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A standard Recertification Survey for Life Safety Code compliance was conducted by the Wisconsin Division of Quality Assurance on 02/27/2013. The Rehab Hospital of Wisconsin (RHOW) 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(a) Standard: Maintenance of Physical Plant was NOT MET.
42 CFR 482.41(a)(2) Standard: Emergency Gas And Water was NOT MET.
42 CFR 482.41(b) Standard: Safety from Fire was NOT MET.
42 CFR 482.41(c) Standard: Facilities was NOT MET.
NFPA 101 (2000 edition) - Life Safety Code was NOT MET.

The RHOW was a 1-story structure completed 08/22/2008, based on NFPA 101 (2000 ed. NEW) section 18.1.6.2, with Type II (111) non-combustible construction. There were no health care additions. There were no satellite clinics. The facility was fully-sprinkled and has smoke detection at hazardous spaces and at smoke barriers in the corridors. The facility has a variance for the Brain Injury Unit due to doors being locked from the unit with delayed egress of 15 seconds. The facility had an emergency generator (Cummins N Power 750 KW) that provided power to the emergency loads. The facility contained 3 patient care sleeping wings and 5 smoke compartments on two levels.

RHOW is licensed for 40 beds, with a census of 30 inpatients at the time of the survey. The facility operated outpatient functions and also had 15 outpatients in the building on the day of entry.

The facility was surveyed under the 2000 Life Safety Code, Chapter 18 for a NEW health care occupancy. Nineteen (19) federal deficiencies of the Life Safety Code were cited as follows:
K-12 (building structure),
K-17 (corridor walls),
K-18 (corridor doors),
K-29 (hazardous spaces),
K-38 (egress),
K-46 (lighting),
K-48 (fire evacuation),
K-50 (fire drills),
K-51(fire alarm & detection),
K-56 (sprinkler installation),
K-62 (sprinkler system maintenance),
K-67 (heating & ventilating system maintenance),
K-69 (commercial cooking hood maintenance),
K-70 (portable heaters),
K-144 (emergency generator maintenance),
K-145 (Type I EES),
K-147 (electrical wiring),
K-154 (sprinkler system out of service), and
K-155 (fire alarm system out of service).
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Based on review of facility Patient and Family Handbook dated February 2013 and 1 of 1 staff interview ( A) the facility failed to ensure patients are informed of all patient rights and responsibilities. This can potentially effect all patients receiving treatment at this facility. Daily census during this survey: 2/25/2013 = 30, 2/26/2013 = 32, and 2/27/2013 = 32.
Findings include:
Review on 2/25/2013 beginning at 2:00 PM of the Patient and Family Handbook dated February 2013, revealed the Patient and Family Handbook listed the patient rights and responsibilities. The Patient and Family Handbook does not include the patients right to be informed of his/her health status.
Per interview with ICEO A on 2/26/2013 beginning at 12:55 PM, ICEO A stated (ICEO A) could not find evidence of the above patient right included in the patient's rights and responsibilities given to patients on admission to the facility via the Patient and Family Handbook.

Based on review of QAPI (Quality Assurance Performance Improvement) indicators and staff interview, the hospital failed to ensure that it had an effective quality assurance program that collected data for all contracted services (Staffing services- Nursing, Staffing services-Therapy and laundry), and compiled aggregate data of adverse occurrences to identify high risk and/or problem-prone trends and patterns. This occurred in 1 of 1 quality assurance interviews conducted (Staff B), and has the potential to affect the total patient population. Daily census during this survey: 2/25/2013 = 30, 2/26/2013 = 32, and 2/27/2013 = 32.

Findings include:

A review of a quality/risk monitoring report for the year of 2012 was done on 02/26/13. This report did not include contract services as listed above (Staffing services and laundry). This omission was confirmed per interview with staff B on 02/26/13 at 1:30 PM. Staff B stated that staffing services and laundry were not included in the hospital's quality improvement program.

Based on medical records review and review of facility policy, the facility staff failed to modify and individualize the patient's care plans when goals were met prior to established goal dates. This deficient practices could possible effect all patients receiving therapy at this facility during the survey, census on 2/25/13 = 30, 2/26/13 = 32 and 2/27/13 = 32.

Finding Include:

Per facility policy reviewed on 2/26/13 at 1:00 PM, titled Patient Documentation revised 2/14/13, states under IV.B.2. "All goals need to be written as: a. Specific b. Measurable/Functional c. Attainable d. Realistic e. Time frame for achievement...4. Barriers to reaching goal achievement will be incorporated into goal planning."

Pt #10's MR review on 2/26/11 at approximately 9:30 AM, the Physical Therapy Care Plan revealed pt #10 has a goal to climb stairs with supervision using one handrail by 2/20/13. On 2/19/13 there is a progress note stating "he needs cues for step to gait pattern for safety." There is no documentation Pt #10 met the goal, and no new date with new interventions to meet the goal. This was confirmed in interview with RN K, on 2/26/13 at 9:30 AM, stating there is no date the goal is met and no new date to meet the goal.

Pt #11's MR review on 2/26/11 at approximately 10:00 AM, the Physical Therapy Care Plan revealed pt #11 has a goal to climb stairs with supervision using two handrails; and climb 1 step with a unilateral rail or appropriate assistive device and supervision by 2/21/13. There is no documentation Pt #11 met the goals, and no new date with new interventions to meet the goals. This was confirmed in interview with RN AK, on 2/26/13 at 10:00 AM, stating there is no date the goal is met and no new date to meet the goal.

Based on MR review in 15 out of 30 MR's reviewed (Pt. #3, 4, 5, 6, 7, 9, 11, 12, 13, 14, 21, 22, 23, 24, 28), P & P review, Medical Staff Rules and Regulations and staff interview, this facility failed to ensure that all entries are properly authenticated with date, time and/or signature of the practitioner completing the entry. Failure to properly authenticate orders with signature, date and time has the potential to affect all patients receiving care in the facility. Daily census during this survey: 2/25/2013 = 30, 2/26/2013 = 32, and 2/27/2013 = 32.

Findings Include:

Per review of Medical Staff Rules and Regulations on 2/25/2013 at 10:30 indicates on page 65, #12. "All clinical entries in the patient's medical record including dictation and transcription shall be accurately dated and authenticated."

Per review of policy titled Medical Record Content, policy number HIM-12.55 dated 10/14/2010 on 2/26/2013 at 3:30 PM indicates under policy: All clinical entries in the patient's medical record will be accurately dated, timed, and authenticated.

Pt #3's MR reviewed on 2/25/13 at 11:40 AM revealed the H & P (History and Physical), dictated 02/13/13 and a consult dictated 02/13/13, signed by the MD with no date or time. Findings confirmed with RN F on 2/25/13 at 11:50 AM.

Pt #4's MR reviewed on 2/25/13 at 3:10 PM revealed the H & P dictated 01/04/13 and a consult dictated 01/29/13, signed by the MD with no date or time. Findings confirmed with RN F on 2/25/13 at 3:10 PM.

Pt #5's MR reviewed on 2/25/13 at 3:40 PM revealed the H & P dictated 02/13/13 and a consult dictated 2/15/13, signed by the MD with no date or time, in addition, the MR contained a consult with no MD authentication dictated 02/22/13. Findings confirmed with RN F on 2/25/13 at 11:50 AM.

Pt #6's MR reviewed on 2/25/13 at 4:00 PM revealed the H & P dictated 10/03/12 and a consult dictated 10/03/12, signed by the MD with no date or time. Findings confirmed with RN F on 2/25/13 at 4:00 PM.

Pt #7's MR reviewed on 2/25/13 at 10:35 AM revealed the H & P was not authenticated by the MD with date and time. Findings confirmed with CPA D on 2/25/13 at 11:00 AM.

Pt #9's MR reviewed on 2/25/13 at 11:40 AM revealed a Consultation report which was not authenticated by the MD with a date and time. Findings confirmed with CPA D on 2/25/13 at 11:55 AM.

Pt #11's MR reviewed on 2/25/13 at 1:45 PM revealed the H & P and a Consultation report which was not authenticated by the MD with a date and time. Findings confirmed with CPA D on 2/25/13 at 1:55 PM.

Pt #12's MR reviewed on 2/25/13 at 1:55 PM revealed a Progress Note which was not authenticated by the MD with a date and time. Findings confirmed with CPA D on 2/25/13 at 2:25 PM.

Pt #13's MR reviewed on 2/26/13 at 9:45 AM revealed the H & P which was not authenticated by the MD with a date or time. Findings confirmed with Manager of PCS R on 2/26/13 at 9:15 AM.

Pt. #14's MR review on 2/25/13 at 1:30 PM revealed the H & P dictated and transcribed on 10/12/12 by physician, was not dated and timed with authentication. A Discharge summary dictated and transcribed on 10/12/12 was not dated and timed with authentication. A Consultation dictated and transcribed on 10/12/12 was not dated or timed with authentication. Findings confirmed with RNCS K on 2/25/13 at 2:40 PM.

Pt. #21's MR reviewed on 2/25/2013 at 2:40 PM revealed consultations dated 2/12/2013, 2/14/2013 and 2/19/2013 were without a date and time next to the MD's authentications. Findings confirmed by HIM Manager N on 2/25//1/3 at 3:00 PM.
Pt. #22's MR reviewed on 2/26/2013 at 7:55 AM revealed the H & P which did not have a date or time next to the MD authentication. Findings confirmed by HIM Manger N on 2/26/13 at 7:55 AM.
Pt. #23's MR reviewed on 2/26/2013 at 10:44 AM revealed the H & P which did not have a date or time next to the MD authentication. Findings confirmed by Him Manager N on 2/26/13 at 11:00 AM.
Pt. #24's MR reviewed on 2/26/2013 at 11:05 AM revealed the H & P which did not have a date or time next to the MD authentication. Consults dated 1/15/2013, 1/21/2013, 1/28/2013, 1/29/2013 and 2/14/2013 did not have the date and time next to the MD authentication. Telephone orders dated 2/9/2013 and 1/31/2013 were not signed by the MD. Findings confirmed with HIM Manger N on 2/26/.13 at 11:30 AM.
Pt #28's MR review on 2/26/13 beginning at 10:25 AM revealed the following, H & P was not dated and timed by physician. Findings confirmed with Manager of PCS R on 2/26/13 at 10:45 AM.

Per interview with RN F on 2/25/13 at 11:50 AM, RN F stated all signatures in the medical record should include a date and time with authentication.


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29972

Based on MR review in 9 out of 30 MR's reviewed (Pt. #4, 5, 6, 11, 12, 14, 21, 24, 26), P & P review, Medical Staff Rules and Regulations and staff interview, the facility failed to ensure that all orders are properly authenticated with date, time and/or signature of the practitioner writing the orders. Failure to properly authenticate orders has the potential to affect all patients receiving care in the facility. Daily census during this survey: 2/25/13 = 30, 2/26/13 = 32, and 2/27/13 = 32.
Findings include:

The facility's policy titled, "Telephone, verbal and written orders for medication," dated 2/4/13, was reviewed on 2/26/2013 at 3:00 PM. The policy states in part on page 1-3, Procedures, "All verbal and/or telephone orders for medications shall include the following criteria: a. Date and time the order is prescribed verbally or via telephone, D. The prescribing practitioner must sign the written record of the verbal/telephone order within 24 hours of giving the order."

Per review of Medical Staff Rules and Regulations dated 11/2011 on 2/25/2013 at 10:30 AM indicate on page 65, #12. "All clinical entries in the patient's medical record including dictation and transcription shall be accurately dated and authenticated."

Pt #4's MR review on 2/25/13 at 3:10 PM revealed there is a telephone order written on 1/10/13 which is signed but not dated or timed by the physician. Findings are confirmed with RN F on 2/25/13 at 3:15 PM.

Pt #5's MR review on 2/25/13 at 3:35 PM revealed telephone orders written on 2/18/13 and 02/21/13 which are signed but not dated or timed by the physician. Findings are confirmed with RN F on 2/25/13 at 3:35 PM.

Pt #6's MR review on 2/25/13 at 4:00 PM revealed telephone orders written on 10/05/12 and 10/07/12 which are signed but not dated or timed by the physician. Findings are confirmed with RN F on 2/25/13 at 4:00 PM.

Pt #7's MR review on 2/25/13 at 10:35 AM revealed there are MD and NP telephone orders written on 2/20/13 and 2/21/13 that are not authenticated by the MD with a date and time. Findings are confirmed with CPA D on 2/25/13 at 11:00 AM.

Pt #11's MR review on 2/25/13 at 1:45 PM revealed there is a telephone order written on 2/22/13 and a re-order for Diazepam written on 2/15/13 that are not authenticated by the MD with a signature, date and/or time. Findings are confirmed with CPA D on 2/26/13 at 1:55 PM.

Pt #12's MR review on 2/25/13 at 1:55 PM revealed there is a dialysis order sheet completed with an MD signature that has no date and time. A date and time was added with no new signature on 2/24/13. Findings are confirmed with CPA D on 2/25/13 at 2:25 PM, adding the order should not be copied with an MD signature in place.

Pt. #14's MR reviewed on 2/25/13 at 1:30 PM revealed a MD order written on 10/12/12 which is not timed. This is confirmed with RNCS K on 2/25/13 at 2:40 PM.

Pt. #21's MR reviewed on 2/25/2013 at 2:40 PM revealed a telephone order dated 2/18/2013 is not signed by the physician.
Pt. #24's MR reviewed on 2/26/2013 at 11:05 AM revealed a telephone orders dated 2/9/2013 and 1/31/2013, are not signed by the physician.
The above findings were confirmed by HIM Manager, N.
Pt #26's MR reviewed on 2/25/13 beginning at 2:45 PM reveals the following, physician telephone order for dressing change dated 2/18/13 not authenticated by physician.
The above finding is confirmed with Manager of PCS R at 3:00 PM.

Per interview with RN F on 2/25/13 at 3:15 PM, RN F stated all authentications in the medical record should have a date and time.






29972

Based on MR review, policy and procedure review, Medical Staff Rules and Regulations review, and staff interview, this facility failed to ensure that telephone/verbal orders are properly authenticated within 48 hours with signature, time and date, by the ordering provider in 2 of 6 closed MR's reviewed (Pt. #18, 19) and 2 of 23 open MR's reviewed ( Pt. #7, 11)with a total universe of 30 MR's reviewed. Failure to properly authenticate verbal/telephone orders within 48 hours has the potential to affect all patients receiving care in this facility. Daily census during this survey: 2/25/13 = 30, 2/26/13 = 32, and 2/27/13 = 32.

Findings include:

The facility's policy titled, "Telephone, verbal and written orders for medication," dated 2/4/13, was reviewed on 2/26/2013 at 3:00 PM. The policy states in part on page 3, D. "The prescribing practitioner must sign the written record of the verbal/telephone order within 24 hours of giving the order."

Per review of Medical Staff Rules and Regulations, dated November 2011 states on page 67, H.1. All orders for medications, treatments, and diagnostic tests shall be in witting and shall be signed, timed and dated by a member of the Medical Staff. Verbal and/or telephone orders must be authenticated by the ordering practitioner within twenty-four hours (24) hours.

Per review of Pt. #18's MR on 2/26/13 at 1:40 PM revealed a telephone order written on 12/30/12 and was signed by the physician on 1/14/13. An order was written on 1/4/13 and was signed by the physician on 1/10/13. An order written on 1/5/13 was signed by the physician on 1/10/13. Findings were confirmed with RNCS K on 2/26/13 at 2:10 PM.

Per review of Pt. #19's MR on 2/26/13 at 2:15 PM revealed a telephone order written on 1/8/13 and was signed by the physician on 1/15/13. An order written on 1/10/13 and was signed by the physician on 1/15/13. An order written on 1/11/13 and was signed by the physician on 1/15/13.

Per interview with DQ B on 2/26/13 at 3:15 PM, DQ B stated that the facility does expect that telephone/verbal orders will be signed within 48 hours.

Based on review of facility policy and procedures, medical record review and staff interview the facility staff (CNA's (certified nursing assistant)) failed to complete required documentation in 10 out of 30 patient's (#8, 9, 13, 16, 17, 18, 19, 26, 27, 28 ) medical record. Nursing staff failed to reassess patients following pain relief interventions in 4 of 30 patient's (#2, 5, 7, 8) medical record. Nursing staff failed to follow physician orders in 4 of 30 patients (#12, 13, 26, 27) medical record. This deficient practice could possibly affect all patients being treated at this facility; census on 12/25/13 = 30 patients, on 2/26/13 = 32 and on 2/27/13 = 32.

Findings include:

Per facility policy reviewed on 2/26/13 at 1:00 PM, titled Assessment and Reassessment-Nursing revised 2/14/13, it states under VI. "CNA's [sic] will document on every patient every shift using the CNA Documentation form. The CNA Documentation form is to be reviewed every shift by the patient's nurse to verify completion."

Per facility policy reviewed on 2/26/13 at 1:00 PM, titled Pain Assessment, Reassessment and Management revised on 2/14/13 states under VIII.A. "Re-evaluation of pain after an intervention will be documented within two hours after the intervention."

Examples of CNA documentation:

Pt #8's MR review on 2/25/13 at 11:15 AM revealed on the night shift for 2/21/13 and 2/22/13 between 10:30 PM and 6:45 AM the CNA Documentation sheet has nothing completed and is signed off by the RN. Findings confirmed with RN F on 2/25/13 at 3:00 PM.

Pt #9's MR review on 2/25/13 at 11:40 AM revealed on the night shift for 2/21/13 and 2/22/13 between 10:30 PM and 6:45 AM the CNA Documentation sheet has nothing completed and is signed off by the RN. Findings confirmed with RN F on 2/25/13 at 3:00 PM.

Pt #13's MR review on 2/26/13 beginning at 9:45 AM revealed that CNA Documentation forms from 2/19/13 to 2/25/13, indicated documentation is not consistently completed and areas are left blank. Findings confirmed with Manager PCS R on 2/26/13 at 10:05 AM.

Pt. #16's MR review on 2/26/12 at 9:30 AM revealed that on 2/7/13 the PM shift the CNA documentation form was not completed by CNA staff. Findings confirmed with RNCS K on 2/26/13 at 10:40 AM.

Pt. #17's MR review on 2/26/12 at 10:45 AM revealed that on 12/30/12 on the PM shift, 12/31/12 on the PM shift and 1/2/13 on the PM shift, the CNA documentation form was not completed by CNA staff. Findings confirmed with RNCS K on 2/26/13 at 11:30 AM.

Pt. #18's MR review on 2/26/12 at 1:40 PM revealed that on 1/8/13 on the PM shift, documentation was not completed by CNA staff. Findings confirmed with RNCS K on 2/26/13 at 2:10 PM.

Pt. #19's MR review on 2/26/12 at 2:15 PM revealed that on 1/8/13 on the PM shift, 1/10/13 on the AM and PM shift, documentation was not completed by CNA staff. Findings confirmed with RNCS K on 2/26/13 at 3:00 PM.

Pt. #26's MR review on 2/25/13 beginning at 2:45 PM revealed that CNA Documentation forms dated 2/19/13 through 2/24/13, indicated documentation is not consistently completed and areas are left blank. This information was confirmed with Manager of PCS R on 2/25/13 at 3:00 PM.

Pt. #27's MR review on 2/25/13 beginning at 3:35 PM revealed that CNA Documentation forms from 2/15/13 through 2/24/13, indicated documentation is not consistently completed and categories are left blank. This information was confirmed with Manager of PCS R on 2/25/13 at 3:50 PM.

Pt #28's MR review on 2/26/13 beginning at 10:25 AM revealed CNA Documentation forms from 2/21/13 through 2/26/13, indicated documentation is not consistently completed and categories are left blank. This information was confirmed with Manager of PCS R on 2/25/13 at 11:00 AM.

Per interview with RNCS K and RN F on 2/25/13 at 3:00 PM, RNCS K and RN F stated that CNA's are expected to complete daily documentation each shift.

Examples of pain documentation:

Pt #2's MR review on 2/26/13 at 9:20 AM revealed on 2/20/13 at 10:30 AM, Pt #2 complained of pain rated 7 out of 10 ("very intense pain"). Pt #2 received cryotherapy (an ice pack) for pain in her right lower extremity. A reassessment is documented with a rating of "4" pain, without a time to ensure the reassessment was done within the two hour timeframe per policy. On 2/21/13 at 9:00 AM, Pt #2 complained of pain rated 5 out of 10 ("very distressing pain"). Pt #2 received an unspecified pain medication at 9:00 AM. A reassessment is documented with a rating of "2" for pain, without a time to ensure the reassessment was done within the two hour timeframe per policy. Findings are confirmed with RN F on 2/26/13 at 9:30 AM.

Pt #5's MR review on 2/26/13 at 11:00 AM revealed on 2/13/13 at 10:30 AM, Pt #5 complained of pain during physical therapy rated 10 out of 10 ("agonizing, unimaginable, or unspeakable pain"). Pt #2 rested and a reassessment is documented with a rating of "0" pain, without a time to ensure the reassessment was done within the two hour timeframe per policy. On 2/15/13 at 11:00 AM, Pt #2 complained of pain rated 10 out of 10. Pt #2 received pain medication, Tylenol, at 11:20 AM. No reassessment is documented within the two hour timeframe per policy. Findings confirmed with RN F on 2/26/13 at 11:00 AM.

Pt #7's MR review on 2/25/13 at 10:35 AM revealed on 2/24/13 at 1:40 AM, Pt #7 complained of pain rated 8 out of 10. Pt #7 received a pain medication Dilaudid at 1:40 AM. A reassessment is documented with a rating of "0" pain, without a time to ensure the reassessment was done within the two hour timeframe per policy. On 2/24/13 at 3:30 PM Pt #7 complained of pain rated 5 out of 10. Pt #7 received a pain medication, Tylenol, at 9:30 PM. A reassessment is documented with a rating of "1" for pain, without a time to ensure the reassessment was done within the two hour timeframe per policy. Findings confirmed with RN F on 2/25/13 at 3:00 PM.

Pt #8's MR review on 2/25/13 at 11:15 AM revealed on 2/17/13 at 8:30 AM Pt #8 complained of pain rated 5 out of 10. Pt #8 received a pain medication, Vicodin, at 8:30 AM. A reassessment is documented with a rating of "2" for pain, without a time to ensure the reassessment was done within two hours per policy. On 2/24/13 at 11:30 AM, Pt #8 complained of pain rated 6 out of 10. Pt #8 received a pain medication Hydrocodone at 11:30 AM. There is no reassessment to determine pain relief. At 4:30 AM, Pt #8 complained of pain rated 5 out of 10. Pt #8 received a pain medication Vicodin at 4:30 AM. There is no reassessment to determine pain relief. At 9:15 PM, Pt #8 complained of pain rated 4 out of 10. Pt #8 received a pain medication Vicodin at 9:15 PM. There is no reassessment to determine pain relief. Findings confirmed with RN F on 2/25/13 at 3:30 PM.

Per interview with RN F on 2/26/13 at 9:30 AM, RN F stated a reassessment is to be documented in such a way as to record the time the reassessment was completed.

Example of MD orders not followed:

Pt #12's MR review on 2/25/13 at 1:55 PM revealed there are hemodialysis orders for 2/25/13 that state the dialysate bath is to be potassium-3, calcium-2.5, a 160 nonreuse dialyzer, and to keep the systolic blood pressure above 90, give 12.5 grams of Mannitol intravenously. Review of the dialysis flowsheet for 2/25/13 revealed the dialyzer used is "18", the bath is potassium-3 and calcium 2. Pt #12's systolic blood pressure is recorded as 87 at 5:10 AM. There is no documentation on the flowsheet or medication administration sheet the Mannitol was given, nor is there documentation of Pt #12's signs or symptoms of hypotension. Findings confirmed with CPA D on 2/25/13 at 2:35 PM.

Per interview with CPA D on 2/25/13 at 2:35 PM stating that the medication should have been documented and orders should have been followed.

Pt. #13's MR on 2/26/13 beginning at 9:45 am revealed the following. Per physician admission orders dated 2/19/13, staff are to monitor Pt #13's I & O's daily. Review of Intake and Output Record dated 2/25/13 revealed the liquid intake section is blank for day shift. Findings confirmed with Manager of PCS R on 2/26/13 at 10:15 AM.

Pt. #26's MR review on 2/25/13 beginning at 2:45 PM revealed the following, Physician order for staff to monitor Pt #26's intake and output (I & O) dated 2/18/13. Per review of Intake and Output Record, on 2/19/13 liquid intake section is blank for days and night shift. Per Pt #26's medication administration record dated 2/19/13, Pt #26 received 350 ml of intravenous (IV) medication during the day shift and 350 ml of IV medication on the PM shift. Per the Intake and Output Record, on 2/19/13 IV fluid intake section is blank for days and PM shift. On 2/20/13 liquid intake section is blank for days and night shift. Findings confirmed with Manager of PCS R on 2/25/13 at 3:15 PM.

Pt #27's MR review on 2/25/13 beginning at 3:35 PM revealed the following; physician insulin orders not dated and timed by physician, Podiatrist Consultation not dated and timed, and Neurologist Consultation not dated and timed. Per physician admission orders dated 2/15/2013, staff are to monitor Pt #27's I & O's daily. Review of Intake and Output Record dated 2/19/13 reveals the liquid intake section is blank for days and PM shift. Findings confirmed with Manager of PCS R on 2/25/13 at 3:55 PM.



18816

Based on staff interview, review of facility P & P, review of the FDA Food Code, and 4 of 6 staff ( G, H, I , J ) observered, the facility failed to prepare and serve food under sanitary conditions. This deficiency could potential affect all patients receiving care in the facility. Daily census during this survey: 2/25/13 = 30, 2/26/13 = 32, and 2/27/13 = 32.

Findings include:

HAIR RESTRAINTS

The 2009 FDA Food Code states that food employees shall wear hair restraints to effectively keep hair from contacting exposed food, clean equipment, utensils, linens, and unwrapped single-service/single-use articles.

Facility's "Uniform, Personal Hygiene and Appearance, Policy FDS 6.46, Review Date: 12/01/2010 states "Hair restraints, (hair covering, beard protectors or ball caps) will be worn in all food production, receiving, and sanitation areas. All hair must be effectively restrained."

On 2/25/2013 at 10:41 AM, in the kitchen, observed Staff H with hair hanging outside of cap. This was confirmed by Staff G.

On 2/25/2013 at 11:20 AM, in the food serving line in the dining room, observed Staff J without a restraint on pony tail.
MONITORING OF INTERNAL TEMPERATURE OF HOT WATER SANITIZATION DISH MACHINE

According to the 2009 FDA Food Code, a system needs to be in place for monitoring a hot water sanitization dishmachine's internal temperature to assure that food contact and utensil surfaces reach a temperature of 160oF as measured by an irreversible registering temperature indicator.

On 2/25/2013, at 10:43 AM, in the dishroom, discussion with Staff G revealed the only time the internal temperature of the hot water sanitization dishmachine was taken is when Public Health comes in and does it during their investigation. Staff G was unaware of this professional standard of practice.

HAND HYGIENE

According to the FDA Food Code, food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation, including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles. Hands are to be washed during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks and before donning gloves for working with food. When gloves are used, they are for single-use only. Multiuse gloves, especially when used repeatedly and soiled, can become breeding grounds for pathogens that could be transferred to food. Soiled gloves can directly contaminate food if stored with ready-to-eat food or may indirectly contaminate food if stored with articles that will be used in contact with food.

Under procedure, line (J) of facility's "Infection Control-Hand Washing," Policy FDS 6.41, review date 12/01/2010 states "All co-workers must wash their hands before starting work and after any other contamination of hands."

On 2/25/2013, 10:32 AM, in the kitchen, twice observed Staff I re-contaminate hands by wiping down the sink after washing hands.

On 2/25/2013, 12:15 PM, in dining room serving line, observed Staff H, wearing the same pair of single-use gloves, touching menu, countertop, pan covers, utensil handles and then grab bun to slice it. Staff H then placed tuna patty onto the bun and with hands, wearing same pair of gloves, then pushed down on top of the patty and moved it around on the plate.

Based on observation and staff interviews, the facility did not maintain the condition of the physical plant and overall hospital environment in a manner to ensure the safety and well being of patients. The facility did not have caulk joints free of damage. This deficiency occurred in 2 of the 5 smoke compartments, and had the potential to affect 2 inpatients, 15 outpatients, 20 staff and an unknown number of visitors within these 2 smoke compartments.

FINDINGS INCLUDE:

1. On 02/25/2013 at 4:17 pm, observation revealed on the Lower Level floor of smoke compartments CS-4 & CS-5, in the AHU Rooms #2 & #3, that a portion of a caulk joint was damaged and in need of repair. Exposed concrete control joints in the lower level Air Handlings Unit Rooms were not properly caulked to prevent ants and other rodents from coming up the cracks in the floor. Caulk was missing at the cut hole seams in the floor. This observed situation was not compliant with 42 CFR 482.41(a).

2. On 02/25/2013 at 4:45 pm, observation revealed on the Lower Level floor of smoke compartment CS-5, in the Boiler Room, that a portion of a caulk joint was damaged and in need of repair. Exposed concrete control joints in the Lower Level Room were not properly caulked to prevent ants and other rodents from coming up the cracks in the floor. Caulk was missing at the cut hole seams in the floor. This observed situation was not compliant with 42 CFR 482.41(a).

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Mgr. of Plant Operations) and staff B (Plant Operations Asst.).
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Based on observation, staff interviews and review of maintenance records, the facility did not provide for emergency gas and water supply. The facility did not have appropriate preventive maintenance of emergency equipment. This deficiency occurred in all of the 5 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 02/26/2013 at 4:14 pm, observation revealed that during a review of facility maintenance documents the facility did not have a comprehensive system to provide for the quantity of emergency water that would be needed to provide care to patients and outpatients. The reviewed documents did not include provisions to: (a) prioritize their use until adequate additional water supplies in the area were available; (b) address the event of a disruption in supply of the entire surrounding area and shipment of a water supply was the only means possible, therefore requiring a contract with a outside water vendor within 24 hours to the building site; (c) determine the quantity needed within a short time through additional deliveries to stay operational for patients and staff. This observed situation was not compliant with 42 CFR 482.41(a)(2).

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Mgr of Plant Operations) and staff B (Plant Operations Asst.).
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A standard Recertification Survey for Life Safety Code compliance was conducted by the Wisconsin Division of Quality Assurance on 02/27/2013. The Rehab Hospital of Wisconsin (RHOW) was found to be NOT in compliance with the following applicable regulations for hospital participation in Medicare-Medicaid:

42 CFR 482.41(b) Standard: Safety from Fire was NOT MET.
NFPA 101 (2000 edition) - Life Safety Code was NOT MET.

The facility was surveyed under the 2000 Life Safety Code, Chapter 18 for a NEW health care occupancy.

FINDINGS INCLUDED: Nineteen (19) federal deficiencies of the Life Safety Code were cited as follows.
K-12 (building structure),
K-17 (corridor walls),
K-18 (corridor doors),
K-29 (hazardous spaces),
K-38 (egress),
K-46 (lighting),
K-48 (fire evacuation),
K-50 (fire drills),
K-51(fire alarm & detection),
K-56 (sprinkler installation),
K-62 (sprinkler system maintenance),
K-67 (heating & ventilating system maintenance),
K-69 (commercial cooking hood maintenance),
K-70 (portable heaters),
K-144 (emergency generator maintenance),
K-145 (Type I EES),
K-147 (electrical wiring),
K-154 (sprinkler system out of service), and
K-155 (fire alarm system out of service).
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Based on 1 of 1 observation ( G ) and review of the FDA Food Code, the facility failed to assure trash is contained properly. This deficient practice could possibly affect all patients being treated at this facility; census on 12/25/13 = 30 patients, on 2/26/13 = 32 and on 2/27/13 = 32.

Findings include:

According to the FDA Food Code, outside receptacles shall be kept covered with tight-fitting lids, doors, or covers.

On 2/25/2013, 10:04 AM, surveyor observed outside dumpster's, of which one dumpster was not covered. This was confirmed by Staff G.

Based on observation, staff interviews and review of maintenance records, the facility did not provide a building that was designed and maintained in accordance with Federal, State and local laws, regulations and guidelines. The facility did not have a building that complied with state regulations that were in effect when the space was built, and construction after plan review and approval by the Wisconsin Department of Health Services . This deficiency occurred in 5 of the 5 smoke compartments, and had the potential to affect 14 inpatients, 15 outpatients, and an unknown number of staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/25/2013 at 4:18 pm, observation revealed on the Lower Level floor of smoke compartments CS-4 & CS-5, in the AHU Rooms #1 & #2, that during a review of facility documents the facility installed heating and ventilating unit systems in a room dedicated to only the air handling units. This arrangement was not maintained from the original design intent. Observed general combustible storage like extra doors, wood storage pallets, cardboard filled boxes of combustible materials and oil droppings from cutting pipe, not separated from the air handling units in accordance with federal and state laws that were in effect at the time of construction. Items and materials required for the maintenance of the air handling units are allowed in the air handling room. If desks and workstations are present, the room must be provided with appropriate fresh air supply and exhaust per 2006 Guidelines requirements. This observed situation was not compliant with 42 CFR 482.41(c).

2. On 02/26/2013 at 4:30 pm, observation revealed that the construction plans for work that created this space were not submitted to the Department of Quality Assurance as required by Wisconsin Administrative Code to ensure the design and installation was in accordance with Federal and State laws that were in effect at the time of construction. At the time of plan review and construction, the 2006 Guidelines was in force for Design and Construction of Health Care Facilities, including Rehabilitation Hospitals with assistance from the US Department of Health and Human Services (DHHS) documentation. The Air Handling Unit #3 for the pool is missing a second filter bank per Table 2.1-3 Filter Efficiencies for Central Ventilation and Air Conditioning Systems in General Hospitals. The filter bed no. 2 should have a (MERV rating of 14 and 90% filtration). Currently the AHU #3 only has one filter bed. The pool is treating both inpatients as well as outpatients requiring this second filter bed. MERV = minimum efficiency rating value. MERV's are based on ASHRAE 52.2 (American Society of Heating, Refrigerating, and Air-Conditioning Engineers). This observed situation was not compliant with 42 CFR 482.41(c).

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Mgr of Plant Operations) and staff B (Plant Operations Asst.).
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Based on 6 of 9 observations of patient care (Pt. #12, 26, RN S, DT T) and 1of 1 kitchen tour, facility P & P review, Nationally accepted standards of practice, review of facility reports, and 2 of 2 staff interviews (Staff W and C), the facility does not ensure that standards of practice are followed and that patients are protected from potential contaminants. Failure to follow standards of practice and protect patients from contaminants has the potential to affect all patients receiving care in the facility. Census on 2/25/13 = 30, 2/26/13 = 32 and 2/27/13 = 32.

Findings include:

Per interview with ICO W on 2/26/13 at 7:10 AM, ICO W provided the Environment of Care Safety Survey Report that includes both safety and IC surveillance. The General Housekeeping section of the surveillance form includes verifying wall and ceiling vents are clean, no pests, dusting of offices and workspaces, medication, intravenous and linen carts are clean, door frames and high areas are dusted. During interview, ICO W confirmed the surveillance does not include specific areas such as flowers in patient rooms, the rehabilitation gym and equipment in the gym. ICO W stated an Ultra Violet disinfection system is used in the patient rooms and gym, but has not confirmed with swab tests if it is effective.
Per facility policy reviewed on 2/26/13 at 1:30 PM, titled Blood Glucose Monitoring revised date 2/14/13, states under VI.A.c. "Test strips are outdated in 4 months once opened. Test strip container must be closed tightly after removing strips."
Per facility policy reviewed on 2/26/13 at 1:00 PM, titled Cleaning Frequency of Unit Based Equipment reviewed date 3/14/12 states under Procedure A. "Patient care equipment that is placed in the immediate vicinity of the patient should be cleaned between patients, such as: pulse ox probes, blood glucose machines,..."
Per facility policy reviewed on 2/26/13 at 2:00 PM titled Patient Room Cleaning-Terminal revised 2/14/13, does not include a process for cleaning imitation flowers in patient rooms. Per interview with PM Q on 2/26/13 at 2:05 PM, who is also the EVS supervisor, stated he is unaware of flowers in the patient rooms, and has never trained staff on how to clean the flowers.
Per Review on 2/25/13 of policy "Care and Maintenance of Midline and Peripherally Inserted Central Catheters (PICC)" last reviewed 12/28/2011, when doing dressing changes staff should clean hands and don clean pair of gloves then remove old dressing. Staff then should remove gloves and wash hands gather sterile supplies and then don sterile gloves. Per policy staff should clean PICC line site 4-5 inches around catheter with Chloraprep applicator in back and forth motion for 30 seconds. Chloraprep should dry for 30 seconds prior to covering site with transparent dressing.

Per review of the 2009 FDA Food Code on 2/25/13 at 3:00 PM, food items and equipment must be properly stored to prevent transmission of foodborne pathogens or contamination. To prevent the food-contact surfaces of equipment and utensils from any accumulation of dust, dirt, food residue and other debris, they must be stored in a clean, dry location where they are not exposed to splash, dust, or other contamination.

Per review of the 2009 Food Code on 2/25/13 at 3:00 PM, states that nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris. Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt and other materials.

Per facility policy reviewed on 2/24/13 at 1:00 PM, titled Isolation: Contact Precautions revised date 9/12/12, states under H. Isolation in Therapy 1. While patient is in Contact Precautions, all therapies that can be done at the patient bedside should be...4. The therapists/assistants working with the patient will wear gloves an a yellow isolation gown...5. A designated mat in the gym will be reserved for isolation patients."
Per CDC 2007 Guidelines for Isolation Precautions: Prevention Transmission of Infectious Agents in Healthcare Settings it states on "In the inpatient and residential settings these include 1) limiting transport of such patients to essential purposes, such as diagnostic and therapeutic procedures that cannot be performed in the patient 's room; 2) when transport is necessary, using appropriate barriers on the patient (e.g., mask, gown, wrapping in sheets or use of impervious dressings to cover the affected area(s) when infectious skin lesions or drainage are present, consistent with the route and risk of transmission; 3) notifying healthcare personnel in the receiving area of the impending arrival of the patient and of the precautions necessary to prevent transmission..."
Per interview with Public Health Representative U on 2/27/13 at 10:25 AM, regarding a patient with infectious disease such as C-diff (gastrointestinal disease), the patient should remain in their room for treatments as much as possible. U also stated that any equipment that is transported with an infectious patient needs to be wiped down prior to leaving the room, this includes wheelchairs and Intravenous poles and pumps."
On 2/26/2013 at 3:00 PM review of the P&P titled, Isolation: Contact Precautions dated 9/12/2012 was completed. The P&P states in part, G. Patient Transport- 3. Patients will be draped with a clean, yellow gown and will perform hand hygiene prior to being transported in the hallway...4. The therapists/assistants working with the patient will wear gloves and a yellow isolation gown. 5. A designated mat in the gym will be reserved for isolation patients.
During tour of the therapy gym with Director of Therapy Services (DTS) C on 2/25/2013 at 10:25 AM, pt. #12 was lying on the therapy table at the south end of the gym. Physical Therapy Aid (PTA) X, was sitting on a stool next to pt. #12 providing therapy. Pt. #12 was wearing a yellow isolation gown and PTA X was wearing a blue isolation gown. During tour it was noted no area or table was visibly designated for pt.'s in isolation. DTS C, explained the gym uses a "red, green" system for cleaning equipment and tables. If an item requires cleaning, the red side of laminated paper is turned up. After it is cleaned the green side is turned up. This is how staff know what equipment can be used. On 2/26/2013 at approximately 7:30 AM ICO W, was asked about the above observation and what was expected. ICO W explained when an isolation pt. comes into the gym the isolation gowns should come off. The gowns are worn only for transporting.
On 2/26/2013 at 8:21 AM PTA X and pt. #12 were observed entering the gym. PTA X was wearing a blue gown, no gloves pushing pt. #12 in a wheel chair. Pt. #12 was wearing a yellow gown over clothes. In the gym PT X removed blue gown and pt. #12's yellow gown. PTA X washed hands with soap & water, pt. #12 complained of stomach cramping. PTA X donned a blue gown, put a yellow gown on pt. #12 and left the gym. Pt. #12 did not perform hand hygiene upon entering or leaving the gym.
On 2/26/2013 at 2:47 PM interview with DTS C was completed. DTS C was questioned about the cleaning process for the gym and where the "red-green" process is documented. DTS C stated it is "home grown" and would find it. At 3:45 PM DTS C presented a P&P titled, Care and Cleaning of Therapy Gyms, dated 2/26/2013. The P&P was incomplete, DTS C confirmed the P&P was created on 2/26/2013.
Per observation on 2/25/13 at 10:17 Pt #12, who has C-diff is observed being transported to the gym in a wheelchair from her room and covered in a gown. The wheelchair was not observed to be cleaned prior to transport.

On 2/25/2013 beginning at 10:50 AM, while observing RN S perform Pt #26's intravenous (IV) medication administration in a contact isolation room. RN S was in a contact isolation gown and gloves, RN S placed the phone on the isolation cart outside of Pt #26's room without cleaning, potentially contaminating the top surface of the isolation cart. RN S did not clean surface of isolation cart after leaving room and retrieving phone.

On 2/25/2013 beginning at 11:30 AM, while observing RN S in contact isolation room performing IV (intravenous) medication administration and PICC line dressing change, the following was observed:

RN S donned gloves without first washing hands. RN S placed a 250 ml Vancomycin IV bag on Pt #26's bedside tray table. Tray table contained food items, paper, and magazines and RN S did not disinfect table prior to placing IV medication on tray table. RN S then picked up bag of Vancomycin and spiked the IV bag; prior to connecting the open end of the tubing to the IV pump, RN S touched the open tubing tip potentially contaminating the IV line administering medication to Pt #26.

RN S proceeded to throw away trash, RN S pushed the trash down in the garbage can and without removing gloves and performing hand hygiene, RN S proceeded to perform Pt #26's PICC line dressing change. RN S obtained sterile supplies, opened and placed sterile supplies on Pt #26's tray table (RN S did not disinfect tray table). RN S removed old dressing and then donned sterile gloves over the non-sterile gloves. Using Chloraprep applicator, RN S scrubbed PICC line site for 10 seconds and not 30 seconds as per policy. RN S immediately applied a transparent dressing, not allowing the Chloraprep to dry for 30 seconds as per policy.

Shared the above findings with RN R on 2/26/13 at approximately 9:00 AM.

Per tour of the facility on 2/25/13 at approximately 10:20 AM there is standing water on the floor in the dialysis storage room. A portable reverse osmosis machine had water dripping from a hose. This was confirmed and observed by CPA D on 2/25/13 at 10:17 AM.
Per tour of the facility on 2/25/13 at 10:25 AM two Sure Step Test Strips for blood sugar testing are open and not dated. The Glucometer has peeling tape wrapped around the back and side of to keep an asset number label attached, and there are two manufacturer labels with warnings also peeling up on the back of the Glucometer. The peeling tape and labels have exposed adhesive preventing thorough cleaning and residual adhesive with attached debris. Per interview with CNA L on 2/25/13 at 10:25 AM, the test strips have an area to write the date opened and they should be dated, and the Glucometer has unwashable areas due to the adhesives.
Per tour of the facility on 2/25/13 at 10:35 AM the crash cart at the nursing station has dust and debris on the horizontal surfaces. This was observed and confirmed in interview with CPA D on 2/25/13 at 10:35 AM, CPA D indicated the cart needed to be placed on the environmental cleaning list.
Per observation of a medication pass on 2/25/13 at 1:04 PM, it was noted there is a bouquet of imitation flowers in a vase on the wall of the patient room. Per interview with EVS staff O and P on 2/25/13 at approximately 1:15 PM, the flowers are in each patient room, dusted daily and they use a 3 step process to clean the flowers when a patient is discharged.

Observation on 2/26/13 beginning at 10:40 AM revealed DT T (dialysis technician) chemically disinfecting and rinsing a dialysis machine in the day room at the end of the "Farmland" hallway. DT T connected the tubing from the portable Reverse Osmosis (RO) machine to the sink faucet, laying tubing in the sink and on countertop. Per interview with DT T at the time of observation, dialysis machines are brought into room 101 or the day room for chemical rinse and disinfection after patient treatments. DT T stated outside surface of dialysis machines are cleaned in room prior to transporting to day room for chemical disinfection. Per observation, after the machine finished rinsing, DT T disconnected tubing from faucet and fluid splashed all over counter top. Using paper towel, DT T wiped down the wet counter top, DT T did not clean or disinfect sink and countertop before or after connection. DT T did not clean RO machine tubing before or after laying in sink and on counter top potentially allowing for cross contamination.

Shared the above findings with RN R on 2/26/13 at approximately 11:45 AM.

On 2/25/2013 at 10:21 AM, observed all of facility's pots, pans, cooking/serving utensils, knives and floor stand mixer's paddle and whisk hanging from the ceiling and walls exposing them to the potential for contamination. Findings confirmed by Staff G on 2/25/13 at 10:21 AM.

On 02/25/2013 at 1:01 PM, observed in SC-1 smoke compartment, Kitchen Storage Room, that the return air grille was dirty and dusty. Findings confirmed by Staff G on 2/25/13 at 10:21 AM.




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29972

Based on review of facility policy and procedure, medical record review and staff interview the facility staff failed to provide documentation of communication with acute care facility, in 1 of 2 ( # 19) patients medical records reviewed who where transferred to an acute care hospital, regarding written or verbal information regarding condition of patient being transferred to another facility for emergency care. This deficient practice could possibly affect all patients being treated at this facility; census on 2/25/13 = 30 patients, 2/26/13 = 32 and 2/27/13 = 32.

Findings include:

Per facility policy reviewed on 2/26/13 at 3:10 pm, entitled "Hand off communication for effective information exchange between caregivers and teams" policy # POC 7.46, review date of 11/29/2012 states: I. Purpose, Implement a standardized approach to "hands-off" communication, including an opportunity to ask and respond to questions to provide accurate information about a patient's care, treatment, and services, current condition and any recent or unanticipated changes. II. Procedure 1. A "hands off" occurs any time the patient leaved the care of one provider to be cared for by another provider may include any of the following situations: 1. Nurse/nurse: change of shift, discharging, or admitting patients 5. Nurse/other providers of care such as EMT services."

Per review of medical record of pt. # 19 on 2/26/13 at 2:15 pm revealed pt. # 19 was admitted to facility on 1/3/13 and was discharged to acute care hospital on 1/11/13 following an episode of increased shortness of breath. No evidence of communication documented from this facility to receiving facility/EMT staff in patients # 19's medical record. The above findings were confirmed with RNCS K on 2/26/13 at 2:45 pm.

Per interview with ICEO A on 2/26/13 at 2:50 pm, ICEO A stated that it is the expectation of the staff to have communication with receiving facility and that information would be documented in the patients medical record.

Based on staff interview and review of facility policy, the hospital failed to maintain policies for OPO (Organ Procurement Organization) procedures. This can potentially effect all patient receiving treatment at this facility. Daily census during this survey: 2/25/2013 = 30, 2/26/2013 = 32, and 2/27/2013 = 32.

Findings include:

The hospital's policy entitled; "Organ Donation" LDR 5.54 reviewed on 01/18/2013 states under procedure; "the Organ Procurement Organization is notified of a patient who has died by contacting Blood Centers of Wisconsin/WDN (Wisconsin Donor Network)/WTB (Wisconsin Tissue Bank) at : 414-937-6999; for 24-hour retrieval service at _______, must follow guidelines, as per the memorandum".

The policy fails to define how to contact the 24 hour retrieval services and does not delineate protocols for organ procurement. The memorandum which contains the guidelines is not identified.

Per interview with staff B on 02/25/13 at 1:30 PM it was confirmed that the hospital rarely has the need to contact the OPO. Staff B stated that the organ donation policy was limited and that the contract with the OPO defined the procedures for organ procurement.