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Based on record review and interview, the facility failed to ensure compliance with Federal Laws and Regulations that Medicare recipients receive an "Important Message from Medicare" (IMM) document within 48 hours of discharge in 1 of 16 Medicare recipient records reviewed (Patient #18) in a total sample of 20.

Findings include:

Review of medical records revealed Patient #18 was admitted to the facility on 07/23/2022 and discharged on 07/27/2022. Patient #18 was a Medicare recipient and did not have a documented second IMM completed prior to discharge.

During an interview on 9/28/2022 at 3:22 PM with Registered Nurse W, when asked if there should have been a second IMM notice within 48 hours of discharge for Pt #18, Registered Nurse W stated, "There was no second one given, I don't see it."

Based on record review, observation and interview the facility failed to ensure that crash carts containing emergency equipment and medications were maintained according to facility policy in 3 of 7 crash carts observed in 1 of 11 departments (Emergency Department) in a total of 11 departments.

Findings include:

A review of the facility policy, titled "Medical Emergency/Code Blue Policy-MMC Minocqua and MMC Park Falls" last revised/reviewed 01/26/2022, revealed: "3.6 Equipment Checks a. Routine Checks-Frequency: Crash carts will be checked at least daily or more frequently in departments supporting 24 hour care."

An observation was made in the Emergency Department (ED) room #2 on 09/27/2022 at 1:00 PM of facility document "Emergency Equipment Checklist" which had no documented daily checks completed on 07/04/2022, 07/19/2022, 08/13/2022, 08/14/2022, 08/29/2022, 08/30/2022, and 08/31/2022.

An observation was made in the Emergency Department (ED) room #3 on 09/27/2022 at 1:00 PM of facility document "Emergency Equipment Checklist" which had no documented daily checks completed on 07/04/2022, 07/19/2022, 07/28/2022, 07/30/2022, 08/13/2022, 08/14/2022, and 08/26/2022.

An observation was made in the Emergency Department (ED) room #4 on 09/27/2022 at 1:00 PM of facility document "Emergency Equipment Checklist" which had no documented daily checks completed on 07/10/2022, 07/19/2022, 07/20/2022, 07/28/2022, 08/01/2022, 08/02/2022, 08/03/2022, 08/06/2022, 08/13/2022, 08/14/2022, 08/18/2022, 08/26/2022, and 08/27/2022.

During an interview on 09/27/2022 at 1:15 PM, Medical/Surgical and ED Manager Q stated, "Yes those dates are missing crash cart checks."

Based on observation, record review and interview, the facility failed to adhere to the hospital policy that governed the handling and disposal of potentially infectious blood and blood components in 1 of 1 departments that store blood products (Laboratory) in a total of 11 departments toured.

Findings:

During a tour of the Laboratory (Lab) Department with Lab Manager U on 09/28/2022 at 9:30 AM, observed one unit of quarantined blood dated "3-28-2022" in a covered plastic container on the bottom shelf of the blood bank refrigerator.

A review of form "SUBSEQUENT POST DONATION INFORMATION OR MANUFACTURING ERROR-BIOLOGICAL MARKET WITHDRAWAL/RECALL-URGENT" dated "3-28-2022", that was wrapped around the unit of quarantined blood found in the Blood Bank refrigerator, revealed: "subsequent to the donation date (3-19-2022), potential donor referral or manufacturing error information has been reported. Potentially Deferring Information: Donor developed minor illness within 48 hours of donation: Post Donation illness flu-like sx [symptoms]...Available Product Action Required: Discard and email proof of discard (i.e. computer screen shot)..."

A review of the facility policy titled, "BLOOD SUPPLIER CONSIGNEE NOTIFICATIONS, RECALLS AND LOOKBACKS", last reviewed 07/08/2022, revealed: "....DEFINITIONS: Non-Conforming Blood Product:...receipt of post-donation information regarding the donor history, health, or behavior which may affect the safety, purity and/or potency of the blood component...If units in inventory: *Physically quarantine unit...*Return products to blood suppliers as requested *Complete documentation for shipment as applicable...If units(s) discarded:...Fax/return completed blood supplier forms(s) to blood supplier..."

During an interview on 09/28/2022 at 9:58 AM with Lab Manager U, when asked about the quarantined unit of blood in the blood bank refrigerator dated 03/08/2022, Lab Manager U stated, "I held onto this one a bit longer than I needed to." Manager U then disposed of the unit of quarantined blood.

During an interview on 09/28/2022 at 11:45 AM with Director of Lab Operations V, when asked about the process of a unit of quarantined blood dated 03/28/2022 in the blood bank refrigerator, Lab Operations V stated, "Oh my goodness, I would not expect that blood to be in there still, we have a robust support system with Transfusion Services that would instruct to discard the unit." When asked if the quarantined unit of blood dated 03/28/2022 should have been discarded, Lab Operations V stated, "Yes, I'm not sure why this was not discarded."

During an interview on 09/28/2022 at 12:01 PM with Transfusion Services Representative W, when asked about the discarding process of the unit of quarantined blood dated 03/28/2022, Representative W stated, "It was discarded in the Blood Bank computer system on 03/31/2022, just wasn't physically discarded." Representative W confirmed that the completed form wrapped around the unit of quarantined blood should have gone back to the Blood Bank to close the loop after discarded.

Based on observation, record reviews 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:

K211 Means of Egress - General Headroom
K291 Emergency Lighting
K351 Sprinkler Installation
K353 Sprinkler System Maintenance and Testing
K363 Corridor Doors
K916 EES Alarms
K920 Power Cords and Extensions

As a result of these deficiencies, 42 CFR 485.623 Condition of Participation: Physical Plant and Environment was NOT MET.

Based on record review, observation and interview, the facility failed to check patient food refrigerators according to their facility policy in 1 (emergency department) of 2 patient food storage areas observed in a total of 11 departments.

Findings include:

A review of the facility policy, titled "Food and Nutrition-Cold Storage Temperatures", last revised/reviewed 06/20/2022, revealed: "3. Procedure body-3.1 Supervisor: b. Each morning at opening and evening at closing, record temperatures of each storage unit; initial each entry."

An observation was made in the Emergency Department (ED) on 09/27/2022 at 1:00 PM of facility document "Nursing Unit Refrigerator Log" which had no documented daily checks completed in August 2022 for 17 out of 31 days and in September 2022 for 19 out of 26 days.

During an interview on 09/27/2022 at 1:15 PM, Medical/Surgical and ED Manager Q stated, "Yes those dates are missing refrigerator checks."

Based on observation, record reviews 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:

K211 Means of Egress - General Headroom
K291 Emergency Lighting
K351 Sprinkler Installation
K353 Sprinkler System Maintenance and Testing
K363 Corridor Doors
K916 EES Alarms
K920 Power Cords and Extensions

As a result of these deficiencies, 42 CFR 485.623(c) Life Safety from Fire was NOT MET.

Based on observation, record review, and interview, the facility failed to maintain a sanitary environment free of potential contamination to patients and staff in 1 of 11 departments (Medical/Surgical) observed, and failed to ensure appropriate infection precautions (hand hygiene) were taken in 1 of 11 departments (Operating Room) observed.

Findings include:

A review of the facility policy, titled "Infection Prevention and Control Services Policy" last revised and reviewed on 02/19/2021, revealed: "Purpose Statement: The purpose IP (Infection Prevention) is to provide a safe environment for patients, employees and visitors through continuous surveillance for infections, institution of appropriate infection prevention and control precautions, quality improvement activities, education, and research to continually update best practices to prevent and control infectious disease transmission throughout the health care system..."

Medical/Surgical Department:

During a tour on the Medical/Surgical (Med/Surg) unit on 09/28/2022 at 4:15 PM with Med/Surg/Emergency Department (ED) Manager Q, multiple areas of chipped paint and chipped wood were noted on doors and walls in 18 of 18 patient rooms observed (Room #'s 205, 206, 207, 208, 209, 210, 211, 212, 213, 221, 222, 223, 224, 225, 226, 227, 228, and 229).

During an interview on 09/28/2022 at 4:15 PM with Med/Surg/ED Manager Q, when asked about the paint chips on the walls, doors and the chipped wood on doors in the patient rooms on the Med/Surg floor, Med/Surg and ED Manager Q stated, "I guess those areas are a low priority since we are going to be building a new hospital."


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Operating Room Department:

A review of facility policy, titled "Hand Hygiene" last reviewed 07/08/2021, revealed: "Hand can be decontaminated with alcohol based hand rubs... Before and after contact with patients... After contact with items in patient room ... before donning gloves... Change gloves and cleanse hands during patient care when moving from a contaminated body site to a clean body site."

On 09/27/2022 at 9:55 AM, during observation of colonoscopy performed on Patient #15, Surgical Technician J assisted with rectal polyp removal. Technician J removed gloves and did not perform hand hygiene before labeling specimen container and donning another pair of gloves.

On 09/27/2022 at 10:00 AM during observation of colonoscopy on Patient #15, Circulation Registered Nurse (RN) K touch Patient #15's left leg. RN K then removed gloves, and then touched computer for computer entry before completing hand hygiene and donning another pair of gloves.

On 09/27/2022 at 10:16 AM during observation of colonoscopy on Patient #15, Doctor M removed gloves and opened procedure room door to exit without completing hand hygiene after glove removal.

On 09/27/2022 at 10:31 AM during observation of colonoscopy on Patient #16, RN K touched Patients #16's back, then removed gloves and touched computer for computer entry before completing hand hygiene and donning another pair of gloves.

On 09/27/2022 at 10:43 AM during an interview with Operating Room Supervisor X, Supervisor X confirmed, "hand sanitizer" should be used after touching a patient and taking off gloves, before donning a new pair of gloves, or before exiting the Procedure Room.