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A standard Recertification Survey for Life Safety Code compliance was conducted by the Wisconsin Division of Quality Assurance on 12/01-04/2014. Select Speciality Hospital Madison was found to be NOT in compliance with the following applicable regulations for hospital participation in Medicare-Medicaid:

42 CFR 482.41 Condition of Participation: Physical Environment was NOT MET
42 CFR 482.41(b) Standard: Safety from Fire was NOT MET
NFPA 101- Life Safety Code was NOT MET

Select Speciality Hospital Madison is a 4-story structure initially built in 1975, with Type I (332) non-combustible construction as a nursing home. It was remodeled in 2006 into a hospital. The facility has several emergency generators that provide power to the emergency loads.

The facility contained 4 multi-story patient care wings and 11 smoke compartments in the hospital portion.

The health care organization did not have any off-site satellite clinics.

Select Speciality Hospital Madison is licensed for 58 beds, with a census of 44 inpatients at the time of the survey. The facility was surveyed under the 2000 Life Safety Code, Chapter 18 for a new health care occupancy. Twenty (20) Federal deficiencies of the Life Safety Code were cited.

The cumulative effect of these deficiencies has the potential to affect the safety of all patients receiving services at the hospital.

K12: Class of Construction did not meet non-combustible standards of a Type I(protected)
K17: Smoke tight corridor not maintained.
K18: Positive latching and smoke tight openings into the corridor.
K20: Vertical shafts were not constructed to the proper hourly rating.
K22: Access to exits without readily visible signs.
K25: Smoke Compartment walls were not smoke tight w/ ratings.
K33: Exit enclosure is open to an unoccupied space.
K38: Access to exits was not accessible due to a dead-end.
K39: Corridor width not maintained.
K46: Lacking exit signage.
K50: Fire drills not done or correctly done.
K56: Sprinkler system was not compliant to NFPA 13 minimum standards.
K62. Sprinkler system was not properly maintained.
K67: The HVAC system did not meet the minimum standards on NFPA 90A.
K69: Kitchen was not properly protected per NFPA 96.
K74: Loosely handing fabrics lacked treatment.
K75: Proper storage and handling of rubbish and soiled materials.
K77: Piped medical gas and valves was not installed properly.
K144: Generators were not inspected or tested in accordance with NFPA 110.
K147: Electrical system not to NFPA 70 minimum standards.

Please refer to the full description and findings within the specific K-tag deficiencies within the appropriate building found later in this report.

Based on interview and record review the facility failed to effectively take actions aimed at improving the health outcomes of patients for wound care and pressure ulcer prevention. This had resulted in worsening wound status in 2 of 31 patients (#16, 18) reviewed for wound care.

Findings:

Facility policy "Orders, Physician" #O02-G dated 1/1/2014 was reviewed on 12/3/2014 at 8:50 AM. The policy states in part that physician orders "will be reviewed and carried out appropriately by facility staff."

Facility policy "Wound Documentation" #WC III-27 dated 4/1/14 was reviewed on 12/2/2014 at 2:00 PM. The policy states in part, "4. All dressing changes and wound site care are documented on the Wound Treatment Record..."

1) Pt. #18's MR, reviewed on 12/2/1014 at 9:05 AM, contains wound care orders dated 10/21/2014 for "saline moistened guaze" dressing to be applied to an abdominal wound twice daily.

Pt. #18 received abdominal wound dressing changes once daily on 10/22/2014, 10/28/2014, 11/4/2014, 11/8/2014, 11/9/2014. There is no documentation of wound dressing changes on 10/23/2014, 10/26/2014, 10/30/2014-11/2/2014. Pt. #18 did not receive 16 of 38 ordered abdominal dressing changes, including 4 consecutive days without a dressing change on 10/30/2014 through 11/2/2014 during the patient's 20 day stay at this facility.

Photographic Wound Documentation dated 10/21/2014 measures a left abdominal wound at 1.2 cm x 5.1 cm in diameter and 4.5 cm deep with no undermining or tunneling (a channel or sinus tract extending from the wound) of the wound. On 11/4/2014 the wound is documented as having 6.5 cm of tunneling. These finding were verified with RN H and CNO D on 12/3/2014 at 10:15 AM. RN H confirmed that the presence of tunneling within a wound is considered "a change for the worse."

2) Per Pt. #16's MR, reviewed 12/2/2014 at 9:10 AM, Pt. #16 was admitted to the facility on 10/15/2014 with orders for a wound care consult. Orders were written on 10/16/2014 at 12:20 PM for calmoseptine ointment to be applied to perianal area every shift (twice daily).

Pt. #16's treatment record documents calmoseptine ointment application once daily on 10/24/2014-10/27/2014, 10/29/2014-10/31/2014, 11/10/2014 and 11/12/2014. There is no documentation of the ointment application on 10/16/2014-10/19/2014, 11/1/2014-11/3/2014. Pt. #16 was discharged from the facility on 11/13/2014 and did not receive 23 of 56 prescribed ointment applications during the patient's 29 day stay at this facility.

On 10/23/2014 Pt. #16's Photographic Wound Documentation lists IAD (incontinence-associated dermitits) on the coccyx. Exudate (drainage) is "none"; the non-open wound bed is noted to be "Pink/beefy red tissue", surrounding skin color is "normal for skin" and wound edges are "normal for skin." Documentation of the site on 11/4/2014 measures an open sore measuring 1.4 cm x 4 cm in diameter x 0.1 cm deep. Exudate amount is documented as "scant", exudate type as "serosanguineous". Surrounding skin color has progressed from "normal" to "bright red." 11/11/2014 documentation measures the site as 3.5 cm x 2.0 cm in diameter x 0.1 cm deep with a "small" amount "serosanguineous" exudate. These findings were confirmed with RN H and CNO D on 12/3/2014 at 10:15 AM. When asked if Pt. #16's pressure ulcer had gotten progressively worse during this hospitalization from 10/15/2014 to 11/13/2014, RN H stated "yes."

Medical record findings of incomplete wound treatment sheets were shared with CNO D on 12/2/2014 at 1:00 PM. CNO D stated that the facility had identified incomplete patient wound treatment sheets as an issue and CNO D had begun an internal audit of wound treatment sheets.

Treatment audit forms, reviewed on 12/2/2014 at 7:00 PM, contained audits for 35 patient records during the month of April 2014. 2 of 6 audit sheets did not include quantitive results data. 4 of the 6 audit sheets revealed a cumulative 169 completed wound care treatments out of 542 identified wound care "opportunities", an average completion rate of 31%.

During an interview with CNO D and Dir A on 12/3/2014 at 9:00 AM, Dir A stated that the facility had noticed pressure ulcer rates were "creeping in the wrong direction" this year. CNO D confirmed that results from the April treatment sheet audits showed a need for improvement, and that the importance of treatment sheet documentation had been addressed at a quarterly CNA meeting.

CNO D stated that no further follow up had been made since April. CNO D could not verify whether or not the CNA education had improved treatment sheet documentation rates or had a positive impact on pressure ulcer rates in any way. CNO D confirmed the facility had not followed a quality process to ensure that improvements had been made.

Surveyor: Balboa, Denise K.
Based on record review and interview the facility failed to provide wound care for patients as prescribed in 7 of 29 (Pts. #10, 12, 13, 16, 18, 21, 25) patient records reviewed. Failure to provide wound care as prescribed has resulted in worsened wound status in 2 of 7 patients (Pts. #16, #18) .

Findings:

Facility policy "Orders, Physician" #O02-G dated 1/1/2014 was reviewed on 12/3/2014 at 8:50 AM. The policy states in part that physician orders "will be reviewed and carried out appropriately by facility staff."

Facility policy "Wound Documentation" #WC III-27 dated 4/1/14 was reviewed on 12/2/2014 at 2:00 PM. The policy states in part, "4. All dressing changes and wound site care are documented on the Wound Treatment Record..."

1) Pt. #18's MR, reviewed on 12/2/1014 at 9:05 AM, contains wound care orders dated 10/21/2014 for "saline moistened guaze" dressing to be applied to an abdominal wound twice daily.

Pt. #18 received abdominal wound dressing changes once daily on 10/22/2014, 10/28/2014, 11/4/2014, 11/8/2014, 11/9/2014. There is no documentation of wound dressing changes on 10/23/2014, 10/26/2014, 10/30/2014-11/2/2014. Pt. #18 did not receive 16 of 38 ordered abdominal dressing changes, including 4 consecutive days without a dressing change on 10/30/2014 through 11/2/2014 during the patient's 20 day stay at this facility.

Photographic Wound Documentation dated 10/21/2014 measures a left abdominal wound at 1.2 cm x 5.1 cm in diameter and 4.5 cm deep with no undermining or tunneling (a channel or sinus tract extending from the wound) of the wound. On 11/4/2014 the wound is documented as having 6.5 cm of tunneling. These finding were verified with RN H and CNO D on 12/3/2014 at 10:15 AM. RN H confirmed that the presence of tunneling within a wound is considered "a change for the worse."

2) Per Pt. #16's MR, reviewed 12/2/2014 at 9:10 AM, Pt. #16 was admitted to the facility on 10/15/2014 with orders for a wound care consult. Orders were written on 10/16/2014 at 12:20 PM for calmoseptine ointment to be applied to perianal area every shift (twice daily).

Pt. #16's treatment record documents calmoseptine ointment application once daily on 10/24/2014-10/27/2014, 10/29/2014-10/31/2014, 11/10/2014 and 11/12/2014. There is no documentation of the ointment application on 10/16/2014-10/19/2014, 11/1/2014-11/3/2014. Pt. #16 was discharged from the facility on 11/13/2014 and did not receive 23 of 56 prescribed ointment applications during the patient's 29 day stay at this facility.

On 10/23/2014 Pt. #16's Photographic Wound Documentation lists IAD (incontinence-associated dermitits) on the coccyx. Exudate (drainage) is "none"; the non-open wound bed is noted to be "Pink/beefy red tissue", surrounding skin color is "normal for skin" and wound edges are "normal for skin." Documentation of the site on 11/4/2014 measures an open sore measuring 1.4 cm x 4 cm in diameter x 0.1 cm deep. Exudate amount is documented as "scant", exudate type as "serosanguineous". Surrounding skin color has progressed from "normal" to "bright red." 11/11/2014 documentation measures the site as 3.5 cm x 2.0 cm in diameter x 0.1 cm deep with a "small" amount "serosanguineous" exudate. These findings were confirmed with RN H and CNO D on 12/3/2014 at 10:15 AM. When asked if Pt. #16's pressure ulcer had gotten progressively worse during this hospitalization from 10/15/2014 to 11/13/2014, RN H stated "yes."

3) Pt. #10's MR, reviewed 12/1/2014 at 1:45 PM, contains orders dated 2/1/2014 for calmoseptine ointment to perianal area twice daily and as needed. Per Pt. #10's treatment sheet, Pt. #10 did not receive 20 of 23 prescribed applications during the patient's inpatient hospital stay from 1/31/2014 through 2/13/2014. These findings were confirmed with CNO D on 12/2/1014 at 1:00 PM.

4) Pt. #21's MR, reviewed 12/2/2014 at 7:30 AM, contains orders dated 5/10/2014 for protective ointment to perianal area twice daily. Per Pt. #21's treatment sheet, Pt. #21 did not receive 9 of 12 prescribed applications from 5/10/2014 through 5/15/2014. On 5/15/2014 the protective ointment order was discontinued and cavilon durable barrier cream ordered to be applied to perianal skin twice daily and as needed with incontinence with additional instruction to "record on treatment sheet." Per the treatment sheet, Pt. #21 received 1 dose of cavilon durable barrier cream on 5/18/2014 during the patient's hospital from 5/9/2014 through 5/18/2014. These findings were confirmed with CNO D on 12/2/2014 at 1:00 PM.

5) Pt. #12's MR, reviewed 12/2/2014 at 8:05 AM, contains orders dated 9/9/2014 for calmoseptine ointment to perianal area twice daily and as needed. Per Pt. #12's treatment sheet, Pt. #12 did not receive 30 of 110 prescribed applications during the patient's inpatient hospital stay from 9/9/2014 through 11/4/2014. These findings were confirmed with CNO D on 12/2/2014 at 1:00 PM.

6) Pt. #13's MR, reviewed 12/2/2014 at 12:00 PM, contains orders dated 10/1/2014 for antifungal cream to perianal area twice daily. Per Pt. #13's treatment sheet, Pt. #13 did not receive 29 of 50 prescribed applications during the patient's inpatient hospital stay from 10/1/2014 through 10/25/2014. These findings were confirmed with CNO D on 12/2/2014 at 1:00 PM.

7) Pt #25's MR review on 12/2/2014 at 12:45 PM the left thigh Would Documentation instructions state to change the dressing three times per week. There is no documentation since 11/28/14 of the dressing change. The right heel Wound Documentation instructions states to apply ointment daily. There is no documentation for 12/1/14. The left heel Wound Documentation instructions states to apply ointment daily. There is no documentation for 12/1/14. There is a Wound Progress Note describing the four wounds, but no mention of dressing changes or applying ointment. This is confirmed in interview with CNO D and RN H on 12/3/14 at 10:15 AM.

During an interview with RN H and CNO D on 12/3/2014 at 10:15 AM, CNO D stated that documentation of dressing changes and ointment application was "not being charted as it's supposed to be."

Based on record review and interview the facility failed to maintain individualized care plan documentation for 25 of 31 patient medical records reviewed (#2, 3, 5, 6, 7, 8, 10, 11, 12, 13, 14, 15, 16, 17, 18, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30).

Findings:

Review on 12/2/14 at 2:30 PM of facility policy titled Nursing Care Plan dated 10/13 states under #9 "The elements of care planning include: a. Assessment b. Problem identification c. Intervention d. Evaluation e. Communication."

Pt #30's MR, reviewed on 12/1/14 at 1:30 PM, revealed the Plan of Care, dated 11/12/14, does not include unique measurable goals and interventions for Anxiety, Comfort, Air Exchange, Sensory Perception, Infection, Tissue Perfusion, Sleep Patterns, Self Care Deficit, Skin Integrity and Nutrition Risk.

Pt. #10's MR, reviewed 12/1/2014 at 1:45 PM, contains a focused nursing problems list dated 1/31/2014. Problem list includes Airway clearance, Mobility, Nutrition and Skin integrity. There is no documentation regarding goals, interventions or resolution status of this problem list.

Pt #11's MR, reviewed on 12/1/14 at 3:30 PM, revealed the Nursing Database, dated 9/3/14, used to develop a care plan, is incomplete missing Chief Complaint (primary medical diagnosis is Sepsis (blood infection)), Pt has heart disease, Pt has impaired mobility, dementia and cognitive deficit. The Focused Nursing Problem List (careplan) dated 9/8/14 , has one Nursing Diagnosis "Alt. (alteration) Safety" initiated on 9/3/14, with no unique measurable goals and interventions.

Pt. #21's MR, reviewed 12/2/2014 at 7:30 AM, reveals a focused nursing problems list dated 5/9/2014. Problems identified include Impaired skin integrity, impaired cardiac output and Risk for infection. There is no documentation regarding goals, interventions or resolution status of this problem list.

Pt # 3 MR, reviewed on 12/2/14 at 8:00 AM, revealed an IDT careplan nursing goal of "maintain stable blood glucose" to promote wound healing. The nursing careplan does not address blood sugars goals, interventions or outcomes.

Pt. #12's MR, reviewed on 12/2/2014 at 8:05 AM, contains a focused nursing problem list. Problems identified include: Impaired mobility, Ineffective airway clearance, Impaired skin integrity and Pain. The date these problems were identified is documented as 9/15/2014. The date these problems are listed as being resolved or referred is documented as 9/15/2014. Pt. #12's was admitted to the facility on 9/9/2014 and discharged on 11/4/2014. There is no documentation regarding care plan goals or interventions related to the nursing problem list.

Pt #14's MR, reviewed on 12/2/14 at 8:20 AM, revealed the Nursing Database, dated 10/4/15, used for care planning, states Pt #14 has an HD (hemodialysis) port and has a renal diet. The Focused Nursing Problem List, dated 10/5/14, does not include problems, interventions and goals unique to Pt #14 including those specific to dialysis. This Focused Nursing Problem List includes Fluid Balance, Nutrition Imbalance and Risk for Infection; there are no interventions or measurable goals, unique the Pt related to these problems.

Pt. #18's MR, reviewed on 12/2/2014 at 9:05 AM, contains a focused nursing problem list dated 10/21/2014. The nursing problem list includes Alteration in hepatic (liver)function, Alteration in comfort, Alteration in nutrition, Potential for infections, Alteration in mobility, Alteration in ADL (activities of daily living) function, potential for hyper/hypoglycemia. Pt. #18 suffered from a worsening abdominal wound during the hospitalization from 10/21/2014 through 11/9/2014. There is no documentation on the care plan to reflect this change in condition or any goals, interventions or resolution status of any of the problems identified on the nursing problem list.

Pt. #16's MR, reviewed 12/2/2014 at 9:10 AM, reveals a plan of care for alteration in skin integrity related to decreased mobility and incontinence on 11/11/2014. Expected outcome at that time: "Patient skin integrity will be maintained or improved during hospitalization." Pt. #16's MR reveals that the patient suffered from a worsening pressure ulcer during the patient's hospitalization from 10/15/2014 through 11/13/2014. There is no documenation in the MR regarding any changes in the care plan goals or interventions to reflect the patient's change in condition or that the expected outcome was not met for this patient at the time of discharge.

Pt #15's MR, reviewed on 12/2/14 at 9:35 AM, revealed the Nursing Database, dated 10/11/14, states Pt #14 has dialysis three days a week. The Plan of Care, dated 11/12/14, does not include the Pt problem related to renal issues and Dialysis. There are problems listed for Anxiety, Comfort, Injury for Fall Risk, Self Care, Nutrition, Infection and Elimination. This Plan of Care has Expected Outcomes (goals) but no measurable goals that are unique to Pt #15 and has general interventions that are not specific to help Pt #15 attain goals.

Pt #17's MR, reviewed on 12/2/14 at 11:05 AM, revealed the Plan of Care, dated 11/15/14, does not include unique measurable goals and interventions for Physical Injury, Skin Integrity, Nutrition Risk, Infection, and Sleep Pattern.

Pt #29's MR, reviewed on 12/2/14 at 11:35 AM, revealed the Plan of Care, dated 11/15/14, does not include unique measurable goals and interventions for Knowledge Deficit, Anxiety, Comfort, Infection, Sensory Perception, physical injury, self care and skin integrity. There is no Plan of Care related to Pt #29 receiving Dialysis.

Pt. #13's MR, reviewed 12/2/2014 at 12:10 PM, contains a focused nursing problems list dated 10/1/2014. Problems identified include: Impaired physical mobility, impaired nutritional intake and Potential for infection. There is no documentation regarding goals, interventions or resolution status of this problem list.

Pt # 2 MR, reviewed on 12/2/14 at 12:45 PM, revealed an IDT careplan nursing goal of "blood glucose will be controlled". The nursing careplan does not address blood sugar goals, interventions or outcomes.

Pt #6's MR, reviewed on 12/2/14 at 1:10 PM, revealed the Plan of Care, dated 11/14/14, does not include unique measurable goals and interventions for Knowledge Deficit, Air Exchange, infection, Elimination, Sleep Patterns, Self Care Deficit, Skin Integrity and Injury.

Pt # 5 MR, reviewed on 12/2/14 at 1:20 PM, revealed an IDT careplan nursing goal of "tolerate tube feedings." The nursing careplan does not address tube feedings goals, interventions or outcomes.

Pt #7 MR, reviewed on 12/2/14 at 1:45, revealed an IDT careplan nursing goals of "blood glucose will be within normal limits" and pt will consume 80 percent of meals." The nursing careplan does not address blood glucose of nutritional goals, interventions or outcomes.

Pt # 8 MR, reviewed on 12/2/14 at 2:15 PM, revealed an IDT careplan nursing goals of "blood glucose will be within normal limits" and "will consume 80 percent of meals". The nursing careplan does not address blood glucose or nutritional goals, interventions or outcomes.


34337




18816

Care plans for patients #22, 23, 24, 25, 26, 27 and 28 were reviewed on 12/02/14 between the hours of 8:20 AM and 11:40 AM. The plans of care for the indicated patients list various problems chosen from a pre-printed form. Problems, expected outcomes and interventions were not individualized for the listed patients.

Patient #22's plan of care dated 11/12/14 includes knowledge deficit, alteration in comfort and self care deficit as problems but does not define unique, individualized, expected outcomes or interventions

Patient #23's plan of care dated 11/15/14 includes anxiety, alteration in elimination and alteration in sleep patterns as problems but does not define unique, individualized, expected outcomes or interventions

Patient #24's plan of care dated 11/18/14 includes knowledge deficit, alteration in comfort and alteration in sleep patterns as problems but does not define unique, individualized, expected outcomes or interventions.

Patient #25's plan of care dated 11/21/14 includes knowledge deficit, alteration in comfort and alteration in elimination as problems but does not define unique, individualized, expected outcomes or interventions

Patient #26's plan of care dated 11/15/14 includes knowledge deficit, anxiety, alteration in comfort and alteration in sleep patterns as problems but does not define unique, individualized, expected outcomes or interventions.

Patient #27's plan of care dated 11/12/14 includes knowledge deficit, alteration in comfort and alteration in sleep patterns as problems but does not define unique, individualized, expected outcomes or interventions.

Patient #28's plan of care dated 11/15/14 includes alteration in comfort and alteration in sleep patterns as problems but does not define unique, individualized, expected outcomes or interventions.

The record findings were discussed with CNO D on 12/2/14 at 2:30 PM, who stated the care plans should have diagnoses with goals and intervention unique to the Pt, and reflect all the Pt needs including dialysis.









20878

Based on observation and interview the hospital failed to ensure confidentiality of medical records in 2 of 3 areas (rooms 213, 218). This has the potential to affect all current and discharged patients at the facility.

Findings:

Facility policy entitled "Security &Accessibility of Medical Records" reviewed on 07/10/14 states; "Medical records shall not be left unattended in areas accessible to unauthorized individuals."

During a tour of soiled utility room 213 on 12/01/14 at 1:30 PM with Environmental Services Director E the following observation was made: Medical records and billing sheets with patient information were found unsecured in room 213 which was labeled "Soiled Utility". E stated at the time of the observation E was not aware of medical records being kept in the room.

During a tour of storage room 218 on 12/01/14 at 1:15 PM with E an unlocked waste bin was observed which contained medical record waste. E stated at the time that this waste was stored there until picked up for shredding and confirmed medical records storage areas should be secured.

Based on record review and interview the facility failed to ensure physician authentication of verbal and telephone orders within 24 hours per facility policy in 12 of 31 medical records reviewed (#6, 10, 11, 13, 14, 15, 16, 17, 21, 23, 25, 29).

Findings:

Facility policy "Orders, Physician" #O02-G dated 1/1/14 states in part "The responsible practitioner...shall authenticate, time and date all orders promptly, within the time frame specified by state law..." This policy was reviewed on 12/3/2014 at 8:50 AM.

The facility's medical by-laws, reviewed on 12/1/2014 at 3:00 PM, specify verbal and telephone orders are to be authenticated by the physician within 24 hours.

Pt. #10's MR, reviewed on 12/1/2014 at 1:45 PM, contained verbal orders dated 2/12/2014 and 2/13/2014 that are authenticated by the MD on 3/3/2014, not within 24 hours.

Pt #11's MR reviewed on 12/1/14 at 3:30 PM revealed there is a VO written on 10/3/14 for wrist restraints due to agitation that is not timed. These findings were confirmed with CNO D on 12/02/14 at 2:30 PM, adding the orders should be timed.

Pt. #21's MR, reviewed on 12/2/2014 at 7:30 AM, contained telephone orders dated 5/18/2014 that are authenticated by the MD on 6/13/2014, not within 24 hours.

Pt #14's MR reviewed on 12/2/14 at 8:20 AM revealed there are two VOs dated 10/30/14, that are authenticated by the MD on 11/12/14 and have no times, over 24 hours and there is a Dialysis order dated 10/31/14 that has no title attached to the signature.

Per review of pt. #23's medical record on 12/02/14 at 9:00 AM 3 telephone orders written on 11/08/14 were not authenticated until 11/12/14.

Pt. #16's MR, reviewed on 12/2/2014 at 9:10 AM, contained verbal orders dated 10/16/2014 that are authenicated by the MD on 10/20/2014, not within 24 hours.

Pt #15's MR reviewed on 12/2/14 at 9:35 AM revealed there is a VO written on 11/5/14 that is authenticated by the MD on 11/12/14, not within 24 hours.

Pt #17's MR reviewed on 12/2/14 at 11:05 AM revealed there is a VO written on 11/5/14 that is authenticated on 11/12/14, not within 24 hours.

Pt #29's MR reviewed on 12/2/14 at 11:35 AM revealed there is a VO written on 11/28/14 that is authenticated on 12/1/14, not within 24 hours.

Pt. #13's MR, reviewed on 12/2/2014 at 12:10 PM, contained verbal orders dated 10/1/2014 that are authenticated by the MD on 10/4/2014, not within 24 hours.

Pt #25's MR reviewed on 12/2/14 at 12:45 PM revealed there is a VO written on 11/26/14 that is authenticated by the MD on 12/1/14, not within 24 hours.

Pt #6's MR reviewed on 12/2/14 at 1:10 PM revealed there are VO's written on 11/20/14 that are authenticated by the MD on 11/28/14, not within 24 hours. And there is a VO written on 11/28/14 that is authenticated on 12/1/14, not within 24 hours.

During an interview with CEO B on 12/1/2014 at 3:00 PM, CEO B confirmed all verbal and telephone orders are expected to be authenticated by the physician within 24 hours.

All findings were confirmed with CNO D on 12/2/2014 between 1:00 PM and 2:30 PM. CNO stated that all telephone orders should have been authenticated within 24 hours.


18816




20878

Based on record review and interview the facility failed to ensure the MR was complete, including progress notes, orders and assessments to determine continuing care of the Pt, in 3 of 30 MRs reviewed (11, 14 and 29).

Findings:

Review on 12/2/14 at 3:00 PM of facility policy titled Discharge Planning dated 7/1/14, it states under #6 "Patient discharge is made only upon written orders from the attending physician or his/her designee."

Review on 12/3/14 at 10:00 AM of facility policy titled Documentation Standards dated 7/1/14, it states under #3 "All entries must be legible...#7. Documentation should be done throughout the shift and not left until the end of the shift."

Pt #11's MR review on 12/1/14 at 3:30 PM revealed there is no discharge order. There is an MD Progress Note dated 10/3/14 with an illegible time and content. There is a VO order for wrist restraint due to agitation 10/3/14, with no date. There is no documentation on 10/3/14 of restraint use, or alternative interventions prior to restraint applications. This is confirmed in interview with CNO D on 12/3/14 at 8:40 AM adding there should be an order for all discharges, notes should be legible and restraint documentation is required.

Pt #11's Patient Transfer Forms dated 10/3/14 are missing documentation of Pt's Self Care status, type of Bed required, Behavior, Mental Status, Communication, Disabilities, Incontinence, Impairments, Activity Tolerance Limitations, Suggestions for Active Care, Weight Bearing, Locomotion, Exercises, Social Activities and Transport. This is confirmed in interview with SW Q on 12/2/14 at 10:20 AM, stating all the transfer forms should be complete.

Pt #14's MR review on 12/2/14 at 8:20 AM revealed the Nursing Admission Database is incomplete, missing Self-Concept Preceptions (sic), Religion and Cultural Practices, Education Assessment of Skin Care, Social Work, learning method and Barriers. This is confirmed in interview with CNO D on 12/2/14 at 2:30 PM, stating all areas are required to be completed.

Pt #29's MR review on 12/2/14 at 1:10 PM revealed Pt #29 required Iodine Contrast for a radiology test. The Pre-Assessment document completed on 11/9/14 at 2:14 PM, states "Ordering physician/prescriber will reassess need for IV contrast if answer is "YES" to any of the above potentially harmful conditions or medications" The Pre-Assessment indicated a "YES" to the questions "Dialysis patient?" and "Pre-Medication including hydration". Pt #29 is also a cancer pt and there was no "Yes" indicated for "Cancer and/or chemotherapy". There is an MD Progress Note dated 11/9/14 at 2:34 PM, the note is illegible, and reader cannot determine if the pt was ok to have the IV contrast. There is a Hemodialysis Order dated 11/28/14 that is not timed. This is confirmed in interview with DON D on 12/2/14 at 2:30 PM, who stated the note cannot be deciphered, and all orders should be timed.

Based on observation and interview, the facility failed to secure biohazard waste in 2 of 2 soiled utility rooms observed.

Findings:

Per review on 12/1/14 at 3:40 PM, of facility policy titled "Master Plan for Hazardous Waste Storage, Disposal and Management" undated, it states "Infectious wastes in red bags are placed in the hazardous waste collection containers in the soiled utility rooms of patient care units or other designated locations." The policy does not address the need to secure biohazard materials.

On 12/1/14 at 11:00 AM, accompanied by IC RN C, noted soiled utility room on 2nd floor, labeled with a biohazard sticker and unlocked. RN C stated at the time of discovery, soiled utility rooms are not kept locked.

On 12/1/14 at 11:20 AM, accompanied by IC RN C, noted soiled utility room on 3rd floor, labeled with a biohazard sticker and unlocked.

A standard Recertification Survey for Life Safety Code compliance was conducted by the Wisconsin Division of Quality Assurance on 12/01-04/2014. Select Speciality Hospital Madison was found to be NOT in compliance with the following applicable regulations for hospital participation in Medicare-Medicaid:

42 CFR 482.41 Condition of Participation: Physical Environment was NOT MET
42 CFR 482.41(b) Standard: Safety from Fire was NOT MET
NFPA 101- Life Safety Code was NOT MET

Select Speciality Hospital Madison is a 4-story structure initially built in 1975, with Type I (332) non-combustible construction as nursing home. It was remodeled into a hospital in 2006. The facility has several emergency generators that provided power to the emergency loads.

The facility contained 4 multi-story patient care wings and 11 smoke compartments in the hospital portion.

The health care organization did not have any off-site satellite clinics.

Select Speciality Hospital Madison is licensed for 58 beds, with a census of 44 inpatients at the time of the survey. The facility was surveyed under the 2000 Life Safety Code, Chapter 18 for an new health care occupancy. Twenty (20) Federal deficiencies of the Life Safety Code were cited.

The cumulative effect of these deficiencies has the potential to affect the safety of all patients receiving services at the hospital.

K12: Class of Construction did not meet non-combustible standards of a Type I(protected)
K17: Smoke tight corridor not maintained.
K18: Positive latching and smoke tight openings into the corridor.
K20: Vertical shafts were not constructed to the proper hourly rating.
K22: Access to exits without readily visible signs.
K25: Smoke Compartment walls were not smoke tight w/ ratings.
K33: Exit enclosure is open to an unoccupied space.
K38: Access to exits was not accessible due to a dead-end.
K39: Corridor width not maintained.
K46: Lacking exit signage.
K50: Fire drills not done or correctly done.
K56: Sprinkler system was not compliant to NFPA 13 minimum standards.
K62. Sprinkler system was not properly maintained.
K67: The HVAC system did not meet the minimum standards on NFPA 90A.
K69: Kitchen was not properly protected per NFPA 96.
K74: Loosely handing fabrics lacked treatment.
K75: Proper storage and handling of rubbish and soiled materials.
K77: Piped medical gas and valves was not installed properly.
K144: Generators were not inspected or tested in accordance with NFPA 110.
K147: Electrical system not to NFPA 70 minimum standards.

Please refer to the full description and findings within the specific K-tag deficiencies within the appropriate building found later in this report.

Based on observation and staff interviews, the facility did not construct, install and maintain a proper ventilation and temperature control system in pharmaceutical, food preparation, and other appropriate areas. The facility did not have a ventilation system that was installed and maintained in accordance with state regulations and manufacturer recommendations. This deficiency occurred in 11 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 12/1/2014 at 12:39 pm, observation revealed on the 2nd floor in room 224.1, that the ventilation to the space could not be confirmed to be compliant with accepted standards. The clean storage room did not have any ventilation. It is required to have 2 outside air changes, 4 air changes total and be positive to the corridor per Guidelines for Design and Construction of Health Care Facilities The Facility Guidelines Institue 2010 (FGI Guidelines) and American Society of Heating, Refrigerating and Air Conditionaing Engineers (ASHRAE) Standard 170. This observed situation was not compliant with 42 CFR 482.41(c)(4).

2. On 12/2/2014 at 8:01 am, observation revealed on the 3rd floor in room 327, that the ventilation to the space could not be confirmed to be compliant with accepted standards. The clean storage room had have negative ventilation. It is required to have 2 outside air changes, 4 air changes total and be positive to the corridor per FGI Guidelines and ASHRAE 170. This observed situation was not compliant with 42 CFR 482.41(c)(4).

3. On 12/2/2014 at 9:48 am, observation revealed on the 4th floor in the room 460, that the ventilation to the space could not be confirmed to be compliant with accepted standards. There is an exhaust grill in the clean supply room creating a negative pressure. The room shall be positive pressure, per FGI Guidelines and ASHRAE 170. This observed situation was not compliant with 42 CFR 482.41(c)(4).

4. On 12/2/2014 at 10:15 am, observation revealed in the Broncoscopy/Procedure room, that the ventilation to the space could not be confirmed to be compliant with accepted standards. The room is a negative pressure room which is acceptable for Broncoscopy. However, other procedures in the room require it to be a positive pressure room, such as Peripheral Inserted Central Catheter (PICC)/Midline procedure. This incorrect pressure relationship is not compliant with FGI Guidelines, ASHRAE 170, and 42 CFR 482.41(c)(4).

5. On 12/2/2014 at 1:08 pm, observation revealed on the roof, where the roof top air handling units are located, that the ventilation to the space could not be confirmed to be compliant with accepted standards. There was no outside air being supplied into RTU3. The outside air dampers were closed. This observed situation was not compliant with 42 CFR 482.41(c)(4).

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Director of Plant Operations), staff F (Corp. Manager of Plant Operations) and staff G (Corp. Director of Plant Operations).

Based on record review, interview and observation the facility failed to practice proper infection control technique per facility policy during observations in care for 3 of 5 patients observed (Pts. #24, 30, 31). The facility also failed to maintain a clean environment in 4 of 4 hospital floors observed, and 1 of 1 exterior storage shed. This has the potential to affect all patients receiving care during the time of the survey (an average daily census of 44).

Findings:


20878

Observations of care:

Per review on 12/2/14 at 2:55 PM, of facility policy titled "Hand Hygiene" dated 7/09, it states hand hygiene should be preformed "when ... before and after every patient contact... before going into a patient room and before leaving a patient room ..."

1) On 12/2/14 at 8:50 AM, observed CNA I, put on PPE gown without tying the back and proceed into Pt. #32's room to deliver a food tray. No hand hygiene was performed when CNA I left room after taking the gown off. Observed CNA I proceed to gown, without tying the back, and proceed into room 371. No hand hygiene was performed. Observed CNA I's PPE gown flapping open and touching the patient bed in the isolation room. CNO D stated, at the time of observation, that CNA I needed to tie the gown and perform hand hygiene.

2) On 12/2/14 at 2:00 PM, observed Wound Nurse H, cut soiled bandaged off the legs of Pt #24 using a clean bandage scissors, then later during the dressing change use the same scissors to cut the new/clean dressings to size without the benefit of cleaning the scissors inbetween the dirty and clean tasks. Per CNO D, on 12/2/14 at 3:30 PM, the scissors should be cleaned inbetween clean and dirty tasks and CNO D would share the feedback with Wound Nurse H.

Examples in Dialysis:
Review on 12/2/14 at 3:00 PM of procedure titled Changing Central Venous Catheter Dressing, dated 1/16/09, states under #5 "Using a circular motion around the catheter, rotation the germicidal soaked gauze starting at the center and working outward to clean a 2" area around the exit site to prevent contamination..#7. Clean the exposed portion of each catheter limb with gauze soaked in the appropriate germicide to remove bacteria from the catheter limbs."

3) At 1:42 PM observed CNA M wearing gloves used during positioning Pt #30 for dialysis, removed a stethoscope from around own neck, removed gown and gloves, replaced the stethoscope around neck and washed hands.

4) At 1:47 PM observed RN P performing a catheter dressing change for Pt #30. RN P scrubbed the exit site back and forth with both the chlorhexideine (aseptic scrub) and alcohol rather than using a circular motion from center out per procedure. RN P did not clean the catheter limbs per procedure.

The above dialysis observations were confirmed during observation with RN C, who added the stethoscope is disposable, should be discarded and not worn around the neck, and catheter changes should be performed per procedure. DQI A, who provided procedures, stated in interview on 12/2/14 at 3:00 PM, the dialysis RN is expected to follow dialysis procedures and facility policies.

Physical Environment:

Examples on 1st Floor:

5) During a tour of the facility on 12/02/14 at 10:00 AM with EVS manager E it was observed that clean microfibre mop heads were stored in the first floor dirty utility room. E stated at the time of the observation that only dirty items should be stored in the room.

Examples on 2nd floor:

6) On 12/1/14 at 10:40 AM, accompanied by IC RN C, noted a storage closet across from the nursing station on 2nd floor containing computer towers and also clean supplies to be warm in temperature. This storage closet contained lab tubes and blood culture bottles labeled to be kept between 39 degrees and 77 degrees Fahrenheit. On 12/1/14 at 12:51 PM maintenance recorded the temperature of this storage room to be 81 degrees.

7) On 12/1/14 at 10:40 AM, a wall mounted cup holder next to ice machine contained a rust. Per RN C, at the time of discovery, this cupholder services patients and should be replaced.

8) On 12/1/2014 at 1:50 PM, observation revealed on the 2nd floor in the room 256 Central Supply, that visible accumulation of dirt and dust were present.

9) During a tour of the 2nd floor service elevator lobby area with E on 12/01/14 at 1:20 PM clean patient care supplies were observed to be stored in an open area containing dirty rubbish trolleys. Clean supplies included boxes of tube feeding formula, medication packaging supplies. The area also contained a kitchenette where patient food is stored and prepared.

Examples on 3rd floor:

On 12/1/14 at 11:10 AM, accompanied by IC RN C, noted the following during a tour of 3rd floor:

10) Room labeled 313, where clean dialysis supplies are stored, noted a personal winter coat stored on top of the clean supplies. RN C stated that the coat belonged to staff and should not be kept in the clean supply room.

11) Shower room, across from nursing desk, contained a supply cabinet with travel size, open and used, lotions, body washes and deodorant. RN C that the items need to be thrown out and not used on more than one patient.

12) On 12/2/14 at 12:47 PM a fan at the third floor nursing station has debris on the blades and protective grid. This is confirmed with RN L on 12/2/14 at 12:47 AM agreeing the fan should be clean.



32670

Examples in Dietary:

Per review on 12/1/14 at 3:30 PM, of facility policy titled "Nutrition Room" undated, it states "check daily for outdated food products and discard if outdated."

Per review on 12/2/14 at 1:45 PM, of facility policy titled "Food and Nutrition Policies and Procedures" dated 1/1/14, it states "Cooler and Freezer... Opened food shall be date marked and stored in containers intended for food..."

Per review on 12/2/14 at 2:15 PM, of facility policy titled "Ware-washing" dated 10/1/14, it states "food service staff is expected to notify management in the event the dish machine temperatures are out of range. If management is unavailable, notify maintenance in a timely manner."

13) On 12/1/2014 at 11:10 AM, the 3rd floor kitchenette used to serve patients contained two expired boxes of Chex cereal, dated 10/28/14. RN C stated the kitchen staff are responsible for checking for outdated food on the nursing floors.

On 12/2/14 at 7:10 AM, during a kitchen tour, accompanied by Dietitian J and Food Service Coordinator K, noted the following:

14) Four metal bins were in the prepped food freezer containing food not labeled or dated. Per Food Service Coordinator K, two bins contained cheese cakes, one bin contained coffee cake, and two bins contained lunch meat and all items should be labeled.

15) Review of dish machine temperature logs for 11/14 and 12/14 revealed the following dates where the wash temperature did not meet the minimum temperature requirement of 160 degrees: 11/5 temp = 158, 11/6 temp = 159, 11/9 temp = 159, 11/10 temp = 158 and the following dates where the rinse temp did not meet the minimum temperature requirement of 180 degrees: 11/6 temp = 178, 11/8 temp = 179, 11/10 temp = 179, 12/1 temp = 130. Food Service Coordinator K, stated at the time of discovery, action should have been taken and interventions should have been recorded on the back of the dish temperature logs.

16) During a tour of the facility's soiled utility rooms (258, 360 and 456) on 12/02/14 at 2:15 PM it was observed that food delivery carts were stored in each of these areas.

Examples on 4th Floor:

17) During a tour of the ICU (4th floor) on 12/02/14 at 2:00 PM clean patient care supplies were observed to be stored in an open area behind the nursing station. At the same time a movable dividing wall with torn rubber sweeps was observed dividing rooms 472 and 473.


18816

Examples from Dialysis on 4th floor:

Review on 12/2/14 at 3:00 PM of procedure titled Checking pH of Final Dialysate with Precision pH Control Paper, dated 6/19/13, states "The following supplies are needed for this procedure...PPE"

Review on 12/3/14 at 3:00 PM of procedure titled Checking Conductivity of Final Dialysate with Myron L DI Meter, dated 8/25/08, states "The following supplies are needed for this procedure...PPE"

The following was observed in the Dialysis room on 12/1/14 between 11:30 AM and 1:45 PM:

18) At 11:35 AM the test strips for Residual Chlorine and pH control paper to test water quality are open and not dated.

19) At 1:05 PM there are chips and scrapes in the walls preventing and intact surface for cleaning.

20) While testing the water conductivity and pH, RN P did not wear PPE (gloves).

The above dialysis observations were confirmed during observation with RN C, who added test strips should be dated when opened, agreed the walls should be smooth and washable. DQI A, who provided procedures, stated the dialysis RN is expected to follow dialysis procedures and facility policies.


12187

Example in Exterior Storage:

21) On 12/2/2014 at 1:16 PM, observation revealed in the utility shed located 10 feet from the hospital building, that there was storage in the shed. The storage included one covered bin of biohazardous waste, one uncovered bin of hazardous waste, approximately 10 empty bins of hazardous waste and other outdoor equipment such as a lawn mower, snow blower, shovels, salt spreaders etc. The unheated building is made out of exposed wood.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Director of Plant Operations), staff F (Corp. Manager of Plant Operations) and staff G (Corp. Director of Plant Operations).

A0749