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Based on observation, staff interviews and review of maintenance documents, the facility did not construct and maintain the building systems to ensure a safe physical environment due to the cumulative effects of environment deficiencies and resulted in the hospital's inability to ensure a safe environment for the patients, which is a Condition of Participation. The facility did not have a facility free of life safety deficiencies. This deficiency occurred in all of the five smoke compartments, and had the potential to affect all of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 05/11/11 at 1:00 PM surveyor #14105 observed that the facility had the following deficiencies:
K-11 (occupancy separation)
K-17 (corridor walls),
K-22 (exit signage for exits),
K-25 (smoke compartments),
K-29 (hazardous areas),
K-62 (sprinkler system maintanence),
K-67 (ventilation),
K-147 (electrical wiring per NFPA 70).

Please refer to the full description of the deficient practice at the cited K-tags: This observed situation was not compliant with CFR 485.623. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff B, and staff J.

Based on observation, staff interviews and review of maintenance documents, the facility did not construct and maintain the building systems to ensure a safe physical environment due to the cumulative effects of environment deficiencies and resulted in the hospital's inability to ensure a safe environment for the patients, which is a Condition of Participation. The facility did not have a facility free of life safety deficiencies. This deficiency occurred in all of the five smoke compartments, and had the potential to affect all of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 05/11/11 at 1:00 PM surveyor #14105 observed that the facility had the following deficiencies:

K-11 (occupancy separation)
K-17 (corridor walls),
K-22 (exit signage for exits),
K-25 (smoke compartments),
K-29 (hazardous areas),
K-62 (sprinkler system maintanence),
K-67 (ventilation),
K-147 (electrical wiring per NFPA 70).

Please refer to the full description of the deficient practice at the cited K-tags: This observed situation was not compliant with CFR 485.623. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff B, and staff J.

Based on 1 of 1 interview (D) by surveyor #29972, the hospital does not ensure that the offsite rehabilitation staff are prepared to handle medical emergencies.

Findings include:
Per interview with Rehabilitation Manager (D) on 5/3/11 at 1:50 pm, the off-site P.T. unit is attached to a medical clinic that is not owned and operated by River Falls hospital. P.T. staff rely on the attached medical clinic staff to handle patient medical emergencies. Per (D), "staff just yell down the hall for help" when there is a medical emergency. Staff D confirmed they do not have their own oxygen supply or Ambu bags and they rely on the attached clinics crash cart, oxygen, and Ambu bags for emergencies. Staff D confirmed there is no policy or procedure in place for handling medical emergencies specific to this offsite Rehab facility.







29972

Based on 3 of 4 crash cart observations, P&P review, and 4 of 4 interviews (C, L, B and M) the hospital failed to ensure that crash cart drugs and biological's are secured from unauthorized access.

Findings include:
Per review, of P&P Medication System Management/Security dated 10/02 directs the following: "Medications will be secured and carefully monitored on patient care units at all times."

1. Per observation, by surveyor #13469 while touring the ED on 5/3/11 at 3:00 PM with ED Manager (C), a crash cart, which contained drugs and biological's, sitting next to a patient gurney in the trauma bay contained a break-away locking device to alert staff if someone had accessed the cart for use. The carts do not have a permanent locking device to ensure unauthorized access by patients, families and visitors.

Per (C), patients, families and visitors are at times left unattended in the trauma bay with curtains drawn and out of continuous staff view. As a result, the cart which contains drugs, biological's and intravenous solutions could be accessed without staff knowledge resulting in tampering, destruction, or removal of the crash cart contents.

2. Per observation, by surveyor #13469 while touring the post-anesthesia recovery unit in the surgery department on 5/4/11 at 9:30 AM with OR Manager (L), a crash cart sitting in the recovery unit contained a break-away locking device to alert staff if someone had accessed the cart for use. Per (L), housekeeping staff are in the unit after hours cleaning and would have access to the crash cart and it's contents.

3. Per observation, by surveyor #29963 and #29972 while touring the special care unit on 5/4/11 at 7:45 AM with Quality/Risk Manager (B) and RN (M) a crash cart sitting in the unit contained a break-away locking device to alert staff if someone had accessed the cart for use. Per (M) when the special care unit has no patients the crash cart is not under constant observation by nursing staff and could be accessed by unauthorized staff and visitors.

Based on observations and interviews by surveyor #13469, the hospital failed to ensure that the facility is kept clean, maintained, and arranged so as to provide a sanitary environment for the prevention of potential contamination or infection. In 1 of 1 observation (L) CRNA's are not following safe injection practices. In 1 of 1 observation patient food is not protected from cross-contamination. In 1 of 1 interview (D) therapy patients are not protected from potential contamination or infections . In 2 of 2 interview (J, I) housekeeping staff are not
ensuring that cleaning solutions are at the proper concentrations and that privacy curtains are on a routine cleaning schedule.

Findings include:
1. CDC guidelines for safe injection practices: 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

Per observation, while touring the OR on 5/4/11 at 9:30 AM with OR Manager (L), CRNA (Q) was noted to have two open multidose vials in his anesthesia cart (Anectine and Rocuronium). Per (L) he prepares syringes from these multidose vials in the OR at the patient's bedside. Per (L), the multidose vials are then returned to the anesthesia cart to be used for future patients. Per (L), he was not aware that multidose vials should not be drawn-up and then kept in the immediate patient treatment area.

2. Per interview, while touring the therapy department with P.T. (D) on 5/9/11 at 10:45 AM, it was revealed that patients who use the therapy equipment at both the hospital therapy department and the off-site location are not asked to wash their hands prior to using the equipment. Per (D), therapy staff do clean the equipment after use to try to prevent cross-contamination between patients but do not have a policy in place to ensure that every effort is made, including patient handwashing, to prevent the spread of communicable diseases.

Per observation, during this same tour, it was noted that pads, balls and steppers were stored directly on the floor allowing for cross-contamination to patients and preventing housekeeping staff from cleaning the area on a routine basis.

3. Per observation, while touring the ED with ED Manager (B) on 5/3/11 at 3:00 PM, it was noted that a refrigerator with food for patients also contained ambulance crew food as well as a dozen eggs. Per interview with (B), patient and staff food should be kept separate to prevent cross-contamination.

4. Per interview, with Housekeeper (I) on 5/4/11 at 10:30 AM by surveyor #13469 and surveyor #29972, it was revealed that privacy curtains throughout the facility are not on a routine cleaning schedule to protect patients and staff from cross-contamination of microorganisms and communicable diseases.




29972

Example by surveyor #29972:
Per interview, with the Manager of Facility services (J) and Housekeeper (I) on 5/4/11 at 10:30 am, it was revealed that there are no quality control checks being done for the automated housekeeping dispensing systems of cleaning solutions. Interview also verified there is no policy in place for quality control checks on the cleaning solution dispensing systems to ensure that the appropriate mixture is obtained for disinfection purposes.
.

29972

Based on 2 of 2 observations, 1 of 1 interview (H), and review of Nutrition Services P&P by surveyor #29972, the hospital does not ensure that dietetic services personnel are competent with regard to handling of food to assure food safety and quality.

Findings include:
1. Per observation, while touring the dietary department with the Nutrition Services Manager (H) on 5/4/11 at 8:05 am the following food containers found in the cooler were not dated as to when they were opened and/or expired per dietary practice:

Cheese wrapped with plastic wrap with no date when it was opened.

Sweet and sour sauce opened with no date as to when it was opened.

Cool whip container opened with no date.

3 bags of shredded mozzarella cheese with no date as to when bags were first opened.

Roasted red peppers in plastic bag no date as to when they were placed in bag.

2 bags of carrots opened no date as to when bags were first opened.

Roast Beef opened dated 4/22/11 and the date was 5/4/11; 12 days since first opened.

Chicken Sauce in plastic container with no date.

Cherries in glass bottle dated as opened on 1/26/11.

Per Interview with Nutrition Manager (H), during the tour, the dietary department does have a policy to date and label all food items and discard unused portions not utilized within 48 hours.

Per review of Nutrition Services P&P on 5/4/11 at 9:00 am, dietary staff are to "label and date all food containers. Cover, label, date and discard unused portions not utilized within 48 hours."

2. During observation of Dietary staff (S) on 5/4/11 at 7:45 am, (S) hair was not completely covered with a hairnet while setting up food trays for hospital patients. Her bangs were not under the hairnet and were hanging down to her eyebrows allowing for potential contamination of patient food if her hair fell out onto the food. Her hairnet only covered her hair on top and back of her head. This example was confirmed in interview with Nutrition Services manager (H), at the time of the observation, that all staff working in kitchen should have a hairnet on at all times which covers all of hair.

Per review of hairnet policy on 5/4/11, staff should wear proper hair restraints.

Based on 4 of 30 MR reviewed (#29, 30, 25, 18), P&P review, and 3 of 3 interviews (C, E, R) by surveyor #13469, the hospital failed to ensure that the MR reflects a chronological picture of cares and treatments provided for each patient.

Findings include:
Per P&P review on 5/9/11 in the AM of medical staff standards for medical record documentation (no date) directs the following: "C. All notes must be prompt and complete."

The following MR examples were reviewed by surveyor #13469 between 5/3/11 at 4:10 PM and 5/10/11 at 9:55 AM:

1. Pt. #29 was seen in the ED on 4/27/10 following a sexual assault. The MR does not include evidence of the SART RN forensic examination. Per interview with ED Manager (C) at the time of the MR review on 5/4/11 at 2:50 PM, the SART contracted service takes the examination information with them and does not leave a copy for the hospital MR.

2. Pt. #30 was seen in the ED on 7/20/10 following a sexual assault. The MR does not include evidence of the SART RN forensic examination. Per interview with ED Manager (C) at the time of the MR review on 5/4/11 at 3:10 PM, the SART contracted service takes the examination information with them and does not leave a copy for the hospital MR.

In addition, there is no evidence found in the MR for Pt. #30 that the ED MD did a medical screening examination. ED MD documentation is as follows: "Patient presents to triage ambulatory. Significant symptoms per patient include having been sexually assaulted this past Friday night while at a bar. She doesn't remember specifics of the assault. Is having lower abdominal pain and cramping. Patient seen and examined by SART nurse, orders done, patient discharged." This documentation does not reflect a medical screening examination by the MD or evidence of a preliminary diagnosis and treatment for her lower abdominal pain and cramping. This was confirmed by (C) at the time of the MR review.

3. Pt. #25 was admitted to swing bed status on 3/3/11. Nursing notes dated 3/15/11 summarize the shift and indicate that patient #25 is to be "discharged to home on Friday." There is no further entries into this MR by either the MD or nursing staff. It is unclear what happened to this patient after the nursing note entered on 3/15/11 at 6:01 AM.

Per interview, with RN (E) at the time of the MR review on 5/10/11 at 8:45 AM, patient #25 went to surgery on 3/15/11 for debridement of her wound and was then readmitted to acute care status. RN (E) was unable to find evidence that the MD did a discharge summary from swing bed status or that the nursing staff closed out the swing bed chart with documentation to indicate what happened to patient #25 after 6:01 AM on 3/15/11.

4. Pt. #18 was seen in the ED on 2/5/11 for shortness of breath. The MR does not include evidence of what happened to this patient after the medical screening examination by the MD and the completion of his treatment in the ED. Per interview with RN (R) on 5/9/11 at 4:10 PM at the time of the MR review it was revealed after researching the record that patient #18 was admitted to the hospital for further treatment. Nursing staff did not document this information in the ED record.

Based on MR review, 3 of 3 interviews (L, N, and E)) and P&P review, in 2 of 18 MR reviewed requiring H&P (#2, 25) out of total of 30 MR reviewed by surveyor #13469, the hospital failed to ensure that a history and physical was completed for all patients before surgery and/or within 24 hours of admission per hospital policy.

Findings include:
Per P&P review on 5/9/11 in the AM of medical staff standards for medical record documentation (no date) directs the following: "In the case of admitted patients, if an H&P was not done before the patient's admission, then it must be completed no later than 24 hours after admission or before any inpatient procedure requiring sedation or general anesthesia, whichever occurs first."

Per MR review, Pt. #2 was admitted for a breast lumpectomy on 11/5/10. The MR did not include evidence that a comprehensive H&P was conducted by the MD prior to surgery. This example was confirmed by RN's (L) and (N) at the time of the MR review on 5/9/11 at 2:10 PM.

Per MR review, Pt. #25 was admitted to swing bed status on 3/3/11. The MR did not include evidence that a comprehensive H&P was conducted by the MD within 24 hours of admission. This example was confirmed by RN (E) at the time of the MR review on 5/10/11 at 8:45 AM.

Based on 20 of 20 ED MR reviewed (#26, 7, 11, 14, 29, 30, 10, 19, 16, 17, 8, 14, 13, 12, 15, 5, 6, 25, 18, 28) out of total of 30 MR reviewed, review of P&P, and 6 of 6 interviews (G, N, R, C, E, L), the hospital failed to ensure that ED notes identify the times of service and treatments.

Findings include:

Examples by Surveyor 29963:
Per review of MR on 5/4/11 at 9:15 a.m. of Pt # 26, the ED notes dated 5/1/2011 do not identify the time that the patient was transported to an inpatient room from ED, the time that the patient presented to ED for treatment, and the time that the patient was assessed by the MD in the ED.

Per review of MR on 5/4/11 at 9:15 a.m. of Pt.# 26, nursing notes dated 5/2/2011 do not identify the time that the MD was notified of abnormal lab results.

These findings were confirmed with RN G on 5/4/11 at 9:15 a.m.



13469

Examples by surveyor #13469:

Per P&P review on 5/9/11 in the AM of medical staff standards for medical record documentation (no date) directs the following: "C. All notes must be prompt and complete."

The following MR examples were reviewed by surveyor #13469 between 5/3/11 at 4:10 PM and 5/10/11 at 9:55 AM:

1. ED notes do not identify the time the MD was notified of the patients admission to the ED and their presenting medical complaints. Examples include: Pt. #7 notes dated 11/6/10, Pt.
#11 dated 1/3/11, Pt. #14 dated 12/5/10, Pt. #29 dated 4/27/10, Pt. #30 dated 7/20/10, Pt. #10 dated 12/2/10, Pt. #19 dated 1/1/11, Pt. #16 dated 2/2/11, Pt. #17 dated 2/6/11, and Pt. #8 dated 6/17/10. The above examples were confirmed at the time of the MR review with RN's (L), (N), (R), (C) and (E).

2. ED notes do not identify the time the MD examined the patient. Examples include: Pt. #7 notes dated 11/6/10, Pt. #14 dated 12/5/10, Pt. #29 dated 4/27/10, Pt. #30 dated 7/20/10, Pt. #10 dated 12/2/10, Pt. #19 dated 1/1/11, Pt. #16 dated 2/2/11, Pt. #17 dated 2/6/11, and Pt. #8 dated 6/17/10. The above examples were confirmed at the time of the MR review with RN's (L), (N), (R), (C) and (E).

3. ED notes do not identify the time the patient was discharged from the ED. Examples include: Pt. #7 notes dated 11/6/10, Pt. #13 dated 12/3/10, Pt. #12 dated 1/4/11, Pt. #15 dated 2/3/11, Pt. #5 dated 11/3/10, Pt. #6 dated 12/3/10, Pt. #14 dated 12/5/10, Pt. #29 dated 4/27/10, Pt. #30 dated 7/20/10, Pt. #25 dated 3/3/11, Pt. #16 dated 2/2/11, Pt. #17 dated 2/6/11, Pt. #18 dated 2/5/11, and Pt. #8 dated 6/17/10. The above examples were confirmed at the time of the MR review with RN's (L), (N), (R), (C) and (E).

4. ED notes dated 2/6/11 for Pt. #17 do not identify the time the patient went to the radiology department, when he returned from the radiology department and the time the MD reduced his ankle fracture in the ED. These examples were confirmed during the MR review by RN (R) on 5/9/11 at 3:45 PM.



29972

Examples per surveyor # 29972:

Review of MR of pt #28 on 5/3/11 at 9:30 am reveals the following: No documented times of arrival to the ED, the time the MD was notified of patient arrival, or the time MD evaluated the patient.

This is confirmed in interview with Staff RN(G) on 5/3/11 at 9:30 am.

Based on interviews with facility staff, record review, and P&P review by surveyor #13469, it was determined that:

In 4 of 5 surgery MR reviewed (#2, 3, 1, 22) out of a total of 30 MR reviewed, and 2 of 2 interview (L, N), the hospital failed to ensure that surgical patients are protected from fire.

In 1 of 5 surgery MR reviewed (#2), 2 of 2 interview (L, N) and P&P review, the hospital failed to ensure that an H&P is completed by the MD before surgery. See Tag C304.

The hospital failed to ensure that it delineate surgical privileges for all surgical staff. See Tag C-321

The cumulative effect of these deficiencies result in the Hospital's inability to ensure safe cares for all surgical patients.

Findings include:
1. Per interview, with OR Manager (L) on 5/4/11 at 8:30 AM the surgery staff are aware of the new CMS directive effective 1/12/07, and do ensure that the alcohol based skin prep is dry before draping. Per (C), their policy on use of alcohol failed to direct staff to document the dry-time in the patient's clinical record's intraoperative notes to validate this part of the process.

Per review of intra-operative nursing notes dated 11/5/10 patient #2 skin was prepped with Chlorhexidene. The intra-operative note does not identify if the staff ensured that this alcohol-based skin prep was dry. This example was confirmed during the record review on 5/9/11 at 2:10 PM with RN's (L) and (N).

Per review of intra-operative nursing notes dated 11/1/10 patient #3 skin was prepped with Chlorhexidene. The intra-operative note does not identify if the staff ensured that this alcohol-based skin prep was dry. This example was confirmed during the record review on 5/9/11 at 2:40 PM with RN's (L) and (N).

Per review of intra-operative nursing notes dated 11/1/10 patient #1 skin was prepped with Providone Iodine. The intra-operative note does not identify if the staff ensured that this alcohol-based skin prep was dry. This example was confirmed during the record review on 5/9/11 at 1:10 PM with RN's (L) and (N).

Per review of intra-operative nursing notes dated 11/4/10 patient #22 skin was prepped with 70% Alcohol. The intra-operative note does not identify if the staff ensured that this alcohol-based skin prep was dry. This example was confirmed during the record review on 5/9/11 at 3:00 PM with RN's (L) and (N).

2. Per P&P review of medical staff standards for medical record documentation (no date) directs the following: "In the case of admitted patients, if an H&P was not done before the patient's admission, then it must be completed no later than 24 hours after admission or before any inpatient procedure requiring sedation or general anesthesia, whichever occurs first."

Per MR review, Pt. #2 was admitted for a breast lumpectomy on 11/5/10. The MR did not include evidence that a comprehensive H&P was conducted by the MD prior to surgery. This example was confirmed by RN's (L) and (N) at the time of the MR review on 5/9/11 at 2:10 PM.

Based on 2 of 6 credentialed staff files reviewed (O and P), and 2 of 2 interview (B, L) by surveyor #13469, the hospital failed to ensure that it detail surgical privileges for all surgical staff.

Findings include:
1. Review of Surgical First Assist (P) credential file on 5/5/11 in the PM revealed that the surgical privileges were described as follows: "First Assist In Surgery privileges include the following: Provide First-Assist services in Surgery." The privilege list does not identify what specifically First Assist (P) can do.

Per interview, with OR Manager (L) on 5/4/11 at 8:30 AM, First Assist (P) does manipulate skin and does at time close the surgical incision. Per (L), the surgical privileges for (P) do not identify what specifically he can do in surgery.

2. While touring the OR with OR Manager (L) on 5/4/11 at 9:30 AM, it was revealed that the CRNA's (certified registered nurse anesthetist) supervise anesthesia students who are performing anesthesia procedures on hospital patients.

Per interview with Quality/Risk Manager (B) on 5/10/11 in the AM, the CRNA's are not privileged to supervise anesthesia students performing anesthesia during surgery procedures.

Review of CRNA (O) privilege list on 5/10/11 did not identify the authority per medical staff and the governing body to supervise anesthesia students performing anesthesia during surgery procedures.

Based on 2 of 2 interviews (B) and (C) by surveyor #13469, the hospital does not ensure that the facility Quality Improvement activities included review of death records in cooperation with the OPO (organ procurement organization).

Findings include:
1. Quality/Risk Manager (B) and ED Manager (C) said in interview on 5/4/11 at 2:30 PM that the facility does get a list of deaths called to the OPO quarterly. The hospital had not established protocols for the review of death records with the OPO. Facility staff are not reviewing death records to determine the effectiveness of it's protocols and policies, and to improve the identification of potential donors.

Based on 1 of 1 interview (K) by surveyor #13469, the hospital failed to ensure that it had dental services readily available for swing bed patients.

Findings include:
Per interview, with Care Manager (K) on 5/5/11 at 9:00 AM, the facility makes every attempt to contact the patient's personal dentist if the need arises while a swing bed patient. The hospital does not however have an agreement with a dentist who is credentialed and privileged with the hospital to meet the dental needs of those patients whose personal dentist is unavailable or for those patients in the swing bed program who do not have a local dentist.