Western Wisconsin Health

“PHYSICAL PLANT AND ENVIRONMENT CFR(s): §485.623 Condition of Participation: Physical Plant and Environment This Condition is not met as evidenced by: 46812 Based on observation, staff interviews, and maintenance records review on 04/16/2024, the facility failed to construct, install, and maintain the building systems to ensure life safety to patients. The facility was found to contain the following deficiencies. Building 05 K-0353 Sprinkler System - Maintenance and Testing As a result of these deficiencies, 42 CFR 485.623 Condition of Participation: Physical Plant and Environment was NOT MET. See K-tags for details of the specific findings.”

“EMERGENCY AND SUPPLIES CFR(s): Equipment and supplies commonly used in life-saving procedures, including airways, endotracheal tubes, ambu bag/valve/mask, oxygen, tourniquets, immobilization devices, nasogastric tubes, splints, IV therapy supplies, suction machine, defibrillator, cardiac monitor, chest tubes, and indwelling urinary catheters. This Standard is not met as evidenced by: 41126 Based on interview, and record review the facility failed to document crash cart and defibrillator monitoring checks daily in 3 of 7 emergency crash carts (Medical-Surgical, Birthing Center, Emergency Department) in a total of 7 emergency code carts observed. Findings include: Review of the facility policy titled, “Code/Crash Cart and Automatic External Defibrillator (AED)” Policy # ED 1011 dated 2023 revealed, “Policy Statement: “ ...Specific operational and supply checks will be validated daily, weekly, monthly and immediately after each use ...” Review of the checklist titled, “ED (Emergency Department) Adult Crash Cart Checklist Daily Checklist April 2024” revealed no documented checks performed on April 8, 9, 12 and 15, 2024. Review of the checklist titled, “Med/Surg (Medical-Surgical), OB (Obstetrics) and ED (Emergency Department) Daily Checklist dated April 2024 revealed no documented checks performed on April 8 and 15. On 4/16/2024 at 9:20 AM in an interview with Medical-Surgical Manager L, Manager L stated that there is one CNA (Certified Nursing Assistant) from the Medical Surgical unit that is assigned to perform the checks on all of the units; Medical Surgical, the Emergency Department and the Birthing Center. “It looks like we missed a few days, that shouldn’t happen.””

“LIFE SAFETY FROM FIRE CFR(s): §485.623(c) Standard: Life Safety From Fire (1) Except as otherwise provided in this section: (i) The CAH must meet the applicable provisions and must proceed in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.) (ii) Notwithstanding paragraph (d)(1)(i) of this section, corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors. This Standard is not met as evidenced by: 46812 Based on observation, staff interviews, and maintenance records review on 04/16/2024, the facility failed to construct, install, and maintain the building systems to ensure life safety to patients. The facility was found to contain the following deficiencies. Building 05 K-0353 Sprinkler System - Maintenance and Testing As a result of these deficiencies, 42 CFR 485.623(c) Standard: Life Safety from Fire was NOT MET. See K-tags for details of the specific findings.”

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (iv) Rules for the storage, handling, dispensation, and administration of drugs and biologicals. These rules must provide that there is a drug storage area that is administered in accordance with accepted professional principles, that current and accurate records are kept of the receipt and disposition of all scheduled drugs, and that outdated, mislabeled, or otherwise unusable drugs are not available for patient use. This Standard is not met as evidenced by: 44431 Based on record review, interview and observation the facility failed to remove expired patient care supplies from 2 (Obstetrics and Radiology) of 16 patient care departments observed, and failed to store and secure medications used for patients in 1 (Radiology) of 16 patient care departments observed. Findings Include: Review of facility policy #NMT1001, titled, “Outdated Medical Supplies” dated 9/22/16, revealed, “Procedure: Each department is responsible for checking for outdated medical supplies monthly. This includes all store rooms....portable procedure carts and/or storage containers where any medical supplies are kept...All medical supplies that have been found to be expired will be brought to the Material Management department.” Review of facility policy #PHA1788, titled, “Medication Storage and Security” last reviewed 8/15, revealed, “All medications are stored, handled, secured and disposed of in a manner that maintains medication integrity between the receipt of medication from the Pharmacy and administration to the patient.....Personnel Access to Medications: 1. Authorized personnel, as defined by position description will be provided access to medication areas to allow them to perform their assigned duties....c. Staff that would not have authorized access and would need to have constant surveillance in areas with medications.....Housekeeping, Materials Management, Maintenance....3. Medications will be under constant surveillance...will be secured as soon as possible, not to exceed 30 minutes from receipt. a. Secure medication storage areas prevent unmonitored access by unauthorized individuals. These areas include: Medication Stations/Rooms, Locked refrigerators designated for medications only, Locked cabinets.” Examples in the OB (Obstetrics) department: On 04/16/2024 from 9:10 AM-10:15 AM during a tour of the OB department, in Suite 100 observed an Infant Ambo bag, “date received unknown, date issued 2/2011, annual inspection 3/11, needs annual inspection.” Observed 1 container of bleach germicidal wipes with an expiration date of 3/24/15, in the OB supply closet observed a special needs feeder with an expiration date of 4/13/24. On 04/16/2024 at 9:30 AM in an interview with CNO (Chief Nursing Officer) B, when asked if the infant Ambo bag was meant to be inspected yearly and last inspection date was 3/2011, CNO B stated, “It implies as such.” When asked if the expiration date on the special needs feeder was correct, CNO B stated, “This shouldn’t be here, it’s expired.” Examples in the Radiology department: On 04/17/2024 at 8:30 AM during a tour of the Radiology department the following areas and items were observed in the CT (Computerized Tomography) treatment room, a container of Bleach germicidal wipes was on the counter with an expiration date of June 22, 2023, and 2 purple topped blood collection tubes in a drawer with an expiration date of 10/31/23; in the ultrasound room in a drawer containing patient supplies 3 alcohol pads had an expiration date of 3/2022, in the mammography (breast exam) room a box of alcohol prep pads with a best by date of 09/2020. On 4/17/2024 at 8:30 AM in an interview with Nuclear Medicine Director W when asked about the expired bleach wipes, W stated, “We don’t use those for this department, not sure how they ended up here, they weren’t here yesterday.” When asked if the blood collection tubes had expired on 10/31/23, W stated, “I would say yes.” When asked what the alcohol wipes were used for, W stated, “We use them to clean an IV (Intravenous) site if we need to.” On 04/17/2024 at 9:00 AM during a tour of the clean utility room in the radiology department, 13 vials of Kenalog injection single dose vials, 8 Bupivocaine single dose vials and 7 vials of Lidocaine 1%-50mg/5 ml single dose vials were observed all stored in the same container on a shelf in the clean utility room. The door to the clean utility room required a code to enter. On 04/17/2024 at 9:10 AM in an interview with Nuclear Medicine Director W when asked who had access to the clean utility room, Director W stated, “Anyone with badge access in the department have access, housekeeping has the code to the door because there is also linen stored in the clean utility room.” When asked why the medication was stored in the clean utility, W stated, “We need to have it in a central location, so the techs have access.””

“EMERGENCY PROCEDURES CFR(s): §485.635(b)(4) Emergency procedures. In accordance with the requirements of §485.618, the CAH provides medical services as a first response to common life-threatening injuries and acute illness. This Standard is not met as evidenced by: 41126 Based on interview and record review, the facility failed to provide education and training to 2 departments that use succinylcholine (a skeletal muscle relaxant used in intubation) (Emergency Department and Birthing Center) staff to effectively treat a potential life-threatening situation in a total of 3 departments that use succinylcholine. Findings include: Review of the MH (Malignant Hyperthermia) website (https://www.mhaus.org/healthcare-professionals/) revealed, “The MH crisis is a biochemical chain reaction response, “triggered” by commonly used general anesthetics and the paralyzing agent succinylcholine (a neuromuscular blocker)...death can result...Dantrolene (medication to treat MH) must be available for all anesthetizing locations within 10 minutes of the decision to treat for MH...” Review of the facility policy titled, “Malignant Hyperthermia” policy # ANE1026 dated 2023, revealed, “Anesthesia will engage in annual activities to maintain MH treatment competency.” On 4/17/2026 at 8:20 AM in an interview with Emergency Department Manager I, when asked if the Emergency Department used succinylcholine for intubation stated, “Sure we do, the Birthing Center may have the opportunity to use it as well in an emergency.” When asked about training of staff, Manager I stated that “only the Hospital Supervisors have been trained, but it does make sense that all staff are trained on the signs and symptoms too.””

“INFECTION PREVENT SURVEIL & CONTROL OF HAIs CFR(s): The infection prevention and control includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and that the program also addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 41126 Based on observation, record review and interview the facility failed to maintain a sanitary environment free of potential contamination to patients and staff by not labeling opened food items in 1 of 6 (Dietary kitchen) departments with food items, not labeling food items removed from their original containers with an expiration date in 1 of 6 departments (Birthing Center) out of a total of 16 departments observed, failed to follow the hand hygiene policy in 8 of 19 (Patients #15, #25 & #27) patient care observations observed; and failed to ensure skin antiseptic is applied as per manufacturer’s guidelines for use in 2 of 2 observations in the Surgery department (Patients #15 & #25) in a total sample of 3 observations in the Surgery department. Findings include: Review of the facility policy titled, “Safe Food Handling” policy # CUL1624 dated 1/24 revealed, “Food Storage: ...All products will be date marked when opened if there is not an expiration date on the package...” Review of the facility policy titled, “Hand Hygiene” policy #INF1006 dated 4/16 revealed, “If hands are not visibly soiled.....use an alcohol-based hand rub for 20-30 seconds in the following situations:...2. Before putting on clean or sterile gloves....4. After contact with patient’s intact skin (e.g., when taking a pulse or blood pressure)...7. After contact with inanimate objects (including medical equipment) in the immediate vicinity of a patient.” Review of CDC (Centers for Disease Control) “Handwashing Steps” last updated November 2022, CDC recommends washing hands with soap and water for a minimum of 20 seconds. Review of policy and procedure #SUR1309 titled, “Skin Preparation of Patients” last reviewed 11/23/2022 revealed, “The operative site and surrounding area will be cleaned with appropriate agent according to...manufacturer’s instructions.” Review of the Chloraprep (alcohol based) 3 ml (milliliter) Applicator packaging instructions for use revealed the antiseptic should be applied for 30 seconds and allowed to dry for 30 seconds. Examples in the Dietary kitchen: On 4/17/2024 at 11:40 AM during a tour of the Dietary kitchen a bottle of apple juice and a bottle of cranberry juice, both 1/4 full were observed in the refrigerator without a label indicating the open or use by date. In the freezer a carton of lactose free ice cream was observed to be almost empty with no label indicating the open or use by date. On 4/17/2024 at 11:45 AM in an interview with Dietary Manager S, Manager S stated, “Those should have each been labeled when opened.” Examples in the OB patient kitchen: On 4/17/2024 at 9:10 AM during a tour of the OB Patient kitchen, observed a single serving of peaches with an expiration date of 4/7/2024, and observed the following items with no expiration date: 12 individual peanut butter containers, 10 graham cracker packages, 8 soda cracker packages, 8 honey packets, 5 chicken broth packets, 1 beef broth packet, 7 jelly packets, 7 mayonnaise packets, 1 tarter sauce packet, 1 ketchup packet, 5 cheese packages, 7 orange juice containers and 7 grape juice containers. On 4/17/2024 at 9:30 AM in an interview with Chief Nursing Officer (CNO) B, CNO B stated, “Nursing checks for outdates of supplies, I believe the process as I recall, is to label each individual item with an expiration date.” On 4/17/2024 at 11:50 AM in an interview with Dietary Manager S when asked about the labeling of stock food supplies on the patient care units stated, “They should all be labeled with an expiration date.” When asked about specifics like peanut butter and jelly packets, Manager S stated, “Yes, even those.” Examples in the RT (Respiratory Therapy) department: On 4/17/2024 at 2:05 PM during an observation of Patient #27 receiving a PFT (Pulmonary Function Test) (a test to measure breathing capacity) observed RT Z use alcohol-based hand sanitizer to cleanse hands at the beginning of the patient treatment. RT Z touched Patient #27, used the computer, adjusted the PFT machine, then gave the patient a breathing treatment, took the patient’s pulse by touching the patient’s wrist and then went back and forth between touching the computer and the patient until the test was completed at 2:48 PM. When the test was completed, RT Z removed a home monitoring device from a box, applied it to the patient’s wrist, instructed the patient in home discharge instructions, removed the home monitoring device from the patient’s wrist and returned it to the box it came in. RT Z then walked the patient to the exit and returned to the RT department. RT Z then put on gloves to clean the equipment. All of these tasks were completed without using hand sanitizer between tasks. On 4/17/2024 in an interview with RT Z, when asked when hand hygiene/hand washing was to be performed, RT Z stated, “Whenever I would touch the patient, I would wash my hands.” 29972 Examples in the Sterile Processing Area: On 04/17/2024 beginning at 10:25 AM, observed Technician GG cleaning the endoscope used for Pt #25’s EGD procedure. After cleaning the endoscope, Technician GG removed his/her gloves then donned a new pair of gloves without performing hand hygiene after removing “dirty” gloves. Examples in the Surgery Department: On 04/17/2024 beginning at 8:30 AM, observed Registered Nurse (RN) CC inserting Pt #25’s Intravenous (IV) line. After inserting Pt #25’s IV, RN CC removed his/her gloves then proceeded to type on the computer keyboard and touch the privacy curtains without first removing “dirty” gloves and performing hand hygiene. On 04/17/2024 beginning at 9:55 AM, observed Certified Registered Nurse Anesthetist (CRNA) EE preparing to administer IV medications to Pt #25. CRNA EE dropped packaged supplies on the floor and then with gloved hands, CRNA EE picked up the supplies and placed the supplies on the cart; CRNA EE then proceeded to administer IV medications to Pt #25 without first removing potentially “dirty” gloves, performing hand hygiene, and donning “clean” gloves. On 04/17/2024 beginning at 10:15 AM, observed Physician FF perform Pt #25’s Esophagogastroduodenoscopy (EGD) (endoscopic procedure used to visualize the esophagus, stomach, and intestine). Physician EE completed the procedure, then removed gloves and then proceeded to wash hands with soap and water for approximately 5 seconds, 15 seconds less than CDC guidelines. On 04/17/2023 beginning at 12:20 PM, observed Physician JJ in the Surgery department operating room performing Pt #15’s lumbar (lower back) steroid injections. Physician JJ used the ChloraPrep 3 ml applicator to perform the skin antisepsis. Physician JJ applied the antiseptic for approximately 15 seconds (15 seconds less than manufacturer guidelines); Physician JJ did not wait 30 seconds for the skin prep to dry before inserting the needle. On 04/17/2024 beginning at 1:00 PM, observed Physician JJ in the Surgery department operating room performing Pt #26’s Sacroiliac (SI) joint (connects pelvis to spine) steroid injections. Physician JJ used the ChloraPrep 3 ml applicator to perform the skin antisepsis. Physician JJ applied the antiseptic to the skin for approximately 12 seconds (18 seconds less than manufacturer guidelines); Physician JJ did not wait 30 seconds for the antiseptic to dry before inserting the needle. Per interview with Surgery Manager V on 04/17/2024 beginning at 1:20 PM, Manager V stated that staff should follow manufacturer’s guidelines for antiseptic use when performing skin antisepsis as per policy. Manager V stated that staff should perform hand hygiene immediately after removing gloves and before touching “clean” equipment, and that staff should wash hands with soap and water for a minimum of 20 seconds. Manager V was present in the operating room during the observations and agreed with the findings.”

“RESTRAINT AND SECLUSION CFR(s): The CAH must have written policies and procedures regarding the use of restraint and seclusion that are consistent with current standards of practice. This Standard is not met as evidenced by: 43037 Based on record review and interview, the facility failed to have a complete Restraint and Seclusion policy that included information on authority and circumstances under which restraints or seclusion should be discontinued and continued monitoring of patient needs in 1 of 1 Restraint and Seclusion policy reviewed in a total sample of 1 Restraint and Seclusion policy. Findings include: A review of facility policy # MED1613 “Restraint and/or Seclusion” revealed there was no indication of the authority or circumstances under which restraint/seclusion should be discontinued. There was no instruction as to monitoring, continued assessment, provision of nutritional needs, range of motion or toileting of the patient while in restraints. In an interview with Director of Quality C on 4/17/2024 at 10:47 AM when asked if the Restraint policy should include these items, Director C agreed and stated that two new policies were currently being developed for restraints and seclusion but were not yet published. Director C stated the new policies do address discontinuation of restraints as well as continued monitoring of the patient while in restraints.”

“An unannounced standard Recertification Survey of Western Wisconsin Health for Life Safety Code compliance was conducted by the Wisconsin Division of Quality Assurance on 04/16/2024. Western Wisconsin Health was found to be NOT in compliance with the following applicable regulations for Critical Access Hospital participation in Medicare-Medicaid: 42 CFR 485.623 Condition of Participation: Physical Plant and Environment was NOT MET 42 CFR 485.623(c) Standard: Life Safety from Fire was NOT MET NFPA 101 - Life Safety Code 2012 edition was NOT MET. Western Wisconsin Health is a single-story structure, with partial basement, built in 2016 with Type II (222) construction. The building also has a two-story clinic that is attached to the health care occupancy, separated with 2-hour rated construction. The clinic was not surveyed as part of the hospital facility. The facility is fully sprinkled and has smoke detection in the corridors and storage rooms. The facility had an emergency generator that provided power to the emergency loads. The hospital is licensed for 25 beds and had an average census of 8 inpatients at the time of the survey. The facility was surveyed under the 2012 Life Safety Code, Chapter 19 for an existing healthcare occupancy. One (1) federal deficiency of the Life Safety Code was cited.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 46812 Based on observation and interview, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 101 (2012 edition) Sections 19.3.5.1, 9.7.1.1, & 9.7.5; NFPA 13 (2010 edition) Section 6.2.7.3; and NFPA 25 (2011 edition) Sections 4.3, 5.1.1.2, 5.2.1.1, 13.4.3.2, 13.4.3.2.2.4, & 13.4.3.2.3. This deficient practice could affect all patients, as well as an undetermined number of staff and visitors. Findings include: 1. On 04/16/2024 at 9:45 am, observation in the med/surg wing in patient room 130 revealed a concealed sprinkler head with a missing cover plate, thereby not completing the sprinkler assembly listing. 2. On 04/16/2024 at 11:03 am, record review of sprinkler system inspections and testing revealed that the facility did not have documentation of a three-year full flow test for the preaction systems. These deficient conditions were confirmed at the time of discovery by a concurrent interview with Staff D.”