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.

GUNDERSEN LUTHERAN MEDICAL CENTER 1910 SOUTH AVE LA CROSSE, WI 54601 Dec. 7, 2016
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on record review and interview the facility failed to ensure 5 of 30 patients were guaranteed their rights; A) to be free from abuse and restraint (#8, #9), B)use of least restrictive interventions (#8, #9) C) to be provided notice of discharge rights (#20, #24) and D) to be provided advance directive information (#20,#27). These deficiencies have to potential to affect all patients served by the hospital.

Findings include:

The hospital failed to ensure patient rights were protected relating to discharge, advance directives, restraints and patient abuse.(see A-117, A-132, A-154, A-165, A-168)
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
Based on record review and interview, facility staff failed to provide follow up discharge rights per policy to 2 of 3 Medicare-eligible discharged patients (Patient #20, Patient #24) out of a sample of 30 patients. This could potentially affect all patients receiving Medicare benefits.

Findings include:

Per review on 12/6/2016 of facility policy "Important Message of Medicare Notice Delivery" No. GL-5014, dated 6/17/2015, states: "The follow up IM [Important Message] notice of Hospital Discharge and Appeal rights is given prior to discharge...within 2 days of discharge from the hospital. ...The units are responsible for the second patient/representative signature which should be obtained 2 days prior to discharge. ...1. CMS requires that hospitals obtain the signature or initials, date AND time on both the initial and the follow up IM notices."

Patient #20 received inpatient services from 10/17/2016 through 10/27/2016. Per review on 12/6/2016 at 2:50 PM, Patient #20's medical record did not contain a signed, dated and timed copy of the follow up IM notice.

Patient #24 received inpatient services from 10/13/2016 through 10/31/2016. Per review on 12/7/2016 at 3:00 PM, Patient #24's medical record did not contain a signed, dated and timed copy of the follow up IM notice.

Director of Nursing Q stated during an interview on 12/6/2016 at 3:00 PM that it is the nurse's responsibility to provide the IM discharge notice and obtain the patient's signature.
VIOLATION: PATIENT RIGHTS: ADVANCED DIRECTIVES Tag No: A0132
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, facility staff failed to provide Advance Directive information to 2 of 2 patients documented as requesting information (Patient #20, Patient #27) out of a sample of 30 patients. This could potentially affect all 218 patients on census at the time of the survey.

Findings include:

Per review on 12/7/2016, facility policy "Advance Care Planning and Advance Directives" No. GL-6068, dated 7/28/2016, states: "ACP [Advance Care Planning] review with admission to the hospital: ...c. If no advance directive exists, offer referral to talk with ACP facilitator and/or to receive education about advance care planning."
Patient #27 was admitted on [DATE]. The nursing admission assessment documents that Patient #27 does not have Advance Directives on file. The assessment includes an Advance Care Planning review that states "Does the patient wish to talk to someone about ACP [Advance Care Planning]? YES." The assessment goes on to state: "Your tasks to complete: Place an order for a Consult for Advance Care Planning. Provide educational materials to the patient and document in the ACP Education section." Both tasks are documented as "Not Done" at the time of Patient #27's record review on 12/6/2016 at 10:30 AM.

Patient #20 was admitted to the facility on [DATE] and discharged on [DATE]. The nursing admission assessment on 10/17/2016 documents that Patient #20 does not have Advance Directives on file. The assessment's Advance Care Planning review states: "Does the patient want to receive educational material? YES." The assessment then states: "Your tasks to complete: Provide educational materials to the patient and document in the ACP Education section." The task is documented as "Not Done" at the time of Patient #20's record review on 12/6/2016 at 2:50 PM.

During an interview on 12/7/2016 at 9:00 AM, ACP Coordinator P stated it is the nurse's responsibility to "ask patients upon admission about their Advance Directives and follow up as appropriate." Per P, the nursing staff "can access resources and provide them to the patient or submit a consult" to the spiritual care group. For patients requesting to talk to someone about Advance Care Planning "a consult should be sent" and "it looks like we are missing something" in the Advance Care Planning process.
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital failed to ensure patients were free from physical abuse in 2 of 2 behavioral health medical records (pt. #8 and #9) of patients out of a universe of 30. This deficiency had the potential to negatively affect 218 patients (pt.) at the time of survey

Findings include:

Per review of policy on 12/06/2016 at 11:00 AM, the facility's policy on restraint: "Restraints and Seclusion" (#GL-6014, revised 12/5/2014) was in effect at the time of these incidents. The policy states there are exceptions to what would be considered a restraint including; "Forensic Controls: Any security device applied and monitored by law enforcement officials to restrain an individual (e.g. hand cuffs, shackles)"

Per review of policies on 12/07/2016 at 1:00 PM, the facility did not have a policy on the role of police officers or use of weapons (such as tasers) on the behavioral health unit.

Restraints used on the hospital's behavioral health inpatient unit include; seclusion and a restraint chair which are considered the most restrictive measures to be used on the unit.

Per review of the medical record on 12/05/2016 at 2:00 PM, patient #8 was admitted on [DATE] suffering with schizoaffective disorder. Following a psychiatric evaluation it was decided that pt. #8 would be placed under a director's hold (emergency detention). When pt.#8 was informed of this pt. #8 became angry and began verbally abusing and threatening staff. Hospital security staff was called to provide presence in the hopes of diffusing the situation. The behavioral unit staff attempted less restrictive measures by verbally engaging pt. #8 and offering alternative ways to calm such as returning to room. Per documentation pt. #8 was very agitated, angry and verbally abusive and not accepting re-direction.

Per interview with RN (registered nurse) YYY on 12/06/2016 at 3:00 PM YYY arrived on the unit on 09/06/2016 at approximately 12:30 PM. YYY stated that the doctor was talking to pt. #8 who was very agitated. YYY observed pt. #8 being "tased" and then cuffed by police officers. Per YYY pt. #8 was moved to a quiet area in an unused unit next door where he remained handcuffed sitting in the restraint chair and was given an injection of Geodon for agitation. YYY stayed to monitor pt. #8 who was subsequently released from cuffs and the chair and taken back to his room to sleep. YYY stated unit staff could not have physically controlled pt. #8 while agitated.

Per review of pt. #8's medical record on 12/05/2016 at 2:00 PM, an order was written for the use of the restraint chair (for one time up to 4 hours) at 12:45 PM on 09/06/2016 pt. #8 was released at 1:04 PM , there was no order for the use of handcuffs on pt. #8.

Per interview with Social Worker XXX on 12/06/2016 at 3:15 PM, on 09/06/2016 at 12:30 PM XXX observed pt. #8 talking with MD and security guards with police officers present. Per XXX pt. #8 verbally escalated and ran at security officers and police. Per XXX pt. #8 was "tased" three times by police officers then handcuffed.

Per interview with security Sgt. ZZZ on 12/06/2016 at 11:45 AM security was called to the behavioral health unit on 09/06/2016 around noon per ZZZ security had been on the unit earlier as a presence when pt. #8 was first told of a director's hold. According to ZZZ pt. #8 was very agitated and stated "I want to get the fuck out of here". ZZZ requested police be called due to pt. #8's extreme agitation and threatening behavior. Per ZZZ pt. #8 did not act out physically until the arrival of the police at which time pt. #8 charged at the security guards knocking one aside and then continuing toward the police officers. Per ZZZ police "tased" pt. #8 and requested security handcuff pt. #8 after which pt. #8 was medicated by unit staff and released from handcuffs to sleep in his room while awaiting transfer.

Contrary to hospital policy the handcuffs were applied by hospital staff (security officers) and monitored by behavioral health unit staff.

Per review of the medical record on 12/05/2016 at 2:30 PM, pt. #9, an adolescent ([AGE] years old) patient with diagnoses of ADHD (attention deficit hyperactivity disorder) and anxiety. Pt. #9 was agitated and not following staff redirection and was subsequently placed in handcuffs by hospital security two times on 09/07 and 09/12/2016. Both times handcuffs were used by security officers according to review of restraint use by the hospital. Contrary to hospital policy there was no order for the use of handcuffs as a restraint. According to the medical record pt. #9 was monitored throughout the time of restraint. These restraints were not ordered by hospital providers and were not applied or monitored by law enforcement officers.

Per interview with unit manager BBB on 12/05/2016 at 11:30 AM, handcuffs re not considered an appropriate restraint for patients on a behavioral health unit.

Per review of an 11/22/2016 e-mail provided by the Behavioral Health Unit manager on 12/07/2016 at 11:00 AM, hospital security were informed that handcuffs would no longer be allowed. Security was notified that handcuffs applied by them would be considered a restraint and that providers would not order them as such.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0165
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital failed to ensure least restrictive methods of restraint were used in 2 of 2 medical records (pt. #8 and #9) of patients restrained out of a universe of 30. This deficiency had the potential to negatively impact 218 pt.s at the time of survey

Findings include:

Per review of policy on 12/06/2016 at 11:00 AM, the facility's policy on restraint: "Restraints and Seclusion" (#GL-6014, revised 12/5/2014) was in effect at the time of these incidents. The policy defines a restraint as; "Any method, physical or mechanical, device, material, or equipment attached or adjacent to the patient's body that cannot be removed by the patient, and thereby restricts freedom of movement or normal access to his or her body." The policy also states there are exceptions to what would be considered a restraint including; "Forensic Controls: Any security device applied and monitored by law enforcement officials to restrain an individual (e.g. hand cuffs, shackles)"

The policy on restraint also lists alternative, less restrictive measures;
"Alternatives may include, but are not limited to
a. continuous observation assignment (1:1)
b. repositioning
c. re-evaluate equipment
d. disguise equipment
e. pain management
f. bed/chair alarm
g. as needed medications for anxiety
h. redirection
i. modify environment - decrease stimulation/increase calmness
j. provide diversional activities
k. engage in therapeutic conversation
l. offer toileting
m. assess oxygen status
n. increase monitoring by staff, family and/or significant other."


Per review of policy on restraint: "Restraints and Seclusion" (#GL-6014, revised 12/5/2014) Restraints used on the hospital's behavioral health inpatient unit include; seclusion and a restraint chair which are considered the most restrictive measures to be used on the unit.

Patient #8 was admitted on [DATE] suffering with schizoaffective disorder. Following a psychiatric evaluation it was decided that pt. #8 would be placed under a director's hold. When informed of this pt. #8 became angry and began verbally abusing and threatening staff. The behavioral unit staff attempted less restrictive measures by verbally engaging pt. #8 and offering alternative ways to calm including: returning to room and nicotine gum or patch. Per documentation pt. #8 was very agitated, angry and verbally abusive and not accepting re-direction. Hospital security staff was called to provide presence in the hopes of diffusing the situation they felt unprepared to deal with the situation and in turn summoned the local police department.

Per interview with RN YYY on 12/06/2016 at 3:00 PM YYY arrived after security officers and escorted police onto the unit on 09/06/2016 at approximately 12:45 PM. YYY stated that the doctor was talking to pt. #8 who was very agitated. YYY observed pt. #8 being tased and then cuffed by police officers. Per YYY pt. #8 was moved to a quiet area in an unused unit next door where he remained handcuffed sitting in the restraint chair and was given a prn (as needed) injection of Geodon for agitation while restrained. YYY stayed to monitor pt. #8 who was subsequently released from cuffs and the chair and taken back to his room to sleep. YYY stated unit staff could not have physically controlled pt. #8 while agitated.

Per interview with Social Worker XXX on 12/06/2016 at 3:15 PM, On 09/06/2016 at 12:30 PM XXX observed pt. #8 talking with MD and security guards with police officers present. Per XXX pt. #8 verbally escalated and ran at security officers and police. Per XXX pt. #8 was tased three times by police officers then handcuffed.

Per review of pt. #8's medical record on 12/05/2016 at 3:00 PM an order was written for the use of the restraint chair (for one time up to 4 hours) at 12:45 PM on 09/06/2016 pt. #8 was released at 1:04 PM , there was no order for the use of handcuffs (or taser) for pt. #8.

Per interview with security officer ZZZ on 12/06/2016 at 11:45 AM pt. #8 was verbally threatening and not complying with directions during the incident on 09/06/2016. Per ZZZ when police arrived they were given control of the situation and directed hospital security to handcuff pt. #8. Per ZZZ less restrictive physical restraints were not used before an escalation to tasing and handcuffing of pt. #8.

Per review of pt. #9's medical record on 12/05/2016 at 2:30 PM, Pt. #9, an adolescent ([AGE] years old) patient with diagnoses of ADHD (attention deficit hyperactivity disorder) and anxiety, was placed in handcuffs by hospital security two times on 09/07 and 09/12/2016 per the medical record. Pt. #9 was restrained following increased agitation and inability to follow staff redirection or accept prn medication. According to restraint use review by the hospital handcuffs were used by security officers contrary to hospital policy in order to restrain and control an agitated pt. #9, according to the medical record pt. #9 was monitored throughout the time of restraint. The restraint chair or seclusion were not used before the application of the handcuffs. Prn Geodon for agitation was administered to pt. #9 while in restraints. The handcuffs were not ordered by hospital providers and were not applied or monitored by law enforcement officers.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital failed to ensure orders were obtained for the use of restraints in 2 of 2 medical records (pt. #8 and #9) of patients restrained out of a universe of 30. This deficiency had the potential to negatively impact 218 pt.s at the time of survey

Findings include:

Per review of policy on 12/06/2016 at 11:00 AM, the facility's policy on restraint: "Restraints and Seclusion" (#GL-6014, revised 12/5/2014) was in effect at the time of these incidents. The policy defines a restraint as; "Any method, physical or mechanical, device, material, or equipment attached or adjacent to the patient's body that cannot be removed by the patient, and thereby restricts freedom of movement or normal access to his or her body." The policy also states; "A restraint may be placed prior to obtaining an order if the situation is emergent. If an emergency application occurs, the physician order must be obtained immediately thereafter and the attending consulted within 24 hours if the attending is not the ordering physician."

Restraints used on the hospital's behavioral health inpatient unit include; seclusion and a restraint chair which are considered the most restrictive measures to be used on the unit.

Patient #8 was admitted on [DATE] suffering with schizoaffective disorder.

An order was written for the use of the restraint chair (for one time up to 4 hours) at 12:45 PM on 09/06/2016 pt. #8 was released at 1:04 PM , there was no order for the use of handcuffs for pt. #8.

Per interview with Social Worker XXX on 12/06/2016 at 3:15 PM, XXX observed pt. #8 on 09/06/2016 at 12:30 PM talking with MD and security guards with police officers present. Per XXX pt. #8 verbally escalated and ran at security officers and police. Per XXX pt. #8 was tased three times by police officers then handcuffed.

Contrary to hospital policy the handcuffs were applied by hospital staff (security officers) and monitored by behavioral health unit staff. There was no physician's order written for the use of handcuffs.

Per review of pt. #9's medical record on 12/05/2016 at 2:30 PM, Pt. #9, an adolescent ([AGE] years old) patient with diagnoses of ADHD (attention deficit hyperactivity disorder) and anxiety, was placed in handcuffs by hospital security two times on 09/07 and 09/12/2016 per the medical record. Pt. #9 was restrained following increased agitation and inability to follow staff redirection or accept prn medication. According to restraint use review by the hospital handcuffs were used by security officers contrary to hospital policy in order to restrain and control an agitated pt. #9, according to the medical record pt. #9 was monitored throughout the time of restraint. The restraint chair or seclusion were not used before the application of the handcuffs. Prn Geodon for agitation was administered to pt. #9 while in restraints. The handcuffs were not ordered by hospital providers and were not applied or monitored by law enforcement officers.

Per review of an 11/22/2016 e-mail provided by the Behavioral Health Unit manager on 12/07/2016 at 11:00 AM, hospital security were informed that handcuffs would no longer be allowed. Security was notified that handcuffs applied by them would be considered a restraint and that providers would not order them as such.
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital failed to implement preventive actions following adverse patient events related to physical restraints and the use of a police weapon. In 2 of 2 records of patients who were physically restrained (#8 and #9) and 1 of 1 patients tased (#8), the hospital failed to provide education to staff. This deficiency had the potential to affect all 218 patients in the hospital at the time of survey.

Findings include:

Per review of policy on 12/06/2016 at 11:00 AM, the facility's policy on restraint: "Restraints and Seclusion" (#GL-6014, revised 12/5/2014) restraints used on the hospital's behavioral health inpatient unit include; seclusion and a restraint chair which are considered the most restrictive measures to be used on the unit.

Per medical record review patient #8 was admitted on [DATE] suffering with schizoaffective disorder.

An order was written for the use of the restraint chair (for one time up to 4 hours) at 12:45 PM on 09/06/2016 for pt. #8.

Contrary to hospital policy the handcuffs were applied by hospital staff (security officers). No policy was provided by the hospital on police involvement on an inpatient unit or use of police weapons.

Per review of pt. #9's medical record on 12/05/2016 at 2:30 PM, Pt. #9, an adolescent ([AGE] years old) patient with diagnoses of ADHD (attention deficit hyperactivity disorder) and anxiety, was placed in handcuffs by hospital security two times on 09/07 and 09/12/2016 and while restrained given IM Geodon contrary to hospital policy in order to restrain and control an agitated pt. #9. These restraints were not ordered by hospital providers and were applied by hospital security personnel.

Per review of an 11/22/2016 e-mail provided by the Behavioral Health Unit manager on 12/07/2016 at 11:00 AM, hospital security were informed that handcuffs would no longer be allowed. Security was notified that handcuffs applied by them would be considered a restraint and that providers would not order them as such.

Pt. #8 was ordered IM Geodon 20 mg 2 times daily prn (as needed) for agitation on 09/06/2016 at 12:52 PM (while restrained), pt. #9 had IM Geodon 20 mg prn daily ordered 09/06/16 at 11:20 AM.

Per review of policy on 12/06/2016 at 11:00 AM, the facility's policy on restraint: "Restraints and Seclusion" (#GL-6014, revised 12/5/2014) was in effect at the time of these incidents. The policy defines chemical restraint as "(a)drug or medication used to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's medical or psychological condition."

Geodon is not considered standard treatment for ADHD and agitation/anxiety (pt. #9). Geodon was administered IM to both pt.#8 and pt.#9 during periods of acute agitation while both patients were restrained.

Per interview with the hospital behavioral health staff on 12/06/2016 at 2:00 PM a root cause analysis (RCA) for these events has not been done there was also no evidence of their QAPI department addressing these adverse events. There was no evidence of staff education related to these events having been initiated.
VIOLATION: SECURE STORAGE Tag No: A0502
Based on observation, record review, and interview, the facility failed to ensure medications are locked and secured in 3 of 30 medication storage observations (Critical Care Unit, Labor and Delivery, Main Clinic lobby). This could potentially affect all 218 patients on census at the time of the survey.

Findings include:

Per review on 12/6/2016, facility policy "Medication Storage" No. GL-6170, dated 8/29/2016, states: "If there is any potential for medications to remain unsupervised...they shall be locked or stored in an area that is not accessible to unauthorized individuals."

During observations of the Critical Care Unit on 12/5/2016 at 1:45 PM, there were eight 50 mL vials of Mannitol and one 20 mL vial of lidocaine in the clean storage room. Neither the medications nor the clean storage room was locked or inaccessible to unauthorized individuals.

During an interview on 12/6/2016 at 3:50 PM, Safety Manager O stated there are facility risk assessments to help determine the need for locks on the clean storage room doors. Manager O stated the medications are kept in locked medication distribution machines. When asked about the unlocked medications in the clean storage room on the Critical Care Unit, Manager O stated "that is unfamiliar to us, we haven't seen that before."






On 12/5/16 while touring the Labor and Delivery unit with QQQ (labor and delivery manager), U (Administrative Director), and II (MD), observed the following:

At 1:50 PM observed a crash cart containing emergency medications secured with zip ties. The crash cart was not secured from unauthorized access and was located in a hallway unattended by staff.

At 2:15 PM observed unlocked anesthesia storage room #HNW5275. Inside the storage room was an unlocked anesthesia medication cart containing multiple medications. Per interview with "II" at the time of the findings, "II" stated the medication cart contained "Epidural medications" used to perform epidurals on women in the Labor and Delivery Unit.

On 12/6/16 at 1:50 PM while touring the 1st floor of the Main Clinic building with U (Administrative Director), observed a crash cart containing emergency medications secured with zip ties. The crash cart was not secured from unauthorized access and was located in an alcove adjacent to the Main Clinic lobby unattended by staff.
VIOLATION: COMPETENT DIETARY STAFF Tag No: A0622
Based on observation, interview and record review, the hospital did not serve and prepare food under sanitary conditions: facial hair was not restrained (Dietary Supervisor E, Cook F, Cook G, Cook H, Cook J, Dietary Aide L, and Cook M, )food items were not labeled, two mixers were dirty, and cross-contamination occurred when single-use gloves were not changed when required (Cook J and Dietary Aide K). This had the potential to negatively impact census of 218 patients at time of survey.

Findings Include:

HAIR RESTRAINTS
On 12/5/2016, 2:50 PM, during an interview with Registered Dietitian-GGG (RD-GGG), RD-GGG reported all dietary managers, dietary supervisors and cooks are ServSafe certified. ServSafe is a nationally recognized program in food safety education and is one of the standards of practice for food safety followed by the hospital. According to ServSafe, hair, including facial hair, needs to be properly restrained to prevent hair falling into food and onto clean equipment.

During the tour of the kitchen on 12/5/2016 and 12/6/2016, and accompanied by Registered Nurse-C (RN-C), Dietary Clinical Manager-D (DCM-D), the following observations of unrestrained hair were made:
12/5/2016, 1:27 PM, Cook M/mustache and beard - no restraint
12/5/2016, 1:34 PM, Dietary Supervisor E/mustache-no restraint; Bistro Cook G/mustache and beard- no restraint, Cook H/mustache - no restraint
12/5/2016, 1:43 PM, Cook F/beard and mustache - no restraint
12/5/2016, 2:01 PM, Dietary Aide L/goatee and mustache - no restraint
12/6/2016, 8:36 AM, Cook J/mustache - no restraint

On 12/5/2016, 1:27 PM, during an interview with Dietary Clinical Manger-D (DCM-D), DCM-D " thought " facial hair could be at least one inch before it had to be covered.

Review of foodservice policy on 12/6/2016, 12:00 PM, " Foodservice Infection Control, " Index Number NtrS-4350, Last Revised 9/2/2016, indicates it does not reflect ServSafe ' s food safety requirement that hair needs to be properly restrained. Foodservice Infection Control policy, Section A. Personnel, 1. Employee Health Standards: 3. Personal Hygiene: a. " Proper attire for food handlers will include a hair bonnet, clean uniform. Fingernails will be short and clean. Mustaches, beards and sideburns must be kept trimmed. "

LABELING
On 12/5/2016, 2:50 PM, during an interview with Registered Dietitian-GGG (RD-GGG), RD-GGG reported all dietary managers, dietary supervisors and cooks are ServSafe certified. ServSafe is a nationally recognized program in food safety education. Food needs to be clearly marked to indicate the date or day by which it is consumed, sold or discarded. According to ServSafe, " when food is stored incorrectly and not used in a timely manner, quality and safety will suffer. "

On 12/5/2016, 1:30 PM, accompanied by Dietary Clinical Manger-D (DCM-D), and Registered Nurse-C (RN-C), observed inside salad room service cooler, one dozen hard cooked eggs that had not been labeled after being removed from its original container. DCM-D stated the eggs should have been dated.

On 12/5/2016, 1:34 PM, accompanied by Dietary Clinical Manger-D (DCM-D), Dietary Supervisor-E (DS-E) and Registered Nurse-C (RN-C), inside meat cooler, observed, as identified by DS-E, a large sheet pan with pork sausage links. The pan of pork sausage links did not have a label. On a bottom shelf, next to the pork sausage links were two 4-inch, half-pans identified by DS-E as containing raw beef patties. The pans did not have labels identifying what the items were. According to DS-E, there should be a label identifying the product inside the pans.

On 12/5/2016, 1:51 PM, in kitchen accompanied by Dietary Clinical Manger-D (DCM-D), Dietary Supervisor-E (DS-E) and Registered Nurse-C (RN-C), inside middle drawer of 3 drawer reach-in cooler, were unlabeled 2 bags identified by DCM-D to contain frozen blueberries.

On 12/5/2016, 1:55 PM, in kitchen accompanied by Dietary Clinical Manger-D (DCM-D), Dietary Supervisor-E (DS-E) and Registered Nurse-C (RN-C), on bottom shelf of baker ' s reach-in cooler were 27 eggs without any type of label.

On 12/5/2016, 2:50 PM, during an interview with Registered Dietitian-GGG (RD-GGG), RD-GGG all dietary managers, dietary supervisors and cooks are ServSafe certified. ServSafe is a nationally recognized program in food safety education. According to ServSafe, food must be labeled and date marked. Date marking food indicates when the food must be sold, eaten, or thrown out.

EQUIPMENT AND UTENSILS
According to ServSafe, a nationally recognized professional standard of practice for food safety used by the hospital per Registered Dietitian-GGG, equipment and utensils shall be free of an accumulation of dust, dirt, food residue and other debris.

On 12/5/2016, 1:47 PM, in kitchen accompanied by Dietary Clinical Manger-D (DCM-D), Dietary Supervisor-E (DS-E) and Registered Nurse-C (RN-C), observed a floor stand mixer with dried, caked on debris in area where paddle of mixer is attached. In addition, top of entire front of mixer had what appeared to be dirt, which was confirmed by DS-E when DS-E wiped dirt off with a damp cloth.

On 12/5/2016, 1:51 PM, in kitchen accompanied by Dietary Clinical Manger-D (DCM-D), Dietary Supervisor-E (DS-E) and Registered Nurse-C (RN-C), observed tabletop mixer with dried debris in area where paddle of mixer is attached. Debris was confirmed by DCM-D and DS-E.

Review of foodservice policy on 12/6/2016, 12:00 PM, " Foodservice Infection Control, " Index Number NtrS-4350, Last Revised 9/2/2016. Foodservice Infection Control policy, Section D. Equipment: 3. " Food service equipment & countertops will be cleaned and sanitized after each use according to procedures in Equipment Manual. "

CROSS CONTAMINATION
According to ServSafe, a nationally recognized professional standard of practice for food safety used by the hospital per Registered Dietitian-GGG, pathogens " can be transferred from one surface or food to another.

On 12/6/2016, 8:30 AM, in kitchen, accompanied by Dietary Clinical Manger-D (DCM-D), Registered Nurse-C (RN-C), observed large garbage receptacle, uncovered and filled with garbage. The garbage receptacle was up against a cart that stores bread products. In front of the garbage receptacle, on the floor, was a fan that was covered with debris and blowing onto the cold preparation area.

On 12/6/2016, 8:39 AM, in kitchen, accompanied by Dietary Clinical Manger-D (DCM-D), Dietary Supervisor-HHH and Registered Nurse-C (RN-C), observed Cook-J preparing breakfast. Wearing one pair of gloves, Cook-J opened drawer to pull out unwrapped cheese. The handle of the drawer is a contaminated surface. Without changing gloves, Cook-J grabbed a roll, along with a piece of kale and orange slice and put onto a plate. Interview with DCM-D, RN-C and Cook-J, discussed the multiple tasks during breakfast prep which resulted in potential for cross-contamination. During an interview with Registered Dietitian-GGG (RD-GGG), RD-GGG stated all dietary managers, dietary supervisors and cooks are ServSafe certified. ServSafe states gloves need to be changed before beginning a different task.

On 12/6/2016, 8:50 AM, in kitchen, accompanied by Dietary Clinical Manger-D (DCM-D), Dietary Supervisor-HHH and Registered Nurse-C (RN-C), observed Dietary Aide-K (DA-K) making chicken salad sandwiches. DA-K was wearing single-use disposable gloves. While wearing gloves, DA-K, opened two bags of bread and took out slices of bread for sandwiches. (The outside of the bag is a contaminated surface.) After putting chicken salad onto bread and still wearing the same pair of gloves, DA-K reached into bag of lettuce and pulled out leaves of lettuce and patted lettuce leaves on top of chicken salad. DA-K finished making sandwiches, cut sandwiches and wearing same pair of gloves, DA-K then opened up individual plastic containers for the sandwiches to go into. Followed up observation with an interview with DCM-D, DS-HHH and RN-C and discussed the potential for DA-K ' s gloves becoming contaminated from touching the outside of the bread bag and the individual plastic containers. DS-HHH agreed and stated will work on a different way of making sandwiches to prevent that from happening.

On 12/6/2016, 8:58 AM, in dishmachine room, accompanied by Dietary Clinical Manger-D (DCM-D), Dietary Supervisor-HHH and Registered Nurse-C (RN-C), observed Dietary Aide-N (DA-N) leave dishmachine room wearing gloves. Observed DA-N return to dishmachine room and while wearing same gloves, rest gloved hand on soiled edge of dish machine. DA-N then proceeded to grab two stacks of clean plates with thumb resting on surface of plate where food is placed. Per interview with DCM-D, DS-HHH and RN-C at the time of observation, discussed the potential for contaminating plate by DA-K ' s soiled gloves. According to ServSafe, a nationally recognized professional standard of practice for food safety used by the hospital per Registered Dietitian-GGG, hands must be washed when touching anything that may contaminate hands, such as dirty equipment.
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
Based on record review, observation and staff interviews, the facility failed to construct, install and maintain the building systems to ensure a physical environment that was safe for patients and staff. The cumulative effects of the environment deficiencies result in the hospital's inability to ensure a safe environment for all patients and staff.

42 CFR 482.41- Condition of Participation: Physical Environment IS NOT MET. These deficiencies have the ability to affect 247 in-patients and an unknown number of outpatients, staff and visitors who were present during the survey.

Findings include:

The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags:

K- 0133 - Multiple Occupancies - Construction Type - - Bld: 01
K- 0161 - Building Construction Type And Height - - Bld: 01
K- 0211 - Means Of Egress - General - - Bld: 01
K- 0222 - Egress Doors - - Bld: 01
K- 0223 - Doors With Self-Closing Devices - - Bld: 01
K- 0225 - Stairways And Smoke proof Enclosures - - Bld: 01
K- 0271 - Discharge From Exit s - - Bld: 01
K- 0281 - Illumination Of Means Of Egress - - Bld: 01
K- 0293 - Exit Signage - - Bld': 01
K- 0311 - Vertical Openings - Enclosure - - Bld: 01
K- 0321 - Hazardous Areas - Enclosure - - Bld: 01
K- 0341 - Fire Alarm System - Installation - - Bld: 01
K- 0345 - Fire Alarm System - Testing And Maintenance - - Bld: 01
K- 0351 - Sprinkler System - Installation - - Bld: 01
K- 0352 - Sprinkler System - Supervisory Signals - - Bld: 01
K- 0353 - Sprinkler System - Maintenance And Testing - - Bld: 01
K- 0355 - Portable Fire Extinguishers - - Bld: 01
K- 0363 - Corridor - Doors - - Bld: 01
K- 0372 - Subdivision Of Building Spaces - Smoke Barrie - - Bld: 01
K- 0374 - Subdivision Of Building Spaces - Smoke Barrie - - Bld: 01
K- 0511 - Utilities - Gas And Electric - - Bld: 01
K- 0541 - Rubbish Chutes, Incinerators, And Laundry Chutes - - Bld: 01
K- 0712 - Fire Drills - - Bld: 01
K- 0912 - Electrical Systems - Receptacles - - Bld: 01
K- 0918 - Electrical Systems - Essential Electric Systems - - Bld: 01
K- 0920 - Electrical Equipment - Power Cords And Extension Cords - - Bld: 01
K- 0100 - General Requirements - Other - - Bld: 02
K- 0161 - Building Construction Type and Height - - Bld: 02
K- 0211 - Means Of Egress - General - - Bld: 02
K- 0222 - Egress Doors - - Bld: 02
K- 0293 - Exit Signage - - Bld: 02
K- 0323 - Anesthetizing Locations - - Bld: 02
K- 0345 - Fire Alarm System - Testing And Maintenance - - Bld: 02
K- 0353 - Sprinkler System - Maintenance And Testing - - Bld: 02
K- 0355 - Portable Fire Extinguishers - - Bld: 02
K- 0362 - Corridors - Construction Of Walls - - Bld: 02
K- 0363 - Corridor - Doors - - Bld: 02
K- 0374 - Subdivision Of Building Spaces - Smoke Barrie - - Bld: 02
K- 0712 - Fire Drills - - Bld: 02
K- 0918 - Electrical Systems - Essential Electric System - - Bld: 02

K- 0311 - Vertical Openings - Enclosure - - Bld: 03
K- 0321 - Hazardous Areas - Enclosure - - Bld: 03
K- 0345 - Fire Alarm System - Testing And Maintenance - - Bld: 03
K- 0353 - Sprinkler System - Maintenance And Testing - - Bld: 03
K- 0355 - Portable Fire Extinguishers - - Bld: 03
K- 0363 - Corridor - Doors - - Bld: 03
K- 0374 - Subdivision Of Building Spaces - Smoke Barrier - - Bld: 03

K- 0200 - Means Of Egress Requirements - Other - - Bld: 04
K- 0300 - Protection - Other - - Bld: 04
K- 0300 - Protection - Other - - Bld: 05
K- 0500 - Building Services - Other - - Bld: 05
K- 0700 - Operating Features - Other - - Bld: 05

K- 0100 - General Requirements - Other - - Bld: 06
K- 0200 - Means Of Egress Requirements - Other - - Bld: 06
K- 0300 - Protection - Other - - Bld: 06

K- 0100 - General Requirements - Other - - Bld: 07
K- 0200 - Means Of Egress Requirements - Other - - Bld: 07
K- 0300 - Protection - Other - - Bld: 07
K- 0900 - Health Care Facilities Code - Other - - Bld: 07
VIOLATION: LIFE SAFETY FROM FIRE Tag No: A0709
Based on record review, observation and staff interviews, the facility failed to construct, install and maintain the building systems to ensure life safety from fire, that was safe for patients and staff. The cumulative effects of the environment deficiencies result in the hospital's inability to ensure a safe environment for all patients and staff.

42 CFR 482.41(b) - Life Safety from Fire: IS NOT MET. These deficiencies have the ability to affect 247 in-patients and an unknown number of outpatients, staff and visitors who were present during the survey.

Findings include:

The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags:

K- 0133 - Multiple Occupancies - Construction Type - - Bld: 01
K- 0161 - Building Construction Type And Height - - Bld: 01
K- 0211 - Means Of Egress - General - - Bld: 01
K- 0222 - Egress Doors - - Bld: 01
K- 0223 - Doors With Self-Closing Devices - - Bld: 01
K- 0225 - Stairways And Smoke proof Enclosures - - Bld: 01
K- 0271 - Discharge From Exit s - - Bld: 01
K- 0281 - Illumination Of Means Of Egress - - Bld: 01
K- 0293 - Exit Signage - - Bld': 01
K- 0311 - Vertical Openings - Enclosure - - Bld: 01
K- 0321 - Hazardous Areas - Enclosure - - Bld: 01
K- 0341 - Fire Alarm System - Installation - - Bld: 01
K- 0345 - Fire Alarm System - Testing And Maintenance - - Bld: 01
K- 0351 - Sprinkler System - Installation - - Bld: 01
K- 0352 - Sprinkler System - Supervisory Signals - - Bld: 01
K- 0353 - Sprinkler System - Maintenance And Testing - - Bld: 01
K- 0355 - Portable Fire Extinguishers - - Bld: 01
K- 0363 - Corridor - Doors - - Bld: 01
K- 0372 - Subdivision Of Building Spaces - Smoke Barrie - - Bld: 01
K- 0374 - Subdivision Of Building Spaces - Smoke Barrie - - Bld: 01
K- 0511 - Utilities - Gas And Electric - - Bld: 01
K- 0541 - Rubbish Chutes, Incinerators, And Laundry Chutes - - Bld: 01
K- 0712 - Fire Drills - - Bld: 01
K- 0912 - Electrical Systems - Receptacles - - Bld: 01
K- 0918 - Electrical Systems - Essential Electric Systems - - Bld: 01
K- 0920 - Electrical Equipment - Power Cords And Extension Cords - - Bld: 01
K- 0100 - General Requirements - Other - - Bld: 02
K- 0161 - Building Construction Type and Height - - Bld: 02
K- 0211 - Means Of Egress - General - - Bld: 02
K- 0222 - Egress Doors - - Bld: 02
K- 0293 - Exit Signage - - Bld: 02
K- 0323 - Anesthetizing Locations - - Bld: 02
K- 0345 - Fire Alarm System - Testing And Maintenance - - Bld: 02
K- 0353 - Sprinkler System - Maintenance And Testing - - Bld: 02
K- 0355 - Portable Fire Extinguishers - - Bld: 02
K- 0362 - Corridors - Construction Of Walls - - Bld: 02
K- 0363 - Corridor - Doors - - Bld: 02
K- 0374 - Subdivision Of Building Spaces - Smoke Barrie - - Bld: 02
K- 0712 - Fire Drills - - Bld: 02
K- 0918 - Electrical Systems - Essential Electric System - - Bld: 02

K- 0311 - Vertical Openings - Enclosure - - Bld: 03
K- 0321 - Hazardous Areas - Enclosure - - Bld: 03
K- 0345 - Fire Alarm System - Testing And Maintenance - - Bld: 03
K- 0353 - Sprinkler System - Maintenance And Testing - - Bld: 03
K- 0355 - Portable Fire Extinguishers - - Bld: 03
K- 0363 - Corridor - Doors - - Bld: 03
K- 0374 - Subdivision Of Building Spaces - Smoke Barrier - - Bld: 03

K- 0200 - Means Of Egress Requirements - Other - - Bld: 04
K- 0300 - Protection - Other - - Bld: 04
K- 0300 - Protection - Other - - Bld: 05
K- 0500 - Building Services - Other - - Bld: 05
K- 0700 - Operating Features - Other - - Bld: 05

K- 0100 - General Requirements - Other - - Bld: 06
K- 0200 - Means Of Egress Requirements - Other - - Bld: 06
K- 0300 - Protection - Other - - Bld: 06

K- 0100 - General Requirements - Other - - Bld: 07
K- 0200 - Means Of Egress Requirements - Other - - Bld: 07
K- 0300 - Protection - Other - - Bld: 07
K- 0900 - Health Care Facilities Code - Other - - Bld: 07
VIOLATION: VENTILATION, LIGHT, TEMPERATURE CONTROLS Tag No: A0726
Based on observation, record review and interview, the facility failed to maintain food refrigerator and freezer temperatures within recommended parameters in 4 of 7 patient refrigerators observed (Critical Care Unit, Rehabilitation Unit, Medical Oncology Unit, and Labor and Delivery) and provide proper ventilation in soiled linen storage/utility rooms in 2 of 2 areas observed (2nd floor Legacy Building , Emergency Department). This deficient practice had a potential to affect all 218 patients on census during the survey.


Findings include:

Per review on 12/6/2016, facility policy "Patient Refrigerator/Freezer Temperature Monitoring" No. GL-6085, dated 12/2/2013, states: "Patient food refrigerator temperatures are inspected daily during the days of department operation. ...b. For inpatient departments/units, the charge nurse or designee assigned by the charge nurse will complete this task daily. 2. The assigned staff member is responsible for checking the temperature to ensure the temperature is within range and documents this activity on the log sheet. 3. If out of range: Charge nurse or department staff member must document the corrective action taken... 6. Completed log sheets are reviewed and initialed weekly by the manager to monitor compliance, identify improvement opportunities, and follow up on compliance to consistently meet standardized processes."

On 12/5/2016 at 1:15 PM, the Critical Care Unit's inpatient nourishment room contained a refrigerator with a sign noting "Temperature Range should be 0-4 degrees Celsius or 32-40 degrees Fahrenheit. The thermometer on the refrigerator read "21" degrees Celsius. The temperature monitoring log for December documents a daily temperature reading of 23.3 - 25.1 degrees. The documentation does not state if the temperature is in Celsius or Fahrenheit and does not fall within range for either parameter. Review of the November 2016 Refrigerator Temperature monitoring log reveals temperatures out of range on 25 of 30 days. Per the log, corrective action of "work order submitted" occurred on 11/1/2016 and 11/23/2016. Review of the facility's work orders show that the thermostat was reset on 11/23/2016, there is no documentation of a work order dated on or around 11/1/2016.

On 12/5/2016 at 2:00 PM, the Rehab Unit's nourishment room refrigerator thermometer read "22" degrees Celsius, more than the maximum allowed temperature. The log does not list any action taken for out of range temperatures.

On 12/6/2016 at 10:45 AM, the Medical Oncology Unit's nourishment room freezer temperature monitoring log documents a temperature of -10 Celsius on 12/4/2016 and 12/5/2016. This is less than the minimum temperature of -18 degrees Celsius. There are no corrective actions listed for the out of range temperatures.

During an interview on 12/7/2016 at 10:30 AM, Manager S stated the thermometers on the refrigerators have to be set daily to monitor the internal temperatures of the refrigerators and freezers or it reads the room temperature. Manager S was unable to state how staff are instructed on monitoring the temperatures or what to do if they are out of range. Manager S stated "I sign the log every week, but I guess I'm not looking to ensure it [the temperature] is in range."






Observations on 12/5/16 at 1:40 PM during tour with QQQ (Labor and Delivery manager), U (Administrative Director), and II (MD) showed a mini refrigerator in labor and delivery room 2. Per interview with QQQ at the time of the tour, QQQ revealed staff do not have evidence of daily temperature checks on this refrigerator; refrigerator is used for patient and family storage of food.

Ventilation Observations:

While on tour of the facility on 12/6/16 with Staff LL (director of surgery), Staff SSS (clinical director of Interventional Radiology, Cath Lab), Staff TTT (emergency department operations lead), Staff UUU (safety manager), Staff VVV (clinical manager), and Staff WWW (maintenance operations worker), surveyors observed that the Soiled Hold Room HM2824 in the 2nd Floor Legacy prep/recovery area was not in negative pressure relative to corridor, the room was instead positive; and the Soiled Utility Room HM1720 in the 1st Floor emergency department was not maintained in negative pressure relative to corridor in accordance with the AIA guidelines referenced in the CDC guidelines. The pressure relationship between the soiled hold and utility rooms was checked by determining the airflow direction through the door under-cut. A thin tissue paper strip was held at the door undercut to determine if there was airflow through the door under-cut from the corridor side (clean environment) to room (dirty environment). Per interview with the above staff at the time of observation, Staff agreed the soiled utility rooms were not in negative pressure.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observations, record review and interview staff failed to implement an effective infection prevention program to minimize the risk for exposure and/or transmission of potential infectious pathogens in 10 of 20 areas observed (Linen Storage/Handling, Renal Dialysis, Gastrointestinal (GI) Lab, Surgery, Urology, Cardiology, Obstetrics, Endocrine, Critical Care unit). This has the potential to affect all 218 patients on census at the time of the survey.

Findings include:

Linen storage and handling:

Review of policy titled, "Asepsis, Patient Supplies & Environment" last revised 10/3/2014 states to...
-Cover clean linen to prevent contamination
-Place dirty linen into a leak-resistant laundry bag
-Secure the soiled linen
-Linen sorters will wear gowns and gloves
-Prevent contact of one's body/personal clothing and the soiled items

On 12/5/16 at 1:40 PM while touring the Short Stay Unit with U (Administrative Director), observed patient washcloth and towel uncovered on counter top in unoccupied "clean" patient rooms #5161, 5113, 5118, and 5124.

On 12/5/16 at 1:50 PM while touring the Labor and Delivery unit observed the following:
-Patient gowns hanging on bathroom door hook in unoccupied "clean" Recovery room 1 and Observation room 1 and 2.
-Patient bed sheets uncovered in baskets in clean supply room
-Yellow gowns and blue scrubs uncovered in baskets in clean supply room

On 12/5/16 at 2:20 PM while touring the Post Partum unit, observed uncovered patient washcloth and towel in bathroom near tub in unoccupied "clean" rooms #5850 and 5851.

On 12/5/16 at 2:45 PM while touring the Pediatric Unit, observed uncovered washcloth and towel on side table in unoccupied "clean" room #5864.

Per interview with RRR (clinic manager) at 3:00 PM, "RRR" revealed after housekeeping cleans the rooms, housekeeping sits out clean washcloth and towel for the next patient admission. Per "RRR" patient gowns are hung on bathroom hook for the next patient admitted into the room.
Per interview at 3:00 PM, "U" revealed clean linen should be covered at all times.

On 12/7/16 at 10:40 AM, observed the dirty linen shoot with U (Administrative Director) and OOO (Director of Linen). Soiled linen was not secured and falling out of the laundry bags thrown down the linen shoot from the patient floors. Observed Laundry staff pick up the bags with short sleeve scrubs, exposing arms and clothes to potential contaminates. Per interview with "OOO" at the time of observation, laundry sorters should have protective gowns on while handling soiled linen.

On 12/7/16 at 10:45 AM, while touring the dirty laundry holding area with "U" and "OOO", observed soiled linen falling out of laundry bags in large bins. Soiled linen was not secured as per policy.

On 12/7/16 at 11:00 AM while touring the main clean laundry storage room with U (Administrative Director) and OOO (Director of Linen), observed the following:
-Holes in linen cart covers exposing clean linen to potential contamination
-Linen cart covers unzipped exposing clean linen to potential contamination
-Dust and Debris on floor behind linen carts
-Dust and Debris on top of linen cart covers
-large dust particles in ceiling vent

Per interview with "OOO" at the time of tour, linen cart covers should be zipped and clean linen should be covered at all times. Per "OOO" the linen cart covers are cleaned semi-annually and linen cart covers are replaced as needed. Per interview with "U" at the time of the tour, the ceiling vents in the main clean laundry storage room are not routinely cleaned.


Renal Dialysis:

Policy titled, "Infection Control: Renal Dialysis" last revised 3/9/16 states the following:
-Dialysis staff will wear disposable gloves whenever they are caring for a patient or touching any patient equipment at the dialysis station.
-Goggles with a mask or a face shield will be worn when initiating or discontinuing dialysis with a fistula or graft, stripping machines, and when the possibility of blood contamination to the face is anticipated.
-"Patient Zone" surfaces such as dialysis machines, laminates hanging from the machine IV pole are disinfected between patients.

Observations on 12/5/16 at 3:15 PM showed staff KKK (IV Therapy team) inserting an Intravenous (IV) Catheter into Patient #35's hand with assistance from JJJ (IV Therapy Team). "KKK" donned glove on right hand and proceeded to insert catheter and draw blood with no glove on the left hand. When "KKK" removed the needle from the catheter, blood drained out of the hub and dripped onto "KKK's" finger. "JJJ" donned gloves and assisted with securing patient #35's IV in place, "JJJ" then proceeded to go into "clean" supply cart to obtain supplies without first removing "dirty" gloves and performing hand hygiene.

On 12/6/16 at 11:05 AM observed MMM (Dialysis LPN) discontinuing Patient # 36's dialysis treatment using an Arteriovenous Fistula. "MMM" disconnected patient # 36's blood lines and removed Patient # 36's fistula needles without donning personal protective equipment (PPE) covering "MMM's" mouth and nose to prevent exposure to blood pathogens. "MMM" touched Patient #36's dialysis machine without gloves on 4 times.

Per interview at 11:30 AM with LLL (Dialysis Manager), "LLL" revealed staff should wear gloves before touching patient's dialysis machine and "MMM" should wear face shield or mask to protect nose and mouth from potential blood splatter.

On 12/6/16 at 11:20 AM observed "MMM" cleaning the dialysis machine and chair after patient 36's dialysis treatment. "MMM" did not clean the dialysis machine Hansen connector tubing, laminates hanging from the IV pole attached to the dialysis machine, and IV pole after patient 36's dialysis treatment.

Main Clinic Building:

Observations on 12/6/16 while on tour of Main Clinic Building between 1:50 PM and 3:45 PM with U (Administrative Director) showed the following:
4th floor Urology clinic:
-Patient rooms #19 and 20 have dust and debris in cabinet under sink.

3rd floor Cardiology/Obstetrics clinic:
-Patient rooms 303 and 305 have dust and debris in cabinet under sink.
-Patient rooms CN3005 and CN3004 have dust and debris in cabinet under sink and in cabinet near window.
-Patient room CN3032 has rust colored residue and dust and debris in cabinet under sink.

1st floor Endocrine clinic:
-Patient room CSE1036 has dust and debris under sink





GI Lab

The facility policy titled "Asepsis - Patient Supplies and Environment" dated 10/3/2014 was reviewed on 12/6/2016 at 12:00 PM. This policy states under "Medical/Surgical Supplies ...a) Store off floor, b) Store away from potentially contaminated surface, c) Keep away from wet areas or areas that pose a risk splashing".

On 12/6/16 at 1:30 PM observed the following in the Gastrointestinal (GI) Lab accompanied by Director of Quality DD:
-Multiple packages Endoscopic lumens/biopsy needles/GI supplies stored hanging on all walls of the GI procedure room exposed and non-covered.
-Seven boxes of Esophageal stents stored on the floor of the GI clean utility room

An interview was conducted with GI Technician EE on 12/6/16 at 1:50 PM who stated the esophageal stents should not have been stored on the floor. GI Technician EE also stated GI supplies hanging on the walls of the GI procedure room are not covered during procedures and would not be cleaned between each case.

Surgery:

The facility policy titled " Asepsis - Patient Supplies and Environment " dated 10/3/2014 was reviewed on 12/6/2016 at 12:00 PM. This policy states under " Medical/Surgical Supplies ...a) Store off floor, b) Store away from potentially contaminated surface, c) Keep away from wet areas or areas that pose a risk splashing.

The facility policy titled " Asepsis -Surgical Procedure / Sterile Technique " dated 8/30/16 was reviewed on 12/6/16 at 12:00 PM. This document states " Don hair covering. Cover all hair and facial hair (beard, moustache and sideburns) before entering the semi-restricted and restricted areas. "

On 12/6/2016 at 9:20 AM observed the following in the Surgical Department accompanied by Director of Quality EE and Medical Doctor FF:
-Operating Room (OR) 220 contained surgical supplies stored on the countertop and an open non-covered rack.
-On 12/6/16 at 10:42 AM observed Certified Surgical Technician GG wearing skull cap with exposed hair on back of neck/head, Registered Nurse HH with exposed hair around front and sides of bouffant cap, and Certified Registered Nurse Anesthetist II with exposed hair around sides of bouffant cap, and MD JJ wearing a skull cap with exposed hair on back of neck/head in OR 5 with Patient #1 on OR table and surgical supplies opened.
-OR table strap in OR 5 used on Patient # 1 was observed to have missing/ripped vinyl that exposed the padding which is not a cleanable surface

An interview was conducted with OR Manager KK on 12/6/16 at 9:30 AM. OR Manager KK stated OR supplies in room 220 are not removed or covered during cases. OR Manager KK stated the facility has ordered a covered cart for this room but has not implemented removing the supplies in the interim.

An interview was conducted with Director of Quality DD on 12/6/16 at 9:20 AM. Director of Quality DD acknowledged the OR table strap in OR 5 needs to be replaced.

An interview was conducted with Administrator/Director of Surgery LL on 12/6/2016 at 12:40 AM. Administrator/Director stated the facility policy states all hair and beards should be covered but the surgeons argue their standard of practice is to allow skull caps which do not cover all hair. Administrator/Director LL acknowledged the facility current policy is that all hair should be covered.

The facility policy titled " Hand Hygiene " dated 6/22/2015 was reviewed on 12/6/2016 at 5:00 PM. This document states " wash hands with soap and water: ...b. After removal of gloves.

On 12/6/2016 at 10:29 PM observed Anesthesia Technician MM remove gloves, and then remove clean supplies from Anesthesia Cart draw without the benefit of hand hygiene.

On 12/6/2016 at 10:34 PM observed Environmental Services Technician NN remove gloves and leave OR 5 without the benefit of hand hygiene.

An interview was conducted with Director of Quality DD on 12/6/2016 at 10:45 AM. Director of Quality DD acknowledged observing Environmental Services Technician NN and Anesthesia Technician MM not washing hands after glove removal. Director of Quality stated the expectation is to perform hand hygiene after glove removal.





Food Storage and Expiration:

The facility policy titled "Foodservice Infection Control" dated 9/2/2016 was reviewed on 12/7/2016 at 9:00 AM. This document states "Food storage on Nursing Units ...expiration dates of nutrition supplement products will be reviewed routinely. Expired products will be taken to purchasing agent's office.
On 12/5/2016 at 1:15 PM the nourishment room refrigerator in the Critical Care Unit contained 3 cartons of milk expired 12/2/2016; sour cream with a use by date of 11/28/2016; opened, undated containers of apple juice and Rejuv beverage and a patient meal dated 11/28/2016.

On 12/5/2016 at 2:00 PM, the nourishment room refrigerator in the Inpatient Rehab Unit contained opened, undated containers of apple juice and Rejuv beverage.

The findings were confirmed at the time of the observations with Manager S. Manager S stated the dietary staff is responsible for expired food items and the nursing staff "should be dating" food and drink items when they are opened.

On 12/5/2016 observed expired orange Jello with an expiration date of May 2016 of the 2nd floor of the East Building.

An interview was conducted with Clinical Manager OO on 12/7/2016 at 1:45 PM. Clinical Manager OO stated the expiration date should be checked by the volunteer or the person stocking the food supplies for outdates. Clinical Manager OO stated they do not have a process or schedule to check for outdated food.
VIOLATION: SURGICAL PRIVILEGES Tag No: A0945
Based on observation, record review and interview this facility failed to establish a credentialing process to grant specific surgical privileges for Certified First Surgical Assistants in the Operating Room in 15 of 15 Certified Surgical Assistants currently employed (PP, RR, SS, TT, PP, UU, VV, WW, XX, YY, ZZ, AAA, BBB, CCC, DDD). This deficiency has the potential to affect all surgical patients at this facility.

Findings include:

The facility job description for Certified First Surgical Assistant dated 6/3/2016 was reviewed on 12/7/16 at 8:30 AM. This document states "11. Assists with closure of incision by applying sutures and dressings. 12. Assists with opening incision, clamps, cuts, ties, vessels to control bleeding; keeps operative site dry by use of suction and cautery."

On 12/6/2017 at 10:00 AM observed Certified First Surgical Assistant PP suturing Patient #31's abdomen in OR 5. MD JJ was in the OR 5 at the time of observation.

On 12/6/2017 at 10:00 AM at the time of the observation OR Manager KK stated Certified First Surgical Assists are able to close under the supervision of the MD and are trained and certified to do so.

On 12/7/2016 at 9:00 AM reviewed personnel file for Certified First Surgical Assistant PP accompanied by Manager of Credential Services QQ. Certified First Surgical Assistant PP's personal file does not contain documented evidence of specific privileges and credentialing to perform surgical procedures that is reviewed a minimum of every two years.

On 12/7/2016 at 9:10 AM Manager of Credential Services QQ stated "it is not our current practice to credential and privilege Certified First Surgical Assistants."

On 12/7/2016 at 12:14 PM reviewed a list of currently employed Certified First Surgical Assistants provided by Manger of Credential Services QQ. There are currently 15 Certified First Surgical Assistants, including Surgical Assistant PP that have not been credentialed or privileged. This was confirmed in interview with Manger of Credential Services QQ at the time of the review.
VIOLATION: REASSESSMENT OF DISCHARGE PLANNING PROCESS Tag No: A0843
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, staff failed to evaluate the efficacy of the discharge planning process for 1 of 1 discharge planning service and 1 of 5 discharged patients reviewed (23) in a sample of 30. This deficiency has potential to affect all 218 patients on census during this survey.

Findings include:

Per review on 12/7/2016, facility policy "Social Services Inpatient Discharge Planning" No. SocS-1300, dated 6/27/2016, states: "Social worker begins discharge planning based on needs identified in the initial assessment and reassesses based on change in patient condition, available supports, and post hospital care needs."

During an interview on 12/7/2016 at 2:00 PM with Social Services Manager EEE and MD FFF, FFF stated the facility had a "30 day readmit group" that met monthly but "most readmissions are not preventable." FFF stated "there was no actionable data to work with so we [the group] haven't met in 6 months." When asked about reviewing readmissions to look for areas of improvement in the discharge planning process, FFF stated "most readmissions are due to progression of disease."

Per medical record review on 12/7/2016 at 1:10 PM, Patient #23 was readmitted to the facility on [DATE] after being discharged on [DATE]. Review of Patient #23's discharge planning documentation on 11/21/2016 revealed Patient #23 had a change in mental status on 11/20/2016. There is no reassessment documenting that the post-acute facility was able to meet Patient #23's needs at the time of discharge on 11/21/2016.

During an interview on 12/7/2016 at 3:00 PM, Manager EEE stated Patient #23 mental status "went up and down" during the hospitalization . EEE stated the assisted living facility came to the hospital to meet the patient prior to discharge, but must have met with the patient "on a good day" and agreed to accept Patient #23 post-discharge.

The Social Services Initial assessment dated [DATE] states: "[Patient #23] will not be able to return to [Assisted Facility]. Staff at this facility are not able to appropriately meet [Patient #23's] needs." The assessment does not include an evaluation of Patient #23's current needs. During an interview on 12/7/2016 at 3:00 PM, Manager EEE stated the Social Workers do not include the patient's ability to perform activities of daily living in their assessments.

When asked if or how Patient #23's record would be reviewed to evaluate potential gaps in discharge planning that may have contributed to Patient #23's readmission, Manager EEE had no comment.
VIOLATION: DEATH RECORD REVIEWS Tag No: A0892
Based on record review and interview, the facility failed to review and evaluate missed death referrals to the Organ Procurement Organization in 1 of 1 quality process reviewed (death referral reconciliation). This deficiency has the potential to affect all patient deaths at this facility.

Findings include:

Per review on 12/7/2016, facility policy "Donation: Organ/Tissue/Eye" No. GL-6145, dated 8/9/2016, states: "...all deaths and patients meeting the Clinical Triggers for Organ Donation, imminent death, shall be reported to the Organ Procurement Program (OPO) in a timely manner... Timely Referral: Referral to Stat line within ONE hour of meeting the Clinical Triggers for imminent death... or within ONE hour of confirmed death of a non-ventilated patient."

During an interview on 12/7/2016 at 8:30 AM, Nursing Systems Specialist BB was unable to provide reconciliation information regarding death referrals to the OPO. Per BB, "I think that is being done through HIM [Health Information Management]."

Review of the facility's referral list on 12/7/2016 at 2:05 PM reveals the facility had 6 missed patient referrals in 2016. BB stated there was no ongoing monitoring of the facility's death referral rate because "I didn't know we were supposed to do that."