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Based on observation, staff interviews, and review of maintenance records on February 5, 2018 the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

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

Findings include:

The facility was found to contain the following deficiencies.
K 321 hazardous areas;
K 341: fire alarm systems;
K 352: fire suppression sprinkler system;
K 353: fire suppression sprinkler maintenance;
K 355: portable fire extinguishers;
K 363: corridor doors,
K 712: fire drills;
K 918: electrical systems;

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, staff interviews, and review of maintenance records on February 5, 2018 the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

42 CFR 485.623(d)(1) Condition of Participation: Safety from Fire was NOT MET

Findings include:

The facility was found to contain the following deficiencies.
K 321 hazardous areas;
K 341: fire alarm systems;
K 352: fire suppression sprinkler system;
K 353: fire suppression sprinkler maintenance;
K 355: portable fire extinguishers;
K 363: corridor doors,
K 712: fire drills;
K 918: electrical systems;

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 a sanitary environment by failing to perform endoscope disinfection per manufacturer recommendation prior to use in 2 of 5 patients receiving endoscopy procedures (Patient #3 and #22); failed to test disinfectant concentrations to ensure germicidal effectiveness in 1 of 1 housekeeping departments reviewed (Environmental Services); failed.to disinfect medication scanners after use in 3 of 4 medication administrations (Patient #4, #5 and #20); and failed to use proper hand hygiene in 1 of 11 patient care observations (Patient #6).

See Tag C-0278

The cumulative effect of these systematic problems has prevented the critical access hospital from providing services in a safe and effective manner (inpatient census 2/05/2018 was 5, 2/06/2018 was 6).

Based on observation, interview, and record review this facility failed to ensure safe storage of medications and biologicals to ensure patient safety in 3 of 4 crash carts (Emergency Rooms 101 & 103, and Medication Room).

Findings include:

Review of policy titled "Lifepak 12 Daily Inspection And Testing Of" #WR 18-034 last revised 4/01/2016 revealed, "it will be inspected and tested each day. The 11-7 shift will be responsible to see that the testing and inspection has occurred and has been documented appropriately".

During observation of the Emergency Department on 2/05/2018 at 12:35 PM, review of the check logs for the crash carts from October 1, 2017 through February 2018 were conducted . Check logs from Emergency Department Room 101 were missing check dates on November 7, 12, 19, 29, December 8, and January 12. Check logs from Emergency Department Room 103 were missing check dates on October 17, November 12, 19, and 29. Check logs from the Medication Room were missing check dates on October 3, 16, 17, 21, 22, November 5, 6, 19, 20, 30, December 3, 4, 8, 13, 17, 18, 20, 25, 29, 30, 31, January 14, 15, 27, 28, 30 and 31.

Per interview with Manager of Patient Care C on 2/05/18 at 12:35 PM during review of the check logs on top of the crash carts, C stated "yes, they were not checked if they were not filled out."

Based on observation, record review and interview, the facility failed ensure a sanitary environment by failing to perform endoscope disinfection per manufacturer recommendation prior to use in 2 of 5 patients receiving endoscopy procedures (Patient #3 and #22); failed to test disinfectant concentrations to ensure germicidal effectiveness in 1 of 1 housekeeping departments reviewed (Environmental Services); failed to disinfect medication scanners after use in 3 of 4 medication administrations (Patient #4, #5 and #20); and the facility failed to use proper hand hygiene in 1 of 11 patient care observations (Patient #6).

Findings include:

Per interview with Infection Preventionists J and N and Patient Care Supervisor B on 2/6/2018 between 10:50 AM and 11:05 AM, regarding nationally recognized standards of practice followed at this facility, Preventionist J stated, "CDC [Centers for Disease Control], APIC [Association for Professionals in Infection Control and Epidemiology], AORN [Association of peri-Operative Registered Nurses], and AAMI [Association for the Advancement of Medical Instrumentation]. Preventionist N stated, "Staff follow the 5 moments of hand hygiene as well."

Endoscope Disinfection

Review of facility policy "Medivator" No. WR-19-039-0610 dated 6/2010 revealed "12. Alcoholing Scope at End of the Day:" followed by the process to alcohol the scope. The facility did not address the need to alcohol with each cleaning cycle as defined in the manufacturer's instructions.

Review of the Medivator endoscope instructions for use reveal "5.8 Instructions for Alcohol Flushing Port: 1. Allow the reprocessor to complete the selected cycle. ..." followed by the process to alcohol the scope.

Review of the endoscope cleaning logs reveal that the red colonoscope was used for Patient #25's colonoscopy on 2/1/2018. The red scope was disinfected after Patient #25's procedure at 9:30 AM, was not alcoholed, and was then used for Patient #3's colonoscopy. The yellow endoscope was disinfected after use for Patient #24's endoscopy procedure on 2/1/2018 at 10:10 AM. The yellow scope was not alcoholed after disinfection and was then used for Patient #3's EGD (upper gastrointestinal scope). The blue colonoscope was disinfected after use for Patient #23's colonoscopy on 2/1/2018 at 8:50 AM. The blue scope was not alcoholed after disinfection and was then used for Patient #22's colonoscopy on 2/1/2018.

During an interview on 2/5/2018 at 11:30 AM, Environmental Services Technician I stated the facility has 5 endoscopes. Per I, the scopes are cleaned and disinfected after each procedure and each scope goes through an alcohol rinse at the end of the day but not between patients.

During an interview on 2/5/2018 at 2:00 PM, Infection Preventionist J stated "there is a misunderstanding in use. [Staff are] currently flushing at the end of the day and it should be after each use and with every washing."

Environmental Services

During observation of the environmental services room and interview on 2/6/2018 at 10:15 AM, Environmental Services Supervisor G stated the facility uses a multi-purpose disinfectant for cleaning environmental surface areas. Per G, the disinfectant is mixed with water by an automated dispenser. When asked if staff were checking the concentration of the solution to ensure recommended germicidal properties, G stated "no."

Review of recommendations for the facility's disinfectant, obtained from the company representative, revealed "Perform a hydrogen peroxide test using the AHP 500 test strips each time the container is replaced." During an interview on 2/6/2018 at 5:00 PM, Environmental Services Supervisor G stated "I don't think [the manufacturer] provided that before, it was an oversight, I should have asked."




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Medication Administration/Disinfection

A patient policy for medical equipment cleaning was requested on 2/6/2018 at 12:45 PM. Staff at the facility provided a policy for equipment cleaning that was specific to the therapy department. The policy did not refer to other patient equipment.

Observation on Medical/Surgical on 2/5/2018 at 2:10 PM, Registered Nurse H entered Patient #4's room and used "Rover" (hand held scanner/cell phone/charting device) to scan Patient #4's identification wrist band. Registered Nurse H then placed the Rover in H's pocket and left the room without disinfecting the scanner.

Observation on Medical/Surgical on 2/06/2018 at 8:10 AM, Registered Nurse H was observed administering subcutaneous medications to Patient #5. Nurse H picked up a Rover off of a cart in the medical/surgical hallway. The Rover was not cleaned prior to entering Patient #5's room. After using the Rover to scan Patient #5's bar coded bracelet and each medication, Nurse H placed the Rover on the nurse server cart in Patient #5's room. Upon exiting the room, Nurse H picked up the Rover and placed it back on the cart in the hallway without cleaning it.

Observation on Medical/Surgical on 2/06/2018 at 8:23 AM, Registered Nurse K was observed administering intravenous medications to Patient #20. Nurse K removed alcohol wipes and a pen from K's pockets to use during the provision of cares to Patient #20. Upon completion of cares, Nurse K removed the computer on wheels, that had an attached bar code scanner (not a Rover) that was used for patient identification, to the medical/surgical hallway and did not clean the device.

Observation on Medical/Surgical on 2/6/2018 at 9:12 AM Nurse K was observed to pull scissors and a roll of tape out of K's pocket to use for covering Patient #6's medication patch on Patient #6's arm. Patient care items are not to be carried in pockets.

During interview with Infection Preventionist N on 2/06/18 at 12:45 PM, Preventionist N stated, "Items used in patient rooms/taken out of patient rooms/put in pockets, should be cleaned" [after leaving a patient room].

During interview with Infection Preventionist N on 2/06/18 at 12:45 PM, Preventionist N stated, "No patient care items should be in pockets."

Hand Hygiene:

The facility's policy titled, "Hand Hygiene," #922, dated 8/15/2017, was reviewed on 2/6/2018 at 12:45 PM. The policy references the Centers for Disease Control. The policy revealed, "The use of gloves does not replace the requirement of hand hygiene procedures...2) Hand Decontamination a) When to use an alcohol-based hand rub: xi) After removing gloves."

On 2/6/2018 at 9:03 AM Certified Nursing Assistant M was observed assisting Patient #6 with a shower. Assistant M applied 3 pair of gloves prior to assisting Patient #6 out of bed. At 9:10 AM Assistant M removed one pair of the gloves and used M's Rover to call Nurse K then continued with cares without performing hand hygiene.

On 2/6/2018 at 9:18 AM Assistant M removed the next layer of M's gloves after performing peri-care on Patient #6 and did not perform hand hygiene.

On 2/6/2018 at 9:25 AM Assistant M removed the last pair of gloves after completing Patient #6's shower and did perform hand hygiene then continued to assist Patient #6 in the bathroom.

On 2/6/2018 at 9:29 AM Assistant M, after performing hand hygiene, was observed waving hands back and forth to air dry them and stated, "That's why I put on multiple layers, then I can just take one off, otherwise it's too hard to get them on" [after hand hygiene when hands are still damp].

During interview with Infection Preventionist N on 2/06/18 at 12:45 PM, N stated, "Multiple gloving in lieu of hand hygiene is not allowed. We do not have a policy for multiple glove use at this facility."

Based on record review and interview, the facility failed to ensure staff maintain resuscitative certification for 2 of 3 Registered Nurse staff personnel files reviewed for credentialing (Registered Nurse H and P).

Findings include:

Per personnel file review on 2/6/2018, Registered Nurse H's ACLS (Advanced Cardiovascular Life Support) certification was expired 1/2017 and PALS (Pediatric Advanced Life Support) certification was expired 4/2016.

Per personnel file review on 2/6/2018, Registered Nurse P's ACLS certification was expired 1/2017 and PALS certification was expired 4/2015.

During an interview on 2/6/2018 at 3:00 PM, Patient Care Supervisor B stated all Registered Nurses are expected to maintain ACLS and PALS for emergency services. Per B, "there have been some scheduling conflicts in getting [H and P] into a class."

Based on record review and interview, facility staff failed to document care plan goals every shift per policy in 3 of 10 patient care plans reviewed (Patient #6, #18, and #19); and failed to align care plan goals with medical orders in 1 of 10 patient care plans (Patient #20) in a total sample of 20 patient records reviewed.

Findings include:

Care Plans

Review of facility policy "Documentation Charting" No. WR 30-135 dated 2/14/2017 revealed "Patient Care Plan: The nursing discipline care plans should address the patient's treatment goals and, as appropriate, the physiological and psychosocial factors and patient discharge planning. ...All members of the interdisciplinary team are accountable to document assessment data, problem per care plan, interventions carried out and the results of those interventions that they perform on behalf of the patient. ...The Registered Nurse is accountable to complete goal evaluations for the nursing discipline every shift and more frequently as the patient condition warrants."

Patient #18 was admitted to the facility for swingbed services on 1/29/2018. Per medical record review, Patient #18's care plan included a problem of "Pain--Acute/Chronic" with a goal of "Pain within patient's stated goals." Goal evaluations were not documented every shift. Goal outcome was documented by nursing staff as "Progressing" on 2/4/2018 at 9:58 PM. The next goal evaluation was documented as "Not progressing" on 2/6/2018, more than 24 hours later. There was no documentation of goal outcomes every shift or documentation why Patient #18 went from progressing toward goal on 2/4/2018 to not progressing on 2/6/2018.

Patient #19 was admitted to the facility for swingbed services on 1/25/2018. Per medical record review, Patient #19's care plan included a problem of "Anxiety." Goal evaluations were not documented every shift. Goal evaluation last documented "progressing" on 2/4/2018 at 9:11 PM. There were no additional goal evaluations, or evidence that the problem was resolved, at the time of the review on 2/6/2018 at 1:15 PM.

Patient #6 was admitted to the facility for swingbed services on 2/2/2018. Per medical record review, Patient #6's care plan included problems of "Risk of Falls," "Pain--Acute/Chronic," and "Skin Integrity Impaired." Goal evaluations were not documented every shift. Goal evaluations were documented on 2/4/2018 at 9:53 AM and then again on 2/6/2018 at 1:22 AM, more than 24 hours later.

During an interview on 2/6/2018 at 1:00 PM, Quality Coordinator F stated "staff should be documenting on care plan goals every shift."

Aligned Goals

Patient #20 was admitted to the facility on 2/5/2018 for pneumonia. Per medical record review, Patient #20's care plan included a problem of "Ineffective Airway Clearance" with an oxygen saturation goal of greater than 90% on room air and a problem of "Impaired Gas Exchange" with an oxygen saturation goal of greater than 88% on room air. Patient #20's orders included an order to "maintain oxygen saturation greater than 90%."

During an interview on 2/6/2018 at 2:15 PM, Quality Coordinator F stated "the goals should match each other and the orders."

Based on record review and interview, facility staff failed to provide Medicare discharge rights information to 1 of 1 eligible patients reviewed (Patient #12).

Findings include:

Per medical record review, Patient #12 received inpatient services from 12/31/2017 through 1/5/2018. The form "An Important Message From Medicare About Your Rights" was signed by Patient #12 on 12/31/2017. There is no documented evidence that Patient #12 was provided notice about discharge rights within 48 hours of the date of discharge, 1/5/2018.

Per interview with Care Manager L on 2/5/2018 at 12:48 PM regarding the Important Message from Medicare form, Manager L stated that the unit clerk is the staff member who gives out the form within 48 hours of admission and 48 hours of discharge.

Based on record review and interview, facility staff failed to assess and provide for discharge needs in 1 of 1 discharged medical inpatient reviewed (Patient #12) in a total of 20 records reviewed.

Findings include:

Review of facility policy "Discharge Planning" No. 30-106 dated 10/17/2017 revealed "Discharge planning shall be initiated on admission to the hospital by assessing the patients discharge needs. A goal for discharge should be discussed with the patient and documented on the admission assessment. C. Hospital discharge planning activities include: 3. Provisions for or referral to services the patient may require to improve or maintain his/her health status while remaining in his/her home, or 4. Providing the patient with discharge instructions and provisions for follow up care."

Per medical record review, Patient #12 was admitted for inpatient services for abdominal pain and gastritis on 12/31/2017. On 1/2/2018 Case Manager L documented "yes" on Patient #12's discharge planning flowsheet under "Community Services Potentially Needed for Discharge." There was no documentation of what type of service or why the service was potentially needed. Under "D/C Planning Discussion" on 1/2/2018: "Abdominal pain with [diagnosis] of colitis. NPO (nothing by mouth). IV [antibiotics]. Elevated WBC (white blood cell count)." On 1/3/2018: "MD anticipates additional 1-2 days..." There was no reassessment of discharge needs or plans for patient post discharge.

Review of nursing notes on 1/4/2018 at 10:09 PM revealed "Patient moaning and crying throughout night. ...[Physician] ordered fluoxitine [antidepressant medication] (for crying and admitted depression)." Nursing notes on 1/5/2018 at 12:36 PM reveal "Patient refusing cares, ambulation, food and getting out of bed. Reapproached many times by staff, refusing every time. Talked to patient regarding starting antidepressant medication...said would just lay around and not eat at home either. Does not want to talk to a counselor or anyone about the medication or issues." Patient #12 was discharged from the facility on 1/5/2018. The discharge summary dated 1/5/2018 lists discharge diagnoses of colitis and depression. Hospital course was documented as "...hospital stay was relatively uneventful." There was no mention of Patient #12's depression or start of an antidepressant medication during the hospitalization. Review of Patient #12's discharge instructions did not include instructions for depression or what to watch for on the newly prescribed antidepressant.

Review of outpatient home health care notes revealed Patient #12 had been receiving home health services at the time of admission on 12/31/2017. Review of notes from the home health service on 1/2/2018 revealed "Call to [Case Manager L] to inform that the patient was receiving services prior to current hospitalization. This writer informed [Case Manager L] that if the patient is inpatient for more than 24 hours a ROC [resumption of care] referral will be required if homecare is needed upon hospital discharge." On 1/4/2018: "[Electronic Health Record] reviewed...DC [discharge] is anticipated for tomorrow, 1/5/2018. ...[Case Manager L] is aware that the patient will require ROC referral...Will continue to monitor for updates r/t [related to] DC plans and ROC referral." On 1/5/2018: "Discharge orders have been entered for patient. ROC have not been received. Call to [Case Manager L]; [left voice message] requesting return call to advise if they will be sending ROC orders or if patient no longer requires homecare." Patient #12's primary care provider staff documented on 1/9/2018, 4 days after discharge to home: "Referral has been placed for reinstatement." There was no documentation from Case Manager L, or other facility staff, addressing Patient #12's need for home health care services prior to discharge, or any coordinated efforts for referral to the service.

During an interview on 2/6/2018 at 4:00 PM, Quality Coordinator F stated "there should be documentation from the case manager."

Based on record review and interview, this facility failed to evalute and incorporate all of their contracted services into their Quality Review process in 38 of 43 of their contracted services (Advanced Disposal, Agnesian Healthcare Hospice Hope, Ahern, Air Gas, Alliant Energy, Beckman Coulter, Cal-Ray Digital x-Ray Sales & Service, Cardinal Health, Celtic Leasing Corporation, Charter Cable, Clean Water Testing, Communication Engineering Company, Community Blood Center, Critical Signal Technologies, Cummins, Family Health/La Clinica, Fox Valley Pathologists, General Electric Healthcare Service Agreement, IOD (Medical Record Copying Service), Instrumentation Lab, Johnson & Johnson Contract, Lab Service Agreement, National Elevator Inspection Service, Novation, Otis, Ortho-Clinical Diagnostics, Inc., Press Ganey, Reinhart Foods, Roche Diagnostics, Stericycle, Steris, Sysco Food Service, Tyco, Universal Hospital Services-General Equipment, Waushara County, Wild Rose Manor, Wil-Kill and Wisconsin Gas).

Findings include:

Review of Quality Assessment and Process Improvement Plan 2017 under VII. Duties of the Quality Assessment and Process Improvement Committee Chairperson, 5. "Annually compile evaluations for all departments, Quality Assessment and Process Improvement activities and prepare an annual program report to be included in the Critical Access Hospital Annual Evaluation Report".

Review of the schedule titled "Quality Reporting Schedule 2017" with Manager Patient Care C on 2/06/2018 at 11:04 AM revealed January through December did not include the 44 contracted services.

Interview with Manager Patient Care C on 2/06/2018 at 3:40 PM, C stated that organ procurement data was reviewed by L and findings shared with the Quality Department, Magnetic Resonance Imaging service quality information was reviewed in the quality meetings, and the Gunderson Uniform and Linen facility was recently toured to assess their procedures and processes for quality, but confirmed that all 38 of their contracted services were not included in quality review.

Interview with Quality Coordinator F on 2/06/2018 at 11:04 AM, F stated that s/he was unsure of what the process was for the review of all contracted services at this facility.

Based on record review and interview, staff at this facility failed to ensure that Swing Bed patients have the required information needed at the time of transfer or discharge in 3 of 3 closed Swing Bed records out of a total of 8 Swing Bed records reviewed (Patient #9, 10, and 11) in a total sample of 20 records reviewed.

Findings include:

Per interview with Care Manager L on 2/5/2018 at 1:03 PM regarding the swing bed program at this facility, Manager L stated that a notice of Medicare non-coverage for payment was given as the discharge notice within 48 hours of discharge if at all possible.

The facility's notice that was given to Swing Bed patients upon transfer/discharge was reviewed on 2/5/2018 at 2:26 PM. The notice does not include language that would inform the patient of the right to know the reason, effective date, or where they would be discharged or transferred should this occur.

The notice does not include information about the Long Term Care Ombudsman, or include information regarding who to contact for patients with developmental disabilities or mental illness.

Per review of the "Swing Bed Program Resident's Statement of Rights and Responsibilities," on 2/5/2018 at 2:26 PM, the statement revealed that swing bed patients are to be given a written notice that includes the reason, effective date, or where they would be discharged or transferred should this occur, as well as information about the Long Term Care Ombudsman and who to contact for patients with developmental disabilities or mental illness.

A medical record review was conducted on Patient #9's closed swing bed record on 2/6/2018 at 2:33 PM accompanied by Patient Services Manager C who confirmed the following finding: Patient #9 was admitted for swing bed services on 11/28/2017 and discharged on 12/8/2017. There was not a complete transfer/discharge notice in the medical record.

A medical record review was conducted on Patient #10's closed swing bed record on 2/6/2018 at 3:06 PM accompanied by Care Manager L who confirmed the following finding: Patient #10 was admitted for swing bed services on 12/28/2017 and discharged on 1/2/2018. There was not a complete transfer/discharge notice in the medical record.

A medical record review was conducted on Patient #11's closed swing bed record on 2/6/2018 at 4:26 PM accompanied by Patient Care Manager C who confirmed the following finding: Patient #11 was admitted for swing bed services on 1/3/2018 and discharged on 1/12/2018. There was not a complete transfer/discharge notice in the medical record.

Based on record review and interview, staff at this facility failed to ensure that an activity assessment was completed for every swing bed patient in 5 out of 8 swing bed medical records reviewed (Patient #5, #10, #11, #18 and #19) in a total sample of 20 records reviewed.

Findings include:

Per interview with Care Manager L on 2/5/2018 at 1:03 PM regarding the activity assessments for swing bed patients, Manager L stated that Occupational Therapy manages the activity program for swing bed patients.

Per interview with the Activity Coordinator, Occupational Therapist O on 2/6/2018 at 12:10 PM regarding O's responsibilities for the activity program in swing bed, Therapist O stated that O does an activity assessment on all swing bed patients. The assessments are documented in the electronic medical record on the activity flow sheet.

A medical record review was conducted on Patient #5's open swing bed record on 2/6/2018 at 12:57 PM accompanied by Patient Care Supervisor B. Patient #5 was admitted for swing bed services on 2/1/18. Supervisor B was unable to find an activity assessment in Patient #5's record. Per interview with Occupational Therapist O at 1:54 PM regarding the activity assessment, Therapist O reviewed the medical record and stated, "It was not done."

A medical record review was conducted on Patient #10's closed swing bed record on 2/6/2018 at 3:06 PM accompanied by Care Manager L who confirmed the following finding: Patient #10 was admitted for swing bed services on 12/28/2017. There is no activity assessment for swing bed.

A medical record review was conducted on Patient #11's closed swing bed record on 2/6/2018 at 4:26 PM accompanied by Patient Services Manager C who confirmed the following finding: Patient #11 was admitted for swing bed services on 12/28/2017. There is no activity assessment for swing bed.




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Patient #18 was admitted to the facility for swingbed services on 1/29/2018. Per medical record review on 2/6/2018, Patient #18 had no documented activity assessment during the hospitalization.

Patient #19 was admitted to the facility for swingbed services on 1/25/2018. Per medical record review on 2/6/2018, Patient #18 had no documented activity assessment during the hospitalization.