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Based on MR review, P/P review and staff interviews (E and F), in 2 of 14 Pts (#14 and 17), out of a total 20 MRs reviewed, the facility failed to document follow up information and offer assistance to develop an AD; and in 5 of 10 (#7, 14, 15, 16 and 19) the facility failed to ensure the IM from Medicare is given to the Pt within 48 hours of admission. This deficiency potentially affects all 8 patients present during survey.

Findings include:

CCO A stated during interview on 7/10/2013 at 3:20 PM the facility does not have a P/P regarding Important Message from Medicare.

Per review on 7/10/13 in the PM of hospital policy titled Advance Medical Directives dated 2/20/2013, it states under Procedure: "2) Also on admission the patient will be asked whether or not they have completed an advance directive. If so, efforts will be taken to locate the document in order for the document to be placed in the patient's medical record. If not, the patient will be asked if they would like to complete one. If the patient is in agreement, a referral will be made to Social Services to assist the patient with completion of the document."

Examples of AD:

Review of Pt # 14's MR on 7/9/2013 at 11:10 AM revealed Pt #14 was admitted on 7/5/2013. On admission documentation pt answered "NO" to having an AD. No follow up documentation is noted in Pt #14's chart regarding the option to complete an
AD or that a referral to Social Services was made. EMT/IT E confirmed, during MR review, there was no further documentation in Pt #14's MR regarding AD.

Review of Pt # 17 on MR on 7/9/2013 at 3:00 PM revealed Pt #17 was admitted on 5/28/2013. On admission documentation pt answered "NO" to having an AD. No follow up documentation is noted in Pt #17's chart regarding the option to complete an AD or that a referral to Social Services was made. EMT/IT E confirmed, during MR review, there was no further documentation in Pt #17's MR regarding AD.

Examples of IM:

Review of Pt #14's MR on 7/9/2013 at 11:10 AM revealed Pt #14 was admitted on 7/5/2013. There is no copy of the IM from Medicare indicating the Pt received the notice within 48 hours of admission. DIR HIM F confirmed, during MR review, there is not an IM in Pt#14's MR.

Review of Pt #15's MR on 7/9/2013 at 12:25 PM revealed Pt #15 was admitted on 7/4/2013. There is no copy of the IM from Medicare indicating the pt received the notice within 48 hours of admission. DIR HIM F confirmed, during MR review, there is not an IM in Pt#15's MR.

Review of pt #16's MR on 7/9/2013 at 12:45 PM revealed pt #16 was admitted on 3/29/2013. There is no copy of the IM from Medicare indicating the Pt received the notice within 48 hours of admission. DIR HIM F confirmed, during MR review, there is not an IM in Pt#15's MR.

Review of Pt #19's MR on 7/10/2013 at 11:25 AM revealed Pt #19 was admitted on 7/9/2013. There is no copy of the IM indicating the Pt received the notice within 48 hours of admission. DIR HIM F confirmed, during MR review, there is not an IM in Pt#19's MR.


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A MR review was conducted on Pt. #7's closed surgical record on 7/9/2013 at 1:10 p.m. accompanied by Dir. F. Pt. #7 was an 83 year old admitted on 12/6/2012 for right hip surgery and was transferred to an acute care facility on 12/7/2012. Pt. #7 did not sign the Medicare Discharge Appeal notice upon admission to the facility. This is confirmed during MR review with Dir F.

Per interview on 7/9/13 at 1:10 p.m., with Dir F, IMs should be on file.

Based on observation, staff interviews, and review of maintenance records, the hospital failed to ensure the physical environment of the building met the minimum requirements of the 2000 Edition of the Life Safety Code for "Existing Healthcare Occupancy" and "New Healthcare Occupancy" chapters of this code.

The findings include:

K11: Building separation wall was missing and not properly rated.
K12: Class of Construction did not meet non-combustible standards of a Type II (1,1,1)
K15: The facility did not provide room finishes that had rated wall finishes.
K18: The facility did not provide corridor separation doors that closed and had positive-latching hardware that worked.
K25: The facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls that had sealed wall penetrations, and rated wall construction.
K29: The facility did not enclose hazardous rooms that had rated doors, and did not enclose hazardous rooms with closer on the doors.
K34: The facility did provide stairways that did open to unoccupied rooms.
K38: The facility did not provide egress paths at all times, and paths with sufficient headroom.
K39: The facility did not ensure corridor doors had the required width.
K51: The facility did not provide a fire alarm system that was installed according to NFPA 72 with a smoke detector at the main fire panel.
K56: Sprinkler system did not meet all minimum regulations per NFPA 13.
K61: The facility did not provide supervision of the control valves on the sprinkler system.
K62: The facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25.
K67: The HVAC system did not meet the minimum standards on NFPA 90A.
K73: The facility did not maintain an egress path that was free of highly flammable furnishings/decoration,and non-combustible decorations
K75: The facility failed to limit trash containers to 32 gallons and not to exceed .5 gallon per square foot of floor area.
K130: The facility failed to properly isolate the emergency generator (EPS) in its own rated room and the facility failed to properly maintain the proper head room in the means of egress.
K143: The facility did not provide space for oxygen storage with separation of oxygen from combustibles
K144: The facility did not test the emergency electrical generator in accordance with the codes, the facility did not monitor derangement signals at a continuously monitored location and did not provide a remote stop switch for the generator
K145: The facility did not provide a Type I essential electrical system that was properly divided.
K147: Electrical system did not meet the minimum regulations for NFPA 70.

The cumulative effect of these deficiencies indicates that the facility failed to provide a safe environment and reliable system to ensure safety to all occupants, patients and staff of this facility.

Based on tour and interview with staff (A and S), in 1 of 8 tours, the facility failed to maintain an environment for the safety of Pts and visitors. This deficiency potentially affects all 8 patients, and all visitors present during the course of the survey.

Findings include:

1) A tour of the nursing unit was conducted on 7/8/2013 from 12:15 p.m.-12:51 p.m. accompanied by CCO A and NS S. The following observations were made during the tour:

* Room 106 had tears/scrapes along the drywall exposing the gypsum board and creating a porous, non-cleanable surface.
* Room 110 had gouges in the drywall behind the bed creating a porous, non-cleanable surface.
* The soiled utility room had a missing kickboard along the perimeter of the room exposing porous non-cleanable plaster. This room also had cleaning chemicals (Virex TB, Hydrogen Peroxide cleaner/disinfectant wipes) that all say "keep out of reach of children." The door to this room is unlocked and children could enter and access the chemicals.
* In the whirlpool tub room there was a large section of the tile floor in front of, and partially under the tub, that was unsealed cement which was porous and non-cleanable.
*A room indicated as the clean supply room (the computer servers were also in this room) was found to be quite hot and humid. Facility maintenance checked the temperature of this room and revealed it was 85 degrees. There are items stored in this room that have temperature storage requirements, namely bottles of normal saline for respiratory therapy (inhalation) treatments. The manufacturer label on these bottles (3 sets on the shelf) indicated not to store above 77 degrees.

These findings were confirmed by COO A and NS S at the time of discovery on 7/8/2013.

2) A tour of the OR and PACU was conducted on 7/9/2013 at 9:00 a.m. accompanied by Surgery Dir G.

* There were numerous scrapes and gouges in the walls of the OR exposing the drywall and creating a /porous, non-cleanable surface.

Dir. G confirmed these findings at the time of discovery on 7/9/2013.

Based on observation, staff interviews, and review of maintenance records, the hospital failed to ensure the physical environment of the building met the minimum requirements of the 2000 Edition of the Life Safety Code for "Existing Healthcare Occupancy" and "New Healthcare Occupancy" chapters of this code.

The findings include:

K11: Building separation wall was missing and not properly rated.
K12: Class of Construction did not meet non-combustible standards of a Type II (1,1,1)
K15: The facility did not provide room finishes that had rated wall finishes.
K18: The facility did not provide corridor separation doors that closed and had positive-latching hardware that worked.
K25: The facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls that had sealed wall penetrations, and rated wall construction.
K29: The facility did not enclose hazardous rooms that had rated doors, and did not enclose hazardous rooms with closer on the doors.
K34: The facility did provide stairways that did open to unoccupied rooms.
K38: The facility did not provide egress paths at all times, and paths with sufficient headroom.
K39: The facility did not ensure corridor doors had the required width.
K51: The facility did not provide a fire alarm system that was installed according to NFPA 72 with a smoke detector at the main fire panel.
K56: Sprinkler system did not meet all minimum regulations per NFPA 13.
K61: The facility did not provide supervision of the control valves on the sprinkler system.
K62: The facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25.
K67: The HVAC system did not meet the minimum standards on NFPA 90A.
K73: The facility did not maintain an egress path that was free of highly flammable furnishings/decoration,and non-combustible decorations
K75: The facility failed to limit trash containers to 32 gallons and not to exceed .5 gallon per square foot of floor area.
K130: The facility failed to properly isolate the emergency generator (EPS) in its own rated room and the facility failed to properly maintain the proper head room in the means of egress.
K143: The facility did not provide space for oxygen storage with separation of oxygen from combustibles
K144: The facility did not test the emergency electrical generator in accordance with the codes, the facility did not monitor derangement signals at a continuously monitored location and did not provide a remote stop switch for the generator
K145: The facility did not provide a Type I essential electrical system that was properly divided.
K147: Electrical system did not meet the minimum regulations for NFPA 70.

The cumulative effect of these deficiencies indicates that the facility failed to provide a safe environment and reliable system to ensure safety to all occupants, patients and staff of this facility.

Based on observation, staff interview (Staff G), P/P review, and nationally recognized standards of practice from the United States Pharmacopeial (USP) and ASHP, in of 1 of 1 observation (Pt. #9, staff H), the facility failed to follow aseptic techniques for medication administration; and in 2 of 8 tours, the facility failed to ensure medications are not accessible to unauthorized people, and labeled if out of original packaging per standard of practice. This deficiency potentially affects all 8 patients present during the course of the survey.

Findings include:

Per USP-797, 2008: All rubber stoppers of vials and bottles and the necks of ampuls are disinfected by wiping with sterile 70% IPA (isopropyl alcohol) and waiting for at least 10 seconds before they are used to prepare CSPs (compounded sterile products-mixing medications).

The facility's policy titled, "Multi-dose Vials," dated 12/2012, was reviewed on 7/10/2013 at 7:29 a.m. The policy cites USP-797 as it's source. On page 2 of the policy it states in part, "Whenever taking medication from a multi-dose vial, a sterile syringe and alcohol swab are to be used."

Per ASHP Technical Assistance Bulletin on Repackaging Oral Solids and Liquids in Single Unit and Unit Dose Packages dated 1983 states under #10 "Control records of all packaging runs must be kept. These records should include the following information: (1) complete description of the product, i.e., name, strength, dosage form, route of administration, etc.; (2) the product's manufacturer or supplier; etc.; (3) control number; (4) the pharmacy's control number if different from the manufacturer's; (5) expiration dates of the original container and the repackaged product; (6) number of units packaged and the date(s) they were packaged; (7) initials of the operator and checker (if any); (8) a sample of the label and, if feasible, a sample of the finished package, which should not be discarded until after the expiration date and which should be examined periodically for signs of deterioration; and (9) description (including lot number) of the packaging materials and equipment used."

Examples in Ambulatory Surgery:

An observation of Pt. #9's Colonoscopy was conducted on 7/8/2013 at 8:15 a.m. CRNA H was observed preparing medications from glass ampules and rubber topped vials for this procedure. CRNA H did not use alcohol to swab the vials prior to entry with a needle after removing the safety cap.

After the procedure room was cleaned, CRNA H was again observed preparing medications for the next procedure and again, CRNA H did not use alcohol to swab the vials prior to entry with a needle.

In an interview with Dir. G on 7/10/2013 at 8:30 a.m. regarding observations in the procedure room, Dir. G stated that it is the expectation that vials are swabbed with alcohol prior to entering them with needles.


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Examples in ED:

During a tour of the ED on 7/8/2013 at 2:25 PM through 2:55 PM, accompanied with ED Dir B, there are two crash carts with breakaway locks in Trauma Room 5 and one crash cart in Exam Room 6. Per ED Dir B, during the tour, the crash carts are not within constant view of staff, and Pts may be unattended allowing unauthorized access to medications.

Examples in Radiology:

During a tour of the Radiology Department on 7/10/2013 at 9:00 AM, accompanied with Radiology Dir M, there are 4 containers in a cupboard in the tech work area containing a white powder substance only labeled with a lot number and date. Dir of Radiology M identified the substance as GoLytely (a medication used for bowel cleansing). Radiology Dir M agreed, during the tour, the name of the medication was not identified on the container, and stated the RT measures the GoLytely from the original package into individual doses.

Based on tour, observation, review of P/P, and interview with staff (A, B, C, D, G, J, M, N, O and S) in 6 of 8 tours the facility failed to ensure there is a comprehensive infection control program, lead by a qualified infection control officer, to monitor, prevent and control potential infections. This deficiency potentially affects all 8 patients present during the course of the survey.

Findings include:

Review on 7/9/13 in the PM, of facility policy titled Lab Cleaning, dated 3/5/12, states under Procedure 1. "Disinfect all counter surfaces and phlebotomy station daily." Per interview with Lab Dir I on 7/9/13 at approximately 4:40 PM, Lab Dir I stated the policy did not state to clean after each Pt.

Review on 7/9/13 in the AM, of facility policy titled Disinfection of Weight Room Equipment, dated 5/7/13, states under Procedure 2. "All equipment with non-porous surfaces will be cleaned with a cloth and bucket of water with the proper dilution of HDQ Liquid Disinfectant, Hydro-Perox MP wipes or spray or facility approved disinfectant. 3. All porous surfaces (i.e. padded handles) will be sprayed with Virex Tb or facility approved disinfectant."

The facility policy titled, "Cleaning of B.M.W.s & Keyboard Skins (Better Mobile Workstation), dated 9/5/2012, was reviewed on 7/10/2013 at 7:10 a.m. The policy states in part, "B.M.W.s will be numbered for tracking purposes and a cleaning guide and cleaning schedule in a sheet protector available on each computer....The keyboard cover and tray can then be wiped with a cloth lightly dampened with disinfectant solution. This will occur Daily."

The manufacturer's instructions for use for KimGuard Sterilization Wrap (blue wrap used to wrap sterilized items) and KimGuard One-Step Sterilization Wrap cautions in the Sterility Maintenance section: " Do not stack trays. Stacking trays can result in damage to the wrap caused by undue pressure from the weight. "AORN also states in Perioperative Standards and Recommended Practices for Inpatient and Ambulatory Settings, 2013: " Recommended Practices for Selection and Use of Packaging Systems for Sterilization, Recommendation VIII Sterilized packages should be considered sterile until an event occurs to compromise the package barrier integrity ...Events that may affect the sterility of a package include, but are not limited to: Multiple handling that leads to seal breakage or loss of package integrity; compression during storage; moisture penetration; exposure to airborne and other environmental contaminates; storage conditions (e.g. type of shelving, cleanliness, temperature, humidity, traffic control); type and configuration of packaging materials used; and use of sterility maintenance covers and method of sealing. " pp 508-9.

A policy titled, "Cleaning Schedule Tasks," dated 4/12/04, was reviewed on 7/10/2013 at 2:00 p.m. The policy purpose is "To assure the cleanliness of all drapes, blinds and room dividers." The policy goes on to say that these items should be cleaned as needed, but at least once per year and a log is used to keep track of when these items should be cleaned.

Per interview with ICO N and Dir Quality O on 7/10/13 at 9:30 AM, ICO N stated she has been in the ICO position since March 2013. ICO N is an RT, and stated in interview has had no experience prior to March 2013 as an ICO. ICO N revealed ICO N has a membership with APIC, but has not had any formal training on Infection Control, is allotted 4 hours a week to perform ICO duties, including tracking, trending and surveillance; and is scheduled to complete ICO web based training during the allotted four hours. Dir Quality O stated during the interview, when ICO N is not available as an ICO, and working as and RT, Dir Quality O performs ICO duties.

Per interview with ICO N and Dir Quality O on 7/10/13 at 9:30 AM, Dir Quality O stated there is no formal tracking and trending of surgical site infections, since mid 2012. Dir Quality O stated the facility relies on the clinics and MDs to report any infections upon discovery. Per review of the surgical site infection information, on 7/10/13 at 9:45 AM, there is one surgical site documented in the last year. Dir Quality O could not state the accuracy of the information due to the lack of a formal tracking system in place.

An interview with Dir. of Environmental Services J was conducted on 7/9/2013 at 11:00 a.m. In regard to the cloth curtain room divider cleaning schedule, Dir. J stated that the cloth curtains are cleaned when they are visibly soiled, "About every 6 months maybe, but there is no log." Allowing for potential cross contamination through use.

Examples in Laboratory:

Per observation on 7/9/13 at 11:15 AM, Phleb D performed a blood draw on Pt #20 in the lab draw room. Once completing the draw and Pt #20 left, Phleb D did not clean the chair or counter, and gathered the lab tubes to return to the lab.

Example in Rehabilitation Department:

Per tour on 7/9/13 at 10:15 AM of the facility rehabilitation department, there is hard water build up on the tap and handles of the sink in the rehabilitation room; the Schwinn stationary bike's left hand grip is torn and made of a porous spongy material. Per interview with PT C on 7/9/10 at 10:15 AM, during the tour, PhT C stated the grips are cleaned with Hydro-Perox wipes. The label on the wipe container states it is to be used on "non-porous surfaces". PhT C provided a spray bottle of HDQ Liquid Disinfectant, stating it is also used to disinfect the sponge grips. The HDQ Liquid Disinfectant label states it is to be used on "non-porous surfaces".


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Examples in Nursing Unit:

A tour of the nursing unit was conducted on 7/8/2013 from 12:15 p.m.-12:51 p.m. accompanied by CCO A and NS S. The following observations were made during the tour:

* The ceiling vent in the shower room had a build up of dust in the grates.
* Room 112 housed two mobile workstations with computers on them. There was a build up of dust on the carts and key boards and tape residue on the border around the screen of one of the computers. Neither NS S or CCO A knew what the cleaning schedule was for the mobile work stations.

These findings were confirmed by COO A and NS S at the time of discovery on 7/8/2013.

Examples in Ambulatory Surgery/Surgery:

An observation of Pt. #9's Colonoscopy was conducted on 7/8/2013 at 8:15 a.m. It was noted that the clean Endoscopy scope cabinet, which was unvented, was housed in the same procedure room where the colonoscopies are being performed.

Storage cabinets for Endoscopy scopes require vents for proper air circulation for scope integrity and cannot be housed in the same room as the procedure in a vented cabinet. This was discussed with Dir. G on 7/9/2013 at 10:30 a.m. who verbalized understanding.

A tour of the Operating Room (OR) and Post Anesthesia Care Unit (PACU) was conducted on 7/9/2013 at 9:00 a.m. accompanied by Surgery Dir G. The following observations were made:

* In the sterile storage room sterile packs were stacked on top of each other instead of vertically on the shelf.
* Under the sink in the PACU there were several patient care items stored that could become soiled or damaged from storing under a sink: suction catheter peel packs, lavage set, flash light.

Dir. G confirmed these findings at the time of discovery on 7/9/2013.


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Examples in ED:

During a tour of ED on 7/8/2013 at 2:55 PM accompanied with ED Dir B, there is dirt buildup on fan blades in Room 5. Rooms 3 and 6 have unsecured carts with drawers containing needles and saline, and Room 4 has an unlocked cupboard containing needles and other sharps. Per ED Dir B, during tour, the fan blades are to be on a cleaning schedule, and stated patients could be left alone in these rooms unsupervised by staff.

Examples in Radiology:

During a tour of Radiology Department on 7/10/2013 at 9:00 AM, accompanied with Radiology Dir M, there is dirt buildup on fan blades in Nuclear Medicine room. Per Radiology Dir M, during tour, fans are to be cleaned by housekeeping when needed.

Based on observations and staff interviews (Staff A and S) this facility failed to indicate dates that food products were opened in one of one refrigerator used for patient food items on the nursing unit. This deficiency potentially affects all 8 patients present during the course of the survey.

Findings include:

A tour of the nursing unit was conducted on 7/8/2013 from 12:15 p.m.-12:51 p.m. accompanied by CCO A and NS S.

On the nursing unit in the kitchenette refrigerator, designated for patient food items, a bottle of coffee creamer and container of shredded cheese were present and undated for the date they were opened.

In an interview with CCO A and NS S at the time of discovery, both stated that the kitchen staff are responsible to maintain the items in the refrigerator and confirmed that these items were not dated and should be.

Based on interview with staff, in 1 of 1 interview (O) the facility failed to ensure policies and procedures are reviewed once a year. This deficiency potenitally affects all 8 patient treated during the course of the survey.

Findings include:

Per interview with Dir Quality O on 7/10/13 at 9:30 AM, Dir Quality O stated the IC policies have not been reviewed in the last year. Dir Quality O stated the policies are to be reviewed annually.

Based on review of the QAPI program, review of 1 of 1 medical record storage contracts, and 2 of 2 staff interviews (staff F and O) this facility failed to ensure that contracted services provided to the facility comply with conditions of participation and that data provided by the OPO is incorporated into the overall QAPI plan that is presented to the Governing Board. Failure to incorporate contracted service data and ensure its compliance has the ability to affect all patients services by the facility.

Findings include:

An interview with medical record department Dir. F was conducted on 7/8/2013 at 1:35 p.m. Dir. F stated that the facility has off-site storage at a medical records storage facility approximately 2 hours away. On 7/8/2013 at 4:30 p.m. Dir. F stated F has not visited the off site storage facility to determine if the area this facility's records are stored is safe and secure.

A review of the medical record contract with Naviant was completed on 7/10/2013 at 8:07 a.m. The contract is noted to say on page 3, #8., "Liability for Stored Materials. Naviant shall not be liable for any loss or destruction of, or damage to Stored Materials."

In an interview with Quality Director O on 7/10/2013 at 9:07 a.m., Dir. O stated O has never been on site at Naviant either. Dir. O was unable to state how the integrity and safety of the facility's MRs that are stored off-site is maintained.

Dir. O also stated that reports to the facility from the contracted OPO service have not gone to the Governing Board as they should be. The results are aggregated and maintained but not reported out.

Based on review of MR, review of P/P and interview with staff, in 1 of 3 death MRs (#3) out of a universe of 20 records, the facility failed to ensure compete documentation of contacting the OPO including contact name and reference number. This deficiency potentially affects all patient deaths at this facility.

Findings include:

Review of Pt #3's MR on 7/10/2013 at 1:30 AM revealed there is no documentation of the OPO reference number and contact name for Pt #3's death. EMT/IT E confirmed findings at time of MR review, and stated the reference number and contact name should be documented.

Per death packet received from CCO A during the OPO interview on 7/9/2013 at 1:00 PM staff are required to enter the name of recovery organization ,name of contact and reference number in the electronic medical record under the Donation screen.

Based on MR review, P/P review, and staff interview, in 3 of 11 MR with reported pain (7, 8 and 18), out of a total 20 MRs, the facility failed to reassess pain after interventions per policy; and in 5 of 15 ED records (# 12, 16, 17, 18 and 19), the facility failed to ensure documentation of the MD examination time, complete documentation of treatments and results of treatments, on going evaluations, complete transfer forms and/or disposition. This deficiency affects all 8 Pt present during survey.

Findings include:

The facility policy titled, "Pain Management-Hospital," dated 10/26/2012, was reviewed on 7/10/2013 at 7:17 a.m. The policy states " The identification and treatment of pain is a vial component of the plan of care...Reassessment intervals following intervention is recommended to occur: *Intravenous medication-30 minutes, Intramuscular medication-60 minutes, *Oral medication-60 minutes, *Non-pharmalogical intervention-60 minutes."

An interview with CCO A and NS S was conducted on 7/9/2013 at 2:05 p.m. A and S stated that patient's acceptable pain levels are determined on the initial assessment upon admission to the facility. At the time of the interview neither A or S could recall what the policy required for pain reassessments after interventions.

Per review on 7/10/13 in the PM of hospital Medical Staff Bylaws, dated 3/21/2013, it states under #13 (a)(xxii) "For patients receiving emergency services, the medical record shall also contain the following information: information concerning the time of the Pt's arrival, means of arrival and by whom transported; pertinent history of the injury or illness including details relative to first aid or emergency care given the Pt prior to his arrival at the hospital; time of physician notification; treatment times, including administration of medications, and time of Pt discharge or transfer from services."

Examples of Pain assessment:

1) A MR review was conducted on Pt. #7's closed surgical record on 7/9/2013 at 1:10 p.m. accompanied by Dir. F. Pt. #7 was an 83 year old admitted on 12/6/2012 for right hip surgery and was transferred to an acute care facility on 12/7/2012.
On the "All Flow sheet Data" (flow sheet nursing uses to document assessments and interventions) it is recorded that Pt. #7 denied pain from 11:53 a.m. through 7:30 p.m. on 12/6/2012 (the time frame of 6:38 p.m.-7:30 p.m. was post-operatively).
At 7:34 p.m. Pt. #7 is documented as having pain and an ice pack was applied to the surgical site. No other interventions are documented on this flow sheet.
Follow up documentation for pain assessment/re-assessment did not occur until 5:42 a.m. on 12/7/2012, a period of 10 hours.

Dir. F confirmed these findings at the time of discovery.

A MR review was conducted on Pt. #8's closed surgical record on 7/10/2013 at 10:15 a.m. accompanied by CI P. Pt. #8 had abdominal surgery on 1/18/2013 for a possible small bowel obstruction. The following pain assessments and interventions are documented in the All Flow sheet Data area of the electronic MR:
1/18/13: 9:39 p.m. (has pain), 11:36 p.m. (denies pain).
1/19/13: 2:49 a.m. (has pain), 8:10 a.m. (has pain) 9:34 p.m. (has pain), 9:44 p.m. (ice pack given).
1/20/13:8:10 p.m. (has pain), 11:34 p.m. (has pain)

CI P confirmed these finding at the time of discovery and it was noted that there were no reassessments of pain documented in this area of the MR other than on 1/18/2013 which was 2 hours after the assessment where Pt. #8 had pain.

2) On 7/10/2013 at 2:00 p.m. Dir. F provided copies of progress notes from Pt. #8's MR which address some further interventions (that as needed medication was given for pain) but agreed that pain re-assessment was not documented. Documentation of interventions occurred:
1/19/13: note time 11:43 a.m., note filed 2:03 p.m., note references that, "Patient complains of pain and writer offered and gave pain medication as needed."
1/19/13: note time 6:05 p.m., note filed 6:09 p.m., note references that, "Patient complains of pain and received pain medication as prescribed."
1/20/13: note time 2:59 p.m., note filed 3:12 p.m., note references that, "Patient received PRN [as needed] pain medication as needed and prescribed."


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3) Review of MR for Pt #18 on 7/10/13 at 11:10 AM revealed Pt was admitted for a diagnosis of exacerbation of chronic back pain. Pain assessment for Pt #18 was documented at 10:29 PM on 7/9/2013. The following reported pain documentation is 10:41 AM the following day 7/10/2013. Per EMT/IT E, during MR review, there should be pain assessments documented between the above times.

Examples of MD exam time:

1) Per review of Pt # 12 MR on 7/9/2013 at 3:25 PM revealed on the ED Pt Care Timeline the Pt arrived to the ED at 9:02 AM on 6/7/2013 but the timeline does not indicate the time the physician was notified of the Pt's arrival or the time the physician began the physical examination of the Pt. Based on this information it cannot be determined when the physician completed the physical examination. This is confirmed during MR review with EMT/IT E.

2) Per review of Pt # 16 MR on 7/9/2013 at 12:45 PM revealed on the ED Pt Care Timeline the Pt arrived to the ED at 12:43 PM on 3/29/2013 but the timeline does not indicate the time the physician was notified of the Pt's arrival or the time the physician began the physical examination of the Pt. Based on this information it cannot be determined when the physician completed the physical examination. This is confirmed during MR review with EMT/IT E.

3) Per review of Pt # 17 MR on 7/9/2013 at 3:00 PM revealed on the ED Pt Care Timeline the Pt arrived to the ED at 6:10 PM on 5/28/2013 but the timeline does not indicate the time the physician was notified of the Pt's arrival or the time the physician began the physical examination of the Pt. Based on this information it cannot be determined when the physician completed the physical examination. This is confirmed during MR review with EMT/IT E.

4) Per review of Pt #18 MR on 7/10/2013 at 11:10 AM revealed on the ED Pt Care Timeline the Pt arrived to the ED at 1:10 PM on 7/9/2013 but the timeline does not indicate the time the physician was notified of the Pt ' s arrival or the time the physician began the physical examination of the Pt. Based on this information it cannot be determined when the physician completed the physical examination. This is confirmed during MR review with EMT/IT E.

5) Per review of Pt #19 MR on 7/10/2013 at 11:25 AM revealed on the ED Pt Care Timeline the Pt arrived to the ED at 6:08 AM on 4/18/2013 but the timeline does not indicate the time the physician was notified of the Pt ' s arrival or the time the physician began the physical examination of the Pt. Based on this information it cannot be determined when the physician completed the physical examination. This is confirmed during MR review with EMT/IT E.

Per interview with EMT/IT E on 7/10/2013 at 11:10 AM the physician should assign his or her self to the Pt in the electronic medical record when notified of the Pt's arrival but do not document the time of physical examination.

Based on tour, interview and P/P review, in 3 of 8 tours the hospital failed to ensure medical records are kept secure from unauthorized persons. This deficiency potentially affects all patients treated at this facility.

Findings include:

Per hospital policy titled "Security of Medical Records and other confidential information" dated 2/20/2013 reads "records are to be stored in a manner that maintains confidentiality of the information contained in the records."

During a tour of the ED on 7/8/2013 at 2:25 PM, accompanied with ED Dir B, 8 radiology call back sheets containing confidential patient information are in an unsecured drawer in Room 3. ED Dir B stated, during the tour, they should be moved to a secure location.

During a tour of the Radiology Department on 7/10/2013 at 9:00 AM, accompanied with Radiology Dir M, radiology films containing confidential patient information are stored in the Radiology Read Room which is unlocked. Per Radiology Dir M, during the tour, the the Read Room "can be secured but we have not."


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An interview and tour of the medical record department with Dir. F was conducted on 7/8/2013 at 1:35 p.m. Dir. F stated that the housekeeping department comes in to clean the medical records department, where there are paper copies of records on open shelving units, in the evening after the department is closed and unsupervised by medical record staff.

Dir. F did state that the housekeeping staff sign confidentiality agreements for the facility but agreed that they are not authorized to have access to medical records.

Based on credential file review, review of the Medical Staff Bylaws, P/P review, and staff interview this facility failed to privilege/credential 1 of 1 PA who manipulates tissue in the OR. This deficiency potentially affects all Pts having orthopedic surgery at the facility.

Findings include:

The Medical Staff Bylaws, dated April 20, 2011, were reviewed on 7/10/2013 at 2:30 p.m. The Bylaws state in part, on page 38, "Health professionals who are qualified and wish to provide treatment to patients at the Hospital may apply for membership to the Associate Staff and privileges in accordance with the procedures outlined in these Bylaws. Associate Staff members who are granted privileges may provide treatment in the Hospital within the scope of their Wisconsin licenses and in accordance with the individually granted privileges."

The policy titled, "Practitioner Privileges," dated 3/26/2013, was reviewed on 7/10/2013 at 2:10 p.m. The policy states that all practitioners performing surgery at [the facility] must have surgical privileges. The policy also states, "Surgical privileges must correspond with the established competencies of each practitioner."

An interview with Dir. G was conducted on 7/9/2013 at 8:20 a.m. Dir. G identified PA U as assisting in orthopedic surgeries by holding retractors, thereby manipulating tissue. PA U is also a Radiology Technologist who functions as a PA first assist in surgery about two times per month, according to Dir. G.

A review of PA U's personnel file revealed no credentials on file. Upon request for PA U's credential/privileging file, COO R stated that PA U was not credentialed or privileged at this facility.

These findings were discussed with CCO A on 7/9/2013 at 3:20 p.m.

Based on review of SB rights given to Pts upon admission to SB, and interview with staff, in 1 of 1 interview (L) the facility failed to ensure list of SB rights provided includes the right to choose a personal physician. This deficiency potentially affects all SB Pts at the facility.

Findings include:

Per review on 7/9/13 in the PM of SB rights provided to Pts upon admission, the rights did not include the right to choose a personal physician to oversee the SB stay. This was confirmed in interview with HCA L on 7/10/13 at 12:15 PM, stating the right should be included.

Based on review of SB rights given to Pts upon admission to SB, and interview with staff, in 1 of 1 interview (L) the facility failed to ensure list of SB rights provided includes the right to choose or refuse to work or provide services for the facility. This deficiency potentially affects all SB Pts at the facility.

Findings include:

Per review on 7/9/13 in the PM of SB rights provided to Pts upon admission, the rights did not include the right to choose or refuse to work or provide services for the facility during the SB stay. This was confirmed in interview with HCA L on 7/10/13 at 12:15 PM, stating the right should be included.

Based on review of SB rights given to Pts upon admission to SB, and interview with staff, in 1 of 1 interview (L) the facility failed to ensure list of SB rights provided includes the right to post or receive personal mail. This deficiency potentially affects all SB Pts at the facility.

Findings include:

Per review on 7/9/13 in the PM of SB rights provided to Pts upon admission, the rights did not include the right to have personal mail sent or delivered during the SB stay. This was confirmed in interview with HCA L on 7/10/13 at 12:15 PM, stating the right should be included.

Based on review of SB rights given to Pts upon admission to SB, and interview with staff, in 1 of 1 interview (L) the facility failed to ensure list of SB rights provided includes the right to have personal property. This deficiency potentially affects all SB Pts at the facility.

Findings include:

Per review on 7/9/13 in the PM of SB rights provided to Pts upon admission, the rights did not include the right to have personal property in their room during the SB stay. This was confirmed in interview with HCA L on 7/10/13 at 12:15 PM, stating the right should be included.

Based on review of SB rights given to Pts upon admission to SB, and interview with staff, in 1 of 1 interview (L) the facility failed to ensure list of SB rights provided includes the right to share a room with a spouse. This deficiency potentially affects all SB Pts at the facility.

Findings include:

Per review on 7/9/13 in the PM of SB rights provided to Pts upon admission, the rights did not include the right to have spouses share a room during the SB stay, if both are in the facility. This was confirmed in interview with HCA L on 7/10/13 at 12:15 PM, stating the right should be included.

Based on review of SB rights given to Pts upon admission to SB, and interview with staff, in 1 of 1 interview (L) the facility failed to ensure list of SB rights provided includes the information on discharge and transfer requirements. This deficiency potentially affects all SB Pts at the facility.

Findings include:

Per review on 7/9/13 in the PM of SB rights provided to Pts upon admission, the rights did not include the rights related to providing notice, in writing, when and why the Pt could be transferred or discharged, including reasons for discharge/transfer, appropriate timing to allow safe and orderly placement, when the the discharge/transfer will happen, and the right to appeal. This was confirmed in interview with HCA L on 7/10/13 at 12:15 PM, stating the information should be included with the Pt rights.

Based on MR review and staff interview, in 3 of 3 SB MRs (Pt.s #10, 11, and 12) the facility failed to provide a notice of transfer/discharge to its swing bed patients. This deficiency potentially affects all SB Pt at the facility.

Findings include:

An interview with CCO A, NS S and health care advocate L regarding the swing bed program was conducted on 7/9/2013 at 2:55 p.m.

Healthcare advocate L and NS S both stated that this facility does not have a separate notice for transfer/discharge for the swing bed patients.

MR reviews for Swing Bed Pt.s # 10, 11, and 12 were conducted on 7/10/2013 between 11:03 a.m. and 12:10 p.m. accompanied by CI P. There are no notices of transfer/discharge in the MRs of any of these patients as the facility does not have one.

MR findings were confirmed by CI P at the time of discovery during MR reviews.

Based on review of 1 of 1 Swing Bed program and staff interview (staff A and L), this facility failed to secure a dental contract in the event dental services are required by their Swing Bed patients. This deficiency potentially affects all SB Pts at the facility.

Findings include:

During an interview with CCO A and healthcare advocate L on 7/9/2013 at 2:55 p.m., regarding the program and requirements of the Swing Bed program, it was discovered that this facility has not had a dental contract since the closing of the previously attached Skilled Nursing Facility in 2009.

CCO A stated patients would probably just go to their own personal dentists.

Based on review of P/P and interview with staff, in 1 of 1 interview (A) the facility failed to ensure the visitor policy included the Pt rights for visitors. This deficiency potentially affects all Pts treated at the facility.

Findings include:

Per review on 7/10/13 at 10:50 AM of facility P&P titled After Hour Visitor and Vendor Sign In, dated 7/20/11, the P&P does not include information related to Pt visitor rights addressing, any restrictions, their choice of visitors and to restrict or change their visitor choice. This is confirmed in interview with CCO A on 7/10/13 at 10:50 AM stating the policy needs to be updated.

Based on review of P/P and interview with staff, in 1 of 1 interview (A) the facility failed to ensure the visitor policy included the Pt rights for no restrictions of type of visitor and visitor treatment. This deficiency potentially affects all Pts treated at the facility.

Findings include:

Per review on 7/10/13 at 10:50 AM of facility P&P titled After Hour Visitor and Vendor Sign In, dated 7/20/11, the P&P does not include information related to Pt visitor rights addressing, no restrictions related to race, color, national origin, religion, sex, gender identity, sexual orientation, or disability; and visitors will be treated in a consistent manner. This is confirmed in interview with CCO A on 7/10/13 at 10:50 AM stating the policy needs to be updated.