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Based on record review and interview, facility staff failed to inform patients of their Medicare discharge rights within 48 hours of discharge for 3 of 3 discharged patients (Patient #20, Patient #21, Patient #22) requiring notification.

Findings include:

Review of facility policy "Important Message From Medicare and Hospital Discharge Appeals" dated 6/12/2015 revealed "3. b) The follow up Important Message must be hand-delivered to the Patient within 2 days before discharge. ...6. a) The original copy of the initial and follow up Important Messages (the signed, dated and timed form) must be retained, scanned and made part of the electronic medical record."

Review of Patient #20's medical record revealed admission to the facility on 9/22/2018 and was discharged on 9/30/2018. Patient #20's record included a signed Important Message from Medicare form dated 9/23/2018. There was no signed form within 2 days of the 9/30/2018 date of discharge.

Review of Patient #21's medical record revealed admission to the facility on 9/24/2018 and was discharged on 10/3/2018. Patient #21's record included a signed Important Message from Medicare form dated 9/25/2018. There was no signed form within 2 days of the 10/3/2018 date of discharge.

Review of Patient #22's medical record revealed admission to the facility on 10/8/2018 and was discharged on 10/12/2018. Patient #22's record included a signed Important Message from Medicare form dated 10/9/2018. There was no signed form within 2 days of the 10/12/2018 date of discharge.

During an interview on 11/13/2018 at 1:10 PM, Case Management Supervisor OO stated the unit clerk staff are responsible to ensure patients receive the Important Message from Medicare upon admission and within 48 hours of discharge.

During an interview on 11/13/2018 at 1:55 PM, Unit Clerk MM stated "We give the patients the form within 48 hours of discharge. Sometimes patients will go home before I get to them."

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Based on record review and interview, the staff failed to renew an order to continue use of physical restraints in 1 of 2 patient (Patient # 3) medical records reviewed.

Findings include:

Review on 11/14/2019 at 8:15 AM of policy titled, "Restraint Use: Policy, Procedure and Protocol" dated 6/8/2018 revealed, "7. Renewal of Restraint Order a. ii. Violent/Self Destructive Behavior restraints require a renewal order every 4 hours."

Review on 11/14/2018 at 8:00 AM of Patient #3's closed medical record revealed bilateral wrist and ankle restraints were placed on 4/27/2018 at 2:00 PM due to violent self destructive behavior. Physician order was obtained on 4/27/2018 at 2:14 PM. Restraints remained in place until 10:55 PM. There was not a physician order to continue the use of the restraints from 6:14 PM through 10:55 PM.

Interview on 11/14/2018 at 8:15 AM Geriatric Clinical Nurse Specialist LL stated, "The nurse should have gotten another order for the restraints, the orders are only good for 4 hours."

Based on record review and interview, the facility staff failed to individualize patient care plans in 3 of 13 inpatient (Patient #7, Patient #27, and Patient #29) medical records reviewed in a total of 33.

Findings include:

On 11/14/18 at 10:05 AM, reviewed facility policy titled "Inpatient Plan of Care" dated 3/22/16. This document revealed, "The plan is individualized and revised based on patient' preferences, ongoing assessment findings, the patient's response to treatment/interventions and evaluation of progress toward goals/outcomes."

Review on 11/13/2018 at 8:25 AM of Patient #7's open medical record revealed an admission date of 11/11/2018 for cardiac issues. The individualized care plan for Patient #7 did not have a problem addressing cardiac issues. During an interview on 11/13/2018 at 9:05 AM, Staff Development Specialist GG stated, "I agree there should have been a cardiac related problem on the care plan."

Reviewed Patient # 27's medical record on 11/15/18 at 8:45 AM. Patient #27 had a vaginal delivery on 11/13/18 and was given Tylenol for pain. There is not a pain problem, goal or intervention on Patient #27's care plan.

Reviewed Patient #29 medical record on 11/15/18 at 9:00 AM. Patient #29 had a vaginal delivery on 10/22/18 and was given ibuprofen for pain. There is not a pain problem, goal or intervention on Patient #29's care plan.

Conducted an interview with Clinical Nurse Specialist MMM on 11/15/19 at 10:26 AM. Clinical Nurse Specialist MMM stated the vaginal delivery care plan should automatically pull in a pain problem. There is a glitch in the system and it should add it the same as the Caesarian section care plan. When asked if the pain care plan could have been manually added Clinical Nurse Specialist MMM states "yes."


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Based on record review and interview, staff failed to promptly complete a medical entry for a post-anesthesia evaluation conducted on post-operative day #1 in 1 of 1 medical record out of 6 surgical records reviewed (Patient #25) in a total of 33.

Findings include:

The facility policy titled, "Legal Medical Record Standards, Content, and Storage," dated 9/24/2015, was reviewed on 11/14/2018 at 10:25 AM. The policy revealed in part, "When a pertinent entry was missed or not written in a timely manner, the author must meet the following requirements: 1. Identify the new entry as a "late entry"..."

Patient #25's closed surgical medical record was reviewed on 11/14/2018 at 8:43 AM accompanied by Registered Nurses RR and SS who confirmed the following finding at the time of the record review: Patient #25 had a total knee replacement on 10/15/2018, stayed overnight and was discharged at 2:45 PM on 10/16/2018. A post-anesthesia evaluation, entered by Anesthesiologist J, revealed it was conducted on 10/16/2018 at 5:18 PM. During an interview on 11/14/2018 at 9:00 AM with Nurses RR and SS regarding the evaluation being conducted after Patient #25 was discharged, Nurse SS stated, "It could be a late entry and [gender] forgot to change the date and time."

Based on observation, record review, and interview, facility staff failed to take action per policy for out of range dishwasher temperatures for 1 of 1 automatic dishwasher (Kitchen) and failed to test sanitizing solution per policy in 1 of 1 staff observed (Supervisor M).

Findings include:

Dishwasher Temperatures

Review of facility policy "Temperature Monitoring of the Dishmachine" No. SI-375 dated 2/20/2018 revealed "1. Temperatures for the dish machine are to be taken 3 times daily by the first person in on each shift in the dishroom and recorded on the sheet provided. 2. If the temperatures deviate from accepted standards (wash temperatures 150 to 160 Fahrenheit, final rinse 180 to 195 Fahrenheit) corrective action is to be taken and recorded. The Dishroom personnel will notify the coordinator on duty of the unacceptable temperatures and the coordinator will notify maintenance of the problem. 3. The coordinator will document actions taken on the dishwasher temp log to correct the problem."

Review on 11/13/2018 at 8:30 AM of the facility's dishwasher temperature recording log revealed "Temperatures not meeting required temp must be reported to lead persons immediately." The log revealed a wash temperature of 138 degrees, less than the minimum 150 degrees required, on 1 of 8 days reviewed (11/5/2018); and rinse temperatures ranging from 150 to 153 degrees, less than the minimum 160 degrees required, on 4 of 8 days reviewed (11/5/2018, 11/6/2018, 11/7/2018, 11/9/2018).

During an interview on 11/13/2018 at 11/13/2018 at 8:40 AM, Food Services Supervisor M stated the temperatures are checked daily and if out of range "the dishwasher [Food Service Tech P] should be reporting that to [Lead Food Service Tech O]."

During an interview on 11/13/2018 at 10:00 AM, Lead Food Service Tech O stated the dishwasher "usually runs smoothly, [P] never really tells me it's below the temp."

During an interview on 11/13/2018 at 10:05 AM, Food Service Tech P stated "I write the temperatures down everyday" and did not state a protocol for addressing out of range temperatures.

Sink Sanitization

Review of facility policy "Three Sink Dishwashing Method" No. SI-383 dated 6/3/2016 revealed "Dishwashing and Sanitizing Set-Up Protocols: -Fill the third sink with Quaternary Sanitizer Solution through the Hydro Dispensing Unit. -Test the third sink containing the Quaternary Sanitizer Solution by immersing a Test Strip for 10 seconds. The Quaternary Sanitizer Solution should contain a concentration of at least 200 PPM."

During observation in the kitchen on 11/13/2018 at 8:40 AM, Food Services Supervisor M tested the sanitizer in the sink by immersing a test strip for approximately 3-4 seconds, less than the 10 seconds listed on the instructions posted near the sink. At the time of the observation, M stated the sanitizer sink is tested "a couple times a day, when the sink is filled." There was no log documenting the frequency or results of sanitizer testing.

During an interview on 11/13/2018 at 10:00 AM, Lead Food Service Tech O stated the sink sanitizer is tested "about once a week."

Based on observation, staff interviews, and review of maintenance records between November 12 and November 13, 2018, the facility did not construct, install and maintain the building systems to ensure life safety to patients.

42 CFR 482.41 Condition of Participation: Physical Environment is NOT MET

Findings include:

The facility was found to contain the following deficiencies.
Hospital

K 0100 Multiple Occupancies - Construction Type
K 0161 Building Construction Type and Height
K 0293 Exit Signage
K 0300 Protection - Other
K 0321 Hazardous Areas Enclosure
K 0323 Anesthetizing Locations
K 0341 Fire Alarm System - Installation
K 0342 Fire Alarm System - Initiation
K 0343 Fire Alarm System - Notification
K 0345 Fire Alarm System - Testing and Maintenance
K 0351 Sprinkler System - Installation
K 0353 Sprinklers Systems- Testing and Maintenance
K 0355 Portable Fire Extinguishers
K 0362 Corridors - Construction of Walls
K 0363 Corridor - Doors
K 0372 Subdivision of Building Spaces - Smoke Barrier
K 0374 Subdivision of Building Spaces - Smoke Barrier
K 0511 Utilities - Gas and Electric
K 0712 Fire Drills
K 0754 Soiled Linen And Trash Containers
K 0900 Health Care Facilities Code - Other
K 0911 Electrical Systems - Other
K 0912 Electrical Systems - Receptacles
K 0920 Electrical Equipment - Power Cords and Extensions
K 0923 Gas Equipment - Cylinder and Container Storage

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, staff interviews, and review of maintenance records between November 12 and November 13, 2018, the facility did not construct, install and maintain the building systems to ensure life safety to patients.

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

Findings include:

The facility was found to contain the following deficiencies.
Hospital

K 0100 Multiple Occupancies - Construction Type
K 0161 Building Construction Type and Height
K 0293 Exit Signage
K 0300 Protection - Other
K 0321 Hazardous Areas Enclosure
K 0323 Anesthetizing Locations
K 0341 Fire Alarm System - Installation
K 0342 Fire Alarm System - Initiation
K 0343 Fire Alarm System - Notification
K 0345 Fire Alarm System - Testing and Maintenance
K 0351 Sprinkler System - Installation
K 0353 Sprinklers Systems- Testing and Maintenance
K 0355 Portable Fire Extinguishers
K 0362 Corridors - Construction of Walls
K 0363 Corridor - Doors
K 0372 Subdivision of Building Spaces - Smoke Barrier
K 0374 Subdivision of Building Spaces - Smoke Barrier
K 0511 Utilities - Gas and Electric
K 0712 Fire Drills
K 0754 Soiled Linen And Trash Containers
K 0900 Health Care Facilities Code - Other
K 0911 Electrical Systems - Other
K 0912 Electrical Systems - Receptacles
K 0920 Electrical Equipment - Power Cords and Extensions
K 0923 Gas Equipment - Cylinder and Container Storage

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 record review and interview, facility staff failed to ensure food freezer temperatures are within range for 3 of 5 inpatient freezers (Medical-Surgical C, Medical-Surgical C2, and 3 South).

Findings include:

Review of facility policy "Required Temperature Monitoring and Cleaning" dated 9/19/2017 revealed "2) Food: b) Food freezers: i.) Food service and patient food freezers 0 degrees Fahrenheit or lower. ...8) Readings out of range: a) Repeat the temperature check... if the temperature is still out of range then contact the facilities power plant..."

Review of the medical-surgical inpatient unit nourishment room freezer log Medical-Surgical C on 11/12/2018 at 12:30 PM revealed temperatures of more than 0 degrees Fahrenheit for 10 of 12 days reviewed. Review of the medical-surgical inpatient nourishment room freezer log Medical-Surgical C2 on 11/12/2018 at 12:35 PM revealed temperatures of more than 0 degrees Fahrenheit for 9 of 12 days reviewed. Review of the medical-surgical inpatient nourishment room freezer log 3 South on 11/12/2018 at 12:40 PM revealed temperatures of more than 0 degrees Fahrenheit for 1 of 12 days reviewed.

During an interview on 11/13/2018 at 9:35 AM, Food Services Director N stated Environmental Services staff monitor and record the temperatures of the freezers on the inpatient units. Per N, staff did not put a minus sign (-) in front of the temperatures when they were recorded. Director N stated "the temperature should be below zero."

Based on observation, record review, and interview, this facility failed to develop and implement an active hospital-wide program for the prevention of infections and communicable diseases by failing to develop and follow policies and procedures for infection prevention for 1 of 2 sterile processing observations (instrument transportation from obstetrics), failed to follow policy for biohazard spill clean up in 1 of 1 spills observed (instrument transportation), failing to perform hand hygiene per policy in 4 of 7 observations (oncology clinic, pre-operative, and inpatient areas), failed to track immunization monitoring in 2 of 6 credentialing files (Anesthesiologist J or Emergency Department doctor JJ); and failed to follow manufacturers recommendations for 1 of 1 chemical dispensing systems (environmental services).

Findings include:

The facility staff failed to perform hand hygiene per policy, failed to clean up biohazard spills per policy, failed to properly transport dirty surgical instruments, failed to prepare medications antiseptically, failed to track immunization monitoring, and failed to disinfect patient care supplies. (See Tag 749).

The cumulative effect of these systemic problems result in the hospital's inability to provide a sanitary environment to avoid sources and transmission of infections and communicable diseases.

Based on observation, record review and interview, facility staff failed to perform hand hygiene per policy in 4 of 7 patient care observations (Patient #8, Patient #9, Patient #10, Patient #33); failed to disinfect blood glucometer after use in 1 of 3 patients observed (Patient #10); failed to disinfect medication vials in 1 of 3 patient (Patient #8 medication administration observations; failed to monitor immunizations records for 2 of 6 physicians (Anesthesiologist J or Emergency Department doctor JJ),

Findings incude:

Hand Hygiene

Review of facility policy "Hand Hygiene" dated 9/25/2018 revealed "5) Hand hygiene shall be performed in each of the following situations, other situations may also apply: a) Before touching a patient; b) Before clean/aseptic procedures; c) After body fluid exposure risk; d) After touching a patient; e) After touching patient surroundings; f) After glove removal."

On 11/12/2018 at 12:30 PM, Registered Nurse XX was observed starting an intravenous catheter line for Patient #8. After doing hand hygiene, donning gloves and drawing up a numbing agent into a syringe, Nurse XX entered the pocket of XX's scrub jacket with the gloved hand and proceeded to continue with the intravenous start, failing to remove/change gloves and do hand hygiene. This finding was discussed per interview with Surgery Manager E on 11/13/2018 at 9:30 AM. After discussion regarding failure to change gloves after entering XX's pocket, Manager E stated, "Ya, I get that part."

During observation of care on 11/12/2018 at 3:05 PM, after performing a blood draw on Patient #9, Phlebotomist K removed gloves and left Patient #9's room without performing hand hygiene. At 3:10 PM, Registered Nurse L donned gloves to administer IV medications to Patient #9. After administering the medication and without changing gloves, L went to the bedside computer, removed alcohol wipes from L's pocket and administered a subcutaneous injection to Patient #9. Registered Nurse L then changed gloves without performing hand hygiene.

During observation of care on 11/13/2018 at 10:45 AM, Registered Nurse KK donned gloves to perform Patient #10's foley catheter care then changed gloves without performing hand hygiene prior to applying medicated ointment to Patient #10's scrotum. During wound care, Nurse KK removed a bandage from Patient #10's foot and did not change gloves or perform hand hygiene prior to cleansing the wound and applying a new dressing.

During an interview on 11/13/2018 at 11:10 AM, Assistant Patient Care Manager AAA stated hand hygiene should be performed "absolutely with glove change and when leaving [the patient] room." During an interview on 12/13/2018 at 11:30 AM, Clinical Nurse Specialist LL stated gloves should be changed when moving from dirty to clean tasks during dressing changes.

On 11/13/18 at 10:15 observed RN HH administer chemotherapy to Patient #33. RN HH donned gloves, hung chemotherapy medication, removed gloves and threw them on the countertop (instead of properly disposing) and did not complete hand hygiene. RN HH then dropped personal protective gown on the clinic floor, picked gown up and donned gown, donned gloves without hand hygiene, cleaned the intravenous port on Patient #33, removed gloves without performing hand hygiene, removed gown and picked up dirty gloves off the counter and placed gloves in the yellow disposal bin without performing hand hygiene.

Conducted an interview with Vice President of Populations II on 10/19/18 at 10:30 AM. Vice President of Populations II confirmed RN HH did not follow hand hygiene policy and stated RN HH "should have taken a new gown if dropped on the floor."

Blood Glucose Monitoring

Review of facility policy "POCT iSTAT 1 Testing" dated 1/23/2018 revealed "12) a) Clean and disinfect the device... ii) If taken into patient's room, clean and disinfect the handheld prior to entering and before leaving the patient room."

During observation of care on 11/13/2018 at 11:00 AM, Registered Nurse KK brought a handheld blood glucose monitor and case into Patient #10's room to perform a blood sugar check. After performing the blood sugar check, KK placed the handheld device inside the portable case and returned the case to the nursing station. Registered Nurse KK wiped the exterior of the case without disinfecting the handheld monitor.

During an interview on 12/13/2018 at 11:30 AM, Clinical Nurse Specialist LL stated the handheld device "should be disinfected" per policy.


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Medication Vials

The facility skills procedure titled, "Medication Administration: Injection Preparation from Ampules and Vials," dated August 2018, was reviewed on 11/14/2018 at 7:24 AM. The procedure revealed in part, "Firmly and briskly wipe the surface of the rubber seal with an alcohol swab, being sure to apply friction, and allow it to dry."

On 11/12/2018 at 2:10 PM, Anesthesiologist J was observed preparing anesthesia medication for Patient #8's surgical procedure. On 2 of 4 occasions observed, Anesthesiologist J failed to cleanse the rubber septum of medication vials prior to piercing the septum and withdrawing the medication.

On 11/12/2018 at 2:00 PM, Registered Nurse H was observed preparing Bupivicaine (local anesthetizing agent) for the sterile surgical table. Nurse H failed to cleanse the rubber septum of the vial prior to piercing the septum. Upon piercing the septum Nurse H inadvertently popped the septum through into the medication rendering it unusable, left the room and returned with a filled syringe and opened vial of Bupivicaine with the rubber septum intact.

These findings were discussed per interview with Surgical Services Manager E on 11/13/2018 at 9:30 AM. Regarding cleansing the rubber septum of medication vials, Manager E stated, "Alcohol is provided, they should be alcoholing."

Immunization monitoring

The facility policy titled, "Physical Exam Requirements for [entity identification removed] Care Personnel," dated 9/19/2018 (effective 1/1/2007), was reviewed on 11/14/2018 at 10:20 AM. The policy revealed in part, "c. The pre-placement exam will include a: i) Medical history with attention to: (2) Immunization History:...Hepatitis B...(dates of immunization and/or verbal history accepted)..."

Provider credential files were reviewed on 11/13/2018 at 11:00 AM accompanied by Director of Medical Staff R and Patient Safety Coordinator S. There was no documentation found regarding Hepatitis status (immunity or if vaccine was needed/given) or if the provider declined vaccine at time of hire for Anesthesiologist J or Emergency Department doctor JJ. During an interview with Director R on 11/13/2018 at 11:21 AM regarding Hepatitis results for providers, Director R stated, "We don't follow Hepatitis in credentialing."


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Decontamination:

On 11/12/18 at 2:00 PM, reviewed facility policy titled "Bloodborne pathogens exposure control plan" dated 8/18/18. This document states "Spill clean up is based on Environmental Services written policies and procedures for appropriate cleaning up spills of blood and body fluids. The following procedure steps are to be used to safely clean up small-volume spills of blood. 1) secure area of the spill to prevent exposure to others. 2) put on gloves...wipe up spill thoroughly with disposable towels and discard towels into a biohazard bag as appropriate. 3)...scrub area with a detergent solution...7) Perform hand hygiene with soap and water...8) for large volume spills call Environmental Services Department..."

On 11/14/18 at 9:30 AM, reviewed facility policy titled "Handling of clean and soiled supplies" dated 2/27/16. This document states "2) Hand hygiene procedures shall be followed at all times...3) Gloves shall be worn when bringing equipment and supplies from a patient care area to decontamination are for processing, 6) Dirty instruments .... must be returned to decontamination in covered plastic bins with lids, and marked with biohazard labels."

On 11/12/18 2:46 PM observed Sterile Processing Technician G remove red biohazard bin containing dirty obstetrics surgical instruments from the dirty utility room on the obstetrics unit and place the red biohazard bin in a blue cart. Sterile Processing Technician G was not wearing gloves. The blue cart was not marked with a biohazard label. At 3:03 PM observed Sterile Processing Tech G pushing blue cart containing the dirty surgical instruments in the hallway leading to the emergency department. Observed the cart leaking blood tinged fluids onto the floor in the hallway creating a trail of fluid down the hallway and a puddle of fluid where the cart was parked. Sterile Processing Technician G was made aware of the biohazard spill and proceeded to clean up the puddle of fluid with blue surgical towels and no gloves on. When asked if Sterile Processing Technician G would like to call for housekeeping to mop, Sterile processing Technician G said "no".
An interview was conducted with Sterile Processing Technician G at the time of the biohazard spill. Sterile Processing Technician G stated "they put too much water in the bin and overfilled it, that's why its leaking." Sterile Processing Technician G confirmed that neither the red bin or the blue transport cart are leak proof.

On 11/13/18 at 8:20 AM observed Sterile Processing Technician VV transport dirty instruments from the emergency department. The instruments in the emergency department were in a red biohazard bin, no liquid was in the bin and the instruments were covered with Enzymatic foam spay to keep them from drying. There was no water/liquid in the bin containing the instruments.

Conducted an interview with Assistant Manger of obstetrics YY on 11/18/18 at 2:30 PM. Assistant Manger YY stated the procedure in obstetrics is to fill the red biohazard bill to the top holes of the basket in the bin and add one pump of enzymatic cleaning solution. Assistant Manger YY stated obstetrics does not use the foam enzymatic solution on their instruments.

Conducted an interview with Manager of Sterile Processing UU on 10/19/18 at 3:30 PM. Manager UU stated the procedure for transporting dirty instruments is to "dump the fluid (in the bin) in the department before bringing them down (to sterile processing)." Manger UU confirmed there is not a policy and procedure for the transporting of dirty instruments from other departments to the sterile processing department. Manager UU stated obstetrics is the only department that uses the enzymatic soak in water instead of the foam enzymatic spray.


Cleaning Environmental Services:

Per review of the manufacturer's recommendations for cleaning products used at this facility, dated July 2017, the recommendations revealed, "We recommend that end users check their disinfectant and/or sanitizer active concentration levels to help ensure dilution and active ingredient accuracy. This can be accomplished through the use of test strips, titration kits, and/or analytical methods."

Conducted an interview with Environmental Services Supervisor WW and Food and Environmental Services Director N on 11/14/18 at 1:30 PM. Per Supervisor WW, this facility uses an automated chemical dispensing system for cleaning product. The facility does not currently have a system in place to routinely check the concentrations of the cleaning products being dispensed. Supervisor WW checked with the manufacturer and stated "they recommend the test strips." Director WW stated they do not have a current policy for these recommendations.

Based on record review and interview, facility staff failed to ensure discharge instruction are individualized to meet patient needs for 2 of 5 discharged patients (Patient #21 and Patient #23) in a total universe of 33 medical records reviewed.

Findings include:

Review of facility policy "Inpatient Discharge Policy and Process" dated 11/28/2017 revealed "2) a) The physician... completes all information needed for discharge to home/next level of care... b) The physical or psychosocial care needed post discharge will be clarified with the physician using the After Visit Summary form. This may include: ...ii) Diet. ...e) Discharge instructions are provided directly to the patient/family prior to any transfer/discharge. Discipline-specific instructions will be reviewed by the discipline providing that instruction."

Review of Patient #21's medical record revealed inpatient services from 9/24/2018 through 10/3/2018 for congestive heart failure. Review of the physician's discharge summary dated 10/3/2018 revealed "Patient Discharge Instructions: 2. Diet: Fluid restriction 2200 mL (milliliters)."

Review of Patient #21's After Visit Summary instructions, provided to the patient at discharge, did not include instructions for fluid restriction. The After Visit Summary included general education for Congestive Heart Failure including "-Follow you healthcare provider's recommendations about how much fluid you should have" and smoking cessation discharge instructions to "-Drink water. Try to drink eight glasses of water a day, unless your provider has told you to limit fluids."

Review of Patient #23's medical record revealed inpatient services from 11/7/2018 through 11/10/2018 for acute kidney failure. During the hospitalization, Patient #23 had a central venous catheter placed and was started on hemodialysis to be continued as an outpatient. Patient #23's discharge instructions did not include instructions for kidney failure, hemodialysis or care of the central venous catheter.

During an interview on 11/13/2018 at 3:45 PM, Clinical Nurse Specialist LL stated discharge instructions "should be" specific to the patient. Per LL, "I would expect the discharge instructions [for Patient #23] to include something about the catheter."

Based on record review and interview, facility staff failed to supply provider options for 2 of 3 patients reviewed requiring home health care services at discharge (Patient #21, Patient #22) in a total universe of 33 patient.

Findings include:

Review of facility policy "Inpatient Discharge Policy and Process" dated 11/28/2017 revealed "1) e) The Case Manager and/or Social Worker will provide the patient/family a list of available facilities that meet the patient's level of care providing the patient or alternate decision maker to choose appropriate post-acute services, e.g. rehab facility, skilled nursing facility, home health/hospice, or other community based services. The patient is offered choice in future care options."

Per medical record review, Patient #21 was discharged from the facility to home on 10/3/2018 with home health care services. Case Manager notes did not include documentation of Patient #21's choice or preferences for home health care services. Patient #21 was discharged to the facility's system-affiliated home health care service.

Per medical record review, Patient #22 was discharged from the facility to home on 10/12/2018 with home health care services. Case Manager notes did not include documentation of Patient #22's choice or preferences for home health care services. Patient #22 was discharged to the facility's system-affiliated home health care service.

During an interview on 11/13/2018 at 11:40 AM, Case Manager PP stated when patients require post-acute services after discharge, facility staff enter an electronic referral into the "Aidin" system. The program then lists all available facilities within the patient's zip code and the patient is offered a choice of available services. Regarding Patient #21 and Patient #22, PP stated "it doesn't look like we put a referral in." Case Manager PP was unable to state whether or not either patient had been offered a choice in home health care services.

Based on record review and interview the facility staff failed to document the Wisconsin Donor Network staff name, case number and consent in 1 of 2 death records (Patient # 5) in a total universe of 33 records reviewed.

Findings include:

Review on 11/13/2018 at 10:30 AM of policy titled, "Donation of Bodies, Organs, and other Tissue" dated 7/26/2016 revealed, "Policy: 2. c. The referring nurse shall be responsible for documenting the referral call to the WDN (Wisconsin Donor Network) in the electronic health record (EHR) or on Record of Death downtime form. 5. ALL deaths will be referred to the Wisconsin Donor Network for determination of donor suitability prior to the family being approached for consent to donation. The notification of the WDN will be documented in the Post-mortem navigator in the EHR. Procedure: 1. Traditional Organ/Tissue Donation b. i. Obtaining Consent: Organ/tissue procurement agencies obtain consent. 1. Consent must be documented in the EHR. The EHR must reflect that the person(s) who may make the anatomical gift has been offered the option to donate organs, tissues, eyes, or has refused to do so. 2. If eligible, documentation of preparation of the body for donation, as well as the disposition of the body must be included in the EHR."

Interview on 11/13/2018 at 11:10 AM with Intensive Care Unit Manager FF stated, "Every call to the Wisconsin Donor Network should be assigned a case number. The Wisconsin Donor Network staff and the case number should be documented on the post-mortem form in the electronic health record."

Review on 11/13/2018 at 9:30 AM of Patient #5's closed medical record revealed documentation of initial contact with Wisconsin Donor Network on 1/2/2018 at 8:23 AM. Documentation did not include the name of the staff at Wisconsin Donor Network or the referral number. There was no consent form noted in the medical record.

Interview on 11/13/2018 at 10:05 AM Staff Development Specialist GG stated, "Staff are to document the phone call including the name of the Wisconsin Donor Network staff and case number assigned on the post-mortem form in the electronic health record. That information is not documented."

Based on observation, interview, and record review, staff failed to follow nationally recognized standards of care in the surgical suite for 1 of 1 surgical patient observation (Patient #8) involving 4 of 7 staff observed (Staff ZZ, G, J, H, and I).

Findings include:

An interview with Surgical Services Manager E was conducted on 11/13/2018 at 8:52 AM. Regarding standards of practice for surgical services, Manager A stated that the facility follows AORN (Association of peri-Operative Registered Nurses) and hospital policies for things like hand hygiene.

Review on 11/13/2108 at 9:45 AM of facility policy titled, "Surgical Attire in the Operating Procedural Room," dated 9/25/2018 revealed, "Head and facial hair must be covered when in the restricted and semi-restricted areas...Masks must cover both mouth and nose and be secured to prevent venting. Masks must be removed and discarded after use with each case."

Review of AORN, Perioperative Standards and Recommended Practices, 2013 Edition, "The mask should cover the mouth and nose and be secured in a manner to prevent venting. A two-tie mask that is securely tied at the back of the head and behind the neck, or a mask that is secured at the crown of the head, helps to prevent infectious particles from reaching the wearer's nose and mouth by passing through leaks at the mask-face seal."

Review of AORN Guideline for Surgical Attire , Publish Date: May 30, 2017, the AORN guideline 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 11/12/2018 at 12:55 PM Anesthesia Technician ZZ was observed wearing a surgical mask and visor at a nursing station desk (not a sterile area).

Observations in operating room 1 were conducted on 11/12/2018 between 1:30 PM and 2:30 PM. The following observations were made:
Between 1:36 PM and 2:30 PM Surgical Technician G was observed wearing a surgical face mask that did not cover beard hair along the sides of the face while opening sterile instruments and attending the sterile field for Patient #8's surgical procedure.

At 1:50 PM Anesthesia Technician ZZ was observed entering operating room 1, did not perform hand hygiene, took supplies out of the anesthesia cart for Patient #8's surgical procedure, then donned gloves, performed more tasks, removed gloves and then did hand hygiene.

Between 2:10 PM and 2:30 PM Anesthesiologist J, Registered Nurse H, and Surgeon I were observed wearing surgical bouffant head coverings that did not cover the ears while sterile instruments were open in the room, including during the surgical procedure (hernia repair) for Patient #1. Surgeon I was also observed to not have the bottom strings of the surgical mask securely tied leaving gaps around the sides and bottom of the mask.

These findings were discussed per interview with Surgical Services Manager E on 11/13/2018 at 9:30 AM. Regarding wearing of personal protective equipment outside of the operating room, Manager E stated Technician ZZ told Manager E that ZZ was getting prepared to enter an operating room for an upcoming case. Manager E stated, "Rather than have the masks tied on and laying on their chests staff keep them on but used attire should be removed." Regarding hand hygiene, Manager E stated that hand hygiene should be performed upon entry and exit of the operating rooms as well as when indicated when inside the room.