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Based on observation, staff interviews and review of maintenance records on December 6, 2012, the facility failed to construct, install and maintain the building systems to ensure a physical environment that was safe for patients and staff. The cumulative effects of the environment deficiencies result in the hospital's inability to ensure a safe environment for all patients and staff.


Findings include:

The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags: (K-11)-Separation walls and doors, (K-17)-Corridor walls not smoke tight,(K-18)-Corridor doors not smoke tight, (K-21)-Doors held open with smoke detection, (K-22)-Exit signs, (K-29)-Hazardous rooms not properly enclosed, (K-56)-Sprinkler blockage, (K-62)-Sprinkler maintenance, (K-67)-HVAC, and (K-69)-Kitchen hood, (K-144)-Generator, (K-147)-Electrical system.

29302

Based on observation, staff interview and review of facility policy and procedures, the facility failed to ensure that patient care equipment is monitored and is in safe operating condition. The deficient practice has the possibility of affecting all patients.

Findings include:

Review of facility policy on 12/5/12 at 2:50 PM, titled Temperature Check of Warmers For Intravenous Fluids or External Fluids, issue date 12/2011, effective date 1/20/12 stated: "4. A. Fluids must be removed on the 14th day. The date of removal must be recorded on the bottle."

Per observation on 12/3/12 at 2:40 PM, a fluid warmer held (2) liter containers of sterile water which did not indicate an expiration date.

Per interview with Emergency Department Manager at time of findings, confirmed that the fluids that were placed in the warmer should have been dated with expiration when placed in the warmer.

On 12/3/12 at approximately 2:25 PM the Emergency Department tour revealed the following:

A warming cabinet was noted in use with blankets inside. No external temperature gauge on outside of machine. No thermometer was noted on inside of machine. Asked ED Manager I how temperature was being monitored, ED Manager I was unable to explain. Vice President of Patient Care B provided literature stating "ECRI Institute recommends that temperature settings on blanket cabinets be limited to 130 degrees... as temperatures above this level unnecessarily increase the risk of burns while providing no added clinical benefit."

Per tour of Emergency Department patient waiting area revealed a bathroom used by visitors of the Emergency Department that did not have an emergency call system located inside the bathroom for visitors to utilize for assistance if needed.

The above findings were confirmed with Manager of Emergency Department I at time of tour.

On 12/3/12 at approximately 11:00 AM a tour of the Maternity Department revealed the following:

An incubator in the nursery had a sticker affixed to its back side indicating its filter had last been changed on 09/2011. Instructions both on the incubator and in the manual for this machine (Ohio Care Plus Incubator) indicate filters should be changed on a quarterly basis.

These findings were confirmed per interview with the Maternity Department manager O on 12/03/12 at 2:00 PM.

Dish Machine Maintenance:

On 12/4/2012, 10:42AM, interview with Staff BB revealed dish machine wash temperatures have not been consistently reaching the required temperature of 160o Fahrenheit since Friday, 11/30/2012. The wash temperature recorded for 12/3/2012 is 120o Fahrenheit.
There are no recorded temperatures for 12/4/2012. Staff BB stated they still used dish machine for dishes.

On 12/4/2012, 10:45 AM, interview with Staff CC stated had received email on Friday, 11/30/2012 regarding wash temperature not reaching required temperature. Staff CC stated doesn't know how dish machine would even get to 160o Fahrenheit since there is not a booster for the wash water. Staff W stated wash temperature always reached the required 160oFahrenheit before. Review of dish machine wash temperature logs for November revealed wash temperatures ranged 160 - 170o Fahrenheit. The recorded wash temperature for the dish machine on 11/30/2012 is 124o Fahrenheit and on 12/3/2012 is 120o Fahrenheit. In the column on log sheet, under corrective action is a statement "working on it."

On 12/4/2012, 12:22 PM, observed dish machine being worked on. Staff U reported the problem has been identified as a malfunctioning gauge which is not accurately recording the temperature.

On 12/4/2012, 2:30 PM, Staff R stated did not know why dish machine was not repaired sooner.









29963

Based on facility tour and staff interview the facility failed to ensure trash and biohazardous materials are stored securely. This has a potential harmful effect on all patients in the facility.

Findings include:


29963

On 12/3/12 at approximately 2:25 p.m. the Emergency Department tour revealed the following:

The unlocked soiled utility room door was labeled with a sticker "biohazard material". A biohazard bin was located inside the room. On the counter top was a gallon of Cavicide Cleaner and in the unlocked upper cupboards was a gallon bottle of Clorox bleach and providone iodine solution.

The housekeeping closet was found to be unlocked. A cart containing bottles of chemicals including Virex, and disinfectant cleaning supplies were noted.

Per interview with CEO A at time of findings indicated that door should be locked when housekeeping staff is not in the direct area. Housekeeper was not in the direct area. This was confirmed with CEO A and ED Manager I.

The above findings were confirmed with Manager of Emergency Department I at time of tour.

On 12/3/12 at 9:55 a.m., a tour of Intensive Care Unit revealed the following:

The unlocked soiled utility room door was labeled with a sticker "biohazard material." A biohazard bin was located inside the room.

Findings were confirmed with Infection Preventionist H, at time of observation.

On 12/3/12 at 10:05 a.m., a tour of third floor medical/surgical unit revealed the following:

The clean supply room had a swipe pad to obtain entrance but door was unlocked. Supplies that were stored in this room included needles and syringes.

The above findings were confirmed with Infection Preventionist H at time of tour.

On 12/3/12 at approximately 11:30 a.m. during a tour of the Maternity Department, the following was observed:

An unlocked soiled utility room (3006) was labeled with a sticker "biohazard material." A biohazard bin was located inside the room.

This finding was confirmed with CEO A at the time of the tour.

On 12/3/12 at approximately 11:30 a.m. during a tour of the Second Floor, the following was observed:

An unlocked soiled utility room (2409) was labeled with a sticker "biohazard material." A biohazard bin was located inside the room.

This finding was confirmed with CEO A at the time of the tour.

Based on observation, staff interviews and review of maintenance records on December 6, 2012, the facility failed to construct, install and maintain the building systems to ensure a physical environment that was safe for patients and staff. The cumulative effects of the environment deficiencies result in the hospital's inability to ensure a safe environment for all patients and staff.


Findings include:

The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags: (K-11)-Separation walls and doors, (K-17)-Corridor walls not smoke tight,(K-18)-Corridor doors not smoke tight, (K-21)-Doors held open with smoke detection, (K-22)-Exit signs, (K-29)-Hazardous rooms not properly enclosed, (K-56)-Sprinkler blockage, (K-62)-Sprinkler maintenance, (K-67)-HVAC, and (K-69)-Kitchen hood, (K-144)-Generator, (K-147)-Electrical system.

Based on observations, P&P review, staff interviews, and 30 of 30 MR review, the GB (governing body) failed to assume responsibility for the hospital's total operation. This affects all current and future patients and staff.

Findings include:


The GB failed to ensure that surgical patients are protected from fire. See Tag C-320

Based on observations, interview with staff and facility policies the hospital failed to ensure drugs and biologicals were monitored for outdates. This deficient practice could possibly affect all patients receiving services and treatment.

Findings include:

During a tour of the Rehab Gym on 12/03/12 at 11:45 AM with CEO A the following items were observed:

In one treatment room near the exercise bikes, next to the storage room, a bottle of unopened saline solution dated 07/12 was found in an unlocked supply cupboard.

In the next treatment room near the exercise bikes, next to the pediatric exam room a bottle of opened isopropyl alcohol dated 09/07 was found in an unlocked supply cupboard.

These findings were confirmed per interview with CEO A at the time of the tour.



29972


According to the Medication Storage and Security Policy and Procedure effective date 1/2012: All non-controlled medications are stored under single lock.

According to APIC (Association for Professionals in Infection Control) Position Paper: Safe Injection, Infusion, and Medication Vial Practices in Healthcare, 2009:

1. Use multidose medication vials for a single patient whenever possible. The risk of transmission posed by multi-dose vials has been clearly demonstrated and mandates a practice of one vial per one patient whenever possible. Infection transmission risk is reduced when multi-dose vials are dedicated to a single patient.

2. Keep Multidose vials away from the immediate patient environment

During OR tour on 12/3/12, the following was observed:

At 2:35 PM observed a medication cart, unlocked, sitting outside of OR room 1 not directly observed by staff. The medication cart contained 6 boxes of Dantrolene, 4 vials of calcium chloride, 2 vials of Lasix, 3 vials of Benadryl, 2 cartridges of Epinephrine, 2 vials of sodium bicarbonate, and 7 vials of Mannitol.

At 3:25 PM observed an opened multi-dose vial of Lidocaine sitting out unsecured and unattended on a table where multiple endoscopic procedures are performed. Per Manager D, the Lidocaine is drawn up and administered to patients in the endoscopic procedure area where staff perform multiple endoscopic procedures daily. This deficient practice does not ensure patient safety by reducing the risk of potential cross contamination of medication vials.

The above findings were confirmed with Manager D and Dir F at the time of the OR tour.

29963

Based on tours, observations, review of P&P and interview with staff in 14 of 29 observations the facility failed to ensure a safe and sanitary environment to prevent and control the potential spread of infection. This deficiency potentially affects all patients treated during survey.

Findings include:

Examples of PPE, handwashing and glove changes:

During observation of pt. # 17's Laparoscopic Cholecystectomy (removal of gall bladder) at 9:30 AM, Surgeon P, CRNA E, and ST K were all observed to be wearing their own eyeglasses which does not provide proper protection from possible contamination of body fluids during the surgical procedure.

Findings were confirmed with Director of Outpatient Services F on 12/4/12 at 10:45 AM.

Examples of environment:

On 12/3/12 at approximately 2:25 PM the Emergency Department tour revealed the following:

? Admission desk had chipped laminate exposing porous wood preventing the surface from being cleanable.
? Cupboard under the sink in the waiting had an accumulation of dust/dirt on shelving.
? Trauma rooms 5 and 6 had unsecured cabinets containing needles and syringes allowing patients and visitors access.
? Exam Room # 1, 3, 4, and 5 revealed dusty ceiling vents.

The above findings were confirmed with Manager of Emergency Department I at time of tour.

On 12/3/12 at 10:05 AM, during tour of third floor medical/surgical unit, the following was revealed:

? The clean supply room had a swipe pad to obtain entrance but door was unlocked. Supplies that were stored in this room included needles and syringes.
? Rooms had nurse servers which had the capability to be locked but were left unlocked which stored a plastic container of needles and syringes.

The above findings were confirmed with Infection Preventionist H at time of tour.

During the observation of a dressing change for pt. #18 on 12/04/12 at 10:00 a.m., RN EE was observed removing a bag of trash from the trash can and placing the soiled bag on a clean counter. This observation was confirmed at the time with Quality Manager C who was in the patient's room.

Examples of breaking sterile field:

During observation of pt. #17's surgical procedure of Laparoscopic Cholecystectomy at 10:25 a.m., Surgical Tech (ST) K turned her back several times to the surgical instrument table while handing supplies to surgeon P. At 10:27 a.m., ST K moved the sterile instrument table directly behind her back as ST K assisted Surgeon P in holding instruments as the procedure was being completed.

The above findings were confirmed with Director of Outpatient Services F at the time of the observation.


29972

Findings include:

During OR tour on 12/3/12 beginning at 2:35 PM, the following was observed:

? Dirt and debris under sink in pathology room.
? Caked on dust on sharps container in pathology room.
? Dirt and debris on stainless steel counter top in pathology room.
? 2 syringes out of original packaging with needle attached laying on countertop in PACU exposed to potential contaminates.
? Gauze out of packaging laying in drawer, exposed to potential contaminates.
? 1 syringe out of original packaging with needle attached found in cabinet exposed to potential contaminates.
? Large container filled with clear fluid in the Endoscopy cleaning room, no endoscopes currently being cleaned. Per Manager D, water with disinfectant is in the container and it should be dumped between cases.

The above findings were confirmed at time of tour with Manager D and Dir F.

On 12/4/12 observed the following before and during Pt #17's laparoscopic surgery:

At 9:35 a.m. observed Tech K don sterile gown and gloves, grab the garbage can to move it closer touching the inside of the garbage can and then proceeded to open sterile supplies without replacing potentially contaminated gloves.

At 9:45 a.m. observed RN J enter OR, move garbage can with hand, type on keyboard, and then proceed to assist Tech K in opening sterile supplies without performing hand hygiene.

From 9:25 a.m. to 11:20 am observed RN J entering and exiting surgical suite during OR set up and surgery, surveyor did not observe RN J perform hand hygiene upon entering the surgical suite. This deficient practice can potentially lead to contamination of sterile equipment and supplies.

Beginning at approximately 9:55 a.m., observed CRNA E preparing to intubate Pt #17. CRNA E did not perform hand hygiene prior to donning gloves. CRNA then reached into clean supply drawer with gloved hands and proceeded to intubate Pt #17. After intubating Pt #17, CRNA E then used tape stuck to computer monitor to tape Pt #17's eyes closed, potentially transmitting contaminates onto Pt #17's eyes and skin. CRNA E then removed gloves and did not perform hand hygiene.

After removing gloves, CRNA E touched knobs on computer monitor, arm rests on chair, pyxis medication drawers, computer mouse, top of head, and rested fingers on face. In between these tasks, CRNA E administered IV(intravenous) medications and spiked a new bag of IV fluids without performing hand hygiene prior to administering medications directly into Pt #17's blood stream. Surveyor did not observe any hand sanitizer within reach of CRNA to ensure hand hygiene is done. This deficient practice can potentially lead to bacterial contamination directly into Pt #17's blood stream.

The above observations were confirmed on 12/4/12 at 11:25 with Dir F.

Based on observations and interviews, the dietary department did not operate in accordance with recognized dietary practices based on the following:

? Improper hand hygiene
? Dirty equipment
? Items stored improperly resulting in exposure to contamination
? Improper 3-compartment dish machine procedure
? No system in place for assuring internal temperature of dish machine reaches proper temperature
? Hair improperly restrained
? Food items improperly stored
? Staff not understanding employee health policy related to illness.

The totality of the issues has the potential to negatively affect all in-house patients.

(Note: Facility uses the Wisconsin Food Code as its professional standard of practice)

HAND HYGIENE:

According to the Wisconsin Food Code, food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation, including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles. Hands are to be washed during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks and before donning gloves for working with food.

On 12/4/2012, observed multiple times Staff Y did not wash hands when changing tasks(going back and forth between trayline to griddle to combioven to microwave to cook's table) and before donning gloves. Those observations are as follows:

? 11:32 a.m., removed soiled gloves, put on new pair of gloves - no hand washing.
? 11:40 a.m. removed soiled gloves, put on new pair of gloves - no hand washing
? 11:46 a.m. removed soiled gloves, put on new pair of gloves - no hand washing.
? 11:56 a.m., washed hands, went to open drawer, which is visibly soiled, retrieved serving utensils, put on new pair of gloves without washing hands.
? 12:07p.m., removed soiled gloves, put on new pair of gloves - no hand washing.
? 12:12 p.m., removed soiled gloves, put on new pair of gloves - no hand washing.

(The above was witnessed by Staff X)

DIRTY EQUIPMENT:

The Wisconsin Food Code states that nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris. Sinks be sanitized before and after each time it is used to wash produce or thaw food.

On 12/4/2012, observed the following:

? 09:55 a.m., the entire outside of the ice machine, located in the kitchen, was soiled with dried on substance/debris/dust.
? 10:05 a.m., inside the walk-in freezer, right side near front door were pieces of chopped link sausage lying exposed on a dirty tray pan.
? 10:18 a.m., cook's refrigerator - outside was splattered with dirt/white substance on entire right side. The refrigerator handles were covered with dirt/crud making it difficult to open refrigerator without touching the crud. Staff W agrees it is more than a day's worth of dirt.
? 10:25 a.m., observed large Hobart mixer, uncovered with dried substance/dirt where paddle is inserted. The table the mixer was sitting on was thick with dirt and dust. Above the mixer, is a fire blanket container with lot of dust hanging from it. Next to the table the mixer is on, is a baker's table. The outside of the 3 drawers of the baker's table had significant amount of dirt/debris/residue.
? 10:33 a.m., in the dishroom is stored a 6 shelf cart which was dirty and dusty.
? 10:45 a.m., steam table very dirty. The right well of the steam table contained a lot of food debris/crumbs. The left well of the steam table was also dirty with food crumbs/debris.
? 10:53 a.m., under the Turbochef oven were stored 2 ceramic cake pans and 3 little ceramic dishes which contained multiple amounts of crumbs and food debris. On the outside of the cake pan was smeared a brown substance. On the inside of the Turbochef oven's door was a build-up of thick grease. Located on the outside top of the Turbochef oven were screens used to move food out of the oven when hot. The screens were thick with dirt/crud and dust.
? 10:56 a.m., the griddle, which was not being used, was dirty with food debris. Lying on the side of the griddle was a very dirty spatula. No cooking was occurring at this time. The dials on the Combi-oven were covered with build-up of debris/dirt. The table legs of the convection oven were covered with multiple splatters of debris.
? 11:10 a.m., the slicer, which was currently not being used, was uncovered and dusty. Stored on the slicer were 2 containers of malted milk powder.
? 11:59 a.m., observed Staff Z thaw steak in a sink that contained vegetable peelings.

All the above observations were verified by Staff W.

CROSS CONTAMINATION:
According to the Wisconsin Food Code, food items and equipment must be properly stored to prevent transmission of foodborne pathogens or contamination. Clean equipment and utensils shall be stored in a self-draining position that allows air dry and covered or inverted.

? On 12/4/2012, 9:53 a.m., observed clean coffee mugs on table, uncovered and butted up against hand washing sink, resulting in exposure to splash during hand washing.
? On 12/4/2012, 10:23 a.m., observed serving utensils, right side up, uncovered and stored in a bucket on storage rack.
? On 12/4/2012, 10:28 a.m., observed stack of stainless steel bowls, stored right side up and uncovered on storage rack, including another container of serving utensils, uncovered.

The above observations were verified by Staff W.

Manual Warewashing, Sink Compartment Requirements:

According to the Wisconsin Food Code, a quaternary ammonium compound solution is to be used according to manufacturer's directions included in the labeling. The dietary department uses Ecolab 146 Multi-Quat Sanitizer. According to review of its product specifications, sanitizing requires immersion of all utensils for at least one minute.

On 12/4/2012, observed staff AA washing equipment in a 3-compartment sink. In the 3rd compartment, which is the sanitizing procedure, several pieces of equipment were piled up, only half being completely immersed. Staff AA states will swish each item, and then will set out to air dry. Staff AA states is not aware that there is a specific time that equipment needs to be immersed.

MONITORING OF INTERNAL TEMPERATURE OF HOT WATER SANITIZATION DISH MACHINE:

According to the Wisconsin Food Code, a system needs to be in place for monitoring a hot water sanitization dish machine's internal temperature to assure that food contact and utensil surfaces reach a temperature of 160oF as measured by an irreversible registering temperature indicator.

On 12/4/2012, 10:31 a.m., observed Hobart dish machine which uses hot water for sanitization. According to the dish machine manual and the machine's data plate, the minimum wash temperature required is 160 degrees Fahrenheit. According to Staff BB, the dish machine's wash temperature is not getting to the required 160 degrees Fahrenheit. Staff BB stated it was reported to maintenance on 11/30/2012, which Staff CC concurred. Staff CC stated he didn't know anything about the monitoring of the utensil surface temperature. Staff R stated EcoLab comes in once a month and services the machine, and that there is not any other temperature monitoring system in place.

HAIR RESTRAINTS:

The Wisconsin Food Code states that "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."

On 12/4/2012, during the times 9:53 a.m. - 2:30 p.m., observed the following staff without having hair properly restrained: Staff W (full bangs); Staff Y (full bangs); Staff Z (full bangs); and, Staff BB (full bangs).

The above was witnessed by Staff X.

FOOD STORED AND PREPARED IN A SAFE MANNER:

According to the Wisconsin Food Code, food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold or discarded, based on the temperature and time combination of 5oC (41oF) or less for a maximum of 7 days. The Wisconsin Food Code also states that food and ingredient contamination is to be protected by storing the food in packages, covered containers, or wrappings ... Food shall be protected from contamination by storing at least 6 inches from floor.

On 12/4/2012, 9:57 a.m., salad refrigerator, observed the following items uncovered/not labeled: apple crisp, sugar-free jello, regular jello, sugar-free pudding, 2 dishes of peaches and 3 turkey sandwiches. Staff W confirmed surveyor's observations.

On 12/4/2012, 10:00 a.m., reach-in freezer, observed the following food items without labels: 1 ? bags butter cookie dough and 1 ? bags of scones. Staff W confirmed surveyor's observations.

On 12/4/2012, 10:05 a.m., walk-in freezer, observed unlabeled bag of garlic toast, pork hocks and donut holes stored directly on floor.

On 12/4/2012, 10:12 a.m.-10:16 a.m., walk-in cooler, the following observations were made: toffee pieces without date and the following items past discard date: bulk ham (11/14), chicken strips (12/3), thickened water (10/18)

The above observations were verified by Staff W.

Employee Health Policy:

According to the Wisconsin Food Code, the facility must have a system in place that requires food service employees to report information about their health and activities as they relate to diseases that are transmissible through food. There are specific conditions that require the removal, adjusting, excluding or restricting a food employee. Example - If a foodservice employee is symptomatic with vomiting or diarrhea, the employee cannot return to work until asymptomatic for at least 24 hours. Food service employees need to know what and when to report an illness and who to report it to.

On 12/4/2012, asked Staff W what is the protocol if sick with fever and diarrhea? Staff W stated would stay home but did not know who to report illness to or exactly when it would be okay to return to work.

On 12/4/2012, asked Staff BB what is the protocol if sick with fever and diarrhea? Staff BB states is very lucky and never gets sick. Staff BB stated would probably go to the doctor but didn't know what the protocol is for returning to work.










29302

29963


Based on medical record review, facility policy and procedures, and staff interview, the facility failed to ensure staff appropriately assessed and met patient care needs in response to interventions in 7 of 31 records reviewed (Pt's #9, 15, 17, 19, 20, 21, 27 ). Consequences of these failures could affect all patients receiving services at this hospital.

Findings include:

The facility's policy titled, "Pain Management," issue date 03/2012 was effective on 4/2012. The policy indicates that pain management needs will be assessed and addressed to meet the expectations of all the patients. The policy also states that reassessment of pain intensity and pain relief as reported by the patient will be assessed and documented as follows: Before and after each pain management intervention.

In an interview with RN Manager DD on 12/4/2012 at 2:30 p.m., during MR reviews, RN Manager DD stated that pain re-assessments following medication administration should occur approximately within an hour of giving the medication.

A record review was completed on Pt. #17's open medical record on 12/5/2012 at 10:00 a.m., in the presence of Clinical Informatics Specialist (CIS) M Patient #17 had a Laparoscopic Cholecystectomy on 12/4/2012. Pt. #17 was admitted for monitoring following surgery due to shortness of breath. The following dates and times are related to pain medication given and the lack of reassessments after the medication.

12/5/12 at 12:37 a.m. pt. #17 received a pain medication, no reassessment was documented until 5:19 a.m..

These findings were confirmed at the time of the MR review by CIS M.

A record review was completed on Pt. #9's open medical record on 12/4/2012 at 3:10 p.m., in the presence of CIS M. Patient # 9's diagnosis included Pancreatitis during this hospitalization. The following dates and times are related to pain medication given and the lack of reassessments after the medication.

? 12/2/12 at 6:02 p.m., Pt. # 9 received pain medication, re-assessment completed at 8:31 p.m.
? On 12/2/12 at 8:43 p.m., pt. received a pain medication, re-assessment completed at 10:40 p.m.
? On 12/3/12 at 5:57 a.m., pt. received pain medication and was re-assessed at 8:02 a.m..
? On 12/3/12, pain medication was given at 2:43 p.m. and was re-assessed at 5:15 p.m.
? On 12/4/12, pain medication was given at 10:45 a.m. and was re-assessed at 1:11 p.m.

These findings were confirmed at the time of the review by CIS M.

In an interview with Emergency Department (ED) Manager I on 12/5/12 at 1:50 p.m., ED Manager I stated that patients in the ED are assessed at least hourly.

Per review of pt. # 29's medical record on 12/5/12 at 1:40 p.m., indicated arrival in the ED on 10/1/12 at 8:58 a.m. and discharged on 10/1/12 at 1:17 p.m. Documentation on flow sheets of assessments completed indicated assessments were done at 9:26 a.m. and 10:42 a.m.

A record review was completed on Pt. #27's closed medical record on 12/5/2012 at 1:30 p.m., in the presence of RN manager O. Patient # 27 was receiving pain medication for pain in her right shoulder. On 08/22/12 at 5:28 a.m., pt. #27 rated pain in her right shoulder at 5/10, she received pain med's at that time. Pt. #27's pain was not reassessed. On 08/22/12 at 10:54 p.m., pt. #27 rated pain in her right shoulder at 7/10, she received pain med's at that time. Pt. #27's pain was not reassessed until 3:20 p.m. the following day, 08/23/12.

These findings were confirmed at the time of the review by RN O.


29972


According to Patient Controlled Analgesia (PCA) Flow Sheet given to surveyor on 12/5/12:

When a patient is placed on a PCA pump, Vital signs, pain, and sedation assessment is to be done every 1 hour x 2 hours, then every 4 hours x 24 hours and as needed.

Pt #19's MR reviewed on 12/5/12 beginning at 9:40 a.m. reveals Pt #19 was on a Morphine PCA Pump from 11/11/12 at 2:00 p.m. until 11/15/12 at 8:02 a.m. Sedation level and pain level not consistently documented as per PCA flow sheet requires. Pt #19 given Norco pain medication on 11/15/12 at 3:30 a.m. Pain reassessment not documented until 4:50 a.m., 1 hour and 20 minutes later. Norco given on 11/15/12 at 10:12 a.m., pain reassessment not done until 4:24 p.m. Documentation of pain assessment does not consistently include pain location, pain orientation, pain quality, or pain frequency as listed in the electronic MR.

Pt #15's MR reviewed on 12/5/12 beginning at 11:25 a.m. reveals Pt #15 was placed on a Morphine PCA pump on 12/1/12 at 5:30 p.m. Sedation level is not consistently documented in MR. Vital signs documented at 5:34 p.m. and 5:54 p.m. do not include respiratory rate. No evidence of vital signs taken again until 7:47 p.m., and pain level not documented again until 8:20 p.m. Documentation of pain assessment does not consistently include pain location, pain orientation, pain quality, or pain frequency as listed in the electronic MR.

Pt #20's MR reviewed on 12/5/12 beginning at 1:45 p.m., reveals Pt #20 was given Norco pain medication 10/16/12 at 5:05 p.m., pain reassessment not done until 8:16 p.m. Norco pain medication given on 10/16/12 at 10:19 p.m., pain reassessment not done until 11:44 p.m. Documentation of pain assessment does not consistently include pain location, pain orientation, pain quality, or pain frequency as listed in the electronic MR.

Pt #21's MR reviewed on 12/5/12 beginning at 2:10 p.m., reveals Pt #21 was given Norco pain medication on 10/16/12 at 5:55 p.m. Pain reassessment not done until 7:29 p.m. Documentation of pain assessment does not consistently include pain location, pain orientation, pain quality, or pain frequency as listed in the electronic MR.

The above findings were confirmed at time of MR review with Dir N.

Based on 12 of 31 medical records (MR) reviewed (#1, 4, 5, 6, 8, 9, 15, 16, 17, 19, 20, 27), interview with staff and review of policies the hospital failed to ensure care plans were kept current for all patients.

Findings include:

There was no evidence found during record review for Pt. #1, 4, 5, 6 and #27 that nursing staff developed a nursing care plan based on an individual assessment of patient needs, or documented response to nursing interventions, updates and revisions of the plan were not evident. These examples were confirmed by RN O at the time of review on 12/05/12 at 1:30 p.m.


29963


Per MR review on 12/4/12 beginning at 2:30 p.m., nursing care plan for Pt. # 8 and # 9 do not contain individualized and measurable goals.

Per MR review on 12/5/12 beginning at 11:00 a.m., nursing care plan for Pt. # 17 did not contain individualized and measurable goals.

Findings confirmed with CIS M at the time of review.


29972


Per MR review on 12/5/12 beginning at 9:40 a.m., nursing care plans for Pt #15, 16, 19, 20, and 21 do not contain individualized and measurable goals. Interventions listed in patient's nursing care plans are not being documented and re-evaluated in the patient's MR. Nursing care plans are not being revised and updated based on the changing needs of the patient. Nursing care plans are not being developed reflecting the patients needs and problems.

Per interview with QM C on 12/5/12 at approximately 3:45 p.m., the facility does not have a policy and procedure on nursing care plans.

Based on 5 of 7 surgical patient records reviewed ( #15, 16, 17, 19, 21) out of a total of 31 records, policy review, staff interviews and accepted standards, the hospital failed to ensure that surgery is performed in a safe manner.

Findings include:

The Association for Operating Room Nurses (AORN) Perioperative Standards and Recommendations, 2008 Edition indicate:

IX.d.1. Waterless, brushless, surgical-scrub solutions should be allowed to dry completely to decrease the potential to produce ignition by static electricity or sparks.

IX.d.3. Provide adequate time for the flammable surgical prep solution to dry completely and any fumes to dissipate before applying surgical drapes, using an active electrode or laser, or activating a fiber-optic light cable.

IX.d.5. Drapes should not be applied until prep solutions are dry, to prevent the accumulation of volatile fumes beneath them.


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Pt #17's MR review on 12/5/12 at 11:00 a.m. revealed Pt #17 had a laparoscopic cholecyctectomy on 12/4/12. Per the surgical documentation the alcohol based Chloraprep was used as a skin prep, there is no documentation that the skin prep was confirmed as dry prior to draping. This was confirmed with Clinical Informatics Specialist M at time of medical record review.


29972



Per Surgery interview on 12/3/12 beginning at 1:40 p.m. with CRNA E, Manager D, and Dir F, the facility does not have a policy and procedure addressing a patient catching on fire in the OR or a policy and procedure addressing the use of alcohol based skin prep in the OR to ensure staff are following professionally accepted standards of practice and manufacturers guidelines. Per Manager D, the OR uses Chloraprep to disinfect the skin prior to surgery. When asked by surveyor how long this alcohol based skin prep takes to dry, Manager D responded, "10 minutes."

Per Chloraprep Manufacturer's guidelines given to surveyor on 12/3/12, the following instructions are listed: "To reduce risk of fire, PREP CAREFULLY: Solution contains alcohol and gives off flammable vapors. Do not drape or use ignition source until solution is completely dry minimum of 3 minutes on, avoid getting solution into hairy area. Wet hair is flammable, hair may take up to 1 hour to dry. Do not allow solution to pool. Remove wet material from prep area." Manager D was unaware of the specific drying time for Chloraprep.

On 12/4/12 observed the following before and during Pt #17's Laparoscopic surgery:

At 9:35 a.m. observed Tech K don sterile gown and gloves, grab the garbage can to move it closer touching the inside of the garbage can and then proceeded to open sterile supplies without replacing potentially contaminated gloves.

At 9:45 am observed RN J enter OR, move garbage can with hand, type on keyboard, and then proceed to assist Tech K in opening sterile supplies without performing hand hygiene.

From 9:25 am to 11:20 am observed RN J entering and exiting surgical suite during OR set up and surgery, surveyor did not observe RN J perform hand hygiene upon entering the surgical suite. This deficient practice can potentially lead to contamination of sterile equipment and supplies.

Beginning at approximately 9:55 am, CRNA E was observed preparing to intubate Pt #17. CRNA E did not perform hand hygiene prior to donning gloves; CRNA then reached into clean supply drawer with gloved hands and proceeded to intubate Pt #17. After intubating Pt #17, CRNA E then used tape stuck to computer monitor to tape Pt #17's eyes closed, potentially transmitting contaminates onto Pt #17's eyes and skin. CRNA E then removed gloves and did not perform hand hygiene. After removing gloves, CRNA E touched knobs on computer monitor, arm rests on chair, pyxis medication drawers, computer mouse, top of head, and rested fingers on face; In between these tasks, CRNA E administered IV(intravenous) medications and spiked a new bag of IV fluids without performing hand hygiene prior to administering medications directly into Pt #17's blood stream. Surveyor did not observe any hand sanitizer within reach of CRNA to ensure hand hygiene is done. This deficient practice can potentially lead to bacterial contamination directly into Pt #17's blood stream.

At approximately 10:00 am, observed RN J place a white adhesive drape around Pt #17 below the waist and below the chest leaving the abdominal surface open. At 10:04 am RN J began scrubbing Pt #17's abdomen with Chloraprep solution. Surveyor observed Chloraprep running down side of Pt #17's abdomen. Surveyor did not observe sterile towels near Pt #17 to absorb runs and drips during application to ensure solution did not soak into draping or patient's linen. At 10:12 a.m. surgeon performed incision, staff did not inspect area to verify Chloraprep was dry and had not pooled on white draping. Staff did not remove wet draping prior to incision.

Review of surgical medical records on 12/5/12 beginning at 9:41 a.m. reveals Pt #15, Pt #16, Pt #19, Pt #20, and Pt #21 did not have alcohol based skin prep drying time documented to ensure staff are allowing the appropriate drying times based on manufacturer's guidelines and ensuring that the alcohol based skin prep solution is completely dry prior to draping.

According to The Association for Operating Room Nurses (AORN) Recommended Practices for Maintaining a Sterile Field dated February 2006:

1. The sterile field should be prepared in the location in which it will be used. Moving tables stirs air currents that can contaminate the sterile field.

2. An open sterile field requires continuous visual observation. Direct observation increases the likelihood of detecting a breach in sterility.

3. The OR environment can be breached by other vectors, such as insects, that could potentially come into contact with open sterile fields, unobserved, unless the sterile field is monitored.

4. The neckline, shoulders, underarms, sleeve cuffs, and gown back are areas of friction and, therefore, are not considered effective microbial barriers. The gown back is considered non-sterile because it can not be constantly monitored.

At approximately 10:30 a.m., during surgery observed Tech K move sterile field containing sterile equipment from the foot of the bed to the side and parallel to Pt #17's bed. Tech K and the Surgeon P had their backs to the sterile field while Tech K assisted Surgeon P with holding the tools during the surgery. This deficient practice did not allow Tech K to appropriately monitor the sterile field at all times and allowed for potential contact of non-sterile gown back with the sterile field.

During Pt #17's surgery between 9:50 a.m. and 11:20 a.m. observed Surgeon P and Tech K wearing regular eyeglasses. The lack of full coverage over the eyes allows for potential splash of Pt #17's bodily fluids to enter into the eye.

The above observations were confirmed with Dir F during interview on 12/4/12 at 11:25 a.m.

Based on medical record review and staff interview the facility failed to ensure pre and post anesthesia evaluations include all the required components in 7 of 31 records reviewed and 7 of 7 surgical records reviewed (Pt #15, 16, 17, 19, 20, 21, 28). This can potentially effect all patients receiving treatment at this facility.


Findings include:

Review of surgical medical records on 12/5/12 beginning at 9:40 a.m. reveals the following:

Pt #15 had hip surgery on 12/1/12 using general anesthesia. Pre-op anesthesia physical exam assessment is documented as "none." No documentation in pre-op anesthesia evaluation of patient's condition prior to induction of anesthesia, or anesthesia drug and allergy history. No documentation of post-op anesthesia evaluation; including but not limited to, cardiovascular status (pulse, BP), respiratory function (respiratory rate, airway patency, Oxygen saturation), level of consciousness, follow-up care/ observations, and any complications occurring during post-anesthesia recovery.

Pt #16 had laparoscopic surgery on 12/3/12 using general anesthesia. Pre-op anesthesia physical exam assessment is documented as "none." No documentation in pre-op anesthesia evaluation of patient's condition prior to induction of anesthesia, or anesthesia drug and allergy history. No documentation of post-op anesthesia evaluation; including but not limited to, cardiovascular status (pulse, BP), respiratory function (respiratory rate, airway patency, Oxygen saturation), level of consciousness, follow-up care/ observations, and any complications occurring during post-anesthesia recovery.

Per review of pt. #17's medical record on 12/5/12 at 11:00 a.m. revealed Pt. #17 had laproscopic cholecystectomy on 12/4/12 using general anesthesia. Pre-op anesthesia assessment note written on 12/4/12 at 8:07 AM which included "Heart- Regular Rate Rhythm, Lungs- Normal". Post-Anesthesia note written on 12/4/12 at 11:58 a.m. states, "Pt AA & O x 3. Airway patent O2 per FM in PACU. Pain 7/10 orders written. Pt tolerated procedure well, vss." Post-Anesthesia noted does not include that pt. # 17 became short of breath while dressing in the post anesthesia care unit and oxygen was applied at 10L per mask. Peri-Operative note by RN states "CRNA in evaluating patient" but no documentation indicating results of assessment was performed by CRNA noted in chart. These findings are confirmed with CIS M during time of medical record review.

Pt #19 had laparoscopic surgery on 11/11/12 using general anesthesia. Pre-op anesthesia physical exam assessment is documented as "none." No documentation in pre-op anesthesia evaluation of patient's condition prior to induction of anesthesia, or anesthesia drug and allergy history. No documentation of post-op anesthesia evaluation; including but not limited to, cardiovascular status (pulse, BP), respiratory function (respiratory rate, airway patency, Oxygen saturation), level of consciousness, follow-up care/ observations, and any complications occurring during post-anesthesia recovery.

Pt #20 had knee surgery on 10/15/12 using nerve block and conscious sedation. Pre-op anesthesia physical exam assessment is documented as "none." No documentation in pre-op anesthesia evaluation of patient's condition prior to induction of anesthesia, or anesthesia drug and allergy history. No documentation of post-op anesthesia evaluation; including but not limited to, cardiovascular status (pulse, BP), respiratory function (respiratory rate, airway patency, Oxygen saturation), level of consciousness, follow-up care/ observations, and any complications occurring during post-anesthesia recovery.

Pt #21 had knee surgery on 10/15/12 using nerve block and conscious sedation. Pre-op anesthesia physical exam assessment is documented as "none." No documentation in pre-op anesthesia evaluation of patient's condition prior to induction of anesthesia, or anesthesia drug and allergy history. No documentation of post-op anesthesia evaluation; including but not limited to, cardiovascular status (pulse, BP), respiratory function (respiratory rate, airway patency, Oxygen saturation), level of consciousness, follow-up care/ observations, and any complications occurring during post-anesthesia recovery.

Pt #28 had laparscopic surgery on 5/13/12 using general anesthesia. Pre-op anesthesia physical exam assessment is documented as "none". No documentation in pre-op anesthesia evaluation of patient's condition prior to induction of anesthesia, or anesthesia drug and allergy history. No documentation of post-op anesthesia evaluation; including but not limited to, cardiovascular status (pulse, BP), respiratory function (respiratory rate, airway patency, Oxygen saturation), level of consciousness, follow-up care/ observations, and any complications occurring during post-anesthesia recovery.


Per interview with CRNA E on 12/5/12 beginning at 11:15 a.m., CRNA does not routinely document or perform all components required of the pre and post anesthesia evaluations.






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29972

Based on review of the Quality Assurance (QA) program, and staff interview (B, C) the facility failed to ensure the quality improvement program includes all hospital services including services under contract. This can potentially impact all patients receiving treatment at this facility.

Findings include:

Per interview on 12/3/12 beginning at 11:30 a.m. with QM C and VP B, department managers oversee quality projects, monitoring quality indicators, setting goals, and evaluating progress. Department managers then report to Quality committee and this committee reports to the Quality board members.

Review on 12/5/12 of the Performance Measures Dashboard used to document and monitor the hospital wide QA program dated November 2012, October 2012, and September 2012, reveals not all hospital services/departments are included and monitored within the hospital wide QA program. Including but not limited to; Food Service, Linen, Housekeeping, Women and Childbirth Services, Contracted Services, Radiology, Lab, Nuclear Medicine, Infection Control. Action plans on the Performance Dash Board and department quality plans do not include time frames to reevaluate effectiveness of action plan; when goals are not met action plans are not being revised or changed.

Department level Quality Plans are being done but they are not being incorporated into the hospital wide QA program.

Review on 12/5/12 of the Linen 2012 Quality Plan, reveals audits of contracted service is not included in quality indicators monitored to ensure laundry is being handled and cleaned according to facility expectations and government regulations. Indicators being measured are as follows: "Clean linen in good repair" and "Maintain inventory levels appropriate to census", these quality measures do not impact or ensure patient safety.

The above findings were confirmed on 12/5/12 at approximately 2:00 p.m. with QM C.













29972

Based on staff interviews and review of 2 of 2 swing bed medical records (#1 and #27) out of a total sample of 31 medical records the hospital failed to provide written swing bed rights to patients.

Findings include:

Per interview with Case Manager Q on 12/03/12 at 10:45 a.m., swing bed patients are informed of their rights when they are admitted. Manager Q confirmed that these rights are not provided in written form and could not be sure that all rights are communicated to the patients. Q confirmed that her department is in the process of printing patient rights but at this time do not provide then in written form.

Hospital policy dictates that patients should receive a list of patient rights and responsibility when presenting for care or treatment.


Per review of pt. #1 and #27's medical records there was no documentation of swing bed rights being provided. This was confirmed per interview with RN O on 12/05/12 at 1:00 PM during record review.