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Based on observation, staff interviews, and review of maintenance records between August 23 and August 29, 2016, the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

Findings include:

The facility was found to contain the following deficiencies.
K 17: corridor walls, or did not meet the permitted exceptions for spaces open to a corridor;
K 18: corridor doors that did not latch;
K 22: exit signage
K 25: improperly constructed and maintained smoke barriers;
K 29: hazardous areas improperly enclosed;
K 38: egress paths were not clear at all times, doors were lockable in the egress path,
K 39: maintaining aisle wide
K 48: training of staff on response to fire
K 51: fire alarm system without manual pull stations at all required locations;
K 56: deficiencies in the sprinkler system;
K 75: improper storage of trash and soiled linens;
K 144: deficiencies in the emergency electrical systems.

Refer to the full description at the cited K tags.

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

Based on observation, record review and interview, facility staff failed to ensure equipment and supplies are maintained in a manner to ensure patient safety and failed to perform daily monitoring of emergency medical equipment in 2 of 4 patient care departments (Inpatient Medical-Surgical and Inpatient Birthing Center).

Findings include:

Facility policy "Intravenous/Irrigation Solutions Warming and Blanket Warmer Cabinets" (no review date listed) states: "-The acceptable blanket warmer maximum temperature is 150 degrees Fahrenheit. -All blanket warmers must be temperature monitored and logged daily to ensure they are in the acceptable temperature range."

During observations of the Medical Surgical Unit on 8/23/16 at 10:05 AM with Director of Nursing B, the temperature of the blanket warmer (#1-30-0914) in the clean supply room was 152 degrees Fahrenheit. The sign on the blanket warmer stated, "Maximum Temperature 150."

Per interview at the time of the tour, B stated the temperature of the blanket warmer should be no more than 150 degrees Fahrenheit and staff should be contacting maintenance when the blanket warmer temperature is out of parameters. B was unsure if nursing staff notified maintenance staff of the blanket warmer being out of parameters.

Review on 8/23/16 beginning at 3:00 PM of the August 2016 "Crash Cart/Defibrillator Check list" which includes the "Blanket Warmer Temp" shows daily temperature log documentation of 152 degrees Fahrenheit from August 2, 2016 through August 23, 2016.

Review on 8/23/16 beginning at 3:00 PM of Preventative Maintenance logs for Blanket Warmer (#1-30-0914) shows no documentation of maintenance staff addressing the blanket warmer temperature at 152 degrees Fahrenheit for 22 days.

On 8/23/16 at 10:15 AM, the clean supply room contained 2 boxes of Eclipse Injection Needles that had expired on 9/2015 and 5/2016.

Per interview at the time of the observation, B stated the injection needles are expired and should have been disposed of.


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During observations of the inpatient medical-surgical and birthing center departments on 8/23/2016 at 3:15 PM, the daily crash cart monitoring check lists were not complete. The check list for the crash cart located on the birthing center was not filled out for 14 of the 23 days in August, 7 of 31 days in July and 15 of 30 days in June. The check list for the crash cart located on the medical-surgical unit was not filled out for 4 of 23 days in August and 5 of 31 days in July.

During an interview at the time of the observations, Director B stated staff is expected to inspect the crash cart and emergency medical equipment "daily" and document on the log.

Based on observation, record review and interview, the facility failed to ensure cabinets are clean in 2 of 2 inpatient patient care departments (Inpatient Medical-Surgical and Inpatient Birthing Center).

Findings include:

Facility policy "General Infection Prevention Policy" states: "...all acute care [sic] clinical area sinks with storage are locked with keys to be available only to facility operations staff."

On 8/23/2016 at 10:00 am during tour of the Medical Surgical unit and Birthing Center with Director of Nursing B, observed the following:

-Dust and debris in cabinet under sink in the Medication Room
-White powder like debris and brown residue in cabinet under sink in the Soiled Utility Room
-White powder like debris and yellow residue in cabinet under sink in the Respiratory Therapy Soiled Utility Room
-Dust and debris in cabinet under sink in Patient Room 2
-Dust and debris and dead fly on floor under carts in the Clean Equipment Room
-White powder like debris in cabinet under sink in Patient Room 21
-Black circular stain in cabinet under sink in Sleep Study Patient Room 22
-White powder like debris in cabinet under sink in Nursery Room
-White powder like debris and Green stain in cabinet under sink in Kitchenette Room

Per interview on 8/23/16 with Director of Nursing B at the time of the tour, B revealed housekeeping is responsible for cleaning inside all cabinets, B does not know if housekeeping routinely performs this task. B was unable to identify the type of debris and residue found in the cabinets under the sink.

During an interview on 8/24/2016 at 1:35 PM, when asked if the housekeeping staff cleans under sinks in the patient care areas, Housekeeping Supervisor DD stated "usually not, they [cabinets under the sinks] are supposed to be locked." DD stated the housekeeping staff does not have keys to clean under the sink.

During an interview on 8/24/2016 at 12:50 PM, Facilities Director T stated the debris "looks like lime residue from condensation" under the sinks. Facilities Director T stated the facility maintenance staff is responsible to "wipe out" any debris under the sinks "every 6 months."

Based on observation, staff interviews, and review of maintenance records between August 23 and August 29, 2016, the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

Findings include:

The facility was found to contain the following deficiencies.
K 17: corridor walls, or did not meet the permitted exceptions for spaces open to a corridor;
K 18: corridor doors that did not latch;
K 22: exit signage
K 25: improperly constructed and maintained smoke barriers;
K 29: hazardous areas improperly enclosed;
K 38: egress paths were not clear at all times, doors were lockable in the egress path,
K 39: maintaining aisle wide
K 48: training of staff on response to fire
K 51: fire alarm system without manual pull stations at all required locations;
K 56: deficiencies in the sprinkler system;
K 75: improper storage of trash and soiled linens;
K 144: deficiencies in the emergency electrical systems.

Refer to the full description at the cited K tags.

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

Based on observation, record review and interview, the facility failed to follow aseptic technique in 2 of 3 medication administrations observed (Patient #2, Patient #3) and failed to ensure food is stored per policy in 3 of 5 patient food storage areas observed (Kitchen, Cardiac Rehabilitation, Birthing Unit).


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Findings include:

Medication Administration

The 8/25/16 at 11:30 a.m. record review of "USP (United States Pharmacopoeia) Chapter 797- Pharmaceutical Compounding-Sterile Preparations, Suggested Standard Operating procedures" stated "19. All rubber stoppers of vials and bottles and the neck of ampuls are sanitized with IPA (isopropyl alcohol) prior to the introduction of a needle or spike for the removal of the product."

Facility policy "Injection Safety- 9.5, effective 8/1/2014" states: "Use aseptic technique to avoid contamination of sterile injection equipment." The policy fails to address the cleansing of the single or multiple dose vial septum's prior to entering it with needle of the syringe.

Observations in ED (Emergency Department) Room 8 of RN (Registered Nurse) D preparing Ativan (anti-seizure medication) injection for Patient #3 on 8/23/16 at 2:02 PM, revealed that RN D failed to cleanse the rubber septum with alcohol after removing cap and before piercing the septum with the needle of the syringe.


29972


During an observation on 8/23/16 beginning at 11:05 AM, Respiratory Therapist (RT) C administered Patient #2's nebulizer treatment. C typed on computer keyboard then proceeded to prepare Patient #2's nebulizer treatment without first performing hand hygiene prior to administering Patient #2's medication. C then washed hands with soap and water for 3 seconds and did not scrub all surfaces of the hands and fingers. C then proceeded to listen to Patient #2's lungs with a stethoscope. After the nebulizer treatment finished, C exited Patient #2's room without cleaning and disinfecting the stethoscope.


37419


Food Storage

Facility policy "Food Delivery and Storage", dated 11/02/2015 states in part, "5. Easily perishable food items (flour, etc.) will be transferred to a rigid container with a tight fitting cover after the original container has been opened. The container will be clearly labeled and dated...Food storage in the patient areas will be maintained in a safe and sanitary manner. A. All refrigerated food will be covered and dated...D. Food service staff will check the storage and refrigerator storage areas for outdated supplies, old food items and dispose of them properly according to P/P and ServSafe Guidelines. "

On 8/23/2016 at 12:45 PM an observation of the dry storage area of the kitchen was completed with Food Services Director H. Two large rigid containers with tight fitting covers, holding white materials, (H stated that it was sugar and flour) and confirmed the sugar and flour were not labeled or dated.

On 8/23/2016 at 12:45 PM an observation of the cooler was completed with H. Two of five hams expired on 6/16/16. One bottle of balsamic vinegar was dated as opened on 3/30/16. When H was asked what the expiration date would be H stated "90 days."

On 8/24/2016 between 10:36 and 10:55 AM an observation of food prep with Food Services Director H and Cook M was completed. One open package of beans was pulled out of freezer and was not dated. M stated "these should have been dated."

Per interview with H on 8/23/2016 at 12:55 PM, H stated that all food that is opened should be labeled and dated per policy.

On 8/24/16 at 8:40 AM during an observation with the Director of Rehabilitation Y, the patient refrigerator on the Cardiac Rehabilitation unit contained 4 expired Orange Juice containers labeled 8/6/2016.

Per interview on 8/24/16 with Y at the time of the tour, Y stated the orange juice is expired and should have been disposed.

On 8/23/16 at 10:05 AM observations on second floor in nutrition room revealed 3 expired baby formula 2 packages of 6 bottles of dry powdered formula and one canister of dry powdered formula labeled expired "4/2016" in the patient cupboard in nutrition room on the second floor unit.

During interview on 8/23/2016 at 10:05 AM with Director of Nursing B looked at the items stated "these should be thrown out".

Food Temperatures

On 8-26-16 at 10 AM review of ServSafe Manager Book, section 7.2, "Guidelines for Holding Food" stated "Hold hot food at 135 degree Fahrenheit or higher. This will prevent pathogens such as Bacillus cereus from growing to unsafe levels. Hold cold food at 41 degrees Fahrenheit or lower. This will prevent pathogens such as Staphylococcus aureus from growing to unsafe levels."

On 8/24/2016 at 11:16 AM, temperatures were obtained from foods on a test tray delivered to the second floor inpatient care unit. The tuna sandwich was noted to be 48 degrees Fahrenheit upon delivery to the unit.

During interview with Food Services Director H on 8-24-16 at 11:16 AM, Food Services Director H stated "I'm not sure what the food serving temperatures should be" and "we follow ServSafe guidelines."

Based on observation and interview, the facility failed to keep clinical records secure in 1 of 4 storage areas (east storeroom on the hospital lower level).

Findings include:

Observations of the east storeroom on the lower level of the hospital on 8/25/16 at 12:32 PM revealed an unsecured door of a room containing radiology records.

During interview with Facility Director T, at the same date and time of the observation above, Director T agreed that this storeroom can be accessed by any engineering staff with their key at any time. Director T stated this door is frequently left open to obtain stored supplies for dietary staff.

Based on observation, record review, and interview staff failed to ensure surgical skin preparation is performed in a manner to prevent patient injury in 2 of 6 surgical patients (Patient #11, Patient #28) and failed to ensure patient equipment/supplies are maintained in manner to ensure patient safety in 1 of 1 surgical departments (Surgery).

Findings include:

Surgical Site Preparation

Facility policy "Perioperative Skin Preparation" (no review date listed) states, "If a flammable prep agent is used, additional precautions should be taken to minimize the risk of surgical fire and patient burn injury. With alcohol based preps-3 minutes need to pass before the draping may begin. The RN will monitor the time."

The manufacturer's instructions for Chloraprep, reviewed on 8/25/16 at 11:40 AM, state: "Do not drape or use an ignition source (e.g., cautery, laser) until the solution is completely dry (allow it to dry for a minimum of three minutes on hairless skin; up to one hour in hair). Avoid getting solution into hairy areas, as wet hair is flammable. Hair may take up to one hour to dry."

On 8/21/16 Patient #11 received a Cesarean Section in the Labor and Delivery operating room. ChloraPrep (alcohol-based antiseptic) was used as the preoperative skin preparation solution. Per Patient #11's medical record, the "prep time" or time ChloraPrep was applied to abdomen was at 9:53 AM and the "drape time" was at 9:57 AM. There is no documentation that staff visualized the antiseptic skin prep site to ensure it was dry prior to draping.

Per interview with Operating Room Registered Nurse F on 8/24/16 at 11:30 AM, F stated surgery staff set a timer for 3 minutes after the skin prep solution is applied and then drape the patient. F revealed surgery staff do not perform "time out" to visually ensure skin prep solution is dry, and staff do not document surgical site is dry in the patient's medical record.

Per interview with Operating Room Nurse Manager X on 8/24/16 at 4:00 PM, X stated staff do not document that the surgical site is dry in the patients medical record. Per X, staff rely on the manufacturer's dry time to ensure skin prep solution is dry.

On 8/24/2016 at 11:35 AM, Patient #28 received an epidural lumbar block injection in Operating Room #1. Patient #28's skin was observed being prepped with ChloraPrep from the lower shoulder blade to the top of the hip at 11:34 AM. Patient #28's surgical site preparation agent had not fully dried before patient was draped at 11:34 AM or prior to the procedure starting at 11:35 AM. Review of Patient #28's medical record documents Patient #28's skin prep time at 11:34 AM and the surgical site draped at 11:34 AM.

Per interview with Surgical Tech EE on 8/24/16 at 11:33 AM, EE stated that they only let the ChloraPrep dry "for a couple of minutes."

Per interview with Surgery Director I on 8/24/16 at 08:30 AM, Surgical Director I stated "the staff rely on manufacturer's dry time and facility policy to ensure skin prep solution is dry."

Surgical Supplies

On 8/24/16 at 10:30 AM the Surgery Department's soiled utility room contained 2 jugs of Cidex (high level disinfectant) with an expiration date of 10/2015 and 3/2016. Per interview with Surgical Tech G on 8/24/16 at the time of the observation, G revealed this Cidex is used for the reprocessing, cleaning, and disinfection of equipment used for surgical procedures. G confirmed the 2 jugs of Cidex were expired and staff should be checking expiration date and disposing of expired supplies.

On 8/24/2016 at 11:15 AM, the Surgery Department's clean supply room contained 3 scopes, 1 shaver, and 1 femoral fracture clamp that were not labeled as to when the equipment was sterilized. G stated at the time of the observation all the sterilized equipment should have a sticker with time and date of when the equipment was reprocessed. Per G, sometimes the stickers do not stick properly and may have fallen off. G stated there is no policy and procedure defining how long sterilized equipment can be stored before repeat reprocessing is required.

Based on record review and interview, the facility failed to ensure death record documentation is complete in 3 of 3 death records reviewed (Patient #19, Patient #20, Patient #23) and failed to have a quality process that reviewed clinical death records to ensure Organ Procurement Organization (OPO) policies were followed.

Findings include:

Facility policy "Organ and Tissue Donation, effective 2015" states: "Death Notification and the Rapid Referral Process, 1. UWHC OPO (The University of Wisconsin Organ Procurement Organization) should be called... 2. Call as soon as possible ... Referral number is given and should be recorded on the Mandatory Death Reporting Log form."

During medical record review on 8/25/2016 at 10:00 AM, Mandatory Death Reporting Log forms are not complete and do not document organ donation status for Patient #19, Patient #20 and Patient #23. Patient #19's Mandatory Death Reporting Log form does not include a referral number.

During an interview with Director W on 8/24/2016 at 4:30 PM, W stated that there was no referral number on Patient #19's Mandatory Death Reporting Log form.

During interview on 8/23/2016 at 3:45 PM with Director of Nursing B stated staff does not review death records to ensure timely notification to the OPO. B stated there was no formal quality program for review of OPO death records.

Based on observation and interview, the facility failed to ensure that patients requiring an occupational or physical therapy assessment received services by a qualified therapist in 2 of 3 patients observed (Patient #24 and Patient #26). This has the potential to affect 3 patients seated in wheelchairs, in a total census of 6 patients on the Prospective Payment System Excluded (PPSE) Psychiatric unit.

Findings include:

1) Observations on 8/24/16 at 10 a.m. in the main dining/ lounge area of the PPSE psychiatric unit revealed Patient #24 was seated in a wheelchair without foot rests attached. Patient #24's feet did not reach the floor when patient tried to self-propel in wheelchair, therefore Patient #24 maintained a slouched posture (buttocks not fully on the chair seat) in the wheelchair so the tips of toes could touch the floor in order to propel self backwards. Patient #24 was observed to have a fall alert alarm connected to back of shirt and wheelchair, which had a long cord. The length of this cord did not allow the facility staff to be alerted to patient movement until the center of body mass was beyond the patient's knees.

2) Observations on 8/24/16 at 10 a.m. in the main dining/ lounge area of the PPSE psychiatric unit revealed Patient #26 sleeping in wheelchair without foot rests attached. Patient #26's feet were dangling above the floor from the wheelchair. The front seat edge of the wheelchair seat was observed to press into the back of Patient #26's anterior thighs. Patient #26 was observed to have a fall alert alarm connected to back of shirt and wheelchair, which had a long cord. The length of this cord did not allow the facility staff to be alerted to patient movement until the center of body mass was beyond the patient's knees.

During interview on 8/24/16 at 10:42 AM, Licensed Practical Nurse S stated patients that need a wheelchair are "just put in one, there is no occupational or physical therapy assessment for wheelchairs when patients have risk for falls."

During interview with on 8/24/16 at 11:05 AM, Director O stated the facility "can request a consult from the hospital's occupational or physical therapist, we probably should use them more often."

Based on record review and interview, the facility failed to ensure that a written description of the gross cranial nerves II through X11 were included in the neurological examination in 1 of 3 patient records reviewed (Patient #25). This has the potential to affect the total census of 6 patients on the Prospective Payment System Excluded (PPSE) Psychiatric unit.
Findings include:
Facility policy "03.002-Interdisciplinary Assessment Overview" states: "A. All patients admitted to the Program receive the following assessments: ...Medical History and Physical Examination, 3. Psychiatric Evaluation, 4. Psychosocial Assessment..."
Patient #25's "Psychiatric admission evaluation note" dated 8/4/16 at 8:14 AM and "History and Physical and Orders" dated 8/4/16 at 5:08 PM do not include documentation of a detailed description of cranial nerves II through XII. There was no documented evidence provided by Psychiatric Director O that revealed a cranial nerve exam since the patient's admission on 8/3/2016 at 4:45 PM.
During an interview with at the time of the record review on 8/25/16 at 10:00 AM, Psychiatric Director O was asked for documentation of cranial nerve assessment. Psychiatric Director O stated "OK", but no written information was provided.

Based on observation, record review and interview, the facility failed to ensure that the therapeutic group activities provided were individualized to meet patient's physical and cognitive abilities, in 1 of 6 patients observed (Patient #26). This has the potential to affect the total census of 6 patients on the Prospective Payment System Excluded (PPSE) Psychiatric unit.

Findings include:

Observations on 8/24/16 at 10 AM in the main dining/ lounge area of the PPSE psychiatric unit revealed Patient #26 seated in wheelchair, in circular arrangement with 5 other patients. The therapeutic active treatment activity scheduled was "exercise group", led by Activity Therapist BB.

Observations of Patient #26 from 10 AM through 10:30 AM revealed that Patient #26, 93 years old with diagnosis of Dementia, slept with head bowed, through this therapeutic group. Patient #26 was not observed to receive any staff interaction in an attempt to get patient to awake or participate in this group activity. This group activity provided no therapeutic intervention to restore optimal function to Patient #26.

Observations of Patient #26 from 10:45 AM through 11:20 AM revealed patient continued to sleep, with head bowed, through "Leisure Education" group activity, led by Therapist BB. Patient #26 was not observed to receive any staff interaction in an attempt to get patient to awake or participate in this group activity. This group activity provided no therapeutic intervention to restore optimal function to Patient #26.

During an interview with Activity Therapist BB on 8/24/16 at 10:32 AM, BB stated that this group activity was "recreation, and not for improvement of physical function." BB stated that the "leisure group was given to get patients to express feeling." When asked if Patient #26's treatment plan had written documentation of any individualized 1:1 activities that covered the purpose of the above given group activities, BB stated "no."

The 8/25/16 at 10 AM record review of Patient #26's "Master treatment Plan" revealed no individualized care planned information to show how attendance in these group activities would benefit Patient #26.