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.

ASCENSION ST FRANCIS HOSPITAL 3237 S 16TH ST MILWAUKEE, WI 53215 Oct. 18, 2012
VIOLATION: CONTRACTED SERVICES Tag No: A0085
Based on review of 1 of 1 list of contracted services and staff interviews, the Governing Body failed to ensure the hospital identified all hospital contracts to include the scope and nature of each service rendered to their patients. Consequences of these failures could affect all patients receiving services at this hospital. Daily census during this survey: 10/15/2012 = 130, 10/16/2012 = 145, 10/17/2012 = 147 and 10/18/2012 = 149.

Findings include:

During the entrance conference on 10/15/12 at 9:30 a.m., reviewed with Director of Quality Improvement (DQI)-A the requested materials list including a list of contracted services, including scope and nature of the services provided.

On 10/16/12 at 10:15 a.m., DQI-A provided a list of contracted services.

On 10/16/12 at 12:30 a.m., Chief Executive Officer (CEO)-CC stated that the Governing Board receives a list of the contracted services and that the governing body ensures that the contracted services comply with conditions of participation through service standards and contracts.

On 10/18/12 at 10:35 a.m., in an interview with DQI-A and Vice President of Human Resources (VP HR)-BB, stated that they were aware that the list of contracted service which was provided, was not all inclusive of all the contracted services utilized by the hospital and that such a list did not exist.

DQI-A and VP HR-BB confirmed that the hospital had not considered that all the services provided under the Wheaton Franciscan Organization, arrangement or agreement to be a contracted services and we would not see them on the list.
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on MR review, policy and procedure review, and staff interview, this facility failed to provide Medicare recipients with the appropriate information regarding their right to appeal their discharge within the time frames set forth by the Centers for Medicare and Medicaid (CMS, within 48 hours of admission and 48 hours of discharge) in 3 of 4 MR's reviewed of Medicare recipients (Pt. # 30, 29, 32) out of a total of 31 MR's reviewed. Failure to notify Medicare recipients of their right to appeal discharge has the potential to affect all Medicare recipients receiving care in this facility.

Findings include:

The facility's policy titled, "Important Message from Medicare," dated October 2011, was reviewed on 10/18/2012 at 1:45 p.m. The policy states in part, "The IM (Important Message) shall be delivered to inpatients within two calendar days of admission. The follow-up copy of the IM shall be delivered as far in advance as possible before discharge, but no more than two calendar days before the day of discharge."

Medical Record (MR) review for Pt. #30 was conducted on 10/18/2012 at 11:40 a.m. in the presence of Registered Nurse (RN)-S and Health Information Management Director (HIM Dir)-Z.

Pt. #30 was admitted on [DATE] and discharged on [DATE]. According to HIM Dir.-Z, the IM form is part of the packet when Medicare patients are admitted to the facility. Pt. #30, who was in the hospital for 4 days should have two IM's in the MR. There is one IM in the MR and it is not signed or dated or timed by the patient.

This finding was confirmed by RN-S and HIM Dir-Z during the MR review.

Per review of pt. #29's medical record on 10/18/12 at 12:00 p.m. through 12:30 p.m. revealed pt. #29 was admitted on [DATE] and discharged from the facility on 8/10/12. There were two Important Message forms in the chart, one form was blank and did not include a signature or a date. The second IM was signed and dated 8/10/12 appropriately.

Findings were confirmed with Patient Safety Coordinator (PSC)-AA on 10/18/12 at 12:30 p.m..

Per review of pt. #32's medical record on 10/18/12 at 11:00 a.m. through 12:00 p.m. revealed pt. #32 was admitted on [DATE] and discharged from the facility on 8/13/12. Only one IM found in MR dated 8/1/3/12, no IM was given on admission.

Findings were confirmed with Quality Improvement Coordinator (QIC)-R on 10/18/12 at 12:00 p.m..
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0164
Based on 2 of 4 restraint records reviewed (# 13, 15 ), staff interview and facility policy the hospital failed to ensure less restrictive interventions were attempted. A total of 31 medical records were reviewed. This deficient practice could potentially effect all patients requiring restraints at this hospital.

Findings include:

Wheaton Franciscan Healthcare policy entitled; "Restraints" states as its rationale; "Restraints will only be used if alternative interventions have been considered or found to be ineffective in protecting the immediate physical safety of the patient, staff, or others."

Pt. # 13's medical record contained documentation indicating the use of restraints on 12/13/11 following threatening statements towards staff. Directly preceding the use of restraints at 3:45 p.m. it is documented; "threatening statements continue, became aggressive with security, restraints initiated at 4:15 p.m." There is no documentation indicating less restrictive measures were attempted.

Pt. #15's medical record indicated use of restraints on 02/20/12. Documentation directly preceding the use of restraints indicates; "Pt. attended approximately 30 minutes of 60 minute group session. Pt. had a great deal of difficulty remaining seated/focused. Pt. religiously preoccupied attempting to 'preach' to other patients. Attempts to redirect were minimally effective." These attempts were not specified nor what led up to the need for the use of restraint.

These findings were confirmed per interview with Quality Improvement Coordinator (QIC)- R on 10/17/12 at 2:00 p.m.
VIOLATION: QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT Tag No: A0308
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 all contracted services. Consequences of these failures could affect all patients receiving services at this hospital. Daily census during this survey: 10/15/2012 = 130, 10/16/2012 = 145, 10/17/2012 = 147 and 10/18/2012 = 149.

Finding include:

During an interview on 10/16/12 at 1:40 p.m. with DQI-A, asked if all contracted staff/services were monitored through QAPI Projects, DQI-A stated that not all services are monitored through the QAPI program.

On 10/16/12 at 10:15 a.m., DQI-A provided a list of contracted services. The list included only Medical Care Professionals who provided care to patients. There were no services included on the list except Wisconsin Donor Network.

During an interview on 10/18/12 at 10:35 a.m. with DQI-A and VP HR- BB, reviewed a list of contracted services and asked how the facility evaluates service provided to WF-SF for QAPI. VP HR BB stated that all credentialing and personal files are checked from a Human Resource component, but DQI-A confirmed that audits of care are not performed to assess services provided.

DQI-A stated that the QAPI projects focus on high priority clinical services and that not all contracted services are monitored.

DQI-A confirmed that WF-SF had not considered any services provided under arrangement or agreement by the Wheaton Franciscan Healthcare organization to be a contracted services.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on medical record review, facility policy and procedures, and staff interview, the facility failed to ensure staff appropriately assessed and met patient care needs in response to interventions in 4 of 31 MR's reviewed (pt's #27, 28, 29, 33 ). Consequences of these failures could affect all patients receiving services at this hospital. Daily census during this survey: 10/15/2012 = 130, 10/16/2012 = 145, 10/17/2012 = 147 and 10/18/2012 = 149.

The facility's policy titled, "Pain Management/Comfort Standard of Care," dated 01/2012 was reviewed on 10/18/2012 at 12:40 p.m. The policy indicates that pain will be reassessed at intervals which are determined by factors such as type of surgery, medical condition, or severity of pain. The policy also states pain is to be reassessed, "After intermittent analgesic medication at the time of expected peak effect and expected duration of relief, until efficacy of analgesic plan has been established."

The policy does not define a time period the pain re-assessments following analgesia should occur.

In an interview with RN-S on 10/18/2012 at 10:30 a.m. during MR reviews, RN-S stated that pain re-assessments following medication administration should occur approximately an hour after giving the medication.

A MR review was completed on Pt. #27's closed MR on 10/18/2012 at 10:00 a.m. in the presence of RN-S and HIM Dir.-Z. Patient #27 had heart surgery for a valve replacement during this hospitalization (7/30/2012-8/8/2012). On 8/5/2012 Pt. #27 was moved from the intensive care unit to the surgical floor and an order for an oral pain medication was started. The following dates and times are related to pain medication given and the lack of reassessments after the medication.

8/5/2012: 1:31 a.m. received pain medication, no reassessment is documented; 7:55 p.m. pain medication was given but there is no documented assessment or reassessment.

8/6/2012: 4:57 a.m. received pain medication, no reassessment is documented; 12:34 p.m. received pain medication, no reassessment is documented; at 5:59 p.m. and 10:41 p.m. pain medications were given but the Comfort section in the computer documentation is missing.

8/7/2012: pain medications given between 12:57 p.m. and 1:34 p.m. (times do not coincide in the documentation), no reassessment is documented; at 5:40 p.m. Pt. #27 rated pain at a 2 on a 0-10 scale, which is not high. At 6:41 p.m. pain medications were given but there is not a coinciding assessment for these pain medications and there was no reassessment documented.

8/8/2012: pain medications were given at 8:52 a.m. and 2:25 p.m. however there are no documented reassessments as the Comfort section of the evaluation in the computerized documentation is missing.

These findings were confirmed at the time of the MR review by RN-S.

A MR review was completed on Pt. #28's closed MR on 10/18/2012 at 10:15 a.m. in the presence of PSC-AA. Patient #28 had Sepsis and Cellulitis of the left leg and foot during this hospitalization (7/29/2012-8/8/2012). The following dates and times are related to pain medication given and the lack of reassessments after the medication.

8/2/12: 12:29 a.m. received pain medication, re-assessment completed at 2:44 a.m. On 8/4/12 at 5:34 a.m. pt. received a pain medication , re-assessment completed at 8:55 a.m. On 8/4/12 at 8:03 p.m. received pain medication and was re-assessed on 8/5/12 at midnight. On 8/6/12, pain medication was given at 6:37 p.m. and was re-assessed on 8/7/12 at 12:30 a.m.

A MR review was completed on Pt. #29's closed MR on 10/18/2012 at 11:00 a.m. in the presence of PSC-AA. Patient #29 had Bronchitis during this hospitalization (7/31/2012-8/10/2012). The following dates and times are related to pain medication given and the lack of reassessments after the medication.

8/3/12: 6:17 a.m. received pain medication, re-assessment completed at 8:00 a.m. Pt rated pain at a 6 and another pain med was given at 8:20 a.m., pt was not re-assessed until 12:00 p.m. Pain medication given at 12:18 p.m., no re-assessment documented. Pt. assessed at 3:45 p.m., pt. rated pain as a 7 and a pain medication was given at 3:58 p.m. Next assessment completed at 6:20 p.m. and pain medication was given.

A MR review was completed on Pt. #33's closed MR on 10/18/2012 at 12:00 a.m. in the presence of PSC-AA. Patient #33 had Chest pain during this hospitalization (8/7/2012-8/10/2012). The following dates and times are related to pain medication given and the lack of reassessments after the medication.

8/8/2012: 11:49 a.m. received pain med, no reassessment is documented.

These findings were confirmed at the time of the MR review by PSC-AA.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on observation of cares in one of one multi-dose vial medication administration out of a total of 5 medication administration observations (Pt. #23, Staff U), staff interview, and nationally recognized standards of practice from the Centers of Disease Control (CDC), this facility failed to follow recommended standards of practice by preparing multi-dose vial medication used for multiple patients at the bedside. Failure to follow standards of practice for medication safety has the potential to affect all patients in this facility. Daily census during this survey: 10/15/2012 = 130, 10/16/2012 = 145, 10/17/2012 = 147 and 10/18/2012 = 149.

Findings include:

Per Centers for Disease Control Safe Injection Practices to Prevent Transmission of Infections to Patients (accessed at <http://www.cdc.gov/injectionsafety/ip07_standardprecaution.html%20> October 22, 2012) 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings
The standard IV.H.7 states: Do not keep multidose vials in the immediate patient treatment area and store in accordance with the manufacturer's recommendations; discard if sterility is compromised or questionable 453, 1003. Category IA.
The facility is not following this standard when multidose vials of insulin are brought to patient rooms and insulin is prepared in that patient room.

On October 17, 2012 during interview with Director of Pharmacy-Q from 8:52 a.m. thru 10:09 a.m. policy on multi dose vials was discussed. (Multi dose vials are vials of injectable medications that contain more than one dose and can be used for multiple patients). During this interview it was indicated that multidose vials can be used for multiple patients. Once opened the vials however are good only for 28 days.

During the same interview on October 17, 2012 from 8:52 a.m. thru 10:09 a.m., an example of multidose vials was discussed specific to insulin. Director of Pharmacy-Q indicated that multi dose vials of insulin are used for multiple patients. Insulin vials are stored in the refrigerator in the medication room. Nurses obtain the vials from the refrigerator and bring the vial to the patients room. In the patient room the insulin vial is scanned on the bar code and then the insulin is drawn up in a syringe in the patient room. In some cases the nurse may draw up the insulin first in the nurse medication room and bring both the vial and the syringe to the patient room in order to bar code scan the vial.

An observation of RN-U giving insulin to Pt. #23 was completed on 10/17/2012 at 8:15 a.m. accompanied by Director of Education- M. RN U removed insulin from the medication room refrigerator, went in to Pt. #23's room, drew the insulin into a syringe and administered the dose subcutaneously (injection into the fatty layers of tissue under the skin) to Pt. #23 at the bedside. When completed RN-U returned the insulin to the medication room refrigerator.

These findings were discussed with Director of Education- M on 10/17/2012 at 1:25 p.m.
VIOLATION: VENTILATION, LIGHT, TEMPERATURE CONTROLS Tag No: A0726
Based on observation and staff interviews the facility did not construct, install and maintain a proper ventilation and temperature control system in Operating Room (OR) suite areas. The facility did not have a ventilation system that was installed and maintained in accordance with state regulations and manufacturer recommendations. This deficiency occurred in 2 of the 5 smoke compartments of building #4, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments. Daily census: 10/15/12- 130, 10/16/12- 145, 10/17/12- 147, and 10/18/12- 149.

FINDINGS INCLUDE:
On 10/16/2012 at 4:00 p.m., observation revealed on the roof of the Surgery & Administration, that the ventilation to the space could not be confirmed to be compliant with accepted standards. Two exhaust discharge outlets were located 9 feet below and 4 feet away from air handling machine (that was feeding air to the OR suites) air intake opening. During survey it was observed, exhaust air was coming out from one of the exhaust discharge outlets. This condition was confirmed at the time of discovery by a concurrent observation and interview with VP, Construction & Facility-NN, Safety Coordinator-OO and Quality Coordinator-PP.
VIOLATION: CONFIDENTIALITY OF MEDICAL RECORDS Tag No: A0441
Based on observation, facility policies and procedures, and interview with staff the hospital failed to ensure the security of medical records in 2 of 10 services offered by the hospital. Consequences of these failures could affect all patients receiving services in the Respiratory Therapy Department, Intensive Care Unit and the outpatient Mammography Clinic.
Findings include:

Policy no. CC-HIPAA states; "It is the policy of the Wheaton Franciscan Healthcare to protect the privacy and security of any and all Protected Health Information".
Protected Health Information is defined as: "Individually identifiable health information that is created by or received by the organization, including demographic information, that identifies an individual, or provides a reasonable basis to believe the information can be used to identify an individual, and relates to:
- Past, present or future physical or mental health or condition of an individual;
- The provision of health care to an individual; and
- The past, present, or future payment for the provision of health care to an individual."

On 10-15-2012 at 10:05 a.m. a tour of patient care areas was started with RN- FF. The findings are as follows. Intensive Care Unit (ICU) was noted to have partial medical records outside the patient rooms in cubby below a charting counter. RN- S explained the record kept outside the rooms is not the entire medical record however on the outside of the charts is a cardex (a card filing system) that contains personal health information and the care plan. RN-FF stated the unit has 20 beds and the unit was full on this day.

At 3:00 p.m. on 10/15/12 during a tour of the respiratory therapy (RT) department it was observed that patient orders were kept in a cardex which was unsecured. According to RT Manager -P, housekeeping has access to the area after hours when no RT staff are present.

At 9:35 a.m. on 10/16/12 during a tour of the outpatient Mammography clinic it was observed that mammographs were unsecured in both the reception office and in the radiology reading room. According to Radiology Tech-N, housekeeping has access to both areas after hours when no clinic staff are present.
VIOLATION: SECURE STORAGE Tag No: A0502
Based on observations, staff interview, and facility policy the hospital failed to ensure drugs and biologicals were kept secure on 4 of 7 floors toured. Consequences of these failures could affect all patients receiving services at this hospital. Daily census during this survey: 10/15/2012 = 130, 10/16/2012 = 145, 10/17/2012 = 147 and 10/18/2012 = 149.

Findings include:

Wheaton Franciscan Healthcare policy entitled; "Storage of Medicines between receipt and administration" stipulates as its rationale: "Ensure the safe and appropriate storage of medications throughout the facility. Appropriate medication storage is designed to assist in maintaining medication integrity, provide the availability of medications, minimize the risk of diversion and reduce potential dispensing errors."

During a tour of the outpatient sleep clinic on 10/15/12 at 1:35 p.m. it was observed in an alcove near exam room #3 an unlocked cupboard containing drug samples. This was confirmed by Outpatient Manager O at the time of the tour.

During a tour of 5 South on 10/15/12 at 10:50 a.m. it was observed in the medication room that the medication refrigerator door was ajar. This was confirmed by Patient Safety Coord (PSC) AA at the time of the tour.

During a tour of 5 East on 10/15/12 at 11:00 a.m. it was observed in the medication room that the cabinet containing respiratory medications was unlocked. This was confirmed by PSC AA at the time of the tour.

On 10-15-2012 at 11:50 AM a tour of the outpatient CIC unit was completed with RN, FF. Crash cart #17 was observed on the East end of the unit, not under constant supervision, with a plastic break away lock.

On 10-15-2012 at 2:20 PM a tour of 6 South was completed with RN, FF. Crash cart #6 was observed in the nutrition area with a plastic break away ring. The cart is not under constant supervision and anyone on the unit has access to the cart.

Per tour of 4 east, Family Birth Center on 10/15/12 at 2:30 p.m., 2 crash carts (adult and neonatal) were noted in corridor next to nurses station secured with breakaway locks which is not in view of staff at all times, as staff may be called away from the desk for emergencies.

This is confirmed in interview with DCWC- B on 10/15/12 at 2:30 p.m..
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observations, staff interview, policy and procedure review, and nationally accepted standards of care from the Centers for Disease Control and the Wisconsin Food Code in 6 out of 11 observations conducted (Pt. #22, 23, 24, 35, 36, 37 and Staff T, U, V, W, X (2 observations)) this facility failed to take precautions to provide an environment free from the potential spread of microorganisms to patients. Failure to take infection control precautions has the potential to affect all patients receiving care in this facility.
The Centers for Disease Control recommendations for hand hygiene and glove use, published in the October 25, 2002 addition of the WMMR (Weekly Morbidity and Mortality Report, www.cdc.gov) are as follows:
IV. Standard Precautions Assume that every person is potentially infected or colonized with an organism that could be transmitted in the healthcare setting and apply the following infection control practices during the delivery of health care.
IV.A. Hand Hygiene
IV.A.1. During the delivery of healthcare, avoid unnecessary touching of surfaces in close proximity to the patient to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands to surfaces.
IV.A.3.a. Before having direct contact with patients.
IV.A.3.b. After contact with blood, body fluids or excretions, mucous membranes, nonintact skin, or wound dressings.
IV.A.3.c. After contact with a patient's intact skin (e.g., when taking a pulse or blood pressure or lifting a patient).
IV.A.3.e. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient .
IV.A.3.f. After removing gloves.
IV.B.2. Gloves
IV.B.2.b.ii. Wear disposable medical examination gloves or reusable utility gloves for cleaning the environment or medical equipment.
IV.B.2.c. Remove gloves after contact with a patient and/or the surrounding environment (including medical equipment) using proper technique to prevent hand contamination. Do not wear the same pair of gloves for the care of more than one patient. Do not wash gloves for the purpose of reuse since this practice has been associated with transmission of pathogens.
IV.B.2.d. Change gloves during patient care if the hands will move from a contaminated body-site (e.g., perineal area) to a clean body-site (e.g., face).

Per review on 10/17/12 at 11:00 a.m. of facility policy and procedure titled: Infection Prevention and Patient Care/Isolation, effective date 5/12, page 2. "A. Hand Hygiene 4. personnel should always perform hand hygiene: a. before and after patient care activities b. before and after performing an invasive procedure, even when gloves are worn c. before and after contact with wounds, whether surgical, traumatic, or associated with an invasive device, even when gloves are worn d. after direct contact with a patient in isolation e. after contact with a patients blood or body substances f. after contact with articles contaminated with blood or body substances g, after contact with the patients surroundings h. after hands are visibly soiled or contaminated i. after removing gloves j. before starting work k. after using toilet facilities l. after sneezing, coughing, blowing or wiping the nose or mouth m. before preparing, serving or eating food."
Per review on 10/17/12 at 11:35 a.m. of Midwest Dialysis Center policy and procedure titled: Central Venous Catheter treatment initiation, revised 10/10. "III. Procedure: F. Separately cleanse and scrub each catheter hub with sterile gauze soaked in betadine solution or chlorhexidine for 1 minute, then soak catheter ports separately in betadine or chlorhexidine for an additional 3 minutes. This will prevent introducing bacteria into the catheter."
In an interview with Infection Control Officer (ICO)-DD on 10/17/2012 at 10:35 a.m., ICO-DD indicated the following pertaining to when hand washing is expected to occur: entry to a room with a patient in it, before gloves are applied, after gloves are removed, before leaving the room, and before and after touching anything in the room.
According to the professional standards of practice, Wisconsin Food Code, Food and Drug Administration Food Code and the Food and Drug Administration's "Employee Health and Personal Hygiene Handbook," the facility must have a system in place that requires food service employees to know to immediately report symptoms of illness and under what conditions the employee is able to return to work. Example - If a food service employee is symptomatic with vomiting or diarrhea, the employee cannot return to work until asymptomatic for at least 24 hours.

On 10/15/2012, 11:10 a.m., interview with Food Service Worker (FSW) -G revealed FSW-G did not know when to return to work following an illness of a fever and/or diarrhea. FSW-G stated guessing I would stay home. "I'm not sure." On 10/15/2012, 1:45 p.m., Food Service Director (FSD)-E stated FSW-G started employment prior to a new implementation for new employees orientation related to sick employee policy and procedure. On 10/15/2012, 1:25 p.m., review of facility's "Food Safety Standards & Requirements," revision date, 1/27/2012, section Employee Health, first bullet point states "Employees know which symptoms and illnesses they must report to the manager (or person in charge). Policy does not address any reference when employee would be able to return to work.

--An observation of RN-T performing a bedside blood glucose test on Pt. #22 was completed on 10/17/2012 at 7:50 a.m. accompanied by Dir.-M. After obtaining a blood sample from Pt. #22's finger (on the second attempt as the first attempt had equipment failure), with gloved hands RN-T opened the curtain in Pt. #22's room, cleaned the outside of the glucometer with a sani-wipe, and packed the blood glucose meter equipment into the bin thereby contaminating all of these items with gloves used to obtain blood from Pt. #22's finger. RN-T then removed the gloves and left the room without washing hands.
In an interview with ICO-DD on 10/17/2012 at 10:35 a.m., ICO-DD agreed that the glucometer should not have been cleaned with the contaminated gloves.
These observations were discussed with Dir.-M at 1:25 p.m. on 10/17/2012.
--An observation of RN-U giving insulin to Pt. #23 was completed on 10/17/2012 at 8:15 a.m. accompanied by Dir.-M. Without the use of gloves, RN-U drew the insulin into a syringe and administered the dose subcutaneously (injection into the fatty layers of tissue under the skin) to Pt. #23. It was also noted that Pt. #23's urinal was on the bedside tray next to the breakfast tray Pt. #23 was eating from.

These observations were discussed with Dir.-M at 1:25 p.m. on 10/17/2012.

--An observation of RN-V changing Pt. #24's left back dressing was completed on 10/17/2012 at 9:05 a.m. accompanied by Dir.-M. After applying gloves RN-V removed Pt. #24's old dressings and discarded them. Without changing gloves or washing hands RN-V then applied two different types of ointment, and applied a new dressing to Pt. #24's back. The tongue depressors used to apply the ointment to the open sores on Pt. #24's back were placed on top of RN-V's papers (which were under empty envelopes from dressings used for the dressing change) on the tray next to RN-V's computer keyboard. These papers traveled with RN-V and did not stay in Pt. #24's room. RN-V then removed the gloves, took a pen from V's uniform pocket and dated the dressing on Pt. #24's back, replacing the pen in the pocket, collected the trash and used tongue depressors from on top of the papers on the cart and discarded these items in the trash can before washing hands.

These observations were discussed with Dir.-M at 1:25 p.m. on 10/17/2012.

--An observation of RN-W obtaining and giving oral medication to Pt. #35 was completed on 10/17/2012 at 9:15 a.m. Without washing hands RN-W entered the electronic medication dispensing unit and obtained Pt. #35's wrapped medication. RN W entered Pt. #35's room, prepared to give the medication (which Pt. #35 did not need as there was an order entry error and it was already given), did not open the medication, left Pt. #35's room, re-entered the medication room and re-entered the electronic medication dispensing unit to return the unused medication to the return drawer. RN-W did not wash hands throughout this process.

These observations were discussed with Dir. M at 1:25 p.m. on 10/17/2012.

--An observation of RN-X providing dialysis care to pt. #36 was completed on 10/17/12 at 7:55 a.m. RN- X was observed touching the dialysis machine (contaminated surface) without use of gloves or RN-X did not complete hand hygiene.

Per interview with RN-X on 10/18/12 at 8:20 a.m., RN-X stated that the dialysis room is used for different patients throughout the day. Patients are brought to the dialysis room in their beds and the only equipment in the room sanitized between patients include: the dialysis machine, bedside table, and blood pressure cuff.

These observations were discussed with QIC-R on 10/18/12 at 8:30 a.m.

--An observation of RN-X providing dialysis care to pt. #37 was completed on 10/18/12 at 10:50 a.m. RN-X was observed removing a thermometer from the top of a supply cabinet (which is not cleaned between patients per interview with RN-X), using on pt. #37 and placing back on top of supply cabinet. RN-X then grabbed a stethoscope off the top of the supply cart and assessed lungs of pt. # 37, no use of gloves and placed stethoscope back on cabinet without cleaning the stethoscope or performing hand hygiene.

--An observation of RN-X providing initiation of dialysis to pt. # 37 through a central venous catheter. RN-X completed hand hygiene and put on gloves, mask and gown. Opened a 4x4's and placed under catheter limbs, poured betadine solution over the limbs and the 4x4's, allowed to soak for 30 seconds and then scrubbed limbs together for 10 seconds. Removed gloves and completed hand hygiene and put on new gloves. Attached syringes to limbs to aspirate and replaced syringes with saline filled syringes to flush and then dialysis was initiated.

Dialysis observations were discussed with CNS-S on 10/18/12 at 11:05 a.m.

Review of Instruction manual for the Neptune waste management system on 10-16-2012 was completed. Page 9 states, Docking Procedure- Warning: the operator must wear gloves and protective eye wear during the docking procedure.

Review of Technical Data for 3M Quat Disinfectant cleaner dated August 2012, was completed on 10/17/2012. The 3 page document states in part, "Apply use-dilution to hard, non-porous surfaces, thoroughly wetting the surface with a cloth, mop, sponge, sprayer, or by immersion. Treated surfaces should remain wet for 10 minutes."

Review of hospital P&P for cleaning surgical rooms between cases was completed on 10-16-2012. The P&P does not state, "Apply use-dilution to hard, non-porous surfaces, thoroughly wetting the surface with a cloth, mop, sponge, sprayer, or by immersion. Treated surfaces should remain wet for 10 minutes."

On 10-16-2012 at 11:40 a.m. a tour of the PACU area was completed with RN-FF and RN-MM.

RN-NN was observed in the PACU patient care area carrying a plastic container of red fluid, uncovered. RN-QQ took the container to the soiled utility room and disposed of in the hopper.

On 10-16-2012 at 2:57 p.m. Surgical Support Assistant (SSA)-II demonstrated how the Neptune machine is emptied. SSA-II removed the used Neptune machine from the OR room and without cleaning it transported it to the Soiled Utility room. SSA-II demonstrated how the machine is emptied, SSA-II was not wearing proper PPE.

On 10-16-2012 at 3:00 PM a tour of the Sterile Processing area was completed with RN-FF, Director-KK and Instrument Technician (IT)-JJ. IT, JJ explained the process for cleaning instruments before going to the sterilizer. IT, JJ uses three sinks to complete the process, one sink has 3-4 pumps of TBQ cleaner to half a sink of water. The sink is not marked and the process is not posted nor part of the manufacturer guidelines.

On 10-17-2012 at 8:25 a.m. a tour of the Scope room was completed with RN-FF, RN-GG, RN-EE and CNA-HH. CNA-HH explained the door to the Scope room is always left open because the staff are coming in with dirty scopes and don't want to touch the door handle. RN-GG explained 4 pumps of enzymatic cleaner should be used in the sink and fill to the line in the sink. The line was very faint and this process was not posted any where. RN-GG explained she did the measurements, and told staff but it isn't written anywhere.

On 10-17-2012 at 9:20 a.m. observation of OR #5 was made. The room was being cleaned between cases. The chemical being used was 25, a 3M chemical. Two staff cleaning were RR and SS. They each cleaned the entire room with one rag, never re wetting the rags in the cleaning solution or making sure all surfaces remained wet for 10 minutes.

The hospital failed to have adequate storage space to ensure sterile items are stored in a manner that ensure package integrity to ensure sterility.

AORN Journal <http://findarticles.com/p/articles/mi_m0FSL/> / May, 2008 <http://findarticles.com/p/articles/mi_m0FSL/is_5_87/>
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
Based on record review and interview, the hospital failed to ensure 3 of 30 (#28, 29, 19) Pt's Medical record's were legible. Consequences of these failures could affect all patients receiving services at this hospital. Daily census during this survey: 10/15/2012 = 130, 10/16/2012 = 145, 10/17/2012 = 147 and 10/18/2012 = 149.

Finding include:

Page 11. III. S. Legibility of Documentation- 1. Requirements for Legibility: All entries in the medical record shall be documented in a manner that is legible. Illegible documentation is any documentation that a reader cannot confidently and correctly interpret due to lack of clear handwriting."

Per review of pt. 28's medical record on 10/18/12 at 10:15 a.m. through 10:55 a.m., revealed a progress noted dated 8/30/12 at 12:00 PM, which was illegible. A progress note dated 7/31/12 at 7:00 p.m. was illegible. A progress note written on 8/1/12 at 7:00 p.m. was illegible.

Findings were confirmed with Patient Safety Coordinator (PSC)-AA on 10/18/12 at 10:55 a.m.

Per review of pt. 29's medical record on 10/18/12 at 11:00 a.m. through 11:55 a.m., revealed a progress note dated 8/4/12 at 7:42 p.m., which was illegible. A progress note written on 8/10/12 at 1:00 p.m. was illegible. A progress note written from Infectious Disease on 8/6/12 at 12:10 p.m. was illegible.

Findings were confirmed with PSC-AA on 10/18/12 at 11:55 a.m..

Per review of pt. 19's medical record on 10/17/12 at 1:00 p.m. through 2:00 p.m., revealed a anesthesia note from 9/4/12 which was illegible.

Findings were confirmed with Clinical Nurse Specialist (CNS)-S on 10/17/12 at 2:00 p.m.
VIOLATION: ORDERS DATED AND SIGNED Tag No: A0454
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on MR review in 5 out of 31 MR's reviewed (Pt. #27, 30, 34, 29, 28), policy and procedure review, Medical Staff Rules and Regulations and staff interview, this facility failed to ensure that all orders are properly authenticated with date, time and/or signature of the practitioner writing the orders. Failure to properly authenticate orders has the potential to affect all patients receiving care in the facility. Daily census during this survey: 10/15/2012 = 130, 10/16/2012 = 145, 10/17/2012 = 147 and 10/18/2012 = 149.
Findings include:

The facility's policy titled, "Medical Record Documentation," dated 6/2012, was reviewed on 10/18/2012 at 1:35 p.m. The policy states in part on page 3, Authentication, "Every entry in the medical record will be dated, timed and authenticated by the person making the entry."

Per review of Medical Staff Rules and Regulation dated April 2011, page 8. 111. E Clinical Entries- "All clinical entries in the medical record shall be dated and timed to reflect the actual date at the time of writing or attending."

MR reviews for Pt. #27, 30, and 34 were conducted on 10/18/2012 from 10:00 a.m.-12:15 p.m. in the presence of Registered Nurse (RN)-S and Health Information Management Director (HIM Dir).-Z.

Pt. #27 was admitted on [DATE] and discharged on [DATE], within this time period there are 3 MD orders that do not include a date or a time the MD wrote them, and 2 MD orders that do not include a time the MD wrote them.

Pt. #30 was admitted on [DATE] and discharged on [DATE], within this time frame there are 2 MD orders that do not include the time the MD wrote them.

Pt. #34 was admitted on [DATE] and left Against Medical Advice on 8/7/2012. There are 2 MD orders that do not include a date or time the MD wrote them within that time frame.

These findings were confirmed at the time of the MR reviews with RN-S and HIM Dir.-Z.

Per review of pt. 28's medical record on 10/18/12 at 10:15 a.m. through 10:55 a.m., revealed a cardiology progress note written on 8/1/12 did not include a time of consultation by the physician. Progress note written on 8/2/12 did not include a time of consultation by the physician. Progress note written on 8/2/12 did not indicate time of progress note and evaluation.

Findings were confirmed with Patient Safety coordinator (PSC)-AA on 10/18/12 at 10:55 a.m.

Per review of pt. 29's medical record on 10/18/12 at 11:00 a.m. through 11:55 a.m., revealed a progress note written on 8/4/12 that did not include a time of the progress note or evaluation. A consult note written on 8/2/12 did not include a time of the progress note and evaluation. A pulmonary consult note written on 8/5/12 did not include a time of the progress note or evaluation.

Findings were confirmed with PSC-AA on 10/18/12 at 11:55 a.m..
VIOLATION: UNUSABLE DRUGS NOT USED Tag No: A0505
Based on observations, staff interview, and facility policy the hospital failed to ensure drugs and biologicals were kept secure.

Findings include:

Wheaton Franciscan Healthcare policy entitled; "Storage of Medicines between receipt and administration" stipulates as its rationale: "Ensure the safe and appropriate storage of medications throughout the facility. Appropriate medication storage is designed to assist in maintaining medication integrity, provide the availability of medications, minimize the risk of diversion and reduce potential dispensing errors."

At 3:00 PM on 10/15/12 during a tour of the respiratory therapy (RT) department it was observed that a multi-dose vial of Trichophyton which had expired 06/12 was kept in the medication refrigerator. there was also a bottle of acetaminophen which had expired 09/12 was kept in a locked cabinet. These observations were confirmed by RT Manager -P who was leading the tour.
VIOLATION: VERBAL ORDERS AUTHENTICATED BASED ON LAW Tag No: A0457
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on MR review, policy and procedure review, and staff interview, this facility failed to ensure that telephone/verbal orders are properly authenticated within 48 hours with signature, time and date, by the ordering provider in 8 of 31 MR's reviewed (Pt. #27, 30, 34, 28, 29, 33, 9, 10). Failure to properly authenticate verbal/telephone orders within 48 hours has the potential to affect all patients receiving care in this facility. Daily census during this survey: 10/15/2012 = 130, 10/16/2012 = 145, 10/17/2012 = 147 and 10/18/2012 = 149.

Findings include:

The facility's policy titled, "Medical Record Documentation," dated 6/2012, was reviewed on 10/18/2012 at 1:35 p.m. On page 3, in the section titled Timeliness and Approved Documenters the policy states in part, "Entries in the medical record will be made as close to the time of delivery as possible. Verbal orders must be signed within 48 hours."

Per review of Medical Staff Rules and Regulations, dated April 2011 state on page 6, C.4. All inpatient and outpatient verbal orders must be authenticated (signed) by the physician Medical Staff member or his/her covering colleague within 48 hours of receiving the order. Those authorized to give verbal/telephone orders must time, date and sign the order.

MR reviews for Pt. #27, 30, and 34 were conducted on 10/18/2012 from 10:00 a.m.-12:15 p.m. in the presence of RN-S and HIM Dir.-Z.

Pt. #27 was admitted on [DATE] and discharged on [DATE], within this time period there are 8 Telephone/Verbal orders (TO/VO) that do not include an MD signature, time, and/or date within 48 hours of the nurse writing the orders.

Pt. #30 was admitted on [DATE] and discharged on [DATE], within this time frame there are 4 TO/VO's that do not include an MD signature, time, and/or date within 48 hours of the nurse writing the orders.

Pt. #34 was admitted on [DATE] and left Against Medical Advice on 8/7/2012. There are 7 TO/VO's that do not include a MD signature, time, and/or date within 48 hours of the nurse writing them within that time frame.

These findings were confirmed at the time of the MR reviews with RN-S and HIM Dir.-Z.

Pt. #28 was admitted on [DATE] and discharged on [DATE]. There are 9 TO/VO's that do not include a MD signature, time, and /or date within 48 hours of the nurse writing them within that time frame.

Above findings were confirmed with PSC-AA on 10/18/12 at 10:55 a.m.

Pt. #29 was admitted on [DATE] and discharged on [DATE]. There are 3 TO/VO's that do not include a MD signature, time, and/or date within 48 hours of the nurse writing them within that time frame.

Above findings were confirmed with PSC-AA on 10/18/12 at 11:55 a.m.

Pt. #33 was admitted on [DATE] and discharged on [DATE]. There are 4 TO/VO's that do not include a MD signature, time, and /or date within 48 hours of the nurse writing them within that time frame.

Above findings were confirmed with PSC-AA on 10/18/12 at 12:30 p.m.

Pt. #10's medical record had two verbal orders transcribed by a nurse on 10/6/12 which were not co-signed by a physician at the time of review on 10/17/12 at 1:00 p.m..

Pt. # 9's medical record contained the following orders which were not co-signed within 48 hours; a telephone order transcribed by a nurse on 09/11/2012 at 1:15 p.m. was not co-signed by the physician until 10/1/12. A telephone order transcribed by a nurse on 09/11/2012 at 4:27 PM was not co-signed by the physician until 10/2/12. A telephone order transcribed by a nurse on 09/13/2012 at 1:30 p.m was not co-signed by the physician until 10/2/12. A verbal order transcribed by a nurse on 09/14/2012 at 10:48 AM was not co-signed by the physician until 9/25/12. A verbal order transcribed by a nurse on 09/14/2012 at 10:10 p.m was not co-signed by the physician until 10/2/12.

The preceding findings were confirmed per interview with QIC-R on 10/17/12 at 2:00 p.m.
VIOLATION: COMPETENT DIETARY STAFF Tag No: A0622
Based on observations, interviews and review of the Food Codes, the facility failed to provide services in a clean, orderly and sanitary manner resulting in the potential to negatively impact all patients and an undisclosed number of staff and visitors at the time of survey. Daily census: 10/15/12- 130, 10/16/12- 145, 10/17/12- 147, and 10/18/12- 149.

Findings include:

According to the professional standards of practice, the Wisconsin Food Code and the Food and Drug Administration Food Code:
-to assure adequacy of sanitization, there should be a system in place to make sure the utensil surface temperature is at least 160 degrees Fahrenheit of a hot water sanitization dish machine which is the type the facility uses;
-food is to be labeled to its identity and food prepared and held for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed, sold or discarded.
-food is to be stored at least 6 inches above the floor to protect from contamination;
-food employees shall clean their hands using a cleaning compound in a handwashing sink. Food employees are to wash their hands with soap and water, before donning gloves for working with food;
-food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles.
Receptacles and waste handling units for refuse, recyclables, and returnable's 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;


MONITORING OF INTERNAL TEMPERATURE OF HOT WATER SANITIZATION DISH MACHINE
On 10/15/2012, 11:04 a.m., observed Food Service Worker (FSW)-G using hot water sanitization dish machine for dirty dishes. Interview with FSW-G and Food Service Director (FSD)-E revealed there is no system in place to check utensil surface temperature and was unaware that there should be.

FOOD STORED AND PREPARED IN A SAFE MANNER
Facility's policy & procedure, Food Safety Standards & Requirements, document number 1.1.4, revision date 1/27/2012 states "All foods prepared in operation must be covered and labeled as to contents and date of preparation prior to storage in refrigerators and freezers. Separation of raw and ready-to-eat foods is critical.

On 10/15/2012, 10:39 a.m. - 11:00 a.m., observed the following food items improperly stored, unlabeled and/or uncovered:
Sliced cheese- uncovered (freezer)
Food item-no label (freezer). FSD E unsure what it is.
Ready to eat tomatoes stored under boxed fresh, unwashed whole tomatoes. (produce cooler)
Macaroni and cheese-uncovered (meat cooler)
Ham - corner of pan uncovered (meat cooler)
Sausage links and patties -no label (meat cooler)
Salisbury steaks - uncovered (meat cooler)

On 10/15/2012, 10:39 a.m., pellets for holding plates were stored in milk crates directly on floor. FSD E stated pellets are no longer being used but acknowledges should not be stored directly on floor.

On 10-15-2012 at 10:05 a.m. a tour of patient care units was started with RN-FF. The following areas were observed to have undated patient food. Intensive Care Unit (ICU) freezer in the nutrition area contained 11 ice cream containers with no use by dates or expiration dates. Separate nutrition area with 6 bags of saltine and graham crackers with no expiration date.
Unit 3 South conference room with a patient food refrigerator contained 12 cartons of sherbet/ice cream and 10-12 popsicles were not dated. Saltine and graham crackers were also not dated. 3 North patient food refrigerator contained 19 containers ice cream/sherbet and 5 popsicles with no dates. 3 West patient food refrigerator contained 17 containers ice cream/sherbet and 4 popsicles with no dates. 3 containers of crackers were also without dates. 6 South patient food refrigerator contained 12 containers ice cream not dated.
6 East nutrition area with 4 ice cream containers and 15 popsicles not dated. 3 bins of crackers with no dates.

Unit 4 East pantry a box of Christmas Tea dated 9/09. Bins of individually wrapped graham crackers (approximately 30) and saltine crackers (approximately 20) with no expiration date noted on items.

Above findings confirmed with DCWC-B on 10/15/12 at 2:05 p.m.

Unit 4 North Pantry- Bins of Saltine (approximately 20) and graham (approximately 30) crackers individually wrapped with no expiration date noted.

Above findings confirmed with DCWC-B on 10/15/12 at 3:10 p.m.


HAND HYGIENE
Facility's policy & procedure, Food Safety Standards & Requirements, document number 1.1.4, revision date 1/27/2012 states "recontamination of washed hands must be avoided by using a paper towel to run off faucets....." "Hands must be washed before putting on gloves."

On 10/15/2012, 11:11 a.m., observed Cook-H rest hand on edge of large garbage bin while talking with co-worker. Cook-H then proceeded to put on disposable gloves without washing hands. FSD-E spoke with Cook-H who then went to wash hands. Observed Cook-H turn off faucet with bare hands. FSD-E made aware.

On 10/15/2012, 11:43 a.m., observed Cook-J remove disposable gloves and then put on new pair of disposable gloves without washing hands. Asked Cook-J if hands were washed prior to putting on new pair of disposable gloves which Cook-J stated no because hands were only sweaty.

HAIR RESTRAINTS
Facility's policy & procedure, Food Safety Standards & Requirements, document number 1.1.4, revision date 1/27/2012 states "Hair restraints (hairnets, hats or caps) must cover hair sufficiently to prevent hair from falling onto food or food equipment and to minimize hand contact with hair.

On 10/15/2012, 11:02 a.m., observed FSW-F in dish room area without any hair cover.
On 10/15/2012, 11:35 a.m., observed FSW-I in kitchen with bangs of hair uncovered.
FSD E validated the above stated observations.

COVERING RECEPTACLES
On 10/15/2012, observed 3 uncovered waste receptacles in dishwasher area pushed up against wall and not in use and containing garbage. FSD-E stated covers are off because staff is frequently throwing things out. FSD-E demonstrated how receptacles would be wheeled up to dirty side of dishmachine. Observations in dishmachine area at 11:00 a.m. - 11:15 a.m. and receptacles were not in use and stored up against the wall.
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
Based on observation, staff interviews and review of maintenance documents, the facility failed to construct and maintain the building systems to ensure a safe physical environment due to the cumulative effects of environment deficiencies and resulted in the hospital's inability to ensure a safe environment for the patients, which is a Condition of Participation. This deficiency occurred in the 37 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

It was observed that the facility had the following life safety deficiencies.
K11 (common walls), K12 (construction type), K17 (corridor walls), K18 (corridor doors), K20 (vertical openings), K21 (exit doors), K22 (exit signs), K25 (smoke barriers), k27 (smoke doors), K29 (hazardous room), K33 (vertical openings), K34 (exit stairs), K38 (exit discharge), K47 (directional exit lights), K50 (fire drills), K52 (fire alarms), K54 (smoke detectors), K56 (sprinkler systems), K62 (sprinkler maintenance), K67 (hvac), K72 (egress obstructions), K74 (curtains and fabrics), K75 (linen carts), K76 (medical gas), K103 (interior walls), 130 (miscellaneous), K143 (oxygen transfer), K144 (generator maintenance), K147 (electrical)

This observed situation was not compliant with CFR 482.41.
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation (tours), CDC guidelines and staff interviews, the facility failed to ensure the hospital monitored and maintained a safe and sanitary environment throughout the hospital. Deficiencies also occurred in 2 of the 5 smoke compartments in building #4 and could potentially affect all Pt's and an undisclosed number of staff and visitors at the time of survey. Daily census: 10/15/12- 130, 10/16/12- 145, 10/17/12- 147, and 10/18/12- 149.

Findings include:

On 10/16/2012 at 11:25 a.m., observation revealed on the Basement floor in the Recycling room, that clean and soiled areas were inter-mixed for storing items. 5 full clean crates of bio hazard containers were stored side by side with soiled linen carts full of soiled linen. This condition was confirmed at the time of discovery by a concurrent observation and interview with VP, Construction & Facility-NN, Safety Coordinator-OO and Quality Coordinator-PP.
On 10/17/2012 at 11:45 a.m., observation revealed on the 2nd floor in the OR-9, that visible accumulation of dirt and dust were present in this health care environment. Accumulation of dirt chipped away the paint in return air grill and exposed portion of the grill got rusted. This condition was confirmed at the time of discovery by a concurrent observation and interview with VP, Construction & Facility-NN, Safety Coordinator-OO and Quality Coordinator-PP.
Per review on 10/17/2012 at 12:50 p.m. of Isolette infant Incubator Operator's Manual 4-14 "I. Check the air intake microfilter WARNING: A dirty air intake microfilter may affect oxygen concentrations and/or cause carbon dioxide build-up. Check filter on a routine basis and change at least every three months."

Per review on 10/17/2012 at 12:50 p.m. of facility policy title: Medical Equipment Management Plan, effective 1/1/12 under plan, "EP4- The hospital identifies in writing frequencies for inspecting, testing, and maintaining medical equipment on the inventory based on criteria such as manufacturer's recommendation, risk levels, or current hospital experience."

Per review on 10/17/2012 at 12:50 p.m. of facility documentation regarding pre-maintenance of Infant Incubator dated 10/17/2011, 4/23/2012, and an undated form which is written in pencil "in progress, due by end of month". The forms are computer generated with a list of task to be completed with a line in front of the task. Line available to indicate filter cleaning, if applicable. On the bottom of the form is a line for a signature and a date. The form is completely empty and no signature or date is completed. Dated forms indicate that pre-maintenance is completed every 6 months and this was confirmed with DQI-A.

Per interview with DCWC-B on 10/16/2012 at 9:30 a.m., indicated that she was not aware that the incubators had filters that needed to be checked and cleaned.

Per tour of 4th floor on 10/15/12 at 10:40 a.m. -12:00 p.m. and 1:40 p.m. - 3:30 p.m. revealed:

4 South:

Ante workroom for special care babies- Gouges noted in wood doors, and microwave with food debris and yellow stains.
Resource room- (used to complete hearing screens on babies) gouges in dry wall and wood doors exposing a surface which is not able to be cleaned.

Clean Utility room- Sterile supplies noted with no expiration date on packaging included:
(3) Suture removal kits
(4) Umbilical clips
(11) Perineal packs
(3) Intravenous secondary sets
(6) Oxygen Tubing
(50) Feeding tubes for infants
(6) boxes of [DIAGNOSES REDACTED]/Palate Nursers
(16) Suction Catheters
(1) Auto Suture Extractor dated 1/2012

10/18/12 at 11:30 a.m. asked DCWC-B who is responsible for checking expiration dates on supplies, DCWC-B stated that the staff are to check the dates on supplies prior to putting in patient rooms or using supplies. asked DCWC-B how staff would know if items are expired if supplies are not dated with expiration date. DCWC-B stated that they would need to go by manufactures guidelines. However, manufacture guidelines are not readily available for the staff to visualize prior to using the supplies.

Clean Utility room crowded with Extra medical supplies including Intravenous stands and pumps. Pumps needed to be shifted in order to walk to other side of room. This room also stored emergency medical equipment such as Evacuation Supplies including a sled which was stored hanging on the wall on the other side of the room. Medical supplies would need to be removed in order to retrieve the emergency medical evacuation supplies.

Soiled utility room- unlocked, containing biohazard containers. Gouges in dry wall and wooden door. Yellow stains noted on floor tiles.

Room 4301- Drywall gouges, room was empty and cleaned, however did find an incentive spirometry in upper cabinet. Chipped and peeling paint on the metal door frame.

Per interview of DCWC-B on 10/15/12 at 11:50 a.m., stated that single use supplies should be discarded when patients leave, no supplies should be left in the room for the next patient.

Room 4303- Gouges in dry wall, floor molding pieces do not match up making it difficult to clean the surface. Chipped and peeling paint on the metal door frames.

Room 4304- Gouges in dry wall,. incomplete floor molding pieces, chipped and peeling paint on the metal door frames.

Room 4305- Drywall is ripped with gouges, incomplete floor molding, and metal door frames have paint chipped and peeling.

Room 4307- Wall paper peeling, metal door frames have paint chipped and peeling along with gouges noted in the wooden doors.

Above findings confirmed with DCWC-B on 10/15/12 at 11:30-12:00 p.m..

4 East:

Nurses Station- Broken laminate on front of desk. Walls in the corridor have wall paper peeling.

Pantry- Gouges in the dry wall, noted a plastic container- unlabeled and undated with a brown powder. Dirt and debris noted in upper cabinets. Dust/dirt and debris noted in drawers containing packets of cream and sugar.

Supply room- Paint chipping on metal door frame, Dusty air intake vent, and yellow stains on the floor tiles.

Supply Room- (2) 0.9% Normal Saline 50 ml bags found with outer packaging opened and placed back into container with rest of unopened packages of intravenous fluids. No new expiration date placed on the bag.

LDR #4- Paint chipped off the walls and the metal door frames. A drawer noted to have a broken lock, the door held supplies such as (2) umbilical line draw kits including a needle. DCWC-B stated a work order had been completed.

Documentation provided of work order that had been completed 6/25/12 and 7/20/12. Lock remained broke on 10/15/12.

Clean Utility- Paint chipped off the metal door frame, drywall peeling, one empty (dirty) Oxygen tank stored with 5 full (clean) Oxygen tanks.

Per interview of DCWC-B on 10/15/12 at 2:15 p.m., stated that used Oxygen tanks are not cleaned prior to placing in container holding clean Oxygen tanks

An Olympic Warmette (fluid and blanket warmer) noted, 4 liter bottles of 0.9% Normal Saline noted on top shelf with several blankets in machine.

Per review of facility policy on 10/17/12 at 11:30 a.m. titled: Fluid Warmer effective 1/06, "Procedure: G. All fluid warmers will be checked on a daily basis to insure that the warmer has not exceeded temperature parameters. In addition, the high and low readings of the last 24 hours will be logged. The thermometer will then be reset to begin the next period. H. The observed temperatures will be recorded on the Warmer Temperature log. I. Temperatures outside of the controlled range indicate a problem with the warmer and should be reported to maintenance and/or charge nurse for immediate corrective action.

Warmer Temperature Log taped to outside of door. Each day of the month, staff is to record temperatures including, current, high and low, initials and any action taken. October 1st- no temperature check completed, row is blank. On 10/2/12 current temperature is recorded as 112 degrees , high temperature is 122 degrees and low temperature is 109 degrees. Documentation of high temperatures continue on 10/3, 10/4, 10/5, and 10/6. Staff initials are present by each day but no action taken. Instruction manual states "Do not exceed 120 degrees for blankets. .

Dirty Utility- biohazard label on an unlocked door and containers stored with biohazard material inside of room.

LDR # 5- Gouges noted in wood door and chipped wall paint.

LDR # 3- Gouges noted in wood door and chipped wall paint.

LDR # 2- Metal door frame paint chipped and peeling.

Housekeeping room- door left open and chemicals noted to be on shelves including bathroom disinfectant cleaner, drywall has gouges and yellow stains noted on the floor.

LDR # 6- Drywall paint peeling and metal door frames have chipped paint.

Above findings confirmed with DCWC-B on 10/15/12 at 1:40 PM-2:45 p.m.

4 North

4503- Wall covering ripped and gouges noted in dry wall.

Pantry- White film noted around spout of ice machine. Brown stains noted in the lower cabinet shelving. Gouges in the dry wall. Stains noted on the floor tiles under the ice machine.

Soiled Utility- biohazard label on an unlocked door, biohazard bins stored in this area. Quat disinfectant cleaner bottle noted in an unlocked cabinet under the sink along with 2 gallon bottles of Cidex cleaner.

4111- Paint peeling off door frames.

4110- Supply drawer noted to be unlocked which held supplies including needles in the butterfly blood draw kits (1). Paint peeling off door frames and gouges in dry wall.

Above findings confirmed with DCWC-B on 10/15/12 at 2:50 p.m. through 3:10 p.m..

4 West

4410- Gouges in the wood doors and gouges in the dry wall.

Dirty Utility room - Biohazard label on an unlocked door and the room contained biohazard bins.

Dirty linen cart stored in alcove of hallway stored right next to clean supplies including a scale and computer on wheels.

Above findings confirmed with DCWC-B on 10/15/12 at 3:20 p.m. through 3:30 p.m..

Per tour of same day surgery Post Anesthesia Care Unit (PACU) with housekeeping manager-L on 10/16/12 at 1:15 p.m. it was observed that the janitorial closet for this area was unlocked, it contained cleaning chemicals and supplies. This was confirmed at the time of the tour.

On 10-15-2012 at 10:05 a.m. a tour of patient care areas was started with RN-FF.

ICU

The ADU (automatic dosing unit) refrigerator was noted to have a bottom shelf with dirt, drawers with a dried pink film. Horizontal surfaces in the medication room had a large amount of dust and dirt accumulated.

Clean supply room of the ICU was noted to have dirt, dust, wrappers, supplies and blood collecting vials on the floor under 3 of 7 shelves.

Housekeeping cart was noted in the charge desk area on the North side of the unit. The cart had cleaning chemicals on top of the cart and an uncovered bucket of cleaning solution on top of the cart. Staff could not say who was watching the cart or where the housekeeper was.

3 South

Room #3313 was noted to have gouges in the drywall, damaged floor tiles, holes in the walls.
Medication room was noted to have paint chipping off the door frame, gouges in the drywall and a large amount of dust and dirt on the horizontal surfaces. The refrigerator inside the medication room was not locked. As part of the ADU system the refrigerator must be closed entirely to work properly.

Nurses station had broken laminate counter tops, leaving those surfaces unclean able.

Soiled utility room door was wood with gouges in the wood making the surface porous. Paint is missing and chipping from the door jamb. The walls inside the room have gouges in the dry wall, the floor tiles are broken and cracked, ceiling tiles are dirty. The room was not locked and contained unsecured cleaning chemicals and a large bio hazard bin.

Housekeeping closet on this floor was unsecured with cleaning chemicals inside.

Rooms #3311, 3310, 3303, had gouges in the drywall, paint coming off the door frames, and dirty ceiling tiles.

Cath Lab

The supply room was noted to have dirt and debris under the supply carts. The dirty utility room was not locked and contained cleaning chemicals and bio hazardous material.

Outpatient CIC Unit

Clean Equipment room with dust and debris on the floor.

3 North

Tour on 10-15-2012 at 1:48 p.m. with RN-FF was started.

Clean Utility room was observed to have gouges in the dry wall.

Patient rooms #3103, 3104, 3105 and 3108 were observed to have paint chipping from door frames, dirty floors with a build up of black substance, including corners.

Housekeeping closet unlocked with cleaning chemicals inside, dirt and debris noted.

Soiled utility room with a marred wood door, room not locked containing bio hazardous material. Floor tiles soiled, holes in the walls.

Medication room with dust and dirt on horizontal surfaces.

Nurses charting station with broken laminate counter tops.

3 West

Tour on 10-15-2012 at 2:10 PM with RN-FF.

Room #3401 was noted to have a soiled floor at the entrance. Room #3403 had gouges in the drywall.

Soiled Utility room was not locked and contained bio hazardous waste.

6 South

Tour on 10-15-2012 at 2:20 p.m. with RN- FF.

Clean Supply room was noted to have cracked floor tiles, gouges in the dry wall. Dirt, debris and supplies on the floor underneath the supply racks.

Soiled Utility room with gouges in the dry wall. Door frames with chipping paint.

Medication room with ceiling tile pushed aside open to floor above. Horizontal surfaces with dirt and dust.

6 East

Tour on 10-15-2012 at 2:36 PM with RN-FF.

Equipment storage room with wood doors that are marred and porous.

Housekeeping cart outside of room #6214 with cleaning chemicals on top of cart, bucket of cleaning solution, uncovered on top of cart with no house keeper near the cart. House keeper was found on the unit in a room on a break.

Paint chipping from door frames on rooms #6211, 6212, & 6202.

Nutrition area with a microwave for warming patient food with dried food. Gouges in dry wall.

Medication room with dust and dirt on horizontal surfaces.

Housekeeping closet on far East end of unit with a wood door that is marred, porous.

6 North

Tour on 10-15-2012 at 2:55 PM with RN-FF.

Clean utility room is not locked and contains unsecured cleaning chemicals.

Out patient Same Day Surgery

Tour on 10-16-2012 at 11:16 a.m. with RN-FF.

Rooms #6, 11, 16, 18, and 24 with gouges in the dry wall.

Clean Storage room with gouges in the drywall.

Pre-Admission Testing Area

Ceiling tile stained. Nursing station with broken laminate counter.

PACU

Tour on 10-16-2012 at 11:40 a.m. with RN-FF.

Soiled Utility room not locked, contain bio hazardous material. Drywall with gouges, ceiling vent dirty.

Nurses charting station with broken laminate counters, cabinet under water/ice machine with paper towels, wash clothes, paint scraper, toilet brush & bucket.

Clean storage room with 5 original shipping boxes on the shelf. The boxes contain Polar Care ice chest equipment. The boxes are covered with a plastic bag. The boxes are uncovered and opened on the unit with the patient.

Surgical Semi-Restricted and Restricted Areas.

Tour on 10-16-2012 at 11:58 a.m. with RN- FF and RN-MM.

OR #4 wood door is with chips in the wood. Ceiling tiles outside room #4 stained and with rough texture, vinyl floor board is pulling away from the wall.

Storage room across from OR #4 is not self latching. Wood door is marred.

Ceramic wall tiles with holes from anchors in the scrub area between OR's 2 & 4.

Dirty ceiling tile outside of surgery desk.

Closet room with dirty and clean mixed together.

Anesthesia work room with paint peeling off walls, gouges in drywall.

Center Core

Tour on 10-16-2012 at 12:30 p.m. with RN-FF and RN-MM.

Door frames with chipping paint. Sub-sterile areas also with door frames with chipping paint.
Sub sterile area between OR's #2 & 4 with dust on horizontal surfaces.

OR #5
Tour on 10-16-2012 at 2:16 PM with RN, FF and RN MM.
Door frame to sub sterile area with chipping paint.

Sterilization and Decontamination Areas

Tour on 10-16-2012 at 3:00 p.m. with RN-FF and Director-KK.

Holding area of decontamination with peeling paint on the ceiling, isolation falling off ceiling pipes.

Decontamination area with dirty cracked floor tiles, peeling paint, broken drywall. Paint peeling off cabinets under sinks, cabinet doors rusted.

Sterilization room with holes in drywall and peeling paint on walls.

Out Patient GI Area.

Tour on 10-17-2012 at 8:03 a.m. with RN-FF.

Room C1 with gouges in the drywall.

Scope room with door open had a dirty ceiling tile. Room is used to clean colonoscopy scopes. White tissue test with the door closed shows no air movement.
Hallway with cracked floor tiles and gouges in the drywall.

Labor and Delivery Unit Surgical Area

Tour on 10-17-2012 at 8:45 a.m. with RN-FF.

OR #1 broken drywall.

Dirty utility room not locked with bio hazard material inside.

Door frames with chipping paint.
VIOLATION: LIFE SAFETY FROM FIRE Tag No: A0709
Based on observation, staff interviews and review of maintenance documents, the facility failed to construct and maintain the building systems to ensure a safe physical environment due to the cumulative effects of environment deficiencies and resulted in the hospital's inability to ensure a safe environment for the patients, which is a Condition of Participation. This deficiency occurred in the 37 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.


FINDINGS INCLUDE:
It was observed that the facility had the following life safety deficiencies.
K11 (common walls), K12 (construction type), K17 (corridor walls), K18 (corridor doors), K20 (vertical openings), K21 (exit doors), K22 (exit signs), K25 (smoke barriers), k27 (smoke doors), K29 (hazardous room), K33 (vertical openings), K34 (exit stairs), K38 (exit discharge), K47 (directional exit lights), K50 (fire drills), K52 (fire alarms), K54 (smoke detectors), K56 (sprinkler systems), K62 (sprinkler maintenance), K67 (hvac), K72 (egress obstructions), K74 (curtains and fabrics), K75 (linen carts), K76 (medical gas), K103 (interior walls), 130 (miscellaneous), K143 (oxygen transfer), K144 (generator maintenance), K147 (electrical)

This observed situation was not compliant with CFR 482.41.