until 4/15/2019 at 3:39 PM and discontinued at 3:40 PM. Patient #5 was discharged on 4/15/2019.

An interview was completed on 7/24/2019 with Infection Control Officer G who, when asked, expectation of isolation with a positive lab test for Clostridium difficile stated "Yeah, when the lab comes back positive they should have put in isolation after notifying the doctor. They didn't. I put the order in on Monday when I saw it wasn't done. They do wear aprons and PPE (personal protective equipment) whenever there maybe exposure to body fluids, it's marked barrier isolation on the flow sheet and that was done all weekend."




38763



Findings:

During an interview on 07/23/2019 at 10:15 AM with EVS (Environmental Services) supervisor E, when asked if the staff used chemical indicator strips when the Oxivir Five (a disinfectant cleaner) is diluted with water prior to use? E stated "I think we have strips but we don't use them." When asked what the manufacturing recommendations where E stated "I don't know."

During an interview on 7/23/2019 at 1:10 PM with housekeeper F, when asked if they tested the Oxivir Five after mixing up the solution. F stated "No."

Per policy titled "Cleaning of Devices and Environmental Surfaces, index number TCMIP-0060 reviewed on 3/13/2019 revealed in part "Designated Personnel 1. The responsibilities for cleaning and disinfection of environmental surfaces and medical equipment are assigned to EVS (sic) staff and others, as indicated. 2. All assigned personnel are trained in the appropriate cleaning/disinfection procedures and the proper use of PPE (Personal Protective Equipment) and cleaning products. Supplies and cleaning products. 1. The facility only uses EPA-registered disinfectants, following the manufacturer's instructions for use."

During an interview on 07/24/2019 at 1:30 PM RN, IC (Infection Control) G stated "It is best practice to test Oxivir Five after dilution per manufacturer's instructions."

Per observation on 7/23/2019 at 1:10 PM observed housekeeper F drop the cleaning cloth on the floor, pick it up and continued cleaning with the contaminated cloth.

During an interview on 07/23/2019 at 4:15 PM with the EVS supervisor E what is the expectation when a staff member drops a cleaning cloth on the floor? E stated "I would expect them to get a clean cloth."