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Based on review of 4 of 4 contracted service lists and staff interviews the GB failed to ensure they had identified all hospital contracts, including those provided under arrangements and agreements related to patient care to ensure they complied with the hospitals conditions of participation for the services rendered. Consequences of these failures could affect all patients receiving services at this hospital.

Findings include:

During the entrance conference 08/06/12 at 9:30 AM, A&LC-A was given a list of required survey materials needed for review to determine portions of the hospital's compliance. The requested materials item #4 "contracted services" was highlighted.

A&LC-A was informed, the highlighted items were needed in a timely manner for review ("timely" was identified as "preferably by noon" (08/06/12).

At the end of the day (4:00 PM) the survey team had not received a list of contracted services. A&LC-A was informed of the missing contract list.

On 08/7/12 at 8:00 AM A&LC-A provided the survey team a list of 23 contracted services (list #1).

After departmental tours 08/06/12 and 08/07/12 and interviews, surveyors found 8 additional contracted services.

Pro-Health Care HIM staff, under a Pro-Health arrangement to provide over-sight to the HIM department including security of the MR's, D HIM-NN and Manager HIM-OO failed to comply with the COP for MR's security and over sight of all MR's, when during a tour on 08/08/12 at 9:30 AM, MR's storage was found in the bio-medical work and storage room (B955) and contracted HIM staff were unaware these MR's were their responsibility.

M HIM-OO, could not identify who 3 shelves of MR's belonged to, indicating it may be stored for a private practice physician. M HIM-OO confirmed as manager OO did not consider radiology films a part of a patients MR. M HIM-OO confirmed all records stored in this room the first shelving area 15 feet (ft) X 8 ft X 33 ft and another shelving area 15 ft X 8 ft X 20 ft, contained PHI, confidential and protected under HIPAA law.

D HIM-NN and M HIM-OO confirmed they did not know all services in the hospital that maintained complete or portions of a Pt's MR.

On 08/07/12 at 1:15 PM, during the GB interview and review of the contracted services list received on 08/07/12 at 8:00 AM, and the additional contracted services found while on facility tour, WMH President - PP and VP Nursing C confirmed they realized contracted services were a problem.

WMH President - PP confirmed that WMH had not considered any services provided under arrangement or agreement by the Pro-Health organization to be a contracted services.

On 08/08/12 at 8:00 AM, A&LC-A provided the survey team with a second list of 30 contracted services (list #2). A&LC-A confirmed the Pro-Health organization (corporation employed staff providing WMH with services) were not included on this new list of 30 contracts.

A&LC-A confirmed that not all 8 contracted services identified during the hospital tours were on this new list.

On 08/08/12 at 3:00 PM, A&LC-A brought the survey team 2 more contracted service lists.

Contracted list (#3) contained 247 contracts that appeared to be all health care related contracted services. However, did not include Pro-Health arrangements or agreements.

Contracted list (#4), contained 1,431 contracted services that had both medical and non medical service (example: office depot).

A&LC-A confirmed the hospital did not understand the federal contracted service requirements under the GB COP and what constituted a contracted service, confirming that all the internal agreements and arrangements were not on 4 of 4 lists or monitored for compliance.

Based on review of 4 of 4 lists of contracted services and staff interviews, the GB failed to ensure the hospital identified all hospital contracts to include the the scope and nature of each service rendered to their Pt's. Consequences of these failures could affect all Pt's receiving services at this hospital. Daily census during this survey: 08/06/2012 = 223, 08/07/2012 = 207, 08/08/2012 = 214 and 08/09/2012 = 239.


Findings include:

During the entrance conference on 08/06/12 at 9:30 AM, A&LC-A Surveyors requested materials including item #4 "contracted services" which was highlighted to ensure this document was received in a timely manner (timely identified as preferably by noon (08/06/12).

At the end of the day (4:00 PM) the survey team had not received a list of contracted services. A&LC-A was informed of the missing contract list.

On 08/7/12 at 8:00 AM, A&LC-A provided the survey team a list of 23 contracted services (list #1).

After departmental tours on 08/06/12 and 08/07/12 and interviews, Surveyors found 8 additional contracted services.

On 08/08/12 at 8:00 AM, A&LC-A provided the survey team with list #2, 30 contracted services. A&LC-A, confirmed the Pro-Health organization (corporation employed staff providing WMH with services) were not included on this new list of 30 contracts.

On 08/08/12 at 3:00 PM, A&LC-A brought the survey team 2 more contracted service lists (#3 and #4).

Contracted list #3 contained 247 contracted services that appeared to be all health care related contracted services. However, did not include Pro-Health contracts under arrangements or agreements.

Contracted list #4 contained 1,431 contracted services that had both medical and non medical service (example: office depot).

On 08/07/12 at 1:15 PM, during the GB interview and review of the contracted services list #1, WMH President-PP confirmed that WMH had not considered any services provided under Pro-Health organization arrangement or agreement to be a contracted services and we would not see them on the list.

A&LC-A confirmed the hospital did not understand the contracted service requirements under the GB CoP, and what constituted a contracted service, confirming that all the internal agreements and arrangements were not on either of the two lists (#3 or #4).

Based on observations, interviews and record reviews, the hospital failed to promote and protect each Pt's rights. This had the potential to effect all In-Pt's daily census during this survey: 08/06/12- 223, 08/07/12- 207, 08/08/12- 214 and 08/09/12- 239.


Findings include:

The Complaint and Grievance policy and Pt Rights brochure failed to include "quality of care" as a reason for referral to the Quality Improvement Organization (QIO) MetaStar, potentially effecting all InPt's. (A 120)

The Pt rights brochure and the complaint/grievance policy failed to include time frames, or information informing the Pt, that they would receive a written response to a grievance or what that written response would entail, potentially effecting all InPt's. (A 122)

The hospital staff failed to follow up with 3 of 30 (#12, 15 and 23) Pt's to determine if these Pt's wanted or needed AD information. (A 132)

The hospital failed to make each Pt's room safe and free from potential suicide risks when the hospital identified a risk in 2010 on the BH unit and failed to enclose sink and toilet plumbing in 10 of 10 rooms (that has the potential to housing a total of 22 Pt's) on the Behavioral Health In-Pt unit. Current Pt census = 5. (A 144)

The hospital failed to document or ensure 1 of 3 (#19) patients had least restrictive measures used or document if the least restrictive measures were ineffective prior to restraining Pt #19. (A 164)

The hospital staff failed to document which if any lesser restrictive measures were used for 1 of 3 (#19) before putting Pt 19 in restraints and therefore the hospital could not confirm that when restraints were initiated for Pt 19, they used the least restrictive measures. (A 165)

The hospital failed to ensure 3 of 3 (# 17, 18 and 9) Pt's had care plans modified to include the use of restraints. (A 166)

The hospital failed to obtain an order in conjunction with hospital policy and state and federal law for 1 of 3 (#19) Pt's who were restrained. (A 168)

The hospital failed to document the discontinuation of restraints for 2 of 3 (#18 & #19) Pt's, to ensure that restraints were discontinued at the earliest possible time. (A 174)

The hospital failed to complete the death reporting document for 1 of 3 (#17) Pt's who died while in restraints and failed to meet the 24 hour reporting requirement. (A 214)

The facility failed to inform each Pt of their right to allow or disallow visitors, or the medical staffs ability to modify the Pt's decision based on medical need. This had the potential to effect all In-Pt's. (A 217)

The cumulative effects of these systemic failures, resulted in the hospital's inability to promote and protect each Pt's rights and the safety of it's Pt's is maintained.

Based on staff interview, review of the Complaint and Grievance P&P and Pt Rights brochure, the facility failed to include "quality of care" as a reason for referral to the Quality Improvement Organization (QIO) MetaStar. This had the potential to effect all InPts. Daily census during this survey: 08/06/2012 = 223, 08/07/2012 = 207, 08/08/2012 = 214 and 08/09/2012 = 239.

Findings include:

On 08/09/12 at 9:15 AM, during an interview and review of the Complaint and Grievance P&P effective date:02/28/2003, last revised 06/13/2012 and last reviewed 06/14/2012, and the Pt rights brochure, Pt Rights staff-PPP confirmed the hospital provides written Pt packet that include written Pr rights and responsibilities.

Pt Rights staff-PPP confirmed that the Pt Rights brochure does not contain information regarding the MetaStar reviewing Pt's quality of care concerns. The brochure states; "You may file an appeal with MetaStar if you are a Medicare patient and believe you are being discharged from the hospital too soon." The brochure implies that the Pt must be a Medicare Pt in order to file a complaint or have a referral on their behalf.

Pt Rights staff-PPP confirmed after review of the Complaint and Grievance P&P effective date:02/28/2003, last revised 06/13/2012 and last reviewed 06/14/2012, that the hospital's complaint and grievance P&P does not address referral to the QIO MetaStar or what the time frame is for a timely referral to the QIO.

29302

Based on P&P review and interview the hospital failed to accept an individual's chosen method and/or ability for filing a grievance. This had the potential to affect every Pt. Daily census during this survey: 08/06/12- 223, 08/07/12- 207, 08/08/12- 214 and 08/09/12- 239.

Finding include:

On 8/9/12 at 3:42 PM, Surveyor reviewed the hospital P&P titled: "Patient, Family Complaint and Grievance Process," effective date:02/28/2003, last revised 06/13/2012 and last reviewed 06/14/2012.

Patient, Family Complaint and Grievance Process P&P indicated the hospital would not accept an individual's chosen method and/or ability for filing a grievance based on it's policy's language as follows: "ii) Written complaints, including letters, emails and faxes, (1) Exception: Comments written on comment cards or Press Ganey surveys are NOT considered a grievance, unless a response is requested OR the organization would usually treat the concern as a grievance."

On 08/09/12 at 9:15 AM, during an interview and review of the Complaint and Grievance P&P effective date:02/28/2003, last revised 06/13/2012 and last reviewed 06/14/2012, and the Pt rights brochure, Pt Rights Staff-PPP confirmed the hospital P&P does not allow for individual's chosen method of filing a grievance.

Pt Rights staff-PPP confirmed, the current P&P does not consider it a complaint/grievance, if a Pt complains on a "comment card", it would not be investigated or considered a grievance, even if it were a quality of care or discharge related complaint.

Based on interview and Pt rights brochure and P&P review, the complaint/grievance documents received by each InPt, failed to include time frames or information informing the Pt that they would receive a written response to a grievance, or what that written response would entail. This had the potential to effect all Pt's. Daily census for this survey: 08/06/2012 = 223, 08/07 = 207, 08/08 = 214 and 08/09 = 239.

Findings include:

On 08/09/12 at 9:15 AM, during an interview and review of the Complaint and Grievance P&P effective date:02/28/2003, last revised 06/13/2012 and last reviewed 06/14/2012, and the Pt rights brochure, Pt Rights staff-PPP confirmed the hospital provides each Pt a packet that includes written Pt rights and responsibilities.

Pt Rights staff-PPP confirmed, although the Complaint and Grievance P&P included the 7 day time frame for a complaint and the P&P indicated the Pt would receive written notification, and what needed to be included in the response letter, the Pt Rights brochure failed to include the information for what the Pt could expect from the hospital should a complaint/grievance be filed by them or on their behalf.

Pt Rights staff-PPP confirmed the hospital's Pt rights brochure did not completely inform their Pt's of the complaint/grievance process.

Based on interview and record review the hospital failed to follow up with 3 of 30 (#12, 15 and 23) Pt's to determine if these Pt's wanted or need AD information. Total universe 32.

Findings include:

The "Advanced Directives" P&P, 6 pages with an effective date of 10/19/10, provided by A&LC-A on 08/06/12 at 11:00 AM, as item #24 on Surveyor requested materials states:
"ProHealth Care recognizes that through an Advanced Directive, a decisional adult patient has the right to express treatment preferences and/or designate an individual to make health care decisions for him or her in the event of decision-making incapacity. All patients who are 18 years or older will be asked if they have written Advanced Directives."
"Patients who do not have an Advanced Directive will be offered information/assistance if they wish to formulate one."
"If the patient does not have written Advanced Directives, ask if (s)he would like information about Advanced Directives. If the patient would like further information, provide them with the Advanced Directives brochure, and/or offer assistance from the Care Coordinator or Social Worker."

Pt #12's MR review on 080/9/12 at 10:20 AM revealed Pt #12 had no AD. There was no documented follow up of providing information or offering to assist in developing and AD. This was confirmed in interview with CI-LLL and UE-RRR on 08/09/12 at 10:20 AM.

Pt #15's MR review on 08/07/12 at 2:30 PM revealed Pt #15 had no AD. There was no documented follow up of providing information or offering to assist in developing and AD. This was confirmed in interview with CI-SSS on 08/07/12 at 2:20 PM.

Pt #23's MR review on 08/09/12 at 1:50 PM revealed Pt #23 had no AD. There was no documented follow up of providing information offering to assist in developing and AD. This was confirmed in interview with CI-LLL and UE-RRR on 08/09/12 at 1:50 PM.

Based on tour observations, interviews and review of risk assessment the hospital failed to make each Pt's room safe and free from potential suicide risks, when the hospital identified a risk in 2010 and failed to enclose sink and toilet plumbing in 10 of 10 rooms (potentially housing a total of 22 Pt's) on the BH In-Pt unit. Current Pt census = 5.

Findings include:

On 08/07/12 at 11:05 AM, during a tour of the BH unit, the managers of BH, JJ and KK confirmed that there were 10 Pt rooms, and had the ability to house a total of 22 Pt's.

Observation in 2 bathrooms identified toilet and sink plumbing uncovered and exposed.

On 08/07/12 at 2:00 PM, A&LC -A provided and reviewed document #1 "Facility & Safety Risk Assessment Form" completed on 03/04/2010, dated reviewed and revised, 05/01/12, that identified the exposed plumbing as low risk "with current controls in place".

Under the header, "Type of injury which could result if harm occurs" was documented, "Patient could hit head on piping or possibly hang themselves".

Under the header, "Current Controls Measures in place", the word "None" was documented.

Under the header, "Further Control Measures required" was documented "install cover over piping"

Under the header, "Person Responsible to implement further measures required and date to implement" Project Manager M-11 was listed. However, no date was documented for implementation of safety measures.

Under the header, "Cost to correct, Corrected Yes or No", nothing was documented. The space was left blank.

The hospital could not provide additional documents; like trends, incidents and prevalence of issues related to the exposed pipes, or how the decision was made that the exposed plumbing was low risk. The hospital did not provide the rationale for not acting on a suicide safety risk identified in March of 2010.

On 08/08/12 at 11:35 AM, Safety Manager M-11 accompanied Surveyor to the BH Unit.

Safety Manager M-11 confirmed, although a plastic cover was placed over some of the sink plumbing, the plastic covers would not negate the potential for hanging if a Pt is suicidal.

Based on staff interview and medical record, the hospital failed to document and ensure 1 of 3 (#19) Pts had least restrictive measures used or document if the measures were ineffective prior to restraining Pt #19. Total universe was 32.

Findings include:

On 08/08/12 between 9:00 AM and 10:45 AM, records were reviewed for restrained Pt's #17, 18 and 19 with ED RN-QQQ and ICU RN YYY and the following was identified and confirmed:

On 06/01/12 at 1200 PM, during the first restraint encounter for Pt 19, the hospital failed to document if the hospital staff had attempted any lesser restrictive measures prior to placing Pt 19 in restraints.

Based on staff interview and MR review, the hospital failed to document which, if any lesser restrictive measures were used for 1 of 3 (#19) Pt's before putting Pt #19 in restraints, therefore the hospital could not confirm that when restraints were initiated for Pt 19, they had used the least restrictive measure. Total universe was 32.

Findings include:

On 08/08/12 between 9:00 AM and 10:45 AM, MRs were reviewed for restrained Pt's #17, 18 and 19 with ED RN-QQQ and ICU RN-YYY and the following was identified and confirmed:

On 06/01/12 at 1200 PM during the first restraint encounter for Pt 19, the hospital failed to document if any lesser restrictive measures (like: 1:1's or redirection) were attempted prior to placing Pt 19 in restraints.

Based on staff interview and MR's and P&P reviews, the hospital failed to ensure 3 of 3 (# 17, 18 and 9) Pt's had CPs modified to include the use of restraints. Total universe was 32.

Findings include:

On 08/08/12 between 9:00 AM and 10:45 AM, closed MR's were reviewed for Pt's #17, 18 and 19 who had been restrained with ED RN-QQQ and ICU RN YYY and the following was identified and confirmed:

The most current restraint policy entitled "Restraint Use" (8 page policy) last reviewed and revised on 06/25/12, noted on page 2: "The use of restraints will be: In accordance with a written modification to the patient's plan of care by a physician or other licensed independent practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with Wisconsin state law."

Pt #17
On 05/02/12 at 9:20 AM, through 05/10/12, Pt 17 was restrained. The hospital staff failed to incorporate the use of restraints into Pt 17's CP.

Pt #18
On 06/01/12 at 1200 PM, Pt 18 was put into restraints. The hospital staff failed to document when Pt 18 was removed from restraints and did not incorporate the use of restraints into Pt 18's CP.

Pt #19
On 06/01/12 at 1200 PM, during the first restraint encounter for Pt 19, hospital staff failed to document the date or time Pt 19 was removed from this restraints encounter. The hospital staff failed to incorporate the use of restraints into Pt 19's CP.

On 06/18/12 at 1900 (7:00 PM), Pt 19 was placed in restraints. The use of restraints was not incorporated into Pt 19's CP.

ED RN-QQQ and ICU RN-YYY confirmed that the CPM electronic CP system the hospital adopted to use for care planning for all hospital Pt's does not include the use of restraints. However, staff had the option to individualize Pt's # 17, 18 and 19's care plans, but did not.

Based on staff interview and MRs and P&P reviews, the hospital failed to obtain an order in conjunction with hospital P&P and state and federal law, for 1 of 3 (#19) Pt's who were restrained. Total universe was 32.

Findings include:

On 08/08/12 between 9:00 AM and 10:45 AM, MR's were reviewed for restrained Pt's #17, 18 and 19 with ED RN-QQQ and ICU RN YYY and the following was identified and confirmed:

The most current restraint policy entitled "Restraint Use" (8 page policy) last reviewed and revised on 06/25/12, noted on page 2: "The use of restraints will be: In accordance with a written modification to the patient's plan of care by a physician or other licensed independent practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with Wisconsin state law."

On 06/01/12 at 1200 PM, during the first restraint encounter for Pt 19, the hospital failed to document that this restraint encounter was done in conjunction with an order from a physician or LIP authorized by the hospital and state licensure to do so.

ED RN-QQQ and ICU RN-YYY confirmed for Pt 19, there was no physician order for the use of restraints during the 06/01/12 at 12:00 PM encounter.

Based on staff interview and MR's and P&P review the hospital failed to document the discontinuation of restraints for 2 of 3 (#18 and #19) Pt's, to ensure that restraints were discontinued at the earliest possible time. Total universe was 32.

Findings include:

On 08/08/12 between 9:00 AM and 10:45 AM, MR's were reviewed for restrained Pt's #17, 18 and 19 with ED RN-QQQ and ICU RN YYY and the following was identified and confirmed:

The most current restraint P&P entitled "Restraint Use" (8 page policy) last reviewed and revised on 06/25/12, note on page 2 states: "The use of restraints or seclusion will be: Discontinued the earliest possible time, regardless of the length of time identified in the order."

Pt #18
On 06/01/12 at 12:00 PM, Pt #18 was placed in restraints. There was no documentation as to when Pt 18 was removed from restraints.

Pt #19
On 06/01/12 at 12:00 PM, during the first restraint encounter for Pt 19, staff failed to document at what time the restraints were discontinued.

ED RN-QQQ and ICU RN-YYY confirmed for Pt's #18 & 19, there was no documentation to identify if the restraints had been removed at the earliest possible time.

Based on interview and review of death reporting required for patients who died while in restraint or seclusion, the hospital failed to complete the death reporting document and failed to meet the 24 hour reporting requirement for 1 of 3 (#17) deaths while in restraints. Total universe 30.

Findings include:

On 08/08/12 at 10:00 AM, during a review of the last 12 months of death reports of Pt's in restraints provided by the hospital, confirmed 1 of 3 (#17) death reports was incomplete. The date and time of report was not documented.

On 08/08/12 at 10:15 AM, CMS Region 5 representative ZZZ confirmed that CMS had received all 3 death reports and that Pt #17's report was missing question #8 (Was restraint used to manage violent or self destructive behavior? Yes or No).

CMS Region 5 representative ZZZ confirmed that this death report was faxed to CMS on 05/18/12 at 9:36 AM, 16 days after Pt #17 expired.

On 08/08/12 at 3:55 PM, A&LC-A confirmed the death report for Pt #17 was incomplete and did not meet the 24 hour reporting of any death while in restraint or seclusion.

Based on review of Pt Rights brochure and staff interview, the facility failed to inform each Pt of their right to allow or disallow visitors, or the medical staffs ability to modify the Pt's decision based on medical need. This had the potential to effect all Pt's. Daily census during this survey: 08/06/2012 = 223, 08/07 = 207, 08/08 = 214 and 08/09 = 239.
Findings include:

On 08/09/12 at 9:15 AM, during a review of the Pt rights brochure and interview with Pt Rights staff-PPP confirmed the hospital provides written Pt packet that include written Pt rights and responsibilities.

Pt Rights staff-PPP confirmed that the Pt Rights brochure does not contain information regarding the Pt's visitation rights or clinically necessary or reasonable restriction or limitation that the hospital may need to place on such rights.

Based on interviews and review of the QAPI program and list of contracted services, the hospital failed to demonstrate evidence that the QAPI program included 3 of the 25 listed contracted services (American Healthways for the Diabetic Center, Organ and Tissue Donors or Lions Eye Bank) or ProHealthCare services provided through arrangement or agreement with.

Finding include:

During an interview on 08/07/12 at 2:15 PM with DPE-D and VPMA-TTT, Surveyor asked if all contracted staff were monitored through QAPI Projects, DPE-D stated that data is collected and clinical services reports to Med-Exec Committee on an annual bases.

On 080/8/12 at 8:00 AM, A&LC-A provided a list entitled Clinical Contracted Services 2012 to Surveyors. The list included 25 contracted services who provided a service to the hospital.

During an interview on 08/09/12 at 2:40 PM with DPE-D and VPMA-TTT, Surveyor reviewed a list of contracted services and data collected to evaluate service provided to WMH for QAPI. No data collection or evaluation was done for the following services: American Healthways for the Diabetic Center, Organ and Tissue Donors or Lions Eye Bank.

VPMA-TTT and DPE-D stated that the QAPI projects focus on high priority clinical services and that not all contracted services are monitored.

WMH President- PP confirmed that WMH had not considered any services provided under arrangement or agreement by the Pro-Health Care organization to be a contracted services.

Based on interview, MR's and P&P reviews, the hospital failed to have complete CPs for 15 of 30 records reviewed, (Pt's #2, 3, 6, 9, 12, 15, 16, 17, 18, 19, 23, 24, 25, 28, & 30). Total universe 32. This deficient practice had the potential to affect all inpt's at the time of survey, 08/06/12 = 223, 08/07/12= 207, 08/08/12= 214 and 08/09/12= 239.

Findings include:

On 08/08/2012 at 8:00 AM, a review of the P&P titled "Inpatient Plan of Care" was completed. The P&P was last reviewed on 5-23-2012. The P&P stated in part, " Purpose Statement: 6. Patient Plan of Care: An age and population-specific document that includes the general plan of care, mandatory and regulatory elements, screenings and risk assessments, appropriate CPG ' s, orders, medications, diagnostic tests, assessments, and interventions. "

" Policy: 1. The Patient Plan of Care is initiated within 8 hours of admission and individualized within 24 hours. It is reviewed, revised, and updated throughout the hospital stay.
2. The patient is involved in the development of the plan of care whenever possible.
3. The Patient Plan of Care is referenced prior to initial patient encounters and documented on throughout the hospital stay by interdisciplinary care team members.
4. The Plan of Care is reviewed with the patient daily (when possible).
5. Progress toward goal/outcome achievement is documented a minimum of every worked shift in the electronic medical record (EMR). "
" Procedure:

1. Initiate at least one age and population-specific CPG based on the primary admitting medical diagnosis or human response. Additional CPG's are added throughout the hospital stay if the patient ' s medical condition or human responses significantly change from admission.
2. Individualize the Patient Plan of Care by incorporating relevant information from the Patient Profile. "


On 08/08/2012 at 3:07 PM, a review of the P&P titled "Fall, Injury Prevention Plan" was completed. The last reviewed date for the P&P was 6-14-2012. The P&P states in part, 2) Inpatient Units: d) Patients will be identified as being high risk for falls if they meet any of the following criteria:
i) A Morse Fall Risk score of 45 or greater;
ii) Have a positive history of frequent falls;
iii) The current admission is related to a fall;
iv) Have fallen during the current hospitalization.
e) For patients determined at high risk for falls, implement the following interventions as appropriate:

iii) Initiate Fall/Trauma/Injury Risk Clinical Practice Guideline.
Initiate and address appropriate individual patient interventions on patient
Plan of Care and document interventions in documentation flow sheet.

On 08/08/2012 at 3:05 PM, CI-III, explained a Morse Fall Scale was completed upon admission. If the score is 45 or greater the EMR automatically makes the Pt a High Risk for Falls and a yellow banner is posted when the record is opened. CI-III, explained a CP for falls should be initiated.

On 08/08/2012 at 10:30 AM, a review of Pt #2's MR was completed with CI-III and M Float Pool-T. Pt. #2 was admitted on 08/03/2012 and discharged on 08/07/2012. The EMR identified Pt #2 was at "High" Risk for Falls yet the CPG for Falls was not part of Pt 2's CP. This was confirmed by CI-III.

On 08/08/2012 at 2:15 PM, a review of Pt #3's MR was completed with CI-III and M Float Pool-T. Pt. #3 was admitted on 08/06/2012. The EMR shows Pt #3 was at "High" Risk for Falls yet the CPG for Falls was not part of Pt #3's CP. This was confirmed by CI-III.

On 08/09/2012 at 10:55 AM, a review of Pt #6's MR was completed with CI-III, M Float Pool-T and UE-JJJ. Pt. #6 was admitted on 08/08/2012. The EMR shows Pt #6 was at "High" Risk for Falls yet the CPG for Falls was not part of Pt #6's CP. This was confirmed by CI-III.

On 08/09/2012 at 2:30 PM review of Pt #9's MR was completed with CI III and M Float Pool-T. The EMR shows Pt #9 was admitted on 08/06/2012 with a diagnosis of diverticulitis and abdominal pain. On 08/06/2012 Pt. #9 had surgery and an umbilical hernia repair and sigmoid colon resection were performed. The nursing admission assessment does not show Pt #9 was assessed for the Pt's acceptable level of pain. The EMR shows on 08/09/2012 at 4:15 PM pain was assessed to be 2 out of 10.
The Adult Pt Care Summary completed 08/06/2012 at 2:44 PM shows Pt. #9's pain level was a 10 of 10 at rest.
At 2:50 PM at rest pain level was a 6.
At 3:00 PM pain level was a 6.
At 3:10 PM pain level was a 4.
At 3:45 PM pain level was a 7. Then Pt #9 was not assessed again until 5:03 PM and pain level remained 7.
At 5:16 PM and 5:27 PM. At 6:15 PM, Pt #9's pain level was 5.
At 8:15 PM Pt #9's pain level was 3.
The CP for Pt #9 was not individualized to the SOP for pain management and failed to identity a tolerable pain level to ensure CP compliance and ensure Pt #9's involvement with 9's CP. This was confirmed by CI-III.


The most current restraint P&P entitled "Restraint Use" (8 page policy) last reviewed and revised on 06/25/12, noted on page 2: "The use of restraints will be: In accordance with a written modification to the patient's plan of care by a physician or other licensed independent practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with Wisconsin state law."

Pt #17
On 05/02/12 at 9:20 AM, through 05/10/12, Pt 17 was restrained. The hospital staff failed to incorporate the use of restraints into Pt 17's CP.

Pt #18
On 06/01/12 at 1200 PM, Pt 18 was put into restraints. The hospital staff failed to document when Pt 18 was removed from restraints and did not incorporate the use of restraints into Pt 18's CP.

Pt #19
On 06/01/12 at 1200 PM, during the first restraint encounter for Pt 19, hospital staff failed to document the date or time Pt 19 was removed from this restraints encounter. The hospital staff failed to incorporate the use of restraints into Pt 19's CP.

On 06/18/12 at 1900 (7:00 PM) Pt 19 was placed in restraints. The use of restraints was not incorporated into Pt 19's care plan.

On 08/08/12 Pt #30 was admitted for seizures with nausea and vomiting and had a history of type II diabetes. Although a safety CP was implemented, it was not individualized specific to the seizures or seizure activity, or the the type II diabetes. This was confirmed at 1:15 PM on 08/09/12 by ED RN-QQQ.

ED RN-QQQ and ICU RN-YYY confirmed that the CPM electronic care plan system the hospital adopted to use for care planning for all hospital patients does not include the use of restraints. However, staff had the option to individualize Pt's # 17, 18 and 19's care plan, but did not.

Pt #12's MR review on 08/09/12 at 10:20 AM revealed the CP lists all potential problems and all possible interventions related to the Pt's hysterectomy and sigmoid colon resection. The individualized Pt goal was "patient will have minimal or no pain upon discharge." Notes related to the CP state "Problem: Hysterectomy Goal: prevent/Manage Potential Problems" or "Problem: General Plan of Care (Adult, Obstetrics) Goal: Plan of Care Review The patient and/or their representative will communicate an understanding of their plan of care. The template includes the following goals: (no goals listed)", and not unique to the Pt. This was confirmed in interview with CI-LLL and UE-RRR on 08/09/12 at 10:20 AM.

Pt #15's MR review on 08/07/12 at 2:30 PM revealed the CP lists all potential problems and all possible interventions related to a delivery of an infant including shoulder dystocia and malpresentation. Pt #15 did not have issues with shoulder dystocia or malpresentation during delivery. This CP was identical to Pt #23's CP and not individualized. This was confirmed in interview with CI-SSS on 08/07/12 at 2:30 PM.

Pt #16's MR review on 08/09/12 at 1:10 PM revealed the CP lists all potential problems and all possible interventions related to the Pt's Aortic Aneurysm/Dissection. It includes the only individualized Pt goals of a code name, winters in Florida and heart rate of 41 on admission. Pt #16 reported chronic pain in the shoulder upon admission. The CP states "Acceptable Pain Control/Comfort level (Acute Pain) with a goal of "Patient will demonstrate the desired outcomes." There are no interventions listed for the chronic pain or acceptable levels of pain per the Pt. The Problem for "Aortic Aneurysm/Dissection" state a goal of "Prevent/Manage Potential Problems", and not unique to the Pt. This was confirmed in interview with CI-LLL and UE-RRR on 08/09/012 at 1:10 PM.

Pt #23 MR review on 08/09/12 at 1:50 PM revealed the CP lists all potential problems and all possible interventions related to a delivery of an infant including shoulder dystocia and malpresentation. Pt #23 did not have issues with shoulder dystocia or malpresentation during delivery. This CP was identical to Pt #15's CP and not individualized. This was confirmed in interview with CI-LLL and UE-RRR on 08/09/12 at 1:50 PM.

Pt #24's MR review on 08/09/12 at 2:40 PM revealed the CP lists all potential problems and all possible interventions related interventions for a newborn. The only individualized goal was "Baby will breast feed successfully by discharge as evidenced by adequate output and acceptable weight loss." This was the same goal as for Pt #25, and not unique to the Pt. Pt #24 was circumcised on 08/08/12. The CP does not include specific goals and interventions related to the circumcision. This was confirmed in interview with CI-LLL and UE-RRR on 08/09/12 at 2:40 PM.

Pt #25's MR review on 08/09/12 at 3:15 PM revealed the CP lists all potential problems and all related interventions for a newborn. The only individualized goal was "Baby will breast feed successfully by discharge as evidenced by adequate output and acceptable weight loss." This was the same goal as for Pt #24, and not unique to the Pt. This was confirmed in interview with CI-LLL and UE-RRR on 08/09/12 at 3:15 PM.

On 08/08/12 at 1:30 PM, a review of Pt # 28 MR was completed with IA-SSS. Pt. #28 was admitted on 7/17/12. The EMR shows pt. #28 was at high risk for fall with a falls risk score of 110 per assessment completed on 08/01/12, yet the CPG for falls was not part of the plan of care. This was confirmed by IA-SSS at the time of the MR review.


22198















18816




29963

Based on observation, interview and record reviews, the MR department of the hospital failed to ensure the confidentiality of all MR or ensure the medical records were complete and comprehensive. This had the potential to effect all InPt's. Daily census during this survey: 08/06/2012 = 223, 08/07 = 207, 08/08 = 214 and 08/09 = 239.

Findings Include:

The MR department of the hospital, failed to ensure all Pt's records containing PHI were kept confidential. While on tour an observation identified MRs open storage in a shared room with bio-medical staff, and the MR administrative staff was unaware of this storage or that the contents were considered a part of a Pt's MR. (A 441)

The MR department of the hospital, failed to ensure all patient records information containing PHI was kept in a secure area. (A 442)

The MR department of the hospital, failed to ensure that 8 of 30 Pt's had complete, dated, timed, and authenticated documentation in their medical records. (A 450)

The MR department of the hospital, failed to ensure 8 of 30 Pt's had properly executed informed consents. (A 466)

The MR department of the hospital, failed to ensure for 5 of 30 Pt's, that all information necessary to monitor the patient's condition was documented in the Pt's medical record. (A 467)

The systemic failures of MR department resulted in the hospital's inability to ensure the confidentiality, security or completion of all Pt's MR's.

Based on observation and interviews the MR department of the hospital, failed to ensure all Pt's records containing PHI were kept confidential. While on tour, an observation identified MR's open storage in a shared room with bio-medical staff, and the MR administrative staff was unaware of this storage area, or that the contents were considered a part of a Pt's MR. The totality of these finding had the potential to effect every Pt receiving services at this hospital. Daily census during this survey: 08/06/2012 = 223, 08/07 = 207, 08/08 = 214 and 08/09 = 239.


Findings include:

On 08/07/12 at 9:00 AM, D HIM-NN and M HIM-OO stated the hospital maintained no hard copy MR's on-site at WMH.

D HIM-NN and M HIM-OO, told Surveyor, that if there are hard copy MR's they are sent to "River Wood" a ProHealth location, then scanned into the Pt's EMR files.

On 08/09/12 at 9:30 AM, while on tour of the LL room B955, Safety Manager M-11 confirmed room B955 was shared space for radiology MR and bio-medical storage and work.

Safety Manager M11 confirmed the MR's observed upon entrance to room B955, were on open shelves, unsecured.

On 08/09/12 at 9:35 AM, DR-VVV told Surveyor, that the radiology department was responsible for these MR's because they were radiology reports and films.

On 08/09/12 at 9:40 AM, M HIM-OO told Surveyor, that HIM was not responsible for the MR's found in room B955, because radiology films and reports are not considered a part of the MR.

M HIM-OO confirmed to Surveyor after reviewing 2 random files pulled from the radiology files, that these files did contain PHI and would be considered a part of the MR, like Pt name, MR number, diagnosis, list of radiology reports and films.

Additional MR's were identified and M HIM-OO could not identify who MR's they were. M HIM-OO stated the MR's appeared to belong to an independent physician, but never confirmed or refuted the statement.

13 Shelves of Pt MR's TNTC were also found in R 955.

Two (2) LSC Engineers were present and took measurements of the space that housed the 13 floor to ceiling open files that contained MR however, MR's were TNTC.

File area #1 measured 15 feet (ft) X 8 ft X 33 ft.

File area #2 measured 15 ft X 8 ft X 20 ft

On 08/09/12 at 11:40 AM, D HIM-NN and M HIM-OO confirmed that the hospital had other unsecured MR storage areas, prior to today (08/09/12) as Director and Manager of HIM, NN and OO were not aware of.

Based on observation and interviews, the MR department failed to ensure all patient records information containing PHI was kept in a secure area.

Findings include:

On 08/07/12 at 9:00 AM, D HIM-NN and M HIM-OO stated the hospital maintained no hard copy MR's on-site at WMH.

D HIM-NN and M HIM-OO confirmed they were not employees of WMH but ProHealth employees working at WMH.

D HIM-NN and M HIM-OO told Surveyor that if there are hard copies MR's they are sent to "River Wood" a ProHealth location, then scanned into the Pt's EHR.

On 08/09/12 at 9:30 AM, while on tour of the LL room B955, Safety Manager M 11 confirmed room B955 was shared space for radiology MR's and bio-medical storage and work.

Safety Manager M 11 confirmed the MR's observed upon entrance to room B955, were on open shelves, unsecured.

Two (2) LSC Engineers were present and took measurements of the space that housed the 13 floor to ceiling open files that contained MR TNTC.

File area #1 measured 15 feet (ft) X 8 ft X 33 ft.

File area #2 measured 15 ft X 8 ft X 20 ft

On 08/09/12 at 11:40 AM, D HIM-NN and M HIM-OO confirmed, after our 9:30 AM finding in the LL room B955, NN and OO had done an initial tour of the hospital looking for unsecured MR storage areas.

D HIM-NN and M HIM-OO confirmed that the hospital had other unsecured MR storage areas, that prior to today (08/09/12) as Director and Manager of HIM, NN and OO they were not aware of.

Based on record review and interview, the hospital failed to ensure 8 of 30 (#12, 15, 23, 24, 25, 26, 28 and 29) Pt's MR's were completed, dated and timed. Total universe was 32.

Findings include:

Pt #12's MR review on 08/09/12 at 10:20 AM revealed, the discharge instructions were not signed by the Pt to confirm receipt. This was confirmed in interview with CI-LLL and UE-RRR on 08/09/12 at 10:20 AM.

Pt #15's MR review on 08/07/12 at 2:30 PM revealed, the consent for the epidural received during labor was not timed when signed by the Pt and the CRNA. This was confirmed in interview with CI-SSS on 08/07/12 at 2:30 PM.

Pt #23's MR review on 08/09/12 at 1:50 PM revealed, the consent for the epidural received during labor was not timed when signed by the Pt and the CRNA. This was confirmed in interview with CI-LLL and UE-RRR on 08/09/12 at 1:50 PM.

Pt #24's MR review on 08/09/12 at 1:50 PM revealed, the discharge instructions were not signed by the Pt to confirm receipt. This was confirmed in interview with CI-LLL and UE-RRR on 08/09/12 at 1:50 PM.

Pt #25's MR review on 08/09/12 at 3:15 PM revealed, the discharge instructions were not signed by the Pt to confirm receipt. This was confirmed in interview with CI-LLL and UE-RRR on 08/09/12 at 3:15 PM.

On 08/08/12 at 1:30 PM, a review of Pt #28 MR was completed with IA-SSS. The consent to operation/procedure form did not allow space for the Pt to date and time the consent form when Pt #28 signed consenting to a Tracheostomy. This was confirmed by IA-SSS at the time of the MR review.

On 08/08/12 at 3:20 PM, a review of Pt #29 MR was completed with IA-SSS. The consent to operation/procedure form did not allow space for the Pt to date and time the form when Pt #29 signed consenting to a Cystoscopy. This was confirmed by IA-SSS at the time of the MR review.

On 08/08/12 at 10:15 AM, a review of Pt. #26 MR was completed with IA-SSS and ED RN- QQQ. The consent to operation/procedure form did not allow space for the Pt to date and time the form when Pt #26 signed consenting for a Pacemaker Lead Revision. This was confirmed by IA-SSS and ED RN-QQQ at the time of the MR review.




29963

Based on MR review and staff interviews, the hospital failed to ensure 8 of 30 (#4, 5, 9, 12, 16, 26, 28 and 29) informed consents were appropriately executed, when it failed to obtain the time and date of the Pt's signature. Total universe 32.

Findings include:

On 08/09/2012 at 7:45 AM, a review of the EMR for Pt #4 was completed with M-Float Pool-T, CI-III and UE-JJJ. Pt. #4's signature on the surgical consent for 08/03/2012 was not dated or timed.

On 08/09/2012 at 9:17 AM, a review of the EMR for Pt #5 was completed with M-Float Pool-T, CI-III and UE-JJJ. Pt. #5's signature on the surgical consent for 08/06/2012 was not dated or timed.

On 08/09/2012 at 2:30 PM, a review of the EMR for Pt #9 was completed with M-Float Pool-T, CI-III and UE-JJJ. Pt. #9's signature on the surgical consent for 08/06/2012 was not dated or timed.

Pt #12's MR review on 08/09/12 at 10:20 AM, revealed there was no consent for anesthesia for a hysterectomy performed on 08/01/12. This was confirmed in interview with CI-LLL and EU-RRR on 08/09/12 at 10:20 AM.

Pt #16's MR review on 08/09/12 at 1:10 PM, revealed there was no consent for anesthesia for a endovascular Abdominal Aortic aneurysm performed on 08/08/12. This was confirmed in interview with CI-LLL and EU-RRR on 08/09/12 at 1:10 PM.

On 08/08/12 at 1:30 PM, a review of Pt #28 MR was completed with IA-SSS. The consent to operation/procedure form does not allow space for the Pt to date and time the form when Pt #28 signed consenting to a Tracheostomy. This was confirmed by IA-SSS at the time of the MR review.

On 08/08/12 at 3:20 PM, a review of Pt #29 MR was completed with IA-SSS. The consent to operation/procedure form does not allow space for the Pt to date and time the form when Pt #29 signed consenting to a Cystoscopy. This was confirmed by IA-SSS at the time of the MR review.

On 08/08/12 at 10:15 AM, a review of Pt #26 MR was completed with IA-SSS and ED RN- QQQ. The consent to operation/procedure form does not allow space for the Pt to date and time the form when Pt #26 signed consenting to a Pacemaker Lead Revision. This was confirmed by IA-SSS and ED RN- QQQ at the time of the MR review.






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29963

22198

Based on interviews and MR and P&P reviews, the hospital failed to ensure contained orders and other notes necessary to identify 5 of 30 (#12, 18, 19, 24 and 25) Pt's conditions. Total universe 32.

Findings include:

On 08/08/12 between 9:00 AM and 10:45 AM, EMR's were reviewed for Pt's 18 and 19 with ED RN-QQQ and ICU RN-YYY, and the following was identified and confirmed:

The most current restraint P&P entitled "Restraint Use" (8 page policy) last reviewed and revised on 06/25/12, noted on page 2: "The use of restraints will be: In accordance with a written modification to the patient's plan of care by a physician or other licensed independent practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with Wisconsin state law." "The use of restraints or seclusion will be: Discontinued the earliest possible time, regardless of the length of time identified in the order."

Pt #18
On 06/01/12 at 12:00 PM, Pt #18 was placed in restraints but no documentation was found as to when Pt 18 was removed from restraints.

Pt #19
On 06/01/12 at 1200 PM, during the first restraint encounter for Pt 19, no order was obtained from a physician or LIP authorized by the hospital and state licensure to order restraints.

Nursing staff failed to document at what time the restraints were discontinued.

Nursing staff failed to document if the hospital staff had attempted any lesser restrictive measures prior to placing Pt 19 in restraints.

Nursing staff failed to document if any lesser restrictive measures (like: 1:1's or redirection) were attempted prior to placing Pt 19 in restraints.

The physician or other designated staff failed to document the face to face evaluation required after placing a Pt in restraints

Pt #12's MR review on 08/09/12 at 10:20 AM revealed the flowsheet indicates Pt #12 reported pain on 08/01/12 at 1:45 PM, there was no documented intervention or follow up on response. On 08/03/12 at 6:51 AM, Pt #12 reported pain, medication was given via PCA, but there was no documented follow up on pain relief. At 2:10 PM, Pt #12 reported a pain level of 4 out of 10, medications were given via PCA, there is no documented follow up on pain relief. On 08/04/12 at 1:30 PM, the flowsheet indicated Pt #12 reported pain, medication was provided, there was no follow up on pain relief. At 4:00 PM, the Pt reported pain, and medication was provided, but there was no documented follow up on pain relief. This was confirmed in interview with CI-LLL and UE-RRR on 08/09/12 at 10:20 AM.

Facility P&P received on 08/09/12 titled "Care of Newborn-Admission, Assessment, Reassessment, Discharged", last reviewed 06/14/12 stated under#14 "Feeding/Output...b) Assess observe newborn breast feeding at a minimum twice daily."

Pt #24's MR review on 08/09/12 at 2:40 PM revealed there is no breastfeeding latch score from date of admission on 08/07/12 to 8/9/12 at 2:33 AM, rather than twice daily minimum per policy. This was confirmed in interview with CI-LLL and UE-RRR on 08/09/12 at 2:40 PM, adding the latch score should be done at least twice daily.

Pt #25's MR review on 08/09/12 at 3:15 PM revealed there was no breastfeeding latch score between 12 noon on 08/07/12 and 12 midnight on 8/8/12, rather than twice daily minimum per policy. This was confirmed in interview with CI-LLL and UE-RRR on 08/09/12 at 3:15 PM, adding the latch score should be done at least twice daily.

Based on tour, review of P&P and staff interviews the hospital failed to ensure IV medications are stored and prepared per policy in 3 of 11 (Surgery, OutPt and Nursing) service areas.

Findings include:

Facility policy provided on 08/09/12, titled Medication Dispensing, Preparation and Administration effective date 09/28/11 and last reviewed 08/08/12 states under #12. "IV solution bags that were removed from the protective outer wrap (if present) but not spiked must be labeled with expiration date of 30 days from the date they were removed from their protective outer wrap. 13. Any unused medication, IV solution or tube feeding bag with a broken seal (i.e. spiked) should be discarded 24 hours after preparation if not administered during that time. If th expiration date of the product is less than 24 hours, the expiration labeling should be followed and the product discarded when the expiration date is reached."

Surgery
Per tour of the Surgery Department on 08/09/12 at 8:00 AM with ND-L there were four spiked IV bags of sodium chloride dated 08/08/12 with an expiration date of 08/12/12, rather than the 24 hours timeframe defined in P&P.

OutPt
Per tour of the Cath Lab on 08/09/12 between 8:10 AM and 9:00 AM, ND-L, DC-Y and Surveyor observed the following:

The medication cart in room 1558 had an IV bag of lidocaine out of the original packaging with no date.

Nursing
On 08/06/12 at 1:50 PM, in the ICU, a drawer filled with 4 syringes of Labetalol 5 mg/ml were found. However, the Pt this medication had been labeled and assigned to, had expired the day before (08/05/12) at 10:30 PM, and the staff failed to return these unsecured medications to the Pharmacy.

A bag of 10% Dextrose 1000 ml was removed from its original packaging and was not labeled. M ICU-H, D ICU-XXX and ICU RN-YYY did not know the open IV fluid would expire 30 day expiration once out of its original packaging.

Based on tours and interview with staff, in (4) of (4) tours, the hospital failed to ensure all medications were not accessible to unauthorized visitors or staff. This deficiency potentially affects all Pt's treated at the facility during this 4 day survey. Daily census: 08/06/2012 = 223, 08/07/2012 = 207, 08/08/2012 = 214 and 08/09/2012 = 239.


Findings include:

Per tour of the Surgery Department on 08/08/12 between 10:15 AM and 11:00 AM with ND-L and SM-UU the following was observed:

The crash cart had a breakaway lock and was not in constant view of surgical staff or in a locked room to prevent unauthorized access.

Per tour of the GI Lab on 08/08/12 between 2:30 PM and 3:30 PM with ND-L and MOGI-GGG the following was observed:

The crash cart had a breakaway lock and was not in constant view of hospital staff or locked room to prevent unauthorized access.

Per tour of the Cath Lab on 08/09/12 between 8:10 AM and 9:00 PM with ND-L and DC-Y the following was observed:

There was a medication refrigerator that contained medications that was unsecured in the clean supply room.

The medication cart in room 1558 had an IV bag of lidocaine out of the original packaging and was not dated to show the 30 day expiration once removed from the original packaging.

The crash cart had a breakaway lock and was not in constant view of hospital staff or locked room to prevent unauthorized access.

Per tour of the OB OR on 08/09/12 at 9:00 AM with ND-L and M OB-BB the following was observed:

The crash cart had a breakaway lock and was not in constant view of hospital staff or locked room to prevent unauthorized access.

Based on observations, staff interviews and review of P&P, the facility failed to prepare and serve food under sanitary conditions. The totality of the following concerns has the potential to affect 214 in-pts on 8/8/12

· Food was exposed to splash from a hand washing sink.
· Several trays ready for room service were wet.
· Non-food safe chemical was used to sanitize the probe of a food thermometer.
· Garbage receptacle that was not in use was not covered.
· Numerous food items in the servery outdated or not dated.
· Dirty equipment and floor in the servery.
· Food items without labels in the main kitchen ' s cooler and reach-in cooler.
· Staff recontaminating hands by wiping down hand sink after washing hands


Findings include:

CROSS-CONTAMINATION/DIRTY EQUIPMENT/
According to the 2009 FDA Food Code, food items and equipment must be properly stored to prevent transmission of foodborne pathogens or contamination. Equipment food-contact surfaces and utensils shall be clean to sight and touch and nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris. Single-service and single-use articles are also to be stored in a clean, dry location, where they are not exposed to splash, dust, or other contamination; and at least 6 inches above the floor.

On 08/08/12 at 8:13 AM, Surveyor observed in the main kitchen, a pan of muffins and caddy of condiments stored on top of a stainless steel table butted up next to hand washing sink. There was evidence of splash based on water on the table top. This was verified by DM-BBB and RSM-CCCC.

On 08/08/12 at 9:06 AM, in the main kitchen, Surveyor observed several wet room service trays that were ready to be used and send on to Pt rooms. RSM-CCCC validated this observation and removed the stack of trays from service.

On 08/08/12 at 9:12 AM and 9:43 AM, in the main kitchen, Surveyor observed Cook-EEE use "PDI Sani Hands ALC Antimicrobial Alcohol Gel Hand Wipes" to clean the probe of the thermometer prior to taking the temperature of the sausage (9:12 AM) and the gravy (9:43 AM). At 9:51 AM, RSM-CCCC stated to Surveyor, CCC called the manufacturer of the hand wipes who confirmed the wipes are not food safe. The contaminated food was disposed of, but this has been the practice of Cook-EEE to wipe down the probes of the thermometer prior to taking temperatures of food.

On 08/09/12 Surveyor was given a P&P, title: "General Sanitation", #Si-310, revised date 08/09/2012, upon review of the P&P at 3:40 PM, Surveyor noted this P&P was revised during the survey period (08/09/2012). Prior to this date, the last effective date was documented as 06/24/92.

On 08/08/12 at 1:08 PM - 2:10 PM, Surveyor toured the servery and made the following observations: The side of freezer had a build-up of white substance; the counter next to ice machine had baskets with uncovered plastic ware; the floor under ice machine and all the way to the right was covered with dirt the color of rust; the top of the knife holder containing 8 dirty knives that were dusty and sticky; two shelves next to sink were dirty and dusty with some type of crumbs scattered throughout; the top of a box containing M&Ms candy was dusty and stored on a bottom shelf right above a live steel mouse trap that had visible debris and dirt build up; the tiles above cooler/freezer had an unknown substance splattered over them; bread baskets with napkin inside were dusty and dirty with crumbs; the dish machine had a dirty build-up of white hard substance on doors, the sink connected to dish machine had a rag hanging over part of the machine, the rinse max and power activator was dirty and dusty; a glass bowl containing a white substance was covered with plastic however, was not labeled or dated; 26 portable coffee canisters from a function earlier in the day, were left as cleaned for the the following day (08/09/12) however, they contained coffee and fluid.

According to DM-BBB, the employee assigned to the servery had left for the day; two coolers located on the same wall down from the dish machines had two roll-in carts with very dirty edges that hold trays of food; a large box containing 40x25 foam cups stored directly on floor next to garbage; 13 baskets of coffee condiments containing straws, creamers, and sugars; two Cambro caddies containing creamers - some of the creamers were open and dripping onto unopened creamers, paper napkins not covered; in the room next to the servery, that held the steam table were shelving cabinets that were dirty and dusty.

On top of the steam table were single use items not covered; a waffle maker had a build-up of grease and remains of dried batter; a cabinet under microwave had a shelf with a large sticky area; inside of microwave was dirty; a 3-tiered basket containing single-use plastic ware not covered; a toaster was dirty with crumbs, an employee's hat and apron were stored on top of soda cooler. Surveyor's observations were verified by CM-BBB.

FOOD STORED AND PREPARED IN A SAFE MANNER
According to the 2009 Federal Food Code, 3-501.17 Ready-to-Eat, Potentially Hazardous Food, (Time/Temperature Control for Safety Food), Date Marking. "(A) ... READY-TO-EAT, POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold or discarded when held at a temperature of 5oC (41oF) or less for a maximum of 7 days."

According to the USDA-FSIS, there are different methods of food dating to assure a product is safe, wholesome and of good quality. The FDA Food Code states food is also to be stored in packages, covered containers, or wrappings.

On 08/08/12 at 8:26 AM, in the main kitchen's cooler, Surveyor observed absence of labels/dates on 10 trays of what DM-BBB stated were pizzas and which DM-BBB verified there should be labels.

On 08/08/12 at 8:54 AM, in the main kitchen, Surveyor observed absence of covers for 5 trays of desserts found in reach-in cooler #57. RSM-CCCC validated Surveyor's observation.

On 08/08/12, 1:08 PM - 2:10 PM, Surveyor toured the servery and made the following observations: moldy sliced American cheese; Items that were outdated or incorrectly dated were: raisins (5/12/12), sour cream (7/16/12), provolone cheese (8/2), Swiss cheese (7/13), jug of salsa (7/16), sliced roast beef with a "future" date of 8/17, 8 granola bars (1/29/2012), 9 packages (each containing one dozen) of flour tortillas (4/16/2012); 12 oz. Log Cabin Syrup (9/16/2009), one gallon of Log Cabin Syrup (11/9/2010). Two black square bowls, no label or date, one with what appears to be brown sugar with a torn slice of bread on top of the sugar and then sealed with plastic wrap, and the other bowl with what appears to be raisins with a torn slice of bread lying on top of raisins; outside bag of imitation bacon bits is dirty with multiple areas of a sticky substance; 1/3 of a 32 ounce bag of powder sugar that was not tightly sealed; Surveyor's observations were verified by DM-BBB.


On 08/08/12 at 3:30 PM, Surveyor's review of facility's P&P "Food Code Dating and Safe To Use Time Line," Policy #Si-302, Revised Date 02-12-09, states "Product will be labeled to expire 3 days from today's date (Marked as a "Use By" date).

COVERING RECEPTACLES
According to the 2009 Food and Drug Administration Food Code, Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered: (A) Inside the FOOD ESTABLISHMENT if the receptacles and units: (1) Contain FOOD residue and are not in continuous use; or (2) After they are filled;

On 08/08/12 at 1:20 PM, in the servery, Surveyor observed a large garbage pail without a cover and the lid was on the floor behind it. The was validated by Safety Manager M11.

HAND HYGIENE
On 08/08/12 a at 3:15 PM, Surveyor's review of facility's P&P "Hand Hygiene", last reviewed 05/24/2012, procedures' #5, 6, and 7, respectively state dry (hands) thoroughly with paper towel, use a clean paper towel to turn off faucet if not foot or knee controlled, discard towels into trash.

On 08/08/12 at 9:26 AM, Surveyor observed Cook-DDD recontaminate her hands by wiping down the hand washing sink after first washing her hands. This was confirmed by cook DDD and RSM CCCC.

On 08/08/12 at 9:36 AM, Surveyor observed FSW-CCC wipe down the hand washing sink after first washing her hands. This was confirmed by FSW- CCC and RSM-CCC.

A standard Recertification Survey for Life Safety Code compliance was conducted by the Wisconsin Division of Quality Assurance on 08/09/2012. The Waukesha Memorial Hospital was found to be NOT in compliance with the following applicable regulations for hospital participation in Medicare-Medicaid:

42 CFR 482.41 Condition of Participation: Physical Environment was NOT MET
42 CFR 482.41(b) Standard: Safety from Fire was NOT MET
NFPA 101- Life Safety Code was NOT MET.

The Waukesha Memorial Hospital was a 5-story structure initially built in 1930, with Type I (332) non-combustible construction. Healthcare additions were constructed in 1948, 1958, 1964, 1965, 1966, 1968, 1978, 1979, 1986, 1990, 1991, 1994, 1996, 1999, 2003, 2009, with the same construction type.

The building also had a Professional Office Building that is attached to the health care occupancy and was surveyed. It was separated with 2-hour fire-rated construction. All portions of the facility were sprinkled. The facility has several emergency generators that provided power to the emergency loads.

The facility contained 6 multi-story patient care wings and 80 smoke compartments in the hospital portion.

The health care organization had 8 off-site satellite clinics of which only 3 were surveyed.

Waukesha Memorial Hospital is licensed for 400 beds, with a census of 320 inpatients at the time of the survey. The facility was surveyed under the 2000 Life Safety Code, Chapter 19 for an existing health care occupancy. Thirty nine (39) Federal deficiencies of the Life Safety Code were cited.

The cumulative effect of these deficiencies has the potential to affect the safety of all patients receiving services at the hospital.

K11: Unreliable separation from a non-healthcare occupancy
K12: Class of Construction did not meet non-combustible standards of a Type II(protected)
K14: Interior finishes without flame spread ratings.
K17: Smoke tight corridor not maintained.
K18: Positive latching and smoke tight openings into the corridor.
K20: Vertical shafts were not constructed to the proper hourly rating.
K21: Rating doors on hold-open without automatic closing capabilities via a local interconnected smoke detector.
K22: Access to exits without readily visible signs.
K25: Smoke Compartment walls were not smoke tight w/ ratings.
K27: Smoke barrier doors were not smoke tight.
K29: Reliable enclosure of hazardous areas was lacking at locations through out the building.
K32: Exit were not provided or properly remote from each other.
K33: Exit enclosure is open to an unoccupied space.
K34: Stairways were not reliably enclosed or protected.
K35: Capacity of exits was exceeded.
K36: Travel distances exceeded code minimums.
K38: Access to exits was not accessible due to a dead-end.
K42: Suite configuration not at code minimums.
K43: Delayed egress door locking devices without proper identification.
K47: Lacking exit directional siganage.
K51: Fire alarm strobes were not installed in all common areas.
K54: Detectors were missing for hold-open devices.
K56: Sprinkler system was not compliant to NFPA 13 minimum standards.
K61: Sprinkler valves were unsupervised.
K62. Sprinkler system was not properly maintained.
K64: Portable fire extinguishers were not properly distributed.
K67: The HVAC system did not meet the minimum standards on NFPA 90A.
K69: Kitchen was not properly protected per NFPA 96.
K74: Loosely handing fabrics lacked treatment.
K75: Proper storage and handling of rubbish and soiled materials.
K76: Medical gas storage was not protected per NFPA 99.
K77: Piped medical gas and valves was not installed properly.
K103: Interior partitions were constructed of combustible materials.
K130: Miscellaneous provisions not found in other K-tags.
K133: Fume hoods were not in accordance with NFPA 99.
K144: Generators were not inspected or tested in accordance with NFPA 110.
K147: Electrical system not to NFPA 70 minimum standards.
K160: Existing elevators were not in accordance with ANSI A17.3
K161: Existing dumbwaiters were not in accordance with ANSI A17.3

Please refer to the full description and findings within the specific K-tag deficiencies within the appropriate building found later in this report.

_________________________

Based on observation, staff interviews and review of maintenance records, the facility did not maintain the condition of the physical plant and overall hospital environment in a manner to ensure the safety and well being of patients. The facility did not have ceilings free of damage. This deficiency could affect 1 of the 80 smoke compartment of the facility, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 08/07/2012 at 11:30 am surveyors observed on the Sub-Basement level floor in the Food Service storage room number SB56, that a portion of the ceiling was damaged and in need of repair. This observed situation was not compliant with 42 CFR 482.41(a). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Enginering, LLC).

______________________________________


18107

Based on observation, staff interviews and review of maintenance records, the facility did not maintain the condition of the physical plant and overall hospital environment in a manner to ensure the safety and well being of all Pt's. The facility did not have complete emergency plans, and floors free of damage. This deficiency could affect all Pt ' s and an undetermined number of staff and visitors. Daily census during this survey: 08/06/2012 = 223, 08/07/2012 = 207, 08/08/2012 = 214 and 08/09/2012 = 239.

Findings include:

Emergency Response Plan:
On 08/07/2012 at 10:24 am Surveyor #18107 observed that the facility did not develop and implement a comprehensive emergency response plan to ensure that the safety and well being of patients are assured during likely emergency situations. The interim life safety plans submitted to this DQA-Office of Plan Review and Inspection were observed not followed. Surveyor #18107 observed two different fire partitions left open for at least several minutes while construction workers moved between these spaces at Corridor in smoke compartment 2-C-2, allowing spaces not to be contained in the event of a fire emergency and not in conformance with hospital infection control policies (ICP) and interim life safety measures (ILSM) for construction areas adjacent to patients. A copy of the ILSM file should always be ready available on-site for review in an emergency. This observed situation was not compliant with 42 CFR 482.41(a). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).

Environmental Maintenance:
On 08/07/2012 at 11:30 am surveyor #18107 observed on the Level 1 floor in the Room 1028B, that a portion of the flooring was damaged and in need of repair. The flooring in the Housekeeping Closet was damaged and broken near the floor sink. The Annual PM Report should have discovered this in the last several years, but no identification was placed in the Annual Report. This damage renders this surface porous and non-cleanable. This observed situation was not compliant with 42 CFR 482.41(a). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).

On 08/06/12 during a tour at 10:30 AM, leaking pipes were found under the sink in Radiology/Oncology clinic, confirmed by MCC-G

On 08/07/2012 at 11:30 AM, Surveyors #29942, #12187 and #27230 observed on the Sub-Basement level floor in the Food Service storage room number SB56, that a portion of the ceiling was damaged and in need of repair. This observed situation was not compliant with 42 CFR 482.41(a). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Engineering, LLC).

On 08/06/2012 at 2:07 PM during a tour of the unit 4 South West M RN-HH, ND-L, and D of Care Management-M confirmed, the housekeeping room #4118D had food crumbs, dirt and debris on the floor, peeling paint on the wall, and bandage scissors on the floor.

Equipment/Machines:
On 08/06/12 during a tour at 10:30 AM, and ice machine had white crusty flaking material in the tray and around the spout where ice was dispensed in the Pt waiting area of the Radiology/Oncology clinic, confirmed by MCC-G

On 08/06/12 at 11:15 AM the air intake vent in the InPt BH unit was dusty.
OutPt BH kitchenette area was dirty, the microwave was dirty inside and out, the toaster was dusty where the slices of bread would enter the toaster with debris inside and under the toaster. The refrigerator contained unlabeled/not dated food, confirmed by BH M ' s JJ and KK

On 08/06/12 at 1:20 PM, in the ICU room #1615, identified as a negative pressure room, had a damaged floor tile with visible dirt build up.

On 08/06/2012 at 1:20 PM during a tour of the unit 4 North West, M RN-FF, ND-L, and D of Care Management-M confirmed, the nutrition room had a build up of dust on the cabinet doors above the microwave. The housekeeping room #4749 had a dust covered air vent.
Sterile supplies package integrity:
On 08/06/12 identified on tour from 10:30 AM to 2:40 PM, in the ICU, 6 rubber banded #11 blades and 2 rubber banded #10 blades compromising the sterility of the package.

On 08/06/12 at 1:20 PM, M ICU-H and CNS YYY confirmed sterile packages should not be rubber banded because it compromised the package integrity.

On 08/06/2012 at 2:30 PM, during a tour of the unit 5 North West M RN-II, ND-L, and D of Care Management-M confirmed, the nutrition center next to the second Nursing Information Center, contained a microwave oven used for Pt food had peeling paint on the inside top of the microwave oven. The water/ice machine #38475 had raised grey matter on and near the dispensing spout, and the refrigerator #38479 used to store Pt food and drinks had a large amount red fluid on the bottom shelf.

Security/Safety:
Per tour of the Surgery Department on 08/09/12 between 10:15 AM and 11:00 AM with ND-L and SM-UU the following was observed:

Ante rooms by room 1643, between OR 14 and 16, and between OR 1 and 2 have formalin with no spill kits. Per interview with EVS-VV on 08/09/12 at 8:40 AM, he expects formalin spill kits to be in each ante room.

Per tour of the OB OR on 08/09/12 at 9:00 AM with ND L and OB M BB the following was observed:

Formalin was stored in the soiled room; there was no formalin spill kit in the OB OR.

On 08/08/12 at 2:35 PM, a tour and observation of a loading dock, identified, the loading dock entered into a large storage room.

Surveyor observed unsecured filled red biohazardous containers stacked on shelved to the left of the large receiving doors.

To the right of the receiving door were additional shelves containing unsecured filled biohazardous containers. 3 unsecured uncovered bins contained biohazardous waste.

An unsecured yellow bag identified containing chemo-therapy (radio-active waste materials) sitting on top of 1 of 15 (95 gallon) paper recyclable bins.

Cleaning chemicals were unsecured in the main large room.

A small room with a door, attached to the large room contained the bulk of the cleaning chemicals; however the door was not closed or secured.

Additional unsecured hazardous materials were identified on tour from 08/06/12 - 08/07/12 in:

The Cancer Center, cleaning chemicals were stored on the counter and an Alde Hyde spill kit was in an unlocked cabinet under the sink in a Pt care area of.

The Radiology/Oncology clinic, room #925F was unlocked and contained enzymatic cleaners.

The diabetic education department, had unsecured STERIS germicidal chemicals in a Pt treatment room. The used germicidal cleaning buckets and brushes were stored in a file cabinet on top of Pt education materials.

The laboratory department, in a common hallway had numerous (TMTC) used slides with specimens stored in an alcove area unsecured. Room B 74B, a biohazardous room contained 5 biohazardous bins that were uncovered.

On 08/06/2012 at 10:45 AM during a tour of the unit 2 North West M RN-DD, ND-L, and Director of Care Management-M confirmed the housekeeping closet #2773, was unlocked with a large biohazard container with biohazard material inside, not covered. In addition, two small, full biohazard containers were also observed.

On 08/06/2012 at 1:20 PM during a tour of the unit 4 North West, M RN-FF, ND-L, and D of Care Management-M confirmed, the soiled utility room #4732 was unlocked and contained a large biohazard bin on the floor and a small biohazard bin on the wall.

On 08/06/2012 at 2:07 PM during a tour of the unit 4 South West M RN-HH, ND-L, and D of Care Management-M confirmed, the closet #4118C was unlocked and contained a large biohazard container, not covered with biohazard contents. The housekeeping room #4118D was had food crumbs, dirt and debri on the floor, peeling paint on the wall, and bandage scissors on the floor.

On 08/06/2012 at 2:30 PM, during a tour of the unit 5 North West M RN-II, ND-L, and D of Care Management-M confirmed, the trash room #5743 was unlocked and contained a large biohazard container with biohazard contents.

On 08/06/2012 at 2:45 PM during a tour of the unit 5 South West, M RN-II, ND-L, and Director of Care Management-M confirmed that room #5118C was unlocked and contained a large biohazard container with biohazard contents.




18816






26390






22198

A standard Recertification Survey for Life Safety Code compliance was conducted by the Wisconsin Division of Quality Assurance on 08/09/2012. The Waukesha Memorial Hospital was found to be NOT in compliance with the following applicable regulations for hospital participation in Medicare-Medicaid:

42 CFR 482.41 Condition of Participation: Physical Environment was NOT MET
42 CFR 482.41(b) Standard: Safety from Fire was NOT MET
NFPA 101- Life Safety Code was NOT MET.

The Waukesha Memorial Hospital was a 5-story structure initially built in 1930, with Type I (332) non-combustible construction. Healthcare additions were constructed in 1948, 1958, 1964, 1965, 1966, 1968, 1978, 1979, 1986, 1990, 1991, 1994, 1996, 1999, 2003, 2009, with the same construction type.

The building also had a Professional Office Building that is attached to the health care occupancy and was surveyed. It was separated with 2-hour fire-rated construction. All portions of the facility were sprinkled. The facility has several emergency generators that provided power to the emergency loads.

The facility contained 6 multi-story patient care wings and 80 smoke compartments in the hospital portion.

The health care organization had 8 off-site satellite clinics of which only 3 were surveyed.

Waukesha Memorial Hospital is licensed for 400 beds, with a census of 320 inpatients at the time of the survey. The facility was surveyed under the 2000 Life Safety Code, Chapter 19 for an existing health care occupancy. Thirty nine (39) Federal deficiencies of the Life Safety Code were cited.

The cumulative effect of these deficiencies has the potential to affect the safety of all patients receiving services at the hospital.

K11: Unreliable separation from a non-healthcare occupancy
K12: Class of Construction did not meet non-combustible standards of a Type II(protected)
K14: Interior finishes without flame spread ratings.
K17: Smoke tight corridor not maintained.
K18: Positive latching and smoke tight openings into the corridor.
K20: Vertical shafts were not constructed to the proper hourly rating.
K21: Rating doors on hold-open without automatic closing capabilities via a local interconnected smoke detector.
K22: Access to exits without readily visible signs.
K25: Smoke Compartment walls were not smoke tight w/ ratings.
K27: Smoke barrier doors were not smoke tight.
K29: Reliable enclosure of hazardous areas was lacking at locations through out the building.
K32: Exit were not provided or properly remote from each other.
K33: Exit enclosure is open to an unoccupied space.
K34: Stairways were not reliably enclosed or protected.
K35: Capacity of exits was exceeded.
K36: Travel distances exceeded code minimums.
K38: Access to exits was not accessible due to a dead-end.
K42: Suite configuration not at code minimums.
K43: Delayed egress door locking devices without proper identification.
K47: Lacking exit directional siganage.
K51: Fire alarm strobes were not installed in all common areas.
K54: Detectors were missing for hold-open devices.
K56: Sprinkler system was not compliant to NFPA 13 minimum standards.
K61: Sprinkler valves were unsupervised.
K62. Sprinkler system was not properly maintained.
K64: Portable fire extinguishers were not properly distributed.
K67: The HVAC system did not meet the minimum standards on NFPA 90A.
K69: Kitchen was not properly protected per NFPA 96.
K74: Loosely handing fabrics lacked treatment.
K75: Proper storage and handling of rubbish and soiled materials.
K76: Medical gas storage was not protected per NFPA 99.
K77: Piped medical gas and valves was not installed properly.
K103: Interior partitions were constructed of combustible materials.
K130: Miscellaneous provisions not found in other K-tags.
K133: Fume hoods were not in accordance with NFPA 99.
K144: Generators were not inspected or tested in accordance with NFPA 110.
K147: Electrical system not to NFPA 70 minimum standards.
K160: Existing elevators were not in accordance with ANSI A17.3
K161: Existing dumbwaiters were not in accordance with ANSI A17.3

Please refer to the full description and findings within the specific K-tag deficiencies within the appropriate building found later in this report.

_________________________

Based on observation, staff interviews and review of maintenance records, the facility did not provide a building that was designed and maintained in accordance with Federal, State and local laws, regulations and guidelines. The facility did not have a building that complied with state regulations that were in effect when the space was built. This deficiency could affect 320 of the 400 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 08/07/2012 at 6:06 pm surveyor #18107 observed that during a review of facility documents the facility failed to install a system that was designed and maintained in accordance with federal, state and local laws that were in effect at the time of construction. The Hyperbaric Chamber layout did not allow proper egress from the Room when the Patient Retrieving Cart is placed and anchored to the end of the Chamber. Metal cabinets were placed near the foot of the Chamber preventing required egress in the event of an emergency situation. This observed situation was not compliant with 42 CFR 482.41(c). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor), staff M6 (Maintenance Mechanic) and staff M2 (Manager of Facilities).

______________________________________

Based on observation, staff interviews and review of maintenance records, the hospital failed to construct, install and maintain a proper ventilation and temperature control system in pharmaceutical, food preparation, soiled linen room and other hospital areas. The facility did not have and a ventilation system that was installed and maintained in accordance with state regulations and manufacturer recommendations. This deficiency could affect 22 of the 80 smoke compartments and could affect all the Pt ' s this hospital is licensed to serve, as well as an undetermined number of staff and visitors.
Finding Include:
The CDC guidelines can be found in the website

1. On 08/07/2012 at 11:40 AM, Surveyor #13960 observed on the 2nd floor in soiled linen closet 2364, the room contained no exhaust ventilation. The ceiling contained a light fixture however, had no exhaust outlet, louver, or grill. Additionally, no air movement was confirmed between the space and the ceiling. The 2006 Guidelines for Design and Construction of Health Care Facilities requires soiled linen rooms to have a negative pressure with relationship to other zones. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M8 (Plant Mechanic).
2. On 08/08/2012 at 3:30 PM, Surveyor #13960 observed in OR room #1 (rm 3193), one of two low return air grills were obstructed by a moveable cart located directly in front of the grill. OR room #2 (rm 3191), had one of two low return air grills obstructed by a moveable cart located directly in front of the grill. These carts are circumventing the intended air flow for this surgical procedural room. The 2006 Guidelines for Design and Construction of Health Care Facilities requires operating rooms to have an adequate low return and high supply to provide a clean sterile air flow over the patient surgical zone. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities).
3. On 08/08/2012 at 3:40 PM, Surveyor #13960 observed that the construction zones North of corridor 2000F, exhausted air directly to the egress corridor. The air is filtered prior to being introduced into the egress corridor however, the fans run independently of the facility's fire alarm system. If a fire were to be initiated within the construction zone products of combustion would be directly fed into the adjoining egress corridor, rendering a vital East-West corridor untenable. The 2006 Guidelines for Design and Construction of Health Care Facilities requires corridors to be protected from adjoining spaces and protected with fans on shut down should detection be positive for smoke or other contaminants from fire. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M8 (Maintenance Mechanic).
4. On 08/07/2012 at 10:00 AM, Surveyors observed on the Level-5 floor on the roof, that the hospital staff were unable to validate the ventilation to the space was compliant with accepted standards. The deficiency included the air intake inlet for air-handling machine # 651-A3 (that serves the former PT area) was located less than 25 feeet away from a roof drain that had mold growing around it. This observed situation was not compliant with 42 CFR 482.41(c)(4). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Engineering, LLC).
5. On 08/07/2012 at 10:0015 AM, Surveyors observed on the Level-5 floor on the roof, that the hospital staff were unable to validate the ventilation to the space was compliant with accepted standards. The deficiency included the air intake inlet for air-handling machine # 651-A4 (that serves the former behavior health, and now is the med/surg area) had the fresh air intake louver in the closed position. In addition, the air intake was less than 10 feet from a plumbing vent. This observed situation was not compliant with 42 CFR 482.41(c)(4). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Engineering, LLC).6. On 08/08/2012 at 9:50 AM, Surveyors observed on the Sub-Basement level floor, in the Boiler room SB146D, that hospital staff were unable to validate the ventilation to the space was compliant with accepted standards. The deficiency included air handling machine number 371-A1SF located inside the boiler room feeding air to the OR. Clean pre-filters were stored by side of the air handling machine inside the dirty boiler room. The facility did not indicate how the filters could be loaded into the air handler without becoming dirty. This observed situation was not compliant with 42 CFR 482.41(c)(4). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M10 (Principal, Pearson Engineering, LLC), and staff M11 (Safety Officer).
This deficient practice had a potential of contaminating air in clean spaces with undesirable contaminants, and causing possible infection for all patients (daily census: 08/06/2012 = 223, 08/07/2012 = 207, 08/08/2012 = 214 and 08/09/2012 = 239) and an undisclosed number of staff and visitors.
7. On 08/06/2012 at 1:21 PM surveyor observed on the Level-4 floor in the House Keeping room number 4064A, that there was no airflow in this room. The room did not have supply air diffuser or return air grill. Since this is a dirty area, ventilation is required. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1, section 9.2, and NFPA 90A (1999 edition), 2-3.11.1. . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).


7.

Based on observation, review of P&P, staff interviews, the facility failed to ensure the hospital monitored and maintained a sanitary environment. This deficient practice could potentially affect all Pt's and an undisclosed number of staff and visitors at the time of survey. Daily census: 08/06/12- 223, 08/07/12- 207, 08/08/12- 214, and 08/09/12- 239.

Findings include:

OUTPT AREAS
On 08/06/12 at 10:15 AM during a tour of the PT/OT outpt therapy gym, Surveyor noted dust and debris behind the ice pack refrigerator. This was confirmed with DTS-O and HDD-N at time of observation.

Per P&P review titled Iontophoresis (a technique using a small electric charge to deliver a medicine or other chemical through the skin) by Surveyor on 08/07/12 at 10:00 AM, effective date: 2001, revision date 01/27/10, and reviewed date 05/20/12, under III. 1. E. With syringe topped with the vial venting cap (red), draw the specified amount of the prescribed medication as indicated on the physician order and size of electrodes. G. Discard any leftover medication after opened and discard the red vial venting cap.

Per P&P review titled Transmission isolation precautions by Surveyor on 08/06/12 at 10:00 AM, effective date 01/01/72, last revised date 06/06/12, and last reviewed on 06/06/12, under 1.f. ii. Do not administer medications from a syringe to multiple patients, even if the needle or cannula on the syringe is changed. Needles, cannulae and syringes are sterile, single use items; they should not be reused for another patient nor to assess a medication or solution that might be used for a subsequent patient.

On 08/06/12 at 10:45 AM, Surveyor requested PT-AAAA to show Surveyor where any medications were stored in this Outpt Department. PT-AAAA took Surveyor to a locked box, upon opening box an opened syringe with a vial venting system was at the bottom of the box. Surveyor asked PT-AAAA if a new syringe was used each time to draw up the Dexamethosone. PT-AAAA stated the syringe was re-used but a new vial venting system was utilized every time to draw up the medication.

On 08/06/12 at 10:45 AM per interview with Surveyor, DTS- O stated that the same syringe was re-used for multiple patients but that the syringe never reaches the Pt. The medication was drawn up and placed directly on the patch.

On 08/07/12 at 10:45 AM per interview with Surveyor, PT-UUU stated the policy was changed today and a new syringe will be utilized with every dose drawn up. The old policy allowed the staff to re-use a syringe for 30 days. No date was noted on the syringe indicating date of expiration when syringe was observed in lock box on 08/06/12.

On 08/06/12 at 10:55 AM, during a tour of the Emergency Department, Surveyor noted the Biohazard Room to have an unlocked door which was accessible to Pt's and visitors.

Soiled Utility Room was unlocked and a Bleach Cleaner Clorox Spray bottle was sitting on the countertop with 2 bottles of Enzymatic Foam Spray.

On 08/06/12 at 11:24 AM, during a tour of the Pain Management Clinic, Surveyor noted the following:

A layer of dust on the upper storage cabinets stocked with food items such as hot chocolate and snack bars.

Approximately 52 snack size packages of Oreo cookies noted, had no expiration date.
An open bag of mini marshmallows dated 05/12.
An open container of chocolate covered raisins dated 09/24/11, and a Styrofoam cup without a lid containing a white powder not labeled or dated.

These findings were confirmed with DTS-O, MIP & NS-P and HDD-N at time of observation. DTS-O stated the raisins and the hot chocolate where only used by staff, however these items where on the same shelf as Pt items (2 plastic boxes filled with individual packets of sugar and equal).

On 08/06/12 at 2:05 PM during a tour of the Congestive Heart Failure Clinic, Surveyor noted the inside of the microwave to have debris and discoloration.

18 individual packages of graham crackers did not have an expiration date.

The above findings were confirmed with DTS-O, and HDD-N at time of observation.

Per tour of the facility off site, ProHealth Care Sleep Center on 08/07/12 at 8:00 AM with SLT-X and DC-Y the following was observed:

All eight sleep room bathrooms had two bath mats that were washed once per month rather than daily, allowing for potential cross contamination and there was saw dust under the sink in the kitchenette.

Per tour of the facility off site ProHealth Stone Ridge on 08/07/12 at 8:30 AM with LS-Z the following was observed:

There was dust on the chair in Lab Draw Room 1, several bottles of cleaning supplies under the sink and there were juices and crackers, an empty drinking cup and bowl used to microwave food stored in the clean supply room.

P-AA performed a lab draw on Pt #11 at 8:40 AM. P-AA failed to perform hand hygiene prior to the lab draw and did not wash after the gloves were removed, after cleaning the chair.

Per tour of the GI Lab on 08/08/12 between 2:30 PM and 3:30 PM with ND-L and MOGI-GGG the following was observed:

There were chips and dings in the walls in the rooms #731, 738, 741, 742, and 743, making them unwashable surfaces. GIT-III stated during observation of scope cleaning, the enzymatic cleaner "is not" tested for concentration.

Per tour of the Cath Lab on 08/09/12 between 8:10 AM and 9:00 PM with ND-L and DC-Y the following was observed:

The doors to rooms 1156, 1158 and 1978 where chipped allowing exposure of porous wood making the surface unwashable, there were dents in the walls in bays 4 and 7 and the biohazard room was not secured.

INPT AREAS
On 08/06/12 at 2:10 PM during a tour of the Medical Oncology Unit, Surveyor noted a room labeled biohazard unlocked.

40 individual packages of saltine crackers and graham crackers were not labeled with an expiration date.

The above findings were confirmed with DTS-O, and HDD-N at time of observation.

Per review of facility policy entitled Central Venous Catheter: care, maintenance and removal: dated 04/01/1999, last reviewed and revised: 06/06/2012 received on 08/08/12 by A & LC-A at 2:30 PM stated under "site care, dressing changes and injection caps", 7. "Remove dressing and dispose of dressing in proper container."

During an observation of a dressing change on 08/07/12 at 8:18 AM, the following was observed by Surveyor: RN-R removed the old dressing from Pt #32's right chest area and placed the old dressing on the bedside table. After completing the dressing change, RN-R picked up the dirty dressing with a gloved hand from the bedside table and placed in garbage can. RN-R removed R's gloves and performed hand hygiene prior to exiting the room. RN-R left the room without disinfecting the surface of the bedside table leaving it contaminated from the dirty dressing removed from Pt #32's chest.
The above findings were confirmed with CPI-S at time of observation.

On 8/8/2012 at 5:34 PM, the ICU-Soiled Utility room: 1626, on Level 1, had cracked ceramic floor and wall tiles.

In the ICU on 08/06/12 at 1:20 PM, partially used and used oxygen tanks were stored next to supply carts in the clean and sterile storage room.

On 08/07/12 at 1:30 PM, A&LC -A provided a policy on event related sterility for manufacturers packages that did not contain an expiration date, entitled: Event Related Sterility. Per event related sterility SOP, an assessment of the areas was requested that would include staff assessments to the event related sterility process and assessment of all areas where event related materials would be storage.
Surveyor received a note saying the areas were ok. No assessment was provided.

Sterile supplies with no expiration dates/package integrity:

On 08/06/12 identified on tour from 10:30 AM to 2:40 PM were sterile packaging issues:
No expiration date:
Suture removal kits
Extension tubing
20 and 22 gauge needles
4 kelly hemostat clamps
2 webster clamps

Compromised packages:
6 rubber banded #11 blades
2 rubber banded #10 blades

1-1000 ml bag taken out of its original container not dated

08/06/12 at 10:30 AM, CCM-G stated, "I wouldn't know when it expired, unless the package was compromised".

08/06/12 at 11:35 AM, when asked how BBBB would know when sterile products were no longer good/sterile if the package did not contain an expiration date, RN BH-BBBB, stated, "I wouldn't know".

08/06/12 at 1:20 PM, M ICU-H and CNS-YYY, confirmed sterile packages should not be rubber banded because it compromised the package integrity.
M ICU-H and CNS-YYY confirmed that H and YYY did not know the answer when asked how long sterile packages are good for it they do not clearly state an expiration date.
M ICU-H and CNS-YYY confirmed they did not know the expiration date of IV fluids removed from their original packaging.

On 08/08/12 at 3:50 PM, A&LC -A confirmed, there was no event related assessment only the note from ICP and Plant operations.

A&LC -A confirmed, that the end users (all floor staff & managers) of the event related sterility process did not know or understand the process.

Per observation in the Surgery Department OR room 6, on 08/08/12 between 9:30 AM and approximately 10:15 AM, and between 12:30 and 1:40 PM with ND-L and SM-UU the following was observed:

ST-RR turned RR's back to the sterile surgical table five times between 9:15 AM and 10:10 AM.

A-SS, when removing the caps from the medication vials lidocaine, Tracrium, fentanyl and propofol, did not clean the membrane prior to inserting needles to draw up the medication. When injecting medication in the IV line, A-SS wiped the port with alcohol for the first medication (lidocaine), and did not wipe the port prior to subsequent medication (propofol).

At 9:54 AM, RN-TT prepared the male patient for a Foley catheter insertion, using one Betadine swab to wipe the glands, another Betadine swab to wipe the glands a second time, then used a third Betadine swab to cleanse the meatus. This cleaning method fails to meet the hospital's P&P urinary cathter insertion that requires cleaning to start with the meatus and clean outward.

At 9:54 AM, AT-AAA removed gloves and donned new gloves without the benefit of washing, cut off a clamp on the IV tubing using scissors kept in AT-AAA's scrub pocket, allowing for cross contamination.

At about 10:00 AM, A-SS removed gloves and donned sterile gloves without the benefit of washing prior to preparing an arterial line in Pt #16's left arm. During this procedure, AT-AAA changed gloves without the benefit of washing and prepped the site with Chlorprep. RN-TT questioned if the prep was dry and A-SS stated "Yes, it is tacky", and inserted the arterial line needle. Per SM-UU, the prep was not dry if it was tacky. This fails to meet hospital P&P that requires dry time for preps.

At 1:25 PM, ST-RR while handing instruments to the surgeon, repeatedly allowed the under arm area of the sterile gown touch the Mayo table and instruments.

At 1:34 PM, MD-DDD removed the surgical gown and gloves, grabbed a cell phone and jacket and left OR 6 without the benefit of washing hands.

At approximately 1:40 PM, RN-TT used the computer keyboard while wearing gloves, allowing for potential contamination.

Per tour of the Surgery Department on 08/08/12 between 10:15 AM and 11:00 AM with ND-L and SM-UU the following was observed:

VR-WW in OR 4 did not have on eye protection and the EVS-VV did not have his beard completely covered by protective beard covering.

The soiled/EVS room had a green substance on the lower cupboard shelf. Upon a return visit to the Surgery Department on 08/09/12 at 8:00 AM, ND-L confirmed there were four (4) spiked IV bags of sodium chloride dated as opened 08/08/12 with an expiration date of 08/12/12, rather than (08/10) the 24 hours timeframe per policy.

Per tour of the Day Surgery Department on 08/08/12 between 11:00 AM and 11:30 AM, with ND-L and MDS-ZZ the following was observed:

There were stains under the sink in the kitchenette area and RN-XX was observed to have lacquered fingernails against policy.

Per tour of the Women's/Ped's unit and NICU on 3rd floor with M-W and ND-L on 08/07/12 at 10:30 AM, the following was observed:

The Soiled room in the corridor by the OB OR was unsecured, and had a biohazard sign and contained a biohazard bin.

The NICU unit had two glucometers that had an unknown brownish substance. There was staining under the sinks in the nutrition room and by the ice machine near room 3115, and in the Pt southwest kitchen.
Per observation on 08/08/12 at approximately 8:50 AM with ND-L and M OB-BB, a circumcision was being performed. In the procedure room, R-NNN was only wearing gloves and was being instructed by MD-OOO who had no PPE on. The ST-MMM had no PPE donned.

Per tour of the OB OR on 08/09/12 at 9:00 AM with ND-L and M OB-BB the following was observed:

The EVS closet had dings in the walls preventing it from being a washable surface, and the floor was dirty and the corridor had dings in the walls preventing it from being a washable surface.

STORAGE and OTHER AREAS
On 08/08/12 at 2:35 PM, a tour and observation of a loading dock, identified, the loading dock entered into a large storage room. There was no separation of materials found. Staff identified this dock as used for removal of soiled linens and biohazardous waste and receiving EVS supplies.

Surveyor observed filled red biohazardous containers stacked on shelved to the left of the large receiving doors; also on the shelves were clean biohazardous containers used in Pt care areas through out the hospital.

To the right of the receiving door were large clean biohazardous bins confirmed as used in Pt care areas of the hospital and clinics. Next to that were additional shelves containing filled biohazardous containers. 3 uncovered bins contained biohazardous waste.

A sealed yellow bag identified containing chemo-therapy (radio-active waste materials) sitting on top of 1 of 15 (95 gallon) paper recyclable bins.

Additional clean and dirty items found in this room:
Filled recyclable paper bins
10 floor cleaning machines
4 floor buffing machines
Uncovered clean mop heads
Uncovered cleaning cloths
Cleaning chemicals
Clean paper products that are used throughout the hospital.
Rolls of clean garbage bags used by the EVS staff

IC areas of concerns observed and confirmed by Maintenance Supervisor M5, Maintenance Technician M-6 and Surveyor #18107 as follows:

On 8/7/2012 at 1:44 PM, the housekeeping room: 1030C, on Level 1, near Cafeteria, had damaged walls near the floor sink, exposing wood underneath. The edge of the corner tile was damaged and cracked.

On 8/7/2012 at 2:25 PM, servery room, on Level 1 next to the Kitchen in the Deli area, had damaged baseboard.

Per tour of the Sterile Processing and Central Supply area on 08/08/12 between 1:50 PM and 2:30 PM with MDP-FFF the following was observed:

An instrument cleaning brush had metal bristles curled over. When IT-EEE was questioned about replacing the brush, IT-EEE stated "it needed to be changed". IT-EEE obtained two more brushes in the same condition, and discovered there were no new brushes available.

On 8/7/2012 at 6:15 PM, in the corridor outside the Pain Management Office, room: 1425C on Level 1, had sheet vinyl not secured to the floor creating a potential for dirt and dust build-up in a patient care area.

On 8/8/2012 at 2:40 PM, ED-Secured Evidence Room: 1733, on Level 1, contained large amounts of medical equipment and storage within the room, it prevented access to the hand washing lavatory.

On 08/08/2012 at 2:25 PM, Surveyors observed at Loading Dock B Materials Management, that air was blowing into the room from the (dirty) loading dock area to the materials management area (clean). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M10 (Principal, Pearson Engineering, LLC) and staff M11 (Safety Officer).

On 08/08/2012 at 1:54 PM, Surveyors observed in room B134A that air was flowing from the dirty side of the suite (decontamination area) into the clean side of the suite (storage area). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M10 (Principal, Pearson Engineering, LLC) and staff M11 (Safety Officer).

On 08/09/2012 at 3:00 PM, Surveyors observed room B722, the clean GI storage room, the air from the dirty mechanical room was flowing into the clean GI storage room. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M10 (Principal, Pearson Engineering, LLC) and staff M11 (Safety Officer).





22198




18816




12187

Based on MR review and interview with staff, in 2 of 8 surgical MRs (16 and 26) the facility failed to ensure documentation the alcohol the skin prep was dry prior to draping. Total universe 32.

Findings include:

Pt #16's MR review on 08/09/12 at 1:10 PM revealed the intraoperative report does not include documentation the Chloraprep used was dry prior to draping and incision. This was confirmed in interview with CI-LLL and UE-RRR on 08/09/12 at 1:10 PM.

Pt #26's MR review on 08/08/12 at 10:15 AM revealed the intraoperative report does not include documentation of the Chloraprep used as dry, prior to draping the area for surgery. This was confirmed in an interview with IA-SSS on 08/08/12 at 10:45 AM.



29963

Based on MR review, review of rules and regulations and interview with staff, the hospital failed to ensure post anesthesia notes were comprehensive and completed timely for 2 of 8 Pt's (#12 and 23) who required anesthesia. Total universe 32.

Findings include:

The Med Staff "rules and regs" dated January 2012 Table of contents listed under C. Department of Surgery" item 2. Division of Anesthesia 35-37 the only thing that addresses post anesthesia notes was on page 36. e. Post anesthesia visits and notes are the responsibility of the individual administering the anesthesia. These shall be made with-in twenty-four (24) hours when possible (and should be repeated if the patient's condition warrants)."
Pt #12's MR review on 08/09/12 at 10:20 AM revealed, there was no post anesthesia note-related to the general anesthesia received during a hysterectomy on 08/1/12. This was confirmed in interview with CI-LLL and UE-RRR on 08/09/12.

Pt #23's MR review on 08/09/12 at 1:50 PM revealed, there was no post anesthesia note related to the epidural received during labor. This wass confirmed in interview with CI-LLL and UE-RRR on 08/09/12 at 1:50 PM.