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1222 E WOODLAND AVE

BARRON, WI 54812

No Description Available

Tag No.: C0196

Based on record review and interview, the facility failed to evaluate contracted services in 1 of 1 telemedicine service reviewed (Telemedicine). This has the potential to affect all patients receiving telemedicine services at this facility.

Findings include:

Facility policy "Telemedicine Credentialing and Privileging" dated 6/27/2016 states: "...Originating Sites [entity where patients are physically located when receiving Telemedicine Services] shall maintain evidence of its internal reviews of Telemedicine Providers' performances and shall provide such performance information to Distant Site [the site where telemedicine providers are physically located] for periodic appraisals of the Telemedicine Providers."

The facility's contract "Professional Telemedicine Services Agreement" dated 11/1/2013 states: "1.5. Quality Standards. Distant site will abide by quality assurance and utilization management programs mutually agreed upon by Distant Site and Originating Site."

On 3/22/2017 at 10:20 AM during review of the facility's telemedicine services, Administrator F and Assistant Administrator Y were unable to provide evidence that quality review of telemedicine services had been performed. On 3/22/2017 at 3:05 PM, Y stated "there is no formal review" of the telemedicine services.

No Description Available

Tag No.: C0220

Based on observation, staff interviews, and review of maintenance records on 3-20-17 through 3-22-17, the facility did not ensure that the building & building systems are constructed, installed, and maintained to ensure life safety to patients as revealed by the following deficiencies:

Bldg 03
K-325 (Alcohol Based Hand Rub Dispenser),
K-341 (Fire Alarm System - Installation),
K-351 (Sprinkler System - Installation),
K-353 (Sprinkler System - Maintenance and Testing),
K-372 (Subdivision of Building Spaces - Smoke Barrier Construction).

Bldg 04
K-353 (Sprinkler System - Maintenance and Testing).

Please refer to the full description of the deficient practices at the individual K-tags. These deficiencies are not compliant with 42 CFR 485.623 and were confirmed at the time of discovery by a concurrent record review, observation, and interview with Staff "B".

No Description Available

Tag No.: C0224

Based on observation, record review and interview, the facility staff failed to secure emergency medications and supplies in 1 of 5 crash carts observed (Medical-Surgical Crash Cart).

Findings include:

Facility policy "Emergency Drug Supplies (Crash Carts)" dated 12/1/2016 states in part: "Medications are readily available and secured against tampering."

During a tour on 3/20/2017 at 2:00 PM, the crash cart located in on the medical-surgical inpatient unit was not locked or secured with a tag. Nursing Supervisor U stated at the time of the observation the crash carts "are normally locked with a tag." During an interview on 3/20/2017 at 2:05 PM, Registered Nurse V stated "the house supervisor checks for outdates [in the cart] on Sunday nights, it's tagged right after that usually."

No Description Available

Tag No.: C0231

Based on observation, staff interviews, and review of maintenance records on 3-20-17 through 3-22-17, the facility did not ensure that the building & building systems are constructed, installed, and maintained to ensure life safety to patients as revealed by the following deficiencies:

Bldg 03
K-325 (Alcohol Based Hand Rub Dispenser),
K-341 (Fire Alarm System - Installation),
K-351 (Sprinkler System - Installation),
K-353 (Sprinkler System - Maintenance and Testing),
K-372 (Subdivision of Building Spaces - Smoke Barrier Construction).

Bldg 04
K-353 (Sprinkler System - Maintenance and Testing).

Please refer to the full description of the deficient practices at the individual K-tags. These deficiencies are not compliant with 42 CFR 485.623(d)(1) and were confirmed at the time of discovery by a concurrent record review, observation, and interview with Staff "B".

No Description Available

Tag No.: C0276

Based observation, record review and interview, the hospital failed to ensure that expired medications were removed from patient care areas, in 1 of 5 rehabilitation areas observed (Physical therapy) and 2 of 2 outpatient locations observed (Therapy clinic and Family Practice Clinic). This has the potential to affect all patients currently receiving in-patients and out-patients currently receiving hospital services.

Findings include:

Facility policy (reviewed on 03/22/17 at 11:30 AM) for "Outdated Medications (Control and Returns)", revised 08/23/2013 stated in part: "It is the policy of (facility) Hospital Pharmacy departments to survey all areas serviced by pharmacy on a monthly basis. This survey will include, inspecting all medications for integrity and outdates. These medications will be removed from the site and returned to the hospital pharmacy".


1) Observations in the main physical therapy patient care area on 3/21/17 at 2:15 PM revealed a locked medication box, used by Physical therapy staff, containing expired Dexamethosone sodium phosphate injection 120 mg. (milligrams) per 30 ml. (milliliters) that had a hospital label that documented expiration on 2/23/17.

During interview with Director O, at time of observation, O stated "this is expired and should be discarded" while removing this medication from the lock box container.






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2) During observations of the family practice/oncology clinic with VP( Vice President) A on 03/21/2017 at 2:50 PM, an expired (02/2017) 1000 ml. bag of intravenous fluid (5% Dextrose/0.45 Sodium Chloride) solution was found in a cabinet in the infusion office. Additionally, 3 expired (02/2017) vials of Abuterol 2.5 mg/3 ml. were found in an emergency box in the same area.

During observations of the lab draw area in the family practice/oncology clinic on 03/21/2017 at 3:00 PM, 3 "Peds Plus" culture vials with expiration dates off 02/28/2017 were found in a wall cabinet.

3) During observations of the off-site therapy clinic on 03/22/2017 at 11:40 AM with DON (Director of Nurses) E, an expired (09/2011) bottle of Providone-Iodine was found in a cupboard in treatment room #1210, and an expired (06/16) bottle of 500 mg Acetaminophen tablets was found in a nursing station cupboard.

Per interview with Staff A, at the time of the observations, expired products should be removed monthly.

PATIENT CARE POLICIES

Tag No.: C0278

Based on observation, record review and interview, the hospital failed to ensure it maintained a system to control the spread of infections (food borne illness, communicable disease) in accordance with written hospital policy and infection control practice standards in 1 of 1 food preparation area (Dietary), failed to use hand hygiene techniques per policy in 1 of 1 wound care observation (Patient #17) and failed to clean and disinfect stethoscopes per policy in 2 of 3 inpatient care observations (Patient #17, Patient #27).

Findings include:

1) Dietary environment

The 3/22/17 at 2:30 PM record review of the "competency-based orientation records" for dietary staffs Z and AA revealed the use of ServSafe and HACCP (Hazard Analysis Critical Control Point) as dietary practices principles used in their orientation training.

Observations in the kitchen on 3/20/17 at 3:45 PM through 6 PM revealed the following:
a) Expired refrigerated food: Cup of black olives, expired 3/6/17; Broccoli, expired 3/19/17; Carrot sticks, expired 3/12/17, Pumpkin pie, expired 3/12/17 and Kale, expired 3/11/17.

During interview with Dietary Cook Z on 3/20/17 at 4 PM, Z stated "the supervisor usually disposes of expired foods every morning", and stated that "the supervisor was away at a conference right now".

b) Food holding temperatures
The 3/20/17 at 5 PM record review of the hot/cold food internal temperatures for 3/13/17 through 3/20/17 revealed 1 set of temperatures for cold/ hot foods prepared and held for patient food service. There is no documented evidence that food temperatures were taken during extended serving periods, after food was prepared, to ensure that safe food holding temperatures are maintained for the prevention of bacterial growth.

During interview with Dietary Cook Z on 3/20/17 at 5 PM, Z stated "I take the hot food temperatures before removing them (food) from the oven".

The 3/23/17 at 5 PM record review of the ServSafe Coursebook, 6th edition, states under "General Rules for Holding Food, Time: Check food temperature at least every 4 hours. Throw out food that is not being held at the correct temperature. You can also check the temperature every two hours. This will leave time for corrective action."

c) Dish/Utensil sanitation
The 3/20/17 at 5 PM record review of dishwasher temperatures for 3/1/17 through 3/20/17 revealed dishwasher temperatures for breakfast on 3/12/17, 3/13/17 and 3/14/17 did not reached the required "wash temp. of 150-160 degrees Fahrenheit". There is no documented evidence that the dietary staff took corrective actions to ensure that dishes and utensils washed during that period were adequately sanitized to prevent foodborne illness.

During interview with Dietary Cook Z on 3/20/17 at 5:45 PM, Z stated "I don't know what was done". During interview with Manager G on 3/22/17 at 1:30 PM, G stated that "There is no additional information (about what was done)".

The 3/23/17 at 5 PM record review of the ServSafe Coursebook, 6th edition, states under "Machine Dishwashing, Monitoring: Check water temperature , pressure and sanitizing levels. Take appropriate corrective actions if necessary...".

d) Communicable Disease risk mitigation
The 3/20/17 at 4:45 PM patient floor observation of Dietary staff AA delivering food tray to Patient #29 revealed that AA did not follow the "contact isolation" precautions that were posted on the patient's outside door frame. The posted contact isolation precautions stated that staff must gown and glove, and use mask if needed. Staff AA walked into the room with food tray, washed hands and put on gloves and delivered tray to patient by placing it on the overbed table. AA did not put on a protective gown over clothing, as required by the posted infection control signage to ensure personal clothing was protected from potentially infectious communicable organisms before going back to the kitchen to prepare, serve and deliver inpatient food.

During interview with Dietitian BB on 3/21/17 at 10:10 AM, BB stated "staff have periodic training in infection control".

The 3/23/17 at 5 PM record review of hospital policy "Isolation precautions: Contact Modified Precautions Policy/ Procedure, revised 7/1/12, revealed " Entering Modified contact precaution room: ...Always don gloves and gown before entering patient room when going past privacy curtain...".


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2) Patient Care Observations

Facility policy "Hand Hygiene/Fingernails Policy" 11/5/2015 states: "The following are indications for hand hygiene: ...ix. After removing gloves..."

Facility policy "Isolation Precautions: Contact Precautions Policy/Procedure" dated 9/28/2016 states: "2. Implementation Contact Precautions: ...While in Room: Change gloves and perform hand hygiene, especially if moving from dirty to clean area or for patient care activities. ...Exiting Contact Precautions Room: Before leaving patient room: ...Perform hand hygiene." The policy goes on to state: "Use dedicated equipment and supplies in precaution room when possible."

Facility policy "Cleaning and Disinfection: Non-Critical Patient Care Items and Environmental Surfaces Policy" dated 2/14/2017 states: "7. Non-critical Patient Care items: ...b. inpatient setting: i. will be disinfected in between patients... Definitions: Non Critical Items: ...Examples of non-critical patient care items are...stethoscopes..."

On 3/21/2017 at 8:20 AM, Registered Nurse W entered Patient #16's contact precaution room to perform a blood sugar check, medication administration and wound care. Registered Nurse W did not remove W's personal stethoscope from around neck prior to entering the contact precaution isolation room. Registered Nurse W donned a gown and gloves and obtained a blood sample from Patient #16. Then without performing glove change or hand hygiene, Registered Nurse administered oral medications to Patient #16. W then removed the gown and gloves and exited Patient #16's room without performing hand hygiene. Registered Nurse W returned to the room, gowned and gloved, and proceeded to remove Patient #16's lower leg wound dressing. After removing the dressing, W used the contaminated gloves to obtain additional supplies from the clean supply drawer. W then changed gloves without performing hand hygiene a total of 3 times during the dressing change process.

On 3/21/2017 at 3:00 PM, Respiratory Therapist X entered Patient #27's room to perform a nebulizer treatment. Respiratory Therapist X used a personal stethoscope to auscultate Patient #27's lungs before and after the treatment. The stethoscope was not disinfected prior to use or after use on Patient #27. When asked at 3:15 PM, Respiratory Therapist X stated X disinfects the stethoscope "periodically throughout the day" but not necessarily between each patient.

During an interview on 3/21/2017 at 3:20 PM, Director of Nursing I states stethoscopes should not be brought into the isolation rooms and hand hygiene is expected to be performed when going in and out of patient rooms and with every glove change.

No Description Available

Tag No.: C0296

Based on record review and staff interview, the hospital failed to ensure that all patients were evaluated and supervised by a RN (registered nurse) or other permitted licensed staff, in 2 of 16 patients reviewed receiving inpatient services (Patient #10, Patient #17).

Findings include:

The 3/23/17 at 5 PM record review of "Assessment and reassessment of the Patient, Routine: Guideline", effective date 5/1/16, revealed "Routine assessment will include the following systems/areas: ...c. Neurological... n. Safe Patient Movement...".

The 3/23/17 at 5 PM record review of "Assessment and Care Planning of the Patient", effective 3/28/1993, revealed "Patient Assessment is initiated by a registered nurse within 24 hours of admission...".

1) The 3/22/17 at 10:45 AM record review of Patient #10 revealed that the swing bed admission nursing assessment, conducted upon transfer from acute care hospital unit, failed to have a complete assessment of this patient's neurological status. Patient #10 was admitted on 3/7/17 with a Left Brain Stroke with weakness experienced on the right side of body.

The 3/22/17 at 10:45 AM record review of Patient #10 revealed Patient #10 had an unwitnessed fall from bed at 11:10 PM on 3/20/17. Record review of the "post fall debriefing guide" and the "fall drill down tool" completed by RN DD after the fall, revealed the patient stood without calling for help. The debriefing guide revealed that Patient #10 was unable to state purpose for standing, and attempted use the tray table which rolled away from patient, causing feet to slip out from under patient. Interventions the briefing guide documented were in place at time of fall was: night light, bed locked, bed alarm, low position bed and call light within reach. RN DD documented that Patient #10 was "impulsive" and that "care plan was initiated". Review of these post fall documents do not include an evaluation of the patient's room environment to determine if necessary patient care items were available: night-time items were within reach, appropriate non-skid footwear available, and positioning of the bed alarm on the bed was appropriate to alert staff and notify patient to all for help, or when toileting assistance had last been provided.

During interview with RN I, at time of the record review, I stated that "the information is not there".


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2) Patient #18 was admitted to the hospital on 3/18/2017 after presenting with complaints of cough, weakness and shortness of breath. Patient #18 was on bedrest upon admission. On 3/20/2017 at 7:00 AM, the activity order changed to "Ambulate: 3x/day." Patient #18's medical record, reviewed on 3/21/2017 at 1:00 PM, contained no documentation that Patient #18 had ambulated on 3/20/2017.

During an interview on 3/21/2017 at 2:00 PM, Director of Nursing I stated "if it [activity] is ordered it should be done." I went on to state that it is expected for staff to fill out an incident report if orders are missed.

No Description Available

Tag No.: C0298

Based on record review and staff interview, the hospital failed to ensure that all patient's nursing care plans were developed and kept current/ revised as needed, in 8 of 16 patients reviewed (Patient #'s 10, 11, 12, 13, 14, 17, 18, 19). This has the potential to affect all inpatients currently hospitalized.

Findings include:

The 3/23/17 at 5 PM record review of "Assessment and Care Planning of the Patient", effective 3/28/1993, revealed "...8. The patient's progress is continuously evaluated against care goals and the plan of care, and when indicated, the plan or goal is revised."

The 3/23/17 at 5 PM record review of the "Lippincott procedures-Care Plan Preparation, revised 4/15/16, used by the hospital revealed that "... A care plan consist of 3 parts: goals and expected outcomes which describes behaviors or results to be achieved within a specified time...".

The 3/22/17 at 10:45 AM record review of Patient #10 revealed Patient #10 had an unwitnessed fall from bed at 11:10 PM on 3/20/17. Record review of the "post fall debriefing guide" and the "fall drill down tool" completed by RN DD after the fall, revealed the patient stood without calling for help. The 3/22/17 at 2 PM record review of Patient #10's interdisciplinary plan of care for fall risk, initiated on 3/7/17 with outcome of "provide safe environment; free from falling and fall related injuries" reflects that on 3/20/17 that this goal was "met" even though patient fell. The fall risk care plan had no documented evidence of interventional changes, to prevent further falls after the 3/20/17 fall experienced by this patient, by the interdisciplinary patient care team.

The 3/22/17 at 3 PM record review of the care plans printed on 3/22/17 at 2 PM for Patient #'s 10, 11, 12, 13, and 14 revealed no documented evidence that the expected patient goals and expected outcomes, which described behaviors or results had a "specified" achievement timeframe.


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Per record review on 3/21/2017 between 12:25 PM and 1:35 PM, care plan documentation for Patient #17, Patient #18 and Patient #19 did not include outcomes within specified timeframes. All goals and interventions are documented as "met."

The records for Patients #17, #18 and #19 were reviewed with Registered Nurse H. On 3/21/2017 at 1:00 PM, H stated the care plans are addressed each shift. When asked how patient progress toward a goal is measured, H stated "I don't know."

No Description Available

Tag No.: C0308

Based on observation, record review and interview, the hospital failed to ensure that patient's medical records were protected from unauthorized access, in 3 of 3 of 6 out-patient departments observed (Out-patient Physical therapy, Out-Patient Family clinic, Off-site therapy clinic). This has the potential to affect all out-patients treated at the hospital.

Findings include:

Facility policy (reviewed on 03/22/2017 at 11:00 AM) for the "Routine Clean Sweep of Protected Health Information Policy", approved 07/22/2015, states in part: "Before leaving a Patient Service Area unattended, the workforce member must: a. Perform a visual check of the room and remove or secure any PHI (protected health information), including medical records and films, clinical documents, and other papers containing PHI".

1) During observation of the family practice/oncology clinic with VP (Vice President) A on 03/21/2017 at 2:30 PM, patient consent forms with PHI were observed in a drawer of nursing station #3. There was no lock on the drawer.

During interview with Staff A, at time of the observation, A stated the area was cleaned by housekeeping after hours (nursing staff not present).

2) During observation of the medical records offices with DON (Director of Nurses) E on 03/21/2017 at 9:50 AM, a bin which contained medical records with PHI that was to be shredded was not properly secured to prevent unauthorized access. Observation of the lock on the bins cover revealed it could not be secured with the one lock on it's cover.


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3) Observations of the out-patient massage therapy treatment room, which had open door and no staff present, on 3/21/17 at 1:40 PM revealed an unlocked drawer which contained medical records of patients receiving massage treatments. Review of a sample of these records revealed the following PHI: name, hospital face sheet containing address, age, religion, marital status, home phone numbers, employer, emergency contacts, insurance information, visit information (hospital admission information), massage therapist patient notes regarding personality and symptomology.

While the information in the drawer was being accessed, Massage Therapist P entered the room and stated "the information is confidential".