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Based on observation, staff interviews, and review of maintenance records between January 9, and January 12, 2017, the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

Findings include:

The facility was found to contain the following deficiencies.
K 100 inappropriate item in the stairs
K 131 Nursing Home / Hospital Separation Wall
K 161 Building Construction type
K 211 Means of egress requirements
K 232 Corridor Width
K 300 Door to Stairs did not latch
K 321 Hazardous Areas
K 342 Fire Alarm Initiation
K 345 Fire Alarm Testing
K 351 Sprinklers
K 363 Corridor doors
K 711 Evacuating and Relocation Plans
K 902 Gas and Vacuum Piped System
K 911 Electrical Systems Other
K 914 Electrical Systems Maintainance and Testing
K 915 Electrical Systems Essential Electrical System.

Refer to the full description at the cited K tags.

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.

Based on observation and interview the facility failed to ensure that the building is maintained to ensure safety of patients in 3 of 9 areas surveyed (Emergency Room, Medical Surgical Unit and Respiratory Therapy). This deficiency has the potential to affect all 3 in patients currently admitted during this survey.

Findings include:

On 1/9/17 at 1:50 PM during observation of Medical/Surgical unit dirty utility room door was unlocked and no sign on the door alerting of biohazards being stored in the room. An interview was conducted with Medical/Surgical Director T on 1/9/17 at 1:50 PM who was in agreement that door should be locked since chemicals are stored in the dirty utility room.

On 1/10/17 at 7:35 AM observed in Emergency Room dirty utility room door was unlocked and no sign on the door alerting of biohazards being stored in the room. An interview was conducted with Emergency Room Manager U on 1/10/17 at 7:35 AM who agreed that door should be locked at all times because of chemicals being stored in the dirty utility room.


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Example in Respiratory Therapy area:

On 1/9/17 at 2:00 PM, it is observed the Respiratory Therapy dirty utility room, and clean room, has cracks and peeling paint on the walls, and the laminate under the sink is chipped making the surfaces unwashable. Per interview with Respiratory Manger F on 1/9/17 at 2:00 PM, Manager F confirmed the cracks and peeling paint and laminate, stating they have tried to repair the walls.

Based on observation, staff interviews, and review of maintenance records between January 9, and January 12, 2017, the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

Findings include:

The facility was found to contain the following deficiencies.
K 100 inappropriate item in the stairs
K 131 Nursing Home / Hospital Separation Wall
K 161 Building Construction type
K 211 Means of egress requirements
K 232 Corridor Width
K 300 Door to Stairs did not latch
K 321 Hazardous Areas
K 342 Fire Alarm Initiation
K 345 Fire Alarm Testing
K 351 Sprinklers
K 363 Corridor doors
K 711 Evacuating and Relocation Plans
K 902 Gas and Vacuum Piped System
K 911 Electrical Systems Other
K 914 Electrical Systems Maintainance and Testing
K 915 Electrical Systems Essential Electrical System.

Refer to the full description at the cited K tags.

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.

Based on observation, record review and interview, the facility failed to ensure aseptic technique is used when staff prepare medications, in 1 of 2 staff observed (M), and medications are stored to prevent unauthorized use in 1 of 9 areas observed (Respiratory Therapy). This deficiency directly affects Patient #22 and potentially affects all surgical patients treated at the facility.

Findings include:

Per APIC (Association for Professionals in Infection Control and Epidemiology) Position Paper: Safe Injection, Infusion, and Medication Vial Practices in Health Care (2016), it states "Disinfect the rubber septum on all vials prior to each entry, even after initially removing the cap of a new, unused vial."

On 1/11/17 at 11:05 AM, Certified Registered Nurse Anesthetist M was observed preparing medications for Patient #22. Nurse M removed the caps of the following medication vials, Propofol (sedative), Versed (amnesia medication), Lidocaine and Alphenta (pain medications), used one alcohol wipe to cleanse the septums. This was discussed with Infection Preventionist R during interview on 1/11/17 at 11:15 AM, who agreed a new alcohol wipe should be used for each vial, and does follow the APIC recommendations.

Per observation on 1/9/17 at 2:00 PM there is an open tube of Benadryl (antihistamine/anti-itch cream) in a drawer in the Respiratory Therapy clean room. Per interview with Respiratory Manager F on 1/9/17 at 2:00 PM, who stated the Benadryl was not for patient use, rather belonged to him/her.

Based on record review and interview the facility failed to ensure a sanitary environment to prevent and control the potential spread of infection in 7 of 9 areas observed (Rehabilitation Services, Pharmacy, Environmental Services, Lab, Nuclear Medicine, Pre-operative, and Operating room); and failed to ensure staff performed hand hygiene per policy in 1 of 3 staff observed (E). This deficiency potentially affects all 3 patients currently admitted during this survey and outpatients receiving treatment in Rehabilitation Services department.

Findings include:

Examples in Rehabilitation Services:

On 1/9/17 at 4:00 PM observed in the Rehabilitation Services department there was a dehumidifier located in the center of the patient exercise area. An interview was conducted with Occupational Therapy Assistant S on 1/9/17 at 4:00 PM who stated she was "unsure" if there was a policy on how dehumidifier was being cleaned and disinfected. On 1/9/17 at 4:16 PM Occupational Therapy Assistant S confirmed that there is no policy in place for cleaning dehumidifier unit.

Examples in Pharmacy:

On 1/10/17 at 2:26 PM observed in the Pharmacy that there was a dehumidifier located on counter top near entrance to clean storage room. An interview was conducted with Pharmacist P on 1/10/17 at 2:26 PM who stated "we have a problem with humidity in the summer". Dehumidifier was not on at time of observation and Pharmacist P confirmed that there is no policy in place for cleaning of the unit.

Examples in Environmental Services:

An interview was conducted with Director of Environmental Services D on 1/10/17 at 8:15 AM who was unable to verbally provide facility standard on cleaning privacy and window curtains. On 1/10/17 at 4:00 PM Director of Environmental Services D provided a three ring binder of hand written notes by housekeepers of privacy curtains that were washed because they were visibly soiled. Director of Environmental Services D states there is no cleaning schedule to ensure that all privacy and window curtains are washed on a regular basis.


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Example of Blood Draw observation:

On 1/9/17 at 2:36 PM Medical Technician E was observed performing a Blood Draw on Patient #11 in the Emergency Department. After Technician E completed the draw, Technician E removed the gloves, donned new gloves, labeled the blood tubes, removed the gloves and returned to the lab without performing hand hygiene between gloves changes. This was discussed with Infection Preventionist R during interview on 1/11/17 at 11:15 AM, who agreed hand hygiene is to be done after glove removal.

Per review of facility policy titled Venipuncture for Blood Collection, Lab-1360, reviewed 5/2/16, it states under Implementation #18 "Remove gloves 19. Hand hygiene"


Example in Nuclear Medication Room:

On 1/9/17 at 3:08 PM a bedside table is observed set up with a towel, a tourniquet, and a 2x2 gauze, out of original packaging. There is a chux (liquid absorbent pad) under the isotope (radioactive) preparation shield that is used and dirty. The window air conditioner baffles have a film of dust and debris. This was confirmed during the observation with Radiology Director G on 1/11/17 at 3:08 PM, who acknowledged the dust on the air conditioner, and confirmed the towel, tourniquet and gauze is for an intravenous start and should not be set up prior to patient arrival, which Director G said was scheduled for the week of 1/16/17. Director G clarified on 1/10/17 in interview at 4:30 PM, the dosing calibrations are no longer done in the room, and the chux should be removed.

Examples of Pre-Operative Exam:

Per review of facility policy titled Hand Hygiene, #35-26, revised 12/29/15, it states under Policy "All staff will use the hand-hygiene techniques...Always after removing gloves...After coming in contact with patient's intact skin..."

On 1/11/17 at 8:25 AM, Certified Registered Nurse Anesthetist M performed an examination of Patient #1 in room 190. Nurse M removed the stethoscope from around his/her neck and listened to Patient #1's heart tones and breath sounds. Nurse M did not clean the stethoscope after use. Nurse M did not perform hand hygiene when leaving Patient #1's Room and proceeded to enter Patient #21's room, #189, across the hall.

On 1/11/17 at 8:55 AM, Medical Doctor N did not perform hand hygiene when leaving Patient #1's room.

Examples in Operating Room:

Per review of facility policy titled Attire in Operating Room Department and Central Supply, #31-04, reviewed 9/4/05, it states under #7 "Surgical masks in combination with eye protection devices, such as goggles, glasses, or chin length face shields, must be worn whenever splashes, spray, splatter, or droplets of blood, body fluids, or other potentially infectious material may be generated and eye, nose or mouth contamination can be reasonably anticipated."

On 1/11/17 at 9:09 AM Nurse M and Doctor N do not have eye protection on during an endoscopy procedure (placing a scope into the patient's esophagus) on Patient #1.

Examples of cleaning the Operating Room:

On 1/11/7 at 10:44 AM there is residual adhesive on the tile walls in Operating Room 2; the left arm of the anesthesiologist's chair is torn with exposed sponge like cushion that is not washable; and the top of the light arms have a film of dust.

Surgical Technician O confirmed the dust on the lights in interview on 1/11/17 at 10:53 AM, during the room cleaning, and said it should be part of the terminal cleaning.

The above observations were discussed in interview with Infection Preventionist/Operating Room Manager R on 1/11/17 at 11:15 AM, who acknowledged staff should be wearing proper Personal Protective Equipment during procedures, the chair should be repaired, and hand hygiene should be performed per policy.

Based on record review and interview the facility failed to ensure a care plan was implemented when restraints are initiated, 1 of 1 restraint record (20). This deficiency directly affects Patient #20 and potentially all restrained patients at this facility.

Patient #20's medical record was reviewed on 1/11/17 at 1:30 PM the care plan did not address the soft wrist or ankle restraints orders on 11/15/2016 at 6:29 PM.
An interview was conducted with Medical/Surgical Manager T on 1/11/17 at 1:30 PM who agreed that there was no care plan problem on Patient #20's chart addressing the soft wrist and ankle restraints and that there should have been.

Based on observation, record review and interview the facility failed to ensure that there is a medical record system that included accurately documented and complete records that include updated care plans with changes in patient care, and ensures records are kept confidential and safe from destruction in 1 of 1 restraint records (20), 1 of 1 record storage room, and 2 of 6 surgical records (#2 and 3), out of a total 20 medical records reviewed. The cumulative effect of these deficiencies potentially affect all patients treated at the facility.

Findings include:

In 1 of 1 restraint record (20) the facility failed to ensure a care plan is implemented when restraints are initiated. See Tag 298.

In 1 of 1 restraint record (20), the facility failed to ensure all orders are authenticated, a new order was obtained to reinstate restraints after they were discontinued and a policy in place to release and reposition patients in restraints. See Tag 306.

In 1 of 2 record storage rooms (closed medical records), the facility failed to ensure medical records are not available to unauthorized people and staff and protected from potential damage. See Tag 308.

In 2 of 6 surgical records reviewed (#2 and 3), the facility failed to ensure a comprehensive post anesthesia note including post-surgical vital signs (blood pressure, pulse, respirations and temperature) reflecting patient recovery from anesthesia. See Tag 322.

Based on record review and interview the facility failed to ensure that all orders of doctors are authenticated promptly, a new order was obtained to reinitiate restraints after they were discontinued, and there is no policy in place to release and reposition restraints on a periodic basis, in 1 of 1 restraint records reviewed out of a total of 20 medical records reviewed (20). This deficiency directly affects Patient #20 and potentially affects all patients in restraints.

Findings include:

The facility policy titled "Medical Records Completion Policy" dated 2/1/15 was reviewed on 1/11/17 at 1:30 PM. This document states "In accordance with Gundersen Boscobel Area Hospital and Clinics policies and regulatory standards, medical records are considered delinquent if all required documents are not completed and authenticated by the practitioner within thirty (30) days of the discharge of a patient." Document also states under "Hospital Medical Record Completion item #7 "Verbal or Telephone Orders, signed, dated and timed within 24 hours".

The facility policy titled "Restraints" dated 1/27/16 was reviewed on 1/11/17 at 1:30 PM. Document states "When the RN determines that the patient no longer requires restraint, (s)he may remove them and discontinue the order. If the restraint is discontinued and restraint needs to be reapplied, a new order is required."

Patient #20's medical record was reviewed on 1/11/17 at 1:30 PM with Medical/Surgical Manager T. The medical record shows a verbal order received from Medical Doctor W on 11/15/16 at 7:29 PM for soft wrist and ankle restraints for "interference with medical treatment". At the time of record review verbal order was not authenticated by Medical Doctor W.

Patient #20's medical record was reviewed in 1/11/17 at 1:30 PM it revealed that the medical record shows restraint flow sheet that order was received to place restraints on 11/15/16 at 6:30 PM. On 11/16/16 at 4:00 AM restraint was "DISCONTINUED". At 8:59 AM on 11/16/16 restraint was charted as "CONTINUED". There is no second order received at the time of reapplying restraints on Patient #20's chart. Per interview with Medical/Surgical Manager T at the time of record review stated "they thought (Patient #20) no longer needed the restraints so they removed them and then (Patient #20) pulled out NG (nasal gastric) tube so they put them back on".

An interview was conducted with Medical/Surgical Manager T on 1/11/17 at 1:30 PM who confirmed the findings in the record acknowledging the intial order should have been authenticated and there should have been a second order for restraints.

The facility policy titled "Restraints" dated 1/27/16 was reviewed on 1/11/17 at 1:30 PM. There is nothing in the policy requiring release and repositioning of restraints on a scheduled basis while patient is restrained. This was confirmed with Medical/Surgical Manager T 1/11/17 at 1:30 PM who was in agreement that the policy was lacking on release and repositioning standards of practice.

Based on observation, record review and interview the facility failed to ensure medical records are not available to unauthorized people and staff, and protected from potential damage, in 1 of 2 record storage rooms (Closed Medical Records). This deficiency potentially affects all patients treated at the facility.

Findings include:

Per review of facility policy titled Security of Medical Records and Other Confidential Information, dated 5/12/15, #16-51, it states under Inactive Medical Record Storage "Medical records are stored in a safe and secure environment to ensure physical and logical integrity and confidentiality."

Per observation on 1/10/17 at 8:35 AM with Director of Environmental Services D, the room containing closed hospital Medical Records also contained multiple file cabinets filled with Rural Health Clinic records, Obstetric delivery kits and CPR (Cardiopulmonary Resuscitation) equipment. There is no means to prevent clinic staff from viewing the hospital records if and when retrieving clinic records, nor hospital staff viewing the clinic records. There is no means to prevent the CPR instructor(s) from accessing the hospital and/or clinic records. This was confirmed in interview with Director D on 1/10/17 at 8:35 AM who was unaware the clinic records and supplies were in the closed Medical Records room.

Based on record review and interview, the facility failed to ensure a comprehensive post anesthesia note including post surgical vital signs (blood pressure, pulse, respirations and temperature) reflecting patient recovery from anesthesia, in 2 of 6 surgical records reviewed (2 and 3) out of a total 20 medical records reviewed. This deficiency potentially affects all surgical patients treated at the facility.

Findings include:

Patient #2's medical record review on 1/10/17 at 12:40 PM revealed Patient #2 had surgery on his/her wrist on 11/14/16. Patient #2 entered the Operating Room at 1:40 PM and left the Operating Room at 2:30 PM. The Post-Anesthesia Note written on 11/14/16 at 2:38 PM included vital signs that were taken at 11:54 AM, prior to the surgery, rather than after admission to the Post-Anesthesia Care Unit. This is confirmed in interview with Advance Training Consultant (for EPIC electronic record system) L on 1/10/17 at 12:40 PM, who acknowledged the vital signs should have been recorded after leaving the Operating Room.

Patient #3's medical record review on 1/10/17 at 1:45 PM revealed Patient #3 had shoulder surgery on 8/26/16. The Post-Anesthesia Note written on 8/26/16 at 1:36 PM states "No apparent Anesthesia problems. Vital signs stable. Home per surgeon order." This is confirmed in interview with Advance Training Consultant (for EPIC system) L on 1/10/17 at 12:40 PM, who acknowledged the note did not follow the template in the EPIC system that includes Anesthesia type, Post-op pain management, Post-Op vital signs, Level of Consciousness, Follow-up care, and Complications.

Based on record review and interview, the facility failed to ensure there is an evaluation of the Discharging Planning program at the facility in the facility Quality Program, in 2 of 2 interviews, (B and T).

Findings include:

Per review of facility polity titled Quality Services Improvement Plan, #26-23, revised 7/11/15, it states under Quality Improvement Goals "To facilitate a planned systematic, organization-wide approach to process design and performance measurement, assessment, and improvement.

Per interview with Medical/Surgical Manager T on 1/10/17 at 9:28 AM, there is no formal review of the discharge planning process.

Per interview with Quality Director B on 1/10/17 at 10:40 AM, Discharge Planning is not included in the Quality Program.