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.

MARSHFIELD MEDICAL CENTER 611 ST JOSEPH AVE MARSHFIELD, WI 54449 April 30, 2014
VIOLATION: REPORTING ADVERSE EVENTS Tag No: A0508
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, this facility failed to notify the MD of a medication error in 1 of 4 MRs reviewed (Pt. #2) where medication errors reached a patient out of a total of 16 MR reviews.

Findings include:

The facilities protocol for Post-Incident reporting was reviewed on 4/30/2014 at 10:30 a.m. The protocol indicates that the role of the RN caring for a patient in which a significant incident had occurred is, "Notifies the physician and ensures guardian/family notification is completed."

A MR review and medication incident report review was conducted on Pt. #2's closed MR on 4/30/2014 at 12:55 p.m. accompanied by PSO E who confirmed the following findings during the review:
Pt. #2, a diabetic, was admitted to the facility on [DATE]. Pt. #2 had an MD order for NPH 70/30 insulin (type of insulin that has both long and short acting properties). While preparing to give the insulin injection on the p.m. shift on 6/30/2013, RN L discovered the bottle of insulin had the correct pharmacy label but the was the wrong type of insulin (it was NPH only, a long acting insulin). At this time it was determined that Pt. #2 had received the wrong insulin on the day shift as the dose was charted but the wrong insulin was made available.

There is no evidence that the MD was notified or made aware of the wrong insulin given. The facility's protocol for contacting the MD was not followed.

In an interview with PSO E on 4/30/2014 at 11:36 a.m. while reviewing the medication incident report, PSO E stated that there was no documentation of provider notification for the wrong insulin being given.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on record review and interview, this facility failed to maintain an environment free from potential contaminants to patients, visitors, and staff by failing to perform curtain cleaning from curtains in isolation patient rooms upon discharge of those patients. This failure has the potential to affect the 21 patients on isolation precautions on the date of the survey (4/30/2014).

Findings include:

PIS D confirmed via e-mail on 5/5/2014 at 1:11 p.m. that the facility follows CDC and APIC for standards of practice in infection control.

APIC Industry Training, Columbus Ohio, 5/30/2012, Terminal Cleaning Practice: Cubicle curtains are changed routinely every 6 months or when visible soiled. In Contact Precaution rooms, frequently touched surfaces of the curtains should be sprayed with approved disinfectant.
In an interview with housekeeper A, related to infection control on 4/30/2014 at 12:50 p.m., housekeeper A stated that privacy curtains in patient rooms are not being cleaned after an isolation patient has been in the room.

The facility's policy titled, "Drapery/Cubicle Curtain Cleaning, dated 4/7/14, was reviewed on 4/30/2014 at 2:55 p.m. The policy states in part, "All drapes, blinds and cubicle curtains in all areas will be inspected daily and routinely cleaned every 6 months per the floor's preventative maintenance log." The policy does not specify a practice for curtains in isolation rooms.

Per interview with housekeeping Supervisor B on 4/30/2014 at 3:05 p.m. related to the curtain cleaning schedule, B stated the privacy curtains are washed as needed and currently isolation room curtains are only being washed when visibly soiled. Supervisor B did say that preliminary work has begun on rectifying the curtain cleaning process.