HospitalInspections.org

Based on record review and interview, the governing body failed to ensure that contracted services were performed in a safe and effective manner, in 5 of 5 contracted services (laundry, housekeeping, organ procurement organization, medical records and laboratory).

Findings include:

During interview on 03/11/2015 at 10:37 AM, CEO N stated, quality improvement processes are reviewed at the MEC meetings. CEO N provided the MEC meeting minutes and stated, the MEC meeting minutes were generalized and titled; "Patient Satisfaction Survey".

During interview on 03/11/2015 at 10:37 AM, Dir. Rehab/Quality T stated, not all contracted services were incorporated into the QAPI program. T also stated, there was no documentation that included rational for projects chosen and approved by the MEC.

1) Laundry
Record review on 03/09/2015 of Policy # 8210.19 - Infection Control Laundry and Linen, last reviewed / revised on 9/2012, states under "4. Commercial linen processing services..., A. The hospital uses a commercial linen processing service. 1. This service agreement is renewed annually with the copy sent to the infection control consultant by the purchasing department. 2. The infection control consultant and materials service personnel do annual inspections of the facility".
During interview with Materials Systems Coordinator H and Building Service Coordinator AA on 3/9/15 at 3:00 PM through 4:00 PM, it was revealed that the hospital had no formalized process of reviewing the contracted services provided by Goodwill (contracted provider). AA stated that visits had been done in the past, but there was no documentation of the visits to verify that Goodwill provides adequate linen sanitation processes, sanitary linen storage processes or sanitary linen transportation services to the hospital. H stated that the hospital had no current or past quality assurance projects or data that are submitted/ reported to the hospitals quality improvement organization as directed by the hospital's governing body.

2) Housekeeping
During interview with Materials Systems Coordinator H and Building Service Coordinator AA on 3/9/15 at 3-00 PM - 4:00 PM, H stated that the hospital uses a contracted service called "Clean power" for its environmental housekeeping. H stated that the hospital has no formalized process for reviewing the contracted housekeeping services provided to the hospital to ensure that cleaning processes are carried out as per documented in the contract.

3) Organ Procurement Organization
During interview with Chief Nursing Officer G on 3/9/15 at 12:30 PM, G states that the nursing department does not have an OPO project that it submits to the hospital's quality improvement organization as directed by the hospital's governing body.

4) Medical Records
During interview with Medical Records Director X on 3/11/15 at 8:45 AM, it was determined that the medical records department did not have a formalized quality assurance project that it submitted to the hospitals quality improvement organization that is directed by the hospital's governing body. Director X states that the medical records department collects data in several areas but uses it internally, such as medical record authentication and medical record completeness to notify physicians who are delinquent. Director X states that this data is collected but not analyzed, measured nor used to improve aspects of hospital services and operations.
Continued interview with Director X, at date and time given above, reveals that the hospital stores medical records at a contracted off-site facility. Director X states that the medical records department does not have documented review of the facility's environment to ensure that hospital medical records stored in the contracted off-site facility are readily retrievable, kept secured to maintain confidentiality, and protected from flood or fire damage.

5) Laboratory

During interview with Manager of Diagnostic Services E on 3/10/2015 at 11:50 AM, Mgr E was unable to demonstrate how the Laboratory department was incorporated into the facility's quality program. Mgr E confirmed having oversight of the department but was unable to produce any type of quality monitoring or reporting done through the laboratory department.

Based on record review and interview, the facility failed to maintain patient grievance records per facility policy, in 1 of 1 patient grievance procedure interviews (Chief Nursing Officer G).

Findings include:

On 03/10/2015 at 3:00 PM, review of facility policy: Grievance Procedure Patient Notice of Rights, dated 12/2014 states in #3.5) All grievances will be reported by the CEO G to the Management Committee, #3.6) The report documents will be retained by Risk Management.

On 03/10/2015 at 4:30 PM, CNO G stated "we don't have any grievances. We get complaints from time to time but we take care of them right away." CNO G stated complaints that may come into the facility are addressed by a number of people including CNO G, CEO N and RN A. CNO G was unable to verify how the facility retains or tracks complaints, "we don't keep track of fixing the complaint."

Based on record review and interview, this facility failed to maintain an effective, ongoing, hospital wide, data-driven quality assessment and performance improvement program in 1 of 1 QAPI programs (Orthopaedic Hospital QA Program) reviewed.


Findings include:

Per interview on 03/11/2015 at 2:20 PM, Dir. Rehab/Quality T verified that 38 of 40 contracted services reviewed were not monitored or incorporated into the QAPI (quality assurance performance improvement) program.

1) This facility failed to analyze and monitor the effectiveness of health outcomes related to patient safety and quality of care in 2 of 3 focused quality indicators (Medication errors and Rehab pain improvement) reviewed. (Reference A-0273).

2) This facility failed to monitor the effectiveness and safety of 38 of 40 contracted services. (Reference A-0273).

3) The hospitals Governing Body failed to ensure that the QAPI program involved all hospital departments and contracted services. (Reference A-308).

The cumulative effect of these systemic problems results in the hospital's inability to maintain an effective ongoing hospital wide QAPI program.

Based on record review and interview, the hospital failed to analyze and monitor the effectiveness of health outcomes related to patient safety and quality of care, in 2 of 3 focused quality indicators (Medication errors and Rehab pain improvement) and 35 of 40 contracted service areas (Medical Gases, Snow Removal, Transcription Services, Hospitalist Services, Housekeeping Services, Chaplain Services, Clinical Trials, Diabetes Consulting, General Maintenance, Infection Control, Information Services, Lab Services, Language Services, Managed Care Contracting, Medical Staff Services, Pharmacy, Printing Services, Quality & Clinical Data Management, Risk Management, Safety, Telecommunications, Transcription, Volunteer Services, Anesthesia Services, Laundry Services, Emergency water (drinking), Organ /Tissue and Eye Donor Agreements, Diagnostic Services, Biomedical Hazard removal, Medical Records, Security, Biomedical Services, Diagnostic (Radiology) Services, Fire protection services, Fuel Delivery) reviewed.

Findings include:

1) Record review on 03/11/2015 between 12:40 PM and 01:55 PM, revealed 2 of 3 quality indicators (Medication errors and Rehab pain management) had no documented evidence of QAPI data analysis reviews to show that this hospital was reviewing these services to ensure quality care was provided. There was no documented evidence provided that the data was continually monitored for it's effectiveness related to patient safety. The hospital had no timelines for how often they reviewed collected data that was reported to the MEC (Medical Executive Committee).

During interview on 03/11/2015 at 10:37 AM with CEO N and Dir. Rehab/Quality T, CEO N stated quality improvement processes are reviewed at the MEC meetings. Dir. Rehab/Quality T stated, there was no documentation that included rational for projects chosen and approved by the MEC.

2) Record review on 03/11/2015 at 2:20 PM, reveals that the hospital has 40 current contracted services. It was found that 35 contracts listed below did not show documented evidence of governing body monitoring of their operations. There was no documented evidence that operational monitoring was conducted to maintain the quality of these contracted services. The 35 hospital contracts reviewed and found deficient are listed as follows:
1) Airgas Puritan Medical/ Medical Gases,
2) American Snow Removal/ Snow Removal,
3) Amphion Medical Solutions/ Transcription Services,
4) Hospitalist Services (Physicians GG and HH),
5) Cleanpower/ Housekeeping Services,
6) Columbia St. Mary's/ Chaplain Services,
7) Columbia St. Mary's / Clinical Trials,
8) Columbia St. Mary's / Diabetes Consulting,
9) Columbia St. Mary's / General Maintenance- During interview with Materials Systems Coordinator H and Building Service Coordinator AA on 3/9/15 at 3-00 PM - 4:00 PM, H stated that the hospital uses a contracted service called "Clean power" for its environmental housekeeping. H stated that the hospital has no formalized process for reviewing the contracted housekeeping services provided to the hospital to ensure that cleaning processes are carried out as per documented in the contract.
10) Columbia St. Mary's / Infection Control,
11) Columbia St. Mary's / Information Services,
12) Columbia St. Mary's / Lab Services-During interview with Manager of Diagnostic Services E on 3/10/2015 at 11:50 AM, Mgr E was unable to demonstrate how the Laboratory department was incorporated into the facility's quality program. Mgr E confirmed having oversight of the department but was unable to produce any type of quality monitoring or reporting done through the laboratory department.
13) Columbia St. Mary's / Language Services,
14) Columbia St. Mary's / Managed Care Contracting,
15) Columbia St. Mary's / Medical Staff Services,
16) Columbia St. Mary's / Pharmacy Services,
17) Columbia St. Mary's / Printing Services,
18) Columbia St. Mary's / Quality & Clinical Data Management,
19) Columbia St. Mary's / Risk Management Services,
20) Columbia St. Mary's / Safety,
21) Columbia St. Mary's / Telecommunications,
22) Columbia St. Mary's / Transcription,
23) Columbia St. Mary's / Volunteer Services,
24) Glendale Anesthesia Group / Anesthesia Services,
25) Goodwill Industries / Laundry Services- Record review on 03/09/2015 of Policy # 8210.19 - Infection Control Laundry and Linen, last reviewed / revised on 9/2012, states under "4. Commercial linen processing services..., A. The hospital uses a commercial linen processing service. 1. This service agreement is renewed annually with the copy sent to the infection control consultant by the purchasing department. 2. The infection control consultant and materials service personnel do annual inspections of the facility".

During interview with Materials Systems Coordinator H and Building Service Coordinator AA on 3/9/15 at 3:00 PM through 4:00 PM, it was revealed that the hospital had no formalized process of reviewing the contracted services provided by Goodwill (contracted provider). AA stated that visits had been done in the past, but there was no documentation of the visits to verify that Goodwill provides adequate linen sanitation processes, sanitary linen storage processes or sanitary linen transportation services to the hospital. H stated that the hospital had no current or past quality assurance projects or data that are submitted/ reported to the hospitals quality improvement organization as directed by the hospital's governing body.
26) Emergency water (drinking),
27) Lions Eye Bank of Wisconsin / Eye Tissue Donor Referral Agreement; Wisconsin Tissue Bank / Tissue Donor Referral Agreement; and Wisconsin Donor Network / Organ Donor Referral Network- During interview with Chief Nursing Officer G on 3/9/15 at 12:30 PM, G states that the nursing department does not have an OPO project that it submits to the hospital's quality improvement organization as directed by the hospital's governing body.
28) Medical College of Wisconsin / Diagnostic Services,
29) Steri-Cycle / Biomedical Hazard removal,
30) On Course Information Services / Medical Records and Source Medical / Electronic Medical Records- During interview with Medical Records Director X on 3/11/15 at 8:45 AM, it was determined that the medical records department did not have a formalized quality assurance project that it submitted to the hospitals quality improvement organization that is directed by the hospital's governing body. Director X states that the medical records department collects data in several areas but uses it internally, such as medical record authentication and medical record completeness to notify physicians who are delinquent. Director X states that this data is collected but not analyzed, measured nor used to improve aspects of hospital services and operations.
Continued interview with Director X, at date and time given above, reveals that the hospital stores medical records at a contracted off-site facility. Director X states that the medical records department does not have documented review of the facility's environment to ensure that hospital medical records stored in the contracted off-site facility are readily retrievable, kept secured to maintain confidentiality, and protected from flood or fire damage.
31) SPI / Internal & External Security (External /Internal contracts),
32) TriMedX / Biomedical Services,
33) Wisconsin Radiology Services / Diagnostic Services,
34) North Shore Fire Department
35) Quick Fuel.

This information was verified by CFO D and Dir. Rehab/Quality T on 03/11/2015.

Based on record review and interview, this facility failed to ensure quality improvement projects are being conducted and that measureable progress is achieved and documented, in 2 of 3 patient safety quality indicators reviewed (medication errors and rehab pain management). .

Findings include:

Record review on 03/11/2015 between 12:40 AM and 01:55 PM, revealed 2 of 3 quality indicators (medication errors and rehab pain management) had no documented evidence of data analysis. There was no evidence provided that the data was monitored for it's effectiveness related to patient safety.

During interview on 03/11/2015 at 10:37 AM, Dir. Rehab/Quality T stated not all contracted services were incorporated into the QA program. T stated there was no documentation that included rational for projects chosen or approved by the MEC (Medical Executive Committee). T stated that there was no documentation of annual review of their QA information to show focused priority on improved quality.

Based on record review and interview, this facility failed to ensure MEC (Medical Executive Committee) provided oversight and maintenance of the Quality Assurance Performance Improvement program in 6 of 6 contracted departments (Laundry, Housekeeping, Organ Procurement, Medical Records, Discharge Planning, Laboratory) reviewed.

Findings include:

1) During interview on 03/11/2015 at 10:37 AM, CEO N stated QAPI is reviewed at the MEC (Medical Executive Committee) meetings. The hospital had no documentation that supported that the QAPI reviews were done by the MEC. CEO N stated the MEC meeting minutes were generalized and titled; "Patient Satisfaction Survey". Dir. Rehab/Quality T stated there was no documentation that included rational for projects chosen and approved by the MEC.


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1) Laundry
Record review on 03/09/2015 of Policy # 8210.19 - Infection Control Laundry and Linen, last reviewed / revised on 9/2012, states under "4. Commercial linen processing services..., A. The hospital uses a commercial linen processing service. 1. This service agreement is renewed annually with the copy sent to the infection control consultant by the purchasing department. 2. The infection control consultant and materials service personnel do annual inspections of the facility".
During interview with Materials Systems Coordinator H and Building Service Coordinator AA on 3/9/15 at 3:00 PM through 4:00 PM, it was revealed that the hospital had no formalized process of reviewing the contracted services provided by Goodwill (contracted provider). AA stated that visits had been done in the past, but there was no documentation of the visits to verify that Goodwill provides adequate linen sanitation processes, sanitary linen storage processes or sanitary linen transportation services to the hospital. H stated that the hospital had no current or past quality assurance projects or data that are submitted/ reported to the hospitals quality improvement organization as directed by the hospital's governing body.
2) Housekeeping
During interview with Materials Systems Coordinator H and Building Service Coordinator AA on 3/9/15 at 3:00 PM - 4:00 PM, H stated that the hospital uses a contracted service called "Clean power" for its environmental housekeeping. H stated that the hospital has no formalized process for reviewing the contracted housekeeping services provided to the hospital to ensure that cleaning processes are carried out as per documented in the contract.
3) Organ Procurement Organization
During interview with Chief Nursing Officer G on 3/9/15 at 12:30 PM, G states that the nursing department does not have an OPO project that it submits to the hospital's quality improvement organization as directed by the hospital's governing body.
4) Medical Records
During interview with Medical Records Director X on 3/11/15 at 8:45 AM, it was determined that the medical records department did not have a formalized quality assurance project that it submitted to the hospitals quality improvement organization that is directed by the hospital's governing body. Director X states that the medical records department collects data in several areas but uses it internally, such as medical record authentication and medical record completeness to notify physicians who are delinquent. Director X states that this data is collected but not analyzed, measured nor used to improve aspects of hospital services and operations.
Continued interview with Director X, at date and time given above, reveals that the hospital stores medical records at a contracted off-site facility. Director X states that the medical records department does not have documented review of the facility's environment to ensure that hospital medical records stored in the contracted off-site facility are readily retrievable, kept secured to maintain confidentiality, and protected from flood or fire damage.
5) Discharge Planning
During interview with Director of Quality T on 3/9/15 at 1:30 PM, Staff T stated that the hospital has not been collecting data regarding hospital readmissions for review in their hospital quality processes. Staff T states the hospital can pull up data for re-admissions within 30 days, but does not review or analyze this data.



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6) Laboratory

During interview with Manager of Diagnostic Services E on 3/10/2015 at 11:50 AM, Mgr E was unable to demonstrate how the Laboratory department was incorporated into the facility's quality program. Mgr E confirmed having oversight of the department but was unable to produce any type of quality monitoring or reporting done through the laboratory department.

Based on interview, the hospital's governing body failed to ensure that they conducted an annual review of QAPI projects that were determined to be necessary, in 1 of 1 QAPI programs reviewed (OHW QA program).

Findings include:

During interview on 03/11/2015 at 10:37 AM, Dir. Rehab/Quality T stated not all contracted services were incorporated into the QA program. T stated there was no documentation that included rational for projects chosen or approved by the MEC (Medical Executive Committee). T stated that there was no documentation of annual review of their QA information to show focused priority on improved quality.

Based on record review and interview the facility failed to document complete and individualized plans of care for 6 of 30 patients reviewed (#10, 12, 15, 16, 17, 22).

Findings include:

Facility policy "Standards of Clinical Nursing Process" dated 8/2011, reviewed 3/11/2015 at 4:00 PM, states in part: "The nurse develops a plan of care that prescribes interventions...the plan is individualized to the client's condition or needs...the plan is documented...The nurse evaluates the client's progress toward the attainment of outcomes...Revisions in diagnoses, outcomes, and the plan of care are documented."

Facility policy "Documentation in the Medical Record" dated 7/2009, reviewed 3/11/2015 at 4:00 PM, states in part: "Nursing documentation in the medical record reflects the patient's status and progress toward goals at the time of transfer from a unit or discharge from the hospital. ...status of goal achievement will be documented."

1) Per MR review on 3/10/2015 at 8:25 AM, Pt. #10 was admitted to the facility on 3/9/2015 for a Right Hip Arthroplasty. Pt. #10's MR contained a standardized plan of care titled "Knee Replacement Clinical Guideline Outcome Sheet." The plan of care contained pre-operative, day of surgery and post-operative documentation standard to post-operative knee surgery, not post-operative hip surgery.

2) Pt. #12's MR, reviewed on 3/10/2015 at 2:25 PM, contains a plan of care with outcomes that are not documented as met or not met at the time of discharge on 1/10/2015.

3) Pt. #15's MR, reviewed on 3/10/2015 at 3:50 PM, contains a plan of care with outcomes that are not documented as met or not met at the time of discharge on 2/20/2015.

4) Pt. #16's MR, reviewed on 3/10/2015 at 4:00 PM, contains a plan of care with outcomes that are not documented as met or not met at the time of discharge on 3/17/2014.

5) Pt. #22's MR, reviewed on 3/11/2015 at 10:15 AM, reveals Pt. #22 was admitted to the facility on 3/31/2014 for shoulder surgery. Pt. #22's MR contains a general nursing care plan for pain relief. There are no identified actual or potential problems related to surgery.

6) Pt. #17's MR, reviewed on 3/11/2015 at 10:30 AM, reveals Pt. #17 was admitted to the facility on 6/2/2014 for shoulder surgery. Pt. #17's MR contains a general nursing care plan for pain relief. There are no identified actual or potential problems related to surgery.

The above findings were verified with RN A at the time of the review. During an interview with RN A on 3/10/2015 at 4:00 PM, RN A stated the facility uses standardized plans of care for the following admitting diagnoses: Cervical Spine; Cervical Fusion; Hip Replacement; Knee Replacement; Diskectomy. Focus areas in the standardized plans of care include: Assessment; Patient Education; Medication; Pain Control; Activity; Diet/Elimination; Spiritual and Emotional Support; Physical Therapy; Occupational Therapy; Discharge Planning. The instructions state: "Most of the outcomes are interdisciplinary." Per RN A, if a patient is admitted for a surgery that is not addressed by one of the the standard plans of care, the facility has a general care plan. The general care plan does not identify any actual or potential problems related to surgery other than pain. RN A stated, the general plan of care "needs improvements"
and does not fully address the needs of the patient population.

Based on observation and record review, the hospital failed to ensure that drugs and biologicals were administered by, or under supervision of, nursing or other personnel in accordance with approved medical staff policies and procedures, in 1 of 4 medication administration observations (RN CC).

Findings include:

On 3/10/15 at 10:15 AM. observations were made of RN (Registered Nurse) CC administering narcotic pain medication (oxycodone 5 mg tablet) to Patient #8. RN CC did not remain in the room to observe Patient #8 ingest and swallow medication after leaving medication (pill and cup) on overbed table.
On 3/11/15 review of the hospital's medication policy, verified by Chief Nursing Officer G at 1:00 PM as the current hospital policy, states "Policy Stat ID: 1263036, Columbia St. Mary, Medication, effective 2/2005", states "7. Patient must be observed taking medication."

Based on record review and interview, the hospital failed to ensure entries in the medical record were authenticated, in 1 of 30 records reviewed (#27 ).

Findings include:

Pt. #27's medical record was reviewed on 03/10/15 at 3:18 PM. The record contained a discharge summary dictated on 02/02/15 which was not signed at the time of review.

Staff A stated at the time of the record review, that the summary should be signed.

Based on record review and interview, the hospital failed to ensure written and verbal orders were timed, dated and authenticated in 8 of 30 medical records (#12, 14, 17, 19, 21, 22, 25, 26 ) reviewed.

Findings include:

Facility policy "Medical Record Documentation: Requirements for Medical Staff and Allied Health Professional Staff" dated 9/2012, reviewed on 3/11/2015 at 11:00 AM, states in part: "All verbal and telephone orders must be authenticated, dated and timed within 48 hours."

1) Pt. (Patient) #12's MR, reviewed on 3/10/2015 at 2:25 PM, contains telephone orders on 1/10/2015 that are not authenticated by the physician until 1/28/2015.

2) Pt. #14's MR, reviewed on 3/10/2015 at 3:20 PM, contains telephone orders dated 1/24/2015 that are not authenticated by the physician until 2/4/2015.

3) Pt. #17's MR, reviewed on 3/11/2015 at 10:30 AM, contains telephone orders dated 6/2/2014 that are not authenticated by the physician until 6/16/2014.

4) Pt. #19's MR, reviewed on 3/11/2015 at 9:45 AM, contains telephone orders dated 2/27/2014 that are not authenticated by the physician until 3/6/2014.

5) Pt. #21's MR, reviewed on 3/11/2015 at 10:05 AM, contains telephone orders dated 3/21/2014 that are not authenticated by the physician until 4/1/2014.

6) Pt. #22's MR, reviewed on 3/11/2015 at 10:15 AM, contains telephone orders dated 3/31/2014 that are not authenticated by the physician until 6/7/2014.

7) Pt. #25's MR, reviewed on 03/10/15 at 2:08 PM. The record contained an order which began; "STOP NOW: evening primrose oil, cinnamon, black cohosh......." which was not authenticated, timed or dated.. RN A stated at the time of the record review that the orders should be signed.

8) Pt. #26's MR, reviewed on 03/10/15 at 2:55 PM. The MR contained orders written on 01/06/15 and 01/07/15 which were not counter-signed until 01/21/15. RN A stated at the time of the record review that orders should be counter-signed within 24 hours.

During an interview on 3/10/2015 at 10:00 AM, CNO G stated telephone orders are to be signed by the physician "as soon as possible." The above findings were verified with RN A at the time of the review. RN A stated "I'm not sure if the doctor is supposed to sign the orders in 24 or 48 hours."

Based on record review, the facility failed to complete medical record documentation per policy in 3 of 21 discharged patient records reviewed (#14, 18, 20).

Findings include:

Facility policy "Medical Record Documentation: Requirements for Medical Staff and Allied Health Professional Staff" dated 09/2012, reviewed on 03/11/2015 at 11:00 AM, states in part: "Medical records must be completed within thirty (30) days of patient discharge. The discharge summary/note...must be authenticated by the author as soon as possible but no later than thirty (30) days post patient discharge."

1) Pt. #14's MR, reviewed on 03/10/2015 at 3:20 PM, contains a note stating: "D/C (discharge) Summary (Not Dictated) Date: 1/27". Pt. #14 received inpatient services at the facility from 01/21/2015 to 01/24/2015.

2) Pt. #18's MR, reviewed on 03/11/2015 at 9:35 AM, Pt. #18 was discharged from the facility on 02/14/2014. Pt. #18's discharge summary is dated 02/16/2014 but is not authenticated by the physician until 04/04/2014.

3) Pt. #20's MR, reviewed on 03/11/2015 at 9:55 AM, contains an operative report dated 03/06/2014. The report is not authenticated by the physician until 08/14/2014.

Based on observations and interviews, the hospital failed to ensure that dietary staff were competent in their duties, in 2 of 3 dietary department areas (Storage and preparation).
Findings include:
1) Observations of the dietary department on 3/10/2015 at 10:40 AM. through 11:00 AM, revealed a tall plastic container of pooled eggs sitting on the prep table. Dietary Director/Chef I was asked to test temperature of these pooled eggs in the container, and stated that the temperature of the pooled eggs was 42°F after testing.
Record review of the National Restaurant Association's ServeSafe food storage guidelines, 6th edition, under section 8-5 states guidelines recommend that pooled eggs should be cooked promptly after mixing or stored at 41°F or lower.
Chef I stated, at the time of this observation, that these eggs should be stored in the refrigerator after their cracking.
Chef I stated at interview on 03/10/2015 at 1:35 PM, that the hospital follows and uses the ServeSafe guidelines.
2) During observation of the dietary department on 03/10/2015 at 10:40 AM through 12:30 PM, it was observed that one of 5 dietary staff did not have effective hair restraint. Dietary staff Y had the fringes of her hair loose hanging around her face.
During an interview with dietary Director/Chef I, I verified there should be no loose hair outside hairnet.
3) During observation on 03/10/2015 at 10:40 AM of metal cooking equipment stored on the lower shelf of a metal table, across from the food coolers, was not protected from dust and debris. The surface of the lower shelf of this metal table was covered with white dust, with beige to brown debris scattered over it's surface.
Chef I stated, at the time of this observation, this cookware will be stored in a clean area.

Based on record and interview, this facility failed to develop screening criteria to identify patients at nutritional risk in 1 of 2 dietary interviews (Dietician Z and Chef I).
Findings include:
During interview with Dietitian Z and Dietary Director/Chef I on 03/10/2015 at 1:35 PM, they both stated that the hospital does not have a formalized process for screening their hospital patients for nutritional risk. Director I states since this is a speciality hospital for orthopaedic surgeries, the patients that come here are generally healthy and don't stay that long. In continued interview with Dietitian Z, Z states that Z had developed no criteria for a nutritional risk assessment, but stated that if the nursing staff found a problem they could contact Z.
Review of the "Pre-screening form" on 03/11/15, which is a review of systems and conditions, filled out by nursing staff for patients prior to surgical services, reveals only 3 questions regarding diet or nutrition status: 1) the presence of acid reflux, heartburn or hiatal hernia, 2) any severe weight loss history and 3) any difficulty swallowing. There is no documented evidence on this "pre-admission form" that this format identifies nutritional risk triggers that should lead to a dietary assessment.
Review of the dietary policies and procedures on 03/11/15, reveals the hospital policies do not have a formal process for dietary screening/assessment to identify patients that may be at nutritional risk when patients are admitted with co-morbid medical conditions that can adversely affect their nutritional intake such as poor dentition, digestive or absorption conditions, diabetes, congestive heart failure, or medications side effects.

Based on observation, interview and review of record documents the hospital failed to be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. These deficiencies in all of the 7 smoke compartments would affect all of the inpatients, outpatients, staff and visitors within the facility.

FINDINGS INCLUDED:
A-701: The facility did not have cabinets free of porous edge surfaces in the Pre-OP Surgery Department and counters free of dust in the Kitchen Serving Line.

A-709: The facility failed to maintain a safe environment from fire based on the following fifteen K-tags.
· K-18 (corridor door openings);
· K-20 (vertical opening or shaft);
· K-22 (exit signs);
· K-27 (smoke barrier doors);
· K-29 (hazardous spaces);
· K-38 (egress & accessibility);
· K-50 (fire drill requirements);
· K-52 (fire alarm testing and maintenance);
· K-54 (smoke device inspections & testing);
· K-56 (installation of automatic sprinkler system);
· K-62 (maintenance of automatic sprinkler system);
· K-64 (maintenance of portable fire extinguishers);
· K-76 (medical gas storage);
· K-77 (piped-in medical gas systems);
· K-147 (electrical wiring, identification & equipment);

Based on the cumulative effects of the above findings, 42 CFR 482.41 Condition of Participation: Physical Environment was NOT MET.
_________________________

Based on observation, interview and review of record documents the hospital failed to be constructed, arranged, and maintained to ensure the patient life safety from fire. These deficiencies in all of the 7 smoke compartments would affect all of the inpatients, outpatients, staff and visitors within the facility.

FINDINGS INCLUDED:

A-709: The facility failed to maintain a safe environment from fire based on the following fifteen K-tags.
· K-18 (corridor door openings);
· K-20 (vertical opening or shaft);
· K-22 (exit signs);
· K-27 (smoke barrier doors);
· K-29 (hazardous spaces);
· K-38 (egress & accessibility);
· K-50 (fire drill requirements);
· K-52 (fire alarm testing and maintenance);
· K-54 (smoke device inspections & testing);
· K-56 (installation of automatic sprinkler system);
· K-62 (maintenance of automatic sprinkler system);
· K-64 (maintenance of portable fire extinguishers);
· K-76 (medical gas storage);
· K-77 (piped-in medical gas systems);
· K-147 (electrical wiring, identification & equipment);

Based on the cumulative effects of the above findings, 42 CFR 482.41(b) Life Safety from Fire was NOT MET.
_________________________

Based on observation and interview, this facility failed to ensure an acceptable level of quality and safety is maintained by monitoring expiration dates on floor supplies, in 2 of 12 hospital departments (Radiology, 3rd floor inpatient unit) observed.

Findings include:

1) On 03/09/015 between 10:05 AM and 10:30 AM an observation on the 3rd floor in-patient unit with RN Supervisor A, revealed in storage room # 3158, 2 outdated packages of outdated Ansell sterile gloves.
During an interview on 03/09/15 at 10:30 AM, RN Supervisor A, stated the process of checking for outdates was both the responsibility of unit staff and central supply.
Six (6) packages of Ansell sterile gloves were found in the same bin of sterile gloves that had a lot number and the date manufactured date of 03/2009, but no expiration date.
During an Interview on 03/09/15 at 10:30 AM, RN Supervisor A stated, staff would not be able to identify if the content of the packages were ok to use. RN Supervisor A stated, RN A did not know if the sterile gloves were ok to use.
During an Interview on 03/09/15 at 10:30 AM, RN Supervisor A stated, RN A was not aware of a process for products that did not have an expiration date, to identify a shelf life.
On 03/09/15, RN Supervisor A brought in an email correspondence between the hospital and Ansell (sterile glove manufacturer) dated 03/09/15 with a response from Ansell product representative at 1:51 PM, that revealed the sterile gloves shelf life was two (2) years from the date manufactured. Further clarifying, " If the gloves were manufactured on 3-2009 the expiration would be 3-31-2011."
On 03/09/15 at 2:40 PM RN Supervisor A, stated all the expired gloves observed were removed from use, and the hospital was aware of manufactured date versus expiration dates for their sterile products.



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2) Observations on 3/10/2015 at 11:50 AM, shows radiology procedure room #2 contained a bottle of sterile water with an expiration date of 6/2013.

During interview with Mgr E, E stated at the time of the observation, "radiology staff is expected to monitor the supplies for expiration, and the expired medication should not be here."

Based on observation, record review and interview the facility failed to provide staff with patient care policies detailing the most current practices in infection prevention for 1 of 3 patient care departments (inpatient nursing).

Findings:

Facility policy "Nursing Policies" dated 8/2011, reviewed on 03/9/2015 at 4:00 PM, states, "Clinical Nursing Skills and Techniques, Perry & Potter will serve as a guide for any procedure not defined in the policy manuals." Perry & Potter lists the steps for administering IV (intravenous) push medications as follows: "IV push: ...Prepare two syringes filled with 2 to 3 ml's (milliliters) of normal saline...Insert needleless tip of syringe with normal saline...flush IV site with normal saline...remove saline-filled syringe...inject medication...after administering bolus, withdraw syringe...attach syringe with normal saline and flush...". Review of the facility's infection control policies reveal the facility had adopted policies specific to the surgical department. There were no infection control policies specific to patient care outside of surgery.


Observation on 03/9/2015 at 12:35 PM, SN A administered IV medication to Pt. #31. SN A used a pre-filled 5 ml's NS (normal saline) syringe to flush Pt. #31's IV with approximately 2.5 ml's of NS, removed the syringe and handed the uncapped syringe to RN R at the bedside. SN A then administered IV medication using the IV push method over 2 minutes, retrieved the NS syringe from RN R and flushed the remainder of the NS fluid into Pt. #31's IV.

Observation on 03/9/2015 at 1:50 PM, SN A administered IV medication to Pt. #10. SN A used a pre-filled 5 ml's NS syringe to flush Pt. #10's IV with approximately 2.5 ml's of NS. SN A removed the syringe and placed the uncapped syringe on the bedside table, administered the IV medication over 2 minutes then retrieved the NS syringe from the bedside table and flushed the remaining NS into Pt. #10's IV.

During an interview on 03/9/2015 at 12:50 PM, RN R stated it was appropriate to reuse the saline syringe, "you can put it on the table on an alcohol wipe, or the other thing you can do is put the cap back on." this observation was validated with RN A on 03/9/2015 at 2:00 PM. RN A stated the facility does not have a policy specific to IV administration practices, but staff is expected to follow Perry & Potter guidance for clinical procedures not defined by hospital policy. RN A was unable to confirm staff had been trained to follow Perry & Potter as a reference for clinical practice policies that are unavailable to staff.

Based on record review and interview, the hospital failed to ensure that it had policies, procedures and processes in place that notified all patients and physicians that they could make a request for a discharge planning evaluations, in 1 of 2 discharge planning interviews conducted (Case Manager DD).

Findings include:

During interview with CM DD on 03/10/15 at 9:30 AM through 10:30 AM, it was revealed that the hospital does not have a standard process for notifying patients or their representatives that they may request a discharge planning/evaluation. Unless patients attend "joint camp (a pre-surgery education process on what to expect after joint surgery)". It was also determined that the hospital does not have a standard process of notification through policy and procedure for notifying physicians that they may request a hospital discharge planning evaluation for their patients . CM DD states the physician can order discharge planning services through use of a post-surgical order set, but there is no standard process for discharge evaluation prior to orthopedic surgery.
On 03/10/15, the review of hospital discharge planning policies and procedures titled: "No. SS1006- Discharge Planning, last reviewed/ revised 6/2/12" and "No. 400.675- Social Service/ Case Management Department Plan, last reviewed/ revised 7/2013", reflects no documented information with regard to a standardized process for notifying patients (except for those attending joint camp) or physicians that they can request discharge planning services before or after surgical services are provided.

Based on record review and interview, the hospital failed to ensure that discharge planning processes were assessed and reassessed on an on-going basis to ensure responsiveness to discharge needs and reduce preventable readmissions, in 1 of 2 discharge planning interviews conducted (Case Manager DD).

Findings include:
Review of hospital discharge planning policies and procedures titled: "No. SS1006- Discharge Planning, last reviewed/ revised 6/2/12" and "No. 400.675- Social Service/ Case Management Department Plan, last reviewed/ revised 7/2013", reveals no documented information with regard to an ongoing process for the assessment of the discharge planning process to reduce preventable readmissions. There is no documented evidence that the hospital uses readmission tracking data in the assessment of readmissions including whether the evaluation of these readmissions were potentially due to problems in the discharge planning process.
During interview with CM DD on 03/10/15 at 9:30 AM through 10:30 AM, CM CC tells of having no knowledge of a discharge planning review process/ audit process that determines whether case management services were delivered appropriately.

Based on record review and interview, the hospital failed to ensure that it had written policies and procedures to maintain donor viability until organ , tissue or eye donations could be made, in 1 of 3 contracts reviewed (Wisconsin Donor Network).
Findings include:
On 03/9/15 review the hospital's agreement with the WDN (Wisconsin donor network), effective April 30, 2004 revealed under "2. Hospital Responsibilities, in "2.4.3. Orthopaedic Hospital of Wisconsin will maintain potential organ donors adequately to ensure organ viability until WDN determines medical suitability and/or family has made a decision about donation".

On 03/9/15 review of hospital Policy #7830.48- Organ and Tissue Donation Process, last reviewed/revised 11/2009, reveals that it has no documented information regarding how the hospital will maintain donor viability while testing is done for potential organ, tissue or eye donations.

During interview with Chief Nursing Officer G on 03/9/15 at 12:30 PM, G stated that the policy does not include information on maintaining donor viability. G states this will be added to the policy.

Based on record review, the surgical staff failed to follow policy and complete intraoperative documentation for 2 of 30 patients (#19, #20).

Findings include:

Facility policy "Documentation of Perioperative Nursing Care" dated 8/2011, reviewed on 03/11/2015 at 11:00 AM, states "Perioperative documentation shall include:... J) Location of any skin prep, including prep solution, and duration."

Per MR review on 03/11/2015 at 9:35 AM, Pt. #19 was admitted to the facility on 02/24/2014 for a Right Hip Arthroplasty. Per operating room nursing notes, Pt. #19's prep site is documented as "ankle to hip" with a prep time of "2 minutes" There is no documentation of what type of prep solution was used.

Per MR review on 03/11/2015 at 9:55 AM, Pt. #20 was admitted to the facility on 03/3/2014 for a Left Knee Arthroplasty. Per operating room nursing notes, Pt. #20's prep site is documented as "Left knee, leg, foot." Prep solution and prep time are not documented.