HospitalInspections.org

Based on record review and interview, facility staff failed to inform 3 of 3 patients of their Medicare discharge rights (Patient 16, Patient 17, Patient 20). This deficiency has the potential to affect all Medicare patients admitted to the facility.

Findings include:

Review of facility policy "Documentation Standard", policy #762177, dated 4/2014 states in part: "Medicare IM (Important Message) Notice Documentation: HUC (Health Unit Coordinator) to provide initial Medicare IM notice for patient signature, and Case Management to support process as needed. Case Management to ensure Discharge Medicare IM notice provided to patient/family within 48 hours of discharge in collaboration with Nursing."

Per medical record review on 3/1/2017 at 10:05 AM, Patient 16, age 68, received inpatient services from 1/28/2017 through 2/7/2017. Patient #16's record did not include a signed copy of the Medicare IM notice or documentation that the patient received the notice.

Per medical record review on 3/1/2017 at 11:05 AM, Patient 17, age 71, received inpatient services from 2/11/2017 through 2/14/2017. Patient #17's record did not include a signed copy of the Medicare IM notice or documentation that the patient received the notice.

Patient 20, age 80, was admitted to the facility on 2/14/2017 and continued as inpatient status at the time of medical record review on 3/1/2017 at 3:00 PM. Patient 20's medical record did not contain documentation that the Patient 20 received notice of discharge rights since admission on 2/14/2017.

During an interview on 3/1/2017 at 4:55 PM, Director of Accreditation Y stated the facility was unable to provide documentation that the above patients had received notice of their discharge rights. Per Y, "there is a question over whose responsibility it is [to provide the notice]."

Based on record review and interview, the facility staff failed to provide Advance Directive Information to 4 of 7 patients (Patient 19, Patient 23, Patient 34, Patient 3) reviewed out of a total sample of 43 patients. This could potentially affect all 901 patients on census at the time of the survey (Patient census 2/27/2017 -173, 2/28/2017 - 243, 3/01/2017 242, and 3/02/2017 - 243).

Findings include:

Review of facility policy "Advance Directives", Policy #869638, dated 5/2014 states in part: "2. During the patient admission assessment process, each patient will be asked by the nursing staff whether he/she has advance directives for health care... 3. If the patient is unable to receive information (due to an incapacitating condition or mental disorder) or to articulate whether he/she has advance directives, the hospital will give advance directives information to the significant other. A. Nursing will document on the Patient Admission Assessment form whether the patient has advance directives... 4. If a patient does not have advance directives, the patient will be asked if he/she would like additional information and/or assistance. If so, a referral will be forwarded to the Case Management Department for forms, additional information, and assistance in completing the document. If the patient does not wish to make verbal or written advance directives, this decision is noted on the Patient Admission Assessment."

The facility policy titled "Advance Directives", Policy #3027578, expiration date 05/2017 was reviewed. This document stated under Inpatient Settings "4. If a patient does not have advance directives, the patient will be asked if he/she would like additional information and/or assistance. If so, a referral will be forwarded to the Case Management Department for forms, additional information, and assistance in completing the document."

The facility policy titled "Medical Social Work Triggers", Policy #3341236, expiration date 02/2020 was reviewed. This document stated under #4 "Case Manager will use these key concepts... on a daily basis to make referrals to a Social Worker". Under Triggers for Medical Social Work Consults, Advanced Directives, "Desires information of Advance Directives".




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Per medical record review on 3/1/2017 at 2:10 PM, Patient 19 received inpatient services from 2/21/2017 through 2/26/2017. Patient 19's admission assessment states "No Advance Directive Document found". Advance Directives "No." A "Yes" or "No" checklist under "Patient Wishes to Update/Receive Further Information" is left blank. There is no documentation that Patient 19 was offered information regarding Advance Directives during the inpatient stay.

Per medical record review on 3/2/2017 at 9:30 AM, Patient 23 was admitted to the facility on 2/11/2017. Patient 23 admission assessment states "No Advance Directive Document found." Advance Directives "Unknown." A "Yes" or "No" checklist under "Patient Wishes to Update/Receive Further Information" is left blank. Case Management notes do not include a discussion of Advance Directives from 2/11/2017 through 2/28/2017. During a patient interview on 2/28/2017 at 9:15 AM, Patient 23 and Patient 23's family stated advance directives had not been discussed with the patient during the hospitalization. Patient 23 and Patient 23's family stated they would like some information about advance directives and "we would like to talk to someone [about advance directives]."

Per medical record review on 3/2/17 at 9:45 AM, Patient 34's nursing and social work documentation revealed no documentation that patient had an established advanced directive, and no documentation that the hospital informed this patient of the right to formulate one.

Patient 43's Medical Record was reviewed on 3/02/2017 at 10:31 AM with Med/Surg Telemetry Manager VVV. Patient 43 was admitted from the Emergency Room to the Medical/Surgical unit on 2/15/17 at 1:51 PM. Admission assessment for advanced directives is marked yes, (requesting information) which triggered a Case Manager referral. No follow-up with advanced directives at time of record review. Patient #43 remains inpatient.

Clinical Nurse Leader YY stated during an interview on 3/1/2017 at 3:00 PM, "nursing staff is expected to ask patients if they have an advance directive upon admission. If the patient would like additional information, a referral is sent to Case Management."


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During interview with Behavioral Health Patient Manager P on 3/2/17 at 9:45 AM, Behavioral Health Patient Manger P stated "nursing and/ or social work is supposed to document that information, but it is not documented for this patient".

Based on record review and interview, the hospital failed to ensure that physical holds utilized for the purpose of involuntary medication administration or prevention of violent acts against self, staff or other patients until other physical restraints could be applied, were assessed and documented under restraint guidelines in 1 of 2 patients (Patient 35) utilizing physical restraint/seclusion. This affects all in-patients/out-patients who have the potential for restraint application.

Findings include:

Review on 3/2/2017 at 4:00 PM, of policy titled "Restraint and Seclusion, revised 1/2017" revealed "Restraint: The use of a manual, physical, or mechanical device, material or equipment attached or adjacent to the patient's body he or she cannot easily remove that restricts freedom of movement or normal access to one's body... A. Physician Orders... 6. Security staff is authorized to assist with restraint application, but only at the direction of and in the presence of a physician or a RN (Registered nurse)...".

Patient 35's medical record was reviewed on3/2/2017 at 9:50 AM and revealed a "code purple" was called for physical violence against patient-to-patient and patient-to-staff behavior. Documentation by RN (Registered Nurse) RRR on 11/13/2016 at 9:18 AM revealed "...Code called and patient subdued; five point restraints ordered".

During interview with Behavioral Health Director N and Behavioral Health Patient Manager P on 3/2/2017 at 10:10 AM, Behavioral Health Patient Manager P stated "the code was a code purple used by the staff to alert security of the need for assistance with patient behavior. The security staff are trained to use physical holds for patients until restraints can be applied". When asked about the restraint documentation for the use of the physical hold applied to Patient 35, N stated "we don't document physical holds, and I was not aware that we had to". Behavioral Health Patient Manager P stated "we did not consider physical holds as a restraint". The hospital had no documented evidence that Patient 35's physical hold, prior to five point restraint application, was documented/evaluated as a physical restraint.

Based on record review and interview, the hospital failed to ensure that medical orders, for restraint application, were obtained within minutes of the emergency application of the restraint, in 1 of 2 patients (Patient #35) utilizing physical restraint/seclusion. This affects all in-patients/out-patients who have the potential for restraint application.

Findings include:

Per review on 3/2/2017 at 4:00 PM review of policy titled "Restraint and Seclusion, revised 1/2017" revealed "... A. Physician Orders 1. A physician's ordered for a restraint is required prior to the initiation of restraints unless it is an emergency. In an emergency situation, a registered nurse may initiate restraint. If this occurs, an order must be obtained during the application or within minutes."

Per review on 3/2/2017 at 9:50 AM review of policy titled "restraint/seclusion" documentation dated 11/13/2016 at 6:20 AM for Patient #35 reveals a "code purple" was called for physical violence against patient-to-patient and patient-to-staff behavior. Documentation by RN (Registered Nurse) RRR on 11/13/2016 at 9:18 AM revealed "...Code called and patient subdued; five point restraints ordered". The 3/2/2017 at 9:50 AM record review of the "restraint/seclusion flow sheet" revealed the five point restraint was initiated at 6:00 AM. Record review of Patient #35's physician "order history" revealed the medical restraint order was "entered and signed electronically" by RN SSS at 9:05 AM.

During interview with Behavioral Health Patient Manager P on 3/2/2017 at 10:10 AM, P stated "when the nurse has to stabilize a crisis situation, it can delay the order entry."

Based on record review and interview, the hospital failed to ensure that restraint and/or seclusion must be discontinued at the earliest possible time based on the patient's condition and the safety of patient and others, in 2 of 2 patients (Patient #35, Patient #36) utilizing physical restraint/seclusion. This affects all in-patients/out-patients who have the potential for restraint application.

Findings include:

Per review on 3/2/2017 at 4:00 PM review of policy titled "Restraint and Seclusion, revised 1/2017" revealed"... 5. A. Discontinuing of Restraint/Seclusion, A. Staff will provide assistance to patient's in meeting the behavioral criteria for release from the restraint and/or seclusion. Restraint and seclusion use is discontinued when the patient meets the behavioral criteria. Behavior criteria may include, but are not limited to: 1. The patient is able to contract for safety. 2. The patient is oriented to the environment. 3. Cessation of verbal threats."

Per review on 3/2/2017 at 9:50 AM medical record revealed Patient #35 was put into five point restraints at 6:00 AM on 11/13/2016 at 6 :20 AM for violent behavior directed at patient peer and patient care staff member. At 6:00 AM, Patient #35 was "self destructive" and "combative" according to the 11/13/2016 "restraint/seclusion flow sheet", which documented demonstrated patient behaviors every 15 minutes.

Continued review of the behavior documented by RN (registered nurse) TTT revealed that from 6:45 AM through 11:30 AM, Patient #35 was described as "quiet", with documentation at 6:30 AM, 6:45 AM and 8:15 AM described as "crying". Patient #35 was documented as "drowsy" 10:00 AM, 10:45 AM and 11:00 AM. At 9:15 AM through 10:30 AM and at 11:30 AM, this patient was documented as being "alert and oriented to surroundings". There was no documented evidence of behaviors on this flow sheet that revealed that Patient #35 was a danger to self or others, and there was no documented evidence of behaviors stating that Patient #35 had not met the hospital policy requirements for restraint release. Patient #35 was in five point restraints continuously for 5 hours and 30 minutes.

Per review on 3/2/2017 at 10:18 AM of Patient #35's medical record review of Physician XXX's behavioral face-to-face progress note dictated at 9:41 AM on 11/13/2016 revealed that when seen Patient #35 was "in restraints", "not psychotic now", "regrets what was done" and was able to agree to a plan to not threaten others (patients on unit) and approve changes to behavioral medications.

Per review on 3/2/2017 at 10:53 AM record review of Patient #36's "behavioral medicine progress notes" revealed "became increasingly agitated after meeting with the doctor and hearing that (patient) would not be discharged today. Patient started verbally threatening staff, slamming doors and acting out aggressively. MD (medical doctor) notified and PRN PO (as needed oral) medication orders were obtained and given. Patient agitation continued to increase, security was called to the unit and MD ordered patient to locked seclusion with 1:1 observation. MD also ordered IM (injection into muscle) PRN (as needed) Haldol (anti-psychotic medication) which was given... Patient was compliant with PRN medication administration and entered seclusion without incident. Shortly after medication administration patient was asleep on mattress in seclusion room. At 10:30 AM, the order for locked seclusion was discontinued and the door was opened. The patient walked out of the seclusion room by self at approximately 11:00 AM ...". The every 15 minute behavior description documented by Staff UUU on the 11/17/2016 "restraint/seclusion flow sheet" describes Patient #36 as "quiet" the entire time. There is no documented evidence that the behavior of this patient justified that locked seclusion was needed for the entire 1 hour period (9:30 AM through 10:30 AM). There is no documented evidence that Patient #36 did not meet the hospital policy criteria for restraint release.

During interview with Behavioral Health Director N and Behavioral Health Patient Manager P on 3/2/2017 at 11:00 AM, Behavioral Health Patient Manager P stated "there could have been better documentation to describe Patient #35 and Patient #36's behavior".

Based on record review and interview, the hospital failed to ensure the physician or other qualified licensed practitioner documented the 1 hour face-to-face evaluation needed for the the use of violent behavior restraint application, in 1 of 2 patient's (Patient #35) utilizing physical restraint/seclusion. This deficiency has the potential to affect all in-patients/out-patients who have the potential for restraint application.

Findings include:

Per review on 3/2/2017 at 4:00 PM review of hospital policy titled "Restraint and Seclusion, revised 1/2017" revealed "... B. Monitoring /Documentation... 3. A physician conducts an in-person evaluation of the patient within one hour of the initiation of restraint or seclusion. At the time of the in-person evaluation, the physician works with the patient and staff to: a. Identify ways to help the patient regain control, b. Make necessary revisions to the patient's treatment plan, c. Provide a new order if necessary...".

Per review on 3/2/2017 at 9:50 AM medical record review of Patient #35's "restraint/seclusion flow sheet" revealed the five point restraint was initiated at 6:00 AM. There is no documented evidence that a physician or other qualified licensed practitioners evaluated and documented the patient's immediate situation, reaction to restraint intervention, medical or behavioral condition, or the need to continue or terminate the restraint/seclusion.

During interview with Behavioral Health Director N and Behavioral Health Patient Manager P on 3/2/2017 at 10:10 AM, Behavioral Health Patient Manager P stated "we recognized the physician did not document the necessary information about the 1 hour face-to face evaluation for Patient #35. When we tried to contact the physician, the physician was on prolonged medical leave from the hospital".

Based on record review and interview, the hospital failed to ensure that patients received a comprehensive nursing evaluation of their chief complaint , in 1 of 1 outpatient patient assessments reviewed (Patient 41) in the Riverwoods outpatient clinic. This has the potential to affect all outpatients seen in the outpatient facilities.

Findings include:

Review of policy titled "Documentation -Admission History and assessment-Patient", revised 5/2015" stated "2. All patients will be assessed on admission by a RN (registered nurse). The RN will use clinical judgment to determine admission assessment guidelines...".

Record review for Patient 41 revealed admission registration as an urgent care out-patient on 2/18/16 for "stomach ache, pain and constipation". Review of the nursing assessment revealed no comprehensive assessment/evaluation of this patient's gastrointestinal system.

An interview was conducted with Urgent Care RN ZZZ at 3/1/17 at 9 AM, ZZZ stated "this should have been done".

Based on record review and interview, nursing staff at this facility failed to develop and maintain an individualized patient plan of care for 16 of 46 medical records reviewed (Patient 3, 5, 6, 7, 9, 10, 16, 17, 18, 20, 27, 31, 32, 33, 34 and 43). This could potentially affect all 901 patients on census at the time of the survey (Patient census 2/27/2017 -173, 2/28/2017 - 243, 3/01/2017 242, and 3/02/2017 - 243).

Findings include:

An interview was conducted with Vice President Patient Care O and Clinical Nurse Specialist W on 3/02/2017 at 9:52 AM. O stated that they had identified gaps in their care plan documentation, but that the general expectation for care plans was that they were started on admission by a Registered Nurse, they were individualized according to the Registered Nurse (RN) patient assessment, and that they were updated with a D = Data; A = Action; R = Response. ...E. Response (DAR) note in the progress note daily by an RN to reflect the plans of care stating "this will be the go-to place" to document and find the plan of care and other information that needs to be passed on from one nurse to another.

Review of the facility policy "Documentation - Progress Notes - Focus Charting", Policy #2700366, dated 8/2016 states: "1. Focus Charting: A. 1. ...The patient's plan of care should include interventions needed to achieve goals identified by the patient and the multidisciplinary health care team. ...B. DAR: Format to the nursing progress notes: D = Data; A = Action; R = Response. ...E. Response: ...2. Responses may deal with the patient's progress toward meeting the expected outcomes as described by the plan of care."

Review of the facility policy "Assessment - Reassessment - Patient", Policy #832894, dated 5/2014 states: "3. Determining Patient Needs/Diagnosis/Care Planning: ...2. The patient's plan of care is developed for patients based upon individual care requirements, identified patient goals and nursing diagnoses present...The purpose of the plan of care is to communicate the patient's care requirements and facilitate achievement of desired outcomes."

Inpatient Services

Medical record review was conducted on Patient 43's open record on 3/02/2017 at 10:31 AM with Medical Surgical Telemetry Manager VVV who confirmed the following: Patient 43 was admitted through the Emergency Department on 2/15/2017 for increasing pain right knee status post right knee arthroplasty on January 10, 2017 and started on Vancomycin and Zosyn (antibiotics). Patient 43's past medical history includes peripheral vascular disease (circulation disorder that causes narrowing or blockage of blood vessels), diabetes mellitus and hypertension. Patient 43 was being monitored for pain control (using PCA (pain medication administered through an intravenous route by the patient within limits set by the physician) and oral medications), received anticoagulation (blood thinner) therapy (intravenous heparin drip, changed to subcutaneous (top layer of skin) injections to oral medication) and was receiving frequent accu-checks for blood sugar control and lab tests for electrolyte monitoring. Standardized, printed care plans dated 2/2015 with an initial on the first 4 pages, included: Altered Comfort, Acute pain, (with an arrow through Medication Management, Anxiety Reduction, Environment Management, Distraction Relaxation Therapy, Exercise Therapy and Other), Safety, Risk for injury/fall (Initiate Fall/Risk Protocol as indicted: Bed/chair alarm Red star on door, Red slippers, Yellow fall risk ID band), Knowledge Deficit with Other marked under Intervention/Date Met and possible surgery infection written in, Mobility, Impaired with Safety, Education and Exercise Therapy checked, Skin integrity, Impaired (under Admission Assessment - skin compromised with the right knee circled and dehisced wound written in). Page 5 of the patient care plan was dated 2/20XX and under Patient Diagnosis/Problem "see DAR notes" was written in. Standardized, printed care plan dated 2/16/2017 for Cardiovascular Status with Cardiac output, decreased checked (nothing was marked under intervention/Date Met) and Knowledge Deficit - Procedure/Treatment Regimen, Activity/exercise and Incision site checked, with multiple interventions checked. Coordinated Care Rounds Documentation Sheet was blank. These care plans were not individualized, did not include goals, and the Data, Action, Response (DAR) notes did not include complete updates reflecting the care received per their policy #2700366.



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Per medical record review on 3/2/2017 at 8:30 AM, Patient 3 was admitted to the facility's inpatient burn unit on 12/21/2016 with severe burn wounds. A nursing care plan for safety due to confusion was initiated on 12/21/2016 with an outcome of "Risk Control." Progress notes related to safety dated 2/23/2017 state: "D: Pt. [patient] unable to follow directions; A: Right arm restraint to protect lines, fall risk measures in place; R: (X) Not Progressing." The care plan and progress notes do not clearly identify the expected goal or outcome related to safety or what is preventing the patient from progressing toward the goal.

Per medical record review on 3/1/2017 at 10:05 AM, Patient 16 received inpatient services for septicemia from 1/28/2017 through 2/7/2017. Patient 16's plan of care includes a diagnosis/problem for safety. The outcome is listed as "Risk Control." There is no documentation of patient specific goals or progress made toward goals during the hospitalization. Patient 16's record contains a progress note dated 2/4/2017 with a nursing diagnosis of "Impaired mobility" with a response of "Progressing." Impaired mobility is not a problem identified in the nursing care plan, there are no interventions or goals associated with the problem.

Per medical record review on 3/1/2017 at 11:05 AM, Patient 17 received inpatient services for sepsis from 2/11/2017 through 2/14/2017. A care plan for Impaired Skin Integrity was initiated on 2/11/2017. The patient outcome states "Admission skin assessment and risk of breakdown completed and documented in EHR [electronic health record]." Admitting assessment documents Patient 17 had a coccyx wound and penile erosion on admission. There is no documentation of interventions or goals related to the prevention of further skin breakdown. Review of Patient 17's skin assessment pressure ulcer prevention measures documents that Patient 17 was positioned on the right side on 2/13/2017 from 2:00 PM to 9:41 PM. Nursing progress notes on 2/13/2017 at 11:36 AM state "D: Coccyx wound and penile erosion noted on admission. A: Turning q 2 hr... R: (X) Progressing." The next progress note is dated 2/14/2017 at 2:09 PM and states: "D: Patient has limited mobility and skin breakdown on right hip...R: (X) Progressing." There is no evidence that the patient had skin breakdown on the right hip at the time of admission. It is not clear toward which goals the patient is making progress.

Per medical record review on 3/1/2017 at 1:30 PM, Patient 18 received inpatient services from 2/8/2017 through 2/14/2017 for dizziness and alcohol withdrawal. Patient 18's record does not contain a care plan with relevant patient problems, goals and interventions.

Per medical record review on 3/1/2017 at 3:00 PM, Patient 20 was admitted to the facility on 2/14/2017 with altered mental status. A nursing diagnosis of "Altered Mental Status" is initiated on 2/15/2017. There are no interventions, goals or outcomes associated with this problem. Nursing progress notes related to the nursing diagnosis of "Altered Mental Status" state Patient 20 is "Progressing" on 2/15/2017 as evidenced by "D: Patient more alert tonight; A: Able to eat dinner... Patient 20 was transferred to the Intensive Care Unit with a change in status on 2/18/2017. Nursing notes on 2/19/2017 state the Patient 20 is "obtunded" yet "Progressing" under the nursing diagnosis of "Altered level of consciousness." There is no documentation to support what mental status goal Patient 20 is progressing toward, there was no change in interventions or goals to reflect Patient 20's change in condition.

The above findings were confirmed at the time of the review with Clinical Nurse Leader YY. During an interview on 3/1/2017 at 2:00 PM, YY stated the nursing care plans are initiated on paper and include the diagnosis and expected outcomes. Per YY, staff is expected to document progress toward goals on a daily progress "DAR" (data, action, response) note in the electronic health record. YY stated, "we've had a lot of education lately [regarding care plan documentation], but I don't recall anything specific to goal setting. The nurses should be doing that as part of the general nursing process."




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Obstetrics/Labor & Delivery/Nursery

A medical record review was conducted on Patient 5's closed maternity record on 2/28/2017 at 10:15 AM accompanied by Manager of Women's and Children's D, Supervisor of Labor and Delivery E, and Supervisor of Post-partum F who confirmed the following: Patient 5 was admitted in labor on 2/19/2017 and had an unplanned cesarean section on 2/21/2017 due to arrested dilation (cervix failed to progress in dilation to accommodate the birth of the baby). Patient 5 also had a suspected chorioamnionitis (inflammation of the fetal membranes due to a bacterial infection). Patient 5's standardized pre-printed nursing care plan does not address either of these problems. Patient #5's care plan section for altered family processes has outcomes identified (with x's in the pre-printed boxes) an outcome met date of 2/24/2017, however there is no initiation date or initials of staff who initiated the problem.

A medical record review was conducted on Patient 6's closed maternity record on 2/28/2017 at 11:00 AM accompanied by Manager of Women's and Children's D, Supervisor of Labor and Delivery E, and Supervisor of Post-partum F who confirmed the following: Patient 6's care plan section for altered family processes has outcomes identified (with x's in the pre-printed boxes) and an outcome met date of 2/20/2017, however there is no initiation date or initials of staff who initiated the problem.

A medical record review was conducted on Patient 7's closed newborn record on 2/28/2017 at 11:45 AM accompanied by Manager of Women's and Children's D, Supervisor of Labor and Delivery E, and Supervisor of Post-partum F who confirmed the following: Patient 7 was born on 2/21/2017 and during the birthing process sustained a 2 x 1.5 centimeter laceration above the right lip. Patient 7 also received intravenous antibiotics (Ampicillin and Gentamycin) due to a maternal infection identified during the birthing process. Patient 7's standardized pre-printed nursing care plan does not address either of these problems. Per interview with Supervisor F during the medical record review regarding the expectation that these problems would be identified on the care plan, Supervisor F stated, "Yes, they should be on there."

Per interview with Supervisor E on 2/28/2017 at 11:48 AM regarding the individualization of care plans, Supervisor E stated, "We are in the process of re-doing our care plans to individualize them. There is currently a gap in the process."

Per interview with Clinical Nurse Specialist Z on 2/28/2017 at 1:45 PM regarding the care planning process for the Neonatal Intensive Care Unit, Nurse Z stated that patients on that unit do not get the typical care plan, instead clinical pathways (task-oriented care plan that details essential steps in the care of patients with a specific clinical problem) are used. The directions on the top of each clinical pathway paper states, "Date and initial each item when completed."

Neonatal Intensive Care

A medical record review was conducted on Patient 9's open Neonatal Intensive Care Unit record on 2/28/2017 at 1:53 PM accompanied by Manager of Women's and Children's D and Clinical Nurse Specialist Z who confirmed the following: Patient 9 is a premature infant born at 27 weeks and 3 days on 2/25/2017. Patient 9's clinical pathway has the following items dated and initialed signifying they are complete: hydration maintained, HA/IL [hyperalimentation/interlipids--a form of intravenous nutrition], I&O [intake and output], monitor VS [vital signs] per protocol, Monitor sat [oxygen saturation] hourly- OWL [oxygen with love] protocol, ET [endotracheal tube], HFOV [high frequency oscillatory ventilation--pertains to the ventilator], UVC [umbilical venous catheter], UAC [umbilical arterial catheter], isolette, humidity <1000 grams, maintain appropriate positioning, tolerates handling, cluster cares, minimal stimulation, use of developmental care products, provide diurnal lighting (lighting to ensure baby experiences normal rhythms of day and night), phototherapy, minimal pain, stress, agitation, assess and reassess pain.

Per interview with Manager of Women's and Children's D and Clinical Nurse Specialist Z at 2:00 PM regarding the completion of all of these problem areas, Nurse Z stated that these problems are still active, have not been resolved, and clearly the staff are not understanding how to use the tool.

A medical record review was conducted on Patient 10's open Neonatal Intensive Care Unit record on 2/28/2017 at 2:03 PM accompanied by Manager of Women's and Children's D and Clinical Nurse Specialist Z who confirmed the following: Patient 10 is a 35 week 1 day baby born on 2/27/2017 with respiratory distress. Patient 10's clinical pathway has the following items dated and initialed signifying they are complete: hydration maintained, monitor vs [vital signs] per protocol, monitor sat [oxygen saturation rate] hourly per OWL [oxygen with love] protocol, assess IV [intravenous] site hourly, normal state-related behaviors, normal fontanel, tolerates handling, weigh daily, OFC [occipital/frontal head circumference]/length weekly, stable in room air, no apnea (periods of no breathing)/bradycardia (low heart rate), and assess and reassess pain. During the medical record review Nurse Z stated that all of these problems are ongoing and not resolved.

Per interview with Manager D and Nurse Z on 2/28/2017 at 2:30 PM regarding a policy or protocol for how to use the clinical pathways, Nurse Z stated, "There is no policy or protocol for how to use them." Manager D stated they are educated on how to use the pathways during the orientation process upon hire. Nurse Z stated they have used these clinical pathways on this unit since 2011.



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Behavioral Health Unit

Record review on 2/27/2017 at 1:30 PM of Patient 31 revealed admission date of 2/25/2017 for auditory hallucination and delusional thoughts. Review of the care planned outcomes (goals) reveals "stabilized symptoms" and "decrease in psychosis". Record review of the nursing care plan since admission revealed that goals for the reduction of negative behaviors was not measurable, therefore the decrease/reduction in these behaviors since admission could not be identified through the care planned nursing documentation.

Record review on 2/28/2017 at 9:15 AM of Patient 32's nursing and therapy care plans and shift report information revealed no information regarding the assessment of medication side effects for anti-psychotic, anti-convulsant or anti-anxiety medication use. Patient 32 was admitted 2/24/2017 with manic agitation and Bipolar Disorder. Record review of the nursing care plan since admission revealed that goals for the reduction of negative behaviors (mania, agitation and anger) was not measurable, therefore the decrease/reduction in these behaviors since admission could not be identified through the care planned nursing documentation.

Record review on 2/28/2017 at 10:30 AM of Patient 33's nursing and therapy care plans and shift report information revealed the patient is not attending group therapy for the care planned problem of "coping". There is no alternative care planned interventions documented to address this patient's problem. Review of the nursing care plan revealed no information regarding the assessment of medication side effects for anti-psychotic, anti-depressant or hypnotic medication use. Patient #33 was admitted on 2/23/2017 with "severe major depression with suicide threats" according to the 2/23/2017 at 6:00 PM psychiatric evaluation. There is no documented evidence of a care plan for the assessment of suicidal ideation.

Record review on 3/2/2017 at 9:00 AM of Patient 34 revealed admission date of 2/9/2017 for Catatonia and Depression. review of the "kardex" reveals under "reason for admit" that patient has been depressed since death of parent. Review of the nursing and therapy care planning under coping reveals no evidence of care planning to address dealing with loss of a loved one. Review of the nursing care plan revealed no information regarding the assessment of medication side effects for anti-psychotic, anti-depressant or anti-anxiety medications.

An interview was conducted with Behavioral Health Director N and Behavioral Health Patient Manager P on 3/2/2017 at 11:00 AM, Behavioral Health Patient Manager P stated that "we will review the care plans".



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Surgical Services

Review of Patient 27's medical record on 3/1/17 at 11:15 AM shows Patient #27 was admitted to the hospital on 2/20/2017 after surgery for a Cervical Spinal Fusion. Per review of Patient #27's Discharge Summary, Patient #27 had "Issues post-op with diabetes control" and "developed dysphagia and hoarseness on POD #4 (post op day 4)." "X-rays showed cervical prevertebral soft tissue edema; Decadron was started and (Pt #27) was kept inpatient another day for observation." Review of Patient #27's nurses assessment from 2/20/17 through 2/23/2017 shows patient was ambulating with a walker and 1 assist and had a cervical collar in place at all times. Review of "Patient Plan of Care" forms shows care plans for "Altered Comfort" and "Coping" are checked. No documentation is identified in the Categories labeled "Outcome", "Expected Outcome Date", and "Outcome Met". No evidence of nursing staff reviewing and/or updating care plans on 2/21/2017, 2/22/2017, and 2/25/2017. Individualized nursing care plans were not initiated for Patient #27's issues pertaining to mobility, skin integrity, safety, diabetes, and dysphagia, to ensure Patient #27's individualized needs are met.

Review of Patient 27's "Cervical Fusion Clinical Guideline" the category's for Physical Therapy, Occupational Therapy, and Discharge planning are blank.

Per interview with Manager MM on 3/1/2017 at 2:05 PM, Manager MM stated nursing care plans should be reviewed and documented on daily. Per Manager MM there should be an interdisciplinary "Cervical Fusion Clinical Guideline" pathway initiated and completed for all patients having Cervical Fusion surgery.

Based on observation, record review and interview, the facility staff failed to ensure that registered nurses administered drugs or wound care therapy as ordered by a qualified medical practitioner, in 1 of 3 out-patient clinic patients (Patient 46 at Water Tower medical Commons) and 1 of 1 inpatient burn unit patients (Patient 3). This affects all in-patients/ out-patients who receive medications or wound care at the hospital burn center.

Findings include:

The 3/2/2017 at 4:00 PM record review of a document titled "Administration of Narcotics in Radiation Oncology" reveals no documented evidence of hospital governing body approval, no effective date and no authorship. This document states that "A. An order for a narcotic will be placed by the Radiation Oncology physician... E. Once the narcotic is administered, the Registered Nurse will document the date and time the narcotic was administered to the patient in the Radiation Oncology medical record.

The 3/1/2017 at 3:30 PM record review of the narcotic count/administration record reveals that Patient 46 received Oxycodone 5 milligrams (narcotic) on 12/29/2016 during an out-patient clinic evaluation. Patient 46's out-patient medical record revealed no documented evidence of a medical practitioner's order for this medication, and no documented evidence of the time this medication was administered by Registered Nurse.

During interview with Oncology Registered Nurse DDDD, at the time of the record review, Oncology Registered Nurse DDDD verified the lack of this information, stating "it's not there".


34337


On 2/28/2017 at 9:50 AM, Registered Nurse T stated Patient 3's current wound care regimen includes Silvadene gauze to the left chest/shoulder and right shin/calf. Review of Patient 3's medication administration record on 3/2/2017 shows Patient 3 received silver sulfadiazine (Silvadene 1%) cream daily from 2/24/2017 through 3/2/2017. Review of Patient 3's orders includes an active order, with a start date of 1/11/2017, for silver sulfadiazine to be applied daily to "bilateral thigh donor sites." There are no other orders for silver sulfadiazine in the record. The dressing change observed on 2/28/2017 included application of silver sulfadiazine to Patient 3's chest and shin, application of silver sulfadiazine to Patient 3's bilateral thighs was not observed.

During an interview on 3/2/2017 at 9:50 AM, Burn Unit Manager M stated all dressing changes are per physician order. Burn Unit Manager M stated Patient 3's wound care changed on 2/24/2017 to reflect what was observed on 2/28/2017. When asked about the order for the change, Burn Unit Manager M stated "sometimes it gets taken as a verbal order and doesn't get documented."

Based on observation, record review, and interview, the hospital failed to ensure that patient information in medical records was protected from unauthorized access in 3 of 8 out-patient services which perform out-patient procedures (GI Procedure area, Pre and Post Procedure east pod, and Specialty Institutes). This has the potential to affect all out-patients having procedures at this facility.

Findings include:

During observation of the GI (gastrointestinal) procedure area on 2/28/17 at 4 PM, a room used by staff to contact pre-operative patients prior procedure had 27 individual patient-identified medical record binders in 3 different carts/tables.

Record review, at time/date above, reveals binders contain the following personal health information: name, appointment time, appointment details, reason for exam, referring physician, and insurance information.

During interview with GI RN (registered nurse) EEEE, at date /time above, EEEE stated that housekeeping staff had after-hours access to this room for the purpose of cleaning it.



29972

On 2/27/17 at 10:10 AM while touring the Pre and Post Procedure east pod with Patient Services Supervisor SS and Director TT, observed 22 patient charts on cart in Holding Room 3595. The patient charts contained patient name, date of birth, medical record number, and type of surgical procedure being performed. The door was propped open with no staff consistently in view of patient charts, the room was located adjacent to an unlocked exit door.

Per interview with TT at the time of the observation, TT revealed patient charts should be in secured from unauthorized access at all times.


37419


During observation of the Specialty Institutes on 2/27/2017 between 10:10 and 11:54 AM with Supervisor of Patient Services R, observed Pulmonary Function Procedure Room 1345 to have two, four drawer filing cabinets with patient records inside them.

During interview with Respiratory Therapist Q, Q stated that these cabinets are left unlocked at all times, "we lost the key a long time ago". Q stated that housekeeping staff had after-hours access to this room for the purpose of cleaning it.

Based on record review and interview, staff at this facility failed to maintain medical records that are complete and accurate in 2 of 2 maternity patients (Patient 5 and 6) and 1 of 1 outpatient rehabilitation patient records reviewed (Patient 21) out of a total of 46 medical records reviewed. This has the potential to affect all patients at this facility.

Findings include:

The facilities policy titled, "Epidural-Spinal Analgesia or Anesthesia in Labor and Delivery," #2552720, dated 7/2016, was reviewed on 3/1/2017 at 10:30 AM. The policy states in part, "Per orders, a RN [Registered Nurse] trained in the removal of epidural catheters may remove the epidural catheter post delivery and document the status of the tip...The patient should be assessed and have a Breen modification Bromage Score (measurement tool for return of sensation after spinal anesthesia/analgesia) >4 prior to ambulation."

Facility policy "Rehabilitation Services Documentation" dated 2/2015 stated: "4. Physician Approval of Initial Plan of Care: ...The physician-signed plan of care must be obtained within 30 calendar days..."

A medical record review was conducted on Patient 5's closed maternity record on 2/28/2017 at 10:15 AM accompanied by Manager of Women's and Children's D, Supervisor of Labor and Delivery E, and Supervisor of Post-partum F who confirmed the following: Patient 5 had a Cesarean Section on 2/21/2017 and had epidural anesthesia provided by an Anesthesiologist. There is no documentation of the condition of the tip of the epidural catheter upon its removal.

Per interview with Supervisor E on 2/28/2017 at 10:36 AM, Supervisor E stated that the Anesthesiologist would usually document the tip appearance of the epidural catheter upon removal for cesarean section patients and nursing would do this documentation for vaginal deliveries.

A medical record review was conducted on Patient 6's closed maternity record on 2/28/2017 at 11:00 AM accompanied by Manager of Women's and Children's D, Supervisor of Labor and Delivery E, and Supervisor of Post-partum F who confirmed the following: Patient 6 had a vaginal delivery on 2/18/2017 and had an epidural for pain management. There is no documentation of the condition of the tip of the epidural catheter upon its removal and there is no documentation regarding the return of sensation to Patient 6's lower extremities. Patient 6's Obstetrical Report, which gives details about the pre-labor/labor and delivery events, does not include estimated blood loss.

Per interview with Supervisor E at 11:18 AM on 2/28/2017, Supervisor E stated that the expectation is to document the return of sensation. Supervisor E also stated, "The estimated blood loss is supposed to be there [documented]."



34337

Patient 21 was admitted to outpatient rehabilitation services on 1/5/2017. Patient 21's initial plan of care was not reviewed or signed by the ordering physician at time of medical record review on 2/28/2017 at 2:15 PM, more than 30 days after the care plan was initiated.

The above finding was confirmed with interview with Rehab Director AAA. AAA stated "I'm not sure about the policy" or the expectations for physician oversight of outpatient rehabilitation services.

Based on record review and interview, the facility failed to ensure blood transfusions consents were timed and dated for 1 of 2 patients reviewed receiving blood transfusions (Patient 22). This has the potential to effect all inpatients and outpatients receiving blood transfusions.

Findings include:

Review of facility policy "Patient Care - Consent for Treatment-Procedures" dated 2/2017 stated: "Informed consent must be obtained for the following procedures... 3. Transfusion of blood products. ...The exact time the consent was executed should be noted."

Patient 22 presented to the Emergency Department on 2/25/2017. Patient 22 received a blood transfusion while in the Emergency Department. Per medical record review on 3/1/2017 at 8:10 AM, Patient 22's record contained a blood transfusion consent form. The consent was signed by the patient but not dated or timed.

During an interview on 3/1/2017 at 8:30 AM, when asked about the process for signing and dating consent forms, Emergency Department Supervisor ZZ stated "we missed that."

Based on observation, record review and interview, facility staff failed to access multi-dose vials in a clean, non-patient care area for 1 of 1 medication administration observed (Patient 1) and failed to maintain multi-dose medication vials per policy. This has the potential to affect all inpatients and outpatients receiving medications by multidose vials.

Findings include:

Review of facility policy "Multi-Dose Vials - Handling and Disposal", policy #3049462, dated 12/2016 stated: "If multi-dose parenteral medications are used, the following approach shall be followed, as recommended by the CDC's Hospital Infection Control Practices Advisory Committee (HICPAC). ...2. Sterile (aseptic) technique shall always be used. This shall include: A. Use of a sterile device each time a multi-dose vial is accessed. ...3. Limitation of the number of multi-dose vials that are opened simultaneously... 6. A. All multi-dose vials shall be dated with an expiration date of 28 days from the date of opening. ...8. Discard multi-dose vials if poor aseptic technique has been observed, or when suspected or visible contamination occurs."

During observation on 2/27/2017 from 10:10 AM to 11:20 AM, 9 open vials of insulin were stored in the medication administration areas of 4 medical-surgical units. When asked about the process or accessing the multi-dose insulin vials, Manager G stated the facility has an electronic scanning system for medication administration. Per Manager G, the nursing staff "brings the vial to the [patient] room to scan" before accessing the vial.

Prior to preparing and administering insulin on 2/27/2017 at 11:20 AM, Manager H withdrew a multi-dose vial of insulin from Manager H's pocket in Patient 1's room. Registered Nurse H then scanned the vial, accessed the vial with a needle and syringe while in Patient 1's room and administered the medication. When asked about the process for administering insulin, Registered Nurse H stated "I grab that [the insulin vial] from the unit and bring it in the room." When finished, Registered Nurse H returned the vial from Patient 1's room back to the medication storage area on the unit.

A multi-dose vial of dexamethasone was observed in the outpatient rehabilitation unit on 2/28/2017 at 2:00 PM. The vial was accessed with a vial dose spike with a syringe attached. There was no expiration date on the vial. Physical Therapy Assistant BBB stated at the time of the observation the vial "is good until the [manufacturer's] expiration date."

Per interview with Anesthesiologist NN on 2/28/17 beginning at 2:45 PM, Anesthesiologist NN stated multidose medication vials are used by the anesthesia staff in surgery while the patient is in the operating room. Per Anesthesiologist NN multidose medication vials are used for multiple patients.

During an interview on 3/2/2017 at 11:10 AM, Pharmacy Manager HHH stated the multi-dose insulin vials should be accessed at the medication preparation area of the unit, not at the patient's bedside. Per Pharmacy Manager HHH, the nursing staff is "not supposed to be doing that, they are supposed to draw it up by the Pyxis station." Pharmacy Manager HHH went on to state multi-dose vials expire 28 days after they are opened. When asked if the facility has standards for the use of spiking devices for multi-dose vials, Pharmacy Director III stated the facility follows CDC recommendations and "we were not aware of that" and "we wouldn't spike [multi-dose vials] with a spike apparatus."


29972

Based on observation and interview, staff at this facility failed to ensure that emergency carts (crash/code carts) are secured against unauthorized access in 8 of 9 carts/medication storage areas observed (Post-partum floor, Labor and Delivery, Heart and Vascular Institute, Orthopaedic and Neuroscience, Testing and Treatment Institute, and Intensive Care Unit (ICU), Heart and Vascular Institute) and 2 of 2 medication refrigerators in the ICU. Failure to secure medications has the potential to affect all patients (Patient census 2/27/2017 of 173 Patients, 2/28/2017 of 243 Patients, 3/01/2017 of 242 patients, and 3/02/2017 of 243) who might need emergency intervention from the carts or medications on ICU.

Findings include:

A tour of the Post-partum floor was conducted on 2/27/2017 at 11:00 AM accompanied by Manager D and Supervisor F who confirmed the following findings:
--The emergency/code cart, equipped with a break-away lock, was observed to be in an equipment room which was unlocked. The room is not in view of staff.
Per interview with Supervisor F at the time of the observation regarding how the facility staff would know that the cart/medications were not tampered with in between nightly checks, Supervisor F responded, "We wouldn't know."
--The emergency/code cart, equipped with a break-away lock, was observed to be in the sterile corridor outside of the operating rooms behind closed double doors in Labor and Delivery, not in view of staff.

Per interview with Supervisor F at the time of the observation regarding when housekeeping cleans the area, Supervisor F stated that housekeeping contacts the charge nurse to find out when a good time to clean would be and then they come to clean the area. Supervisor F stated that staff are not necessarily in the area and stated, "I don't know," when asked how unauthorized access to the carts contents would be ensured.


29963


A tour of the 3 Specialty units (Heart and Vascular Institute, Orthopaedic and Neuroscience, and Testing and Treatment Institute) was conducted on 2/27/2017 at 11:20 AM accompanied by Supervisor of Patient Care Services R who confirmed the following finding:
--the emergency/code carts located in each of the 3 Specialty units (Heart and Vascular Institute, Orthopaedic and Neuroscience, and Testing and Treatment Institute) were equipped with a break-away lock, and observed in the corridors pushed back into an alcove, and not in the view of staff.

Per interview on 2/27/2017 at the time of observation, Supervisor of Patient Care Services R confirmed that the cart was not in constant supervision of staff and staff would not be aware if carts were accessed by unauthorized staff.


29972


A tour of the Intensive Care Unit was conducted on 2/27/2017 at 3:35 PM accompanied by the Intensive Care Unit with Manager GGG who confirmed the following findings:
--Observed 2 medication refrigerators in the medication area on "side B" and "side A" of the Intensive Care Unit. The medication refrigerators were not locked and contained patient antibiotics and cardiac medications. At the time of the observation no staff were in view of the medication refrigerators.

Per interview with Intensive Care Unit with Manager GGG on 2/27/2017 at 3:45 PM, GGG revealed the refrigerator is unable to lock and staff are working on obtaining locked refrigerators that are connected to the Pyxis medication dispenser but this has not yet happened.

Based on observation, record review and interview, the Director of Dietary and Nutrition Services failed to: (1) ensure 2 of 3 staff (Dish Room Staff B and Food Prep Cook C) should know the required time to be off before returning to work after being ill; (2) the internal temperature of the hot water sanitizing machine was being monitored daily to ensure dishes were being effectively sanitized per 1 of 1 policy (#F019); and (3) ensure 3 of 3 pans of diced tomatoes were identified with labels. The totality of these issues have the potential to negatively impact all patients at the hospital during survey time - (Patient census 2/27/2017 -173, 2/28/2017 - 243, 3/01/2017 242, and 3/02/2017 - 243).

Findings include:

On 2/27/2017 at 10:15 AM, during an interview with Director of Dietary and Nutrition Services A, it was reported all management are ServSafe certified. ServSafe is a nationally recognized program in food safety education. Director of Dietary and Nutrition Services A also stated all food codes are followed - local, state (Wisconsin Food Code) and federal (2013 Food and Drug Administration (FDA) Food Code. According to the current, 6th edition ServSafe Coursebook, if a foodservice employee is symptomatic with vomiting or diarrhea, the employee cannot return to work until asymptomatic for at least 24 hours. It also states "Labeling food is important".

RETURN TO WORK AFTER ILLNESS

Review of the facility policy titled ""Sanitation and Infection Control" "Infection Monitoring of Associates" #F004, revise date 1/2014 was reviewed on 2/28/2017 at 12:45 PM. The policy states in the section identified "Vomiting or Diarrhea", staff can return to work when the following conditions are met: "1. Provides written medical documentation from health practitioner stating that symptoms are from noninfectious condition. 2. Is asymptomatic for at least 24 hours."

An interview was conducted on 2/27/2017 at 10:50 AM with Dish Room Staff B. B has worked for facility for 28 years and was not aware that there was a time requirement for returning to work after certain illnesses, specifically diarrhea.

An interview was conducted on 2/27/2017 at 11:25 AM with Food Prep Cook C. C was not aware that there was a time requirement for returning to work and stated that they make their own decision on when to return after any illness.

During an interview on 2/28/2017 at 8:55 AM with Director of Food and Nutrition Services A and Clinical Nutrition Manager MMM when questioned on above responses, they confirmed that staff should be aware of need to be off a certain amount of time depending on the type of illness.

DISH MACHINE SANITATION

Federal 2013 Food and Drug Administration (FDA) Food Code, a nationally recognized professional standard of practice for food safety, states a system needs to be in place for monitoring a hot water sanitization dish machine's internal temperature reaches 160oF.

The facility policy titled "Dishmachine Temperature", #F019, dated 1/2014 was reviewed on 2/27/2017 at 1:40 PM. This document states, under section titled Procedures, Supervisor/Food and Nutrition Associate as assigned: "Once a day, run a test strip through the dishmachine to verify the surface temperature of a dish".

An interview was conducted on 2/27/2017 at 11:22 AM with Director of Dietary and Nutrition Services A. A stated dietary staff uses external gauges to monitor hot water temperature of hospital's mechanical hot water sanitizing dish machine, they do not monitor internal temperatures of their dish machine.

LABELING OF FOOD

On 2/27/2017, 10:15 AM, during an interview with Director of Dietary and Nutrition Services A, it was reported all management staff are ServSafe certified. ServSafe is a nationally recognized program in food safety education. Director of Dietary and Nutrition Services A also stated all food codes are followed - local, state and federal.

According to the current, 6th edition ServSafe Coursebook, "Labeling food is important for many reasons. Illnesses have occurred when unlabeled chemicals were mistaken for food such as flour, sugar, and baking powder. Customers have also suffered allergic reactions when food was unknowingly prepped with a food allergen that was not identified on the label," and "when food is stored incorrectly and not used in a timely manner, quality and safety will suffer."

On 2/27/2017, 10:41 AM, in the Produce Cooler, accompanied by Director of Dietary and Nutrition Services A, observed 3 pans, identified by Director of Dietary and Nutrition Services A as containing diced tomatoes. There was nothing to identify what the food item was, how long it had been there and when it should be discarded. During an interview with Director of Dietary and Nutrition Services A, it was stated their policy is to have an orange label identifying food items when anything is opened and not having the tomatoes labeled is unacceptable.

On 2/27/2017, 2:55 PM, received policy "835854" titled "Refrigerators - Freezers - Cleaning and Defrosting" "Last Revised: 05/2014", per request for a policy on food labeling. Under section "Procedure" "Refrigerators" bullet "B." "a.", it states, in yellow highlight, "All food should be dated." Surveyor did not receive any other policy regarding labeling of food.

A unannounced recertification survey of Columbia St. Mary's Hospital for Life Safety Code was conducted February 20-22, 2017 and March 2-3, 2017. The facility was found to be NOT in compliance with the following applicable regulations for hospital participation in Medicare-Medicaid per 42 CFR 482.41 Condition of Participation: Physical Environment. Seven (7) related facilities/buildings of Columbia St. Mary's had a combined census of 1,753 inpatients, outpatients and an unknown number of staff and visitors at the time of the survey. See the detailed narrative of the K-tags at each of the seven (7) buildings surveyed.


FINDINGS INCLUDED:

Between February 20-22, 2017 and March 2-3, 2017 the Physical Environment and Life Safety from Fire was NOT MET as evidenced by twenty nine (29) federal deficiencies of the Life Safety Code, referred to as K-Tags, that were cited from survey document review, survey inspections and interview of select staff at different times. A total of seven (7) buildings were surveyed over this course of time. These deficient practices were confirmed by staff members LS1 thru LS 16 and a number of staff identified on the master identifier key.

A unannounced recertification survey of Columbia St. Mary's Hospital for Life Safety Code was conducted February 20-22, 2017 and March 2-3, 2017. The facility was found to be NOT in compliance with the following applicable regulations for hospital participation in Medicare-Medicaid:

42 CFR 482.41 Condition of Participation: Physical Environment was NOT MET.
42 CFR 482.41 (b) Standard: Safety from fire was NOT MET.
NFPA 101 (2012 edition) - Life Safety Code was NOT MET.

These seven (7) related facilities/buildings of Columbia St. Mary's had a combined census of 1,753 inpatients, outpatients and an unknown number of staff and visitors at the time of the survey. Twenty nine (29) federal deficiencies of the Life Safety Code were cited for these buildings. See the detailed narrative of the K-tags at each of the seven (7) facilities/buildings surveyed.

K131 (Multiple Occupancies),
K161 (Existing Building Construction),
K211 (Means of Egress - General),
K222 (Locking Egress Doors),
K223 (Doors w./ Self-Closing Devices),
K271 (Exterior Discharge from Exits),
K281 (Illumination of Means of Egress),
K293 (Exit Signage),
K300 (Protection - Other - NFPA 101),
K311 (Vertical Openings - Enclosure),
K321 (Existing Hazardous Areas - Enclosure),
K341 (Fire Alarm System - Installation),
K345 (Fire Alarm System - Testing and Maintenance),
K346 (Fire Alarm - Out of Service),
K347 (Smoke Detection),
K351 (Existing Sprinkler System - Installation),
K353 (Sprinkler System - Maintenance and Testing),
K355 (Portable Fire Extinguishers),
K363 (Corridor Doors),
K372 (Subdivision of Building Spaces - Smoke Barrier Construction),
K374 (Subdivision of Building Spaces - Smoke Barrier Doors),
K511 (Corridor Doors),
K521 (HVAC & Required Environmental Air Balancing Between Spaces),
K711 (Evacuation and Relocation Plan),
K754 (Soiled Linen & Trash Containers),
K900 (Health Care Facilities Code),
K911 (Electrical Systems - Other),
K915 (Electrical Systems - Essential Electrical System),
K918 (Electrical Systems - Essential Electrical System - Maintenance and Testing).

Based on observations, interview and record review, the facility did not keep the surrounding area of the dumpsters free from debris potentially creating a potential nesting site for pests. This potentially put at risk all patients. (Patient census 2/27/2017 -173, 2/28/2017 - 243, 3/01/2017 242, and 3/02/2017 - 243).

On 2/27/2017 at 10:15 AM, during an interview with Director of Dietary and Nutrition Services A, it was reported all management are ServSafe certified. ServSafe is a nationally recognized program in food safety education. Director of Dietary and Nutrition Services A also stated all food codes are followed - local, state (Wisconsin Food Code) and federal (2013 Food and Drug Administration (FDA) Food Code. ServSafe states foodservice operations need to develop and implement an integrated pest management system. "Garbage attracts pests and provides them with a breeding ground."

On 2/27/2017, 10:00 AM, accompanied by Director of Food and Nutrition Services A, observed outside area under dumpster. Under the dumpster were large quantities of garbage - a large, filled kitchen size garbage bag, empty yogurt container, Styrofoam cup, paper debris, cardboard debris, several empty plastic grocery store type bags.

On 2/27/2017, 2:07 PM - 2:15 PM, accompanied by Director of Environmental Services S and Vice President of Patient Care O, went to dumpster area to show earlier observation of all the garbage under the dumpster from 10:00 AM that morning. During interview with Director of Environmental Services S, it was agreed it is a problem and will order a power washer and have area cleaned up by tomorrow.

On 2/27/2017, 4:15 PM, received Duty List #:121, Area: Waste Handler (Women's & Mail Lower Level) - Revised Date: 7/12/2016; Duty List #:122 Area: Waste Handler (Main Hospital 8th - 1st Floor) - Revised Date: 7/12/2016; Duty List #:220, Area: Waste Handler (Women's & Main Lower Level) - Revised Date: 7/11/2016; Duty List #:221, Area: Waste Handler (Main Hospital 8th - 1st Floor) - Revised Date: 7/11/2016. All four Duty Lists were stapled together. On all of the Duty Lists was a section titled "Notes." "3. Remove all trash from compactor area ramp daily. 4. Clean around Compactor area daily. 5. Power Wash Compactor area monthly." On the front of the form "Duty List #:121" were two sticky notes. One sticky note had hand written statement: Re: Dumpster Cleaning Information. The other sticky note had hand written statement: Responsibilities: #5 was added on 2/27/17. Surveyor never received a formal policy and procedure regarding cleaning outside dumpster area.

Based on observation, record review and interview staff at this facility failed to follow its policies and procedures to maintain an environment for patients and staff that is free from potential contamination of microorganisms in 42 of 42 observations that include 7 patients (Patient 3, 4, 13, 14, 15, 26 and 30) out of 901 patients on census at the time of survey and 40 of 40 observations in 11 areas (Labor and Delivery, 3West, Gastrointestinal Lab, 4th Floor Surgery, Specialty Institutes, Obstetrics, Intensive Care, Surgical Services, Interventional Radiology, Inpatient Services, Outpatient Clinic/Riverwoods.). This has the potential to affect all inpatients and outpatients at the time of this survey (Patient census 2/27/2017 -173, 2/28/2017 - 243, 3/01/2017 - 242, and 3/02/2017 -243).

Findings include:

ENVIRONMENT

General

An interview with Director of Environment Services J was conducted on 2/28/2017 at 7:30 AM. The facility uses an automated 4 bottle system for filling mop buckets and buckets for cleaning rags. The facility does not check chemical indicator strips when bottles are changed out to ensure that the automated system is functioning properly and delivering the proper amount of disinfecting solutions for effective cleaning. Director J stated that the company who supplies the chemicals comes quarterly or semi-annually and checks the systems for proper functioning of the system but, "We are currently not checking them in house."

Per interview at 1230 on 2/28/2017 with Director J, Director J presented the manufacturer recommendations for the automated system. Director J stated that per the manufacturer representative, each time a new bottle is replaced on the auto-fill system, a chemical strip should be checked to ensure proper dilutions.

An observation of Housekeeper AA performing a terminal clean of a discharged patient room on the antepartum floor was conducted on 2/28/2017 at 3:00 PM accompanied by Manager of Women's and Children's D. Housekeeper D was observed removing gloves outside of the patient room, retrieved new gloves, obtained supplies for bathroom handling toilet paper, paper band for toilet, bottle of blue solution for the toilet bowl, and then applied the new gloves to continue cleaning equipment in the room without performing hand hygiene. This observation was discussed with and confirmed per interview with Director D who stated, "I saw the same thing."

Labor and Delivery

Review of the facility policy titled, "Whole Blood Glucose Testing-Accu-Check Inform II System," #2156537, dated 2/2016, was received on 2/27/2017 at 3:10 PM. The policy states in part, "Disinfect the meter to destroy pathogenic and other types of microorganisms...Meters should be cleaned and disinfected between each patient use."

The following observations were made:
A tour of the Labor and Delivery area was conducted on 2/27/2017 at 12:00 PM accompanied by Manager D and Supervisor E who confirmed the following observations:
--In the clean supply room a full trash can was observed to have a bag of trash which Supervisor E identified as being from a "Vag [vaginal] table set up." The bag contained wrappings and package material from sterile supplies as well as used/discarded gloves. Per interview with Supervisor E at the time of the observation regarding the trash being in the clean supply room, E responded, "No, it shouldn't be there.
--It was observed that the toilets in the cleaned, unoccupied rooms on the Antepartum section of Labor and Delivery did not have a paper band or blue water signifying a cleaned bathroom/toilet (as was observed on the Post-partum floor) in rooms 447, 448, 450, and 452. Per interview with Supervisor E regarding bathroom cleaning, Supervisor E stated that housekeeping staff is supposed to put the paper band on the toilet to show that it has been cleaned. Supervisor E stated, "That's how we tell."
--In the nurse's station an Accucheck [blood glucose monitor] machine that was in the charging stand was observed to have a dirty screen that was smudged with a reddish/brown substance. Per interview with Supervisor E at the time of the observation, E stated that the cleaning protocol is to wipe the machine down with a bleach wipe after it is used. When asked if the monitor looked clean Supervisor E stated, "No, it does not."

An interview was Environmental Services J on 2/28/2017 at 8:00 AM regarding identification of clean bathroom facilities, Director J stated that a paper band is applied around the toilet bowl or blue solution is added to the water. Director J stated, "If neither of these are present you can assume the toilet has not been cleaned."

3 West

Review of the facility Policy titled, "Infection Prevention" (Surgery) last reviewed 4/2014, stated bedside equipment such as blood pressure cuffs, EKG cable, non-disposable pulse oximetry cables, and all surfaces and equipment that have had contact with the patient or with gloved or unwashed hands of personnel should be wiped down with disinfectant wipe between patients.

Review of the facility Policy titled, "Infection Prevention-Control for Ambulatory Care Settings..." last reviewed 4/2014, stated "All clean linen should be stored in cabinets or covered until used."

The facility Policy titled "Refrigerators-freezers...", last reviewed 5/2014, stated all patient and staff refrigerators will be spot cleaned daily and thoroughly cleaned weekly on Saturday or Sunday

The following observations were made:
--On 2/27/17 between 9:50 AM and 4:00 PM observed a total of 6 crash carts in the Pre and Post Procedure unit, 3 Center, 3 West, Gastrointestinal Lab (GI), Post Anesthesia Care Unit (PACU), and Intensive Care Unit. The red top of the suction canisters on the crash carts were visibly soiled with dust.

--On 2/27/17 at 10:30 AM observed patient gowns hanging from baskets outside of 6 unoccupied patient rooms. Per interview with Registered Nurse UU at the time of observation, UU stated the patient gowns will be used for the patients admitted in the morning, per UU the patient gowns will sit out overnight.

An interview was conducted on 2/27/17 at 10:30 during observation with Services Supervisor SS. SS stated clean patient linen should be covered.

-- On 2/27/2017 at 11:15 AM in Nourishment Room 3589, the refrigerator and freezer compartments contained food particles and residue.

An interview was conducted with Services Supervisor SS on 2/28/17 at 10:00 AM, SS stated crash cart suction equipment is not routinely covered to protect from contamination.

Gastrointestinal Lab

--On 2/27/17 observed Registered Nurse ZZ cleaning equipment after Patient 30's colonoscopy procedure. ZZ did not clean and disinfect the blood pressure cuff, cardiac monitor, EKG leads/wires, computer station/keyboard, and clipboard used during the procedure.

--On 2/28/17 at 11:30 AM observed Environmental Services staff QQ cleaning the operating room after Patient 26's surgery. QQ did not clean the sides of the mattress on the surgery table, the Sequential Compression Device monitor, and all surfaces of the Bair Hugger machine used during Patient 26's surgery.


4th Floor/Surgery

Review of the facility Policy titled "Refrigerators-freezers...", last reviewed 5/2014, stated all patient and staff refrigerators will be spot cleaned daily and thoroughly cleaned weekly on Saturday or Sunday.

The following observations were made:
--On 2/27/17 at 3:55 PM observed Special Equipment Room 4221 contained dust, debris, and packaging material on floor under clean equipment.
--Nourishment Room near nurses station with a microwave used for patients, containing food particles and residue.



37419


Specialty Institutes

The following observations were made:
During tour of the Specialty Institute on 2/27/2017 between 10:10 AM and 11:54 AM with Supervisor of Patient Services R.
--Rooms 1325, 1415, and 1547 were labeled as Soiled Utility with biohazard stickers and were noted to be unlocked. All three rooms contained red and yellow biohazard bins and cleaning chemicals.
--In gray cart in Procedure Room 1550 were two culture swabs dated 6/2014 and one Hibiclens 8 ounce bottle dated 12/2014.
--In gray carts in Exam Room 1554, one 500 ml bottle of sodium chloride expired 6-01-2014 and one 8 oz bottle Hibiclens expired 12-2014.
--In Exam Room 1549, one 8 oz bottle Hibiclens expired 10/2014 and one 100 ml bottle AquaSonic ultrasound gel expired 5/2016.
--In Clean Supply Room 1324 was a pair of sterile surgical gloves with expiration date of 5/2016.
--In Pulmonary Function Room 1345, a single use nasal cannula tubing attached to oxygen dispenser on wall wrapped around the flow meter. During observation with Respiratory Therapist Q, Q stated that the tubing is changed once a day, not with each patient.

An interview was conducted during tour of Specialty Institute with Supervisor of Patient Care Services R on 2/27/17 who confirmed the findings. R stated "supplies that are expired should not be in any of the carts". R also stated the dirty utility doors are always left unlocked, "I didn't know they had to be locked".




26711


OBSERVATIONS/HAND HYGIENE

Per interview with Infection Preventionist "I" on 3/1/17 at 9:15 AM, "I" revealed staff follow AORN (Association of Perioperative Registered Nurses) guidelines.

Review of the facility policy titled, "Multi-Dose Vials-Handling and Disposal," #3049462, dated 12/2016, was received on 3/1/2017 at 7:30 AM. The policy states in part, "Cleanse rubber diaphragm of multi-dose vials with 70% alcohol before inserting a sterile device into the vial."

Review of the facility policy titled, "Operating Room Attire-Scrubs," #2366180, dated 4/2016, was received on 3/1/2017 at 10:28 AM. The policy states in part, "All personnel entering the semi-restricted and restricted areas of the operating room will wear hats to cover all hair and sideburns...All personnel in the periOperative setting will have all jewelry confined or removed...Masks that are secured around the ears (vs[versus] around the head) are not permitted. Masks will be carefully removed and discarded after each use. Do not save mask by Hanging it around the neck or tucking it into a pocket for future use."

Obstetrics/ Labor and Delivery

An interview with Manager D, Supervisor E, and Supervisor F was conducted on 2/27/2017 at 10:00 AM. Manager D and Supervisor E stated that the Obstetrics department follows the professional standards of practice from the Association of peri-Operative Registered Nurses (AORN) and Centers of Disease Control (CDC).

Review of the facility policy titled, "Exposure Control Plan-Bloodborne Pathogens," #1536083, dated 3/2016, was received on 3/1/2017 at 10:25 AM. The policy states in part, "Sharps handling and disposal...Needles should not be recapped, bent or broken by hand, removed from disposable syringe or otherwise manipulated by hand...If no alternative is feasible, recapping or needle removal must be done with a device or a one-handed scoop technique. Areas permitted to recap with a device or use a one-handed scoop technique include:...Anesthesia."

--On 2/27/2017 at 2:25 PM Doctor K was observed walking through the hallway with a surgical mask still looped around K's ears, pulled down below the nose but still covering the mouth. Per interview with Supervisor E at the time of this observation regarding Doctor K wearing the surgical mask outside of the surgical arena, E stated, "[Doctor K] just came out of delivery...no, [Doctor K] is not supposed to have it [the mask] on."

The following observations took place in the Labor and Delivery Operating Room on 2/28/2017 between 3:45 PM and 5:30 PM for preparation for Patient #13's cesarean section:
--Obstetrics technician BB was observed wearing a surgical bonnet with ears exposed (wearing earrings) between 3:45 PM-4:33 PM when Registered Nurse CC approached BB and pulled the bonnet down to cover BB's ears.
--Registered Nurse CC entered the Operating Room at 4:00 PM, CC dropped a glove on the floor, picked it up and put it on and continued to assist with setting up equipment (warmer crib for newborn) in the room.
--At 4:10 PM Doctor EE was observed setting up medications for spinal anesthesia. Doctor EE recapped the needles on the syringes by pushing the tip of the plastic cap with EE's index finger down onto the syringe.
--At 4:25 PM Doctor EE was observed removing gloves after prepping Patient #13's back with ChloroPrep, did not perform hand hygiene and proceeded to open packages of equipment, handle cords from monitors, and open supplies for spinal anesthesia before doing hand hygiene.
--At 4:53 PM Registered Nurse DD was observed inserting a foley catheter into Patient #13's bladder. Registered Nurse DD dislodged the catheter causing it to become contaminated, removed gloves, did not do hand hygiene, and reinserted a new foley catheter after applying sterile gloves (Registered Nurse CC opened the new kit).
--Between 4:53 PM and 5:15 PM Obstetrics Technician BB was observed to have BB's back to the surgical table with the sterile supplies set up on it.

The above findings (with the exception of the needle re-capping observation) were discussed with and confirmed per interview by Manager D on 2/28/2017 at 5:30 PM. Manager D did say that D did not see the missed hand hygiene opportunity by Registered Nurse DD on the second foley catheter insertion, but was in agreement with the rest of the observations and saw the same things.

Per interview with Director of Accreditation Y on 3/1/2017 at 9:25 AM regarding the observation of recapping needles, Y stated, "No, that's not the right way."

Intensive Care Unit

The following observations were made:
--On 3/1/2017 at 6:50 AM, Respiratory Therapist HH was observed accessing the Pyxis machine for medications for Patient #14's ventilator respiratory treatment. Respiratory Therapist HH did not perform hand hygiene prior to entering the Pyxis.
--On 3/1/2017 at 6:53 AM, Respiratory Therapist HH entered Patient #14's room and did not perform hand hygiene then put on gloves to prepare items in the room/add medications to the ventilator port.
--After completing Patient #14's treatment and documentation, Respiratory Therapist HH removed gloves, did not do hand hygiene, applied new gloves and left the room with HH's face mask still on (Patient #14 was in droplet precautions).
--At 7:10 AM Registered Nurse GG was observed preparing insulin for Patient #14. It was observed that the insulin was in a multi-dose vial dated 3/18/2017. Registered Nurse GG brought the vial of insulin into Patient #14's room to scan it for the medical record, while in the room drew up the dose required, then administered the dose to Patient #14.
Per interview with Nurse GG at the time of the observation regarding the insulin vial, Nurse GG stated it was a multi-dose vial for multiple patients and after cleaning the vial with a sani-wipe it would be put back into the refrigerator for use for other patients.
--During the course of care delivery between 7:10 AM and 7:30 AM, Registered Nurse GG was observed entering a supply cart in Patient #14's room on 2 occasions with gloves on that were worn to provide cares/medications to Patient #14.

These observations were discussed per interview with Director of Respiratory Care Services FF, who was present for the Intensive Care Unit observations, on 3/1/2017 at 7:50 AM. Director FF stated, "Yes, I saw the same things."

Surgical Services

Review of the Policy titled, "Multi-dose Vials..." last reviewed 12/2016, stated staff should "Cleanse rubber diaphragm of multi-dose vial with 70% alcohol before inserting a sterile device into vial."

The following observations were made:

--On 2/27/17 at 12:25 PM observed Registered Nurse "YY" perform an Intravenous (IV) needle insertion on Patient 30. "YY" reached into pocket to obtain a pen, labeled the Tegaderm, then proceeded to insert Patient 30's IV. "YY" did not remove potentially contaminated gloves and perform hand hygiene prior to IV insertion.
--On 2/27/17 at 1:00 PM observed Registered Nurse "ZZ" drawing up medication during Patient 30's colonoscopy procedure. "ZZ" did not clean the rubber diaphragm of the medication vial with 70% alcohol wipe prior to piercing rubber septum.
--On 2/27/17 between 1:00 PM and 2:00 PM, observed Registered Nurse "ZZ" throughout Patient 30's colonoscopy procedure, drawing up and administering medications, then touching clipboard and pen, and then proceeding again to draw up and administer Patient 30's Intravenous medications. "ZZ" did not remove gloves and perform hand hygiene after touching pen and clipboard and prior to administering Patient 30's IV medications. During observation of Registered Nurse "EEE" cleaning the room after Patient 30's colonoscopy procedure, "EEE" did not clean and disinfect the clipboard and pen used during the procedure. The clipboard and pen were not cleaned and disinfected prior to Patient 30's procedure.
--On 2/27/17 at 1:50 PM observed Registered Nurse "EEE" handling the endoscope used for Patient 30's colonoscopy. "EEE" removed gloves, opened supply drawer, and retrieved and donned new pair of gloves. "EEE" did not perform hand hygiene after removing "dirty" gloves and before obtaining clean gloves. Observed "EEE" clean the colonoscopy equipment in the room after Patient 30's colonoscopy. "EEE" removed the soiled gloves, then donned new pair of gloves, and proceeded to set up for the next patient. "EEE" did not perform hand hygiene between glove changes.
--On 2/28/17 at 9:55 AM observed Anesthesia Technician "PP" intubating Patient 26 for surgery. "PP" donned 2 pair of gloves, intubated Patient 26, then removed top pair of gloves and proceeded to draw up and administer medications and document on clipboard without removing 2nd pair of gloves, performing hand hygiene, and donning new pair of gloves.

Per interview with Infection Preventionist "I" on 3/1/17 at 9:15 AM, "I" stated double gloving is not recommended and Anesthesia staff should not be double gloving.

Interventional Radiology

An interview was conducted with Interventional Radiology Supervisor R at 8:25 AM regarding the standards of practice followed by the Interventional Radiology Department. Supervisor R stated the department is not considered a surgical suite and they do not follow the recommendations of the Association of peri-Operative Registered Nurses (AORN), they follow standard practices with the rest of the hospital-the Centers for Disease Control.

The following observations were made on 3/1/2017 for Patient #15's spinal injection for pain management:
--At 8:27 AM, 8:31 AM, and 8:35 AM Doctor II was observed entering and exiting Patient #15's pre-procedure room without performing hand hygiene.
--At 8:42 AM Doctor II performed hand washing at the sink in the procedure room and used clean hands to shut off the water faucet without a paper towel barrier.
--At 8:45 AM Registered Nurse JJ removed the protective plastic caps from medication vials for Contrast Dye and Dexamethasone, and did not cleanse the rubber septum prior to holding the vials for Doctor II to access with needles for injections.
--At 8:59 Doctor II performed hand washing at the sink in the procedure room and used clean hands to shut off the water faucet without a paper towel barrier.
--At 9:01 AM Registered Nurse JJ removed gloves, discarded trash, picked up Patient #15's chart and left the room and did not perform hand hygiene.
--Between 8:40 AM and 9:00 AM, Radiology technician HH did not perform hand hygiene upon entry or exit to/from the procedure room.

Per interview with Registered Nurse JJ on 3/1/2017 at 9:02 AM regarding cleansing medication vials septum's prior to accessing, Nurse JJ stated JJ does not clean the vial before access, "Because we don't touch it and it's only one time use."

An interview was conducted with Supervisor R on 3/1/2017 at 9:13 AM. The observations of Patient #15's spinal injection were discussed regarding cleansing of the medication vial. Supervisor R stated that the vial septum should be cleaned with alcohol, it is not sterile under the protective plastic cap.



29963


The following observations were made on 2/28/2017 at 1:30 PM for Patient #44's Central Venous Catheter Insertion for use during Dialysis:
--Between 1:10 PM and 2:30 PM observed Neuro-interventional Technician JJJ wearing a surgical cap with ears exposed. Neuro-interventional Technician JJJ had 2 inches of hair on back side of head and side burns exposed. Physician Assistant KKK and Registered Nurse LLL were noted to be wearing bouffant type surgical hats with ears exposed.
--Between 1:10 PM- 2:30 PM observed Physician Assistant KKK inserting a Central Venous Catheter, wearing only personal glasses. No protective eyewear noted or a face shield.
--at 2:20 PM observed RN LLL did not wipe either the white or red caps of the central line prior to administering solution per syringe into the lines.
--At 2:30 Neuro-inerventional Technician JJJ and Registered Nurse LLL did not wash hands after removing gloves after procedure.

An interview was conducted on 3/2/2017 at 9:36 AM with Manager of Medical Imaging PPP and Director of Medical Imaging QQQ. The observations of Patient #44's Central Venous Catheter insertion were discussed Director of Medical Imaging QQQ stated staff should be wearing a bouffant cap, covering all hair, ears, and sideburns. Manager of Medical Imaging PPP stated that staff should be washing their hands per protocol and "perhaps the physician assistant didn't anticipate any spraying since it was a venous procedure."



34337


Inpatient Services

Review of the facility policy "Hand Hygiene Protocol" dated 3/2015 states "3. Indications for Hand Hygiene: Alcohol-Based Hand rub: -Before donning gloves; -After removing gloves; -Moving from a contaminated site to a clean body site during patient care."

The following observations were made:
--On 2/28/2017 at 9:30 AM, RN U donned clean gloves to prepare Patient #4 for foley catheter insertion. RN U used aseptic wipes to clean Patient #4's perineal area. Without removing gloves or performing hand hygiene, RN U donned sterile gloves on top of the pair of gloves already donned. RN U proceeded to perform foley catheter insertion. When asked about donning sterile gloves over the top of another pair of gloves, RN U stated "I always do it that way so I always have gloves on."
--On 2/28/2017 at 9:50 AM, RN T donned clean gloves and then donned sterile gloves over the clean gloves to wash Patient #3's chest, arm and leg with wet fluff pads. After washing, RN T removed the outer sterile gloves and, without removing the clean gloves or performing hand hygiene, proceeded to don another pair of sterile gloves over the same pair of clean gloves. RN T then applied medicated dressings to Patient #3's chest. After the dressing change, RN T again removed the outer pair of sterile gloves and donned a new pair of sterile gloves without performing hand hygiene.

During an interview on 2/28/2017 at 10:35 AM, RN T stated "not everybody does that [dons sterile gloves over clean gloves]...sterile gloves have to be changed several times, it's a trick I learned, it makes changing sterile gloves easier."





09948


Outpatient Site - Riverwoods

The following observations were made:
--On 2/28/17 at 4:15 PM in the sterile reprocessing suites revealed that clean supplies for the next day's surgical cases were commingled (touching) contaminated medical records that were printed for the identification of the next day's surgical cases.

An interview was conducted with FFFF, at time of observation, FFFF stated "'we will have to do something about the records".

Based on record review and interview, the facility failed to provide discharged patients with a list of discharge medications that clearly indicate changes in medications that occurred during the inpatient stay for 4 of 4 discharged patients reviewed (Patient 16, Patient 17, Patient 18, Patient 19). This deficiency has the potential to affect all patients discharged from this facility (Patient census 2/27/2017 -173, 2/28/2017 - 243, 3/01/2017 242, and 3/02/2017 - 243).

Findings include:

Facility policy "Discharge Planning - Assessment Process", policy #750758, dated 2/2014 states in part: "6. Patient Education: B. The discharge plan incorporates instruction on various teaching elements related to a safe discharge. These may include...medication management..."

Per medical record review on 3/1/2017 at 10:05 AM, Patient 16 was discharged from the facility on 2/7/2017 with a diagnosis of sepsis. Patient 16's discharge summary states Patient 16 was discharged to home with new intravenous antibiotics, changes in previous insulin regimen and changes to home blood pressure medications. Patient 16's discharge instructions include a list of discharge medications, there is no documentation to indicate which medications are new, changed or discontinued as a result of the hospitalization.

Per medical record review on 3/1/2017 at 11:05 AM, Patient 17 was discharged from the facility on 2/14/2017 with a diagnosis of sepsis. Patient 17's medication list upon discharge included new medications. The discharge instructions do not clearly indicate the changes made to Patient 17 medication regime as a result of the hospitalization.

Per medical record review on 3/1/2017 at 1:30 PM, Patient 18 was discharged from the facility to home on 2/14/2017 with a diagnosis of chemical dependency. Patient 18's discharge summary documents changes in previous home medications as well as newly prescribed medications. The discharge instructions provided to Patient #18 at discharge do not clearly indicate the medication changes that occurred during the hospitalization.

Per medical record review on 3/1/2017 at 2:10 PM, Patient 19 was discharged from the facility to home on 2/26/2017 with a diagnosis of gastrointestinal bleed. Patient 19's discharge instructions do not clearly indicate the changes to Patient 19's medication list from admission to discharge.

These findings were confirmed at the time of the medical record review on 3/1/2017 with Clinical Nurse Leader YY. During an interview on 3/1/2017 at 10:30 AM, Clinical Nurse Leader YY stated the discharge list does not identify new, changed or discontinued medications.

During an interview on 3/2/2017 at 11:10 AM, Pharmacy Manager HHH stated pharmacy staff will "sometimes" review discharge medications with patients prior to discharge. Per Pharmacy Manager HHH, "we write on there [the patient's discharge instructions] the new medications and highlight the changes, if discontinued we will write it on there." Pharmacy Manager HHH stated there is an emphasis to reconcile medications with "core measure" patients but not all patients have their medications reconciled upon discharge. Pharmacy Manager HHH stated the pharmacy staff write directly on the patient's discharge instructions, there is no way to confirm the education or instructions the patient receives regarding medication changes.

Based on record review and interview, the hospital failed to ensure that all practitioners performing surgical tasks are privileged to perform tasks in 1 of 1 job description reviewed (Surgical First Assistant). This could potentially impact all patients receiving surgery at this facility.

Based on record review and interview, the hospital failed to ensure that all practitioners performing surgical tasks are privileged to perform tasks in 1 of 4 job descriptions reviewed (Surgical First Assistant). This could potentially impact all patients receiving surgery at this facility.

Findings include:

Review on 2/28/2017 at 3:00 PM of job description for "Surgical First Assistant", shows the job responsibilities include, "Provides visualization of the operative site using appropriate method, including manipulation of tissue and materials, retraction, sponging, suctioning and irrigation." "Assists with body plane closure, application of wound dressings and securing of drainage systems."

Per interview with Director of Perioperative Services FFF on 2/28/17 beginning at 2:00 PM, Perioperative Services FFF revealed that Surgical First Assistants do not go through the privileging process to perform duties listed on the job description.

Per review of the Surgery staff roster on 3/1/17 beginning at 11:00 AM, there are 4 Surgical First Assistants staffed in the Surgery Department.

Based on record review, observations, and interview staff failed to ensure alcohol based skin prep solution is dry in 4 of 4 surgical records reviewed (Patient #26, Patient #27, Patient #28, Patient #29) and 1 of 1 surgery observed using alcohol based skin prep solution (Patient #26). This could potentially affect all patients receiving surgery at this facility.

Findings Include:

Policy and procedure titled, "Fire Plan and Risk Assessment--Surgical Services" last reviewed 9/2016 states, "Alcohol based skin prep solutions must be allowed to dry for at least 3 minutes before application of drapes." "Ensure that solution soaked materials have been removed from the field prior to draping."

On 2/28/17 beginning at 9:55 AM, observed the skin prep application for Patient #26's hernia repair surgery. Registered Nurse "PPPP" applied alcohol based skin prep (ChloraPrep) to Patient #26's abdomen. Surgery staff waited 3 minutes for skin prep to dry but did not acknowledge if the skin prep was visibly dry prior to draping.

Per interview with Operating Room Coordinator LL on 3/1/17 at 10:40 AM, Operating Room Coordinator LL revealed operating room staff do not verbalize skin prep being visibly dry during "time out" prior to draping patients, staff wait 3 minutes for alcohol based skin prep to dry and then drape patients. Per Operating Room Coordinator LL staff do not document in patient medical records that the alcohol based skin prep is visibly dry prior to draping patient.

Review of surgical records for Patient #26, Patient #27, Patient #28, Patient #29, shows no documented evidence of staff ensuring that alcohol based skin prep is visibly dry prior to draping patients.

Based on record review and interview, the facility failed to develop policies and procedures for the routine intake and monitoring of patients seeking emergency services in 1 of 1 Emergency Service reviewed (Emergency Department). This would have the potential to affect any persons in the community seeking emergency room treatment.

Findings include:

Per medical record review on 3/1/2017 at 8:10 AM, Patient #22 presented to the Emergency Department (ED) on 2/25/2017 at 10:44 PM with complaints of vaginal bleeding, dizziness and left flank pain. The nursing ED assessment documentation does not include any focused body system assessment.

Per medical record review on 3/1/2017 at 8:35 AM, Patient #23 presented to the ED on 2/6/2017 at 12:54 AM with complaints of difficulty breathing and chest pain. Patient #23 rated pain level as an "8"/10 at admission. Vital signs taken upon admission at 12:56 AM show Patient #23 presented with an elevated blood pressure, elevated heart rate and an elevated temperature. Patient #23's temperature was taken a second time at 1:58 AM. Patient #23 was discharged from the ED to home at 3:03 AM with no other vital signs on record. Pain was not reassessed during the ED stay. Review of the nursing ED assessment documentation does not include any focused body system assessment.

These findings were confirmed at the time of the review with ED Supervisor ZZ. During an interview on 3/1/2017 at 8:45 AM, ED Supervisor ZZ stated that nurses in the ED perform a general assessment followed by a "focused assessment" related to presenting complaint. ED Supervisor ZZ stated both Patient #22 and Patient #23 "should have" a focused assessment on file. ED Supervisor ZZ went on to state "I would expect another set of vitals and pain assessment" on Patient #23.

During an interview on 3/2/2017 at 7:50 AM, Director Y stated "there is no policy to guide documentation expectations [in the Emergency Department], staff is expected to use clinical decision making skills."

During an interview on 3/2/2017 at 11:55 AM, ED Director OOO stated "there should be a focused assessment" based on the chief presenting complaint. After sharing the documentation findings on Patient #22 and Patient #23, ED Director OOO stated "it shouldn't be that way." ED Director OOO was unable to confirm expectations for obtaining vital signs in the ED.