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Based on observation, interview, and record review the facility failed to ensure that emergency supplies were stocked and available by failing to document crash cart and defibrillator monitoring checks daily in 3 of 9 crash carts (Medical-Surgical, Pediatric, Post-Anesthesia/Recovery Department), in 2 of 2 exchange crash carts (Pharmacy), and the Monitor/Defibrillator at the Cherry Point Outpatient Rehab Center in a total of 1 of 1 outpatient rehab facilities toured; the facility failed to perform weekly tests for proper functioning of the eye wash stations in 2 of 5 departments (Pharmacy and Emergency Department) observed with eye wash stations.

Findings:

Examples in Medical-Surgical/Pediatrics:

A review of the Lifepak 15 Monitor/Defibrillator Operator's Checklist revealed: "...use to inspect and test this monitor/defibrillator. Daily inspection and test and recommended."

Review of 6 months of the Monitor/Defibrillator checklist for Medical/Surgical revealed the following: February 2022: 2 of 28 dates missing documentation of the daily check- 2/26/2022, 2/28/2022; March 2022: 4 of 31 dates missing documentation of the daily check- 3/18/2022, 3/25/2022, 3/27/2022, 3/31/2022; April 2022: 2 of 30 dates missing documentation of the daily check - 4/22/2022, 4/29/2022; May 2022: 8 of 31 dates missing documentation of the daily check - 5/6/2022, 5/11/2022, 5/20/2022, 5/21/2022, 5/22/2022, 5/23/2022, 5/27/2022, 5/29/2022; June 2022: 4 of 30 missing documentation of the daily check - 6/1/2022, 6/3/2022, 6/7/2022, 6/24/2022; July 1- 12, 2022: 7 of 12 dates missing documentation of the daily check- 7/2/2022, 7/5/2022, 7/6/2022, 7/7/2022, 7/8/2022, 7/9/2022, 7/11/2022.

Review of 6 months of the "Daily Crash Cart Checklist" for Medical-Surgical revealed the following: February 2022: 6 of 28 dates missing documentation of the daily check - 2/6/2022, 2/9/2022, 2/11/2022, 2/15/2022, 2/26/2022; March 2022: 8 of 31 dates missing documentation of the daily check- 3/1/2022, 3/17/2022, 3/18/2022, 3/20/2022, 3/21/2022, 2/25/2022, 3/27/2022, 2/31/2022; April 2022: 2 of 30 dates missing documentation of the daily check- 4/10/2022, 4/22/2022; May 2022 8 of 31 dates missing documentation of the daily check - 5/6/2022, 5/11/2022, 5/20/2022, 5/21/2022, 5/22/2022, 5/23/2022, 5/28/2022, 5/29/2022; June 2022: 5 of 30 dates missing documentation of the daily check- 6/1/2022, 6/3/2022, 6/20/2022, 6/22/2022, 6/23/2022; July 1-12, 2022: 7 of 12 dates missing documentation of the daily check- 7/2/2022, 7/5/2022, 7/6/2022, 7/7/2022, 7/8/2022, 7/9/2022, 7/11/2022.

Review of 6 months of the "Peds (pediatric) Cart Monthly Restock and Outdates" revealed no documentation of checks for the months of April, June, July 2022.

On 7/12/2022 at 9:45 AM in an interview with Medical-Surgical/Pediatric Coordinator E, Coordinator E stated, "These checks should all be done daily and it looks like we aren't doing that."

Example in Post-Anesthesia/Recovery:

Review of 6 months of the "Crash Cart Restock and Monthly Outdates" form revealed no documentation for the months of January and February 2022.

On 7/13/2022 at 9:40 AM in an interview with Director of Surgery W, Director W confirmed that the checks should be performed monthly. Director W stated, "We had some issues early in the year with who was supposed to be checking the carts - we now assign it."

Examples in the Pharmacy:

Review of 6 months of the "Crash Cart Restock and Monthly Outdates" form revealed no testing checks done for 2022.

On 7/12/2022 at 12:15 PM in an interview with Director of Pharmacy M, Director M confirmed that the checks should be performed monthly "but these 2 carts are exchange carts that are not in service, I know that's not a perfect answer." When asked about the medication and supplies that are stocked in the 2 exchange crash carts, Director M stated, "A House Supervisor could pick one up in the middle of the night if they need supplies." Director M confirmed that at times the pharmacy uses supplies from the 2 exchange crash carts, but supplies should be unloaded and stocked in the pharmacy-and the carts taken out of service.

During an interview on 07/12/2022 at 3:45 PM, House Supervisor U stated, "When crash cart meds [medications] need to be re-stocked on the floor, we use the crash carts stored in the pharmacy."





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Example of Lifepak 1000 Defibrillator at the Rehab Services branch located in the Cherry Point Mall in Sturgeon Bay:

A review of the Lifepak 100 Defibrillator, Operating instructions revealed: "Inspection: Routinely inspect all devices, accessories, and cables."

A review of the Lifepak 1000 Defibrillator user's checklist revealed: "Dates checked: 3/15, 4/27 and 7/11 for 2022."

During an interview on 7/12/2022 at 1:20 PM, Director of Rehab K stated, "Our policy is to check the Lifepak every month." Director K confirmed that the Lifepak checks for May and June are missing.

Examples of eye wash stations in the Emergency Department (ED):

A review of the facility policy, titled "Weekly Maintenance and Monitoring of Plumbed Eyewash and Drench Shower Stations", last reviewed on 7/15/2021, revealed: "Procedures: A. The Department leader or designated staff member will be responsible for weekly monitoring of the eyewash and/or drench shower. B. The inspection should be carried out as follows: 1. Eyewash and Drench shower weekly inspection checklist...Immediately upon completion of the week inspection (same day), the staff member will document the findings on the tag affixed to the station."

Review of the 2022 Log for Eye Wash testing of the eye wash station in the Emergency Department (ED) nurses station revealed monthly checks instead of weekly checks documented for 2022.

Review of the 2022 Log for Eye Wash testing of the eye wash station in the ED dirty utility room revealed no testing checks since 2/2022.

During an interview on 7/12/2022 at 12:10 PM with ED Director I when asked about checks of the eye wash station, Director I stated, "We are not doing it according to our policy."









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Examples of eye wash station in the Pharmacy:

Review of the 2022 Log for Eye Wash testing of the eye wash station in the Pharmacy medication prep room revealed monthly and/or bi-monthly checks instead of weekly checks documented for 2022.

During an interview on 07/12/2022 at 2:40 PM with Pharmacy Director M, when asked about checks of the eye wash station, Director M stated, "Techs [Technicians] do the checks." Director M confirmed that checks are not being done weekly, they are being done by Pharmacy Techs when they are in the medication prep room.

Based on observation, record review 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.

42 CFR 485.623 Condition of Participation: Physical Environment was NOT MET

Findings include:

The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags:

K-321 Hazardous Areas - Enclosure
K-353 Sprinkler System - Maintenance and Testing
K-374 Subdivision of Building Spaces - Smoke Barrier Doors

Based on observation, interview, and record review the facility failed to follow their policies and procedures to ensure the safe use of blanket and fluid warmers in 1 of 9 blanket and fluid warmers (Emergency Department) observed.

Findings:

A review of the facility policy titled, "Fluid and Blanket Warmers", last reviewed 3/26/2021, revealed: "a. Warming cabinets containing IV (Intravenous) solutions and/or irrigation solutions should be set to ensure the temperature does not exceed 104 F (Fahrenheit). 2. Blankets may be warmed in a blanket warming unit to a temperature not to exceed 150 degrees. 5. The temperature of warming cabinets will be monitored daily by a staff member or monitored through a continuous monitoring system."

A review of the facility document titled, "Blanket Warmer Temperature Log", revealed: "Unit ED, Month/Year: June 2022 missing checks on 6/9/2022 and 6/10/2022 and July 2022 missing checks on 7/2/2022 and 7/4/2022."

During an interview on 7/12/2022 at 9:30 AM, ED Director I stated, "The fluid and blanket warmers should be checked every day."

Based on observation, record review 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.

42 CFR 485.623(d)(1) Safety from Fire was NOT MET

Findings include:

The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags:

K-321 Hazardous Areas - Enclosure
K-353 Sprinkler System - Maintenance and Testing
K-374 Subdivision of Building Spaces - Smoke Barrier Doors

Based on interview and record review, the facility failed to provide education and training to the Emergency Department staff to effectively treat a potential life-threatening situation in 1 of 1 training programs reviewed.

Findings:

Review of the MH (Malignant Hyperthermia) website (https://www.mhaus.org/healthcare-professionals/) revealed, "The MH crisis is a biochemical chain reaction response, "triggered" by commonly used general anesthetics and the paralyzing agent succinylcholine (a neuromuscular blocker)...death can result...Dantrolene (medication to treat MH) must be available for all anesthetizing locations within 10 minutes of the decision to treat for MH..."

On 7/13/2022 at 10:20 AM in an interview with Anesthesiologist X when asked about MH drills stated that one was held in May 2022 for Surgery staff. When asked if the Emergency Department staff was included in the drill Anesthesiologist X stated, "Good point, they use succinylcholine there and should have the training."

Based on observation, record review and interview, the facility failed to follow their policies for annual staff Tuberculosis (TB) screening and follow-up in 3 of 3 infection control policies; facility failed to maintain a clean and sanitary environment to avoid sources and transmission of infection in 3 of 19 departments observed; facility failed to follow their hospital-wide infection surveillance and prevention program that adhered to Centers for Disease Control (CDC) nationally recognized, "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the COVID-19 Pandemic Infection Control Guidelines" in 1 of 1 infection control programs reviewed. The failure of these deficient Infection Control practices has the potential to adversely affect all patients, visitors and staff.

Findings include:

The facility failed to follow infection prevention and control guidelines for annual staff Tuberculosis (TB) medical screening reviews, and failed to follow-up and provide instruction for staff. See Tag 1208

The facility failed to maintain a clean and sanitary environment to avoid sources and transmission of infection, including: inappropriate storage of dirty instruments and disposal of expired nourishment/food. See Tag 1208

The facility failed to ensure systems are in place and operational for infection prevention and control for COVID-19, including: failed to ensure screening for COVID-19 exposure and symptoms, and failed to post COVID-19 infection prevention and control signs/visual alerts to help prevent the transmission of COVID-19. See Tag 1225

Based on observation, interview and record review, the facility failed to follow Infection Prevention and Tuberculosis facility policies to control HAIs (healthcare-associated infections) for 1 employee (Registered Nurse J) of 13 employee personnel files reviewed, facility failed to store dirty instruments in appropriate areas and failed to remove expired nourishment/food in 3 of 19 departments observed (Medical-Surgical, Birthing Center and Intensive Care Unit).

Findings include:

A review of the facility policy titled, "Infection Prevention Program", last reviewed 02/01/2022, revealed: "...A. Employee Health/Occupational Health: The Infection Preventionist, who operates a dual role as Employee Health nurse collaborates with Employee Support and Development on potential infection related to health care personnel including the following:...3. Tuberculosis prevention and control activities...10. Health Care Worker Counseling, Screening, and Evaluation-Follow-up TB testing will be done if an employee is inadvertently exposed to a patient with TB."

A review of the facility policy titled, "Tuberculosis Control Plan", last reviewed 02/02/2022, revealed: "Policy Statement: It is the policy of [Facility Name] to have a plan to control the transmission of Tuberculosis (TB) among patients, employees, and others entering the facility. Procedures: 1. Responsibility-The Infection Control Professional will develop, implement, periodically reassess, and supervise the Tuberculosis Control Program.

A review of the facility policy titled, "Follow-up after exposure to Tuberculosis (TB)", last reviewed 02/01/2022, revealed: "...Procedure: I. Prompt and thorough investigation after exposure to TB is imperative...D. Begin contact investigation, and have all employees that were directly exposed come to Employee Health for baseline TB skin testing."

A review of ED Registered Nurse (RN) J's "Employee Annual TB/Health Questionnaire" form completed by Nurse J on 09/02/2021 revealed that Nurse J documented "Yes, In the ER" to question #1: "To your knowledge, during the course of this past year, have you provided medical care, or become exposed to a patient with known active TB?"

During an interview on 07/13/2022 at 12:40 PM with Infection Preventionist (IP)/Employee Health Nurse BB, when asked if there was any follow-up with Nurse J after receiving and signing off on his/her (Nurse J's) TB Health questionnaire on 09/03/2021, IP/Employee Health Nurse BB stated "No." When asked if there should have been follow-up done, IP/Employee Health Nurse BB stated, "Follow-up with employee and possibly a TB skin test." Facility policy indicates that a follow-up TB test "will be done if an employee is inadvertently exposed to a patient with TB."

During an interview on 07/13/2022 at 12:42 PM with Safety Officer/Employee Health Nurse O, when asked if he/she was the one that reviewed and signed off on Nurse J's Annual TB/Health Questionnaire that stated "yes" to question #1, Safety Officer/Employee Health Nurse O stated "I reviewed the form and missed it."

During an interview on 07/13/2022 at 3:30 PM with Infection Preventionist (IP)/Employee Health Nurse BB, when asked if any type of investigation and testing was completed, IP/Employee Health Nurse BB stated "no" and that he/she was made aware when they received a report through the "WEDSS [Wisconsin Electronic Disease Surveillance System]" dated 10/26/2021 (54 days after the incident occurred) that showed the patient in the ED had no communicable TB, it was "extrapulmonary, not via pulmonary/lungs."



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Examples in Medical-Surgical Department:

On 7/12/2022 at 9:30 AM during a tour of the Medical-Surgical nursing department 4 instruments were observed in a covered plastic container on the counter in the "Medication Prep Room". The container had a label "Dirty" on the top.

In an interview on 7/12/2022 at 9:30 AM with Director of In-patient Services F, when asked if the instruments were used and dirty, Director F stated, Yes they are and they shouldn't be in this room."

Example in the Birthing Center:

On 7/12/2022 at 10:55 AM during a tour of the Birthing Center supply room, 8 4-packs of Similac Neosure 22 calorie infant formula with expiration dates of April 1, 2022 and 4 6-packs of Enfamil 20 calorie infant formula with expiration dates of June 1, 2022 were observed.

On 7/12/2022 at 10:55 AM in an interview with RN (Registered Nurse) Coordinator E, Coordinator E confirmed that the formula was expired and should have been removed from stock.

Example in ICU (Intensive Care Unit):

On 7/12/2022 at 11:05 AM during a tour of the ICU the following expired products were observed in the ICU patient nourishment refrigerator: an ice cream cup with an expiration label of 2/22, container of Ensure (nutrition supplement) with a room number, no name, with an expiration date of 6/22, and 2 containers of coffee creamers with expiration dates of 1/22, and 6/22.

On 7/12/2022 at 11:05 AM in an interview with Director of In-patient Services F, Director F removed the products stating, "Dietary staff is supposed to be checking the dates and removing expired items. They obviously missed these."

Based on observation, interview and record review, leadership failed to ensure all visitors and patients are screened for COVID-19 exposure and symptoms in 2 of 2 public entrances observed. and the facility failed to post COVID-19 visual alerts in strategic places throughout all of the facility with current recommendations for infection prevention and control practices.

Findings:

Review of CDC Nationally recognized, "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, last updated February 2, 2022, stated, "Ensure everyone is aware of recommended IPC [infection prevention control] practices in the facility. -Post visual alert (e.g., signs, posters) at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias) with instructions about current IPC recommendations (e.g., when to use source control and perform hand hygiene). Dating these alerts can help ensure people know that they reflect current recommendations. Establish a process to identify anyone entering the facility, regardless of their vaccination status, who has any of the following three criteria so that they can be properly managed:
1) a positive viral test for SARS-CoV-2
2) symptoms of COVID-19
3) close contact with someone with SARS-CoV-2 infection (for patients and visitors).."

A review of the facility policy titled, "COVID-19 Plan", last reviewed 01/03/2022, revealed: "Purpose: To protect the employees, visitors, patients and residents of [Facility Name] from transmission of COVID-19...in accordance with the Centers of Disease Control (CDC) and Occupational Safety and Health Administration (OSHA) for management of the COVID-19 pandemic...1. All patients are assessed for possible symptoms of COVID-19. If symptomatic, they are tested for COVID-19 before admission or pre-procedure..."

A review of the CDC COVID Data Tracker reveals that the COVID-19 Community Transmission Level for Door County, Wisconsin was "High" for the tracking period from 7/14/2022-7/20/2022.

On 7/12/2022 at 1:20 PM in an interview with Chief Quality Officer (CQO) A, Quality Officer A stated, "There used to be a sign with COVID symptoms listed at the front entrance." When asked about posted visual alerts related to COVID-19 infection prevention and control practices in strategic areas throughout the facility, Quality Officer A stated "they got taken down." Quality Officer A stated that the volunteers at the entrance used to ask the COVID-19 screening questions until they started getting "harassed" so they stopped asking the beginning of April this year.

On 7/12/2022 at 1:33 PM in an interview with Infection Preventionist/Employee Health BB, Infection Preventionist BB confirmed that the facility follows Infection Control guidelines directed by the CDC (Centers for Disease Control) for COVID-19.