HospitalInspections.org

Based on review of facility data and 2 of 2 staff interviews (Q, R) the facility failed to collect data to integrate into the Quality Improvement Program. This deficiency could possibly effect all patients in the hospital.

Findings include:

Per interview with LICU RN (Lead Intensive Care Unit Registered Nurse) Q and SDE (Staff Development Educator) R on 3/6/13 at 9:15 AM, SDE R stated that the facility does not independently gather data regarding organ, tissue and eye donation. The facility receives information from the OPO (Organ Procurement Organization) with results of audits completed by the OPO.

During review of OPO data collection on 3/6/13 at 9:30 AM, it was noted that the facility reported 19 deaths for February 2012 and actual deaths were 20. LICU RN Q could not explain details of the discrepancy, LICU RN Q stated the facility does discuss missed opportunities but does not document discussions based on OPO data collection and was unable to recall a discussion/interventions regarding that specific data.

Based on interviews, review of the QAPI (Quality Assessment and Performance Improvement) program, and review of the list of contracted services, the facility failed to include 2 of 8 contracted services in the QAPI program: Laundry Services with Gundersen Linen and Dining Services with Sodexho Systems. This has the potential to affect all patients who receive inpatient services at this facility.

Findings include:

Per QAPI review from 8:10 a.m. to 8:50 a.m. on 3/5/13, no proof of the contracted Laundry and Dining services was discovered as part of the QAPI regime.

On 3/5/13 at 2:00 p.m. Laundry Management staff PP stated during interview that laundry is a contract service with Gundersen Linen. Laundry services is not reviewed in QAPI unless Gundersen reports a problem. When PP was asked if problems such as linen shortage, items found in dirty linen, etc. are tracked and reviewed, PP said, "Gundersen takes pictures of items found in dirty linen and sends the pictures to this facility and if we are short of linen, we just call them and they bring more." When asked if logs/records are kept on these issues for QAPI, PP said, "No."

On the afternoon of 3/6/13 a list of contract services was provided and reviewed and noted that the facility has a total of 8 contracted services.
At 2:30 p.m. on 3/6/13 when Director E was asked if the contracted services for laundry and the kitchen were reviewed in QAPI, E said, "No."

Based on review of credentialing files and 2 of 2 staff interviews (staff LL and F) the medical staff failed to ensure 1 of 1 Credentialing Committee Department Chair (MD- FF) followed governing body approved credentialing processes. Failure to follow approved credentialing processes has the potential to affect all staff credentialed at this facility.

Findings include:
Per interviews and credentialing file reviews with Medical Staff Coordinator LL and VP Medical Affairs F on 03/05/13 between 1:00 PM and 2:30 PM, Physician Assistant (PA) NN's credential file contained this year's performance record (2013) for PA NN that was not signed by the credentialing committee department chair, as indicated on the reappointment document section "E". Instead, a verbal recommendation was given by MD FF.
Medical Staff Coordinator LL stated there were no medical staff by-laws or P&P that allowed the practice of verbal recommendations for privileging or credentialing, that a signature was required.
VP Medical Affairs F confirmed there is no P&P or approval in the medical staff by laws for this verbal process.
Documented in PA NN's most current privileging and credentialing approval from 2/6/2013 was: "Verbal recommendation @ CC mtg from Dept. Chair FF MD." This statement was documented by Medical Staff Coordinator LL during the Credentialing meeting, however there is no indication that LL documented this.
Medical Staff Coordinator LL was asked if LL was not present for this interview on 3/5/2013, how this "approved as credentialed and privileged" verbal recommendation could be validated as authentic? Medical Staff Coordinator LL acknowledged it could not be validated if LL were not present to claim the writing as LL's own.
Medical Staff Coordinator LL stated the credentialing committee department chair MD FF was at the credentialing committee meeting and easily could have signed the papers.
Medical Staff Coordinator LL confirmed credentialing committee department chair MD FF did not authenticate the verbal recommendation for reviewing and approving PA NN as qualified for reappointment.

Based on P/P review, 1 of 1staff interview (staff RR), and MR review, in 2 out of 3 closed OB MR (Pt. #2 and #3) out of a total of 30 MR reviewed, this facility does not update OB careplans with changes in patient's condition or special circumstances of the new mom requiring added interventions over and above that of a normal post-partum course. Failure to update and keep care plans current has the potential to affect all patients receiving Obstetrical care in this facility.

Findings include:

The facility policy titled, "Patient Plan of Care," dated 11/01/11, was reviewed on 3/6/2013 at 2:35 p.m. The policy states in part, "The patient care plan is kept current by ongoing assessment of the patient's needs, patient's response to interventions, goal setting and updating or revising the patient's plan of care...."

MR reviews were conducted on Pt. #2 and 3's closed OB MRs on 3/5/2013 from 1:06 p.m.-2:30 p.m. accompanied by Optimization Specialist (OS) L.

Pt. #2 entered the facility on 1/7/2013 anticipating a normal vaginal birth but due to complications of labor required a Cesarean Section (C-section). The Patient Individualized Plan of Care was not updated to reflect the need for the C-section or the care for a C-section patient. At the time of discovery OS L agreed that the care plan did not reflect the change in conditioin and need to change the delivery plan from a vaginal birth to a C-section.

In a phone interview with Clinical Specialist RR on 3/6/2013 at 3:30 p.m., RR stated that Pt. #2 should have had a peri-operative care plan.

Pt. #3 was admitted for a normal vaginal delivery on 12/13/2012. Pt. #3 has a Factor V deficiency (blood clotting deficiency) and had an order to go home with Lovenox (a type of blood thinner injected into the body through a needle). There is no evidence of education being completed for the Lovenox injections and the care plan was not updated to reflect the need for Lovenox. At the time of discovery OS L agreed that the care plan did not reflect the need for this medication.

In a phone interview with Clinical Specialist RR on 3/6/2013 at 3:30 p.m., RR stated, in regards to Pt. #3's care plan, "The Lovenox should have been on the care plan."

Based on observation, national standards of practice, facility P/P, and 1 of 1 staff interview (Staff K), this facility failed to follow safe medication practices regarding multi-dose vials in patient care areas in 1 out of 3 anesthesia carts observed. Failure to follow safe medication practices has the potential to affect all patients receiving anesthesia services in this facility.

Findings include:
The facility's policy titled,"Sterile Medication Preparation," dated 11/7/2012, was reviewed on 3/6/2013 at 6:15 a.m. This policy addresses sterile medication preparation that takes place in the pharmacy, however in regard to multiple dose vials it also states in part, "When stored on patient care units a) The vials are treated as single use only. b) Following administration of a medication noted to be in a multiple dose vial dispose remainder of the medication in the appropriate receptacle."

According to nationally accepted standards of practice from the Center for Disease Control (CDC) Safe Injection Practices 2007 Recommendations IV.H.7. "Do not keep multidose vials in the immediate patient treatment area and store in accordance with the manufacturer's recommendations; discard if sterility is compromised or questionable 453, 1003. Category IA"

A tour of the Family Birth Center was conducted on 3/5/2013 from 8:30 a.m.-10:40 a.m. accompanied by VP H and Supvr I. The Family Birth Center has two Operating Rooms (OR) for Caesarean Section (C-Section) patients.

In the anesthesia cart in OR 1 there was one open vial of Robinul (used to dry secretions) marked for expiration on 4/13/2013 and one open vial of what looked to be spelled Nesacaine 3% marked for expiration on 3/19/2013.

In an interview with Anesthesia Assistant K on 3/5/2013 at 10:30 a.m., K stated that Anesthesia does keep and re-use vials of medication on the anesthesia carts for immediate patient care use. These vials are then returned to the medication drawer in the anesthesia cart.

The facility is not following their policy of discarding the vials used as multiple dose vials in this patient care area.

Based on observation and 2 of 3 staff interviews (Staff D and H), the hospital failed to ensure confidentiality of patient's medical records. This has the potential to affect all inpatients.

Findings include:

The facility policy titled, "Protection of Medical Records," dated 11/1/2012, was reviewed on 3/6/2013 at 3:30 p.m. The policy states in part, "Records that are located temporarily on patient care units are in secured, supervised areas. When possible, they should be placed in fire resistance, lockable cabinets. Portions of active patient records may be located within the patient's wall unit within the patient room."

During a tour of the surgical inpatient unit (5th floor) it was observed that patient medical records were kept in unsecured holders on the wall outside patient's rooms. This was observed and confirmed to be the case for all occupied rooms (501, 502, 506, 507,508, 509, 514, 515, 516, 522, 523, 524, & 525);

This observation was confirmed per interview with Medical Director D on 03/04/13 at 3:15 PM. D stated confidential patient information is contained in these unsecured medical records.



26711

A tour of the Family Birth Center was conducted on 3/5/2013 from 8:30 a.m.-10:40 a.m. accompanied by VP H and Supvr I.

Wooden chart holders were noted outside of each of the 15 inpatient rooms along the corridors in the post-partum section of the unit. These chart holders were designed to hold the portion of the MR that is paper and are accessible to any patient, staff, or visitor walking past even though the name of the patient cannot be seen while the chart is in the holder.

The charts on the Family Birth Center contained information such as general consents for care, circumcision consents (for boy babies), other surgical consents, patient care plans, demographic face sheets (patient address is on these forms), and immunization records, care plans and some of the consent forms were stamped with a patient name plate that included dates of birth.

Based on 9 out of 30 MR reviews and 1 of 1 staff interviews (Staff T), this facility failed to keep complete and accurate MRs that 1. Include the time discharge instructions were completed (Pt.s #2, 3, 5, and 6), 2. Include identifiable data for infants at discharge (Pt. #6), 3. Have properly executed transfer forms (Pt.s #20, 25 and 29), and 4. Determine a time line for the physician seeing patients in the ED (Pt. #25, 32, and 33). Failure to keep complete and accurate MRs that can establish a chronological time line has the potential to affect all patients receiving care in this facility.

Findings include:
A MR review was conducted on Pt. #2's closed OB MR on 3/5/2013 at 1:06 p.m. accompanied by Optimization Specialist (OS) L. On the line for date/time on the discharge instructions, Pt. #2's MR does not have a time they were signed. OS L agreed the time was missing on this form.

A MR review was conducted on Pt. #3's closed OB MR on 3/5/2013 at 2:08 p.m. accompanied by OS L. On the line for date/time on the discharge instructions, Pt. #3's MR does not have a time they were signed. OS L agreed the time was missing on this form.

A MR review was conducted on Pt. #5's closed Newborn MR on 3/5/2013 at 1:52 p.m. accompanied by OS L. On the line for date/time on the discharge instructions, Pt. #5's MR does not have a time where the parent signed the form. OS L agreed the time was missing on this form.

A MR review was conducted on Pt. #6's closed Newborn MR on 3/5/2013 at 2:36 p.m. accompanied by OS L. Pt. #6's discharge instructions do not include the newborn identification number required on the form for the parent to verify the numbers match to the parents. The discharge instructions also do not have a time the parent signed the form. OS L agreed the time was missing on this form and it should have had the baby's identification number on it.

A MR review was conducted on Pt. #20's closed ED MR on 3/6/2013 at 11:20 a.m. accompanied by Project Mgr (PM) M.
Pt. #20, a 3 year old, was transferred to an alternate acute care facility after suspected ingestion of sedatives as this facility does not admit Pediatric patients. The transfer form does not indicate what the specific benefit of the transfer to the patient will be, does not indicate if an RN or MD did the Systems Assessment, does not indicate what pieces, if any, of the MR were sent with Pt. #20, does not indicate the risks of transfer specific to the patient, and does not include a time the authorized person, RN/witness, or MD signed the form. The RN and MD signatures are also without a date for the signature. PM M agreed that these items were missing.
In an interview with ED Supvr T at 2:00 p.m. on 3/6/2013 regarding the transfer form information, ED Supvr T agreed that the form did not contain the benefit of transfer that was specific to Pt. #3, and indicated it could be written in on the line that says "other."

A MR review was conducted on Pt. #29's closed ED MR on 3/6/2013 at 1:00 p.m. accompanied by Project Mgr M.
Pt. #29, a 6 year old, was transferred to an alternate acute care facility for observation. The transfer form does not indicate what the specific benefit of the transfer to the patient will be, does not indicate what pieces, if any, of the MR were sent with Pt. #29, and does not include a time the authorized person, RN/witness, or MD signed the form. The RN and MD signatures are also without a date for the signature. PM M agreed these items were missing from the form. Supvr T also agreed when these finding were reviewed with T at 2:00 p.m. on 3/6/2013.


29963

Per interview with ED Supvr T on 3/7/13 at 1:50 PM, ED Supvr T stated that the physician will assign self to a patient and will start to review the medical record. The documentation on the ED Pt. Care Timeline which states "Begin physical exam" is utilized by the physicians to indicate when review of the medical records was initiated and not when the physician is actually at bedside performing the physical exam. ED Supvr T stated that this facility is not capturing the actual time the physician goes in to see the patient.

Per review of pt. #25 MR on 3/6/13 at 11:05 AM revealed an ED Pt. Care Timeline that indicates that the Physician began his physical examination on 1/13/13 at 1:24 PM. Physician dictated a note which is dated and timed on 1/13/13 at 1:42 PM. Based on this information it cannot be determined when the physician actually was completing the physical examination. Pt. #25 also had a transfer form which is signed and dated by the pt. Form also contains a signature from the MD and RN but neither signature contain a date or time as to when the form was authenticated. Findings confirmed with CIN U on 3/6/13 at 11:45 AM.

Per review of pt. #32 MR on 3/6/13 at 1:00 PM revealed an ED Pt. Care Timeline that indicates that the Physician began his physical examination on 12/10/13 at 11:34 AM. Physician dictated a note which is dated and timed on 12/10/13 at 12:00. Based on this information it cannot be determined when the physician actually was completing the physical exam. Findings confirmed with CIN B on 3/6/13 at 1:25 PM.

Per review of pt. #33 MR on 3/6/13 at 1:30 PM revealed an ED Pt. Care Timeline that indicates that the Physician began his physical examination on 11/7/12 at 6:13 PM. Documentation in chart indicates that at 6:15 PM, ED staff went to waiting area to call pt. #33 to be roomed and pt was no longer in waiting room and that pt had left without being seen. Documentation on ED Pt. Care Timeline indicates pt. #33 arrived in the ER at 4:12 PM, was triaged at 4:19 PM, and at 6:13 PM pt. #33 was no longer in waiting area. No documentation from 4:19 PM to 6:13 PM regarding checking on status of pt. or communication between staff and pt. Findings confirmed with CIN B on 3/6/13 at 2:00 PM. ED Supvr T also confirmed findings on 3/6/13 at 2:00 PM and stated it is difficult to determine why pt. #33 left without treatment based on documentation in medical record.

Based on MR reviews and 1 of 1 staff interviews (Staff SS), this facility failed to have properly executed consent forms for 2 out of 3 OB patients with Epidurals (Pt.s #2, 4) out of a total of 30 MR reviewed. Failure to obtain properly executed consent for procedures has the potential to affect all patients receiving care in this facility.

Findings include:

In an interview with Mgr SS on 3/6/2013 from 9:45 a.m.-10:30 a.m., Mgr SS stated that a properly executed surgical/procedural consent form would be signed by the MD and patient/designated person and dated and timed. Director G was present during this interview taking notes.

A MR review was conducted on Pt. #2's closed OB MR on 3/5/2013 at 1:06 p.m. accompanied by Optimization Specialist (OS) L.
According to the MR Pt. #2 had 3 Epidurals (pain relief measure inserted into the spine). There are only two consent forms for Epidurals.
Pt. #2 has two Anesthesia consent forms that do not include the time the Anesthesia providers signed the form. OS L agreed, there should have been 3 consents for Epidurals and there were only 2, and the times were missing on these forms.

A MR review was conducted on Pt. #4's closed OB MR on 3/5/2013 at 3:00 p.m. accompanied by OS L.
Pt. #4's consent for the Epidural does not include a date or time Pt. #4 signed the form. OS L agreed that this form is missing dates and times.

Based on observation and 1 of 1 staff interview (Staff I), this facility failed to secure medications in emergency/crash carts from unauthorized access in 7 out of 8 emergency carts observed. Failure to secure medications has the potential to affect all patients receiving care in this facility who require emergency interventions with crash cart medications.

Findings include:

According to the facility's medication charge sheet for crash carts, the following medications are in each crash cart: 2 strengths of Epinephrine, Vasopressin, Amiodarone, 2 strengths of Lidocaine, Magnesium Sulfate, Atropine, Dopamine, Adenosine, Aclcium Chloride, Sodium Bicarbonate, and Naloxone. Syringes and needles are also in the drawers of the carts.

1. A tour of the Family Birth Center was conducted on 3/5/2013 from 8:30 a.m.-10:40 a.m. accompanied by VP H and Supvr I. The Family Birth Center has two Operating Rooms (OR) for Caesarean Section (C-Section) patients. In the corridor of these ORs an Emergency/Crash cart with a plastic breakaway lock is located.

In an interview with Supvr I during the tour it was determined that housekeeping has access to the ORs after C-Sections for cleaning purposes. This would allow unauthorized persons (housekeeping staff) access to the medications, needles, and syringes while the cart is unsupervised by staff.

VP H and Supvr I were made aware of this finding at the time of discovery.


05409

2. At 12:57 p.m. on 3/4/13 on the 3rd floor medical unit crash cart #10 was in an unsecured alcove area with a blue plastic breakaway lock. The area where the cart is stored near a main hall corridor. This area was not occupied and no staff were in the area at this time. The area is easily accessible to visitors or pts. who walk in the corridor.

3. At 1:55 p.m. on 3/4/13 on the 7th floor Oncology Medical unit, the crash cart for this unit is in an unsecured alcove with access to the main corridor.

4. At 1:15 p.m. on 3/5/13 crash cart #18 located on the 6th floor was not under constant supervision by staff.

5. During tour of the C-SPA areas (Cardiac Special Procedures area) at 1:47 p.m. on 3/6/12, a crash cart at the end of the hall by the patient bathroom was noted to have a breakaway lock and not in constant supervision of staff.

6. During tour of the 5th floor (Surgical Medical unit) at 3:15 p.m. on 3/4/12, a crash cart was kept in an unsecured alcove which was not under constant supervision by staff. The crash cart was locked with a plastic breakaway device. This observation was confirmed at the time by Medical Director D who said "medications should be secured from patients and visitors."

7. During a tour of the off-site outpatient clinic in the endoscopy clinic at 2:00 p.m. on 3/6/12, a bronchoscopy cart containing medications was discovered unsecured in unlocked equipment storage room N2808. Medications in this unlocked cart included; injectable lidocaine, topical lidocaine and injectable epinepherine. These observations were confirmed at the time of discovery by Director of Pharmacy E who said medications should be locked away to prevent unauthorized access.

Based on observations, federal food safety standards and staff interview, the hospital failed to ensure that 6 of 6 dietary staff observed (Cook DD, Dietary Staff BB, AA, CC, Manager Y and Supervisor Z) has all hair covered and restrained when working in food preparation and serving areas, failed to ensure that in 1 of 2 food preparation areas (tray line) that foods are handled in a sanitary way, and failed to ensure that all foods throughout the facility are fresh and have not expired. This has the potential to affect all patients hospitalized during the survey and an undiscolsed number of staff, and visitors using the cafeteria services.

Findings include:

The following observations were made on 3/4/13 from 12:10 p.m. through 2:30 p.m.:

1) Observations of food service tray line preparation at 12:10 p.m. reflects that Cook DD, salad prep Staff BB, and tray line staffs AA and CC are wearing black half caps which do not provide effective coverage or restraint for their hair on the front, back and sides. During dietary tour with Manager Y and Supervisor Z, on 3/4/13 from 12:10 p.m. through 2:30 p.m., they did not have effective hair coverage or restraint. Their hairnets did not cover their front bangs or sides of hair.

The 2009 Federal drug administration Food Code states under 2-402.11 Effectiveness. states: "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."

In interview with Manager Y, Supervisor Z and Clinical Operations Director G at approximately 2 p.m. on 3/4/13, Manager Y stated that hair was not restrained, and stated that Y was told that the black caps staff were wearing was OK.

2) Cook DD was observed to remove gloves, at approximately 12:20 p.m. on 3/4/13, and handwash with soap and water in a small sink next to the food prep areas across from the cook stove. There was open (uncovered) pre-prepared foods (parsley, celery and lemons) laying 5 inches away from this sink on the tray line prep table. Cook DD did not protect these foods from splash contamination during handwashing.

In interview with Manager Y, Supervisor Z and Clinical Operations Director G at approximately 2 p.m. on 3/4/13, Manager Y and supervisor Z stated that they would look into what could be done to protect food from splash.

3) During surveyor observations of food service tray line preparation at 12:20 p.m. through 12:30 p.m. on 3/4/13, Cook DD was asked where steam table (holding table for cooked foods while lunch trays are being prepared) food temperatures are recorded.

Supervisor Y brought a form dated "3/4/13 -Daily Taste/Temp Panel Chart". This form had no lunch temperatures recorded. Cook DD stated, in interview, at the time of the observation and record review, that DD did not have the time to record temperatures.

At 12:30 Cook DD took steam table temperatures of the following items: beef gravy, chicken gravy, whipped potatoes, rice, chicken noodle soup, garden vegetable soup tomato soup and tomato based meat sauce. Cook DD stated that DD is suppose to take and record temperatures every 2 hours. Cook DD and dietary staff BB stated that the food has been on the steam table since approximately 9:45 a.m. to 10 a.m.




05409

The following was observed during inspection of the therapy office and storage room from 2:15 p.m. to 2:30 p.m. on 3/4/13:

Two containers of apple sauce in the speech therapy cupboard in the storage room were expired: 1 expired on 4/15/11 and the other expired on 5/30/11. Therapy Manager OO said yes when asked if noted applesauce containers had expired.

Based on observation, staff interview and review of maintenance records between 3/04 -3/12/2013, the facility failed to construct, install, and maintain the building system to ensure safety to all patients, staff and visitors.
Findings include:
Building #01: 4-Story Hospital Building
(i) lack of fire rated occupancy separation wall between the Nuclear Medicine Procedure rooms used by inpatients and outpatients, and the rest of the business occupancy areas on the 2nd Floor of the medical office building (MOB South);
(ii) lack of positive latching in one double leaf corridor doors, and failure to latch in another set of corridor double doors;
(iii) lack of self-closing devices on doors protecting hazardous spaces in two locations;
(iv) obstruction in one means of egress corridor;
(v) Fire Alarm system not installed to minimum standards of NFPA 72, trouble signals not transmitted to and annunciated at the central monitoring station, and lack of evidence of automatic transmission equipment to transmit trouble signals from phone line failure in accordance with NFPA 72 Chapters 1, 5 and 7;

(vi) lack of proper maintenance of batteries for main fire alarm panel;
(vii) lack of maintenance of sprinkler system - dirty sprinkler heads & missing escutcheon plate;
(viii) lack of evidence of the vacuum system station inlet performance test;
(ix) lack of a visual and audible derangement signal at a continuously monitored location for emergency generators of the essential electrical system
(x) Lack of adequate ventilation in one space; and lack of positive and negative pressures in clean and dirty spaces respectively.
See K-11, K-18, K-29, K-39, K-51, K-52, K-62, K-77, K-106, and A-726 for detail.


Building #02: Medical Office Building East
(i) clearance at the meeting edge of double corridor doors too wide;

See K-18 for detail.

Building #03: MRI and Oncology Building
(i) one patient treatment area not separated from corridors;
See K-17 for detail.

Building #05: Medical Office Building South (business occupancy)
(i) one stairwell exit door not latching;

See K-130 for detail.

Building #08: Encircle Health (ambulatory health care and business occupancy)

(i) one hazardous area not protected as a hazardous area.

See K130 for detail.

The cumulative effect of these environment problems resulted in the hospital's inability to ensure a safe environment for the patients.

Based on observation and interview, the facility failed to ensure safety and well-being of patients due to lack of proper maintenance of ceiling surfaces in two spaces in the Laboratory in accordance with 42 CFR 482.41(a). This deficient practice had a potential of affecting undetermined number of patients served by the Laboratory.

Findings include:

During a tour of the facility with Staff M1 (vice president, facilities operation), Staff M2 (director of facilities), Staff M3 (facilities supervisor), and Staff M4 (facilities supervisor, Theda Clark MC), Staff M5 (corporate safety officer), Staff M7 (safety specialist), Staff M8(security supervisor), and Staff M9 (laboratory supervisor) surveyor observed on 3/6/13 at 8:50 AM that six lay-in-ceiling panels in each of the Phlebotomy and Blood Bank spaces in the Laboratory on the 2nd Floor were dirty. The observed condition was confirmed at the time of discovery by a concurrent observation and interview with the facilities supervisor and laboratory supervisor.

Based on observation, staff interview, and review of facility maintenance records the facility failed to ensure 'life safety from fire' for all patients, staff and visitors.

Findings include:
Building #01: 4-Story Hospital Building
K11: lack of fire rated occupancy separation wall between the Nuclear Medicine Procedure rooms used by inpatients and outpatients, and the rest of the business occupancy areas on the 2nd Floor of the medical office building (MOB South);
K18: lack of positive latching in one double leaf corridor doors, and failure to latch in another set of corridor double doors;
K29: lack of self-closing devices on doors protecting hazardous spaces in two locations;
K39: obstruction in one means of egress corridor;
K51: Fire Alarm system not installed to minimum standards of NFPA 72, trouble signals not transmitted to and annunciated at the central monitoring station, and lack of evidence of automatic transmission equipment to transmit trouble signals from phone line failure in accordance with NFPA 72 Chapters 1, 5 and 7;

K52: lack of proper maintenance of batteries for main fire alarm panel;
K62: lack of maintenance of sprinkler system - dirty sprinkler heads & missing escutcheon plate;
K77: lack of evidence of the vacuum system station inlet performance test; and
K106: lack of a visual and audible derangement signal at a continuously monitored location for emergency generators of the essential electrical system.
See K11, K18, K-29, K-39, K-51, K52, K62, K77, and K106 for detail.

Building #02: Medical Office Building East (health care occupancy)
K-18: clearance at the meeting edge of double corridor doors too wide.

See K-18 for detail.

Building #03: MRI and Oncology Building (health care occupancy)
K17: one patient treatment area not separated from corridors.
See K17 for detail.

Building #05: Medical Office Building South (business occupancy)
K130: one stairwell exit door not latching.

See K-130 for detail.

Building #08: Encircle Health (ambulatory health care and business occupancy)

K130: one hazardous area not protected as a hazardous area in accordance with NFPA 101 38.3.2.1.

See K130 for detail.

Based on observation, MSDS (Material Safety Data Sheet), and 1 of 1 staff interview (staff E) the hospital failed to ensure cleaning supplies were secured in 1 of 2 outpatient settings observed (outpatient sleep lab). This has the potential to affect all outpatients in the sleep clinic.

Findings include:

During a tour of the off-site outpatient clinics on 03/05/13 at 2:00 PM the following observations were made; in the sleep lab in both room #1 (S3207) and room #3 (S3221) Virustat TBQ (a disinfectant used for cleaning equipment) was stored in an unlocked wall cupboard next to the patient's bed.

The MSDS for Virustat states; HAZARD IDENTIFICATION Primary Routes of Entry: Eye and Skin Contact Effects of Acute Exposure: Eye-May cause redness: Moderate eye irritation. Skin-May cause: Moderate skin irritation. Inhalation: None Known. Ingestion: May cause: Nausea,vomiting, abdominal discomfort. If taken internally, product may cause irritation to mouth, throat or stomach.

These findings were confirmed by Director of Pharmacy E on 03/06/13 at 2:40 PM. Dir E stated that according to the hospital's Safety Officer cleaning fluids should not be in a patient care area.

Based on observation and staff interviews, the facility did not provide proper ventilation due to (i) lack of adequate ventilation in one space, (ii) lack of positive pressure in two spaces, and (ii) lack of negative pressure in three spaces as recommended in the CDC and AIA guidelines. This deficient practice had a potential of contaminating air in clean spaces with undesirable contaminants, and causing possible infection for undetermined number of patients at this hospital.

The CDC guidelines can be found in the website



Findings include:

1. On 3/04/2013 between 1:30 PM and 2:30 pm, surveyor observed that the clean Corridors 1200 and 1193 adjacent to day surgery rooms on the 1st Floor of Groth Center were not under positive pressure to cause airflow from clean to dirty spaces in accordance with the CDC Guidelines, and AIA Guidelines for Design and Construction of Health Care Facilities. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff M3 (facilities supervisor).

2. On 3/04/2013 at 3:15 pm, surveyor observed that the clean Supply Room 102 in the Emergency department on the 1st Floor was not under positive pressure in accordance with the CDC Guidelines, and AIA Guidelines for Design and Construction of Health Care Facilities. The space was instead under negative pressure causing airflow in the wrong direction. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff M3 (facilities supervisor), and Staff M19 (ED supervisor).

3. On 3/04/2013 between 3:25 PM and 3:45 pm, surveyor observed that the dry food Storage in the Kitchen on the 1st Floor main hospital building (Building 01) did not have ventilation in the room in accordance with the AIA Guidelines for Design and Construction of Health Care Facilities. The air in the room was stagnant. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff M3 (facilities supervisor), and Staff M17 (dietary manager).

4. On 3/05/2013 at 11:43 am, surveyor observed that the Soiled Utility Room 208R in the post-anesthesia care unit (PACU) on the 2nd Floor was not under negative pressure relative to adjacent spaces to cause airflow from recovery area into the utility room in accordance with the CDC Guidelines, and AIA Guidelines for Design and Construction of Health Care Facilities. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff M3 (facilities supervisor).

5. On 3/06/2013 at 8:42 am, surveyor observed that the Histology Room in the Laboratory on the 2nd Floor was not under negative pressure relative to adjacent spaces in accordance with the CDC Guidelines, and AIA Guidelines for Design and Construction of Health Care Facilities. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff M3 (facilities supervisor).

6. On 3/06/2013 at between 8:30 am and 9:05 am, surveyor observed that the Bronchoscopy Room in the Laboratory on the 2nd Floor was not under negative pressure relative to adjacent spaces in accordance with the CDC Guidelines, and 2006 AIA Guidelines for Design and Construction of Health Care Facilities. The space was instead under positive pressure causing airflow in the wrong direction. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff M3 (facilities supervisor).

Based on 5 out of 12 observations of care (Staff J, W, OO, P, and O), nationally accepted standards of practice, Food and Drug Administration (FDA) guidelines, P/P review, and 7 out of 7 staff interviews (Staff Z, Y, LL, F, A, HH, and C), the hospital failed to develop a system for 1. Maintenance of kitchen sanitation in 4 of 5 kitchen areas observed (dry storage, cold storage, kitchen equipment storage and cooking elements) 2. Maintenance of documentation for Rubella vaccination or immunity for 1 of 5 staff (II) employees and failed to maintain documentation for 3 of 10 (JJ, KK and MM) personnel or credentialed staff, to verify the hospital staff had been vaccinated, had proof of immunity or declined the vaccination Hepatitis B Virus (HBV) vaccination. 3. Following handwashing guidelines and appropriate glove use (Staff J,W,OO, P, and O), and 4. Maintenance of a sanitary environment in 3 out of 15 areas observed (FBC, cafeteria, therapy department). Failure to maintain a sanitary environment, ensure proper handwashing and gloving is completed, and that staff are free of communicable diseases has the potential to affect all patients, staff, and visitors in this facility.

Findings include:

Kitchen
1) Dry Storage
Observations of the dry storage room at approximately 12:42 p.m. on 3/4/13 reflects that the following items: small clear plastic bag of shredded coconut, large clear plastic bag of spiral multi-grain pasta, and large white 25 pound bag of bread crumbs which was torn open; were not securely closed leaving these food items with the potential to be contaminated.

The 2009 FDA Food Code states in 3-305.11 Food Storage. Food shall be protected from contamination by storing the food in a clean dry location and where it is not exposed to splash, dust or other contamination...".

In interview with Supervisor Z, at the time and date of the observation above, Z stated that these items should be secured with twist ties after staff uses them.

2) Cold Storage
Observations of the cold storage (refrigerator) room at approximately 12:55 p.m. on 3/4/13 reflects that the large commercial ceiling fan in the center of this room circulating cold air, has 3 vent grids with gray fuzzy debris covering their surfaces.

Observations of the freezer room at approximately 12:55 p.m. on 3/4/13 reflects that the large commercial fan circulating cold air has gray fuzzy debris covering it's grid surface and had gray colored cobwebs hanging off of electric cords attached to it. The sprinkler heads in this freezer room were covered with gray debris. This room was noted to have a pan of uncovered chicken broth on a shelf near the door, which was exposed to the blowing air from these dust covered surfaces.

The 2009 FDA Food Code states in 3-305.11 Food Storage. Food shall be protected from contamination by storing the food in a clean dry location and where it is not exposed to splash, dust or other contamination...".

In interview with Supervisor Z, at the time and date of the observation above, Z stated that the chicken broth was uncovered because it was being cooled. Supervisor Z stated that this room will be cleaned.

Food prep Area
3) Observations on 3/4/13 at approximately 12:55 p.m. to 1:30 p.m. show there is a large 3 tiered bell shaped intake vent directly over the main food preparation table that has scattered gray debris on it's smooth white surface.

Observations on 3/4/13 at approximately 12:55 p.m. to 1:30 p.m. show that on the table holding the Robot Coupe food cutter there is a large wall mounted fan that had gray debris and cobweb strings on it's gridded surface cover.

After identifying the dust on the fan, Manager Y stated in interview on 3/4/13 at approximately 1:10 p.m. that Y saw it.

4) Observations on 3/4/13 at approximately 12:55 p.m. to 1:30 p.m. show there are 3 large metal food storage carts and 1 metal rack sitting outside the food storage freezer. These carts/rack were identified by Supervisor Z as being used to hold prepared foods. These 3 metal carts were greasy to touch on their front door surfaces, and have greasy black debris along the surfaces where the doors open. The metal rack was greasy to touch with dried sticky brown and black liquid stains.

Supervisor Z stated in interview, on 3/4/13 at approximately 1 p.m., that these carts/rack have been washed but may need to be scrubbed.

5) Observations on 3/4/13 at approximately 12:55 p.m. to 1:30 p.m. show that near the un-used wash sink area adjacent to the freezer, there is a metal table holding a device (Robot Coupe) used to cut food, that had dried brown and black pieces of debris covering it's surface.

Manager Y identified this debris as onions. Y stated in interview, on 3/4/13 at approximately 1:05 p.m., that it was probably used over the weekend and that staff was responsible for cleaning it after use.

6) Observations on 3/4/13 at approximately 12:55 p.m. to 1:30 p.m. show that under the table, holding the Robot Coupe, there was a 1/4 of a peeled onion bulb and scattered debris on the floor.

After identifying the food debris on the floor, Manager Y stated in interview on 3/4/13 at approximately 1:10 p.m. that Y saw it.

Equipment Storage
7) Observations on 3/4/13 at approximately 12:55 p.m. to 1:30 p.m. show there are 3 large metal racks holding inverted (turned upside down) commercial sized pots and pans. The underside of these racks are dripping with clear to cloudy sticky and greasy liquid. The 3 random pans removed from these racks for inspection, had dried multi-colored food debris in them.

When they were showed to Supervisor Z, Z immediately took them away and stated in interview, on 3/4/13 at approximately 1:15 p.m., that the racks and pots needed to be cleaned.

8) Observations on 3/4/13 at approximately 12:55 p.m. to 1:30 p.m. show the ledges under the food preparation tables were scattered with dried white, tan and black debris, and had dried liquid spills on their surfaces. These ledges held "clean serving trays and dishes" used in food preparation. Random inspection of 3 drawers holding measuring and cooking utensils reflects that the bottoms of all 3 drawers held scattered crumbs that were white, tan and black in color. There are clear liquid stains in these drawers.

In interview with Supervisor Z, on 3/4/13 at approximately 1:30 p.m., Z stated that these areas would be cleaned.

Cooking Elements
9) Observations on 3/4/13 at approximately 12:55 p.m. to 1:30 p.m. show the Vulcan oven had a heavy build-up of black grease on it's door surface, and had a large build up of black grease on it's handle surfaces that could be easily scraped off with an ink pen. The door's surface was covered with dark brown dried liquid stains and dried crusted black debris.

In interview with Manager Y, on 3/4/13 at approximately 1:40 p.m., Y stated that these areas would be cleaned.

10) Observations on 3/4/13 at approximately 12:55 p.m. to 1:30 p.m. show the main stove, had approximately 1/8th of a layer of black grease built up on it's front and exposed left side surface. The dial holes have gray fuzzy dust debris covering the black grease that is recessed in these holes.

In interview with Manager Y, on 3/4/13 at approximately 1:40 p.m., Y stated that these areas would be cleaned.





22198

Personnel/Credential files
The facility's policy titled, "Pre-placement for Rubella, Rubeola, Varicella, and Tuberculosis (T.B.) Screening/Protection of ThedaCare Employees," dated 12/2012, was reviewed on 3/6/2013 at 8:00 a.m. The policy states in part, "All hospital/clinic employees will provide proof of immunity or be vaccinated against Rubella."

On 03/05/2013 between 2:45 PM and 4:45 PM a review of 5 personnel files with interviews was conducted with QC A, RN Unit Educator GG and HR Consultant HH

Certified Occupation Therapy Assistant (COTA) II was hired 02/11/1991 but did not have proof of Rubella vaccination or immunity in II ' s file. After additional searching through employee health files, QC A, RN Unit Educator GG and HR Consultant HH confirmed there was no proof of Rubella vaccination or immunity for COTA II.

HBV infection is transmitted through exposure to blood and other potentially infectious materials (OPIM), as defined in the OSHA Bloodborne Pathogens standard, 29 CFR 1910.1030.



On 3/5/2013 between 1:00 PM and 2:30 PM credentialing/employee health files were reviewed and interviews were conducted with Medical Staff Coordinator LL and VP Medical Affairs F.

MD JJ ' s employee health file did not contain a HBV vaccination, proof of immunity or a declination indicating that MD JJ understood the risk of refusing the vaccination.

Medical Staff Coordinator LL stated LL was responsible for all credentialed files. Medical Staff Coordinator LL confirmed MD JJs file did not have the required HBV vaccination or declination in JJs file. Also present and acknowledged the HBV information was not in the file was VP Medical Affairs F.

On 03/05/2013 between 2:45 PM and 4:45 PM a review of personnel files and interviews were conducted with QC A, RN Unit Educator GG and HR Consultant HH

COTA II ' s employee health file did not contain a HBV vaccination, proof of immunity or a declination indicating that COTA II understood the risk of refusing the HBV vaccination.

HR Consultant HH searched through additional files during this review and interview, confirming COTA IIs file did not have the required HBV vaccination or declination on file. QC A and RN Unit Educator GG were also present and acknowledged the missing HBV vaccination or declination for COTA IIs employee health record.

CNA KK ' s employee health file did not contain a HBV vaccination, proof of immunity or a declination indicating that CNA KK understood the risk of refusing the HBV vaccination.

HR Consultant HH searched through additional files during this review and interview, confirming CNA KKs file did not have the required HBV vaccination or declination on file. QC A and RN Unit Educator GG were also present and acknowledged the missing HBV vaccination or declination for CNA HHs employee health record.

ST MM ' s employee health file did not contain a HBV vaccination, proof of immunity or a declination indicating that CNA KK understood the risk of refusing the HBV vaccination.

HR Consultant HH searched through additional files during this review and interview, confirming ST Ms file did not have the required HBV vaccination or declination on file. QC A and RN Unit Educator GG were also present and acknowledged the missing HBV vaccination or declination for ST MMs employee health record.






26711

Handwashing/Appropriate Glove use:
Standard of Practice recommendations from the CDC published in the October 25, 2002 addition of the Weekly Mortality and Morbidity Report (WMMR) are in part:
IV.A. Perform hand hygiene:
IV.A.3.a. Before having direct contact with patients.
IV.A.3.b. After contact with blood, body fluids or excretions, mucous membranes, nonintact skin, or wound dressings.
IV.A.3.c. After contact with a patient's intact skin (e.g., when taking a pulse or blood pressure or lifting a patient).
IV.A.3.d. If hands will be moving from a contaminated-body site to a clean-body site during patient care.
IV.A.3.e. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient .
IV.A.3.f. After removing gloves.

IV.B.2. Gloves
IV.B.2.a. Wear gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, nonintact skin, or potentially contaminated intactskin (e.g., of a patient incontinent of stool or urine) could occur.
IV.B.2.b. Wear gloves with fit and durability appropriate to the task.
IV.B.2.b.i. Wear disposable medical examination gloves for providing direct patient care.
IV.B.2.b.ii. Wear disposable medical examination gloves or reusable utility gloves for cleaning the environment or medical equipment.
IV.B.2.c. Remove gloves after contact with a patient and/or the surrounding environment (including medical equipment) using proper technique to prevent hand contamination. Do not wear the same pair of gloves for the care of more than one patient. Do not wash gloves for the purpose of reuse since this practice has been associated with transmission of pathogens.
IV.B.2.d. Change gloves during patient care if the hands will move from a contaminated body-site (e.g., perineal area) to a clean body-site (e.g., face).

The facility's policy titled, "Hand Hygiene," dated August 2012, was reviewed on 3/6/2013 at 7:45 a.m. The policy references the CDC's recommendations from the WMMR cited above. The policy also outlines the following procedure for handwashing with soap and water, "...e. Dry thoroughly with disposable towel. f. Use clean/dry towel to turn off the faucet."

In an interview with Infection Preventionist (IP) C on 3/4/2013 at 1:25 p.m., IC C stated that the handwashing expectation in this facility is alcohol gel or soap and water on entry and exit from rooms, before applying gloves, after removing dirty dressings from wounds, and after completing procedures.

During a tour of the FBC on 3/5/2013 from 8:30 a.m.-10:40 a.m. accompanied by VP H and Supvr I, while in the newborn nursery RN J was observed completing circumcision care on Pt. #1. RN J removed gloves, washed hands at the sink, and turned off the faucet with clean hands, thereby re-contaminating J's hands. Supvr I was present during the procedure.

During an observation of Phlebotomist W and Pt. #34, accompanied by Supvr X and QC V on 3/6/2013 at 8:32 a.m., Phlebotomist W pushed W's long hair back from the work area (that being Pt. #34's left arm) with gloved hands. After pushing hair back with gloved hands, Phlebotomist W continued with obtaining a blood sample from Pt. #34. QC V was present during this observation.

Sanitary Environment
During a tour of the FBC on 3/5/2013 from 8:30 a.m.-10:40 a.m. accompanied by VP H and Supvr I, in the FBC Operating Room 2 a baby warmer was noted to have tacky tape residue over a large area of the dial tower. This tacky residue is a potential harborer of microorganisms. Supvr I and VP H both saw and acknowledged the baby warmer in Operating room 2 was not cleaned.

The water/ice machine in the kitchenette of the Labor/Delivery area was noted to have a build up of calcium deposits on the spigot of the machine and on the grates of the drain cover. This calcium build up has the potential to harbor microorganisms. Supvr I and VP H both saw this finding at the time of discovery.

In the cafeteria during the lunch periods between 11:30 a.m. and 12:30 p.m. on 3/4/2013, 3/5/2013, and 3/6/2013 numerous staff were noted to have stethoscopes on their person and away from patient care areas. Some of these stethoscopes were around staff's necks, some of them had rolls of tape meant for patient care use hooked on them, some of them were in staff pockets, considered a dirty area, and some of them had cloth "scrunchies" on them. There is a potential for cross-contamination with these patient care items in a public area with open food items.

In an interview with IP C on 3/5/2013 at 3:35 p.m., IP C stated while there is no policy for leaving the stethoscopes on the unit and the Association for Prevention in Infection Control (APIC) does not really address this, staff have been encouraged in the past to not take stethoscopes off the units.

The facility's policy titled, "Dress Code/Appearance Standards," dated 1/28/2013, was reviewed on 3/6/2013 at 8:52 a.m. The policy states in part, "Hair must be kept clean, brushed and well managed."

During an observation of Phlebotomist W and Pt. #34, accompanied by Supvr X and QC V on 3/6/2013 at 8:32 a.m., it was noted that Phlebotomist W had hair that went past W's shoulders which was not tied back and when leaning forward for the blood draw, W's hair was very close to the work area on Pt. #34's left arm. QC V was present for this observation.




05409

Handwashing/Appropriate Glove use
(1.) Per observation of a nebulizer treatment by R.T. (Respiratory Therapist) staff OO from 12:59 p.m. to 1:10 p.m. on 3/4/13 for Pt. #19 in room #309, the following was noted and witnessed by R.T. Manager QQ:

OO cleansed hands with alcohol gel, donned gloves and proceded to do the following tasks without changing gloves:
Checked #19's posterior and anterior lung sounds opened premixed nebulized solution of albuterol, bromide, and saline, dispensed it into the nebulizer cup, started the treatment by turning on the oxygen, checked #19's pulse by touching left wrist, manipulated the mouse on the computer in room #309 and typed in information on the key board, contaminating the key board and mouse. OO doffed the gloves and donned a new pair without cleansing hands.

2.) The following was noted and witnessed by R.T. Manager QQ: Per observation of Dialysis RN P providing Hemodialysis to Pt. #12 in room #814 from 7:25 a.m. to 8:50 a.m. the following was noted at 7:40 a.m.: RN P when wearing gloves, knocked Pt. #12's urinal off the overbed table and onto the floor (Pt. #12 had mentioned that 12 had been using the urinal prior to the observation when asked at approximately 7:40 a.m.), RN P then picked up the urinal that #12 had been using to urinate in with gloved hands and placed it back on the table. Without changing gloves or cleansing hands, RN P took stethoscope, placed it on #12's chest and listened to #12's lung sounds, contaminating the stethoscope.

3.) Per observation of Medical Assistant O providing wound care to Pt. #35 in the outpatient treatment center on 03/05/13 at 2:37 PM; O picked up a dirty glove from the floor then took a pair of clean gloves, placed them in O's pocket (thereby contaminating them), before washing hands. Staff O then proceeded to don the contaminated gloves before handling clean/sterile supplies. This observation was confirmed on 03/05/13 at 2:55 PM by Outpatient Treatment Center Manager N who said staff O contaminated her gloves by touching them with dirty hands.

Sanitary Environment
During tour of the therapy department from 2:03 p.m. to 2:30 p.m. on 3/4/13 the following was observed: One bottle of "Endure" alcohol solution with an expiration date of June of 2008 and one bottle of sterile water with an expiration date of February 2012 was in the miscellaneous therapy cupboard in the therapy storage room available for use. V.P. Operations staff H was asked to verify the expirations dates and nodded in agreement that the supplies as above were expired.

Based on MR review and staff interview this facility failed to obtain properly authenticated surgical consent forms in 11 out of 11 surgical MR reviewed (Pt.s #6, 7, 8, 13, 14, 16, 17, 18, 26, 27, and 28) out of a total of 30 MR reviewed. Failure to obtain properly authenticated consent forms has the potential to affect all patients receiving surgical services in this facility.

Findings include:

In an interview with Mgr SS on 3/6/2013 from 9:45 a.m.-10:30 a.m., Mgr SS stated that a properly executed surgical/procedural consent form would be signed by the MD and patient/designated person and dated and timed. Director G was present during this interview taking notes.

A MR review was conducted on Pt. #6's closed Newborn MR on 3/5/2013 at 2:36 p.m. accompanied by OS L.
Pt. #6's Circumcision consent is not dated and timed by a parent, and the MD 's signature does not include a time the MD signed the form. OS L agreed that dates and times were missing on this form.

A MR review was conducted on Pt. #7's closed Newborn MR on 3/5/2013 at 3:13 p.m. accompanied by OS L.
Pt. #7's Circumcision consent is not timed by a parent, and the MD 's signature does not include a time the MD signed the form. OS L agreed that the times were missing on this form.



05409

Per medical record review of Pt. #8 beginning at 1:35 p.m. on 3/5/13, review of the surgical consent form signed by Pt. #8 lacks the time #8 signed it, the RN did not document the date or time signed under witnessed by, and the physician did not document the time signed.

Per medical record review of Pt. #14 beginning at 10:05 a.m. on 3/6/13, review of the surgical consent form signed by Pt. #14 lacks the time #14 signed it, the RN did not document the date or time signed under witnessed by, and the physician did not document the time signed.

These findings were reviewed with Dir E at 2:30 p.m. on 3/6/13. When these examples were shown to Dir E, E replied, "Putting times and dates on signatures is a problem."


20878

Per medical record review of Pt. #13 beginning at 9:15 a.m. on 3/6/13, review of the surgical consent form signed by Pt. #13 lacks the time at which the physician signed.

Per medical record review of Pt. #16 beginning at 10:40 a.m. on 3/6/13, review of the surgical consent form signed by Pt. #16 lacks the time at which the physician signed.

Per medical record review of Pt. #17 beginning at 11:00 a.m. on 3/6/13, review of the surgical consent form signed by Pt. #17 lacks the time at which the physician signed.

Per medical record review of Pt. #18 beginning at 1:10 p.m. on 3/6/13, review of the surgical consent form signed by Pt. #18 lacks the time at which the physician signed.

Per medical record review of Pt. #26 beginning at 1:30 p.m. on 3/6/13, review of the surgical consent form signed by Pt. #26 lacks the time at which the physician signed.

Per medical record review of Pt. #27 beginning at 1:50 p.m. on 3/6/13, review of the surgical consent form signed by Pt. #27 lacks the time at which the physician signed.

Per medical record review of Pt. #28 beginning at 2:10 p.m. on 3/6/13, review of the surgical consent form signed by Pt. #28 lacks the time at which the physician signed.

These findings were reviewed with Dir E at 2:30 p.m. on 3/6/13.