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.

FROEDTERT MEMORIAL LUTHERAN HOSPITAL 9200 W WISCONSIN AVE MILWAUKEE, WI 53226 Aug. 21, 2013
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on observation and CDC guidelines for Injection Safety the facility failed to ensure safe and aseptic technique when administering medications in 1 of 1 staff observation (NP D). This could potentially effect all patients undergoing a surgical procedure in IR (Interventional Radiology).


Per CDC Website titled, Injection Safety Medication Administration Questions last updated February 2011; Is it acceptable to use the same syringe and/or needle to administer multiple injections to the same patient (e.g., in the case of numbing a large area of skin or to provide incremental doses of intravenous medication)?(Answer): The safest practice is for a syringe and needle to be used only once to administer a medication to a single patient, after which the syringe and needle should be discarded. This practice prevents inadvertent reuse of the syringe and protects healthcare personnel from harms such as needlestick injuries.
Findings include:

Observations on 8/21/13 beginning at 12:00 PM of Pt #1's surgical procedure for a mediport placement in IR revealed the following issues: NP D took a needle attached to a syringe filled with medication and inserted the needle into Pt #1's chest and administered the medication, NP D then proceeded to remove the needle from Pt #1's chest, remove the syringe from the needle, apply a new syringe filled with medication to the used needle, and then reinserted the used needle into Pt #1's chest to administer additional medication.

The above findings were shared with QC A, Dir B, ICC H, and ICC I on 8/21/13 beginning at 3:45 PM.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation, policy and procedure, staff interview, and AORN(Association of Perioperative Registered Nurse) standards of practice, the facility failed to ensure infection control practices are followed in the acute care dialysis unit and IR (Interventional Radiology) department in 3 of 4 staff observations (NP D, RN F, RN G). This could potentially effect all patient receiving acute inpatient dialysis and patients undergoing IR procedures.


Review on 8/21/13 of the "Invasive Procedure Antisepsis"--Imaging Services P & P last revised 5/10/2013 states, "It is not recommended to turn one's back to a sterile field."

Review on 8/21/13 of "Cleaning and Disinfection" P& P last revised 3/20/2013 states the following;
-The area that includes the Chairside charting device is considered a clean are and not part of the patient station.
-Use clean hands without gloves on computers and keyboards
-Hand hygiene performed after contact with chairside computer and before contact with patient.

Review on 8/21/13 of "Personal Protective Equipment" P & P last revised 3/20/2013 states the following;
-Change gloves and practice hand hygiene between each patient and/or station
-Hand hygiene must always be performed after glove removal
-Avoid touching surfaces with gloved hands that will be touched with ungloved hands

Standard of Practice:
AORN Recommended Practice for Maintaining a Sterile Field--February 2006 states, "The neckline, shoulders, underarms, sleeve cuffs, and gown back are areas of friction and, therefore, are not considered effective microbial barriers. The gown back is considered nonsterile because it cannot be constantly monitored."

Findings include:

Observation in Interventional Radiology Department:

Observations on 8/21/13 beginning at 12:00 PM of Pt #1's surgical procedure for mediport placement revealed the following; while performing this procedure, NP D had back to sterile field and NP D's gown back touched the sterile draping multiple times, allowing for potential contamination of the sterile field.

Shared the above findings with ICC H and ICC I on 8/21/13 beginning at 3:45 PM, staff confirmed this is not an acceptable practice.

Observations in Acute Care Dialysis unit on 8/21/13:

Observations beginning at 12:50 PM, of RN F perform a CVC (central venous catheter) dressing change on Pt #3 at St 6 revealed the following:
Tray table between St 5 and St 6 contained clean packaged patient supplies next to 3 folders, empty lab tube, 2 tape rolls, notebook, and pen. RN F worked at the tray table with gloved hands and with ungloved hands preparing supplies, lab tubes, and charting on patients. The tray table did not reflect a distinct "clean area".
After checking the machine at St 5 with gloved hands, RN F used pen to write on paper at tray table between St 5 and St 6 donning same gloves. RN F then removed gloves, performed hand hygiene, and then touched same pen and paper touched with gloves; RN F did not clean and disinfect tray table before applying patient supplies, RN F then donned gloves, to change the CVC dressing on Pt #3 at St 6. RN F obtained potentially contaminated supplies on tray table and placed it on Pt #3's bed and proceeded to open supplies and prepare the CVC for treatment. RN F then removed safety glasses and face mask and placed on tray table on top of folder. This deficient practice can potentially lead to cross contamination of patient's and staff.

Observations beginning at 1:30 PM of RN G performing initiation of dialysis treatment using AVF(arteriovenous fistula) at St 8 revealed the following:
RN G applied tape to bed rail, after AVF needle insertion RN G removed tape from bed rail and applied same tape to patients skin to hold down gauze. Bed rail was not cleaned and disinfected prior to applying tape. This deficient practice can potentially transfer contaminates from bed rail to patients skin. Tray table/cart between St 7 and St 8 contained clean supplies, folder, and RN G's face mask and safety glasses. After cannulating patient at St 8, RN G removed gloves and placed contaminated gloves on tray table/cart; RN G performed hand hygiene, and then proceeded to obtain clean gloves and placed them on the tray table/cart near the used gloves. RN G then connected patients dialysis blood lines, and proceeded to push up safety glasses with gloved hand. RN G then removed gloves, performed hand hygiene, and placed safety glasses and face mask on tray/cart table. The tray tables are used between stations and contain patient and staff supplies and patient charts with no distinct separation of "clean" and "dirty".

Per interview on 8/21/13 beginning at 4:15 PM with DM E, it is not an acceptable practice to place tape on the bed rail.