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LIFECARE HOSPITALS OF WISCONSIN
CONTENT OF RECORD: ORDERS DATED & SIGNED
Tag No.: A0454
Based on review of medical records, review of medical records quality assurance monitoring and staff interview the hospital failed to ensure that 2 of 11 (#8 and #9) medical records had verbal/telephone orders authenticated to ensure the orders met the 48 hour requirement.
Findings include:
On 03/16/10 at 2:00 p.m. Surveyor #22198 along with Director of Quality B during a review of Quality Assurance Program Improvement (QAPI) data collected and review of medical records for Patients # 8 and #9 confirmed Verbal Orders (VO)/Telephone Orders (TO) had not been authenticated by the physician to ensure the order had been reviewed and authenticated within the 48 hours required by the hospital.
Director of Quality B confirmed to Surveyor #22198 during review of QAPI data that the hospital was struggling with physician compliance for VO/TO order authentication.
INFECTION CONTROL PROFESSIONAL
Tag No.: A0748
Based on review of the current infection control policies and procedure, review of infection control tracking and trending and staff interview the hospital failed to update their infection control policies and procedure based on current standards of infection control practice.
Findings include:
On 03/16/10 at 1:15 p.m. during an interview and review of the hospital's current infection control policies and procedures, Surveyor #22198 along with Director of Quality B confirmed that the current infection control policies being used date from 2004 through 2009. Furthermore, Director of Quality B confirmed the infection control policies do not define what nationally accepted infection control standards of practice are being used to ensure they are current.
Director of Quality B confirmed to Surveyor #22198, that the infection control policies had not been updated to comply with the hospital's requirement of yearly review/revisions.
Director of Quality B confirmed to Surveyor #22198 during review of infection control tracking and trending, the hospital failed to include employee illness in their infection control program as defined in established the hospital ' s employee health policies.