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.

AURORA BAYCARE MEDICAL CTR 2845 GREENBRIER RD GREEN BAY, WI 54311 Dec. 8, 2016
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
Based on record review and staff interview the facility failed to ensure the safety of other patients by self reporting 1 of 1 surgical fire (patient #1) at the facility according to protocol and federal requirements. This could potentially impact all patients who receive care at this facility.

Findings include:

Staff failed to report 1 of 1 (patient #1) surgical fire. See tag 714

The impact of these failures and the serious outcome in response to these failures has the potential to affect the health and safety of all patients receiving care at this facility.
VIOLATION: FIRE CONTROL PLANS Tag No: A0714
Based on record review and interview, the facility staff failed to follow a written fire control plan that included provisions for prompt reporting of fires. This deficiency could affect all patients admitted to this facility.

Findings include:

Per review of policy titled Patient Safety Event Reporting/Sentinel Event Management, policy # ADM-066, dated 8/15 stated in part under, H. Sentinel Event: A patient safety event that reaches a patient and results in any of the following: xiii. Fire, flame or unanticipated smoke, hear, or flashes occurring during an episode of patient care. Under Procedures: A. Reporting 1. Reporting of patient safety event using the Fair and Just Principles of Aurora BayCare Medical Center, is encouraged. Reporting is necessary from a systems perspective to reduce patient safety event and improve outcomes.

Per review of incident report # 1 on 12/8/16 at 10:00 AM, indicated that on 2/29/16, an incident occurred in the Outpatient Surgery Area- East side. Report states the following: "Surgeon used cautery (instrument used to destroy abnormal tissue by burning) and yelled fire. Surgeon removed the drapes and threw them on the floor. Dr. (L) removed oxygen mask from the patient and removed the hose from the anesthesia machine. Surgical technician placed saline saturated towels on patient and grabbed a pitcher of saline put on patient. Fire lasted approximately 1 minute."

Per interview with Chief Support Officer G on 12/8/16 at 1:30 PM, Chief Support Officer G stated being aware that all building fires are required to be reported within 72 hours to the state, however because this incident did not trigger a fire alarm, sprinkler activation, or response of the local fire department, the incident was not reported to Chief Officer G. Chief Officer G stated he was not aware that this type of incident fell under a mandatory report to the state.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation, interview, and record review, staff at this facility failed to follow policy regarding hand hygiene in 1 of 1 surgical observation (Patient #11, Staff F), and failed to follow policy regarding surgical attire in 1 of 1 surgical observation (Patient #11, Staff H). Failure to follow policy and recommended practices for infection control has the potential to affect all patients under going surgery at this facility.

Findings include:

The facility's policy titled, "Hand Hygiene/Surgical Hand Scrub," #IC [facility's abbreviation for Infection Control]-301, dated 2/16, was reviewed on 12/8/2016 at 1:30 PM. The policy states in part, "Hand rub (alcohol-based waterless hand sanitizer) c. Before and after patient contact. After contact with a patient's intact skin (as in taking a pulse or blood pressure, or lifting a patient)...h. After removing gloves...i. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient."

The facility's policy titled, "Proper Attire in the Operating Room Environment," #PERI [facility abbreviation for periOperative]-008, dated 10/15, was reviewed on 12/8/2016 at 1:30 PM. The policy does not address skull caps but does state, "Staff may wear a personal cloth hat only if it is completely covered by a disposable bonnet worn over the top."

On 12/8/2016 between 11:55 AM and 12:10 PM, the following observations were made in the Operating Room where Patient #11 was to undergo a surgical procedure on the right hand/wrist:

At 12:01 PM, Registered Nurse F removed a pair of blue gloves after positioning Patient #11 on the operating table. Hand hygiene was not performed and Registered Nurse F proceeded to handle inanimate objects in the vicinity of Patient #11, and then apply sterile gloves to perform the surgical site preparation with Choloraprep.

At 12:05 PM, Surgeon H entered the operating room after performing a surgical scrub. Surgeon H had a skull cap type covering on H's head, exposing the nape of the neck below the hair line and both ears.

In an interview with Surgery Supervisor E on 12/8/2016 at 12:10 PM regarding these observations, Supervisor E stated, "Yes, I saw that," in reference to both Registered Nurse F's missed opportunity for hand hygiene, and Surgeon H's exposed ears/neck.

In an interview with Director of Surgical Services C on 12/8/2016 at 12:15 PM regarding the observations in the operating room, Director C stated that the facility is aware of the issues with the skull caps and exposure of skin and that the facility is currently working on the policy for surgical attire.

In an interview with Director C regarding the surgical attire policy not specifically addressing skull caps on 12/8/2016 at 3:10 PM, Director C stated, "They are supposed to cover the skull caps, it's in the revision."