Madison Medical Center

In the surveyor’s words

From the most serious findings on record at Madison Medical Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF868Nov 17, 2025

  Based on interview and record review, the facility failed to maintain quarterly Quality Assurance & Performance Improvement (QAPI) meetings with the required members. The facility's census was 61.Review of the facility's policy, QAPI Program, dated July 2020, showed:- The QAPI team will meet on a monthly basis to discuss indicators and their performance, as well as other pertinent issues revolving around the operations of the facility. Representatives from the QAPI Team will also meet on a quarterly basis with physicians, nurse practitioners and other departments to report the tracking results of their indicators;- The policy did not address the required QAPI members. […]

• No harm, potential for more than minimal, patternF628Nov 17, 2025

  Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to a hospital, including the statement of appeal rights or the name, address, or telephone number of the Office of the State Long Term Care Ombudsman (advocates for the residents in nursing facilities) within the transfer and discharge notices for seven residents (Resident #5, #7, #8, #21, #24, #37, and #43 ) out of 15 sampled residents. […]

• No harm, potential for more than minimal, isolatedF759Nov 17, 2025

  Based on observation, interview, and record review, the facility failed to maintain an error rate of five percent or less when medications were administered and staff failed to prime insulin pens before the administration of insulin. There were 25 opportunities with three errors made, for an error rate of 12%. This affected three residents (Resident #31, #42, and #50) outside of the 15 sampled residents, with the potential to affect all residents. The facility's census was 61.Review of the facility's policy, Insulin Administration, revised 01/24, did not address the use of insulin pens.Review of insulin lispro (Humalog) pen (insulin in a pen-type device) directions showed:- Remove cap;- Attach needle;- Prime pen by turning dose selector to select two units;- Press and hold button to make… […]

• No harm, potential for more than minimal, isolatedF880Nov 17, 2025

  Based on observation, interview, and record review, the facility failed to maintain proper infection control practices during wound care for two residents (Residents #10 and #56) out of two residents sampled for wound care. The facility's census was 61.Review of the facility's policy, Dressing Change, revised March 2023, showed: - This is a clean procedure, not sterile; - Check order for dressing change in the electronic treatment administration record (ETAR); - Gather supplies, including a clean towel, paper towels or paper plate as a field for the dressing change and supplies; - Wash hands at least 15 seconds and use friction, dry hands; - Apply non-sterile gloves; - Remove old dressing and throw in trash bag; - Observe wound for redness, bleeding, and any kind of drainage, dried blood… […]

• No harm, potential for more than minimal, isolatedF880Sep 13, 2024

  Based on observation, interview, and record review, the facility failed to maintain infection control practices to prevent the development and transmission of infection during incontinent care for one resident (Resident #3) out of 15 sampled residents and one resident (Resident #16) outside the sample. The facility's census was 59. Review of the facility's Handwashing policy, revised June 2024, showed: - The purpose is to ensure that hand washing is conducted appropriately; - Personnel should always decontaminate their hands before having direct contact with patients; after a situation during which unanticipated microbial contamination of hands might have occurred, especially those involving contact with mucous membranes, blood or other body fluids, secretions, or excretions; if moving… […]