The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

WAUKESHA MEMORIAL HOSPITAL 725 AMERICAN AVE WAUKESHA, WI 53188 Sept. 10, 2014
VIOLATION: OPERATING ROOM POLICIES Tag No: A0951
Based on observation, record review, and interview, the facility failed to ensure 5 of 65 staff (K, L, M, N, O) follow policies regarding use of surgical masks and 3 of 3 vendor representatives (H, I, J) failed to follow policies requiring the use of name badges in the operating room area during surgical procedures occurring between 9:00 AM and 10:00 AM on 9/10/2014. This deficiency has the potential to affect all patients having surgery at this facility (33).

Findings include:

Per review on 9/10/2014 at 10:00 AM of policy titled Vendor Management, dated 6/9/2014, stated under "4) Vendor Representatives (VR) must display a vendor badge at all times when on Pro Health Care (PHC) premises."

Per review on 9/10/2014 at 10:00 AM of policy titled Surgical Attire in the Operating Procedural Room, dated 10/25/2012, stated in part under 5. Nonscrubbed personnel should wear long sleeved jackets. 9. Masks must be removed and discarded after use, not saved by hanging around neck or tucked in a pocket.

Per observation on 9/10/2014 at 9:00 AM, VR H was observed leaving Operating Room (OR) #3 and walking down the hall with a mask hanging around neck. Anesthesia Tech (AT) T noted asking VR H to remove and dispose of mask.

Per observation on 9/10/2014 at 9:10 AM, Anesthesiologist K was observed leaving OR #1 and entering the Physician lounge with a mask hanging around neck.

Per observation on 9/10/2014 at 9:15 AM, Cardiothoracic Surgeon L was observed coming out of OR #16 and walking down the hall entering the Catheterization Lab with a mask hanging around neck.

Per observation on 9/10/2014 at 9:20 AM, Circulating Nurse (CN) M was observed walking down the hall with a mask hanging around neck.

Per observation on 9/10/2014 at 9:55 AM, Surgical Tech (ST) N was observed walking down the hall with a mask hanging around neck.

Per observation on 9/10/2014 at 9:15 AM of VR H in OR #3, name badge was not visible.

Per observation on 9/10/2014 at 9:20 AM of VR I in OR #11, name badge was not visible. VR I noted to have sleeves of jacket pushed up exposing forearms while in room during surgical procedure.

Per observation on 9/10/2014 at 9:20 AM of VR J in OR #1, name badge was not visible.

Per observation on 9/10/2014 at 9:45AM of AT S in OR #16 with sleeves of jacket pushed up exposing forearms while in room during surgical procedure.

Per interview with Vendor Representative (VR) H on 9/10/2014 at 9:15 AM, VR H stated "Vendors are to wear long sleeved jackets and masks with shields in the operating rooms. Masks should be removed and thrown away when leaving the surgical room."

Per interview with Assistant Manager of Operating Room (AMOR) C on 9/10/2014 at 9:50 AM, AMOR C stated "Sleeves of jackets should not be pushed up exposing forearms when staff are in the operating rooms."

Per interview with Director of Surgical Services (DSS) B on 9/10/2014 at 10:10 AM, DSS B stated "Getting staff to follow surgical attire policy has been an issue. The current policy is under review to make more realistic for staff to follow yet continue to follow AORN (Association of periOperative Registered Nurses) standards. The new policy will hold staff more accountable." DSS B stated "Vendor representatives are required to complete registration requirements daily upon entering the facility, once this is completed a name badge is printed for the vendor representative to wear while in the building."

Per interview with Accreditation Licensure Coordinator (ALC) E on 9/10/2014 at 10:30 AM, ALC E stated "VR J had not checked in for the day, therefore a name badge was not printed. VR H and VR I had not put on their name badges."