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Based on MR review and interview with staff (M), in 2 of 18 MRs that require AD information documented (6 and 8), the facility failed to ensure documentation of an AD, and offering information and/or help preparing an AD. This deficiency potentially affects all 9 Pts treated at the facility during this survey.

Findings include:

Pt #6's MR review on 11/20/13 at 7:00 AM revealed there is no documentation of Pt #6 having an AD or follow up of if Pt #6 wanted information and/or help preparing an AD. This is confirmed in interview with OBM W on 11/20/13 at approximately 11:45 AM, adding AD information should be addressed.

Pt #8's MR reviewed on 11/20/13 at 12:00 PM revealed there is documentation Pt #8 does not have an AD, there is no documentation of follow up indicating if Pt #8 wanted information and/or help preparing an AD. This is confirmed in interview with OBM W on 11/20/13 at approximately 12:00 AM, adding AD information should be addressed.

Based review of P&P, review of standards of practice, observation and staff interviews, in 2 of 2 interviews (T and Q) the hospital failed ensure the full 36 vials of dantrolene needed to respond to a malignant hypothermia emergency was in the facility. This deficiency has the potential to affect all surgical patients treated at this facility.

Findings include:

Per review of policy on 11/19/2013 at 8:25 AM titled "Malignant Hyperthermia" states "4. Dantrolene administration: Hospital unit clerk to call the ER of these hospitals for additional dantrolene: Spooner Hospital (12 vials) Indianhead Medical Center (Shell Lake) (12vials) (prior agreement for above hospitals to immediately transport vials to HAMH)."

Per Pharmacy Newscapsule, Wisconsin Department of Health Services, Division of Quality Assurance (DQA) issued/dated November-December 2012 it states "One item in the recommended supply list includes dantrolene. In the past dantrolene was very expensive and rarely used, costing facilities significant resources. In the past, to defray these costs, facilities may have had policies to share dantrolene with neighboring facilities, in some cases located miles away. To adjust for the physical separation, facilities may have adopted a policy to include law enforcement or EMS to quickly courier the product between neighboring facilities. Today, however, the cost of dantrolene has decreased. And, what the MH crisis really requires is that supplies be IMMEDIATELY available when an emergent crisis demands them. For these reasons facilities that are at risk for an MH crisis are recommended to have 36 vials of dantrolene immediately available. These recommendations can be accessed at".


On 11/19/2013 at 8:05 AM during a tour or Surgical Area CRNA T confirmed there are only 6 vials of Dantrolene (a medication used to treat an emergent side effect of anesthesia called Malignant Hyperthermia) in the MH cart. When asked where the other 30 vials were stored CRNA stated they have an agreement with the local police department to retrieve the remaining vials from nearby hospitals if needed.

During an interview with Pharmacist Q on 11/19/2013 at 2:27 PM Pharmacist Q stated they do no have any Dantrolene stored in the pharmacy. The hospital stock is stored in the MH cart. Pharmacist Q confirmed they have an agreement to share the Dantrolene stock with nearby hospitals. Pharmacist Q stated they follow DQA pharmacy newsletter and updates but was unaware the MH change in practice.

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


Findings include:

The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags: (K-11)-Separation doors not closing, (K-17)-Room open to the Corridor,(K-18)-Corridor doors not latching, (K-25)-Smoke wall penetrations not sealed, (K-29)-Hazardous rooms not properly enclosed, (K-56)-Missing Sprinklers, and (K-62)-Sprinkler maintenance.

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


Findings include:

The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags: (K-11)-Separation doors not closing, (K-17)-Room open to the Corridor,(K-18)-Corridor doors not latching, (K-25)-Smoke wall penetrations not sealed, (K-29)-Hazardous rooms not properly enclosed, (K-56)-Missing Sprinklers, and (K-62)-Sprinkler maintenance.

Based on tour, observation, MR review and interview (A, C, D, E, H, J, M, W, X, CC) the facility failed to ensure that patient services are provided in a appropriate and safe manor in 8 of 8 departments toured and in 2 of 2 observations, and CP are appropriate and unique in 4 of 22 MR (6,7,18,19) reviewed at this facility.

Findings include:

In 1 of 8 department tours, the facility failed to ensure all multidose medication vials are dated when opened to monitor for optimum quality. See tag 276

In 8 of 8 tours of patient care areas and in 2 of 2 observations, the facility failed to ensure a safe and sanitary environment to prevent and control the potential spread of infection. See tag 278.

In 6 of 6 areas toured where food is stored or prepared the facility failed to ensure the kitchen and utensils are maintained in a sanitary manner to prevent potential cross contamination and/or spread of disease; food is stored, labeled and/or dated to prevent cross contamination and maintain optimal nutritional value; contaminated non- food items are stored separately from food items; and all hair is contained in a bonnet or beardnet. See tag 279.

In 4 of 19 MR needing CPs the facility failed to ensure there is a CP developed that is unique to the Pts need. This deficiency potentially affects all 9 Pts treated at the facility during this survey. See tag 298.

The cumulative effect of these deficiencies potentially affects all Pts treated at this facility.

Based on tour, review of P&P and interview with staff (H), in 1 of 8 department tours, the facility failed to ensure all multidose medication vials are dated when opened to monitor for optimum quality. This deficiency potentially affects all 9 Pts treated at the facility during this survey.

Findings include:

Review on 11/20/13 in the AM of facility P&P titled Sterile Product Preparation, revised 3/13 states under G. Expiration Dating "Multidose vials which do not require reconstitution may be used for up to 28 days after opening."

Per tour of the Radiology Department on 11/19/13 at 10:00 AM, The MRI (Magnetic Resonance Imaging) and CT (Computed Tomography Scan) rooms each contained an open bottle of Gastrografin (oral iodine contrast) with no open date per policy. This was confirmed with RDM H during tour on 11/19/13, adding the medication should be dated.

Based on tours, observation, review of P&P, review of APIC standard of practice and interview with staff (H, E, CC), in 8 of 8 tours of patient care areas and in 2 of 2 observations, the facility failed to ensure a safe and sanitary environment to prevent and control the potential spread of infection. This deficiency potentially affects all 9 Pts treated at the facility during this survey.

Findings include:

Review on 11/19/13 in the PM of facility P&P titled Laboratory Department Standard Operating Procedures, revised 12/08, it states under L. Personal Protection 2. "ALWAYS wear a lab coat and gloves when performing lab work."

Review on 11/20/13 in the PM of facility P&P titled Standard Precautions, revised 10/12, it states under A. "Handwashing is considered the single most important procedure for interrupting the transmission of most infections to patients/residents and employees. Hands will be washed: 1. Before and after caring for each patient/resident. 2. Before and after performing invasive procedures...4. If contaminated with blood or other body fluids (immediately)...8. After gloves are removed." Under C. Gloves "1. Wear non-latex gloves when it can be reasonably anticipated contact with blood or other potentially infectious materials, mucous membranes, non-intact skin could occur."

Per APIC...Professional training 5/30/2012, Terminal Cleaning Practice- "Hospitals change curtains after Contact Precaution patients, Cubicle curtains are changed routinely every 6 months or when visible soiled, In Contact Precaution rooms, frequently touched surfaces of the curtains should be sprayed with approved disinfectant, Vinyl shower curtains are cleaned when visibly soiled or replaced as needed. "

Per review on 11/20/2013 at 9:30 AM of hospital policy titled "Housekeeping department policy/procedure" states "Divider Curtains and Shower Curtains: Cubicle and shower curtains are checked daily when room is occupied, or upon discharge, and changed as needed. If contact precautions have been taken in discharged room, curtains will be changed."

Example in Radiology:

Per tour of the Radiology Department on 11/19/13 at 10:20 AM The CT room contained a bedside table set up for an IV (intravenous). Attached to the table are three pieces of precut tape. This practice allowed for potential contaminates to adhere to the tape, and transfer to Pts allowing for potential transfer to Pts. This is confirmed during tour with RDM H, agreeing the tape should not be precut.

Examples in Lab:

Per tour of the Laboratory on 11/19/13 at 9:20 AM MLT F is noted working without a lab coat. LS E stated in interview during the tour, MLT F is supposed to wear a lab coat.

Example of observations:

Per observation on 11/20/13 at 12:30 PM of MLT V performing a lab draw on an Pt #9 in the Nursery. MLT V was observed to removed gloves after obtaining a vial of blood, placed gloves in the lab tray, did not wash and handled items in the tray. MLT V located a new IV site without the benefit of gloves, and did not wash prior to donning gloves for the additional blood draw. Pt #9 is a newborn and not yet bathed per OBM W during the observation. Prior to leaving the nursery, MLT V discarding the dirty gloves from the lab tray, returned to the lab, donned new gloves, removed them and donned new gloves without the benefit of washing. MLT V did not recall placing dirty gloves in the lab tray when questioned at approximately 12:45 PM.

At 12:35 AM CRNA T and CRNA St U entered the nursery to start an IV line on Pt #9. CRNA St U did not wash hands, donned gloves, and stood observing the lab draw with the gloves hands resting on own hips. CRNA St U is in street clothes. CRNA St U is observed stepping up to the warmer, placed hands, contaminated from the street clothes on the warmer then on Pt #9 to assist stabilizing Pt #9's limb for the IV start, potentially contaminating Pt #9.

Per interview with HRA Assistant on 11/20/13 at 1:20 PM CRNA St U are instructed and provided access to P&P's including Standard Precautions regarding gloves and handwashing at time of orientation. CRNA St U's orientation date is 10/21/13.


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Examples in housekeeping:

Per interview on 11/20/13 at 8:25 AM with Housekeeping Manager CC curtains are replaced after an infectious patient or when visibly soiled. The curtains are not cleaned every six months or on a schedule per facility policy.

Per interview on 11/10/2013 at 9:05 AM Infection Preventionist R stated this facility follows APIC guidelines.

Based on tour, review of P&P and facility documents, and interview with staff (C, D, M, A, J), in 6 of 6 areas toured where food is stored or prepared the facility failed to ensure the kitchen and utensils are maintained in a sanitary manner to prevent potential cross contamination and/or spread of disease; food is stored, labeled and/or dated to prevent cross contamination and maintain optimal nutritional value; contaminated non- food items are stored separately from food items; and all hair is contained in a bonnet or beardnet. This deficiency potentially affects all patients, staff and visitors who eat at this facility.

Findings include:

Review on 11/19/13 in the PM of facility policy titled Cleaning Procedures dated 7/11 it has no required timelines for the ovens, steam tables, refrigerators cooler and plate cart. There are cleaning guidelines as follows: Range tops-clean daily, Can Opener-clean after each use, Stainless Steel Counter, Shelves and Tables-clean daily, Range Hoods and filters-clean monthly, Refrigerated table and soup warmer-clean after each use, Food Carts-clean after each use, Refrigerated Table-clean daily.

Review on 11/19/13 in the PM of facility policy titled Cleaning Schedules dated 4/95, states under #2 "The employee checks off each task as it is completed."

Examples in Dietary:

Per tour of the kitchen on 11/18/13 between 11:45 AM and 1:00 PM the following is noted:

The refrigerator near the deep fryer had grease splatters along the side.
The outer surfaces of the deep fryer had grease.
The work table between the deep fryer and refrigerator has visible grease, and had two unlabeled bottles of liquids (soy sauce and oil per CDM C), two staff water containers, a piece of cooked meat wrapped in a paper towel, and an unlabeled bucket containing cleaning solution.
The range/oven front had grease, the stove top had baked on grease and multiple splatter of food stuffs along the edges and back, the oven had baked on food items along bottom, sides, back and racks.
The soup kettle back and spigot has baked on grease and visible debris.
The holding ovens had food splatter along the back and the bottom had baked on food stuffs, the outside was greasy.
The hood/vent was greasy, along the back and anterior lip.
The steamer has food splatter on the back inner wall and the outside has grease.
The Turbo oven had a tray on top containing seasonings and an instant read thermometer that has visible food debris on the spike, the tray has visible dust, debris.
The prep table across from the steamer and Turbo oven had a industrial can opener with visible food stuffs on the blade and front, the table and shelf above has dust and powder on surface.
The cooling/storage racks have visible dust, and food sills.
Three prep counters have visible dust and debris.
The cart holding plates and plate warmers for patients have visible dust and lint.
The proofing cabinet had a metal tray at the bottom with cloudy water, and mineral residue.

The daily cleaning schedules state "Initial When Task is Completed". Each day there are lists of the item to be cleaned as follows:

Sunday- Wash stove, inside of microwave (turbo) and cart, clean grill/fryer, wash all small carts and clean and organize prep table #8 and area around it.
Monday-Wash stove, wash inside of microwave, wash all tall carts including tray and bakery cart,.
Tuesday-Wash stove, wash inside microwave, wash holding ovens, wash serving counter, wash slicer table including bottom shelf.
Wednesday-Wash tray line counter area, clean microwave by trayline, wash state (sic) station, clean and organize prep table #8 and area around it, wash stove, wash inside microwave and wash cart.
Thursday-Clean and organize prep table #8 and area around it, wash shelf above trayline, wash inside microwave and shelf, wash stove.
Friday-Wash tray line service stations, wash inside of microwave and wash cart, wash stove, wash bakers table, shelves and drawers, clean holding and convection ovens.
Saturday-wash stove, wash inside microwave, clean stove oven.

Per review of the kitchen cleaning schedules for 10/27/13-11/2/13 and 11/10/13- 11/16/13 there were no initials indicating the cleaning task was done for the above listed items for the following days:
Sundays 10/27/13 and 11/10/13-all items; Mondays 10/28/13 -carts, 11/11/13-all items; Tuesdays 10/29/13-stove and microwave, 11/13/13-all items; Wednesdays 10/30/13 and 11/14/13-all items; Thursdays 10/31/13 and 11/15/13-all items; Fridays 11/1/13 and 11/16/13-all items.

Per interview with Dietition D on 11/19/13 at 7:15 AM, staff "forget to check off doing cleaning" and agrees the kitchen needs to be cleaned. CDM C confirmed all food items are to be labeled and date in the refrigerators and freezer.

Additional findings in the kitchen:

Staff Z did not have a beard net covering a goatee, and Staff AA did not have all hair covered by a bonnet.

There is a scoop in the flour bin.

The following food is unlabeled and/or undated:
In kitchen walk-in freezer:
Churro's(Mexican dessert)

In freezer/fridge by fryer:
pancake batter
tater tots
hashbrowns

In cooler:
Unknown food stuff in container

On 11/19/13 during dishwashing observation at 2:00 PM, dish racks were placed on the floor allowing for potential contamination of cooking utensils, plates and silverware.

Per interview with CDM C during tour on 11/18/13 between 11:45 AM and 1:00 PM, CDM C stated staff should wear beardnets and all hair should be covered, all foods should be labeled, and on 11/19/13 at 2:00 PM CDM C could not confirm the dishwasher would be able to sanitize the dish racks properly after being set on the floor.

Examples from tours of kitchenettes and departments:

Per interview with D D on 11/19/13 at 7:15 AM, there is no P&P related to staff food stored in Pt refrigerators.

Per tour of OB department on 11/18/13 at 2:00 PM staff food items are in the refrigerator in Pt Room 52. And there are 3 bottles of infant formula Similac expired on 8/1/13 in Pt Room 50; 3 bottles of infant formula Similac expired 8/1/13 and 1 bottle infant formula Similac expired 9/1/13 in Room 51.

Per tour of the ED with RN M on 11/19/13 at 1:00 PM the Pt refrigerator has two open milk cartons with no date and a loaf of bread with no date; the freezer has cold packs along side food items. RN M stated during tour, the cold packs are not used in ED and the the food items should be dated.


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During a tour of outpatient services on 11/18/2013 at 1:30 AM accompanied by Oncology Clinical Lead I noted in room labeled "Nutrition Room", the refrigerator contained 2 containers of soup, 1 sandwich, 1 bottle of mayonnaise, 1 bottle of BBQ sauce, 1 jar of salsa, 1 bottle of mustard and 1 jar of pickles opened and undated. This refrigerator also contained 7 reusable ice packs and 1 box of breast biopsy ice packs in the freezer where patient food is being stored. Per interview with VP of Nursing A on 11/11/2013 at 1:35 PM the above items were staff use items and should not be put in the patient refrigerator. Per VP of Nursing A they do not have a policy regarding intermingling staff and patient food.

During a tour of the medical/surgical unit on 11/18/2013 at 2:40 PM accompanied by Clinical Lead J noted in the Water Wing nutrition room 2 bins containing reusable ice packs in the freezer where patient food is being stored. Clinical Lead J confirmed these findings at the time of discovery. Per Clinical Lead J on 11/18/2013 at 2:00 PM they do not have a policy regarding the storing of ice packs in the nutrition room fridge.

During a tour of the medical/surgical unit on 11/18/2013 at 3:25 PM accompanied by Clinical Lead J noted in the Woods Wing nutrition room refrigerator 2 loafs of bread open and undated. This refrigerator also contained 2 bins full of reusable ice packs in the freezer where patient food is being stored. Clinical Lead J confirmed these findings at the time of discovery.

Based on MR review, review of P&P and interview with staff (W, X), in 4 of 19 MR needing CPs (6, 7, 18, 19) out of a total of 22 MR reviewed the facility failed to ensure there is a careplan developed that is unique to the Pts need. This deficiency potentially affects all 9 Pts treated at the facility during this survey.

Findings include:

Per review on 11/20/2013 at 10:40 AM policy titled "Patient Care Plans" states "1. Medical diagnosis specific care plans are available for the RN to use on each patient. These care plans are individualized for each patient on admission as soon as the initial nursing assessment is completed."

Pt #6's MR reviewed on 11/20/13 at 7:00 AM revealed Pt #6 was admitted for delivery of an infant on 8/10/13. There is no careplan for labor, post-partum care or post surgery related to fallopian tubes tied. This is confirmed in interview with OBM W at approximately 11:45 AM, adding the careplan should be related to Pt #6 surgery.

Pt #7's MR reviewed on 11/20/13 at 7:25 AM revealed Pt #7 had a circumcision on 8/11/12. There is no careplan related to the circumcision. This is confirmed in interview with OBM W at approximately 11:45 AM, adding there is a careplan for circumcision that should be initiated.


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A MR review of Pt # 18 was conducted on 11/20/2013 at 11:25 AM accompanied by Clinical Nurse Educator X. Pt # 18 was admitted on 10/8/2013 for a 5th toe amputation. A computerized CP for Risk for Falls was initiated which is standardized for all patients with this problem and is not individualized to reflect the unique needs of Pt # 18. Pt #18 also had went to surgery and had experienced pain which was not addressed in the care plan.

A MR review of Pt # 19 was conducted on 11/20/13 at 12:00 PM accompanied by Clinical Nurse Educator X. Pt #19 was admitted on 11/17/2013 for abdominal pain and kidney stones. A computerized CP for pain was initiated which is standardized for all patients with this problem and is not individualized to reflect the unique needs of Pt #19. Pt #19 also had a problem of urinary incontinence which was not addressed in the care plan.

Based on MR review, review of R&R, review of P&P and interview with staff (M and W), in 8 of 22 MR's reviewed (1, 2, 3, 4, 5, 6, 7, and 8) the facility failed to ensure consents are completed including signatures, dates, times and risks are specific to Pt's condition; and in 1 of 2 SA (Sexual Assault) MR (1) the facility failed to ensure there is a record of the SA exam. This deficiency potentially affects all 9 Pts treated at the facility during the time of this survey.

Findings include:

Per review on 11/20/13 in the PM of facility P&P titled Health Information Services revised 3/11 it states under Purpose "Every entry in the medical record should include a complete signature and credential of the person making the entry and a complete date (month, date, and year) as well as the time of the entry."

Review on 11/20/13 in the PM of facility R&R dated 5/11 it states under #16 "Pertinent progress notes, sufficient to permit continuity and transferability of care, shall be recorded at the time of observation."

Pt #1's MR reviewed on 11/18/13 at 11:35 AM revealed Pt #1 arrived in the ED on 6/3/13 with a complaint of SA. There is no SA examination in the MR. Results of an HIV blood test is in the MR, there is no consent for an HIV test. This is confirmed in interview with RN M on 11/19/13 at 1:20 PM, stating the exam should be in the MR , and the HIV consent should be in the MR.

Pt #2's MR reviewed on 11/18/13 at 11:45 AM revealed Pt #2 arrived in the ED on 11/10/13 with a complaint of SA. The consent for an HIV test dated 11/10/13 has no time when signed by the Pt or witness. This is confirmed in interview with RN M on 11/19/13 at 1:20 PM, stating the consent should be timed.

Pt #3's MR reviewed on 11/19/13 at 8:00 AM revealed Pt #3 arrived in the ED on 9/1/13 with a complaint of a stroke, Pt #3 was transferred to a facility with higher level of care. The Patient Transfer Form has no transfer risks specific to Pt #3's complaint. This is confirmed in interview with RN M on 11/19/13 at 1:20 PM stating the form should include specific risks.

Pt #4's MR reviewed on 11/19/13 at 8:05 AM revealed Pt #4 arrived in the ED on 8/6/13. The General Consent and Authorization for Treatment, Care and Billing is not signed, dated, timed or witnessed by the Pt, or representative, and staff. This is confirmed in interview with RN M on 11/19/13 at 1:20 PM, stating the consent should be signed, dated and timed.

Pt #5's MR reviewed on 11/19/13 at 8:15 AM revealed Pt #5 arrived in the ED on 6/30/13 with a complaint of a head injury, Pt #5 was transferred to a facility with higher level of care. The Patient Transfer Form has no transfer risks specific to Pt #5's complaint. This is confirmed in interview with RN M on 11/19/13 at 1:20 PM stating the form should include specific risks.

Pt #6's MR reviewed on 11/20/13 at 7:00 AM revealed Pt #6 delivered an infant on 8/10/13, followed with a surgical procedure to tie fallopian tubes. The consent for anesthesia is not dated and timed by Pt #6 nor staff, and there is no attestation by the anesthesia provider the risks and benefits were explained related to an epidural received for relief of pain during labor. Pt #6's surgery was performed on 8/11/13 at 5:30 PM, the MD attestation related to risks of the surgery is signed on 8/11/13 at 6:00 PM, after the surgery. This is confirmed in interview with OBM W on 11/20/13 at approximately 11:45 AM, adding all the information should be signed dated and timed.

Pt #7's MR reviewed on 11/20/13 at 7:25 AM revealed Pt #7 is a newborn on 8/10/13. Pt #7 received a circumcision on 8/11/13, the consent for the circumcision has no risks and there is no attestation my the MD risks were discussed. This is confirmed in interview with OBM W on 11/20/13 at approximately 11:45 AM, adding the consent should include risks signed by the MD.

Pt #8's MR reviewed on 11/20/13 at 12:00 PM revealed the General Consent and Authorization for Treatment, Care and Billing is not dated and timed by Pt #8. This is confirmed in interview with OBM W on 11/12/13 at approximately 12:00 PM, adding the consent should be dated and timed.

Based on MR review, review of R&R, review of P&P and interview with staff (W), in 4 of 22 MRs (6, 7, 16, 17), the facility failed to ensure MD progress notes are written daily, related to Pts condition, and RN assessments and re-assessments of Pt condition are recorded in the frequency directed by facility policy. This deficiency potentially affects all 9 Pts treated at the facility during this survey.

Findings include:

Review on 11/20/13 in the PM of facility R&R dated 5/11 it states under #15 "Inpatients must be seen by the attending physician or his/her designee with appropriate privileges at least each calendar day, except for patients in the Transitional Care Unit who must be seen weekly...16. Pertinent progress notes, sufficient to permit continuity and transferability of care, shall be recorded at the time of observation."

Review on 11/20/13 in the PM, of facility P&P titled Care of circumcised Infant, revised 6/12/09 it states under #1 "The first few hours after circumcision observe for signs of excessive swelling and bleeding. Check at half hour intervals times two. Record findings in baby's chart and then every shift."

Per review on 11/20/2013 at 11:05 AM policy titled "Pain Management" states "all patients will be assessed for presence, absence, and history of pain. A measure of pain intensity and a measure of pain relief are recorded on a permanent record that facilitates regular review by members of the health care team. The patient is included in the pain management process."

Pt #6's MR reviewed on 11/20/13 at 7:00 AM revealed Pt #6 delivered an infant on 8/10/13, followed with a surgical procedure to tie fallopian tubes. There are no MD progress notes in the MR to record progress of recovery surgery. This is confirmed in interview with OBM W on 11/20/13 at approximately 11:45 AM, adding there should be progress notes between the surgery and discharge.

Pt #7's MR reviewed on 11/20/13 at 7:25 AM revealed Pt #7 is a newborn on 8/10/13. Pt #7 received a circumcision on 8/11/13, there is no documentation of Pt #7 circumcision assessment from the first assessment immediately after the procedure at 11:04 AM to the next shift nearly 7 hours later at 5:48 PM. Pt #7 was discharged on 8/12/13, there is no documentation who received Pt #7 at discharge. This is confirmed in interview with OBM W on 11/20/13 at approximately 11:45 AM, adding there should be results of treatment documented per policy and who Pt #7 was discharged to should be documented.


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Per MR review on 11/20/2013 at 11:45 AM accompanied by Clinical Nurse Educator X, Pt # 16 received Vicodin for pain on 9/26/2013 at 8:49 PM and on 9/27/2013 at 8:42 AM. Per Clinical Nurse Educator X Pt #16's MR does not reflect a follow up pain assessment was documented after either pain medication administration.

Per MR review on 11/20/2013 at 11:20 AM accompanied by Clinical Nurse Educator X, Pt #18 received Vicodin for pain on 10/10/2013 at 9:52 PM and on 10/11/2013 at 12:20 AM . Per Clinical Nurse Educator X Pt #18's MR does not reflect a follow up pain assessment was documented after either pain medication administration.

Per interview on 11/20/13 at 11:25 AM with Clinical Nurse Educator X pain assessment should be documented at the time the pain medication was given and the effectiveness of the pain medication should be reassessed and documented within 1 hour of the administration of the medication.

Based on observation, MR review, review of P&P, review of AORN standards of practice and interview with staff (N) in 1 of 1 surgical MRs (#14) out of a total of 22 MRs reviewed and in 1 of 1 staff observations (BB), the facility failed to ensure verbal confirmation and written documentation reflect the alcohol based skin preparation is dry prior to draping; and in 3 of 3 staff observations (K, L, T) and interview (N) the facility failed to ensure proper attire is worn in the OR; and in 2 of 2 interviews (N) and observation the facility failed to ensure proper cleaning and storage of surgical instruments and scopes.

Findings include:

Per AORN Perioperative Standards and Recommended Practices 2013 Edition, all hair is to be covered, long sleeved jackets should be worn to cover exposed skin if not gowning.

Per AORN Perioperative Standards and Recommended Practices for Inpatient and Ambulatory Settings 2013 Edition, it states under RP: Cleaning and Processing Flexible Scopes and Endoscopes, IX "Flexible endoscopes should be stored in a manner that protects the device from damage and minimizes microbial contamination. IX.a. Flexible endoscopes should be stored in a closed cabinet with venting that allows air circulation around the flexible endoscopes..."

Per AORN Perioperative Standards and Recommended Practices under RP: Care of Instruments, XIV "Special precautions should be taken for reprocessing ophthalmic surgical instruments...XIV.h.. Detergents and enzymatic detergents should be used and diluted according to cleaning agent manufacturers' written instructions...XIV.j.. After cleaning or decontamination, instruments should be thoroughly rinsed with distilled or deionized sterile water and dried... XIV.k. After cleaning, lumens should be thoroughly flushed with sterile water (expelling the liquid into a drain, not the rinse water) and dried with filtered, oil-free compressed air."

Per AORN Perioperative Standards and Recommended Practices under RP: Sterilization, VII "Immediate used steam sterilization should be kept to a minimum and should be used only in selected clinical situations and in a controlled manner...The term flash sterilization has historically been used to describe steam sterilization of unwrapped items intended to be used immediately. Flash sterilization cycles have traditionally been either 3 or 10 minutes of exposure, depending on the nature of the device being sterilized or the type of cycle indicated, minimal or not dry time, and no cool down, thereby making the entire cycle time shorter than the cycle times of wrapped or terminally sterilized items...VII.a. Immediate use steam sterilization should be used only when there is insufficient time to process by the preferred wrapped or container method intended for terminal sterilization. Immediate use steam sterilization should not be used as a substitute for sufficient instrument inventory.

"Per review of policy titled "Transporting of Endoscopy Scopes" on 11/19/13 at 11:30 AM, the policy is labeled "dirty side" which states: ..... the scope is manually cleaned and brushed. The scope is hooked up to the scope buddy and run through the cleaning cycle X 1. The scope is then placed in the Medivator Endoscope Reprocessor for complete disinfection." the policy further states under the section labeled "clean side" ..."8. Scope is removed from the reprocessor. 10. Scopes are then stored in the "clean" cabinet in hanging position with doors closed."

Per review of policy titled "Fire in Operating Room" on 11/19/13 at 3:00 PM under "Minimizing Fuel Risks (Scrub Tech and Nurse Focus" it states "1. Avoid pooling or wicking of flammable liquid skin preps. 2. Allow flammable liquid preps to dry fully before draping; pooled or wicked liquid will take longer to dry than will prep on the skin alone."

Per review of policy titled "Immediate use steam sterilization" on 11/20/2013 at 11:00 AM steam sterilization should be used only when there is insufficient time to process by the preferred wrapped or container method intended for terminal sterilization. Immediate use steam sterilization in surgery" states "Immediate use steam sterilization should not be used as a substitute for sufficient instrument inventory"

Per review on 11/20/2013 at 11:05 AM of policy titled "Sterilization of Cataract instruments" states under heading "procedure" 1. Emergency only. 2. Thoroughly decontaminate, clean and dry all instruments."

On 11/19/2013 at 2:15 PM review of the insert provided with the scope brush from the manufacturer labeled "Pentax Tri-Bristled Cleaning Brush" states "1. Intended Use. Note: This brush is provided non-sterile for one time use. Never reuse the brush on more than one instrument."

Per interview with Surgical Services Clinical Lead N on 11/19/2013 at 10:25 AM this facility follows AORN standards of practice.


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Examples of surgical attire:

On 11/19/2013 at 9:15 AM observed Surgical Tech K, RN circulator L and CRNA T in OR 1 during a surgical procedure wearing short sleeve surgical uniforms.

Per interview with Surgical Services Clinical Lead N on 11/19/2013 at 11:05 AM the OR personnel are aware of AORN standards to wear long sleeves and removed the long sleeve jackets at the preference of the surgeon.

Examples of alcohol based skin preparation:

On 11/19/13 at 9:45 AM RN L applied Chloraprep (alcohol based skin prep) to Pt #14's Right chest and neck in preparation for a permanent vascular device insertion. Immediately RN L finished applying Chloraprep MD BB began applying drapes to Pt #14's neck and chest. There was no verbal statement the Chloraprep was dry prior to draping and the dry time of the prep was not included in the "time out" prior to incision. During interview on 11/19/13 at 10:30 AM Surgical Services Clinical Lead N stated the skin prep should be dry prior to draping but they do not perform a check or verbal acknowledgement that the prep is dry. Review of Pt #14's MR on 11/20/13 at 11:00 AM revealed the Intra-operative record includes box checked "yes" next to the statement "Alcohol base prep solution dry." During interview with Surgical Services Clinical Lead N on 11/20/13 at 11:00 AM this box should not have been checked as no one confimed the prep was dry prior to draping.

Examples of scope cleaning and storage:

On 11/10/2013 at 10:25 AM during a tour of the Surgical Area accompanied by Clinical Lead N noted 5 clean endoscopy scopes stored in an unvented cabinet in the same room used for dirty scope processing. Per Clinical Lead N at the time of discovery they consider the scopes to be on the "clean side of the room" and the scope processing to be on the "dirty side of the room." Clinical Lead N agree there is nothing to separate the clean side from the dirty side."


On 11/10/2013 at 10:25 AM during a tour of the Surgical Area accompanied by Clinical Lead N noted an endoscopy scope brush in the sink half filled with water in the Endoscopy scope processing room. Per Clinical Lead N at time of discovery the scope brush will be used for cleaning of all the scopes for that day and then disposed of.

Examples of sterilization of cataract eye kits:

Per interview with Clinical Lead N on 11/19/2013 at 10:30 AM, Clinical Lead N stated they flash (immediate-use sterilize) the cataract eye kits. Per Clinical Lead N they have 2 eye kits on hand and usually have 6 eye/cataract surgical cases consecutively and the eye kits are flash sterilized for the last 4 cases.

Per interview with Surgical Clinical Lead N on 11/20/13 at 11:00 AM, when asked how they decontaminate the instruments in the eye kits Surgical Clinical Lead N stated "we flush them with sterile water."

Examples of pre and post anesthesia evaluations:

In 4 of 4 Surgical MR (6, 10, 17, 18) out of total of 22 MRs the facility failed to ensure surgical MRs have a pre anesthesia evaluation and a post anesthesia evaluation that includes at minimum, Cardiopulmonary status, Level of consciousness, follow-up care, observations and/or complications. See tag 322.

The cumulative effect of these deficiencies potentially affects all surgical Pts and Pts requiring anesthesia services treated at this facility.

Based on MR review, review of R&R and interviews with staff (W, X), in 4 of 4 Surgical MR (6, 10, 17, 18) out of total of 22 MRs the facility failed to ensure surgical MRs have a pre anesthesia evaluation and a post anesthesia evaluation that includes at minimum, Cardiopulmonary status, Level of consciousness, follow-up care, observations and/or complications. This deficiency potentially affects all surgical Pts treated at the facility.

Findings include:

Review on 11/20/13 in the PM of facility R&R dated 5/11 it states under #14 "The anesthetist or CRNA shall maintain a complete anesthesia records, to include evidence of pre-anesthetic evaluation and post-a anesthetic follow up of the patient's condition."

Pt #6's MR review on 11/20/13 at 7:00 AM revealed Pt #6 had an epidural to relieve pain during delivery on 8/10/13. There is no pre evaluation for the epidural. The post anesthesia evaluation on 8/11/13 at 6:57 PM does not include at minimum return of sensation and removal of the catheter with an intact tip. On 8/11/13, Pt #6 had fallopian tubes tied under general anesthesia. The post anesthesia note on 8/11/3 at 7:15 PM does not include documentation of Pt #6's recovery from anesthesia, including Cardiopulmonary status, Level of consciousness, follow-up care, observations and/or complications. This is confirmed in interview with OBM W on 11/20/13 at approximately 11:45 PM, adding the pre anesthesia evaluation should be documented, and acknowledged the missing post anesthesia information should be documented.


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A MR review was conducted on Pt. #10's surgical record on 11/20/2013 at 11:00 AM accompanied by Clinical Nurse Educator X, who confirmed the following findings: Pt #10 had a permanent vascular device implanted on 10/19/2013. Anesthesia record states the following under "Post Anesthesia" "Aldrete Score 10. Nursing Criteria Met? Yes". There is no documentation on the MR by the anesthesia regarding cardiopulmonary status, level of consciousness, follow up or observations, vital signs or whether any complications occurred during post-anesthesia recovery.

A MR review was conducted on Pt. #17's closed surgical record on 11/20/2013 at 8:00 AM accompanied by Clinical Nurse Educator X, who confirmed the following findings: Pt. #18 had a laproscopic appendectomy (removal of the appendix) on 9/26/2013. Anesthesia record states the following under "Post Anesthesia" "Aldrete Score 9." The question "Nursing Criteria Met? Yes or No" was left blank. There is no documentation on the MR by the anesthesia regarding cardiopulmonary status, level of consciousness, follow up or observations, vital signs or whether any complications occurred during post-anesthesia recovery.

A MR review was conducted on Pt. #18's closed surgical record on 11/20/2013 at 11:25 AM accompanied by Clinical Nurse Educator X, who confirmed the following findings: Pt. #18 had a 5th toe amputation 10/10/2013. Anesthesia record states the following under "Post Anesthesia" "Aldrete Score 10. Nursing Criteria Met? Yes". There is no documentation on the MR by the anesthesia regarding cardiopulmonary status, level of consciousness, follow up or observations, vital signs or whether any complications occurred during post-anesthesia recovery.

Based on review of facility documents and interview with staff, in 1 of 1 interviews (B and S) the facility failed to include review of contracts as part of the QI (Quality Improvement) process. This deficiency potentially affects all 9 Pts treated at the facility during this survey.

Findings include:

Review of QI minutes on 11/20/13 at 9:00 AM, the Radiology Department reported off on peer review for telemedicine Radiology. This report did not include an overall report of quality of the service.

Per interview with DQRM B and PIC S on 11/20/13 at 9:00 AM, contracted services are not reviewed by the QI committee. PIC S stated it is up to the departments that have the contracts to review, and do not report off to the QI committee to ensure quality of care is to the facility standard.

Based on review of facility documents and interview with staff, in 1 of 1 interviews (B and S) the facility failed to ensure infection control data related to HAI (hospital acquired infections) and medication therapies are reported regularly to the QAPI committee. This deficiency potentially affects all 9 Pts treated at the facility during this survey.

Findings include:

Per review on 11/20/13 at 9:00 AM of facility QI (Quality Improvement) minutes, IP R reports on IC issues twice a year. The minutes from April 2013 include a handwashing study, and does not include HAI information.

Per interview with DQRM B and PIC S on 11/20/13 at 9:00 AM the IC committee meets monthly, and the same people are on both the IC and QI committee. DQRM B and PIC S could not find in the QI minutes where HAI information is presented, and confirmed IP R reports twice a year on projects.