HospitalInspections.org

Based on observation, staff interview and review of maintenance records on 08/24-08/29/2022, the Thedacare Medical Center-Wild Rose failed to construct, install, and maintain the building systems to ensure life safety to patients.

Findings include

The facility was found to contain the following deficiencies.

1. K281 Illumination of Means of Egress
2. K291 Emergency Lighting
3. K321 Hazardous Areas - Enclosure
4. K341 Fire Alarm System - Installation
5. K351 Sprinkler System - Installation
6. K361 Corridors-Areas Open to Corridor
7. K521 HVAC
8. K919 - Electrical Equipment - Other

As a result of these deficiencies, 42 CFR 485.623 Condition of Participation: Physical Plant and Environment was NOT MET.

See K-tags for details of the specific findings.

Based on observation, staff interview and review of maintenance records on 08/24-08/29/2022, the Thedacare Medical Center-Wild Rose failed to construct, install, and maintain the building systems to ensure life safety to patients.

Findings include

The facility was found to contain the following deficiencies.

1. K281 Illumination of Means of Egress
2. K291 Emergency Lighting
3. K321 Hazardous Areas - Enclosure
4. K341 Fire Alarm System - Installation
5. K351 Sprinkler System - Installation
6. K361 Corridors-Areas Open to Corridor
7. K521 HVAC
8. K919 - Electrical Equipment - Other

As a result of these deficiencies, 42 CFR 485.623(c) Life safety from fire was NOT MET.

See K-tags for details of the specific findings.

Based on record review and interview the facility failed to ensure that there were physician orders for each time a restraint was placed in 1 of 1 (Patient # 7) non-behavioral restraints applied and that patients with a behavioral restraint applied had documented every 15 minute checks completed by the Registered Nurse per facility policy in 1 of 1 (Patient #8) out of a total universe of 20 open and closed medical records reviewed.

Findings include:

The facility document titled "Restraints (Non-Behavioral and Behavioral)" #838 last revised 6/2/2022 was reviewed. This document revealed "D. Order Requirements/Patient Evaluation: 1. An order must be obtained for each restraint episode...E. Monitoring and Reassessment of Patient: 1. All patients in restraints will be monitored and reassessed. The following are minimal standards for assessment, intervention, evaluation and re-intervention...Non-Behavioral Patient: Time frame to obtain order: Prior to placement. Emergent situation: Obtain order immediately...Monitoring and Assessment Frequency: Behavioral Patient: Monitoring and Assessment Frequency: Continuous in-person observation by an assigned clinical staff member. Patient assessed by an RN every 15 minutes. Release and re-apply restraints a minimum of every 2 hours as patient condition allows...Discontinuation: Based on the above assessments, the patient is to be released from restraints at the earliest possible time...If the patient's condition again escalates or becomes exacerbated after discontinuation of initial restraint episode. A NEW ORDER MUST BE OBTAINED."


Examples of no physician order for restraints:

Patient #7's closed medical record was reviewed with EMR (Electronic Medical Record) Trainer I. Patient #7 was taken to the facility Emergency Department (ED) on 2/8/2022 by law enforcement for medical clearance. Patient #7 arrived with hand cuffs on and while was in the ED was moving arms and hands around and hand cuffs were causing injuries to the skin on hands and wrists. An order for non-behavioral wrist restraints was placed at 4:11 PM and they were documented as removed at 5:12 PM (approximately 30 minutes later). Wrist restraints were documented as placed again at 7:23 PM and remained in place until the patient was discharged from the facility and the hand cuffs were placed back on Patient #7. There was no documented physician order to place the wrist restraints back on at 7:23 PM.

An interview was conducted with Manager of Regulatory L at the time of record review who, when asked, the expectation of a new physician order stated "Yes. There should have been a new order gotten from the doctor."

Examples of no 15 minute checks completed by Registered Nurse:

Patient #8's closed medical record was reviewed with EMR (Electronic Medical Record) Trainer I. Patient #8 was taken to the ED on 11/29/2021 for agitation after an attempted drug over dose. An order for behavioral wrist restraints was ordered at 12:31 AM. Patient # had cardiac arrest at 3:19 PM and was documented as expired at 4:10 PM. Review of the "Behavioral Restraints" flowsheet for Patient #8 revealed the initial charting on placing the restraints at 12:31 PM. There was no documented restraint charting for the remainder of Patient #8's time in the ED.

An interview was conducted with EMR Trainer I at the time of record review who stated "I agree with you there are no documented 15 minute checks."

Based on observation and record review staff at this facility failed to maintain a sanitary environment free of potential contamination to patients and staff by not adhering to infection prevention (handwashing, hair being covered by hair net, foods covered in refrigerator and foods labeled with date of opening) policies in 1 of 14 patient care areas (Dietary), in a total sample of 14 Patient Care areas observed.

Findings include:

The facility document titled "Hand Hygiene" #922 last revised 11/1/2022 was reviewed. This document revealed "2. Hand Decontamination: a. When to use an alcohol-based hand rub:...vi. Before putting on (donning) gloves."

The facility document titled "Wisconsin Food Code FACT SHEET. Using Disposable Gloves" was reviewed. This document revealed "Rules of Glove Use: Hands are to be washed and dried before putting on new gloves.

The facility document titled "Wisconsin Food Code FACT SHEET. Handwashing Basics" was reviewed. This document revealed "When to wash your hands:...Before putting on gloves."

The facility document titled "Dietary-Infection Control Practices" #WR07-051 last reviewed 5/19/2022 was reviewed. This document revealed "1. GOOD PERSONAL HYGIENE AND HEALTH:...c. Hair must be short or worn up if it is long. d. Hairnets or caps must be worn in food production areas. e. Proper hand washing techniques:...4. EQUIPMENT:...b. Cleaning schedules are established for all areas."

The facility document titled "Food Storage Guidelines Food with Manufacturer Lot" #WR 07-010 last reviewed 5/19/2022 was reviewed. This document revealed "All food and non-food supplies will be stored under sanitary and secure conditions with proper expiration date. A. All products must have an expiration date or use by date on product when stored. B. Products will also be dated with receiving date to ensure First in First out (FIFO) rule...G. After expiration date is located, it will be properly labeled on product or storage containers and rotated as new products arrive."

Examples of no hand hygiene performed between glove change:

On 8/24/2022 at 7:56 AM Cook H was observed while preparing trays for the hospital patients. It was observed that at 7:56 & 7:58 AM Cook H removed the gloves they were wearing to prepare food and donned new gloves without performing hand hygiene and moved from preparing food to assisting staff at the cash register without removing gloves.

An interview was conducted with Dietary Supervisor B at the time of observation. When asked about the expectation for hand hygiene to be completed between glove change Dietary Supervisor B stated "Only if they are going from one task to another type of task."

Examples of hair not being covered by hairnet:

On 8/24/2022 at 7:56 AM Dietary Aide G was observed while preparing trays for the hospital patients. It was observed that Dietary Aide G had hair not covered by the hair net at the nape of the neck.

An interview was conducted with Dietary Supervisor B at the time of observation. When asked about the expectation for hair nets Dietary Supervisor B stated "Yes it should all be in the hairnet."

Examples of uncovered foods in refrigerator:

On 8/24/2022 at 7:25 AM it was observed that there were 12 small, clear plastic bowls with jello and fruit in them in the refrigerator sitting on a tray with no covering over the bowls.

An interview was conducted with Dietary Supervisor B at the time of observation. When asked about the expectation for food being covered Dietary Supervisor B stated "Oh they will put a cover on it before they serve it."

Examples of food with no "in" date in freezer"

On 8/24/2022 at 7:30 AM it was observed that there were 4 gallon zip lock bags with breaded chicken breasts in them with no in date on them so as to know when they needed to be used by.

An interview was conducted with Dietary Supervisor B at the time of observation. When asked about the expectation for food labeled with an in date Dietary Supervisor B stated "Yeah, it should be dated when it was put in those bags or we need to get rid of it."