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PRINTED:DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESOMB NO. 0938-0391STATEMENT OF DEFICIENCIES(X1) PROVIDER/SUPPLIER/CLIAAND PLAN OF CORRECTIONIDENTIFICATION NUMBER:151325(X2) MULTIPLE CONSTRUCTIONCOMPLETED05/15/2012B. WINGSTREET ADDRESS, CITY, STATE, ZIP CODE1116 MILLIS AVEBOONVILLE, IN 47601ST MARY'S WARRICK HOSPITAL INC(X4) IDSUMMARY STATEMENT OF DEFICIENCIESIDPREFIX(EACH DEFICIENCY MUST BE PERCEDED BY FULLPREFIXREGULATORY OR LSC IDENTIFYING INFORMATION)TAGTAG(X3) DATE SURVEY00A. BUILDINGNAME OF PROVIDER OR SUPPLIERS040808/30/2012FORM APPROVEDPROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE APPROPRIATEDEFICIENCY)(X5)COMPLETIONDATE410 IAC 15-1.4-2QUALITY ASSESSMENT ANDIMPROVEMENT410 IAC 15-1.4-2 (a)(2)(A)(B)(C)(D)(a) The hospital shall have aneffective, organized, hospital-wide,comprehensive quality assessment andimprovement program in which all areasof the hospital participate. Theprogram shall be ongoing and have awritten plan of implementation thatevaluates, but is not limited to, thefollowing:(2) All functions, including but notlimited to the following:(A) Discharge planning.(B) Infection control.(C) Medication therapy.(D) Response to emergencies asdefined in 410 IAC15-1.5-5(b)(3)(L)(i).Based on document review and interview,the facility failed to include dischargeplanning in the facility's QualityAssessment and PerformanceImprovement (QAPI) program.S0408Findings included:1. Review of facility documents on5-15-12 lacked evidence that dischargeplanning is included in the facility's QAPIprogram.2. Interview with B#17 on 5-15-12 at1405 hours confirmed that dischargeplanning is not included in the facility'sState FormEvent ID:0PUT11Discharge Planning is now a partof the QA/PI program and assuch is being reported throughthe CORE (Quality) meeting on ascheduled basis.100% ofinpatients admitted to the medicalsurgical floor are assessed fordischarge planning needs onadmission either by nursing orcase management. A referral tocase management will be madefor discharge planning needs ifthe assessment shows thatpatients have assistive orfollow-up needs.100% of allinpatient acute patients will beaudited. Collection of data will bedone by case management whoFacility ID:005111If continuation sheet07/23/2012 12:00:00APage 7 of 26

PRINTED:DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESOMB NO. 0938-0391STATEMENT OF DEFICIENCIES(X1) PROVIDER/SUPPLIER/CLIAAND PLAN OF CORRECTIONIDENTIFICATION NUMBER:151325(X2) MULTIPLE CONSTRUCTION(X3) DATE SURVEY00A. BUILDINGCOMPLETED05/15/2012B. WINGSTREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER1116 MILLIS AVEBOONVILLE, IN 47601ST MARY'S WARRICK HOSPITAL INC(X4) IDSUMMARY STATEMENT OF DEFICIENCIESIDPREFIX(EACH DEFICIENCY MUST BE PERCEDED BY FULLPREFIXTAGREGULATORY OR LSC IDENTIFYING INFORMATION)TAGPROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE APPROPRIATEDEFICIENCY)(X5)COMPLETIONDATEwill analyze and report data toCORE (QI oversight committee)on a bimonthly basis.ResponsibleParty: Case ManagersQAPI program.State Form08/30/2012FORM APPROVEDEvent ID:0PUT11Facility ID:005111If continuation sheetPage 8 of 26

PRINTED:DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESOMB NO. 0938-0391STATEMENT OF DEFICIENCIES(X1) PROVIDER/SUPPLIER/CLIAAND PLAN OF CORRECTIONIDENTIFICATION NUMBER:151325(X2) MULTIPLE CONSTRUCTIONA. BUILDING00COMPLETED05/15/2012STREET ADDRESS, CITY, STATE, ZIP CODE1116 MILLIS AVEBOONVILLE, IN 47601ST MARY'S WARRICK HOSPITAL INC(X4) IDSUMMARY STATEMENT OF DEFICIENCIESIDPREFIX(EACH DEFICIENCY MUST BE PERCEDED BY FULLPREFIXREGULATORY OR LSC IDENTIFYING INFORMATION)TAGTAG(X3) DATE SURVEYB. WINGNAME OF PROVIDER OR SUPPLIERS042008/30/2012FORM APPROVEDPROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE APPROPRIATEDEFICIENCY)(X5)COMPLETIONDATE410 IAC 15-1.4-2.2QUALITY ASSESSMENT ANDIMPROVEMENT410 IAC 15-1.4-2.2 (a)(1)Reportable eventsSec. 2.2. (a) The hospital's qualityassessment and improvement programunder section 2 of this rule shall include thefollowing:(1) A process for determining theoccurrence of the following reportableevents within the hospital:(A) The following surgical events:(i) Surgery performed on the wrong bodypart, defined as any surgery performed on abody part that is not consistent with thedocumented informed consent for thatpatient. Excluded are emergent situations:(AA) that occur in the course of surgery; or(BB) whose exigency precludes obtaininginformed consent;or both.(ii) Surgery performed on the wrong patient,defined as any surgery on a patient that isnot consistent with the documentedinformed consent for that patient.(iii) Wrong surgical procedure performed ona patient, defined as any procedureperformed on a patient that is not consistentwith the documented informed consent forthat patient. Excluded are emergentsituations:(AA) that occur in the course of surgery; or(BB) whose exigency precludes obtaininginformed consent;or both.(iv) Retention of a foreign object in a patientafter surgery or other invasive procedure.The following are excluded:(AA) Objects intentionally implanted as partState FormEvent ID:0PUT11Facility ID:005111If continuation sheetPage 9 of 26

PRINTED:DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESOMB NO. 0938-0391STATEMENT OF DEFICIENCIES(X1) PROVIDER/SUPPLIER/CLIAAND PLAN OF CORRECTIONIDENTIFICATION NUMBER:151325(X2) MULTIPLE CONSTRUCTIONA. BUILDING(X3) DATE SURVEY00COMPLETED05/15/2012B. WINGSTREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER1116 MILLIS AVEBOONVILLE, IN 47601ST MARY'S WARRICK HOSPITAL INC(X4) IDSUMMARY STATEMENT OF DEFICIENCIESIDPREFIX(EACH DEFICIENCY MUST BE PERCEDED BY FULLPREFIXREGULATORY OR LSC IDENTIFYING INFORMATION)TAGTAG08/30/2012FORM APPROVEDPROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE APPROPRIATEDEFICIENCY)(X5)COMPLETIONDATEof a planned intervention.(BB) Objects present before surgery thatwere intentionally retained.(CC) Objects not present prior to surgerythat are intentionally left in when the risk ofremoval exceeds the risk of retention, suchas microneedles or broken screws.(v) Intraoperative or immediatelypostoperative death in an ASA Class Ipatient. Included are allASA Class I patient deaths in situationswhere anesthesia was administered; theplanned surgicalprocedure may or may not have beencarried out.(B) The following product or device events:(i) Patient death or serious disabilityassociated with the use of contaminateddrugs, devices, or biologics provided by thehospital. Included are generally detectablecontaminants in drugs, devices, or biologicsregardless of the source of contamination orproduct.(ii) Patient death or serious disabilityassociated with the use or function of adevice in patient care in which the device isused or functions other than as intended.Included are, but not limited to, the following:(AA) Catheters.(BB) Drains and other specialized tubes.(CC) Infusion pumps.(DD) Ventilators.(iii) Patient death or serious disabilityassociated with intravascular air embolismthat occurs while being cared for in thehospital. Excluded are deaths or seriousdisability associated with neurosurgicalprocedures known to present a high risk ofintravascular air embolism.(C) The following patient protection events:(i) Infant discharged to the wrong person.(ii) Patient death or serious disabilityState FormEvent ID:0PUT11Facility ID:005111If continuation sheetPage 10 of 26

PRINTED:DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESOMB NO. 0938-0391STATEMENT OF DEFICIENCIES(X1) PROVIDER/SUPPLIER/CLIAAND PLAN OF CORRECTIONIDENTIFICATION NUMBER:151325(X2) MULTIPLE CONSTRUCTIONA. BUILDING(X3) DATE SURVEY00COMPLETED05/15/2012B. WINGSTREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER1116 MILLIS AVEBOONVILLE, IN 47601ST MARY'S WARRICK HOSPITAL INC(X4) IDSUMMARY STATEMENT OF DEFICIENCIESIDPREFIX(EACH DEFICIENCY MUST BE PERCEDED BY FULLPREFIXREGULATORY OR LSC IDENTIFYING INFORMATION)TAGTAG08/30/2012FORM APPROVEDPROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE APPROPRIATEDEFICIENCY)(X5)COMPLETIONDATEassociated with patient elopement.(iii) Patient suicide or attempted suicideresulting in serious disability, while beingcared for in the hospital, defined as eventsthat result from patient actions afteradmission to the hospital. Excluded aredeaths resulting from self-inflicted injuriesthat were the reason for admission to thehospital.(D) The following care management events:(i) Patient death or serious disabilityassociated with a medication error, forexample, errors involving the wrong:(AA) drug;(BB) dose;(CC) patient;(DD) time;(EE) rate;(FF) preparation; or(GG) route of administration.Excluded are reasonable differences inclinical judgment on drug selection anddose. Includes administration of amedication to which a patient has a knownallergy and drug-drug interactions for whichthere is known potential for death or seriousdisability.(ii) Patient death or serious disabilityassociated with a hemolytic reaction due tothe administration of ABO/HLA incompatibleblood or blood products.(iii) Maternal death or serious disabilityassociated with labor or delivery in a low-riskpregnancy while being cared for in thehospital. Included are events that occurwithin forty-two (42) days postdelivery.Excluded are deaths from any of thefollowing:(AA) Pulmonary or amniotic fluid embolism.(BB) Acute fatty liver of pregnancy.(CC) Cardiomyopathy.(iv) Patient death or serious disabilityState FormEvent ID:0PUT11Facility ID:005111If continuation sheetPage 11 of 26

PRINTED:DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESOMB NO. 0938-0391STATEMENT OF DEFICIENCIES(X1) PROVIDER/SUPPLIER/CLIAAND PLAN OF CORRECTIONIDENTIFICATION NUMBER:151325(X2) MULTIPLE CONSTRUCTIONA. BUILDING(X3) DATE SURVEY00COMPLETED05/15/2012B. WINGSTREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER1116 MILLIS AVEBOONVILLE, IN 47601ST MARY'S WARRICK HOSPITAL INC(X4) IDSUMMARY STATEMENT OF DEFICIENCIESIDPREFIX(EACH DEFICIENCY MUST BE PERCEDED BY FULLPREFIXREGULATORY OR LSC IDENTIFYING INFORMATION)TAGTAG08/30/2012FORM APPROVEDPROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE APPROPRIATEDEFICIENCY)(X5)COMPLETIONDATEassociated with hypoglycemia, the onset ofwhich occurs while the patient is being caredfor in the hospital.(v) Death or serious disability (kernicterus)associated with the failure to identify andtreat hyperbilirubinemia in neonates.(vi) Stage 3 or Stage 4 pressure ulcersacquired after admission to the hospital.Excluded is progression from Stage 2 orStage 3 if the Stage 2 or Stage 3 pressureulcer was recognized upon admission orunstageable because of the presence ofeschar.(vii) Patient death or serious disabilityresulting from joint movement therapyperformed in the hospital.(viii) Artificial insemination with the wrongdonor sperm or wrong egg.(E) The following environmental events:(i) Patient death or serious disabilityassociated with an electric shock while beingcared for in thehospital.Excludes events involving plannedtreatment, such as electrical countershockor elective cardioversion.(ii) Any incident in which a line designatedfor oxygen or other gas to be delivered to apatient:(AA) contains the wrong gas; or(BB) is contaminated by toxic substances.(iii) Patient death or serious disabilityassociated with a burn incurred from anysource while being cared for in the hospital.(iv) Patient death or serious disabilityassociated with a fall while being cared for inthe hospital.(v) Patient death or serious disabilityassociated with the use of restraints orbedrails while being cared for in the hospital.(F) The following criminal events:(i) Any instance of care ordered by orState FormEvent ID:0PUT11Facility ID:005111If continuation sheetPage 12 of 26

PRINTED:DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESOMB NO. 0938-0391STATEMENT OF DEFICIENCIES(X1) PROVIDER/SUPPLIER/CLIAAND PLAN OF CORRECTIONIDENTIFICATION NUMBER:151325(X2) MULTIPLE CONSTRUCTION(X3) DATE SURVEY00A. BUILDINGCOMPLETED05/15/2012B. WINGSTREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER1116 MILLIS AVEBOONVILLE, IN 47601ST MARY'S WARRICK HOSPITAL INC(X4) IDSUMMARY STATEMENT OF DEFICIENCIESIDPREFIX(EACH DEFICIENCY MUST BE PERCEDED BY FULLPREFIXREGULATORY OR LSC IDENTIFYING INFORMATION)TAGTAG08/30/2012FORM APPROVEDPROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE APPROPRIATEDEFICIENCY)(X5)COMPLETIONDATEprovided by someone impersonating aphysician, nurse, pharmacist, or otherlicensed healthcare provider.(ii) Abduction of a patient of any age.(iii) Sexual assault on a patient within or onthe grounds of the hospital.(iv) Death or significant injury of a patient orstaff member resulting from a physicalassault, that is, battery, that occurs within oron the grounds of the hospital.Based on document review and interview,the facility's Quality Assessment andPerformance Improvement Committee(QAPI) failed to include serious adverseevents, reportable to the Indiana StateDepartment of Health (ISDH), in thefacility QAPI program.S0420Findings included:1. Review of QAPI documents on5-15-12 lacked evidence that seriousadverse events, reportable to the IndianaState Department of Health, wereincluded in the program.2. Interview with B#17 on 5-15-12 at1405 hours confirmed serious adverseevents, reportable to the Indiana StateDepartment of Health, are not included inthe facility's QAPI program.State FormEvent ID:0PUT11Serious safety events that arereportable to ISDH are nowincluded in the QA/PI programand as such will be discussed atthe CORE (Quality) committeemeeting on a monthly basis.Serious safety events arereported to CORE (QI oversightcommittee). Because there hasnot been a serious event, it wasnot noted as an agenda item inthe CORE minutes. This subjectitem is being added to the agendaand will be reported monthly as "serious safety events(reportable)" reflected by theagenda and the minutes. Anyserious safety event will bediscussed as an agenda item atthis meeting.Responsible Party:QA Analyst, CNO, ResponsibleDepartment HeadsFacility ID:005111If continuation sheet07/19/2012 12:00:00APage 13 of 26

PRINTED:DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESOMB NO. 0938-0391STATEMENT OF DEFICIENCIES(X1) PROVIDER/SUPPLIER/CLIAAND PLAN OF CORRECTIONIDENTIFICATION NUMBER:151325(X2) MULTIPLE CONSTRUCTIONCOMPLETED05/15/2012B. WINGSTREET ADDRESS, CITY, STATE, ZIP CODE1116 MILLIS AVEBOONVILLE, IN 47601ST MARY'S WARRICK HOSPITAL INC(X4) IDSUMMARY STATEMENT OF DEFICIENCIESIDPREFIX(EACH DEFICIENCY MUST BE PERCEDED BY FULLPREFIXREGULATORY OR LSC IDENTIFYING INFORMATION)TAGTAG(X3) DATE SURVEY00A. BUILDINGNAME OF PROVIDER OR SUPPLIERS055408/30/2012FORM APPROVEDPROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE APPROPRIATEDEFICIENCY)(X5)COMPLETIONDATE410 IAC 15-1.5-2INFECTION CONTROL410 IAC 15-1.5-2(a)(a) The hospital shall provide a safeand healthful environment thatminimizes infection exposure and riskto patients, health care workers, andvisitors.Based on observation and staff interview,the facility failed to provide anenvironment that minimized risk topatients for 1 surgery department toured.S0554Findings include:1. During tour of the surgery departmentbeginning at 10:35 a.m. on 5/15/12 thefollowing items were observed in theanesthesia cart located in the anesthesiawork room:(A) Numerous personal items including,but not limited to, chewing gum, mints,lotion, coins, and mail, were stored withpatient care items.(B) The only #2 LMA in the cart had anexpiration date of 5/5/12.2. RN #1 verified during observation thatthe anesthesia cart was the only one atfacility and that the personal items werenot to be kept in the cart. He/she alsoindicated that the department did not havean additional #2 AMA available at thetime of tour.State FormEvent ID:0PUT11Personal items were removedfrom the anesthesia cart on theday of the surveyor tour (5/14/12).Anesthesia provider was madeaware of finding and was told thathe may not keep personal itemsin the anesthesia cart.Anesthesia provider was given acopy of the Indiana Code for hisreview, informing him of theinfection control issues related tothis deficiency. Unannouncedchecks every week x 4, thenmonthly to assure that infectioncontrol standards are met andthat no personal items are placedin this cart. The Surgery Manageris responsible for ensuringcompliance with thisstandard.Surgery does not doemergency pediatric surgery.Therefore, the LMA was removedfrom the supply cart the day ofthe survey and is no longer astock item. Scheduled cases areevaluated for supply needs by asurgical nurse/tech at leastone-four days prior to case and ifan LMA may be required for safecare, one is delivered to thehospital from the main campus.Facility ID:005111If continuation sheet05/16/2012 12:00:00APage 14 of 26

PRINTED:DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESOMB NO. 0938-0391STATEMENT OF DEFICIENCIES(X1) PROVIDER/SUPPLIER/CLIAAND PLAN OF CORRECTIONIDENTIFICATION NUMBER:151325(X2) MULTIPLE CONSTRUCTIONCOMPLETED05/15/2012B. WINGSTREET ADDRESS, CITY, STATE, ZIP CODE1116 MILLIS AVEBOONVILLE, IN 47601ST MARY'S WARRICK HOSPITAL INC(X4) IDSUMMARY STATEMENT OF DEFICIENCIESIDPREFIX(EACH DEFICIENCY MUST BE PERCEDED BY FULLPREFIXREGULATORY OR LSC IDENTIFYING INFORMATION)TAGTAG(X3) DATE SURVEY00A. BUILDINGNAME OF PROVIDER OR SUPPLIERS055608/30/2012FORM APPROVEDPROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE APPROPRIATEDEFICIENCY)(X5)COMPLETIONDATE410 IAC 15-1.5-2INFECTION CONTROL410 IAC 15-1.5-2(b)(b) There shall be an active,effective, and written hospital-wideinfection control program. Included inthis program shall be system designedfor the identification, surveillance,investigation, control, and preventionof infections and communicablediseases in patients and health careworkers.Based on observation, document review,and interview, the facility failed to havean effective infection control program in1 of 1 departments (rehabilitationdepart

ST MARY'S WARRICK HOSPITAL INC 1116 MILLIS AVE S0308 410 IAC 15-1.4-1 GOVERNING BOARD 15-1.4-2 (c)(6)(B) (c) The governing board is responsible for managing the hospital. The governing board shall do the following: (6) Require that the chief executive officer develops policies and programs for the following: (B) Orientation of all new employees,