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Based on observation, record review and interview, the facility failed to maintain accurate records for the receipt and distribution of prescription medication samples according to Wisconsin Administrative Code in 1 of 1 medication sample storage areas. This deficiency has the potential to affect all patients receiving medication samples and all clinical staff with access to this storage area.

Findings include:

Wisconsin Administrative Code, Standards for Dispensing and Prescribing Drugs. Medical Examining Board, Med Chapter 17, Regulation 17.05(1)(a) states "A practitioner shall maintain complete and accurate records of each prescription drug received, dispensed or disposed of in any other manner."

Observation of the outpatient primary care clinic on 8/26/2014 at 2:25 p.m. revealed a sample drug storage room. Clinical Services Mgr BB stated that the drug room housed sample medications used for patients. Medications from the sample drug room administered to patients are documented on the patient's electronic health record. In an interview on 8/26/2014 at 2:25 p.m., Clinical Services Mgr BB stated there was no comprehensive process in place to track the types and number of medications coming into or being dispensed from the sample drug room. Mgr BB stated that the facility maintains delivery invoice sheets of medications brought into the facility and housed in the sample drug room.

On 8/27/2014 at 10:40 a.m. the sample drug room contained a minimum of 130 different medications. Review of delivery invoice papers on 8/27/2014 at 10:15 a.m. accounted for 27 of the 130 different medications contained in the sample drug room.

Based on tour of the facility with facility staff between August 25th through August 26th, 2014; this surveyor observed that the hospital failed to be constructed, arranged, or maintained to ensure the safety of the patients. The cumulative effect of these environmental problems resulted in the hospital's inability to ensure a safe environment for the patients in six of the six smoke compartments. The Existing Health Care Occupancy chapter of the Life Safety Code (2000 Edition) [NFPA 101] was used for this survey.

Findings Include:
K-18: Corridor openings were not smoke tight;
K-29: Hazardous areas were not enclosed with hourly rated fire barriers;
K-56: Sprinkler system was not installed per NFPA 13; and
K-147: Electrical system was not installed per NFPA 70.

Please refer to the specific K-tags for additional details.

Based on observation and staff interview, this facility failed to maintain an environment for the safety of patients and staff in 2 of 11 department tours (ER and OB). Failure to maintain a safe environment has the potential to affect all patients and staff who enter these departments.

Findings include:

During a tour of the ER on 8/25/2014 at 2:10 p.m. accompanied by DON F, it was observed that in the ER bays there were containers of sani-wipes out on the counters that state, "Keep out of reach of children." DON F acknowledged this and stated they could be put away in a cabinet out of reach of children.

Also during the ER tour a scissors was found in a drawer in ER room B. This scissors could be a potential source of injury to patients and/or staff. In an interview with ER Mgr B on 8/25/2014 at 2:30 p.m. regarding the unsecured scissors, Mgr B stated that the scissors is usually not in there, that it is usually in the trauma room and put away.

During a tour of the OB unit on 8/25/2014 at 2:50 p.m. accompanied by DON F and Mgr D, it was observed that in the OB rooms containers of sani-wipes that state, "Keep out of reach of children," were in reach of children on counter tops. Mgr D acknowledged this and stated they could be put away in a cabinet out of reach of children.
Also during the OB tour, several rooms had scissors in the nurse servers (cabinets with supplies used for patient care) in the rooms that could be a source of potential injury. DON F acknowledged this and stated the scissors could be put away.

Based on tour of the facility with facility staff between August 25th through August 26th, 2014; this surveyor observed that the hospital failed to be constructed, arranged, or maintained to ensure the safety of the patients. The cumulative effect of these environmental problems resulted in the hospital's inability to ensure a safe environment for the patients in six of the six smoke compartments. The Existing Health Care Occupancy chapter of the Life Safety Code (2000 Edition) [NFPA 101] was used for this survey.

Findings Include:
K-18: Corridor openings were not smoke tight;
K-29: Hazardous areas were not enclosed with hourly rated fire barriers;
K-56: Sprinkler system was not installed per NFPA 13; and
K-147: Electrical system was not installed per NFPA 70.

Please refer to the specific K-tags for additional details.

Based on observation, record review and interview the facility failed to ensure that patient services are provided in an appropriate and safe manner with medications and food storage in 7 of 11 departments toured (Rehab, Radiology, Primary Care Clinic, OR, Med/Surg, ER, and Kitchen), failed to develop and update individualized nursing care plans in 8 of 18 MRs reviewed out of a total of 25 MRs reviewed (Pt. #4, 6, 8, 9, 12, 15, 16, and 22), and failed to have updated employee health files in 2 of 10 personnel files reviewed (Staff J and II).

Findings include:

1. The facility failed to maintain accurate records for the receipt and distribution of prescription medication samples according to Wisconsin Administrative Code in 1 of 1 medication sample storage areas in the Primary Care Clinic. (see C-0152)

2. This facility failed to follow it's policies and professional standards of practice for medication safety in 4 of 11 departments observed (Rehab, Radiology, Primary Care Clinic, and OR). (see C-0276)

3. This facility failed to follow its medication error reporting policies evidenced by failing to report medication errors that reached the patient to the physician in 4 out of 10 out of 20 in-patient medication error reports reviewed between 3/2013-4/2014. (see C-0277)

4. This facility failed to follow its policies and procedures and the recommendations of nationally recognized professional standards of practice evidenced by failing to maintain an environment that was free from potential contaminants to patient, staff, and/or visitors in 8 out of 11 departments observed (Primary Care Cllinic, Surgery, Decontamination, Med/Surg, Laundry, ER, OB, and RT) and 2 out of 10 employee health files reviewed (staff J, II). (see C-0278)

5. The facility failed to follow proper food storage precautions in 3 of 3 departments with food storage areas out of a total of 11 departments observed (Med/Surg, ER, Kitchen). (see C-0279)

6. The facility failed to ensure that nursing plans of care are developed and updated in accordance with patient's individualized needs in 8 of 18 patient care plans out of a total of 25 MR reviewed (Pt. #4, 6, 8, 9, 12, 15, 16, and 22). (see C-298)

The cumulative effect of these systematic failures has the potential to affect all patients who receive care at this facility.

Based on observation, record review, and staff interview this facility failed to follow it's policies and professional standards of practice for medication safety in 4 of 11 departments observed (Rehab, Radiology, Primary Care Clinic, and OR). Failure to follow medication safety practices has the potential to affect all patients serviced by these departments, included the averaged 5 inpatients during the course of the survey.
Findings include:
In an interview with IPC C on 8/25/2014 at 9:30 a.m. IPC C stated that the facility follows the CDCs recommendations from the One and Only One campaign for safe injection practices. One needle, one syringe, one patient.
Per CDC, March 2, 2011, "A needle or other device should never be left inserted into a medication vial septum for multiple uses. This provides a direct route for microorganisms to enter the vial and contaminate the fluid." Also per the CDC, "Do not administer medications from a syringe to multiple patients, even if the needle or cannula on the syringe is changed. Needles, cannula and syringes are sterile, single-use items; they should not be reused for another patient nor to access a medication or solution that might be used for a subsequent patient."
Per review of facility policy on 8/26/14 at 4:00 PM titled "Surveillance, Prevention, and Control of Infection Sterile Preparations: Single-Dose and Multiple Dose Vials" it states "Once opened, single use and multiple dose containers will be discarded after the following time period, unless otherwise specified by the manufacturer, ... Single dose vial 6 hours, ... Multiple dose vial 28 days

Rehabilitation department:
A tour of the Rehab department was conducted on 8/27/2014 at 10:05 a.m. accompanied by Rehab Mgr, PT FF. The following observations were made on this tour:
--A bottle of Dexamethasone, made by the facility's pharmacy on 8/8/2014, was found opened and undated in the medication cabinet.
--A non-needled syringe used for the Dexamethasone was found in the medication cabinet. Per PT FF this syringe is used for about a week and then discarded and replaced. It is used for multiple patients, approximately 8 times per day.
--Two vials of 0.9% sodium chloride (normal saline), were found in the medication cabinet opened and undated. One of the vials was spiked with a stopcock to allow for needless syringe access.

These findings were discussed at the time of the observation with Rehab Mgr FF who was unaware that the CDC recommendations related to safe injection practices would apply to this department for the purposes of Rehab's use.


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On 8/26/14 during a tour of the Primary Care Clinic at 2:30 PM, accompanied by Clinical Service Manager BB, VP of Clinical Services CC, and Dir of Quality A, an observation of open, undated Hydrogen Peroxide and sterile water in rooms: D6, D7, C1, C8, B8, A1. Dir of Quality A stated, at the time of discovery, that hydrogen Peroxide would be considered a medication and would need to follow the hospital dating policy. During interview on 8/27/14 at 10:00 AM Dir of Quality A stated the hospital does not have a current policy for dating after opening sterile water but that it should be dated.

On 8/26/14 during a tour of the Primary Care Clinic at 2:30 PM, accompanied by Clinical Service Manager BB, VP of Clinical Services CC, and Dir of Quality A, an observation of 4 sample size tubes of Premarin vaginal cream (prescription medication) in the cupboard of patient care room D8. Per interview with Clinical Services Manager BB at the time of discovery, patients would be left unattended in this room allowing the patients potential access to the drug. Clinical Services Manger BB also stated the Premarin should be kept in the sample drug room.

During interview on 8/25/14 at 1:00 PM, CRNA HH stated the Pyxis (automated medication dispensing system) in the OR rooms contains multi-dose vials of neuromuscular agents which are drawn up in the OR and then replaced in the Pyxis for use on multiple patients. Per Dir of Quality A on 8/26/14 at 4:00 PM, the facility does not have a policy regarding the use of multi-dose vials in patient care areas.

During an interview conducted during a tour of the Pharmacy on 8/26/2014 at 11:35 a.m. Dir of
Pharmacy Q stated that any multi-dose vials are to be dated for a 28 day expiration and are kept in the Pyxis in a common drawer to be accessed in the medication room. Dir of Pharmacy Q could not recall any medications in the anesthesia carts that would be for multiple patients.



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Example in Radiology:
During observation of the radiology department on 8/25/2014 at 3:25 p.m., accompanied by Dir N, the digital fluoroscopy room was found to contain an open, undated bottle of barium sulfate tablets. The manufacturer expiration date on the bottle was 3/2014. Dir N stated that radiology staff is responsible to ensure that medications used for patients is not expired.

Based on record review and interview, this facility failed to follow its medication error reporting policies evidenced by failing to report medication errors that reached the patient to the physician in 4 out of 10 out of 20 in-patient medication error reports reviewed from 3/2013-4/2014.

Findings include:

The facility's policy titled, "Medication Errors," dated 5/2014, was reviewed on 8/27/2014 at 11:25 a.m. The policy states in part, "The patient's physician shall be notified for follow-up any time the patient receives and consumes a medication in error."

In another policy titled, "Medication Errors," dated 4/30/14 (reviewed 8/27/2014 at 11:30 a.m.), the policy states in part, "The person discovering the error or the nursing or pharmacy supervisor shall notify the patient's physician of the error immediately."

In an interview with Quality Dir A on 8/27/2014 at 10:30 a.m., during the time the medication error reports were reviewed, Dir A stated that it is the expectation of this facility that the policies be followed and that physicians are notified of medication errors that reach the patient. Medication omissions are not addressed in either policy.

A random sampling of Medication Error reports from 2013 and 2014 were reviewed on 8/27/2014 at 10:30 a.m. The following are examples of medication administration errors not reported to physicians:

A report filed by the pharmacy on 4/19/13 states that from 4/16/13-4/18/13 a 76 year old patient was given an extra dose of a medication called Tussionex (a cough medicine with a narcotic additive) every day for three days until the error was caught. The report indicates that the physician was not notified.

A report filed by the pharmacy states that on 5/29/13 nursing gave Seroquel IR (a medication for the psychiatric disorder of bi-polar and/or schizophrenia which is immediate release) to a patient instead of the ordered Seroquel XR (extended release) to a patient and the physician was not notified of the wrong drug given to the patient.

A report filed by nursing indicates that on 8/18/2013 the medication dispensing system was stocked with the wrong IV solution and a bag of 0.45% normal saline was hung on a 73 year old patient instead of the ordered 0.9% normal saline. The physician was not notified of the error.

A report filed by nursing indicates that on 9/14/13 a nurse gave MS Contin (a time released form of Morphine, an opioid based narcotic pain reliever) to a 73 year old patient instead of Oxycodone (also known as Percocet, another opioid based narcotic pain reliever which is not time released). The physician was not informed of this error.

The remainder of the reports (six of them dated 12/19-12/20/2013, 4/28-29/2013, 1/6/2014, 1/15/2014, 3/5/2014, and 3/12/2014) were all reports of medications that were omitted and the physician was not notified. The medications were either incorrectly ordered and therefore did not generate a proper order in the facility's electronic system and the patient did not receive the medication, or the medication was not given to the patients as ordered by the physicians.

Quality Dir A confirmed that these medication error reports do not indicate the physician was notified after reviewing the reports on 8/27/14 at 11:20 a.m.

Based on observation, record review, and staff interview, this facility failed to follow its policies and procedures and the recommendations of nationally recognized professional standards of practice evidenced by failing to maintain an environment that was free from potential contaminants to patient, staff, and/or visitors in 8 out of 11 departments observed (Primary Care Cllinic, Surgery, Decontamination, Med/Surg, Laundry, ER, OB, and RT) and 2 out of 10 employee health files reviewed (staff J, II). Failure to maintain an environment free from potential contamination affects all patients, staff and visitors in the facility, including the averaged 5 inpatients during the course of the survey.

Findings include:

In an interview with IPC C on 8/25/2014 at 9:30 a.m. regarding which standards of practice this facility follows for infection control, IPC C stated that the facility follows the recommendations from APIC, CDC, AORN, and AAMI.

Per facility Policy and Procedure titled: "Health Screening Requirements for New Employees", dated 12/2010, last reviewed 03/31/2014, under catagory II Policy: "(A) All prospective employees will have a pre-employment health assessment prior to the assumption of duties. Under catagory III Procedure: (D) The safety coordinator or designee will complete the health assessment by reviewing the health screening questionnaire and the immunization records, (G) If the prospective employee is unable to prove immunity, titers will be offered and drawn, (H) If the prospective employee demonstrates a non-immune status appropriate immunizations will be offered, (I) If the prospective employee chooses not to have the titer(s) drawn or the immunzations(s) administered, a Health Services Declination Form will be signed."

A review on 8/27/2014 at 7:45 a.m. of facility policy "Handling Soiled Linen" dated 08/09 states that the following items are laundered internally using a "hot water wash, hi-efficiency detergent, and bleach if needed": all baby clothes; all scrubs owned by facility; dietary dishrags, towels and aprons; sheets, pillowcases, mattress pads and spreads used by sleep study; lab coats; patient clothing; privacy curtains; microfiber mops and cleaning rags. The policy fails to define "hot water wash" and "hi-efficiency detergent".

Per the CDC guidelines for Environmental Infection Control in Health Care Facilities,
"Laundry equipment should be used and maintained according to the manufacturer's instructions to prevent microbial contamination of the system." The guideline goes on to state, "The antimicrobial action of the laundering process results from a combination of mechanical, thermal and chemical factors."

Review on 8/25/14 at 3:30 PM of facility policy titled "Hand Hygiene" dated 1/26/14 reveals in part, "Hand hygiene is indicated at the following times: ... 3) after handling inanimate items/equipment in the vicinity of the patient"

Per review on 8/25/14 at 2:00 PM, of facility policy titled "Surgical Suite Cleaning Procedure" dated 2001 it states in part, "C. a. Thoroughly clean all furniture and equipment by wiping all surfaces. Per interview with Surgical Services Manager G on 8/25/14 at the time of the policy review, Surgical Services Manager G stated items on the open shelves are not able to be cleaned as part of the terminal cleaning and should be in a closed cabinet.

Per review of facility policy on 8/25/14 at 3:45 PM titled "Reprocessing of Endoscopic Equipment" undated, it states "1. Proper handling of scopes is necessary to prevent damage ... 2. Do not coil or bed scopes. 3. Prevent scopes from dragging on the floor or falling."

Observations in ER:
During a tour of the ER on 8/25/2014 at 2:10 p.m. accompanied by DON F, it was observed that an uncovered trash can, approximately 3 feet high, in Bay 1 was half full of trash (paper, used gloves). ER staff confirmed there had not been an ER patient in that bay all day but that ambulatory care had been using that room for IV starts for surgical patients earlier during the day. According to the ER staff, trash is emptied once per shift by the CNAs, or as needed if the CNA thinks it should be emptied.

Observations in OB:
During a tour of the OB unit on 8/25/2014 at 2:50 p.m. accompanied by DON F and Mgr D, it was observed that a bottle of ultrasound gel was sitting at the bedside in an unoccupied room. The bottle had the manufacturer name of "Aquasonic Ultrasonic Transmission gel".
Per interview with Mgr D on 8/25/2014 at 2:50 p.m., D stated that the staff refill the gel bottles and do not discard them or clean them when empty.
In the next room (room 146) there were two clear bottles at the bedside with no manufacturer labeling and no indication of what was inside. One of the bottles had the push top cover open allowing the contents to be opened to the air. Mgr D stated they were ultrasound gel bottles but that they were not marked.

Observations in RT:
During a tour of the RT area on 8/26/2014 at 1:20 p.m. accompanied by RT Mgr S it was observed that in one of the sleep study rooms a red biohazard plastic bin was on the counter. Per RT Mgr S, this bin contained clean face masks used for patients who would be having sleep studies. When questioned about the cleanliness of these masks and how staff would know if they were clean being in a biohazard bin, Mgr S stated, "I never even thought about the bin before."


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Observations in the Surgical Department:
On 8/25/14 at 11:40 AM RN I was observed opening sterile packages. RN I then moved a rolling trash container and continued to open sterile packages without the benefit of hand hygiene.

On 8/25/14 at 11:50 AM ST J was observed opening sterile packages. ST J then moved a rolling trash container and continued to open sterile packages without the benefit of hand hygiene. Per interview at the time of the observation, ST J stated it would not be necessary to perform hand hygiene between touching contaminated objects and opening sterile packages as long as the sterility of the items packaged was not compromised.

Per interview on 8/25/14 at 11:55 AM, Surgical Services Manager G stated that hand hygiene should be performed after touching the garbage bin and that further education may be needed.

During a tour of the Surgical Department on 8/25/14 at 10:15 AM the following observtions were made: 1) holes and gouges in the plaster on the walls in OR 1 and OR 3 leaving these surfaces un-cleanable, 2) open shelves on the back wall in OR 1 and OR 3 containing anesthesia supplies, lotion, tubing and other miscellaneous items.

Per interview on 8/25/14 with Housekeeper L at 12:30 PM, Housekeeper L stated the items on the open shelves are not cleaned as part of the terminal cleaning but rather the shelve itself is wiped down. Housekeeper L stated they were instructed to leave those items untouched.

Observations in Decontamination/Sterilization Department:
During a tour of the Decontamination area on 8/25/14 at 10:10 AM, observations of the Steris 1E machine (high level disinfectant endoscope cleaning machine) in the sterile packaging room and the scope flush in the dirty/decontamination room were made. When asked how the scopes are transported from the decontamination room to the scope cleaning machine in the sterile packaging room, Surgical Services Manager G stated they are carried uncovered by staff through the surgical hallway past the sterile packaging table.

Per interview on 8/27/14 at 9:00 AM, the Infection Prevention Coordinator C stated that the scopes should be covered or in a container during transport from room to room to prevent contamination.

Observations in the Primary Care Clinic:
On 8/26/17 during at tour of the Primary Care Clinic at 2:30 PM, accompanied by Clinical Service Manager BB, VP of Clinical Services CC, and Dir of Quality A, it was observed that there were files containing patient education materials stored under the sinks in all 45 patient rooms. Per interview with Dir of Quality A at the time of discovery, Dir of Quality A stated nothing should be stored under the sink and the items will be removed.


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Other observations in the outpatient clinic on 8/26/2014 at 2:25 p.m. were: 3 tubes of opened, undated antibiotic ointment were found in patient rooms D-5, D-7 and D-9. Mgr BB stated that the tubes were used for multiple patients and was unable to confirm if the tubes were intended for single patient use.

Observations in Med/Surg Nursing unit:
During observation of the Med/Surg unit on 8/25/2014 at 2:05 p.m., accompanied by Mgr D, the ante room (storage room in the Med/Surg hallway) was found to contain the following supplies: an open, unlabeled tube of denture adhesive cream, an unpackaged toenail clipper, electric razor and curling iron. Mgr D stated that denture cream is intended for single patient use and "should be thrown out." Mgr D stated that it is hospital policy that if fingernail or toenail clippers are used on a patient the items are sterilized, packaged and returned to the floor to be used again and that an open, unpackaged toenail clipper "should not be" available for use on the floor. Mgr D stated that the procedure for cleaning multi-patient items, such as the razor and curling iron, is to wipe the items down with anti-septic wipes in between patients. Inspection of the equipment revealed multiple pieces of hair attached to the curling iron. This finding was shared with Mgr D. The facility was not able to produce a policy or procedure for the cleaning multi-patient items. The Med/Surg tub room was observed on 8/25/2014 at 2:15 p.m. and was found to contain an open, unlabeled tube of toothpaste on the table. Dir D stated, "Toothpaste is also considered a single patient use item."

Observations in Laundry Services:
The laundry facilities were observed on 8/26/2014 at 2:05 p.m. accompanied by Mgr GG. The facility uses residential-grade washer, dryer and detergent for internal laundering. Mgr GG stated that it is "difficult to monitor" the water temperature of the washer and could not ensure that the temperature reached an antimicrobial level during washings. Mgr GG stated that there was not a protocol in place to ascertain an adequate or appropriate antimicrobial ratio for detergent or bleach, and that the detergent and bleach were added to the machine "not above the max fill line." There is no system in place to ensure that the mechanical, thermal and chemical mechanisms used are adequate to ensure an antimicrobial effect on linens laundered within the facility.

The laundry room has one point of entry and exit. Upon entering the laundry room, soiled linens were bagged on the left side of the entry. Exposed soiled linens were to the right upon entry. Removing clean linens from the room would require passing soiled linens on each side of the exit, increasing the potential for cross-contamination.

During an interview on 8/27/2014 at 9:10 a.m., IPC C stated that the facility could not provide evidence that the detergent used was adequate to kill microbes and was unable to confirm whether or not the laundry detergent used at the facility was reviewed and approved by the infection control committee.


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Employee Health Files:
On 08/26/2014 at 10:00 AM, a review of employee health documents revealed Staff J, employed at this facility since 08/21/2006, did not furnish appropriate documentation of infectious disease titers or immunizations required for employment. Per interview with Staff C, ICP stated: "[Staff J] was found not to be immune to Rubella when drawn in 2006. I followed employee health files and looked for immunity to Rubella, for people I found that didn't have documentation, I had titers drawn, and [Staff J] is one that was missed." Quotation validated by Staff V on 08/26/2014 at 10:10 AM.

On 08/26/2014 at 10:15 AM, review of Staff II, employed since 07/23/2012, employee health file revealed a missing Hepatitis B vaccination or declination. Per interview on 08/26/2014 at 10:20 AM, Staff C stated: "Hepatitis B requirement is in the letter of employment application, if they have come without anything, you then ask for a declination of Hepatitis B to be provided, I failed to follow up with [her] to get those records." Quotation validation by Staff V on 08/26/2014 at 10:20 AM.

Based on observation, record review and interview, the facility failed to follow proper food storage precautions in 3 of 3 departments with food storeage areas out of a total of 11 departments observed (Med/Surg, ER, Kitchen).

Findings include:

Review on 8/26/2014 at 3:30 p.m. of facility policy "Storage of Food and Supplies" dated 8/15/2013 states in part "All products shall be labeled and dated or thrown away in 24 hours if not dated...refrigerated raw foods are stored below prepared foods...prepared foods in dry or refrigeration storage are in closed bags, wrappers, or sealed containers..."

The facility's adopted food storage guidelines "Food Keeper A Consumer Guide to Food Quality & Safe Handling" (a publication developed by the Food Marketing Institute) was reviewed on 8/26/2014 at 3:30 p.m. The Food Keeper brochure details expiration dates for a variety of foods, both opened and unopened, for storage in pantry, refrigerator and freezer.

Med/Surg observations:
During a tour of the medical-surgical nursing department kitchenette on 8/25/2014 at 2:05 p.m. accompanied by RN Mgr D, the kitchenette refrigerator contained undated prepared jello containers and 4 open, undated bottles of flavored syrups. An opened, undated loaf of bread was on the counter in the kitchenette. RN Mgr D stated that the flavored syrups were used to flavor ice chips for patients on a clear liquid diet and that the jello and bread are supplied by the dietary staff.

Kitchen observations:
On 8/26/2014 at 12:00 p.m., observations made in the facility kitchen include a box of open rice with an unsealed plastic bag over the top of the box and an undated plastic container of opened pasta. The kitchen freezer contained an undated, unlabeled plastic bag of shredded cheese and an undated, unlabeled plastic bag of hamburgers. Dietary Director X and Dietary Supervisor Y were unable to verbalize the recommended time frame for how long these foods could safely be stored in the freezer or how long the rice and pasta could safely be used after opening. The kitchen refrigerator contained a plate with beef steaks. Director X stated that the steaks were thawing in the refrigerator. A plate of prepared food covered in plastic wrap was on the shelf directly below the thawing beef steaks.

During an interview with Dietary Director X and Dietary Supervisor Y on 8/26/2014 at 11:45 a.m., Director X stated that all opened foods should be dated according to policy. When asked if the dates would indicate the date the food product was opened or the date in which the food product was no longer safe to consume after opening, Director X and Supervisor Y stated that the facility did not have a system to identify how long the food products were viable after opening and dating.


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ER observations:
During a tour of the ER on 8/25/2014 at 2:10 p.m. accompanied by DON F, in the kitchenette a partially used bag of bread was found opened and undated. When ER Mgr B was asked about this at 2:35 p.m. on 8/25/2014, Mgr B stated that same day surgery uses that bread to make toast post-operatively for patients.
Also found in the cabinet in the kitchenette was an almost empty can of liquid thickener (Thick and Easy, used to thicken liquids for people with swallowing disorders). There was no date to indicate when this product was opened.

DON F confirmed these findings at the time of discovery during the tour.

Based on record review and staff interview, the facility failed to ensure that nursing plans of care are developed and updated in accordance with patient's individualized needs in 8 of 18 patient care plans out of a total of 25 MR reviewed (Pt. #4, 6, 8, 9, 12, 15, 16, and 22).

Findings include:

Facility policy "Inpatient Care Standards" dated 4/1/2014 was reviewed on 8/26/2014 at 4:00 p.m. The policy states in part, "Patients are provided individualized nursing care which includes physical, psychosocial, educational and spiritual care based on his/her needs...the registered nurse(s) providing care will develop and maintain a plan of care with expected outcomes...the plan of care will be evaluated and updated as needed."

Pt. #4's MR was reviewed on 8/26/2014 at 8:50 a.m. accompanied by HIM Mgr O, who confirmed the following findings: Pt. #4 was admitted to the facility for bowel surgery. A general surgery care plan was developed upon admission in accordance with the patient's needs. During the course of Pt. #4's 10 day hospitalization, the patient suffered from prolonged postop ileus and general deconditioning. Power of Attorney was activated during the hospitalization and the patient was discharged to swing bed with potential plan for palliative care. Pt. #4's care plan failed to reflect any post-surgical complications, the activated power of attorney or the need for discharge to swing bed.

Per Pt. #6's MR review on 8/26/2014 at 10:18 a.m. accompanied by HIM Mgr O, who confirmed the following findings: Pt. #6 was admitted to the facility for "pain management." Initial nursing assessment documented the patient reporting constant pain at a level of 8/10. Pt. #6's plan of care failed to include a plan for pain.



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Per review of Pt # 8's MR on 8/26/14 at 8:00 AM accompanied by Medical Records Manager O, noted Pt #8 had an admitting diagnosis of back pain and was receiving pain medications and interventions. The care plan for Pt #8 does not reflect any pain management goals or interventions.

Per review of Pt # 9's MR on 8/26/14 at 8:40 AM accompanied by Medical Records Manager O, noted Pt #9 had an admitting diagnosis of abdominal pain and was receiving pain mediations and interventions. The care plan for Pt #9 does not reflect any pain management goals or interventions.

Per interview with MR Manager O on 8/26/14 at 8:50 AM, MR Manager O stated that the nursing staff should have added the goals and interventions under the pain care plan.


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A MR review was conducted on Pt. #12's closed OB record on 8/26/14 at 2:44 p.m. accompanied by RN Z. Pt. #12 had a cesarean section (surgical removal of the baby through the abdominal wall) however Pt. #12 had a vaginal delivery post-partem (after delivery) pathway for a care plan. In an interview at the time of these findings with RN Z, Z stated that the pathways are from the old computer system and were unable to be individualized.

A MR review was conducted on Pt. #15's closed newborn record on 8/26/2014 at 3:55 p.m. accompanied by RN Z. Pt. #15 had no care plan in the MR. In an interview with RN Z during the MR review, RN Z stated, "There are no care plans for babies.

A MR review was conducted on Pt. #16's closed newborn record on 8/26/2014 at 4:12 p.m. accompanied by RN Z. Pt. #16 had a generic newborn "pathway" (protocol for newborn babies) which was not individualized to the patient. RN Z confirmed this finding.

A MR review was conducted on Pt. #22's open OB record on 8/27/2014 at 9:03 a.m. accompanied by RN AA. Pt. #22 had a "General POC [plan of care]" when admitted to the unit. The general POC lists the following generic, non-individualized goals, "The patient and/or their representative will communicate an understanding of their plan of care...The patient and/or their representative will achieve their patient-specific goals related to the plan of care." There are no interventions and the care plan does not list what the patient's POC is so staff can evaluate the patient's understanding. In an interview with RN AA about this care plan, RN AA stated, "I just know what the POC is."
Pt. #22, who gave birth on 8/25/2014, did not have a post-partum care plan addressing the needs of a patient after they give birth. This was confirmed by RN AA during the MR review on 8/27/2014 at 9:03 a.m.

Based on record review and staff interview, this facility failed to maintain a complete and accurate record evidenced by 1. Failing to establish a chronological timeline for 1 of 2 SA patients in ER (Pt. #17) out of a total of 25 MR reviewed; 2. Failing to document proper identification upon discharge of newborns for 2 of 2 newborns discharged from OB (Pt. #14 and 15) out of a total of 25 MR reviewed; and 3. Failing to document pain reassessments per policy after pain interventions were needed for 3 of 6 patients (Pt. #8, 9, and 13) out of a total of 25 MR reviewed.

Findings include:

Per review on 8/26/14 at 3:40 PM of facility policy titled "Pain Management" dated 2/2013 it states "Pain is reassessed after interventions have reached their peak or anticipated effect (i.e. 15-30 minutes after parenteral drug therapy, 1 hour after oral analgesia and 30 minutes after non-pharmacological intervention.)"

Chronological time line
A MR review was conducted on Pt. #17's closed SA record on 8/26/2014 at 8:32 a.m. accompanied by Quality Dir A who confirmed the following finding: Pt. #17 is documented as arriving to the ER on 7/5/14 at 3:03 a.m. The ER RN triaged Pt. #17 at 3:05 a.m. The ER MD saw Pt. #17 at 3:43 a.m. The SA RN is documented as doing Pt. #17's SA assessment at 1:50 a.m. A time frame of approximately an hour and 10 minutes before Pt. #17 is documented as arriving at the ER. The ER timeline is not chronological and the documentation does not support the time discrepancies.

These findings were reviewed with ER Mgr B on 8/27/2014 at 9:00 a.m. who stated B was unable to determine the time discrepancy from the MR documentation.


Proper identification for newborns
A MR review was conducted on Pt. #14's closed newborn record on 8/26/2014 at 4:12 p.m. accompanied by RN Z who confirmed the following findings: There is no documentation in the MR regarding matching identification numbers between Pt. #14 and the parent indicating that the newborn was released to the correct parent. In an interview with RN Z during the MR review, RN Z stated that when Z discharges a newborn to a parent, RN Z documents the baby's identification number from the hospital band and the mother's identification number to be able to verify that the right baby is being discharged with the right mom.

A MR review was conducted on Pt. #15's closed newborn record on 8/26/2014 at 3:55 p.m. accompanied by RN Z who confirmed the following findings: There is no documentation in the MR regarding matching identification numbers between Pt. #15 and the parent indicating that the newborn was released to the correct parent.

In an interview with Quality Dir A on 8/27/2014 at 8:45 a.m. regarding documentation of matching identification bands between mom and baby on discharge, Dir A stated that staff should be documenting that the bands match in the MR.

Pain reassessments
A MR review was conducted on Pt. #13's closed OB record on 8/26/14 at 3:20 p.m. accompanied by RN Z who confirmed the following findings: Pt. #13 had a pain assessment on 6/28/14 at 5:36 p.m. At that time Pt. #13's pain was rated at 7 on a 0-10 scale, medication was administered and reassessment was due at 6:07 p.m. according to the MR. Pt. #13's pain was not documented as being reassessed until 8:08 p.m. (2 1/2 hour time span).
On 6/29/14 Pt. #13 had a pain assessment with pain rated as a 4 on a 0-10 scale at 12:30 p.m. Ibuprofen was administered and the next pain reassessment after this intervention is documented at 3:00 p.m. (2 1/2 hour time span) where the pain is documented as being a 3 and Percocet (a narcotic pain reliever) was given. The next pain reassessment after this intervention is documented at 8:28 p.m. (5 1/2 hour time span).

RN Z agreed that these assessments were not conducted in a timely manner


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Per review of Pt #8's MR on 8/26/14 at 8:00 AM accompanied by HIM Mgr O who confirmed the following findings: Pt #8 received Toradol IV and Oxycodone orally (pain medication) on 8/26/14 at 5:16 AM. No pain assessment is documented at the time of administration or within 30 minutes after administration to evaluate the effectiveness of the medication.

Per review of of Pt #9's MR on 8/26/14 at 8:40 AM accompanied by HIM Mgr O who confirmed the following findings: Pt #9 received Hydromorphone IV (pain mediation) on 8/24/14 at 4:16 PM and on 8/25/14 at 1:58 AM. No pain assessment is documented at the time of administration or within 30 minutes after administration to evaluate the effectiveness of the medication.

During interview on 8/26/14 at 3:45 PM, Dir of Quality A stated pain assessment and reassessment should be documented within 30 minutes to 1 hour after pain medication is given as per policy.

Based on record review and staff interview this facility failed to obtain a properly executed consent form that contains date, time, and witness signature for 11 out of 25 MRs with general consents for treatment (Pt. #1, 6, 7, 8, 9, 10, 12, 13, 14, 17, and 22) and 2 out of 6 MRs with surgical/anesthesia consents out of a total of 25 MR reviews (Pt. #13 and 15).

Findings include:

The facility's policy titled, "Informed Consent Policy," dated 3/1/2014, was reviewed on 8/27/2014 at 8:40 a.m. The policy addresses general consents for care as well as surgical consents. Regarding general consents the policy states that all patients are required to have one for each inpatient or outpatient encounter at the facility, and that the form will be signed prior to receiving treatment except in the cases of emergent need for treatment. The policy does not address the requirement of dating, timing, or a facility representative signing the general consent.

Regarding the documentation of Informed Consent (surgical consents), the policy states, "A [facility] employee who observes the patient signing the form may verify that fact by signing the informed consent form as a witness to the signature."

A MR review was conducted on Pt. #12's closed OB record on 8/26/14 at 2:44 p.m. accompanied by RN Z who confirmed the following findings: Pt. #12 was admitted to the facility on 5/8/14. There is a general consent to treat dated 5/7/14 and one for 5/8/14. Neither of these consents have the time they were signed or a signature from a witness from the facility. RN Z stated Z did not know why there would be a consent dated for 5/7/14.

A MR review was conducted on Pt. #13's closed OB record on 8/26/14 at 3:20 p.m. accompanied by RN Z who confirmed the following findings: Pt. #13 did not have a general consent for treatment on file. The surgical consent and anesthesia consent did not have the times that the patient, provider, or witness signed them.

A MR review was conducted on Pt. #22's open OB record on 8/27/14 at 9:03 a.m. accompanied by RN AA who confirmed the following findings: Pt. #22's consent was not yet scanned into the MR (admitted 8/25/14). A copy of the consent from HIM, obtained 8/27/14 at 10:30 a.m., revealed that the consent did include signature, date, and time of the patient but the date was 8/26/14 not the admission date, and the consent was not signed by a facility representative. Quality Dir A confirmed this finding on 8/27/14 at 10:30 a.m.

A MR review was conducted on Pt. #14's closed newborn record on 8/26/2014 at 4:12 p.m. accompanied by RN Z who confirmed the following findings: Pt. #14 was born on 5/8/14. The general consent to treat does not have the time it was signed by the parent and there is no facility representative signature, date, or time.

A MR review was conducted on Pt. #15's closed newborn record on 8/26/2014 at 3:55 p.m. accompanied by RN Z who confirmed the following findings: Pt. #15 had a circumcision on 6/29/14. The consent does not have the time it was signed by the parent or provider and the time on the line for the witness is also missing however there is a time written below the line for the witness's time entry. RN Z stated Z did not know what that time would signify.

Pt. #17's closed SA MR was reviewed on 8/26/14 at 8:32 a.m. accompanied by RN Z who confirmed the following findings: Pt. #17's general consent for care does not include a time the patient signed or date, time or signature of a facility representative.


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Pt. #7's open inpatient MR was reviewed on 8/26/14 at 7:40 AM accompanied by HIM Mgr O who confirmed the following findings: Pt. # 7's general consent for care does not include a time it was signed or a date, time or signature from a facility representative.

Pt. #8's open inpatient MR was reviewed on 8/26/14 at 8:00 a.m. accompanied by HIM Mgr O who confirmed the following findings: Pt. # 8's general consent for care does not include a date, time or signature from a facility representative.

Pt. #9's open inpatient MR was reviewed on 8/26/14 at 8:40 a.m. accompanied by HIM Mgr O who confirmed the following findings: Pt. # 9's general consent for care does not include a date, time or signature from a facility representative.

Pt. #10's closed inpatient MR was reviewed on 8/26/2014 at 9:45 AM accompanied by HIM Mgr O who confirmed the following findings: Pt. # 10's general consent for care does not include a time it was signed or a date, time or signature from a facility representative.


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Pt. #1's consent for treatment, reviewed on 8/27/2014 at 11:55 a.m., was signed, dated and timed by the patient. The consent was not authenticated by a staff witness signature.

Pt. #6's consent for treatment, reviewed on 8/27/2014 at 11:55 a.m., was signed, dated and timed by the patient. The consent was not authenticated by a staff witness signature.

The lack of authentication by a facility witness on these consents was confirmed by Quality Dir A on 8/27/2014 at 11:55AM.

Based on record review and interview this facility failed to follow its policies to ensure there was a history and physical completed and in the MR for 1 out of 2 OB patients out of a total of 25 MR reviews (Pt. #12).

Findings include:

The facility policy titled, "Completion of Medical Records," dated 7/31/2014, was reviewed on 8/27/2014 at 7:35 a.m. The policy states in part, " history and physical examination shall be completed and placed on the chart within twenty-four (24) hours of inpatient admission...An operation or potentially hazardous diagnostic procedure, except in an extreme emergency, shall not proceed unless the history and physical examination has been completed and placed on the record.

A MR review was conducted on Pt. #12's closed OB record on 8/26/14 at 2:44 p.m. accompanied by RN Z. Pt. #12 was admitted on 5/8/14 for a repeat cesarean section. The history and physical on Pt. #12's chart is the first pre-natal visit to the physician dated 10/1/2013. Pt. #12 was an inpatient for 2 days and went to surgery without an updated history and physical on the chart. In an interview with RN Z during the MR review, RN Z stated that the first pre-natal office visit to the physician should not be considered a history and physical for this patient.

Based on record review and staff interview, this facility failed to ensure that all services affecting patient care are evaluated and included in the overall Quality plan for the facility in 2 of 4 contracted services reviewed (Nuclear Medicine and CRNA services). Failure to evaluate all services for quality of care has the potential to affect all patients receiving care in this facility. The average daily inpatient census during the survey was 5.

Findings include:


In an interview with Quality Dir A on 8/25/2014 at 10:15 a.m. regarding the contracted nuclear medicine service which is overseen by Radiology Mgr N. Quality Dir A stated that this contracted service does do tracking and trending of QI data and Mgr N receives reports from them that go on Radiology's dashboard (tracking tool for aggregated data), however Quality Dir A is not provided with this information. Quality Dir A stated that the same is also true for the contracted CRNA services in this facility. The data for CRNA services goes to the surgery department.

Quality Dir A stated that the data submitted by the contracted services of Nuclear Medicine and CRNA services are not reviewed at the Quality committee for safety and effectiveness.

A review of the Quality binder for the facility was completed on 8/25/2014 at 11:45 a.m. No data for Nuclear Medicine or CRNA services was found.

Based on record review and staff interviews this facility failed to include all of the required contents for the discharge/transfer notice in the information they provide prior to discharge/transfer to 2 of 2 swing bed patients (Pt. #24 and 25). Failure to provide all of the required information to swing bed patients upon discharge/transfer has the potential to affect all swing bed patients served at this facility. There were 0 swing bed patients present during the course of the survey.

Findings include:

A review of the packet given to swing bed patients upon admission was reviewed on 8/26/2014 at 7:30 a.m. There was no information related to the discharge/transfer notice in the packet.

An interview regarding the swing bed program at this facility was conducted with RN CM R, PT Mgr FF, DON F, and Quality Dir A on 8/26/2014 at 11:00 a.m. Regarding the discharge/transfer notice, RN CM R stated that patients are given the Notice of Medicare Non-Coverage two days prior to discharge by the case management department.

A review of the Notice of Medicare Non-Coverage, completed on 8/27/2014 at 7:33 a.m. revealed that this notice does not contain the reason for discharge/transfer, the location of where the patient is being discharged/transferred to, contact information for the long term care ombudsman, office of developmental disabilities, or mental illness as appropriate. These findings were confirmed by Quality Dir A on 8/27/2014 at 7:40 a.m.

A MR review was conducted on Pt. #24 and #25's closed swing bed record on 8/27/2014 between 8:38 a.m. and 10:00 a.m. accompanied by HIM Mgr O who confirmed these findings at the time of the MR review.
There was no discharge/transfer notice in Pt. #24 and #25's MRs that included the reason for discharge/transfer, the location of where the patient is being discharged/transferred to, or contact information for the long term care ombudsman.