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.

DOOR COUNTRY MEDICAL CENTER 323 SOUTH 18TH AVENUE STURGEON BAY, WI 54235 April 11, 2018
VIOLATION: EMERGENCY AND SUPPLIES Tag No: C0888
Based on observation, record review and interview, facility staff failed to monitor emergency crash carts and equipment per policy in 1 of 5 crash carts observed (Emergency Department).

Findings include:

Review of facility policy "Nursing Standards of Care - Emergency Department (ED)" dated 3/28/2018 revealed "Nursing staff will perform routine checks of equipment every 12 hours, equipment checked includes: 1. Suction/oxygen equipment; 2. Cardiac monitors; 3. Crash cart locks; 4. Defibrillator..."

During observation of the Emergency Department on 4/9/2018 at 10:45 AM, the Emergency Department crash cart checklist was not marked off as checked daily. During an interview on 4/9/2018 at 10:45 AM, Emergency Director O stated the checklist was expected to be completed twice daily. Review of the checklist from 3/1/2018 through 4/9/2018 revealed shift checks had not been done on 7 of 40 AM shifts on 3/11/2018, 3/14/2018, 3/22/2018, 3/26/2018, 3/29/2018, 3/30/2018 and 4/2/2018; and had not been done on 13 of 39 PM shifts on 3/1/2018, 3/4/2018, 3/9/2018 through 3/12/2018, 3/19/2018 through 3/21/2018, 3/26/2018, 3/30/2018, 3/31/2018 and 4/5/2018. When asked who is reviewing the checklist to ensure the checks are being performed as expected, O stated "the staff monitor themselves."
VIOLATION: PHYSICAL PLANT AND ENVIRONMENT Tag No: C0910
Based on observation, staff interviews, and review of maintenance records on April 9, 2018 the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

42 CFR 485.623 Condition of Participation: Physical Environment was NOT MET

Findings include:

The facility was found to contain the following deficiencies:
K 271 discharge from exits;
K 311 vertical openings - enclosure;
K 321 hazardous areas;
K 341 fire alarm systems - installation;
K 346 fire alarm - out of service;
K 351 sprinkler system - installation;
K 353 sprinkler system - maintenance and testing;
K 354 sprinkler system - out of service;
K 355 portable fire extinguishers;
K 361 corridors - areas open to corridor;
K 363 corridor doors;
K 372 subdivision of building spaces - smoke barrier construction;
K 374 subdivision of building spaces - smoke barrier doors;
K 511 utilities - gas and electric;
K 754 soiled linen and trash containers;

Refer to the full description at the cited K tags.

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.
VIOLATION: MAINTENANCE Tag No: C0914
Based on observation, record review and interview, staff at this facility failed to maintain a clean environment in 3 of 7 patient care areas observed (Family Birth Center, Diagnostic Imaging, Surgical Suite), failed to perform eyewash station checks per policy in 11 of 11 eyewash stations reviewed and failed to address out of range test results for 1 of 5 locations with eyewash stations (Laboratory).

Findings include:

Family Birth Center:

A tour of the Family Birth Center was conducted on 4/9/2018 at 11:00 AM accompanied by Supervisor I and Director of Quality B. The following observations were made and confirmed by I and B during the tour in 5 of the 6 patient rooms:

Room 2011-The bathroom vent had a build up of dust on it.

Room 2012-The bathroom vent had a build up of dust on it. One of the walls has paint chips missing creating a porous surface which is not cleanable.

Room 2014-The bathroom vent and the main room vent had a build up of dust on them.

Room 2015-The bathroom vent and the main room vent, along with several ceiling tiles surrounding the main room vent, had a build up
of dust on them.

Room 2016-The main room vent and surrounding ceiling tiles had a build up of dust on them.

Per interview with Director of Environmental Services M on 4/9/2018 at 2:15 PM regarding cleaning of the ceilings and vents in the Family Birth Center, Director M stated, "We clean them every day." Director M was not aware of the dust build up on the vents in these rooms.

Diagnostic Imaging:

A tour of the Diagnostic Imaging department was conducted on 4/9/2018 at 2:40 PM accompanied by Director of Diagnostic Imaging N and Chief Nursing Officer A. The following observations were made and confirmed by N and A during the tour:

Ultra sound rooms (3 rooms)-These rooms have ultra sound gel warmers with bottles of ultra sound gel in them which revealed that the temperature of the gel must be maintained between 32 degrees Fahrenheit and 90 degrees Fahrenheit. Per interview with Director N on 4/9/2018 at 2:40 PM, there is not a way to monitor the temperature of these warmers to ensure the temperature of the gel is maintained at the optimal levels.

The interventional radiology room had a build up of dust on the wall air vent. Per interview with Nursing Officer A on 4/9/2018 at 2:43 PM regarding this observation, Chief Nursing Officer A stated, "Oh ya."

In x-ray room #3 there was a large hole in the wall behind the door leading to the external corridor. This door also was missing laminate along the corridor side of the door and had plastic tape along the inside edge of the door that was dirty and frayed which was covering a separation of the laminate from the door. Per interview with Director N regarding the condition of the door, Director N stated, "It's probably from the ER [emergency room ] carts."

Surgical Suite:

A tour of the Surgical Suite was conducted on 4/10/2018 with observations conducted between 8:25 AM and 10:40 AM accompanied by Director of Peri-operative Services R who confirmed the following findings at the time of the observation:

On 4/10/2018 at 8:25 AM an arm board in Operating Room 3 was observed to have a significant amount of sticky tape residue rendering the surface non-cleanable. In this same room there was a piece of non-laminated paper taped to the side of an image capturing machine that was non-cleanable due to the porous nature of paper. At 10:08 AM on 4/10/2018 the edging of a computer station desk top is missing large pieces of laminate exposing a porous non-cleanable surface.





Eyewash Stations:

Review of facility security guidelines "Standard Operating Procedure" dated 2/15/2018 revealed "Eyewash station checks will be conducted for the Hospital Facility weekly. ...Any station that does not meet the required specifications for flow and temperature will be written up in a work order as an urgent repair."

During observation of the laboratory on 4/9/2018 at 1:35 PM, the eyewash station was noted to have white residue over the eyewash faucet outlets. When asked how often and by whom the eyewash stations are checked, Laboratory Director BB stated "maintenance does that, I'm not sure how often."

During an interview on 4/9/2018 at 2:30 PM, Compliance and Safety Director P stated the eyewash stations are checked by security. Per P, the stations are checked weekly and security reports any issues to Director P. Review of the March 2018 eyewash station testing log revealed testing had been performed on 3/1/2018, 3/15/2018 and 3/29/2018. During an interview on 4/11/2018 at 7:50 AM, Compliance and Safety Director P stated the testing hadn't been performed weekly due to "staffing issues." Per P, the laboratory has 5 eyewash stations. The testing log does not indicate which results are correlated to which eyewash station. When asked how to match the test results with the correct stations, Director P stated "I don't know." Review of the log for the laboratory eyewash stations revealed that one of the stations had a test result of 2 gpm, less than the minimum pressure of 3 gpm, on 3/1/2018, 3/15/2018 and 3/29/2018. There was no evidence that the out of range test result was written up as a work order, reported or addressed.
VIOLATION: PROPER VENTILATION, LIGHTING, AND TEMPERATURE Tag No: C0926
Based on observation, record review and interview, facility staff failed to monitor temperatures of blanket and gel warmers in 4 of 6 patient care areas with warming devices observed (Emergency Department, Diagnostic Imaging, Medical-Surgical, and Intensive Care Unit).

Findings include:

Review of facility policy "Fluid and Blanket Warmers" dated 1/12/2018 revealed "The temperature of warming cabinets will be monitored daily by a staff member or monitored through a continuous monitoring system."

On 4/9/2018 at 10:40 AM, the blanket warmer in the Emergency Department contained 4 bottles of ultrasound gel. Review of manufacturer storage recommendations, located on the bottle, revealed "store at a max temperature of 104 degrees Fahrenheit." The warmer at the time of the observation was noted to be 107 degrees, and then 109 degrees on 4/9/2018 at 11:00 AM. During an interview on 4/9/2018 at 10:40 AM, when asked about a temperature monitoring log, Emergency Director O stated "we only monitor the temperatures of the warmers if they contain IV solutions."

On 4/9/2018 at 2:40 PM, the ultrasound rooms in the Diagnostic Imaging Department contained ultra sound gel warmers with bottles of ultrasound gel in them which revealed that the temperature of the gel must be maintained between 32 degrees Fahrenheit and 90 degrees Fahrenheit. Per interview with Diagnostic Imaging Director N on 4/9/2018 at 2:40 PM, there is not a way to monitor the temperature of these warmers to ensure the temperature of the gel is maintained at the optimal levels.

During observation of inpatient units on 4/10/2018 at 2:00 PM, neither blanket warmer in the Intensive Care Unit nor the Medical Surgical Unit had a temperature monitoring log. During an interview at the time of the observation, Director of Nursing V stated "the blanket warmers don't have to be monitored, they just need to be below 150 degrees per our policy."
VIOLATION: LIFE SAFETY FROM FIRE Tag No: C0930
Based on observation, staff interviews, and review of maintenance records on April 9, 2018 the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

42 CFR 485.623(d)(1) Condition of Participation: Safety from Fire was NOT MET

Findings include:

The facility was found to contain the following deficiencies:
K 271 discharge from exits;
K 311 vertical openings - enclosure;
K 321 hazardous areas;
K 341 fire alarm systems - installation;
K 346 fire alarm - out of service;
K 351 sprinkler system - installation;
K 353 sprinkler system - maintenance and testing;
K 354 sprinkler system - out of service;
K 355 portable fire extinguishers;
K 361 corridors - areas open to corridor;
K 363 corridor doors;
K 372 subdivision of building spaces - smoke barrier construction;
K 374 subdivision of building spaces - smoke barrier doors;
K 511 utilities - gas and electric;
K 754 soiled linen and trash containers

Refer to the full description at the cited K tags.

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.
VIOLATION: PATIENT CARE POLICIES Tag No: C1014
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, facility staff failed to provide accurate home medication lists at discharge for 2 of 3 discharged patients (Patient #23, Patient #24). Failure to provide patients with accurate discharge instructions has potentially contributed to the readmission of Patient #23.

Findings include:

Review of facility policy "Discharge from Inpatient Setting" dated 2/16/2018 revealed "A registered nurse (RN) will review the Physician Discharge Order/Instruction Sheets, making sure appropriate diet, medications, supplies or equipment needs are filled out. Have patient or significant other sign discharge and medication instruction/reconciliation sheets after reviewing with him/her. Give patient or significant other copy of Discharge and medication instruction/reconciliation sheets."

Review of facility policy "Medication Reconciliation - Inpatients and Ambulatory and Observation Patients in Inpatient Beds, PC-002-DC" dated 10/19/2017 revealed "Medication Reconciliation is a multi-step process which includes: ...C. Comparing the hospitalized Patient's Home Medication List against the provider's admission and discharge orders, identifying and bringing any discrepancies to the attention of the provider and, if appropriate, having the provider make changes to the orders. ...11. Upon discharge or transfer to another facility, the Home Medication List must be updated in the hospitalized Patient's medical record. A complete copy of the Home Medication List must be given to the hospitalized Patient and/or the receiving health care facility upon discharge or transfer."

Per medical record review, Patient #23 was admitted to the facility on [DATE] for shortness of breath and a diagnosis of heart failure. Per Patient #23's discharge summary, Patient #23 was discharged home on 3/17/2018 with orders to resume 17 home medications and start 4 new medications with prescriptions provided. Review of Patient #23's discharge instructions do not include a list of home medications. There was no evidence a list of ordered discharge medications was provided to Patient #23.

Patient #23 was readmitted to the facility on [DATE] with cough and shortness of breath. Review of Patient #23's readmission History and Physical, dated 3/19/2018, revealed "Patient was discharged 2 days ago. ...on metolazone (diuretic) every other day but did not take it after discharge." During an interview on 4/10/2018 at 4:05 PM, Quality Director B stated the medication lists are provided to patients at discharge and "should be" in the medical record. Per B, "I'm not sure why it's not there."

Per medical record review, Patient #24 was admitted to the facility on [DATE] for shortness of breath, fluid overload and heart failure. Per Patient #24's discharge summary, Patient #24 was discharged on [DATE]. Home medications listed on the discharge summary include spironolactone 25 mg daily. Review of Patient #24's discharge medication list, provided to Patient #24 at discharge, includes instructions to take spironolactone 50 mg daily. During an interview on 4/10/2018 at 4:30 PM, Quality Director B stated the medication list provided to the patient should match the medications indicated by the physician at discharge.

During an interview on 4/11/2018 at 10:00 AM, Chief Nursing Officer A stated "we have identified a lot of issues related to discharge instructions."
VIOLATION: POLICIES - INFECTION CONTROL Tag No: C0278
Based on observation, record review and interview, facility staff failed to perform hand hygiene per policy in 5 of 10 patient care observations (Patient #1, Patient #2, Patient #12, Patient #13, Patient #26); failed to disinfect medication vials prior to accessing for patient use in 1 of 2 intravenous medication administrations observed (Patient #26); failed to perform medication compounding per protocol in 1 of 1 pharmacy staff observed (Pharmacy Technician J); failed to ensure cleaning solution is mixed to recommended germicidal concentrations in 1 of 1 decontamination area observed (Surgical Services); and they did not serve and prepare food under sanitary conditions in 1 of 1 food preparation area observed (Dietary Services).

Findings include:

Patient Care Observations:

Review of facility policy "Isolation" dated 1/12/2018 revealed "Hand hygiene must be done when: ...entering and exiting a patient's room."

On 4/10/2018 at 8:40 AM, during observation of care, Registered Nurse W donned a gown and gloves prior to entering Patient #13's room. Patient #13 was on contact precautions for Clostridium Difficile infection. Review of the precaution sign on Patient #13's door revealed "Perform hand hygiene with hand gel before entering the room." Registered Nurse W did not perform hand hygiene prior to donning personal protective equipment and entering Patient #13's room. During an interview on 4/10/2018 at 2:20 PM, Director of Nursing V stated "it is the expectation that they [staff] would do hand hygiene before entering the room."

Review of facility policy "Hand Hygiene" dated 1/12/2018 revealed "Decontaminate hands: According to the WHO 5 moments of hand hygiene: A. Before and after having direct contact with patient or resident. B. After contact with blood, body fluids, excretions, mucous membranes, non-intact skin, or wound dressings. C. After contact with inanimate objects in the immediate vicinity of the patient or resident even if not in contact with the patient or resident. D. After removing gloves. E. When moving from a contaminated body site to a clean site during patient or resident care. F. Before donning sterile gloves or placing invasive devices."

During observation of care on 4/10/2018 at 8:15 AM, Registered Nurse X removed gloves after inserting Patient #12's intravenous device and proceeded to obtain supplies from the clean supply cart without first performing hand hygiene. During an interview on 4/10/2018 at 2:20 PM, Director of Nursing V stated "yes, hand hygiene should be done after removing gloves."

During observation of care on 4/9/2018 at 2:30 PM, Respiratory Therapist Q donned gloves to perform Patient #2's nebulizer treatment. Respiratory Therapist Q assessed Patient #2, administered treatment, charted at the bedside computer, reassessed Patient #2 and charted again at the computer with the same set of gloves. During an interview on 4/10/2018 at 2:20 PM, Director of Nursing V stated "if staff wear gloves at the computer, they need to be clean."

On 4/9/2018 at 3:30 PM an observation of Phlebotomist U performing a blood draw on Patient #1 was conducted. Upon entry to the room Phlebotomist U performed hand hygiene and put on gloves. Phlebotomist U then performed the blood draw, touching Patient #1's skin and obtained a syringe full of blood. Upon completion of the blood draw, with the gloves still on, Phlebotomist U transferred the blood into vacutainers, reached into the pocket of U's lab coat to obtain a pen, documented on labels for the vacutainers, handled the television remote, handled the marker for the white board (dry erase board) in the room, retrieved tape from the clean supply basket which was put back in to the lab coat pocket after use. Phlebotomist U then removed gloves and performed hand hygiene before leaving the room. These findings were discussed with and confirmed per interview by Director of Nursing A on 4/9/2018 at 3:45 PM.

On 4/10/2018 at 10:01 AM, while preparing medications for Patient #26, Doctor S was observed removing the protective plastic cover off a vial of Midazolam (sedating agent), and did not cleanse the septum of the vial prior to accessing with needle. Doctor S then put this medication filled syringe in S's scrub jacket pocket and left the operating room. At 10:16 AM Doctor S removed the protective plastic cover off vials of Lidocaine and Propofol and did not cleanse the septums prior to accessing them with a needle. This finding was discussed and confirmed per interview by Director of Peri-Operative Services R on 4/10/018 at 12:00 PM. During an interview on 4/9/2018 at 1:05 PM, Infection Preventionist L stated that vials should be cleansed with alcohol when opened and before accessing them. Per L, "They should clean the vial prior to every access."

On 4/10/2018 at 10:19 AM Doctor S was observed removing gloves and applying clean gloves without performing hand hygiene. At 10:20 AM Doctor S removed gloves after applying tape to Patient #26's eyes, then documented in the medical record before crossing the room to perform hand hygiene. This finding was discussed with and confirmed per interview by Director of Peri-Operative Services R on 4/10/018 at 12:00 PM.

Per interview with Infection Preventionist L on 4/9/2018 at 1:05 PM, L stated that the facility follows the guidelines for professional practice from the following organizations: APIC (Association for Professionals in Epidemiology and Infection Control), CDC (Centers for Disease Control), AORN (Association of peri-Operative Registered Nurses), and AAMI (Association for Advancement in Medical Instrumentation). Regarding hand hygiene practices throughout the facility, Infection Preventionist L stated, "All departments follow the same guidelines as anyone else. There are no different guidelines for different departments." Infection Preventionist L stated that staff are expected to do hand hygiene upon entry and exit of the patient care area and the facility follows the recommendations from WHO (World Health Organization): Before patient contact; before an aseptic task; after body fluid exposure risk; after contact with patient surroundings.





Pharmacy/Medication Compounding:

On 4/9/2018 at 12:30 PM, an observation of Pharmacy Technician J compounding intravenous medications was conducted. Technician J entered the sterile compounding room with the bottom of the surgical mask rolled up and not securely containing the bottom of the chin. Per interview with Pharmacy Director K at 12:35 PM on 4/9/2018 regarding this observation, Director K stated, "I see that," and intercommed into the room and told Technician J to fix the mask because it was turned up on the bottom. At 12:38 PM Technician J was observed accessing vials of medication/saline to mix the antibiotic Cefepime. The rubber septums of three vials were not disinfected upon re-entry into the vials. Per interview with Director K on 4/9/2018 at 12:40 PM regarding this observation, Director K stated, "It is not necessary because it's the same drug." During an interview on 4/9/2018 at 1:05 PM, Infection Preventionist L stated that vials should be cleansed with alcohol when opened and before accessing them. Per L, "They should clean the vial prior to every access."

Surgical Services:

On 4/10/2018 at 10:40 AM Surgical Technician T was observed cleaning surgical instruments that arrived from the operating room after surgery. The directions for use on the bottle of enzymatic cleaner revealed that the concentration of cleaner to water is 1 ounce to 1 gallon. The sink in the decontamination room is not marked for the appropriate water level. Per interview at the time of observation, regarding the sink not being marked Technician T stated, "Our other sink is marked so we just gauge the amount by that." The other sink Technician T is referring to is in the endoscope reprocessing room and is not in the same room as the unmarked sink.





Dietary Services:

Uncovered Facial Hair
During an interview with Nutritional Services Director-C (NSD-C) on 04/09/2018 at 10:11AM, NSD-C reported NSD-C and chefs are Food Handler ServSafe certified. ServSafe is a nationally recognized program in food safety education.

During the tour of the kitchen and accompanied by NSD-C on 04/09/2018 at 10:30 AM, observed Chef D preparing lunch for the day. Chef D has facial hair surrounding his entire mouth and chin which was not covered.

During the tour of the kitchen and accompanied by NSD-C on 04/09/2018 at 10:43 AM, observed Chef E doing food prep. Chef E has facial hair surrounding his entire mouth and chin which was not covered.

NSD-C stated during the interview on 04/10/2018 at 8:30 AM, that chefs were told to keep the facial hair at a inch and no longer. It was NSD-C's understanding that it was okay to have facial hair as long as it did not exceed inch. NSD-C stated the ServSafe Coursebook is used instead of individual foodservice policies and procedures. According to ServSafe Coursebook, 7th Edition, page 4.12 and Table 4.2: Work Attire Guidelines, it states food handlers with facial hair should also wear a beard restraint.

Cross-contamination
On 04/09/2018, at 11:22 AM, observed Chef D preparing a pesto pasta dish. Using gloved hands, Chef D removed a cooked chicken patty from a pan. Chef D took a knife and diced up the chicken. While wearing the same gloves, Chef D scooped up the diced chicken and put on top of the pesto pasta. Chef D then walked over to the reach in cooler, opened the lid and removed half an orange slice and half a cherry tomato with the same gloved hands that scooped up the diced chicken. Chef D then placed the orange slice and cherry tomato garnish onto the dish containing the diced chicken and pesto pasta.

Interview with Nutrition Services Director-C (NSD-C) on 04/09/2018 at 1:05 PM, disclosed that Chef D should not have been wearing the same gloves to get the garnish that scooped up the chicken.

Per interview with Chef D on 04/10/2018 at 8:47 AM, Chef D stated "I know what I did was wrong." Chef D acknowledged should not have worn the same gloves that scooped up the chicken into the bowl to get the orange and tomato garnish.

NSD-C stated the ServSafe course book is used instead of individual foodservice policies and procedures. According to ServSafe Coursebook, 7th Edition, pages 4.9 and 4.11, single-use gloves are designed for one task, after which they must be discarded. Food handlers must change single-use gloves before beginning a different task.

Improper Sanitization
On 04/09/2018 at 11:10 AM, and accompanied by Nutrition Services Director-C (NSD-C), observed Nutrition Aide-F (NA-F) performing 3-compartment sink washing. In the third (sanitizing) compartment was a large colander. Half of the colander was above the sanitizing solution. NA-F removed the colander and placed it onto the mat to air dry. During an interview with NA-F, it was demonstrated how to perform 3-compartment sink washing. NA-F stated the items need to be fully submerged in the sanitizing solution for 60 seconds. NA-F stated was not aware the colander was not fully submerged in the sanitizing solution. During an interview with Nutrition Services Director-C (NSD-C) on 04/09/2018 at 1:05 PM, NSD-C acknowledged the colander was not properly sanitized by NA-F.

NSD-C stated the ServSafe course book is used instead of individual foodservice policies and procedures. Review of ServSafe Coursebook, 7th Edition, on pages 12.4 and 12.7, revealed sanitizing reduces pathogens on a surface to safe levels. Food-contact surfaces must be sanitized after they have been cleaned and rinsed. "Make sure the entire surface has come in contact with the sanitizing solution."
VIOLATION: EMERGENCY PROCEDURES Tag No: C1032
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, facility staff failed to monitor patients per policy in 1 of 3 patients reviewed seeking Emergency Services (Patient #5).

Findings include:

Review of facility policy "Documentation Process of Emergency Department" dated 3/28/2018 revealed "Indications for reassessment include: -Minimums based on ESI Level: ...-Level 3: 60-90 minutes, depending on patient condition. ...Discharge: Vitals, pulse, respirations, temp (if elevated at admission and treatment provided) and blood pressure will be completed on all discharges when the patient was in the emergency department for greater than two hours and/or the patient received a resource."

Patient #5 (MDS) dated [DATE] at 2:19 PM with a chief compliant of "tonsillectomy [2 days prior on 4/4/2018], yesterday unable to drink, last night increased pain, today refusing to eat/drink; only 2 wet diapers since 0900 yesterday." Patient #5 was triaged at a level 4 severity. Vital signs obtained at 2:32 PM include an elevated temperature of 99.8, an elevated heart rate of 128 and pulse oxygen level of 93%. While in the Emergency Department, Patient #5 was diagnosed with post-tonsillectomy dehydration. Patient #5 received intravenous fluid boluses of 300 mL x 2 doses for rehydration, and intravenous medications of acetaminophen and dexamethosone (steroid). Patient #5 was discharged on [DATE] at 6:51 PM, more than 4 hours after arrival. Patient #5's medical record does not include another set of vitals after the admission vitals were obtained at 2:32 PM. There was no documentation of reassessment after an initial nursing assessment at 2:32 PM.

During an interview on 4/9/2018 at 11:40 AM, Emergency Director O stated "there should be a reassessment and another set of vitals. There is always expected to be a full set of vital signs at discharge, I don't see that."
VIOLATION: NURSING SERVICES Tag No: C1048
Based on record review and interview, nursing staff at this facility failed to document inspection of an epidural catheter upon removal in 1 of 1 maternity patient with an epidural catheter (Patient #17).

Findings include:

Patient #17's medical record was reviewed on 4/10/2018 at 3:59 PM accompanied by Registered Nurse Y who confirmed the following findings during the medical record review: Patient #17 received spinal anesthesia with an epidural (catheter remains in after delivery) on 3/14/2018 and baby was delivered vaginally on 3/15/2018. In the electronic medical record, in a nursing assessment area, was an area for documenting if an epidural/spinal catheter was discontinued and if it was intact (inspected upon removal to ensure the catheter had not broken off inside the body during placement/removal.) There was no documentation in the medical record regarding the epidural catheter appearance upon its removal.

Per interview with Nurse Y on 4/10/2018 at 4:19 PM regarding the removal of the epidural catheter, Nurse Y stated that typically a nurse will remove the catheter after the patient has met department criteria, but in this case it was not documented.

The facility's policy titled, "Epidural Analgesia," # 26, dated 3/29/2017, was reviewed on 4/11/2018 at 11:16 AM. The policy failed to identify the facility practice of inspecting the epidural catheter after removal. Per e-mail from Chief Nursing Officer A on 4/11/2018 at 11:28 AM regarding the epidural catheter policy, Chief Nursing Officer A revealed, "In response to your question it is our standard practice but not in our policy."
VIOLATION: NURSING SERVICES Tag No: C1050
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, facility staff failed to implement nursing care plans related to patient problems for 3 of 5 current inpatients reviewed (Patient #2, Patient #14, Patient #15).

Findings include:

Review of facility policy "Inpatient Nursing Required Documentation" dated 10/11/2017 revealed "X. Plan of Care: A. An RN will initiate a standard plan of care based on the patient's admission assessment within 8 hours of admission, and then tailor it to fit the patient's specific needs throughout the hospitalization ."

Per medical record review, Patient #2 was admitted to the facility on [DATE] with difficulty breathing and a primary admission diagnosis of acute on chronic respiratory failure with hypoxemia (low blood oxygen saturation). Patient #2's initial nursing assessment on 4/6/2018 at 2:07 AM includes the following respiratory assessment: "Bilateral lung sounds: Crackles, Diminished. Observation: Short of Breath, Tachypnea, Unable to Lie Flat, SOB with Exertion" with notes of intermittent, non-productive cough. Review of Patient #2's care plan on 4/10/2018 at 9:30 AM did not include any nursing problems, goals or interventions related to Patient #2's primary admission diagnosis or the respiratory status issues identified in the admission nursing assessment.

Per medical record review, Patient #14 was admitted to the facility's swing bed services on 4/5/2018 for long-term antibiotic administration related to osteomylitis (bone infection). Patient #14's initial nursing assessment on 4/5/2018 at 1:15 PM includes documentation of altered/impaired skin integrity for the following: "bilateral abdominal folds; sacrum" and documents open wound locations of: "left great toe; left second toe; right achilles heel; dorsal right foot; distal right great toe." Review of Patient #14's care plan on 4/10/2018 at 1:05 PM did not include any nursing problems, goals or interventions related to Patient #14's primary admission diagnosis of infection or nursing assessment of impaired skin integrity and open wounds.

Per medical record review, Patient #15 was admitted to the facility's swing bed services on 4/9/2018 for long-term antibiotic administration to treat an infected left leg ulcer. Patient #15's initial nursing assessment on 4/9/2018 at 10:42 AM includes documentation of an open wound at Patient #15's left lower lateral leg. Review of Patient #15's care plan on 4/10/2018 at 1:25 PM did not include any nursing problems, goals or interventions related to Patient #15's primary admission diagnosis of infection or nursing assessment of the open wound.

These findings were confirmed at the time of review with Registered Nurse CC. During an interview on 4/10/2018 at 9:50 AM, Registered Nurse CC stated "I would expect there to be nursing problems related to the patient's admission diagnosis."
VIOLATION: PROTECTION OF RECORD INFORMATION Tag No: C1120
Based on observation and interview, staff at this facility failed to ensure that patient medical records are secured from unauthorized access at 1 of 2 outpatient therapy sites observed (Cherry Point Mall).

Findings include:

A tour of the off-site, outpatient therapy area at Cherry Point Mall was conducted on 4/11/2018 between 9:05 AM-9:15 AM accompanied by Director of Therapy Services Z. During an interview conducted at 9:10 AM on 4/11/2018 regarding storage of medical records that are not in electronic format with Director Z, Director Z stated that these records are kept in a file cabinet in a separate room.

An observation of the file cabinet revealed that the cabinet was not locked. After Director Z was observed locking the cabinet with the push button lock, Director Z was observed attempting to open the file cabinet with several keys given to Z by the receptionist. None of the keys worked.

Per interview with Therapy Department Assistant AA on 4/11/2018 at 9:11 AM, Assistant AA stated that the cabinet is not locked and does not have a key. Assistant AA stated that a contracted housekeeping service cleans the department after hours and the department may not have staff present when the contracted service is there, allowing for potential access of unauthorized persons to protected health/personal information.
VIOLATION: ANESTHETIC RISK AND EVALUATION Tag No: C1144
Based on interview and record review, anesthesia staff at this facility failed to document pre-anesthesia evaluation times in 2 out of 6 patients requiring anesthesia services (Patient #10 and 11), and failed to perform the post-anesthesia evaluation in a time frame that was sufficient for the patient to recover from the anesthesia they received in 5 of 6 patients requiring post anesthesia evaluations (Patient #7, 8, 10, 11 and 16), and failed to document return of sensation after spinal/epidural anesthesia in 2 of 2 maternity patients requiring anesthesia services (Patient #16 and 17).

Findings include:

Per interview with Anesthesiologist, Doctor S on 4/10/2018 at 9:15 AM, Doctor S stated that the process for the post-anesthesia evaluation is to," Watch over the patient, watch vital signs, make sure they are stable. Then a separate note is required within 24 hours."

Patient #7's medical record was reviewed on 4/10/2018 at 11:01 AM accompanied by Director of Per-Operative Services R who confirmed the following findings during the medical record review: Patient #7 received general anesthetic for a laparoscopic choleycystectomy (gall bladder removal) on 3/5/2018. The procedure started at 3:07 PM and ended at 3:52 PM. Patient #7 arrived in recovery at 3:55 PM. The post-anesthesia evaluation was documented at 3:57 PM, 2 minutes after arrival in the recovery room. No other anesthesia documentation was found.

Patient #8's medical record was reviewed on 4/10/2018 at 11:21 AM accompanied by Director of Per-Operative Services R who confirmed the following findings during the medical record review: Patient #8 received general anesthetic for an abdominal hysterectomy on 3/14/2018. The procedure started at 10:15 AM and ended at 11:37 AM. Patient #8 arrived in recovery at 11:38 AM. The post-anesthesia evaluation was documented at 11:37 AM, 1 minute before arrival in the recovery room. No other anesthesia documentation was found.

Patient #10's medical record was reviewed on 4/10/2018 at 1:03 PM accompanied by Director of Per-Operative Services R who confirmed the following findings during the medical record review: Patient #10 received general anesthetic for colectomy (surgery on the bowel) on 3/30/2018. The procedure started at 12:52 PM and ended at 2:25 PM. The pre-anesthesia assessment did not include a time it was conducted. Patient #10 arrived in recovery at 2:30 PM. The post-anesthesia evaluation was documented at 2:36 PM, 6 minutes after arrival in the recovery room. No other anesthesia documentation was found.

Patient #11's medical record was reviewed on 4/10/2018 at 1:18 PM accompanied by Director of Per-Operative Services R who confirmed the following findings during the medical record review: Patient #11 received general anesthetic for repair of a fractured ankle on 3/22/2018. The procedure started at 12:51 PM and ended at 1:32 PM. The pre-anesthesia assessment did not include a time it was conducted. Patient #11 arrived in recovery at 1:39 PM. The post-anesthesia evaluation was documented at 1:43 PM, 4 minutes after arrival in the recovery room. No other anesthesia documentation was found.

Per interview with Director R on 4/10/2018 at 1:30 PM regarding the time frames for the post-anesthesia evaluations, Director R stated that R agreed, these time frames are not sufficient for the patient to be recovered from their anesthesia.

Patient #16's medical record was reviewed on 4/10/2018 at 3:24 PM accompanied by Registered Nurse Y who confirmed the following findings during the medical record review: Patient #16 received spinal anesthesia (catheter does not remain in) for a cesarean section on 3/12/2018. Anesthesia services started at 12:20 PM and ended at 1:13 PM. Patient #16 arrived in recovery at 1:14 PM. The post-anesthesia evaluation was documented at 1:13 PM, 1 minute before arrival to recovery. There was no documentation from anesthesia regarding return of sensation to Patient #16's lower extremities after receiving spinal anesthesia.

Per interview with Nurse Y on 4/10/2018 at 3:35 PM regarding the post-anesthesia evaluation for patients who receive spinal or epidural anesthesia, Nurse Y stated, "They usually come back at the end of the day when all their cases are over to check on them but I don't know where they document this."

Patient #17's medical record was reviewed on 4/10/2018 at 3:59 PM accompanied by Registered Nurse Y who confirmed the following findings during the medical record review: Patient #17 received spinal anesthesia with an epidural (catheter remains in after delivery) on 3/14/2018 and baby was delivered vaginally on 3/15/2018. The post-anesthesia evaluation was documented at 8:03 AM on 3/15/2018. There was no documentation from anesthesia regarding return of sensation after receiving the epidural.
VIOLATION: QA - PERFORMANCE IMPROVEMENT Tag No: C0342
Based on record review and interview, facility staff failed to investigate patterns of complaints in an effort to improve patient quality of care for 3 of 3 complaints reviewed (Patient #27, Patient #28, Patient #29).

Findings include:

Review of facility policy "Patient Complaints Process, ADM-162" dated 3/27/2018 revealed "Leader/Designee will conduct complete investigation into all issues, and will involve any and all appropriate staff or departments in the investigation. Leader/Designee will document an investigation report which includes the following components: -Investigation results for each complaint. -Action plans or adjustments recommended for resolution. -Any service recovery initiated. ...Complaints against the medical staff will be handled through the medical staff peer review process..."

Per review of the patient complaint log, the facility had received a minimum of 3 different complaints classified as "Attitude/Courtesy/Communication" regarding Emergency Department (ED) Physician FF dated 12/28/2017 (Patient #27), 1/15/2018 (Patient #28), and 1/22/2018 (Patient #29). There was no documentation of an investigation into the alleged concerns on any of the complaint files. Follow up documentation to Complaint #9438, filed on 1/22/2018 by Patient #29, included a note dated 2/12/2018 from Quality Director B that documents "I will send a task to [Chief Medical Officer DD] as an FYI. [DD] has scheduled a meeting to discuss pattern of concerns." The complaint file was closed on 3/12/2018 with the following description: "[Chief Medical Officer DD] aware of the patient's concerns, discussed at grievance committee meeting. Meeting held with [ED Medical Director EE], [Chief Medical Officer DD], [ED Director O] and [Quality Director B] to discuss pattern of concerns with this provider. [Chief Medical Officer DD] and [ED Medical Director EE] will follow up with [Physician FF]."

During an interview on 4/10/2018 at 12:05 PM, Chief Nursing Officer A stated that Chief Medical Officer DD was not available for interview but A confirmed with DD that DD had not reached out to Physician FF or had any contact with FF about the complaints. When asked about the investigation process into the above complaints, Quality Director B stated that physician concerns are handled by the Medical Director and Chief Medical Officer. Per B, there was no documentation of the investigation, recommendations or action plans that resulted from these complaints.
VIOLATION: ORGAN, TISSUE, & EYE PROCUREMENT Tag No: C1511
Based on record review and interview failed to review process improvement data related to death referral rates in 1 of 1 Organ Procurement Organization contract reviewed (Wisconsin Donor Network).

Findings include:

Review of facility policy "Anatomical Gift Donation, ADM-015" dated 3/27/2018 revealed "Process Improvement: A. A representative from WDN [Wisconsin Donor Network] completes an audit on site biannually and provides a report for the organization."

During an interview on 4/10/2018 at 3:30 PM, Chief Nursing Officer A stated the facility contracts with a WDN for organ procurement services and that WDN sends quarterly and annual reports for death referral and donation data. Review of the most recent death record review from WDN reported the facility had a death referral rate of 97.5%, with 76 of 78 deaths referred to the organization in calendar year 2017. Review of the facility's death log for 2017 revealed a total of 54 patient deaths had occurred at the facility, not 78 as reported by WDN. When asked about the discrepancy, Chief Nursing Officer A stated "I think their [WDN's] report includes all deaths in our organization, including those at the SNF [skilled nursing facility]." When asked if someone at the facility is reconciling the data provided from the Wisconsin Donor Network with facility data, A stated "we haven't been."
VIOLATION: PATIENT VISITATION RIGHTS Tag No: C1056
Based on observation, record review and interview, staff at this facility failed to ensure patients admitted to this facility have been informed of their rights in 1 of 3 patient interviews (Patient #25).

Findings include:

The facility's policy titled, "Patient Rights and Responsibilities," # 03, dated 6/21/2017, was reviewed on 4/11/2018 at 8:00 AM. The policy states in part, "A copy of the Patient Rights and Responsibilities will be provided to the patient at the time of admission."

Per interview with Patient #25 on 4/11/2018 at 7:35 AM regarding patient rights, Patient #25 stated that the hospital chaplain was in to talk about advanced directives but to #25's knowledge no one has informed Patient #25 of patient rights at this facility. Patient #25 was admitted to this facility on 4/9/2018. The binder in the room that contains the patient rights was observed to be on a shelf in the room and still had the paper band on it, indicating it had not been opened since Patient #25's admission. Housekeeping applies the band after wiping it down during terminal clean of the room from the previous patient. Patient #25 stated no one went through the binder. This finding was discussed with and confirmed per interview by Director of Nursing V and Chief Nursing Officer A on 4/11/2018 at 7:40 AM.

Per interview with Director R on 4/10/2018 at 11:30 AM regarding where it is identified in the medical record that patients are informed of their rights at this facility, Director R stated that the rights are in a binder in the patients room but staff do not document in the medical record to indicate that patients are made aware of their rights once they are admitted .