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Based on observation, staff interviews, and review of maintenance records on 4-17-18 through 4-18-18, the Westfields Hospital And Clinic did not ensure that the building & building systems were constructed, installed, and maintained to ensure life safety to patients as revealed by the following deficiencies:

K-324 (Cooking Facilities),
K-363 (Corridor - Doors),
K-372 (Subdivision of Building Spaces - Smoke Barrier Construction),
K-712 (Fire Drills),

Please refer to the full description of the deficient practices at the individual K-tags. These deficiencies are not compliant with 42 CFR 485.623.

Based on observation, record review and interview, facility staff failed to ensure fluids are stored per manufacturer recommendations in 1 of 3 fluid warmers observed (Emergency Department).

Findings include:

Review of Baxter (manufacturer) recommendations dated 10/25/2017 revealed "Warming recommendations for large volume intravenous (IV) solutions in plastic bags: IV solutions of volumes 150 mL or greater can be warmed in their plastic overpouches to temperatures not exceeding 40 degrees Celcius (104 degrees Fahrenheit), and for a period no longer than 14 days."

On 4/17/2018 at 11:00 AM, the Emergency Department fluid warmer contained 3 bags of IV fluid. The temperature of the unit was 106 degrees Fahrenheit, 2 degrees higher than maximum temperature recommendation. Review of the signage posted on the warmer revealed "Fluid max 122 [degrees Fahrenheit]."

During an interview on 4/17/2018 at 1:10 PM, Emergency Department Manager U stated the maximum temperature of 122 is for sterile water which is also stored in the warmer, and not for IV fluids. Per U, "we will have to update the tag on the warmer."

Based on observation, staff interviews, and review of maintenance records on 4-17-18 through 4-18-18, the Westfields Hospital And Clinic did not ensure that the building & building systems were constructed, installed, and maintained to ensure life safety to patients as revealed by the following deficiencies:

K-324 (Cooking Facilities),
K-363 (Corridor - Doors),
K-372 (Subdivision of Building Spaces - Smoke Barrier Construction),
K-712 (Fire Drills),

Please refer to the full description of the deficient practices at the individual K-tags. These deficiencies are not compliant with 42 CFR 485.623.

Based on record review and interview, the facility staff failed to develop policies and procedures guiding the use of video monitoring in the Emergency Department and failed to disclose the use of video monitoring to 1 of 1 Emergency Department patient's reviewed on video monitoring surveillance (Patient #18) in 1 of 4 Emergency Department records reviewed.

Findings include:

Review of facility policy "Suicide/Self Harm Assessment and Precautions" No. WF-CL-GN-54 revealed "A patient on 'high risk' suicide precautions has: a) Staff member observation of patient unless a responsible party is with the patient who is in constant attendance (parent, relative, social worker, law enforcement, etc.) OR b.) Direct observation: patient observation in which the patient safety assistant has the patient in view at all times via direct line of site. ...Indirect observation: patient observation in which the patient safety assistant has the patient in view at all times via video monitoring."

Patient #18's medical record review revealed Patient #18 presented to the Emergency Department on 4/9/2018 at 4:56 PM with suicidal ideation. Review of nursing progress notes revealed "[Parents] are both present in the room, appearing to be supportive of patient" at 5:21 PM; "Camera in room being watched at desk for safety" at 6:41 PM; "[Parent] remains at bedside" at 6:51 PM; "[Parent] lying next to patient" at 8:10 PM. There was no documentation of when the indirect observation started or ended, or that the video monitoring as a suicide precaution was disclosed and explained to Patient #18 and/or Patient #18's parents.

During an interview on 4/17/2018 at 10:45 AM, when asked about expectations surrounding the use of video monitoring, Emergency Department Manager U stated "it should be documented in the medical record" and staff are expected to tell patients when they are being monitored. Manager U confirmed the facility does not have a policy for the use of video monitoring in the Emergency Department.

Based on record review and interview, facility staff failed to provide medication lists as ordered at discharge for 3 of 5 discharged patients reviewed (Patient #24, #20, and #23) and failed to ensure signed discharge instructions were on medical record in 2 of 4 maternity patients reviewed (Patient #3 and #5). Discrepancies in discharge medication instruction led to the readmission of one patient (Patient #24) in 7 discharged patient records reviewed.

Findings include:

Review of facility policy "Medication Reconciliation" No. WF-CL-PH-122 revealed "Discrepancies: a. If there is a discrepancy between the prior to admission medications and current patient orders, transfer orders and/or discharge orders, the physician is contacted to address the discrepancy. b. Documentation of clarification is entered in the EHR [electronic medical record] as an order. ...Discharge: 3. Inpatients: Med Surg [Medical Surgical] /High Obs [Observation] /Swing Bed/Maternity Care: when a patient is being discharged from the inpatient unit...the provider uses the Discharge Navigator in EHR to reconcile the medications for discharge. a. A copy of the After Visit Summary (AVS) is given to the patient and becomes part of the permanent medical record. OB [Obstetrics] may utilize a preprinted list of discharge medications. b. Detailed information on new medication is also given to the patient. 4. At discharge, patients are instructed to bring discharge medication list to their next visit with physician or on next admission to a healthcare facility."

Patient #24's medical record revealed Patient #24 was discharged from the facility to a group home on 1/19/2018 with discharge diagnoses of COPD (chronic obstructive pulmonary disease) and CHF (congestive heart failure). Review of patient #24's discharge summary, dated 1/19/2018 revealed that during the hospital course "Patient was started on aggressive diuretic therapy with excellent subsequent diuresis (increased or excessive production of urine) and improvement in respiratory status. ...was safe for discharge with close follow up with PCP [Primary Care Provider] for management of fluid status." The discharge summary medication list included an order for furosemide [diuretic to manage fluid status] 40 mg daily with a note to "See the new instructions." A discharge prescription order for furosemide 40 mg tablets was written on 1/19/2018, quantity 90 tablets, with instructions to "Take 1 tab by mouth daily." Review of Patient #24's After Visit Summary, provided to Patient #24 at discharge, included instructions to "Stop taking these medications: ...furosemide 40 mg tablet." Furosemide was not listed in Patient #24's instructions to continue or start taking. There was no evidence in the discharge instructions that a furosemide prescription was provided to Patient #24 or sent to a pharmacy for pick up.

Patient #24 medical record revealed Patient #24 was readmitted to the facility on 1/26/2018, 7 days after discharge, with "weight gain, leg swelling." Patient #24's admission history and physical report, dated 1/26/2018, revealed "Since 1 week ago, [group home] staff noted that [Patient #24] has gained weight and that oxygen was low...prior to admission." Patient #24 was administered 2 doses of intravenous furosemide upon admission on 1/26/2018. The admission history and physical report listed furosemide 40 mg daily as a current outpatient/home medication on 1/26/2018 and revealed "[Patient #24] appears in volume overload on exam." Review of medication reconciliation list upon readmission on 1/26/2018 did not include furosemide as a current home medication. Furosemide was listed in Patient #24's orders as an active medication on 1/26/2018 with a start date of 1/19/2018.

On 4/18/2018 at 3:50 PM during an interview with Pharmacy Director BB, when asked why the current, active order for furosemide was not on the home reconciliation list on 1/26/2018 or why Patient #24 was given discharge instructions to stop taking an ordered medication on 1/19/2018, Pharmacy Director BB stated "I don't know, that's a really great question."

On 4/18/18 at 3:55 PM during an interview with Chief Nursing Officer (CNO) A, when asked if Patient #24 was taking furosemide at home prior to being readmitted on 1/26/2018 (Patient #24 was instructed to not take the medication at discharge on 1/19/2018), CNO A stated "it's not really clear."

Patient #20's medical record was reviewed and revealed Patient #20 was discharged from the facility to home on 2/12/2018. Patient #20's discharge summary, dated 2/12/2018 at 10:40 AM, included a discharge medication list with instructions to continue taking warfarin (blood thinner) 4 mg daily and omeprazole (to treat acid reflux) 20 mg daily. Patient #20's After Visit Summary, provided to Patient #20 at discharge, included instructions to stop taking warfarin and omeprazole. Review of Patient #20's pharmacy discharge education note revealed "...reviewed home medication and discussed the following changes: dose decrease on warfarin." There were no written instructions on the After Visit Summary for a new or changed warfarin dose, other than to stop taking the medication. There was no mention of discontinuing omeprazole in the note. The note was signed by the pharmacist 2/12/18 at 9:41 AM, prior to the discharge summary written by the discharging physician.

Patient #23's medical record was reviewed and revealed Patient #23 was discharged from the facility to home on 3/21/2018 with a discharge diagnosis of small bowel obstruction. Patient #23's discharge summary included a medication list with instructions to continue taking the following: hydrocodone 5-325 mg tablet (pain medication) every 8 hours as needed , potassium chloride 20 mEq (mineral needed in your blood) daily, tizanidine 2 mg (muscle relaxer) every 8 hours as needed and trazodone 50 mg (antidepressant) at bedtime as needed. Patient #23's "After Visit Summary", provided to Patient #23 at discharge included instructions to stop taking all of the above medications.

On 4/18/2018 at 3:25 PM during an interview with Pharmacist CC, when asked about the discrepancies in the discharge medications listed on the physician's discharge summary and patient discharge instructions, Pharmacist CC stated that the pharmacist performs a discharge medication reconciliation on all patients prior to discharge. Per CC, the pharmacist consults with the physician, the pharmacist may make changes to the discharge medications as needed, and the physician "signs off" on them.

On 4/18/2018 at 3:30 PM during an interview with Hospitalist DD, Hospitalist DD stated "sometimes the doctor forgets to go back and refresh the discharge summary or add an addendum." DD stated, all medications listed on the After Visit Summary are ordered by the physician. Both Pharmacist CC and Hospitalist DD stated the medications as listed on the After Visit Summary discharge medication list are the "correct" medications for the patient at discharge.

Maternity Patients

Patient #5's medical record was reviewed and revealed Patient #5 was delivered on 10/1/17 by Cesarean section and discharged home with parents on 10/4/17. There was no documented signed copy of discharge instructions to responsible party for Patient #5's medical record.

On 4/18/18 at 1:10 PM an interview was conducted with Obstetric Registered Nurse O and Infection Preventionist F who confirmed the "scanned copy of the signed discharge is missing."

Patient # 3's medical record was reviewed and revealed Patient #3 was admitted on 10/1/17 and discharged on 10/4/17 after delivering a baby by Cesarean section. There was no documented signed copy of discharge instructions in Patient #3's medical record.

On 4/18/18 at 2:05 PM an interview was conducted with Obstetric Registered Nurse O and Infection Preventionist F who confirmed "there should be a copy of the signed document scanned in and there isn't."







37420

Based on record review, observation and interview, the facility failed to maintain a sanitary environment to avoid sources and transmission of infections in 2 of 2 procedure observations (Patient # 22 and #30) and 1 of 1 Dietary Departments; and failed to perform hand hygiene per policy in 2 of 10 patient care observations (Patient #11 and #31).

Findings include:

On 4/18/18 at 3:06 PM during an interview with Infection Preventionist F, F stated the facility follows the CDC (Center for Disease Control) "safe needle practices" and vials should be cleansed with alcohol when opened and before accessing them.

Review of Association for peri-Operative Registered Nurses, Publish Date: May 30, 2017 "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.

Review of policy "Surgical Services Attire" #WF-CL-SUR-95 undated, revealed under III. Procedures #2. Head a. a "surgical head cover or hood that confines all hair and covers scalp skin should be worn." Under #4 a. "Surgical masks in combination with eye protection devices, such as goggles, glasses with solid side shields, or chin-length face shields must be worn whenever splashes, spray, spatter, or droplets of blood, body fluids, or other potentially infectious material may be generated...#6... a. Jewelry that cannot be contained or confined within the scrub attire should not be worn."

On 4/17/18 at 10:57 AM during observation of colonoscopy procedure on Patient # 11, observed Surgical Nurse HH remove the protective plastic cover off vials of Fentanyl, Versed, and Zofran and did not cleanse the septum's prior to accessing them with a needle.

On 4/17/18 at 11:08 AM during observation of colonoscopy procedure (insertion of a long, flexible tube into the rectum which allows the doctor to view the inside of the entire colon) on Patient # 11, observed Scrub Tech GG with uncovered beard and sideburns and hair sticking out the back of head covering.

On 4/17/18 at 11:44 AM during observation of colonoscopy procedure on Patient # 11, observed Scrub Tech GG and Gastrointerologist KK both with personal eyeglasses on without solid side shields or face shields.

On 4/18/18 at 7:43 AM during observation of right inguinal hernia repair on Patient #30, observed Surgical Nurse HH with stud earrings not covered, Surgical Tech II with ears uncovered and stud earrings not covered, Surgeon PP with sideburns not covered and hair sticking out of the back of head covering.

On 4/18/18 at 8:55 AM during an interview with Manager of Surgical Services FF, FF stated they follow the standards of practice of AORN (Association for peri-Operative Registered Nurses), APIC (Association of Professionals for Infection Control and Epidemiology, and CDC (Centers for Disease Control). FF confirmed the above findings stating that it was hard to get the staff on board.

On 4/18/18 at 3:06 PM during an interview with Infection Preventionist F, F confirmed it is their policy to wear shields when infectious material may be generated, including colonoscopy procedures. F also confirmed "they should clean the vial before every access."

Dietary

Review of policy "Dress and Appearance" No. WF-AG-NU-1, undated, under III. revealed "PROCEDURES LEADER RESPONSIBILITY" #7 "Hairnets will be provided by the hospital for all dietary food service employees. Hair is to be completely covered by the hairnet and worn for the entire shift."

On 4/17/18 at 11:45 AM observed Dietary Staff NN and Dietary Staff OO in the kitchen preparing patient lunch trays with hair hanging out from under hair net.

Hand Hygiene

Review of policy "Hand Hygiene" No. WF-IP-15 not dated, under III Policy, c. Hand Hygiene indications, iii After body fluid exposure, #5. "After contact with patients' body substances... #7.... GLOVES MUST BE REMOVED WHEN THE NEED FOR PROTECTION NO LONGER EXISTS AND HAND HYGIENE SHOULD BE PRACTICED IMMEDIATELY AFTER REMOVAL OF GLOVES."

On 4/17/18 at 11:48 AM during observation of colonoscopy procedure on Patient #11, observed Scrub Tech GG remove gloves after procedure without performing hand hygiene prior to assisting with transfer of patient out of procedure room #2.

On 4/18/18 at 9:28 AM observed Laboratory Assistant QQ in the Outpatient Laboratory Department perform a blood draw on Patient #31. Upon completion of the blood draw, with the gloves still on, Laboratory Assistant QQ transferred the blood into vacutainers, applied a bandaid to Patient #31's arm, and wheeled Patient #31 back into the Laboratory Waiting Room without removing gloves or doing hand hygiene.

On 4/18/18 at 9:32 AM during an interview with Laboratory Manager RR and Director of Quality B, B confirmed Laboratory Assistant QQ did not follow the facilities policy on hand hygiene.

On 4/18/18 at 3:06 PM during an interview with Infection Preventionist F, F stated the facility follows the CDC's recommendations for hand hygiene and the 5 moments of hand hygiene from WHO (World Health Organization). F confirmed "the staff were not following the facilities policies."





37420

Based on record review and interview, the facility failed to ensure nutrition consultation services were provided as ordered for 1 of 1 patient record reviewed requiring nutritional consult (Patient #20).

Findings include:

Patient #20's medical record review revealed Patient #20 was admitted for swing bed services on 2/4/2018. Patient #20's record included an order from the physician, dated 2/4/2018 at 9:33 AM for "Nutrition Consult (instruct patient on low sodium diet)." Patient #20 was discharged from the facility on 2/12/2018. There was no evidence in Patient #20's medical record that Patient #20 had been seen by the dietician prior to discharge.

On 4/18/2018 at 7:40 AM during an interview with Nursing Manager T, when asked about the process and expected time frames for consult orders to be completed, Nursing Manager T stated "This order was signed and held, it was never released [in the electronic health record]. The orders have to be released by the RN.[Registered Nurse]." Further review of the order revealed "Released on 2/04/2018 at 1:13 PM" by the RN. Nursing Manager T was unable to state why Patient #20 was not seen by the dietician as ordered.

Based on record review and interview the facility failed to ensure complete record documentation to monitor the patient's condition on patient's having ordered physical restraints in 1 of 3 restraint charts reviewed (Patient #9).

Findings include:

Review of policy "Restraints" No. WF-CL-GN-29 revealed IV: PROCEDURE #2 "An order must be obtained from a physician permitted by the State of Wisconsin and Westfields Hospital to order a restraint. The order should identify the specific reason for the restraint and the specified period of time the restraint may be used. Orders for restraints may never be written as standing or PRN (as needed) orders. The physician must see and evaluate the need for restraint or seclusion within 1 hour after the initiation of this intervention. The restraint order must be followed by consultation with the patient's treating physician as soon as possible if the restraint is not ordered by the patient's treating physician... #6 The original order may only be renewed in accordance with these limits for up to a total of 24 hours."

Patient #9's medical record was reviewed on 4/18/18 at 2:40 PM. Patient #9 was admitted on 12/14/17 for a deep vein thrombosis in left leg and was transferred to a Geriatric Psychology Unit on 12/26/17. "Plan of Care" on 12/16/17 at 5:36 AM revealed "Combative and agitated from 1:20 AM until approximately 4:15 AM. Soft restraints placed around 4:15 AM and all restraints except right wrist restraint removed around 5:15 AM; pt became very agitated when attempting to remove right wrist restraint so left on at this time." "Non Violent Restraint Flowsheet" dated 12/16/17 documented 15 minute checks from 4:10 AM until 7:10 AM. There was no documented restraint flowsheet charting after 7:10 AM for the remainder of stay in Patient #9's medical record. "Progress Notes" dictated by Physician LL on 12/16/17 at 8:29 AM revealed "Pt became acutely confused overnight, combative, screaming, thrashing at staff per report. [He/she] required multiple sedating medications for this. This started around 1:40 AM and seemed to start settling down around 5 AM." There was no documentation addressing the use of restraint, discontinuation of restraint order, renewal of restraint order, or face to face completed at that time or through remainder of inpatient stay. "Plan of Care" note on 12/19/17 at 10:07 PM, 12/24/17 at 4:51 AM, 12/24/17 at 10:48 AM, 12/24/17 at 7:22 PM, & 12/25/17 at 8:23 PM documented "Restraint, Nonbehavioral (Nonviolent)" as an active problem on the care plan. There was no documented restraint order or renewal of original restraint order on 12/26/17.

On 4/18/18 from 2:40 PM to 3:00 PM during interview, while reviewing Patient #9's medical record, with Registered Nurse MM and Infection Preventionist F, Registered Nurse MM and Infection Preventionist F confirmed there was missing restraint documentation in Patient #9's medical record.

Based on record review and interview, the facility failed to provide swing bed patients with required information related to discharge rights in 2 of 2 swing bed patients reviewed (Patient #20, Patient #21).

Findings include:

Review of the facility's notice of discharge form, provided to swing bed patients prior to transfer or discharge, does not include the name, address and telephone number of the State long term care ombudsman.

Patient #20's medical record was reviewed and revealed Patient #20 received swing bed services from 2/4/2018 through 2/12/2018. Patient #20's discharge notice did not include state ombudsman information.

Patient #21's medical record was reviewed and revealed Patient #21 received swing bed services from 3/23/2018 through 3/28/2018. Patient #21's discharge notice did not include state ombudsman information.

On 4/18/2018 at 7:40 AM during an interview with Nurse Manager T, T stated "we have a patient rights and responsibilities notice that we use, but it doesn't have any ombudsman information. We are looking into it."