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Based on tour of the facility with several of the facility staff between June 30th to July 2nd, 2014; this surveyor observed that the hospital failed to be constructed, arranged, or maintained to ensure the safety of the patients. The cumulative effects of these environmental problems resulted in the hospital's inability to ensure a safe environment for the patients. The Existing Health Care Occupancy chapter of the Life Safety Code (2000 Edition) [NFPA 101] was used for this survey.

42 CFR 485.623: Condition of Participation: Physical Plant is NOT MET.

K-tags cited were as follows:
K-17: Corridors smoke-tight
K-25: Smoke compartments built as one-hour
K-29: Hazardous areas built as one-hour
K-56: Sprinkler system installed per NFPA 13

These deficient practices were confirmed by observation and interview with Staff F (Facilities Director), Staff G (Construction Director), Staff I (Facilities Maintenance Specialist) and Staff H (Regional Safety Coordinator) at the time of discovery.

Based on observation, record review and interview, the facility failed to properly label and store biohazard waste in 1 of 1 hazardous waste storage areas (outdoor gated generator area). This deficiency could potentially affect all employees and patients at this facility.

Findings include:

Per review of facility policy on 7/2/2014 at 8:30 AM titled "Waste Management and Recycling" dated 10/2/2013 it states under Hazardous Waste "Collect hazardous waste, including medication waste, in containers specifically labeled for hazardous waste." It further states "g. lock hazardous waste in storage rooms and limit access to authorized personnel only."

During a facility tour on 7/1/2014 at 8:50 AM, accompanied by EVS supervisor O, ED Dir A and Facilities Maintenance Specialist I, noted four covered barrels placed next to the generator outside in a locked/gated area. Two of the barrels were red and marked biohazard. Two barrels were gray and un-marked. When asked what was inside the un-marked barrels, Facilities Specialist I opened the bin and stated "red bags which would indicate biohazard materials". When asked why the biohazard materials were in an un-marked barrel that is a different color from the other biohazard barrels, Facilities Specialist I explained that the barrels are provided by the contracted company for their biohazard waste and was unsure why they are not all labeled and colored the same. Facilities Specialist I further explained the barrels are placed in this area for pick up by the contracted company. All four barrels were outside collecting rain.

Per review on 7/2/2014 at 8:15 AM the facility contract with Stericycle, Inc., the contracted service used for hazardous waste removal, it states "the generator is solely responsible for properly segregating, packaging and labeling of regulated medical waste."

Per interview on 7/22/2014 at 9:20 AM with Regional Safety Coordinator H and Safety Coordinator P via phone conference, after Safety Coordinator P review of Wisconsin Code, P stated the biohazard containers should be stored in an enclosed building where infectious waste in not exposed to weather and must be visibly labeled with the bio-hazard emblem.

Based on tour of the facility with several of the facility staff between June 30th to July 2nd, 2014; this surveyor observed that the hospital failed to be constructed, arranged, or maintained to ensure the safety of the patients. The cumulative effects of these environmental problems resulted in the hospital's inability to ensure a safe environment for the patients. The Existing Health Care Occupancy chapter of the Life Safety Code (2000 Edition) [NFPA 101] was used for this survey.

42 CFR 485.623 (d)(1) Standard: Life Safety from Fire is NOT MET

K-tags cited were as follows:
K-17: Corridors smoke-tight
K-25: Smoke compartments built as one-hour
K-29: Hazardous areas built as one-hour
K-56: Sprinkler system installed per NFPA 13

These deficient practices were confirmed by observation and interview with Staff F (Facilities Director), Staff G (Construction Director), Staff I (Facilities Maintenance Specialist) and Staff H (Regional Safety Coordinator) at the time of discovery.

Based on observation, record review and interview the facility failed to ensure a safe and sanitary environment to prevent and control the potential spread of infection in 4 of 8 areas observed (ED, Surgery Department, laundry/linen department, kitchen). This deficiency has the potential to affect all 10 patients being served at the time of the survey.

Findings include:

Examples in Surgery Department:

Per review of facility policy on 7/2/2014 at 10:00 AM titled "Cleaning the OR Room" dated 12/12/2013 it states "Terminal Cleaning.... b. The equipment and areas that should be included, but not limited to are: Surgical lights and light arms, All furniture and equipment in the room, wall mounted fixtures..."

During a tour of the PACU on 7/1/2014 at 12:30 PM, accompanied by Surgery Dir R, noted two Yankauer suction heads (a tool used to suction oral secretions) opened and attached to the suction canisters. Per interview with Surgery Dir R at the time of discovery the Yaunkauer suction heads should be in the packaging to prevent contamination.

During a tour of the OR suite on 7/1/2014 at 12:20 PM, accompanied by Surgery Dir R, noted racks hanging in the OR suite containing approximately 30 cardboard boxes of suture material. When asked how the suture material on the rack are cleaned during the OR terminal cleaning process, Surgery Dir R stated they are not able to be cleaned.

Examples in ED:

During a tour of the ED on 06/30/14 at 3:00 PM with ED Dir A, clean supplies were found to be stored in a dirty utility room. 30 new suction containers and their lids were observed stored on a shelf in the ED dirty utility room. ED Dir A stated at the time of the observation that clean supplies should not be kept in the dirty utility room.


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Examples in Laundry/linen department:

Per review on 7/2/2014 at 10:20 AM of facility policy titled "Laundry and Linen Handling Guidelines" dated 10/13 it states "All clean linen should be stored and transported in carts used exclusively for this purpose." it further states "dirty linen should be clearly separated from areas where clean linen is handled. Ventilation air, on the other hand, should flow from the cleanest to the dirtiest areas. All areas should be cleaned on a regular basis."

During a tour of the laundry department on 7/1/2014 at 8:00 AM accompanied by EVS Supervisor O and ED Dir A, noted linen storage room to contain clean linen on uncovered wooden shelves. Also stored among the clean linen were curtain rods, curtain track systems, cardboard boxes containing hangers and other miscellaneous items, a desk/sewing machine. Noted linen storage room is not vented, ceiling tiles are stained, chipped and damaged. Walls noted to have areas of paint missing.

Per interview with EVS Supervisor O on 7/1/2014 at 8:15 AM, Supervisor O stated that items that are not linen are wiped down prior to being stored in the linen storage room. EVS Supervisor O agreed linen should be stored in a clean, restricted environment.

During a tour of the laundry department on 7/1/2014 at 8:00 AM accompanied by EVS Supervisor O and ED Dir A, noted rusted vent pipes and rusted vent grates hanging above washers and dryers. Also noted missing and peeled paint in this area. EVS Supervisor O stated they are looking at a plan to revamp the laundry areas.

Examples in the Kitchen:

During a tour of the kitchen on 07/01/14 at 10:00 AM with Food and Nutrition supervisor L, observed the floor of the 'Garland' holding oven covered with debris and grease. Per interview with Supervisor L at the time of the tour it was stated that ovens are cleaned monthly. Supervisor L was unable to produce documentation of a cleaning schedule.

Based on record review and interview, the facility failed to ensure medical records are secure from unauthorized access in 1 of 2 (HIM Department) areas where medical records are stored. This deficiency potentially affects all patients receiving services at this facility.

Findings include:

Per review on 6/30/2014 at 2:30 PM of P&P titled "Security and Privacy of Patient Information in the HIM Department" dated 12/30/2014 it states "only authorized personnel are permitted within the HIM Department." Per Assistant Admin M on 6/30/14 at 2:35 PM, the facility does not have a policy that addresses record security during cleaning in the HIM department.

On 6/30/14 at 1:30 PM during a tour of the HIM department accompanied by Record Analyst C and Dir of Med/Surg K noted an open shelving unit containing medical records. Per interview with Record Analyst C at the time of discovery, the HIM department is locked when HIM staff are not present. When asked if EVS staff clean department during HIM business hours, Record Analyst C stated EVS staff clean after hours and have a key to the area. Record Analyst C agreed EVS staff would have unsupervised access to any records kept in the HIM area.

Based on record review and interview, the facility failed to document a complete post-anesthesia evaluation prior to patient discharge in 3 of 3 surgical records reviewed (#7, 8, 21) out of a total universe of 23 records reviewed. This deficiency affects all patients receiving anesthesia services at this facility.

Findings include:

Per review on 7/1/2014 at 11:00 AM of facility policy titled "Anesthesia Post Operative Note" dated 1/3/2014 it states "At least one note shall be written within 24 hours after anesthetic is given. Stability of the patents' vital signs, level of consciousness, patient state of mind, and general condition and complications or complaints may be noted, approval for patients to be discharged from hospital noted."

Per review of Pt # 7's MR on 7/1/2014 at 3:15 PM accompanied by RN J revealed the following post-anesthesia note dated 5/16/2014; "No Post Op Anesthesia Comp VSS." The post-anesthesia note does not address cardiopulmonary status, level of consciousness or follow up care and observations.

Per review of Pt # 8's MR on 7/1/2014 at 3:30 PM accompanied by RN J revealed the following post-anesthesia note dated 2/10/14 at 11:15 AM; "No post Op Anesthesia Comp VVS." The post-anesthesia note does not address cardiopulmonary status, level of consciousness or follow up care and observations.

Per review of Pt #21's MR on 7/1/2014 at 4:00 PM accompanied by RN J revealed no post-anesthesia note was written for Pt #21. The post-anesthesia note section was left blank in the MR followed by a signature by CRNA Q and dated 1/9/2014. The entry was not timed.

CRNA Q stated during interview on 7/1/2014 at 10:45 AM "I usually write, vitals stable, no complications but we are currently reviewing our forms to include more information."

Based on record review and interview, the facility failed to document swing bed patients' attendance, interventions and response to swing bed activities program in 2 of 2 swing bed records reviewed (#4, 5) out of a total universe of 23 records reviewed. This deficiency has the potential to affect all swing bed patients receiving care at this facility.

Findings include:

Per review on 7/2/2014 at 10:00 AM of facility policy titled "Required Documentation - Transitions" dated 1/7/2014, it states "Attendance Records, A record of attendance will be maintained on a monthly activity calendar of the patient's participation in the Activity Therapy Program."

Per review on 7/2/2014 at 10:00 AM of facility policy titled "Activity Participation Document" dated 1/7/2014, it states "Completed activity attendance calendar sheets for transitional care unit patients will be shredded after documentation has been entered into the patients medical chart software after patients' completed day."

Per review of Swing Bed Pt # 4's MR on 7/1/2014 at 2:00 PM accompanied by RN J, the MR does not contain documentation of activities attended or offered to Pt #4 or any response to activity interventions.

Per review of Swing Bed Pt #5's MR on 7/1/2014 at 2:30 PM accompanied by RN J, the MR does not contain documentation of activities attended or offered to Pt #5 or any response to activity interventions.

Per interview on 7/2/2014 at 10:55 AM with Activities Director N, each patient is given an activities calendar during the initial activities assessment. Staff note on the activities calendar when swing bed patients attend activities but the calendar is not a part of the MR. Activities staff do not chart activities attended, the patients response or outcomes to activities in the MR at this time.