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Based on observation, staff interviews, and review of maintenance records between January 30 and February 1, 2017, the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

Findings include:

The facility was found to contain the following deficiencies.
Hospital
K 161 Building Construction type and height
K 211 Means of Egress
K 223 Doors with Self-Closing Devises
K 232 Aisle, Corridor, or Ramp Width
K 241 Number of Exits
K 293 Exit Signage
K 300 Protection
K 311 Vertical Openings Enclosure
K 321 Hazardous Areas
K 341 Fire Alarm System
K 351 Sprinklers Installation
K 363 Corridor - Doors
K 372 Subdivision of Building Space Smoke Barrier
K 521 HVAC
K 754 Soiled Linen and Trash Containers
K 906 Gas and Vacuum Piped Systems Central Supply
K 911 Electrical Systems
K 916 Electrical Systems Essential Electrical System
K 917 Electrical Systems Essential Electric System
Office Building
K 100 General Requirements

Refer to the full description at the cited K tags.

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.

Based on observation, record review and interview, the facility failed to ensure expired medications are not available for patient use in 1 of 1 outpatient location observed (Urgent Care).

Findings include:

Facility policy "Storage of Medications" dated 6/2016 states in part: "All expired, damaged, and/or contaminated medications are segregated until they are removed."

During a tour of the off-site urgent care with RN S on 01/31/2017 at 8:35 AM, an unopened expired (08/15) 500 ml bottle of saline irrigating solution was found in the medication refrigerator. Per interview with staff S at the time of the observation there should be no expired products stored in the refrigerator.

Based on observation, staff interviews, and review of maintenance records between January 30, and February 1, 2017, the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

Findings include:

The facility was found to contain the following deficiencies.
Hospital
K 161 Building Construction type and height
K 211 Means of Egress
K 223 Doors with Self-Closing Devises
K 232 Aisle, Corridor, or Ramp Width
K 241 Number of Exits
K 293 Exit Signage
K 300 Protection
K 311 Vertical Openings Enclosure
K 321 Hazardous Areas
K 341 Fire Alarm System
K 351 Sprinklers Installation
K 363 Corridor - Doors
K 372 Subdivision of Building Space Smoke Barrier
K 521 HVAC
K 754 Soiled Linen and Trash Containers
K 906 Gas and Vacuum Piped Systems Central Supply
K 911 Electrical Systems
K 916 Electrical Systems Essential Electrical System
K 917 Electrical Systems Essential Electric System
Office Building
K 100 General Requirements

Refer to the full description at the cited K tags.

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.

Based on record review and interview, the facility failed to ensure mid-level providers are supervised by the attending physician per policy in 1 of 20 medical records reviewed (Patient #18).

Findings include:

Facility policy "Medical Staff Policies" dated 5/2016 states in part: "All documentation by the Physician Assistant/Nurse Practitioners will be co-signed/authenticated in a timely fashion by the supervising physician as required by hospital policy..."

Per Patient #18's medical record, reviewed on 1/31/2017 at 11:30 AM, Patient #18 received inpatient services from 12/15/2016 through 12/22/2016 for a left total knee arthoplasty. Patient #18 was admitted to the hospital by MD Y, the attending orthopedic surgeon. Patient #18 was anticipated to be discharged from the facility on 12/18/2016 but developed urinary retention on 12/16/2016, and hypoxia and shortness of breath on 12/17/2016. Patient #18's discharge was subsequently delayed to 12/22/2016. During Patient #18's inpatient stay, progress notes are documented daily by Physician Assistant X. There is no evidence in the record that MD Y saw or documented care for the patient from 12/16/2016 through 12/22/2016.

Physician Assistant X's "Core Privileges & Procedures" dated 8/10/2015 states: "The entire practice of the physician assistant shall be under the supervision of a licensed physician who is a member of the medical staff...the supervising physician countersigns within 72 hours the patient record prepared by the physician assistant."

During an interview on 2/1/2017 at 10:10 AM, Physician Assistant X stated MD Y rounds in conjunction with X "except on the weekends." When asked how MD Y supervised X's care of patients, X stated "I'm pretty sure [MD Y] reads our notes. When we charted on paper [MD Y] would sign our notes, but I'm not sure how that's done in Epic [Electronic Health System]." Physician Assistant X stated MD Y "definitely" saw Patient #18 during 18's inpatient stay.

During an interview with Chief Nursing Officer N and Vice President of Patient Services I on 2/1/2017 at 8:15 AM, N and I were unable to clearly define the expectations for physician supervision over Physician Assistants and Nurse Practitioners, and were unable to state if supervising physicians were expected to review and countersign progress notes. N stated "the policy isn't clear, we will have to review it."

Based on observation, record review and interview, facility staff failed to ensure medications are monitored and not accessible to unauthorized personnel in 1 of 1 pharmacy department (Pharmacy).

Findings include:

Facility policy "Storage of Medication," dated 6/2016, states: "In accordance with state and federal regulations all drugs and biologics are kept in secure areas and locked as appropriate."

On 1/31/2017 at 2:20 PM, the central pharmacy refrigerator was accessible from the Medical-Surgical unit hallway. The refrigerator was not locked or visually observed by staff. The refrigerator was opened for approximately 30 seconds and then closed at which time Pharmacist U entered the pharmacy room from an adjacent office. When asked how medications in the pharmacy are monitored, Pharmacist U stated "we don't visualize the refrigerator but we listen for anyone coming in [to the pharmacy]." U went on to state: "we close the door if we are not here."

During an interview on 1/31/2017 at 2:25 PM, Chief Nursing Officer N stated "I can see how that [unauthorized access to medications in the pharmacy] could be a concern. We can start shutting the door right now."

Based on observation, record review and interview, the facility failed to maintain a sanitary environment per policy in 5 of 12 departments observed (Intensive Care Unit, Dietary, Medical Surgical Unit, Emergency Department, Surgical Department) and failed to perform hand hygiene per policy in 3 of 5 direct patient care observations (Patient #1, Patient #2, Patient #3).

Findings Include:

Intensive Care Unit (ICU)

Hospital policy titled "Cleaning/Disinfection & Sterilizing Patient Care Equipment" dated 11/2016 (reviewed on 02/01/2017 at 10:00 AM) states: "Return cleaned and disinfected equipment promptly to clean storage area."

The dirty utility room on the ICU was observed on 01/31/2017 at 3:50 PM, cleaned "slipp sheets" (used for positioning patients in bed) were left hanging to dry in this dirty utility room. Per interview with CNA T at the time of the observation, slipp sheets are washed and left to dry in the dirty utility room.


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Dietary

Facility policy "Date Marking of Potentially Hazardous, Ready-to-Eat Foods and Product Ingredients" dated 1/2016, states: "Dry storage ingredients such as sugar, flour, pasta, etc. should be dated 6 months from the date the item was opened."

During observations of the kitchen on 1/30/2017 at 11:15 AM, the following was observed: a large unlabeled, undated container of flour and a large container of sugar was dated with a "use by" date of 12/24/2016. During an interview at the time of the observation, Food Services Manager V stated the flour and sugar "are good for 6 months and should be labeled and dated." Opened spices near the prepping station were not dated. Cook Z stated the spices "are good for 6 months from the date they are opened." When asked how staff knows when the spice was opened, Z stated the spices "aren't labeled."

Facility policy "Cleaning Food and Nutrition Services" dated 9/2016 states: "A. Cleaning the Kitchen: -Weekly ceilings/walls, windows and hood will be cleaned. Daily checks walls/windows...as deemed necessary..."

On 1/30/2017 at 11:30 AM, a thick layer of dust was observed behind the stove and oven in the kitchen. The dust covered the wall, the back of the equipment and the electrical cords. During an interview on 1/30/2017 at 3:00 PM, Food Services Manager V stated Environmental Services staff clean the walls and behind the equipment in the kitchen "weekly." When asked about the dust observed in the kitchen, V stated "it looks like it has been longer than that."

During an interview with Environmental Services Manager AA on 2/1/2017 at 8:40 AM, AA stated "it is the kitchen staff's responsibility to clean behind the equipment in the kitchen."


29972

Medical Surgical Unit

On 1/30/2017 at 11:15 AM during tour of Medical Surgical Unit with Vice President of Patient Services I, observed dust, debris, and greenish blue residue in cabinet under sink in the "Nutrition Room." Per interview with I at the time of observation, I did not know what the greenish blue residue was and stated unit staff are responsible and should be cleaning under the sink.

Emergency Department

Per review of policy and procedure titled, "Cleaning/Disinfecting Patient Care Rooms" last reviewed 1/2016, staff should thoroughly disinfect environmental surfaces and medical equipment to ensure objects and surfaces are decontaminated. Per policy frequently touched sites include: Bed and bed rails, IV pole/pump/monitor, workstation on wheels, call light and cord, sink, monitor controls and cables.

While cleaning Emergency Department Room #7 after patient discharge on 1/30/2017 at 11:20 AM, Registered Nurse J did not clean/disinfect the following: All surfaces of the mattress; Bed railings; Call light and cord; Workstation on wheels; IV pole/pump; Thermometer; sink; blood pressure cuff. Registered Nurse J retrieved clean bed linens from the cabinet and placed the sheets directly on the "dirty" sink, then used the same sheets to make up the bed for the next patient.

Per interview with Emergency Department Manager K on 1/30/17 at 11:30 am, K stated all patient equipment and the above listed items should be cleaned between patients.

On 12/31/2017 at 12:30 PM, Registered Nurse L administered intravenous medication to Patient #1 in the Emergency Department. L typed on the keyboard at the computer workstation, donned gloves, then proceeded to administer Patient #1's medication via intravenous catheter without first performing hand hygiene.

Surgery Department

Per review of policy and procedure "Hand Hygiene" last reviewed 10/2016, staff should perform hand hygiene "upon entry and exit of patient care area or environment" and "after removing gloves and other personal protective equipment."

Per review of policy and procedure "Cleaning Anesthesia Work Station" last reviewed 10/2016, the anesthetist is responsible for cleaning the anesthesia machines and work stations; reusable items shall be cleaned between use on patients, reusable items include blood pressure cuff, EKG leads, skin temperature probes.

Per review of policy and procedure "Surgical Attire" last reviewed 2/2016, a clean surgical head cover or hood that confines all hair should be worn and remain on if leaving the restricted area; cell phones, tablets and other hand held electronic equipment should be cleaned with a low level disinfectant before and after being brought into the perioperative setting.

On 1/31/2017 at 9:40 AM, during preparation for Patient #2's inguinal hernia repair surgery, Registered Nurse F exited the operating room to obtain a blood pressure cuff, and upon re-entry did not perform hand hygiene. Registered Nurse F then proceeded to apply blood pressure cuff to Patient #2. Surgeon H then entered the operating room without performing hand hygiene, placed a cell phone on red cart, donned gloves and proceeded to help position Patient #2. H then removed gloves, retrieved cell phone and exited operating room without performing hand hygiene.

On 1/31/2017 at 10:50 AM, the following was observed preceding and during Patient #3's colonoscopy procedure: Registered Nurse C did not have cover over facial hair (beard); Physician D removed gloves after Patient #3's colonoscopy, then retrieved electronic device and exited patient room without first performing hand hygiene and cleaning/disinfecting electronic device; Registered Nurse C removed gloves after Patient #3's colonoscopy, obtained a plastic collection bag from the clean supply cart and typed on keyboard at workstation without performing hand hygiene after glove removal; Certified Nurse Anesthetist B did not thoroughly clean anesthesia workstation, patient heart monitor control and wires, and blood pressure cuff, after Patient #3's colonoscopy; Surgical Technician A did not clean/disinfect the computer workstation after Patient #3's colonoscopy.

Per review of policy and procedure "Flexible Endoscope Reprocessing" last reviewed 2/2016, appropriate PPE (personal protective equipment) must be worn including face protection.

On 1/31/2017 at 11:00 AM, Surgical Technician A cleaned and disinfected the endoscope used for Patient #3's colonoscopy. A did not have face protection of nose and mouth while cleaning endoscope.

Based on record review and interview, facility staff failed to reassess pain following pharmaceutical intervention in 4 of 8 patient records reviewed with an identified nursing problem of pain (Patient #4, Patient #7, Patient #11, Patient #18).

Findings include:

Facility policy "Pain Assessment and Management" dated 4/2016 states: "-Reassess patient's response to pain medication. Pain will be reassessed 60 minutes after an intervention. -Effectiveness of analgesic will be documented in Epic under pain location. A progress note may also be necessary."

Per Patient #18's medical record, reviewed on 1/31/2017 at 11:30 AM, Patient #18 was admitted to the facility on 12/15/2016 for a left total knee arthoplasty. Patient #18 had a self-rated pain level of "4" on 12/15/2016 for which analgesic medication was administered at 5:38 PM. Patient #18's pain was next assessed at 8:55 PM, more than 3 hours after the medication intervention. On 12/16/2016, Patient #18 was given pain medication at 3:24 PM for a pain rating of "5." Patient #18's pain level was next assessed on 12/16/2016 at 11:14 PM, approximately 8 hours after the medication intervention.


20878


Patient #4's medical record was reviewed on 01/31/2017 at 2:00 PM. Patient #4 was admitted to the hospital on 01/30/2017 for abdominal surgery related to a stab wound. Documentation in Patient #4's medical record shows pain was treated by nursing staff. Pain medication was provided on 01/31/2017 at 7:24 AM for pain rated 9 out of 10. Patient #4 was not re-evaluated for pain again until 8:20 AM when pain medication was provided again. At the time of record review Patient #4's pain had not been re-evaluated.

Patient #7's medical record was reviewed on 01/31/2017 at 2:30 PM. Patient #7 was admitted to the hospital on 01/30/2017 for a knee replacement. Documentation in Patient #7's medical record shows pain medication was provided on 01/31/2017 at 10:01 AM for pain rated 6 out of 10 and again at 1:58 PM for pain rated 7 out of 10. At the time of record review Patient #7's pain had not been re-evaluated.

Patient #11's medical record was reviewed on 01/31/2017 at 1:30 PM. Patient #11 was admitted to the hospital on 01/30/2017 for abdominal pain. Documentation in Patient #11's medical record shows pain medication was provided on 01/31/2017 at 6:13 AM for pain rated 8 out of 10 and again at 10:03 AM for pain rated 8 out of 10. At the time of record review Patient #11's pain had not been re-evaluated.

During an interview on 1/31/2017 at 1:00 PM, Vice President of Patient Services I stated nursing staff "should be documenting a follow up assessment after giving medication."

Based on observation and record review staff failed to follow safe injection practices when administering medications using multi-dose vials in 1 of 1 patient care department (Anesthesia Services). This could potentially impact all patients needing anesthesia services at this facility.

Findings include:

Review of policy and procedure titled, "Safe Practice for Needle & Syringe Use" last reviewed 1/2016 states, "The use of multi-dose vials is discouraged. One med, one patient, then discard, if possible."

Per interview with Certified Nurse Anesthetist G on 1/30/17 beginning at 2:20 PM, G stated Labetelol multi-dose vial is used in the Operating room, the medication is drawn up in the Operating Room for patients who require this medication for blood pressure issues. Per G one multi-dose medication vial may be used for more than 1 patient and is not automatically thrown away after using on a patient.


34337

Based on observation, record review and interview the facility failed to ensure medical records are not available to unauthorized people and staff, and protected from potential damage, in 2 of 12 departments observed (Outpatient Rehabilitation, Medical Records). This deficiency potentially affects all patients treated at the facility.

Findings include:

Per review of policy and procedure "Information Systems Security," dated 1/2016, "Access to every office, computer machine room, and other work areas containing sensitive information must be physically restricted to those people with a need-to-know. When not in use, sensitive information must always be protected from unauthorized disclosure."

Per review of facility policy "Release of Patient Records Information," dated 01/2016, "All Medical Records are the property of Stoughton Hospital and information contained within them is to be maintained as confidential."

During a tour of Outpatient rehab clinic with Rehab Services Manager R on 01/31/2017 at 8:25 AM, file cabinets were observed in the staff office. Medical records were stored in these unlocked file cabinets. Per interview with staff R at the time of the observation, the file cabinets are not locked at night and the building is leased and accessible by the owner who is not authorized to view medical records.


29972

Observation of Medical Records department on 1/30/2017 at 1:50 PM showed patient records on the front desk and multiple files of patient X-ray films.

Per interview at the time of the observation, Health Information Associate M stated Environmental Service staff cleans the Medical Records department in the evening when Medical Records staff are gone for the day. Per M, medical records are left out on the desk or in unlocked file cabinets overnight. This practice allows Environmental Service staff unauthorized access to patient records.