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Based on observation, staff interviews, and review of maintenance records between March 3, 2014 and March 6, 2014, the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

42 CFR 485.623: Condition of Participation: Physical Plant and Environment: NOT MET

Findings include:

The facility was found to contain the following deficiencies.
K 11: did not properly construct the rated separation wall between the nursing home and hospital;
K 14: did not provide corridor finishes with rated wall finish materials;
K 17: did not meet the permitted exceptions for spaces open to a corridor;
K 18: did not provide corridor separation doors with positive-latching dutch doors;
K 25: improperly constructed and maintained smoke barriers;
K 29: hazardous areas improperly enclosed;
K 38: doors were lockable in the required means of egress path;
K 51: fire alarm system not properly designed to transmit information of relocation;
K 52: did not maintain the fire alarm system according to NFPA 72 requirements;
K 56: deficiencies in the sprinkler system;
K 75: improper storage of trash and soiled linens;
K 106: did not provide a compliant Type I Essential electrical system;
K 130: Hospital: improper distance between bulk oxygen tank and combustibles; failed to located the tanker truck for refilling the bulk oxygen tank over a noncombustible surface;
K130: South Clinic: failed to properly protect the basement and main office which are hazardous areas from the rest of the building; failed to properly protect the north stair well out of the basement; and the walls of the exit enclosure out of the basement were not built to one hour fire rated construction.
K130: North Clinic: failed to properly protect the furnace room and storage areas; did not provide a landing at the top of an exit stair; did not maintain common path of travel within 75 feet; and did not properly protect the central stair well out of the basement;
K 144: the emergency generator did not have a remote stop; and
K 147: deficiencies in the general electrical system.

Refer to the 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 and interview with staff I, the hospital failed to ensure mechanical exercise equipment was properly maintained. This deficiency potentially affects all 8 patients served at the facility during this survey using physical therapy equipment.

Findings include:

Per observation, during a tour of the physical therapy gym and cardiac rehabilitation on 03/04/14 at 3:00 PM recumbent bicycles and steppers were observed in both locations. Per interview with Physical Therapy manager I at the time of the tour he and his staff are responsible for the maintenance of these pieces of equipment. According to I repairs and maintenance are done as needed and there is no formal preventive maintenance program in place.

Based on observation and interview with staff J the hospital failed to have a procedure in place to remotely monitor the temperature control of refrigeration in the pharmacy/drug room. This deficiency potentially affects all 8 patients served at the facility during this survey.

Findings include:

During a tour of the pharmacy with Pharmacist J on 03/05/14 at 9:00 AM it was observed that the refrigerator was not equipped to remotely alarm in the event of malfunction. According to J pharmacy staff record the refrigerator temps twice daily. J stated they are reliant on maintenance to notify them of electrical outages but do not have a formal procedure in place.

Based on observation, staff interviews, and review of maintenance records between March 3, 2014 and March 6, 2014, the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

42 CFR 485.623(d) Standard: Safety from Fire was NOT MET

Findings include:

The facility was found to contain the following deficiencies.
K 11: did not properly construct the rated separation wall between the nursing home and hospital;
K 14: did not provide corridor finishes with rated wall finish materials;
K 17: did not meet the permitted exceptions for spaces open to a corridor;
K 18: did not provide corridor separation doors with positive-latching dutch doors;
K 25: improperly constructed and maintained smoke barriers;
K 29: hazardous areas improperly enclosed;
K 38: doors were lockable in the required means of egress path;
K 51: fire alarm system not properly designed to transmit information of relocation;
K 52: did not maintain the fire alarm system according to NFPA 72 requirements;
K 56: deficiencies in the sprinkler system;
K 75: improper storage of trash and soiled linens;
K 106: did not provide a compliant Type I Essential electrical system;
K 130: Hospital: improper distance between bulk oxygen tank and combustibles; failed to located the tanker truck for refilling the bulk oxygen tank over a noncombustible surface;
K130: South Clinic: failed to properly protect the basement and main office which are hazardous areas from the rest of the building; failed to properly protect the north stair well out of the basement; and the walls of the exit enclosure out of the basement were not built to one hour fire rated construction.
K130: North Clinic: failed to properly protect the furnace room and storage areas; did not provide a landing at the top of an exit stair; did not maintain common path of travel within 75 feet; and did not properly protect the central stair well out of the basement;
K 144: the emergency generator did not have a remote stop; and
K 147: deficiencies in the general electrical system.

Refer to the 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 and interview with staff H, the hospital has failed to develop a policy governing the security of prescription pads. Based on observation and interview with staff J the hospital failed to have a procedure in place to remotely monitor the temperature control of refrigeration in the pharmacy/drug room. This deficiency potentially affects all 8 patients served at the facility during this survey.

Findings include:

Per observation, prescription pads were found unsecured throughout the hospital and clinics of this facility.

During a tour of the south clinic on 03/04/14 at 1:30 PM with clinic manager M unsecured prescription pads were found in unlocked drawers in the nursing station. Per interview with M during the tour the nursing station is sometimes not staffed. This lack of security could allow unauthorized access to prescription pads by staff, patients or visitors.

During a tour of the north clinic on 03/04/14 at 2:30 PM with clinic manager N unsecured prescription pads were found in unlocked drawers in the nursing station as well as in an unlocked storage room. Per interview with N during the tour the nursing station is sometimes not staffed. This lack of security could allow unauthorized access to prescription pads by staff, patients or visitors.

During a tour of the Outpatient Clinic office on 03/05/14 at 8:00 AM with Respiratory Therapy manager G unsecured prescription pads were found in unlocked drawers in the office. Per interview with G the office door is not locked. This lack of security could allow unauthorized access to prescription pads by staff, patients or visitors.

Per interview with Nurse Manager H on 03/05/14 at 2:00 PM the hospital has no policy governing the security of physician's prescription pads.

Based on observation, policy and interviews with facility staff (D,I,M &N), the hospital failed to ensure that all drugs and biologicals are appropriately stored to ensure the safety of patients and to prevent unauthorized access. This deficiency potentially affects all 8 patients served at the facility during this survey.

Findings include:

1. Per observation, while touring the facility with Radiology manager L on 03/03/14 at 2:00 PM, it was noted that the drug reaction kit which contain drugs and biologicals (Atropine, Atropine Sulfate, Benadryl, Epinephrine, Solu-Cortef, Ventoline and Ammonia inhalant capsules) located in the Computed Tomography (CT) room was in an unlocked drawer. The CT room is unlocked and accessible to unauthorized individuals.

Per interview, with L at the time of the observation, patients,visitors and unauthorized staff could access the carts without staff knowledge.

2. Per observation, while touring the rehabilitation department with Physical Therapy Manager I on 03/04/14 at 3:00 PM, drugs and biologicals (ethezyme ointment, bacitracin and santyl) were found in an unlocked drawer in the therapy department.

3. Per observation, while touring the Emergency department (ED) with ED Manager D on 03/05/14 at 10:00 AM, expired drugs and biologicals (2 X 20 milliliter vials of saline expiration dates 3/1/14) were found in the pediatric crash cart.

Per interview with ED Manager D at the time of the tour outdated med's should be monitored by staff.

Hospital policy entitled: "Procedure for checking outdates" dated 08/12 states;

"At the end of every month the pharmacy tech will check medications at the nurse's station, emergency room, and OR for outdates and replace them.

Medications in the pharmacy are checked monthly by the pharmacy tech for outdates.

Crash cart outdates will be done monthly by nursing staff as assigned."

4. Per observation, while touring the Nursing station medication room with ED Manager D on 03/05/14 at 10:30 AM, expired drugs and biologicals (2 bottles of "GI cocktail" expiration date 12/13) were found in the wall cabinets.

Hospital policy entitled; "Multidose Vials" revised 02/09 states; "Multidose vials have to be dated when opened and can be used for a length of 28 days as long as they contain preservatives and are labeled for the date and time vial is open."

5. Per observation, while touring the South Clinic with clinic manager M on 03/04/14 at 1:30 PM, multi-dose vials of lidocaine were found opened with no date of opening indicated. M stated at the time of the tour that opened multi-dose vials should be dated and discarded after 28 days. During this same tour liquid nitrogen was found unsecured in an unlocked storage room, outdated culture swabs were found in the nursing station and a tank of nitrous oxide in the basement. M agree that the basement is accessible by unauthorized staff who do not need access to the nitrous oxide.

6. Per observation, while touring the North Clinic with clinic manager N on 03/04/14 at 2:15 PM, a multi-dose vial of lidocaine was found opened with no date of opening indicated. N stated at the time of the tour that opened multi-dose vials should be dated and discarded after 28 days. During this same tour outdated culture swabs were found in the nursing station and unsecured medications were found in an unlocked procedure room.

Based on observation and interviews with facility staff, the hospital does not ensure that patient supplies and medications are properly stored, the environment is kept clean, and that there is a system in place to prevent potential sources of contamination and infection. This deficiency potentially affects all 8 patients served at the facility during this survey.

Findings include:

1. Supplies are stored in cabinets under sinks in the following areas;

-In the hallway by radiology exam room #2 various supplies were stored under a sink including;cleaning supplies, paper towels and photobrome tablets. This was observed on 03/03/14 at 2:05 PM during a tour with Radiology Manager L. L agreed at the time of the tour that supplies should not be stored in this area.

-During a tour of the Emergency Department (ED) with ED manager D on 03/05/14 at 10:00 AM it was observed that a cabinet under the sink was used for storage. Items stored there included; cleaning supplies, sand bags (for patient positioning) and a sharps container. D agreed at the time of the tour that this area should not be used for storage.

-During a tour of the Physical Therapy (PT) Gym with PT manager I on 03/04/14 at 3:00 PM it was observed that a cabinet under the sink was used for storage. Items stored there included; cleaning supplies, syringes and medications. I agreed at the time of the tour that this area should not be used for storage.

-During a tour of Central Supply (CS) with CS manager E on 03/05/14 at 11:30 AM it was observed that a cabinet under the sink in the sterilizing room was used for storage. Items stored there included; cleaning supplies and basins. E agreed at the time of the tour that this area should not be used for storage.

-During a tour of the Recovery Room with Surgical manager F on 03/04/14 at 10:00 AM it was observed that a cabinet under the sink was used for storage. Items stored there included; a formalin spill kit, masking tape and a spray lubricant. F agreed at the time of the tour that this area should not be used for storage.

-During a tour of the Respiratory Therapy (RT) office/ outpatient Clinic office with RT manager G on 03/05/14 at 08:00 AM it was observed that a cabinet under the sink in the office was used for storage. Items stored there included; cleaning supplies, paper towels and gloves. G agreed at the time of the tour that this area should not be used for storage.

-During a tour of the nursing station medication room with ED manager D on 03/05/14 at 10:30 AM it was observed that a cabinet under the sink in the med room was used for storage. Items stored there included; paper towels and plastic bags. D agreed at the time of the tour that this area should not be used for storage as items stored there could become wet, dirty and unusable.

-During a tour of the south clinic with clinic manager M on 03/04/14 at 1:30 PM it was observed that cabinets under the sinks in the nursing station were used for storage. Items stored there included; educational materials, labels, clipboards and cleaning materials. In addition clean linen was found uncovered in the supply room. Items stored under the sinks are subject to contamination and moisture, linen should be covered to prevent its contamination by dust.



12187

FINDINGS INCLUDE:

1. On 03/03/2014 at 2:10 PM, observation revealed that the air flow in the material management sterile area, was from outside the room into the room (from dirty to clean). Compliant air flow is from clean to dirty. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance).

2. On 03/03/2014 at 3:14 PM, observation revealed that the ceiling tile in the women's locker room near the laundry had ceiling tiles with darken areas on them which looked like mold. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance).

3. On 03/04/2014 at 8:50 AM, observation revealed that the operating room (autoclave area) has a floor drain. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance), and staff P (Maintenance Supervisor).

4. On 0304/2014 at 9:05 AM, observation revealed that the air flow for the dirty 'clean up room' was from the room into the corridor, or from dirty to clean. Compliant air flow is from clean to dirty. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance), and staff P (Maintenance Supervisor).

5. On 03/04/2014 at 9:15 AM, observation revealed that the air flow for the clean supply room (OR area) was into the room from the corridor, rather than out of the room, or from dirty to clean. Compliant air flow is from clean to dirty. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance), and staff P (Maintenance Supervisor).

6. On 03/04/2014 at 9:18 AM, observation revealed that the air flow for the sterile storage area, was into the room from the corridor, rather than out of the room, or from dirty to clean. Compliant air flow is from clean to dirty. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance), and staff P (Maintenance Supervisor).

7. On 03/04/2014 at 10:00 AM, observation revealed that in the nurse's lounge bathroom, 'scrubs' and spare IV pumps are stored in the room uncovered. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance), staff P (Maintenance Supervisor), and Staff Q (RN).

8. On 03/04/2014 at 10:30 AM, observation revealed that in the PT bathroom, clean linens and 5 large water bottles for water coolers were stored within this bathroom. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance), and staff P (Maintenance Supervisor).

9) On 03/04/2014 at 9:30 AM, observation revealed that staff B was in the clean operating room 'setting up' without a mask covering his beard. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (CRNA).

Based on medical record review, and interviews with facility staff, in 12 of 18 medical records reviewed requiring a nursing care plan (#1 through 7, 9, 10, 11, 13 &15) out of a total of 30 MR reviewed, the hospital does not ensure that nursing care plans developed for each patient are kept current to reflect progress toward goals. This deficiency potentially affects all 8 patients served at the facility during this survey on the medical-surgical unit.

Findings include:

1. Per MR (medical record) review on 03/03/14 through 03/06/14 the nursing care plans found in the MR of patients #1, 2, 3, 4, 5, 6, 7, 9, 10, 11, 13, 15 did not contain nursing staff documentation reflecting progress towards goals

Per interview, with Informatics Nurse C on 03/06/14 at 10:00 AM, the nursing care plans are developed from a computer system. Per C, she was able to print a list of nursing goals being "achieved" or "progressing", but is not sure why the nursing staff are not specifying nursing interventions or progress as part of the nursing care plan. As a result, the nursing care plan in incomplete and not kept up-to-date.

Based on tour of the hospital with staff and review of policy, the facility failed to ensure records are protected from potential loss or damage. This deficiency potentially affects all 8 patients served at the facility during this survey.

Findings include:

Hospital policy entitled; "Confidentiality Policy" dated 10/13 states;

"All medical records are the property of the hospital and the confidence of the records is the right of the patient. Wisconsin Statutes 146.81, 146.82 and 146.83 regulate the confidentiality of and access to patient health care records. Release of these records is prohibited without the written information consent of the patient or their legal guardian."

Per tour of the radiological record storage area with Radiology Manager L on 03/03/14 at 2:05 PM the door to a public hallway was unlocked as well as a service window being open. The records area was not routinely staffed by hospital personnel. This lack of security allows for unauthorized access to medical records by patients, visitors and staff.

Per tour of the Central supply (CS) area with CS Manager E on 03/05/14 at 11:00 AM the door to a public hallway was unlocked. Billing records with patient information were stored in the CS area. The area was not staffed by hospital personnel. This lack of security allows for unauthorized access to medical records by patients, visitors and staff.

Per tour of the South Clinic with clinic manager M on 03/04/14 at 1:30 PM the door to a storage room was unlocked and medical records were stored unsecured. Additional unsecured medical records were stored in the office and in the basement of the clinic. This lack of security allows for unauthorized access to medical records by patients, visitors and staff.

Based on medical record review and interview with facility staff in 5 of 5 medical records reviewed requiring a post operative anesthesia exam (#17, 18, 19, 20, 21) out of a total of 30 records reviewed, the hospital failed to ensure that the post operative examinations are complete to include cardiopulmonary status (vital signs), level of consciousness, any follow-up care and /or observations and any complications occurring during post-anesthesia recovery. This deficiency potentially affects all 8 patients served at the facility during this survey.

Findings include:

1. Per MR (medical record) review, on 03/06/14 at 11:00 AM , the post-anesthesia evaluation note dated 01/30/14 found in the MR of patient #17 did not include a cardiopulmonary evaluation (Heart rate, respiratory rate, blood pressure or oxygen saturation), pain, level of consciousness or level of activity. The note was not timed.

2. Per MR review, on 03/06/14 at 11:00 AM , the post-anesthesia evaluation note dated 03/04/14 found in the MR of patient #18 did not include evaluation of respiratory rate.

3. Per MR review, on 03/06/14 at 11:00 AM , the post-anesthesia evaluation note dated 01/22/14 found in the MR of patient #19 did not include evaluation of respiratory rate, oxygen saturation or level of activity.

4. Per MR review, on 03/06/14 at 11:00 AM , the post-anesthesia evaluation note dated 01/28/14 found in the MR of patient #20 did not include a cardiopulmonary evaluation (Heart rate, respiratory rate, blood pressure or oxygen saturation), pain, level of consciousness or level of activity. The note was not timed or dated.

5. Per MR review, on 03/06/14 at 11:00 AM , the post-anesthesia evaluation note dated 11/14/13 found in the MR of patient #21 did not include a evaluation of respiratory rate, pain or level of activity.

These examples were confirmed per interview with Informatics Nurse C on 03/06/14 at 11:00 AM. She stated that the documentation was incomplete.

Based on review of policies and interview with staff B, the hospital failed to review and update policies related to anesthesia. This deficiency potentially affects all 8 patients served at the facility during this survey.

Findings include:

Per interview with CRNA (Certified Registered Nurse Anesthetist) B on 03/04/14 at 11:30 AM Anesthesia policies had not been reviewed since 1994. The "Anesthesia Procedure Policies" provided for review were not dated.