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Based on record review and interview, the staff failed to document advanced directive information in 3 of 20 medical records reviewed (Patient #10, Patient #11 & Patient #12).

Findings include:

Review of policy, "Advanced Directives", no policy number, review date 11/27/2017 revealed, "1. Upon admission, each patient is provided the Wisconsin Advanced Directives packet...The clinician will document in the clinical record that the information was provided and record all discussions concerning Advance Directives".

Review of patient #10's medical record on 12/6/2017 at 9:40 AM, there was no documentation noted in medical record that there was a discussion about advanced directives.

Review of patient #11's medical record on 12/6/2017 at 9:55 AM, there was no documentation noted in medical record that there was a discussion about advanced directives.

Review of patient #12's medical record on 12/6/2017 at 10:10 AM, there was no documentation noted in medical record that there was a discussion about advanced directives.

Interview on 12/6/2017 at 10:15 AM, Operating Room Nurse F stated, "Advanced Directives are not reviewed with patients upon admission for procedures or operations."

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-0321 - Hazardous Areas
K-0347 - Smoke Detection
K-0352 - Sprinkler System - Supervisory Signals
K-0363 - Corridor - Doors
K-0374 - Subdivision of Building Space
K-0374 - Subdivision of Building Space
K- 0521 - HVAC
K-0712 - Fire Drills
K-0918 - Electrical Systems - Essential Electric System Maintenance and Testing

Based on observation, and staff interviews, the facility failed to construct, install and maintain the building systems to ensure life safety from fire. 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-0321 - Hazardous Areas
K-0347 - Smoke Detection
K-0352 - Sprinkler System - Supervisory Signals
K-0363 - Corridor - Doors
K-0374 - Subdivision of Building Space
K-0374 - Subdivision of Building Space
K- 0521 - HVAC
K-0712 - Fire Drills
K-0918 - Electrical Systems - Essential Electric System Maintenance and Testing

Based on record review, observation, and interview the facility failed to ensure that expired medications and biologicals are not available for patient use, medication syringes are labeled and secured in 1 of 11 areas observed (Surgical Area).

Findings include:

Review of policy "Outdated Medication", no policy number, last review date 5/18/2015 revealed, "Medication storage areas at Rusk County Memorial Hospital will be checked monthly by pharmacy personnel or other departmental personnel who have medications (or kits containing medications) in their areas of operation as instructed by the managing pharmacist. Any outdated medications found will be returned to the pharmacy for replacement and proper disposal."

Review of policy "Outdated Sterile Supplies", policy number 612-, last review date 3/1/2015 revealed, "Shelf life will be as follows: OR/CS (operation room/central supply) personnel will check supplies monthly for outdated supplies in CS."

Review of policy "Locking of carts; Medication and Anesthesia", no policy number, last review date 12/5/2017, revealed, "Cart is to be locked if not within eye view of Nurse/CRNA."

Review of policy "Medication Safety-Labeling", no policy number, no review date, revealed, "Purchased or Re-packaged unit of Use Medication labels shall include at a minimum: The Generic name of the medication, the dose, manufacturer's lot number, the expiration date, name of manufacturer."

Surgical Area:

On 12/5/2017 at 12:00 PM observed 4 vials of 9% Sodium Chloride Injection 10 milliliters with expiration date of November 1, 2017 noted in the drawer in the Endoscopy Room.

On 12/5/2017 at 1:00 PM observed 3 culture swabs in Operating Room #2 with expiration dates of 4/2017, 9/2017, and 7/2017.

On 12/5/2017 at 1:10 PM observed Anesthesia Cart unlocked in unoccupied Operating Room #1, the top drawer contained the following: A syringe filled with a medication labeled Ephedrine and the second syringe of medication labeled Phenylephrine. The syringes did not contain an expiration date.

On 12/5/2017 at 1:15 PM observed Anesthesia Cart unlocked in unoccupied Operation Room #2, the top drawer contained the following: 2 syringes filled with a medication labeled Phenylephrine 1mg/10 ml's. The syringes did not contain an expiration date. There was a vial of Diprivan 200 mg/20 ml's that had the cover removed and a piece of nylon tape placed over the septum which stated "clean".

During an interview on 12/5/2017 at 1:30 PM, Operating Room Nurse F stated "Supplies and medications should be checked weekly by designated staff during down times and expired supplies and medications should be removed from area", and "Anesthesia carts should be locked at all times, and medication syringes should be labeled correctly including the expiration date".

Based on observation, record review, and interview, staff failed to follow facility policy to ensure proper prewash cleaning to prevent potential contamination of surgical equipment (in 1 of 2 prewash sinks in the surgical area) and that staff employees were properly trained on infection control policies and procedures and that there was an active Infection Control Surveillance program that was ongoing and tracking and trending all areas of the facility.

Findings include:

Review of policy "Use of Prolysitca", 612-, review date 12/2017 revealed "1. Fill sink with warm water to appropriate level marked with red line (7 gallons) in reprocessing area of procedure room or (2 gallons) washer/decontamination room in Central Sterilization.

During observation of Disinfection/Sterilization room on 12/5/17 at 12:45 PM revealed the sink used to prewash surgical equipment, the sink did not have a red line marked in the sink. During an interview with Surgical Technician H on 12/5/17 at 12:45 PM stated, "The sink is small I just know how full it should be."

Examples in Laboratory:

Review of facility policy "PHLEBOTOMY BY VACUTAINER SYSTEM" last reviewed 1/20/2015 revealed,
on page 2 under "Procedure" item #5 "Apply tourniquet. Cleanse area with alcohol. Do NOT palpate vein after cleansing. Do NOT remove the tip of your glove to palpate the vein."

On 12/6/17 at 11:45 AM observed Lab Technician I perform lab draw on Patient #21. Lab Technician I cleansed area with alcohol swab then palpated vein five times with gloved finger without recleansing after palpation. Then inserted needle into vein.

On 12/6/17 at 11:50 AM observed Lab Technician J perform lab draw on Patient #21. Lab Technician J cleansed area with alcohol swab then palpated vein four times with gloved finger without recleansing after palpation. Then inserted needle into vein.

Examples in Infection Control Surveillance Program:

Review of facility policy "Infection Control Plan" last reviewed 8/17/16 revealed on page 3 of document bullet point #2 states "Review and approve all policies and procedures related to infection surveillance, prevention and control activities in all departments/services. All hospital departments are responsible for following specific infection prevention policies and procedures for their unit." Page 4 states "The surveillance results from surgical procedures, device related infections, communicable disease exposure events and environmental incidents are reviewed for variances and reported to the Quality Improvement Manager on a monthly basis." On page 5 stated "Monitoring and evaluation of data produced from the surveillance process, analyzing data for trends and risks, and communicating this information to staff to ensure proper awareness. Key aspects (but not inclusive) are: I. Device related infections. II. Surgical Site Infections. III. Multi-Drug Resistant Organism Infections. IV. C-difficile Associated Diarrhea. V. Tuberculosis. VI. Occupational Exposure to Blood/Body Fluids/Sharps. VII. Other communicable Diseases. VII. Employee Health Trends. IX. Hand Hygiene Surveillance/Compliance."

The facility infection control surveillance documents were reviewed on 12/6/17 at 1:45 PM and revealed the following: that hand hygiene audits were completed from January 1, 2017 until June 2017 and none since. There were no documented hand hygiene audits documented in other departments (ie: surgery, emergency room, radiology, laboratory, environmental services, or disinfection/sterilization) other than on medical/surgical nursing floor from January 1, 2017 to 12/6/17. There are no stated goals or documented attainment of the goals to stop doing surveillance, no documented isolation surveillance since June 2017, no stated goals or documented attainment of the goals to stop surveillance, no documentation of surgical procedure surveillance surgical site infections, multi drug resistant organism infections, no documentation of analysis of data, tracking, trends or aggregation of data collected.

An interview was conducted with Infection Control Director L on 12/6/17 at 2:15 PM who confirmed the lack of tracking, trending, aggregation of data and ongoing surveillance of all departments. "I was embarrassed to give you all that stuff because I know it isn't right. I get all this information given to me but am not sure how to put it all together. I enter the CMS required information and that is what I report to the board."

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 affected Patient #20.

Findings include:

The facility policy titled "Restraints" last reviewed on 11/2017 was reviewed on 12/6/17 at 1:00 PM on page 2 under letter e. "The use of the restraint must be in accordance with a written modification to the patient's plan of care."

Patient #20's medical record was reviewed on 12/06/17 at 2:30 PM the care plan did not address the leather restraints used on all four extremities ordered on 07/09 & 7/10/2017.

An interview was conducted with Medical/Surgical Director M on 12/06/17 at 12:55 PM who agreed that there was no care plan problem on Patient #20's chart addressing the leather wrist and ankle restraints for either date they were ordered and that "there should have been".

Based on record review and interview the facility failed to ensure that patient charts had complete documentation in 3 of 20 (2 in discharged records and 1 in surgical records) medical records reviewed.

Findings include:

Discharged records:

Facility form "Discharge Instruction" was reviewed on 12/6/17 at 9:35 AM stated "Discharge instructions have been explained to the patient. The patient or the person responsible for the patient verbalizes understanding of the instructions. Signature indicates that the patient has been given a copy of written discharge instructions."

Review of policy, "Procedures Needing Written Consent", no policy number, review date 11/2017, revealed, "It is the policy of Rusk County Memorial Hospital to obtain written consent for invasive procedures", and under "5. Consents must be signed before the patient receives his preoperative medication because forms signed after sedatives are given are legally invalid."

Patient #16's medical record was reviewed on 12/6/17 at 9:35 AM with Director of Medical/Surgical Department M. Patient #16 was admitted on 9/15/17 with chief complaint of generalized weakness and was discharged on 9/22/17 to home. On review of medical record there was one scanned in "Discharge Instruction" sheet that was dated the date of admit and does not have a signature under "Patient/Parent/Guardian Signature:" or "Staff Initials:".

Patient #17's medical record was reviewed on 12/6/17 at 10:28 AM with Director of Medical/Surgical Department M. Patient #17 was admitted on 9/19/17 with chief complaint of shortness of breath and bronchitis (infection in bronchiole of lung) and was discharged home on 9/21/17. On review of medical record there was one scanned in "Discharge Instruction" sheet that was dated the date of admit and does not have a signature under "Patient/Parent/Guardian Signature:" or "Staff Initials:"

Surgical records:

Patient #9's medical record was reviewed on 12/6/17 at 8:55 AM with Operating Room Nurse F. Patient #9 was admitted on 9/26/17 for a Laparoscopic Cholecystectomy and was discharged on 9/26/17 to home. On review of medical record, the informed consent for operation was not timed by the physician. Operating Room Nurse F stated, "The physician did not enter the time when he signed the consent."

The above deficiencies were confirmed in interview with Director of Medical/Surgical Department M who stated "I thought we were pretty good about getting those signed but those are definitely missing."

Based on record review, and interview the staff failed to complete documentation of the pre anesthesia evaluation in 1 of 4 surgical records reviewed (Patient #11) and failed to complete a post anesthesia evaluation in 1 of 4 surgical records reviewed (Patient #12).

Findings include:

Review of policy "Pre-Anesthesia Evaluation", no number, revised date 3/10/2009 revealed, "2. Documents in the patient's medical record, pertinent information relative to the choice of anesthesia. Except in extreme emergency cases, this evaluation should be recorded prior to the patient's transfer to the operating area and before preoperative medication has been administered.

Review of policy "Admission to Surgery", 612-002, review date 12/20/2014 revealed, "B. Have a pre-anesthesia assessment performed by the anesthesia provider to determine that the patient is an appropriate candidate to undergo the planned anesthesia."

Review of Patient #11's medical record on 12/6/2017 at 9:55 AM revealed the pre-anesthesia evaluation completed on 11/9/2017 at 10:33 AM for a Cystoscopy Transurethral Resection Bladder Tumor, anesthesia start time was documented on 11/9/2017 at 10:03 AM.

Review of Patient #12's medical record on 12/6/2017 at 10:10 AM revealed the pre-anesthesia evaluation completed on 11/27/2017 for a colonoscopy. There was not a post anesthesia assessment documented.

Findings were shared with Operating Room Nurse F on 12/6/17 at time of review, and Operating Room Nurse F


During an interview on 12/6/2017 at 10:20 AM, Operating Room Nurse F stated, "It looks like the pre-anesthesia evaluation [for patient #11] was not documented prior to the start of the procedure, and there is no documentation that a post anesthesia assessment [for patient #12] was completed."

Based on record review and interview the facility failed to ensure that facility policies and procedures are being updated on an annual basis in 88 out of 103 health care policies and procedures reviewed.

Findings include:

The following facility policies and procedures had no documented review dates: Bedside Evaluation, Respiratory Muscle Strength, Chest, Physiotherapy and Postural Drainage, Closed Tracheal Suction System, Cpap/Bipap, Endotracheal Care Daily, Endotracheal Tube Placement Verification Following Intubation/Reintubation, Extubation, Expap, Heated High Flow Cannula Therapy, High Flow Nasal Cannula, Medication Administration Documentation, Metered Dose Inhaler (MDI) or Dry Powder Inhaler (DPI) Instruction, Nasal Cannula, Nasopharyngeal Airway (Trumpet), Oral Airway Insertion, Oxygen Weaning, Oxygen Protocol for Qualifying for Home O2 Therapy, Oxymask, Peak Flow Measurement, Respiratory Care Consult Service, Respiratory Care Therapy Documentation, Suctioning, ET Tubes and Tracheostomy, Nasotracheal Suctioning, Administration of Tobramycin, Nebulizer Updraft, Medication Safety Labeling and Swing Bed Referral Acceptance Policy.

The following facility policies and procedures had a "last review date" greater than 1 year from 12/05/17: Personal Protective Equipment #600-950 review date 2/09, Pre Anesthesia Evaluation review date 3/10/09, Same day Surgery review date 3/1/15, Admission to Surgery #612-002 review date 12/20/14, Outdated Medications review date 5/18/15, Outdated Sterile Supplies #612- review date 3/1/15, Restraints review date 4/20/15, Medical Staff Peer Review Process issued 12/15/15 with no review date, Asthma Protocol review date 10/29/15, Standards for the administration of aerosolized medications review date 10/26/15, Aerosolized Medication to Mechanically Ventilated Patients review date 10/26/15, Aerobika Mucus Clearing Device review date 10/26/15,Acetylcysteine(Mucomyst) Administration review date 10/26/15, Engineered Sharps Injury Protection #600-821 review date 04/11, Employee Infectious Disease Outbreak Surveillance #600-859 review date 12/14, Employee Health Guidelines Policy #600-858 review date 12/2014, Prevention of Catheter-Associated Urinary Tract Infections #600-830 review date 11-13, Boiling Water Advisory review date 08/10, Biohazardous Waste #600-995 review date 5/27/15, Contract Employee and Student Health Surveillance #600-843 review date 4/17/15, Criteria for Surveillance of Infection #600-960 review date 12/05, Disease Reporting #600-810 review date 12/11, Employee Exposure Protocol #600-860 review date 04/14, Cleaning and Disinfecting Computers #600- review date 12/29/14, Exposure Control Plan #600- review date 5/12/2015, Employee Exposure to Communicable Disease #600-861 review date 04/30/2015, CHG Bathing Prior to Surgery #600-870 review date 02/02/2015, Guidelines for Handling MRSA and other MDRO Cases #600-886 review date 05/15, Exposure Control Plan #600- review date 5/12/2015, Infection Control-Cleaning Schedule by Nursing Service #600-991 review 05/12/2015, Immunization of Hospital Employees #600-805 review date 09-14, Ice Machine Disinfection #600-806 review date 02/18/2015, Ice Scoop and Container Cleaning #600-807 review date 08/09, Hepatitis A Prophylaxis #600-868 review date 12/13, HIV Testing-Employee Exposure #600-941 review date 12/13, Handling and Processing of Soiled Linen #600-874 review date 04/1/2015, Hair Care Supplies #600-803 review date 09/14, Handling and Processing of Heavily Soiled Linen-OR Department #600-875 review date 07/15/2013, Infection Prevention Committee Membership #600-826 review date 01/20/2015, Infection Control-Personnel Guidelines #600-993 review date 8/17/2016, Use of Multiple Dose Vials #600-920 review date 01/07/2015, Meningococcal Meningitis Prophylaxis-Employees #600-922 review date 5/12/2015, Maxair PAPR System #600-801 review date 04/17/2015, Isolation Implementation #600-889 review date 04/27/2015, Isolation Implementation Specific Guidelines #600-887 review date 12-11, Pet Visitation #600-925 review date 02/18/2015, Prevention of TB Transmission and Management of Exposures #600-842 review date 04/12, Reporting of Urgent Health Importance "After Hours" #600-811 review date 04/16/2015, Reporting Personnel Illness #600-808 review date 12/13, Wound VAC Dressings #600-970 review date 04/23/2015, Wisconsin Immunization Registry #600-999 review date 4/29/2015, TB Testing for Physicians with Privileges #600-0844 review date 04-12, and Sharps and Containers-Collection and Disposal #600-822 review date 12/01/2014.

The above findings were confirmed in an interview with Chief Executive Officer A on 12/5/17 at 4:15 PM who stated "We know we have a problem with that and we are working on them and putting a new system in place."

Based on record review and interview the facility failed to have a Quality Assessment Program that is continuous and ongoing based on facility needs. In 1 of 1 Quality Assessment Programs reviewed.

Findings include:

The facility policy titled "QUALITY PLAN" was reviewed on 12/6/17 at 9:00 AM revealed "All departments have ongoing QAP/PI projects throughout year, and report to Performance Improvement Committee a minimum of annually."

An interview was conducted with Director of Patient Care/Quality C on 12/6/17 at 8:35 AM who stated "Every department was told to have 2 projects for quality at the beginning of the year and once they were completed they are done."