HospitalInspections.org

Based on record review and interview the facility failed to provide information and assistance in formulating an Advance Directive in 1 (Patient #20) of 15 inpatient medical records reviewed. In a total sample of 27 medical records reviewed.

Review of facility policy HIM1007 "Advance Directives" last revised 5/1/2017 revealed, in part, "Patients inquiring about information regarding advanced directives will be directed to the Social Services Department. Social Services will be able to answer questions, provide information, and assist the individual in completing an advance directive." Under Procedure 1.b. "if the patients response is no (to having an advance directive) a note will be made in the EMR (electronic medical record). A consultation for Social Services will be offered it the patient requests information."

Review of Patient #20 revealed a 65 year old admitted on 10/11/2019 and discharged on 10/13/2019. The admission nursing assessment dated 10/11/2019 at 12:16PM under the heading "Advance Directives" revealed the response "no" when asked if the patient had advance directives. The query "would patient like additional information" indicated a response of "yes" and a note stating, "referral made to Social Services." Review of the medical record did not reveal any referral made or note from Social Services. There was not an Advance Directive document in the medical record.

In interview with Staff E on 1/15/2020 at 1:30PM the lack of consult and Advance Directives for this patient was confirmed. Staff E stated, "nursing should have made the consult to Social Services."

Based on observation, record review, and staff interviews, the facility failed to construct, install and maintain the building systems to ensure a physical environment that was safe for patients and staff. The cumulative effects of the environment deficiencies result in the hospital's inability to ensure a safe environment for all patients and staff.

Findings include:

The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags:

K-0321: Hazardous Areas - Enclosure
K-0342: Fire Alarm System - Initiation
K-0345: Fire Alarm System - Testing and Maintenance
K-0351: Sprinkler System - Installation
K-0353: Sprinkler System – Maintenance and Testing
K-0363: Corridor – Doors
K-0521: HVAC
K-0914: Electrical Systems – Maintenance and Testing
K-0920: Electrical Equipment – Power Cords and Extension Cords

Based on record review, observation and interview the facility failed to ensure that patient equipment (blanket/fluid warming cabinets & crash carts) were maintained according to facility and manufacturer's recommendation in 2 of 4 areas observed (medical surgical inpatient floor and emergency department) in a total universe of 4 areas observed.

Findings include:

The facility policy titled "Fluid and Blanket Warmers" Policy #ED1657 effective date of 3/11 was reviewed on 1/13/2020. This document revealed "2. The temperature of warming cabinets will be monitored daily when department is open. Documentation will be recorded by unit staff via current log sheet. a. If a recorded temperature is outside of the acceptable set temperature in a warming cabinet (130 degrees F) (Fahrenheit) containing blankets only, staff may first attempt to decrease temperature setting. If temperature remains above set temperature; notify WWH's (Western Wisconsin Health) biomed vendor."

An observation was made on 1/14/2020 at 10:00 AM of the blanket warmer on medical surgical in patient floor had a temperature of 133 degrees. Current log sheet document blanket warmer temperature should not be greater than 130 degrees Fahrenheit. Temperature documented on log sheet on 1/13/2020 was 132 degrees F (2 degrees greater than recommendation). On 1/14/2020 at 12:15 PM blanket warmer observed to be at 131 degrees F. On 1/14/2020 at 3:00 PM blanket warmer observed to be at 133 degrees F. On 1/15/2020 at 9:00 AM blanket warmer observed to be at 132 degrees F.

An interview was conducted with Clinical Project Manager A on 1/14/2020 at 10:00 AM who agreed that the blanket warmer currently registered out of limits posted on log and that 1/13/2020 was documented to be out of limits posted on log.

An observation was made on 1/14/2020 at 10:15 AM of facility document "Crash Cart Monthly Outdates" from 2019 had no documented checks completed in February, March, August, November or December. The pediatric crash cart "Crash Cart Monthly Outdates" in 2019 had no documented checks completed in December 2019. The facility document "ROOM DEEP CLEANING QT ON ALL SURFACES" for patient room #'s 120-130 had no documented cleaning completed for the month of June 2019. The facility document "MED/SURG OUTDATES" had no documented checks for the months of February, April, patient rooms in May, July, August, September, patient rooms in October and December 2019. The facility document "Noninvasive Equipment Cleaning schedule M/S (medical/surgical) 2019" had no documented checks for the months of July, August, and October 2019. And had partial entries for the months of May, June, September, November and December 2019.

An interview was conducted Clinical Project Manager A on 1/14/2020 at 10:15 AM. When asked about the expectation of the above documents Clinical Project Manager A stated "They should all be filled out every month."



41127


Review of the facility policy #ED1011 titled, "Code/Crash Cart & Automatic External Defibrillator (AED)," effective date 12/16 revealed, "...Weekly operational check of defibrillators will be performed. Check will be documented with strip attached to checklist."

During a tour of the emergency department on 1/14/20 at 9:44 AM, the document titled, "Emergency Department Checklist...January 2020" was observed to reveal missing data in the column titled, "Blanket Fluid Warmer Temperature (write in temp.)." The past 6 months of checklists were requested. The checklists were reviewed on 1/15/20 and revealed the following:

The document titled "Emergency Department Checklist...June 2019" revealed no blanket or fluid warmer temperatures were documented for 7 out of 30 days (6/1/19; 6/14/19; 6/20/19; 6/26/19; 6/27/19; 6/29/19; and 6/30/19).

The document titled "Emergency Department Checklist...July 2019" revealed no blanket or fluid warmer temperatures were documented for 12 out of 31 days (7/4/19; 7/7/19; 7/9/19; 7/14/19; 7/16/19; 7/18/19; 7/19/19; 7/24/19; 7/27/19; 7/28/19; 7/30/19; and 7/31/19).

No document was received for the month of August, 2019.

The document titled "Emergency Department Checklist...Sept (September) 2019" revealed no blanket or fluid warmer temperatures were documented for 9 out of 30 days (9/1/19; 9/3/19; 9/5/19; 9/16/19; 9/17/19; 9/19/19; 9/20/19; 9/21/19; 9/22/19). There was no fluid warmer temperature documented on 9/24/19.

No document was received for the month of October, 2019.

The document titled "Emergency Department Checklist...Nov (November) 2019" revealed no blanket or fluid warmer temperatures were documented for 10 out of 30 days (11/1/19; 11/4/19; 11/14/19; 11/17/19; 11/18/19; 11/19/19; 11/22/19; 11/23/19; 11/24/19; and 11/27/19).

The document titled "Emergency Department Checklist...Dec (December) 2019" revealed no blanket or fluid warmer temperatures were documented for 13 out of 31 days (12/4/19; 12/6/19; 12/7/19; 12/8/19; 12/9/19; 12/10/19; 12/22/19; 12/23/19; 12/25/19; 12/27/19; 12/29/19; 12/30/19; 12/31/19).

The document titled "Emergency Department Checklist...January 2020" revealed no blanket or fluid warmer temperatures were documented for 6 out of 14 days (1/3/20; 1/4/20; 1/5/20; 1/6/20; 1/7/20; and 1/12/20).

During a tour of the emergency department on 1/14/20 at 9:57 AM, 1 crash cart with a defibrillator was observed in the "Trauma" room and 1 crash cart with a defibrillator was observed in the "Supply" room. When asked how often the defibrillators are to be checked, Chief Nursing Officer C stated, "Weekly."

The documents titled, "Weekly Monitor Check" were reviewed on 1/15/20 and revealed no monitor strips titled, "Shift/System Check" for the defibrillators in the Emergency Department "Trauma" or "Supply" room were attached for 10 out of a total 31 weeks reviewed (6/26/19; 7/24/19; 7/31/19; 8/7/19; 8/28/19; 9/4/19; 10/23/19; 11/27/19; 12/18/19; 12/25/19).

On 1/16/20 at 7:15 AM, the "Weekly Monitor Check" documents were reviewed with Clinical Project Manager A. When asked to confirm the missing monitor strips, Clinical Project Manager A stated, "They are expected to be done weekly. There are probably some missing."

Based on observation and staff interviews, the facility failed to construct, install and maintain the building systems to ensure live safety from fire was safe for patients and staff. The cumulative effects of these deficiencies result in the hospital's inability to ensure a safe environment for all patients and staff.

Findings include:

The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags:

K-0321: Hazardous Areas - Enclosure
K-0342: Fire Alarm System - Initiation
K-0345: Fire Alarm System - Testing and Maintenance
K-0351: Sprinkler System - Installation
K-0353: Sprinkler System - Maintenance and Testing
K-0363: Corridor - Doors
K-0521: HVAC
K-0914: Electrical Systems - Maintenance and Testing
K-0920: Electrical Equipment - Power Cords and Extension Cords

Based on record review, observation and interview staff failed to 1) meet the requirements of Wisconsin State Law 51.61 which states, in part, "Except as provided in sub. (2), each patient shall: upon admission or commitment be informed orally and in writing of his or her rights under this section. Copies of this section shall be posted conspicuously in each patient area, and shall be available to the patient's guardian and immediate family. Every patient has the right to: Be treated with dignity and respect by all staff of the provider, Be informed of his or her rights, Be informed of any costs of his or her care", and 2) failed to perform annual review of their policies.

Findings include:

The facility failed to provide Patient Rights to patients upon admission. See Tag 1006

The facility failed to perform annual review of their policies. See Tag 1022.

Based on record review and interview the facility failed to ensure that nursing staff were following facility policy in regards to reassessment of patient pain after the administration of pain medication (either oral or intravenous) in 2 of 27 medical records reviewed (Patients # 3, 10), failed to ensure patient's were given a copy of their patient rights according to facility policy in 13 of 27 (Patient #'s 1, 2, 3, 7, 13, 15, 16, 17, 18, 19, 20, 26 & 27) records reviewed and failed to ensure staff obtained consent to treat signatures as per facility policy in 10 of 27 (Patient #'s 1, 3, 7, 11, 12, 13, 14, 16, 17, 20) in a total universe of 27 medical records reviewed.

Findings include:

The facility document "Skills Pain Assessment and Management" was reviewed on 1/16/2020. This document revealed "23. Reassess the patient's pain status, allowing for sufficient onset of action per medication, route, and the patient's condition. Assess the patient for adverse effects of the medication."

The facility document "Patient and Visitor Rights" Policy #SOC1607 effective date of 6/1/89 was reviewed on 1/15/2020. This document revealed "The purpose of the policy is to outline the rights and responsibilities of patients of Western Wisconsin Health and includes visitor rights. Western Wisconsin Health encourages patients to speak openly with their health care team, take part in their treatment choices, and promote their own safety of being well-informed and involved in their care. The following Patient Rights and Responsibilities will be displayed in public areas and throughout the hospital. Upon request of the patient or their representative a copy of the Patient Rights and Responsibilities will be printed and given to them. Every patient, upon admission, shall receive written notice of these rights in the admission package."

The facility document "Informed Consent for Procedure, Test, or Treatment" Policy #RMN1603 effective date of 2/04 was reviewed on 1/14/2020. This document revealed "Informed consent must be obtained and documented prior to initiating the treatment/procedure...A legal signature is any mark intended to be a persons signature. All signatures on any documents should be in ink, including the signatures of a witness and any other information written on the document. Witnesses: Employees who are at least 18 years of age may legally sign as a witness to consent. Methods of Consent: 3. Written Consent-A completed Informed Consent for Procedure, Test, or Treatment consent form, confirms the patient's decision to obtain treatment. It must be signed and dated by those indicated on the form, including the patient-and may be witnessed by any employee on the care team. It is kept in the patient's permanent medical record. Responsibility: 2. Non-Provider Care team members are responsible for: Ensuring that the consent form is present in the medical record before a treatment or procedure is initiated. Reviewing the appropriate consent form and/or the supplemental documentation in the medial record for completeness. Being available to witness the patient's signature-although not responsible for securing the consent or ensuring that proper information was given to the patient, witnessing staff should ask the patient the following questions: Have you read the consent form? Do you understand the consent form? Do you have any questions?"

Examples of no pain reassessment:

Patient #3 was admitted to swing bed status on 1/1/2020. On 1/11/2020 Patient #3 was given an oral analgesic (Percocet) for pain at 7:32 AM, there was no documented reassessment of pain until 9:00 PM (13.5 hours later). A Percocet was given on 1/11/2020 at 4:34 PM, there was no documented reassessment of pain until 9:00 PM (4.5 hours later). A Percocet was given on 1/12/2020 at 8:07 PM, there was no documented reassessment of pain until 9:56 PM (1.75 hours later). On 1/14/2020 a Percocet was given at 3:39 PM, there was no documented reassessment of pain until 6:00 PM (2.5 hours later).

Patient #10 was admitted to inpatient unit on 12/17/2019. On On 12/18/2019 at 12:33 AM intravenous Dilaudid (controlled analgesic) was given. There was no documented reassessment until 2:32 AM (2 hours later). At 2:32 AM Dilaudid was given IV, there was no documented reassessment until 7:12 AM (4.5 hours later). At 4:16 AM there was a documented dose of IV Dilaudid given with no assessment completed prior to administration or after administration until 8:40 AM (4.5 hours later). At 6:52 PM IV Dilaudid was administered and there was no documented reassessment of pain until 7:48 PM (1.5 hours later). On 12/18/2019 oral Roxicodone (controlled oral analgesic) was given at 1:38 PM. There was no documented reassessment of pain until 3:47 PM (3 hours later). At 3:47 PM Roxicodone was given, there was no reassessment of pain until 6:52 PM (3 hours later). At 7:48 PM a Roxicodone was given, there was no reassessment of pain until 9:15 PM (1.5 hours later).

An interview was conducted with Inpatient Nurse Manager B on 1/17/2017 at 11:15AM who stated when shown the above entries "Yes, there should be a reassessment of pain 1 hour after being given an oral analgesic and 30 minutes after being given on IV (intravenously) and they are not there."

Examples of patient rights:

Patient #1 was admitted to inpatient unit on 1/13/2020. There was no documented receipt of "Patient Rights and Responsibilities" in medical record for this admission.

Patient #2 was admitted on inpatient unit on 1/13/2020. There was no documented receipt of "Patient Rights and Responsibilities" in medical record for this admission.

Patient #3 was admitted to swing bed on 1/1/2020. There was no documented receipt of "Patient Rights and Responsibilities" in medical record for this admission.

Patient #7 was admitted to inpatient unit on 7/7/2019. There was no documented receipt of "Patient Rights and Responsibilities" in medical record for this admission.

Patient #13 was admitted to inpatient unit on 11/5/2019. There was no documented receipt of "Patient Rights and Responsibilities" in medical record for this admission.

Patient #15 was admitted to the Birthing Center on 12/15/2019. There was no documented receipt of "Patient Rights and Responsibilities" in medical record for this admission.

Patient #16 was admitted to the inpatient unit on 12/31/2019. There was no documented receipt of "Patient Rights and Responsibilities" in medical record for this admission.

Patient #17 was admitted to the inpatient unit on 1/2/2020. There was no documented receipt of "Patient Rights and Responsibilities" in medical record for this admission.

Patient #18 was admitted to the inpatient unit on 10/22/2019. There was no documented receipt of "Patient Rights and Responsibilities" in medical record for this admission.

Patient #19 was admitted to the inpatient unit on 12/18/2019. There was no documented receipt of "Patient Rights and Responsibilities" in medical record for this admission.

Patient #20 was admitted to the inpatient unit on 10/11/2019. There was no documented receipt of "Patient Rights and Responsibilities" in medical record for this admission.

Patient #26 was admitted to inpatient unit on 1/13/2020. There was no documented receipt of "Patient Rights and Responsibilities" in medical record for this admission.

Patient #27 was admitted to inpatient unit on 1/13/2020. There was no documented receipt of "Patient Rights and Responsibilities" in medical record for this admission.

Interview with Staff A on 1/15/2020 at 3:00PM, when questioned about giving patient rights stated, "they are in the binders that are in each room." Review of the contents of the binders did not reveal any documents concerning patient rights.

Staff D on 1/16/2020 at 1:00PM stated that the rights are in the binder in the patient rooms, went to retrieve a binder, and returned saying, "I guess they aren't in the binders."

Examples of consent for treatment:

Patient #1 was admitted to inpatient unit on 1/13/2020. The "Consent for Treatment" document had spouses signature on it. There was no documented date, time or witness signature.

Patient #3 was admitted to swing bed on 1/1/2020. The "Consent for Treatment" document had spouses signature on it. There was no documented date, time or witness signature.

Patient #7 was admitted to inpatient unit on 7/7/2019. There was no "Consent for Treatment" in medical record for this admission.

An interview was conducted with Inpatient Nurse Manager B on 1/16/2020 at 11:15AM. When requested Manager B to find the above stated documents in the medical records Manager B stated "They are not in there".

Patient #11 was admitted to inpatient unit on 10/17/2019. The "Consent for Treatment" document had patient's signature on it. There was no documented time after the patient's signature and no witness signature, date or time.

Patient #12 was admitted to a Swing Bed on 10/31/2019. The "Consent for Treatment" document had the patient's signature date and name. There was no witness signature, date or time.

Patient #13 was admitted to the inpatient unit on 11/5/2019. The "Consent for Treatment" document had patient's signature on it. There was no documented time after the patient's signature and no witness signature, date or time.

Patient #14 was admitted to a Swing Bed on 11/18/2019. The "Consent for Treatment" document had the patient's signature date and name. There was no witness signature, date or time.

Patient #16 was admitted to the inpatient unit on 12/31/2019. The "Consent for Treatment" document had a signature indicating "granddaughter". There was no witness signature, date or time.

Patient #17 was admitted to the inpatient unit on 1/2/2020. The "Consent for Treatment" document had a signature indicating "husband". The signature was dated there was no time. There was no witness signature, date or time.

Patient #20 was admitted to the inpatient unit on 10/11/2019. The "Consent for Treatment" document had patient's signature on it. There was no documented date or time after the patient's signature and no witness signature, date or time.

During interview with Chief Nursing Officer C on 1/17/2020 at 8:30AM when asked about expectation for completion of this form stated, "If there is a place for date and time and a witness line I would expect someone to witness it."



41126

Based on record review and interview the facility failed to provide appropriate dietary consult when the malnutrition score on the nursing admission assessment indicated a consult was required in 2 (Patients #16, 20) of 15 inpatient medical records reviewed in a total sample of 27 records reviewed.

Medical record review of Patient #16 revealed a 77 year old admitted on 12/31/2019 with a wrist fracture and discharged on 1/7/2020. The admission nursing assessment dated 12/31/2019 7:00PM indicated a malnutrition score of 2 and the instruction, "score of 2 or more the patient is at risk of malnutrition and requires a Nursing Consult to Dietitian." There was no consult or note from a Dietician in the medical record.

Medical record review of Patient #20 revealed a 65 year old admitted on 10/11/2019 with nausea and vomiting and discharged on 10/13/2019. The admission nursing assessment dated 10/11/2019 at 12:16PM indicated a malnutrition score of 2 and the instruction, "score of 2 or more the patient is at risk of malnutrition and requires a Nursing Consult to Dietitian." There was no consult or note from a Dietician in the medical record.

Interview with Staff E on 1/15/2020 at 2:30PM confirmed that "there should have been a consult made on these patients and there are none."

Based on record review and interview the facility failed to ensure that facility policies and procedures are being updated on an annual basis in 164 policies and procedures in 1 of 1 policy and procedure directory.

Findings include:

The facility policy titled "Guidelines for Policies and Procedures" dated effective 6/04 was reviewed on 1/16/2020 at 8:30 AM. This document stated under "PURPOSE: The purpose of this policy is to ensure that employees of Western Wisconsin Health have ready access to consistently, up to date, well-developed and understandable policies."

The facility's electronic policy manager lists Policy and Procedures that are "overdue as of" and the date review was due to be completed. This document was reviewed on 1/16/2020 at 8:45 AM. The following policies all "overdue for review" greater than 1 year from 1/16/2020: "Document 'Acute & Communicable Disease Case Report' is overdue for review as of 5/7/2019. Document 'Anti-platelet and Anticoagulant screening for Elective Procedures-SUR1689' is overdue for review as of 10/1/2018. Document 'Aseptic Technique-SUR1615' is overdue for review as of 10/1/2018. Document 'Assisting Helicopter Personnel-FS1604' is overdue for review as of 7/1/2017. Document 'Auto Transfusion System Set Up, Collection and Reinfusion-MED1006' is overdue for review as of 4/1/2019. Document 'Automatic Stop Orders for Medications-PHA1622' is over due for review as of 11/27/2019. Document 'Blood-borne Pathogens Control Plan-INF1297' is overdue for review as of 7/1/2017. Document 'Bubble Echocardiogram Studies' is overdue for review as of 9/13/2019. Document 'Business Associate Agreements-COM1609' is overdue for review as of 6/1/2017. Document 'Care and Handling of Operating Room Instruments-SUR1616' is overdue for review as of 2/1/2019. Document 'Cellular Phone Usage-IT1611' is overdue for review as of 10/30/2019. Document 'Central Venous Catheter Tunneled Catheter Care-MED1624' is overdue for review as of 10/26/2018. Document 'Central Venous Catheter Occlusions-Cathflo Activase-MED1624' is overdue for review as of 10/26/2018. Document 'Central Venous Catheter PICC Line Use and Care-MED1630' is overdue for review as of 10/26/2018. Document 'Central Venous Catheter Port-a-Cath Use and Care-MED1208' is overdue for review as of 10/26/2018. Document 'Central Venous Catheter Subclavian Use and care-MED1295' is overdue for review as of 10/26/2018. Document 'Chemical Monitoring Strip, Steris-SUR1656' is overdue for review as of 8/22/2018. Document 'Chemical/Material Spills-ERP' is overdue for review as of 4/4/2019. Document 'Chemotherapy and Other Hazardous Drugs-PHA1695' is overdue for review as of 10/1/2019. Document 'Cleaning in the Surgery Department-SUR1206' is over due for review as of 2/1/2019. Document 'Cleaning of Patient Care Equipment-INF1613' is overdue for review as of 11/27/2019. Document 'Cleaning of Patient Rooms after Discharge-INF1651' is overdue for review as of 11/28/2019. Document 'Clinical Management and Control of Multi-Drug Resistant Organisms-INF1003' is overdue for review as of 7/1/2017. Document 'Complementary Pharmacologic Therapy-PHA1700' is overdue for review as of 11/27/2019. Document 'Computer System User Identification and Password Management-IT1606' is overdue for review as of 10/30/2019. Document 'Condition Code 44 Inpatient Admission Changed to Outpatient-UR1631' is overdue for review as of 9/10/2019. Document 'Controlled Substance Management Outside of Pharmacy-PHA1651' is overdue for review as of 8/1/2019. Document 'Controlled Substances in Pharmacy Department-PHA1620' is overdue for review as of 8/1/2019. Document 'Counts-SUR1296' is overdue for review as of 10/1/2018. Document 'Diagnostic Cycle-Steris System 1E-SUR1650' is overdue for review as of 8/22/2018. Document 'Disinfection Process Monitoring-SUR1679' is overdue for review as of 6/1/2018. Document 'Dispensing of Discharge/Take Home Medications-PHA1627' is overdue for review as of 11/27/2019. Document 'Disposal of Hardware of Electronic Media Containing ePHI-IT1600' is overdue for review as of 10/30/2019. Document 'Division of Emergency Power-FS1627' is overdue for review as of 7/1/2017. Document 'Drug Formulary System-PHA1617' is overdue for review as of 6/1/2019. Document 'Drug Recalls, Drug Defects and Safety Alerts-PHA1615' is overdue for review as of 11/1/2019. Document 'Drug-Food Interactions-PHA1675' is overdue for review as of 11/27/2019. Document 'Elsevier Clinical Skills-RMN1003' is overdue for review as of 8/22/2018. Document 'Email Usage-IT1003' is overdue for review as of 10/30/2019. Document 'Emergency Buttons-FS1600' is overdue for review as of 6/1/2017. Document 'Emergency Water Supply-FS1202' is overdue for review as of 7/1/2017. Document 'Employee Health-Strep Screens-EMP1604' is overdue for review as of 12/1/2017. Document 'Employee HIV Post-Exposure Prophylaxis-EMP1600' is overdue for review as of 6/1/2017. Document 'Employee Influenza Vaccination Informed Consent Form' is overdue for review as of 10/24/2018. Document 'Evaluation of Inpatient and Outpatient Procedural Infections & Healthcare Associated Infection-INF1202' is overdue for review as of 7/1/2017. Document 'Evaluation of Security Policies and Procedures-IT1601' is overdue for review as of 10/30/2019. Document 'Exercise Related Emergencies-CRH1605' is overdue for review as of 4/4/2019. Document 'Floor Stock Medication-PHA1610' is overdue for review as of 11/27/2019. Document 'Gifts in Recognition of Volunteer Efforts from Non-Referral Source-COM1001' is overdue for review as of 6/15/2018. Document 'Gifts to Individuals from Vendors-COM1623' is overdue for review as of 6/15/2018. Document 'Guidelines for the Prevention of Catheter-Associated Urinary Tract Infections-INF1658' is overdue for review as of 3/2/2019. Document 'Hand Hygiene-INF-1006' is overdue for review as of 4/4/2019. Document 'Handling of Isolation Trays-INF1648' is overdue for review as of 11/28/2019. Document 'Handling/Storage and Shelf Life of Sterile Disposable and Non disposable supplies-SUR1324' is overdue for review as of 8/22/2018. Document 'Heart Failure Program-CRH1640' is overdue for review as of 11/1/2018. Document 'HIV (AIDS) Antibody Positive Precautions in Patient Care Units-INF1618' is overdue for review as of 7/1/2017. Document 'HIV Antibody Testing-INF1200' is overdue for review as of 7/1/2017. Document 'Hospice: Admission of Hospice Patient for Acute Care for Symptom Management-CMN1200' is overdue for review as of 10/5/2018. Document 'Immediate Use Steam Sterilization (IUSS)-SUR1669' is overdue for review as of 2/1/2019. Document 'Implant Log-SUR1692' is overdue for review as of 7/16/2019. Document 'Infection Prevention Program/Plan-INF1647' is overdue for review as of 7/1/2017. Document 'Infectious Waste Spills-INF1603' is overdue for review as of 7/1/2017. Document 'Influenza Declination Form Non-Medical' is overdue for review as of 10/24/2018. Document 'Informed Consent for Procedure, Test, or Treatment (Surgery)-RMN1603' is overdue for review as of 10/7/2017. Document 'Inspection of Egress Doors in Controlled Environments-INF1005" is overdue for review as of 10/1/2017. Document 'Inspection of Medication Storage Areas-PHA1665' is overdue for review as of 11/27/2019. Document 'Interruption of Natural Gas Service-FS1203' is overdue for review as of 7/1/2017. Document 'IV Infusion & Care Albumin Transfusion-MED 1600' is overdue for review as of 10/26/2018. Document 'IV Infusion & Care Daily Intravenous Site Care, Tubing Change, and Solution-MED1672' is overdue for review as of 10/26/2018. Document 'IV Infusion & Care Local Anesthetic for Venipuncture (EMLA or 1% Lidocaine)-MED1268' is overdue for review as of 10/26/2018. Document 'IV Infusion and Care Infusion of Fat Emulsions (Lipids)-MED1601' is overdue for review as of 10/26/2018. Document 'IV Infusion and Care Transfusion Reaction of Blood or Blood Products-MED1209' is overdue for review as of 10/26/2018. Document 'Latex Allergy-Care of the Latex Sensitive Patient-INF1301' is overdue for review as of 7/1/2017. Document 'Loss of Hot Water Supply-FS1619' is overdue for review as of 6/1/2017. Document 'Loss of HVAC Service-FS1625' is overdue for review as of 6/1/2017. Document 'Loss of Medical Vacuum/Suction-FS1623' is overdue for review as of 6/1/2017. Document 'Loss of Oxygen-FS1622' is overdue for review as of 6/1/2017. Document 'Loss of Piped Medical Gases-FS1624' is overdue for review as of 6/1/2017. Document 'Loss of Refrigeration-Refrigerator Freezer-FS1626' is overdue for review as of 6/1/2017. Document 'Loss of Water Service-FS1621' is overdue for review as of 7/16/2019. Document 'Low Lift Program-EMP1605' is overdue for review as of 8/14/2018. Document 'Management of Concentrated Electrolytes in Patient Care Areas-PHA1663' is overdue for review as of 10/11/2018. Document 'Management of Infectious Viral (Norovirus) Gastroenteritis-INF1652' is overdue for review as of 7/1/2017. Document 'Management of Occupational Exposures-INF1204' is overdue for review as of 7/1/2017. Document 'Management of Pharmaceutical Waste-PHA1789' is overdue for review as of 10/11/2018. Document 'Managing High-Alert/High-Risk Medications-PHA1772' is overdue for review as of 10/1/2019. Document 'Mandatory Flu Vaccinations-INF1659' is overdue for review as of 8/7/2018. Document 'Medical Gas Cylinder Storage-FS1610' is overdue for review as of 7/19/2019. Document 'Medical Supply Samples-MMT1006' is overdue for review as of 7/24/2019. Document 'Medication Administration and Documentation-PHA1030' is overdue for review as of 10/11/2018. Document 'Medication Assessment and Monitoring Expectations for Pharmacists-PHA1744' is overdue for review as of 11/27/2019. Document 'Medication Expiration Date Management-PHA1802' is overdue for review as of 11/27/2019. Document 'Medication Management Overview-PHA1604' is overdue for review as of 11/27/2019. Document 'Medication Ordering and Prescribing-PHA1621' is overdue for review as of 11/27/2019. Document 'Medication Ordering and Prescribing-PHA1621' is overdue for review as of 11/27/2019. Document 'Medication Range Orders-PHA1207' is overdue for review as of 11/27/2019. Document 'Medication Refrigerators/Freezers Monitoring and Maintenance-PHA1666' is overdue for review as of 8/24/2019. Document 'Medication Shortages-PHA1778' is overdue for review as of 11/27/2019. Document 'Medication Storage and Security-PHA1788' is overdue for review as of 10/1/2019. Document 'Medications Dispensed Through Materials Management-PHA1808' is overdue for review as of 11/27/2019. Document 'Nebulized Morphine-RTH1640' is overdue for review as of 3/26/2019. Document 'New Employee Recommended/Required Immunization-EMP1601' is overdue for review as of 10/1/2017. Document 'New Supply Request and Value Analysis Process-MMT1004' is overdue for review as of 6/1/2019. Document 'Nitrous Oxide Analgesia in Labor-BC1017' is overdue for review as of 9/17/2019. Document 'Non-Formulary Medications-PHA1782' is overdue for review as of 11/27/2019. Document 'NPO Guidelines & Preoperative Medications-ANE1080' is overdue for review as of 10/30/2019. Document 'Nursing Department Orientation Process-MED1667' is overdue for review as of 4/1/2018. Document 'Nursing Department Orientation Process-MED1667' is overdue for review as of 4/1/2018. Document 'Obstetrical Patients in the Emergency Department-ED1013' is overdue for review as of 7/13/2019. Document 'Orientation-PHA1655' is overdue for review as of 11/27/2019. Document 'OSHA Standard-Access to Confidential Employee Exposure and Health Records Standards-INF1639' is overdue for review as of 7/1/2017. Document 'Patient's Own Medication Usage-PHA1636' is overdue for review as of 10/1/2019. Document 'Personal Internet Usage-IT1004' is overdue for review as of 10/30/2019. Document 'Pharmacists Refusal to Dispense-PHA1659' is overdue for review as of 10/30/2019. Document 'Pharmacy and Therapeutics Function-PHA1659' is overdue for review as of 11/27/2019. Document 'Pharmacy Budget and Inventory-PHA1606' is overdue for review as of 11/27/2019. Document 'Pharmacy Downtime and Recovery-PHA1029' is overdue for review as of 11/27/2019. Document 'Pharmacy Equipment-PHA1809' is overdue for review as of 11/27/2019. Document 'Pharmacy Licensing-PHA1607' is overdue for review as of 11/272019. Document 'Pharmacy Pricing Policy-1762' is overdue for review as of 11/27/2019. Document 'Pharmacy Scope of Care and Services-PHA1603' is overdue for review as of 10/11/2018. Document 'Physician Notification Regarding Drug Allergy History-PHA1672' is overdue for review as of 11/27/2019. Document 'Physician Recruitment-ADM1001' is overdue for review as of 8/23/2019. Document 'Portable Media Encryption Policy-IT1201' is overdue for review as of 10/30/2019. Document 'Prevention of Transmission of Bloodborne Pathogens or Infectious Diseases from Health Care Workers to Patients and from Patients to Health Care Workers-INF1254' is overdue for review as of 7/1/2017. Document 'Procedure for Preparing and Sterilizing Wrapped Autoclave Loads-SUR1665' is overdue for review as of 8/22/2018. Document 'Process for Resolving Patient Complaints/Grievances to Manage Risk-RMN1605' is overdue for review as of 10/1/2017. Document 'Processing Human Immunodeficiency Virus (HIV) Labs (Inpatient and Outpatient)INF1617' is overdue for review as of 10/1/2017. Document 'Procurement of Medical Equipment-MMT1009' is overdue for review as of 9/18/2019. Document 'Protection from Virus and Other Malicious Activity-IT1609' is overdue for review as of 10/30/2019. Document 'Reference Materials-PHA1804' is overdue for review as of 11/27/2019. Document 'Reporting Computer Related Security Incidents-IT1602' is overdue for review as of 10/30/2019. Document 'Safe Haven for Newborns-SOC1001' is overdue for review as of 11/1/2019. Document 'Safe Medical Device Act Reporting-RMN1000' is overdue for review as of 7/12/2019. Document 'Safe Practice Guidelines for Adult IV Push Medications-MED1008' is overdue for review as of 10/26/2018. Document 'Safety Management Program for Pharmacy-PHA1797' is overdue for review as of 10/31/2019. Document 'Safety, Environmental, Chemical, Electrical in Surgery Department-SUR1298' is overdue for review as of 8/22/2018. Document 'Sample Medications-PHA1033' is overdue for review as of 9/18/2019. Document 'Security Officer-IT1604' is overdue for review as of 10/30/2019. Document 'Sedation by Non-Anesthesia Personnel-ER1012' is overdue for review as of 5/3/2019. Document 'Serious Clinical Adverse Event-RMN1612' is overdue for review as of 12/1/2017. Document 'Service and Repair Requests-FS1601' is overdue for review as of 7/1/2017. Document 'Sewage Utilities-FS1617' is overdue for review as of 7/1/2017. Document 'Six Minute Walk Test-RTH1636' is overdue for review as of 3/26/2019. Document 'Sleep Study Procedure-RTH1635' is overdue for review as of 3/26/2019. Document 'Software, Access, Establishment, Modification and Termination-IT1605' is overdue for review as of 10/30/2019. Document 'Staffing Patterns In Post Anesthesia Care Unit-PAC1621' is overdue for review as of 2/1/2019. Document 'Storage of Home Medications-PHA1806' is overdue for review as of 7/13/2018. Document 'TB Infection Control Plan-INF1641' is overdue for review as of 7/1/2017. Document 'The Vest Airway Clearance Percussion Vet-RTH1638' is overdue for review as of 3/26//2019. Document 'Time Out Body Diagram-Attachment A' is overdue for review as of 7/13/2018. Document Transcutaneous Pacing-MED1653' is overdue for review as of 1/1/2018. Document 'Treatment of Drug Infiltration/Extravasation/Phlebitis-PHA1765' is overdue for review as of 9/18/2019. Document 'Use of Leak Testing Endoscopes-SUR1660' is overdue for review as of 8/22/2018. Document 'Use of Multi-Dose/Single-Dose Parenteral Medications-PHA1763' is overdue for review as of 11/27/2019. Document 'Utilization Review Denial Process-Swing Bed-UR1613' is overdue for review as of 9/20/2019. Document 'Utilization Review HINN12-Noncovered Continued Stay-UR1629' is overdue for review as of 9/20/2019. Document 'Utilization review Hospital Requested Review (HRR)-UR1629' is overdue for review as of 9/20/2019. Document 'Utilization Review Letter11-HINN Noncovered Continued Stay-UR1629' is overdue for review as of 9/20/2019. Document 'Utilization Review Medicare Discharge Appeal Rights-UR1625' is overdue for review as of 9/19/2019. Document 'Utilization Review Pre-Admission/Admission Hospital-Issued Notice of Non-Coverage (HINN)-UR1626' is overdue for review as of 9/18/2019. Document 'Vaccine Adverse Event Reporting System-INF1203' is overdue for review as of 3/2/2019. Document 'Vancomycin Pharmacokinetic Consult Service-PHA1031' is overdue for review as of 9/18/2019. Document "Verification and Monitoring of Professional Licenses, Board Certification-ADM1024' is overdue for review as of 7/12/2019. Document 'Visitor in Operating Room-SUR1619' is overdue for review as of 8/22/2018. Document "Workstation Use and Physical Security-IT1610' is overdue for review as of 10/30/2019."

An interview was conducted with Clinical Project Manager A on 1/16/2019 at 8:30 AM. When asked about the above listed policies with overdue review dates replied "yes they should have been done every year. Now it will be every other year (regulation changed in December 2019) but these should have been done by their review date and they weren't."

Based on record review and interview the facility failed to ensure there was a care plan for each patient that included all nursing cares and diagnosis for 4 of 15 inpatients (Patients #11, 12, 18 and 26) in a total universe of 27 medical records reviewed.

Findings include:

The facility policy titled "Nursing Assessment, Documentation and Care Plans" Policy #MED1627 effective date of 5/93 was reviewed on 1/15/2020. This document revealed "Western Wisconsin Health will provide comprehensive individualized care to patients. This care will be outlined and documented in nursing care plans. 1. Each patient receives nursing care and supervision based on individual needs."

Patient #26 was admitted to medical/surgical floor on 1/13/2020 with an admission diagnosis of sepsis (infection that is systemic) and a medical history of insulin dependent Diabetes Mellitus with blood sugars to be checked before each meal and at bedtime with corresponding insulin doses based on blood sugar results. Patient #26's care plan did not contain a problem for Diabetes, blood sugar control or insulin administration.

An interview was conducted with In Patient Nurse Manager B on 1/16/2020 at 8:40 AM. When asked the expectation of nursing care plan problems that include nursing cares and medical diagnosis Manager B stated "Yes they should have a problem addressing that and there is not one on here."


41126


Patient #11 was a 76 year old admitted to a Swing Bed on 10/17/2019 with weakness and discharged on 10/21/2010. Review of the medical record revealed a past medical history, in part, of congestive heart failure, chronic obstructive pulmonary disease, used a BiPaP (device to assist with breathing at night), had type II diabetes, and was on a blood thinner for rapid heart rate. Review of the care plan did not find care plan problems addressing any of these diagnosis.

Patient #12 was a 83 year old admitted to a Swing Bed on 10/31/2019 with weakness and discharged on 11/5/2019. Review of the medical record revealed a past medical history, in part, of hypertension, coronary artery disease, type II diabetes, lung cancer and was on a blood thinner for a rapid heart rate. Review of the care plan did not find care plan problems addressing any of these diagnosis.

Patient #18 was a 73 year old admitted to an inpatient bed on 10/22/2019 after an open hernia repair and discharged on 10/25/2019. Review of the medical record revealed no Nursing Care Plan.

In interview with Staff F on 1/15/2020, Staff F confirmed these findings and stated, "Yes we should be including all the patient's diagnosis and I am really surprised that (Patient #18) didn't have a care plan at all."

Based on record review, observation and interview the facility failed to ensure the adherence to infection prevention and control policies and procedures by staff in 3 of 12 areas observed(dietary department, emergency department, obstetric department) patient care areas in a total universe of 12 (dietary, surgery, lab, radiology, rehabilitation, outpatient clinic-3 areas, medical surgical department, obstetric department, emergency department & pharmacy) areas observed.

Findings include:

The facility policy titled "Safe Food Handling" Policy #CUL1624 effective date of 4/85 was reviewed on 1/15/2020. This document revealed "All Culinary Services staff will observe sanitation precautions in handling, preparation, and service of TCS (time and temperature controlled for safety) and ready to eat foods to protect from contamination, cross-contamination and spoilage. All Opened, prepared, and thawed products will be date marked. c. Freezer Storage: Frozen foods are to be clearly labeled and dated and properly stored/wrapped to prevent freezer burn. Expiration dates of products will be checked on a consistent basis per cleaning schedule. Expired products will be disposed of immediately, including those that are stored in alternate locations and replaced with new products."

Review of facility policy # SUR1308, titled, "Transporting/Cleaning Dirty Instruments from Other Service Areas," effective date 3/94 revealed, "Purpose: To outline pre-cleaning and transportation of reusable instruments. Proper pre-cleaning helps to maintain the integrity of instruments...Procedure: Pre-Cleaning: When a tray or reusable instrument is used in locations other than the operating room, it will be pre-cleaned in the local dirty utility room. Instrumentation will have gross contamination removed prior to transport by rinsing with tap water or pre-cleaned with properly diluted instrument cleansing solution...Transportation: ...Cleaning solution will be drained before transport to CSR (Central Sterile Room). Instruments will be transported to CSR by Central Supply Technician or by department using instruments...Responsibility: CSR staff will process instruments daily (Monday - Friday). With turnaround times dependent on workload in CSR, but approximately 24-48 hours..."

Review of the "ProClense" instructions for use on the detergent bottle revealed, "...Directions: ProClense is recommended for use as a manual cleaning agent in pans or sinks. Start with 1 oz. (ounce)...of ProClense per gallon of warm water...For best results allow instruments to soak for at least 5 minutes to soften dried soils. Avoid soaking metal instruments or glassware over one hour...Contraindications: ProClense is not recommended for use on lensed instruments, scopes or soft metals such as aluminum, copper and brass."

Review of the document titled, "ProClense FAQs (Frequently Asked Questions) revealed, "...Can ProClense be used as a holding solution? It is not recommended because of its high pH. ProEz 2 dual enzymatic detergent, ProEZ 1 proteolytic enzymatic detergent or ProSpray C-60 holding/decontamination solution would be more suitable."

Examples in Dietary:

An observation of dietary department was conducted at 7:10 AM on 1/15/2020. In walk in freezer there was four, 9 x 13 in foil pans with six to eight frozen zip lock bags of homemade tomato sauce in each pan. There was no documented date that sauce was made or date to be used by on any of the pans or Ziploc bags containing products. There was one 9 x 13 in foil pan with bags labeled "chicken gravy" with an outdate of 12/17/2019. Another 9 x 13 foil pan had frozen bags of "chicken gravy" with no creation date or use by date and was obsereved to have freezer burn crystals in the bags.

An interview was conducted with Dietary Manager H on 1/15/2020 upon observation of the above stated items. Dietary Manager H stated "There should be a date on there of when it was made and frozen but I guess we don't have a system of knowing how long the items we make are good in the freezer. I see what you mean."


41127


Examples in Emergency Room:

On 1/14/20 at 10:06 AM, during a tour of the Emergency Department's soiled utility room, a one-gallon container of detergent labeled "ProClense" was observed with a pump dispenser emerging from the top of the container on a cart that also contained covered metal containers. There were no instructions for pre-cleaning or dilution of the detergent found posted in the room.

During an interview at 12:08 PM, Emergency Department Registered Nurse (ED RN) T stated, "When we have dirty instruments, we rinse them and put them in one of the covered bins and cover the instruments with the cleaner liquid." When asked how often the instruments are picked up for processing, ED RN T stated, "They pick them up daily. If the instruments are sitting more than a day I will rinse them and re-soak."

Examples inpatient obstetric area:

At 1:10 PM, during a tour of the obstetric department's soiled utility room with Inpatient Nurse Manager B, a one-gallon container of detergent labeled "ProClense" was observed with a pump dispenser emerging from the top of the container. There was a laminated note attached to the wall behind the detergent which revealed instructions to place dirty instruments into a metal container and cover the instruments with 1 pump of the detergent. Inpatient Nurse Manager B stated they then fill the container with enough water to cover the instruments, and place the cover on the container until it was transported to Central Sterile Processing. When asked how much detergent was dispensed with one pump, Inpatient Nurse Manager B stated, "You mean like a measurement? I don't know. We have never measured to see what the exact amount was."

On 1/15/20 at 10:06 AM, during an interview with Central Sterile Surgical Technician (CSST) U, when asked how other departments pre-clean and hold dirty instruments prior to reprocessing, CSST U stated, "Well, they use this ProClense. I am not too familiar with it." CSST U was observed pulling out a 1 gallon container of "ProClense" from a lower shelf and began to read the instructions for use on the back of the container. When asked if there were instructions for proper dilution, CSST U stated, "It says here one ounce per gallon of water." When asked if there were recommendations for a maximum length of time the instruments could soak in the detergent, CSST U stated, "I don't think there is a time limit. Wait, oh, I see it says for no more than one hour." When asked how often instruments from other departments are picked up for processing, CSST U stated, "Every day." When asked about weekends, CSST U stated, "Well no, not on weekends." When asked if there was the potential that instruments could be soaking for more than 1 hour prior to being picked up, CSST U stated, "Yes."