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.

FOND DU LAC COUNTY ACUTE PSYCH UNIT 459 E FIRST ST FOND DU LAC, WI April 19, 2017
VIOLATION: PATIENT VISITATION RIGHTS Tag No: A0217
Based on record review and interview, the facility failed to include information in patient rights brochure regarding not restricting visitation based on race, color, national origin, religion, sex, gender identity, sexual orientation, or disability in 1 of 1 patients rights brochure review. This deficient practice has the potential to affect all patients admitted to this facility.

Finding include:

Per review of Client Rights and Grievance Procedure Brochure on 4/17/17 at 11:00 AM, the brochure dated 12/2008, stated "You may see visitors daily. You may designate who may visit." There is no indication that the facility may not restrict visitation based on race, color, national origin, religion, sex, gender identity, sexual orientation, or disability.

Per interview with Director of Nursing C on 4/18/17 at 2:00 PM, Director of Nursing C confirmed that the "brochure does not list that the facility can not restrict visitation based on race, color, national origin, religion, sex, gender identity, sexual orientation, or disability".
VIOLATION: GOVERNING BODY Tag No: A0043
Based on record review and interview, the governing body failed to ensure staff followed governing body's policies and procedures to conduct and evaluate staff performance to ensure care was provided in a safe and effective manner on 6 of 7 licensed staff, L, M, N, O, P, and Q. This deficient practice extends to all licensed staff at this hospital and has the potential to affect the quality of care received by all 21 inpatients at this facility during this survey.

Findings include:

Review of policy titled Fond Du Lac County Policy and Procedure Governing Annual Performance Evaluations dated 3/2/2012 was completed on 4/19/17 at 10:55 AM. The policy states "all employees will receive an annual performance evaluation performed by their immediate supervisor... Purpose of the Evaluation Program ... To improve performance by describing strengths and weaknesses of employee performance, urging improvement of any weaknesses, and identifying areas where employees can gain additional knowledge and skills."

Review of credentials with Payroll Assistant S on 4/18/2017 at 1:10 PM revealed Alcohol and Other Drug Abuse (AODA) Counselor L with hire date of 8/03/81, last performance evaluation (PE) was done in 2008, Occupational Therapist M hire date was 7/09/01, last PE done in 2009, Registered Nurse N with hire date of 5/09/88, last PE done in 2002, Licensed Practical Nurse O with hire date of 6/29/82, no PE completed, Nurse Assistant P with hire date of 6/03/08, last PE done in 2013, and Nursing Assistant Q with hire date of 7/18/14 with no PE completed. Payroll Assistant S stated the credentials folders included the last performance evaluation records for the listed staff.

An interview was conducted with Deputy Director A on 4/19/2017 at 10:55 AM which confirmed the lack of annual performance evaluations. A stated that there was not enough time to conduct performance evaluations or "shuffle the paperwork" on each employee on an annual basis.
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
Based on medical record review and staff interview, the governing body failed to establish a policy that allowed staff to review patient complaints in 3 of 3 patient complaints reviewed (patient #2, 3, and 4). This deficient practice has the potential to affect all patients receiving care at this facility who filed a complaint.

Findings include:

Per review on 4/19/2017 at 2:00 pm of Facility policy titled Grievance Procedure, Directive # 01-074-01, revision date 11/26/2012 stated in part on page 5. The Client Rights Specialist shall have full access to all information needed to investigate the grievance, all relevant areas of the program names in the grievance, and all records pertaining to the matters raised in the grievance. If necessary the Client Rights Specialist shall obtain all the appropriate consents by signed release of information documentation to assess all records. The inquiry of the Client Rights Specialist may include questioning staff, the client or clients on whose behalf the grievance was presented, other clients, reviewing applicable records and charts, examining equipment and materials, and other necessary activity in order to form an accurate, factual basis for the resolution of the grievance.

When an inquiry requires access to confidential information protected under s.51.30 Stats., and the Client Rights Specialist does not otherwise have access to the information under the exception found in s. 51.30(4)(b), Stats., the client, or the guardian or parent of the client, if the guardian or parent's consent is required, may be asked to consent in writing to release of that information to the Client Rights Specialist and other persons involved in the grievance resolution process. The Client Rights Specialist may proceed with the inquiry only if written consent is obtained.

Per review on 4/19/2017 at 2:00 PM of the complaint report completed by patient #2, the complaint is documented as being received on 6/20/2016. Patient #2 stated the staff was unprofessional and talked about confidential patient information in front of other patients. There was no documentation of investigation or follow up of patient #2's complaint.

Per review on 4/19/2017 at 2:05 PM of the complaint report completed by patient #3, the complaint is documented as being received on 6/20/2017. Patient #3 stated the staff was heard by other patients discussing patient issues. There was no documentation of investigation or follow up of patient #3's complaint.

Per review on 4/19/2017 at 2:10 PM of the complaint report completed by patient #4, the complaint is documented as being received on 6/21/2016. Patient #4 stated that staff talks negatively about one another around patients and staff have shared confidential patient information in front of other patients. Clients Right Specialist K completed a letter to complainant/patient #4 on 7/14/2016 stating "I received a written complaint from you, while you were on our inpatient unit. I attempted to call your cell phone but the number has been changed or disconnected. I believe the issue has resolved itself since you are no longer at our facility. If you disagree, please contact me by: July 25th, 2016 if you would like a resolution to your grievance". There was no documentation indicating an investigation or follow up of patient #4's complaint.

Per interview with Client Rights Specialist K on 4/18/2017 at 1:15 PM, Client Rights Specialist K stated once a complaint report is received, an attempt is made to reach out to the complainant to obtain details regarding the complaint. If the complainant does not respond to the phone call, a letter is sent out to the complainant and the complaint is considered closed. Client Rights Specialist K stated did not complete an investigation for complainant #2, 3, or 4, as no response was received from the complainants. Client Rights Specialist K sent an email to Director of Nursing C to pass along the patient concerns in the complaints.

Per interview with Director of Nursing C on 4/19/2017 at 8:40 AM, Director of Nursing C stated "just because a patient is discharged does not dismiss the complaint, all complaints need to be investigated". Director of Nursing C also stated that the "patient complaints could have been investigated by staff and patient interviews".
VIOLATION: USE OF VERBAL ORDERS Tag No: A0407
Based on observation, record review and interview the facility failed to minimize verbal orders and do a proper read back per policy in 1 of 1 observations. This deficient practice has the potential to affect all 21 current inpatients at the time of this survey.

Findings include:

Reviewed facility policy titled "Verbal M.D. Orders" dated December 1, 1991 on 4/18/17. This document states "When the nurse talks with the M.D. [Medical Doctor], the nurse should repeat the order to the M.D. The nurse is responsible for asking any questions about the order.

On 4/18/17 between 12:00 PM and 12:45 PM observed Medical Director D give verbal orders to RN H repeatedly during the care planning conference for all current inpatients. RN H took notes on these orders throughout the conference. At 12:45 PM, after the care planning conference, RN H went to the nursing station on the Acute Inpatient Unit and proceeded to write the verbal orders in the patient's charts. At no time did RN H repeat back or confirm the orders with Medical Director D.

On 4/18/17 at 3:45 PM conducted an interview with Director of Nursing C. Director of Nursing C agreed that verbal orders should be kept to a minimum and confirmed that RN H and Medical Director D did not follow the facility policy to repeat back orders to promote safety.
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
A recertification survey for the Life Safety Code compliance was conducted by the Wisconsin Division of Quality Assurance on 4/17/17. The Fond du Lac County Acute Psych Unit, Fond du Lac, was found to be NOT in substantial compliance with the requirements of the following applicable regulations:

42 CFR 482.41 Condition of Participation: Physical environment was NOT MET
42 CFR 482.41 (b) Standard: Life safety from fire was NOT MET
NFPA 101 (2012 edition) - Life Safety Code was NOT MET

Findings include:

The Fond du Lac County Acute Psych Unit was found not to have a safe environment, properly constructed and maintained to protect the health and safety of patients based on the following.

K281 - failure to provide 2-bulb lighting fixture, or two lighting units in all exit discharge;
K324 - failure to provide automatic electric power shut-off to all electric cooking equipment;
K345 - failure to ensure automatic dialer components of fire alarm system are tested for phone line failure.
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on observation and interview the staff failed to ensure the hospital environment was maintained in a manner that was safe and sanitary to control the spread of infection and promote patient safety in 1 of 1 acute hospital units. This deficiency has the potential to affect all 21 inpatients in the facility during this survey.

Findings include:

On 4/17/17 at 9:30 AM observed vanity with sink in patient room number 3 with the corner chipped/broken. This corner was covered with white tape. The vanity with sink in room number 4, 6 and 13 were also chipped and cracked with wood showing.

Per interview with Deputy Director A at on 4/17/17 at 9:40 AM, at the time of discovery, Deputy Director A stated the facility recently updated the sinks but not the vanities.





On 4/17/17 at 9:35 AM on tour of nursing unit patient room doors #2, 4, 5, 6, 9, 10, 12, and 13 were noted to have chipped and marred wood present on hinged side of door. On wall outside of patient room #9 & 12 paint chipped below room sign. In seclusion room there is a 12 inch vertical crack in the drywall on wall, 2 areas of chipped paint and 1 area of missing/chipped baseboard not allowing for smooth cleanable surface.

The above findings were confirmed in interview with Deputy Director A at the time of unit tour who agreed areas were in "need of repair".
VIOLATION: LIFE SAFETY FROM FIRE Tag No: A0709
A recertification survey for Life Safety Code compliance was conducted by the Wisconsin Division of Quality Assurance on 4/17/17. The Fond du Lac County Acute Psych Unit, Fond du Lac, was found to be NOT in substantial compliance with the requirements of the following applicable regulations:

42 CFR 482.41 Condition of Participation: Physical environment was NOT MET
42 CFR 482.41 (b) Standard: Life safety from fire was NOT MET
NFPA 101 (2012 edition) - Life Safety Code was NOT MET

Findings include:

The Fond du Lac County Acute Psych Unit was found not to have a safe environment, properly constructed and maintained to protect the health and safety of patients based on the following.

K281 - failure to provide 2-bulb lighting fixture, or two lighting units in all exit discharge;
K324 - failure to provide automatic electric power shut-off to all electric cooking equipment;
K345 - failure to ensure automatic dialer components of fire alarm system are tested for phone line failure.
VIOLATION: REASSESSMENT OF DISCHARGE PLANNING PROCESS Tag No: A0843
Based on interview, the facility failed to have a mechanism in place for ongoing reassessment to track readmissions rates and identify potentially preventable readmissions and the effectiveness of the discharge planning and include in the hospital wide Quality Program in 1 of 1 discharge planning process. This deficiency has the potential to affect all 21 inpatients in the facility during this survey.

Findings include:

An interview was conducted with the Director of Nursing C on 4/17/17 at 2:00 PM who stated "Readmits happen frequently but I do not track them".