Every finding on record at Madison Medical Center

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. Review of the facility's 2024-2025 QAPI Plan showed: - The facility will improve quality within the organization by maintaining a Quality Improvement (QI) Team to oversee QI activities and evaluate QI process on an ongoing basis and to review policies and procedures relating to each function and to make necessary revisions. The QI Team includes leadership, medical staff representation, and department supervisors;- Leadership will review quality performance monthly with department directors, guiding them to meet goals;- A cross-functional team will be assigned for organization-wide functions. The team responsibilities include meeting on a periodic basis as established by the committee;- The Quality Improvement Director assures ongoing communication, reporting, and documentation of quality information by moderating QI discussions/reviews and holding QI meetings. Review of the facility's QAPI Meeting Minutes, provided by the Administrator, showed:- The Infection Preventionist (IP) did not attend the meeting on 11/15/24;- The physician or nurse practitioner (NP) did not attend the meeting on 02/14/25;- The physician or NP did not attend the meeting on 05/16/25. During an interview on 09/26/25 at 1:11 P.M., the Administrator said there is an IP on the hospital side, but it looks like there wasn't an IP at the November meeting. They will look at having another staff obtain the certification to become IP. Usually, the doctor or NP are at the meetings; she isn't sure why they aren't on the list or if they were there. She would expect all required members to be at the meetings.

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. The facility's census was 61.Review of the facility's policy, Patient Transfer Form, revised July 2024, showed: - The purpose is to provide pertinent information to the facility to which the resident is being transferred and to assure continuity of care; - When a resident is being transferred to another facility for an out-patient care, acute care admission or emergency room care, the resident's Continuity of Care Document (CCD) will be printed from their electronic health record (EHR) and sent with them; - The nurse will document a progress note regarding the resident's transfer; - The nurse will complete the nursing home transfer/bed hold observation; - Social Services will review and complete the bed hold notification; - The policy did not address written notification of the transfer to the resident or resident's responsible party. 1. Review of Resident #5's medical record showed: - admitted on [DATE]; - Resident transferred to the hospital on [DATE] and returned to the facility the same day; - Resident transferred to the hospital on [DATE] and returned to the facility the same day; - No documentation that written notification of transfer was provided to the resident and/or the resident's representative for the resident's transfer to the hospital. 2. Review of Resident #7's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility the same day; - The resident transferred to the hospital on [DATE] and returned to the facility the same day; - No documentation that written notification of transfer was provided to the resident and/or the resident's representative for the resident's transfer to the hospital. 3. Review of Resident #8's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility the same day; - The resident transferred to the hospital on [DATE] and returned to the facility the same day; - No documentation that written notification of transfer was provided to the resident and/or the resident's representative for the resident's transfer to the hospital. 4. Review of Resident #21's medical record showed: - admitted on [DATE]; - Resident transferred to the hospital on [DATE] and returned to the facility the same day; - No documentation that written notification of transfer was provided to the resident and/or the resident's representative for the resident's transfer to the hospital. 5. Review of Resident #24's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility the same day; - The resident transferred to the hospital on [DATE] and returned to the facility the same day; - The resident transferred to the hospital on [DATE] and returned to the facility the same day; - The resident transferred to the hospital on [DATE] and returned to the facility the same day; - No documentation that written notification of transfer was provided to the resident and/or the resident's representative for the resident's transfer to the hospital. 6. Review of Resident #37's medical record showed: - admitted on [DATE]; - Resident transferred to the hospital on [DATE] and returned to the facility the same day; - No documentation that written notification of transfer was provided to the resident and/or the resident's representative for the resident's transfer to the hospital. 7. Review of Resident #43's medical record showed: - admitted on [DATE]; - Resident transferred to the hospital on [DATE] and returned to the facility the same day; - Resident transferred to the hospital on [DATE] and returned to the facility the same day; - Resident transferred to the hospital on [DATE] and returned to the facility the same day; - Resident transferred to the hospital on [DATE] and returned to the facility the same day; - Resident transferred to the hospital on [DATE] and returned to the facility the same day; - Resident transferred to the hospital on [DATE] and returned to the facility the same day; - No documentation that written notification of transfer was provided to the resident and/or the resident's representative for the resident's transfer to the hospital. During an interview on 09/25/25 at 4:00 P.M., Registered Nurse (RN) C said when a resident goes to the emergency room (ER), they send a face sheet and there's another form where they answer questions. Nurses fill out a transfer/bed hold form and call the family and doctor. During an interview on 09/26/25 at 10:57 A.M., the Social Services Designee (SSD) said he only sends the bed hold policy when a resident is hospitalized and not when they're sent to the ER. He does not ever send the transfer form. If they are sent to the ER and come back, he just notes Resident returned from the ER on the transfer form. During an interview on 09/26/25 at 1:40 P.M., the Administrator said she would expect residents and their families to be notified in writing of their transfer or discharge from the facility. During an interview on 09/26/25 at 3:36 P.M., the Administrator said the SSD does maintain a binder in his office for each transfer/discharge. The SSD does mail these out to the responsible party any time there is a transfer/discharge with the resident name and where they were sent. During an interview on 09/30/25 at 2:59 P.M., the Chief Operating Officer said residents who are sent to the emergency room for evaluation are considered to be on therapeutic leave in the census and not classified as a transfer, as the Emergency Department is part of the facility.

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 sure drop of insulin appears;- Select dose;- Give injection;- After dose counter reaches zero, hold for five to ten seconds;- After injection, remove needle and place in sharps container.1. Observation on 09/25/25 at 11:05 A.M. showed:- Licensed Practical Nurse (LPN) A obtained the finger stick blood sugar (FSBS) for Resident #31;- LPN A obtained the insulin lispro pen from the medication cart and adjusted the pen to the amount of insulin ordered;- LPN A did not prime the pen with two units of insulin per the manufacturer's directions prior to administering the ordered dose to the resident.2. Observation on 09/25/25 at 11:10 A.M. showed:- LPN A obtained the FSBS for Resident #42;- LPN A obtained the Humalog insulin pen from the medication cart and adjusted the pen to the amount of insulin ordered;- LPN A did not prime the pen with two units of insulin per the manufacturer's directions prior to administering the ordered dose to the resident.3. Observation on 09/25/25 at 11:15 A.M. showed:- LPN A obtained the FSBS for Resident #50;- LPN A obtained the Humalog insulin pen from the medication cart and adjusted the pen to the amount of insulin ordered;- LPN A did not prime the pen with two units of insulin per the manufacturer's directions prior to administering the ordered dose to the resident.During an interview on 09/25/25 at 11:20 A.M., LPN A said he/she doesn't prime pens, but they technically should be primed with two units of insulin. The reason that the pens aren't primed is the new needles the facility received are retractable and as soon as you let up off the button, the needle retracts, so there is no way to prime the needle. He/she is unaware if the problem has been discussed with the Director of Nursing (DON).During an interview on 09/26/25 at 1:40 P.M., the Administrator and DON said they would expect insulin pens to be primed before administering insulin and for the medication error rate to be 5% or less.

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 or odor; - Remove gloves and put in trash; - Wash hands at least 20 seconds, use friction and dry. Hand sanitizer is acceptable; - Apply gloves; - Gently clean wound as prescribed and pat dry with gauze pad or 4x4; - If treatment requires ointment, use a small amount, apply to a cotton tip applicator or clean gauze pad, apply to open area and not surrounding skin; - Cover wound as ordered by physician; - Initial and date the tape applied to dressing; - Remove gloves and wrap all trash in small bag and remove from room; - Wash hands at least 15 seconds, use friction and dry. Hand sanitizer is acceptable; - Document in the ETAR when you have completed the treatment. Review of the facility's policy, Enhanced Barrier Precaution (EBP), dated May 2024, showed: - The purpose is to protect residents and staff from multi-drug-resistant organisms by utilizing enhanced barrier precautions; - Enhanced barrier precautions consists of donning gown and gloves; - Staff will utilize EBP during high contact resident care activities for residents with any of the following: Infection or colonization with an MDRO (multi drug resistant organism) when Contact Precautions do not apply, wounds and/or indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status; - High contact resident care activities include: dressing, bathing/showering, transfers, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator and wound care: any skin opening requiring a dressing; - Staff will change Personal Protective Equipment (PPE) before caring for another resident; - All residents infected or colonized with MDRO will be placed on isolation precautions per infection preventionist or provider orders. Review of the facility's policy, Handwashing, revised June 2024, showed: - Personnel should decontaminate hands before direct contact with patients, before donning sterile gloves, after contact with mucus membranes or body fluids, when moving from contaminated site to clean or after touching inanimate source that might have been contaminated and after removing gloves; - Wearing gloves does not replace the need for handwashing; - Approved waterless sanitizer may be used in place of washing hands as long as hands are not visibly soiled. 1. Observation on 09/25/25 at 10:30 A.M. of wound care for Resident #10 showed: - Registered Nurse (RN) B gathered wound supplies and entered the resident's room; - RN B did not don a gown for EBP; - RN B washed his/her hands in the resident's room; - RN B picked up the resident's glasses off the floor, did not wash or sanitize his/her hands, and donned gloves; - RN B removed the old dressing from a wound on the left breast, did not change gloves, and cleansed the area with gauze soaked in wound cleanser; - RN B removed gloves and did not wash or sanitize his/her hands; - RN B donned gloves and applied a small amount of calcium alginate (wound treatment) over the wound and applied tape to secure in place; - Resident #10 complained of right breast pain. While wearing the same gloves, RN B assessed the resident's right breast; - RN B removed gloves, placed trash in the trash can, and washed his/her hands. During an interview on 09/26/25 at 10:25 A.M., RN B said he/she should have put on a gown before doing wound care and wore it the whole time as he/she has been instructed to wear a gown with any type of wound and during catheter care. He/she should wash or sanitize hands before starting wound care, after touching soiled linens, with glove changes, and when finishing wound care or if there is a hole in a glove. He/she should change gloves when removing an old dressing, when the gloves are severely soiled, if there is a tear in the glove, and before putting on a new dressing. If an item is in the floor, he/she should clean it before giving it to the resident and he/she should clean scissors after use. 2. Observation on 09/26/25 at 9:10 A.M of wound care for Resident #56 showed: - RN B and the Assistant Director of Nursing (ADON) donned gowns, washed hands, and donned gloves upon entry to the resident's room; - RN B placed all supplies, except scissors and tape, on a paper plate and placed on the bed; - RN B placed the scissors and tape on the bed with no barrier; - ADON held Resident #56's leg in position; - RN B picked up the scissors from the mattress and cut the dressing off the resident's right foot; - RN B placed the scissors back on the resident's bed; - While wearing the same gloves, RN B obtained wound cleanser-soaked gauze from a cup and cleaned the wound; - While wearing the same gloves, RN B placed xeroform (topical wound dressing used to promote healing) and a gauze pad onto the wound, and wrapped the resident's foot and lower leg with gauze; - While wearing the same gloves, RN B picked the tape up from the bed and placed a piece on the gauze; - While wearing the same gloves, RN B reached under his/her gown into a pocket, obtained a marker, and initialed the tape; - While wearing the same gloves, RN B wrapped the area with an ace wrap (a gentle compression bandage); - The ADON lowered the resident's leg and placed a protective boot onto his/her left foot; - The ADON removed gown and gloves, and washed hands; - RN B threw trash away, then placed scissors and marker on the counter next to the sink; - RN B removed gown and gloves, and washed hands; - RN B picked scissors and marker up from the counter and placed into his/her pocket without cleaning. During an interview on 09/26/25 at 9:20 A.M., RN B said he/she had forgot to bring in a pad to put down as a barrier and should have cleaned the scissors before putting them in a pocket. Normally, they would have been cleaned with an alcohol wipe, soap and water, or a special spray. During an interview on 09/26/25 at 1:40 P.M., the Administrator and Director of Nursing (DON) said they would expect staff to wear appropriate PPE for EBP, a barrier to be used for supplies during wound care, staff to wash their hands after picking something up off the floor and before starting wound care, gloves to be changed from a dirty to clean task, and for hands to be washed or sanitized in between glove changes. They would expect markers and scissors to be sanitized after use.

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 from a contaminated body site to a clean body site during patient care; after touching inanimate sources that might have been contaminated with virulent or epidemiological microorganisms; and after removing gloves; - Wearing gloves does not replace the need for hand washing because gloves may have small unapparent defects, may be torn during use and hands can become contaminated during removal of gloves; - Facility-approved waterless hand sanitizer may be used in place of washing hands with soap and water as long as hands are not visibly soiled; - If an employee is non-compliant, they must wear gloves at all times when they are with patients and the hand hygiene policy must be reviewed with the employee and documented as a corrective action. Review of the facility's Perineal Care with a Catheter policy, revised January 2024, showed: - Wash hands and apply gloves; - Place bed protector under buttocks; - Expose the perineal area; - For the female resident, separate the labia and gently wash around the opening of the urethra with disposable non-rinse wipes; - Wash the catheter from the opening of the urethra outward four inches or farther if needed. Do not pull on catheter; - Using a fresh non-rinse wipe, continue washing the peri area. Dry the perineal area; - Remove any soiled items and place in appropriate container; - Remove gloves and dispose in appropriate container. Wash hands; - Apply clean gloves before applying barrier cream. Remove gloves, wash hands. 1. Observation of Resident #3 on 09/12/24 at 9:12 A.M. showed: - Certified Nursing Assistant (CNA) A and CNA C sprayed disposable wipes with peri-wash on a barrier on a supply cart outside the room, entered the resident's room, washed their hands, and donned gloves and a gown; - CNA C helped to position the resident while CNA A cleaned the resident's perineal area and catheter with two separate wipes and placed the used wipes on the disposable bed pad; - CNA A, while performing peri and catheter care, found bowel movement (BM) on his/her glove, removed gloves and laid the soiled gloves on the disposable bed pad with the soiled wipes; - CNA C positioned the resident on the resident's right side; - Without performing hand hygiene, CNA A donned new gloves and cleaned the resident's buttocks again with two separate wipes, placed the used wipes on the soiled bed pad and then wiped BM from the resident's buttocks with the corner of the disposable bed pad and folded the soiled corner of the bed pad over onto itself; - CNA C removed gloves, did not perform hand hygiene, went out in the hall to get more gloves, re-entered the room, washed hands, donned gloves and handed gloves to CNA A; - CNA A removed gloves and, without performing hand hygiene, donned new gloves and continued to wipe BM from the resident's buttocks with wipes; - CNA A rolled up the bed pad and tucked it under the resident; - While CNA B repositioned the resident, CNA A pulled the soiled disposable bed pad from under the resident and handed the soiled bed pad containing soiled wipes to CNA C, who threw the bundle in the trash can beside him/her; - CNA A and CNA C removed gloves and, without performing hand hygiene, donned new gloves; - CNA A then wiped the resident's catheter and peri area again and put a new disposable bed pad under the resident; - With the same soiled gloves, CNA A covered the resident with a blanket; - CNA A and CNA C removed their gloves and gowns; - CNA A washed his/her hands while CNA C pulled the full trash bag from the trash can with bare hands, tied the bag, and set it on the floor beside the trash can; - CNA C washed his/her hands, grabbed the top of the bag of trash with a paper towel, and both CNAs left the room. 2. Observation of Resident #16 on 09/12/24 at 9:51 A.M. showed: - CNA A and CNA B entered the room and washed their hands; - CNA A touched the resident's closet door, clothes in the closet, and the resident's bed, then donned gloves; - CNA B donned gloves; - CNA B positioned the resident while CNA A performed peri care; - CNA A reached for loose wipes on a barrier on the nightstand with gloves being used to perform peri care and touched the clean gloves sitting beside the wipes; - CNA A and CNA B removed the disposable bed pad from under the resident, and CNA B disposed of it in the trash can near CNA A; - CNA A removed her gloves and, without performing hand hygiene, donned the last pair of gloves that was sitting on the nightstand; - CNA B removed his/her gloves; - CNA A laid a clean brief under the resident and applied barrier cream while CNA B helped position the resident with bare hands; - Without performing hand hygiene, CNA A and CNA B fastened the clean brief's tabs on either side of the resident and dressed the resident with bare hands; - Without performing hand hygiene, CNA B opened the door, went into the hall to retrieve the sit to stand and the resident's wheelchair; - Without performing hand hygiene, CNA A touched the resident, his/her clothing, bed, and pillow with bare hands; - Without performing hand hygiene and with bare hands, CNA A and CNA B reached under the resident's arms to position the resident on the edge of the bed and fastened the sit-to-stand sling on the resident for a bed to wheelchair transfer; - Once the resident was transferred to the wheelchair, and without performing hand hygiene, CNA B brushed the resident's hair, touching the hairbrush and the resident's hair with his/her bare hands; - CNA A and CNA B washed their hands and exited the room with the resident. During an interview on 09/12/24 at 2:21 P.M., the Infection Preventionist (IP) said she would strongly encourage staff to wash/sanitize their hands with glove changes. Staff should wash before starting peri care and perform hand hygiene and put on new gloves before cleaning up a bowel movement. If the resident has a catheter and catheter care needs done again after cleaning up the bowel movement, staff should perform hand hygiene and put on new gloves before performing catheter care again. During an interview on 09/12/24 at 2:30 P.M., CNA B said he/she normally washes before beginning resident care and after resident care. In between tasks during resident care such as peri-care, he/she usually just changes gloves and does not wash or sanitize hands. It just depends on what he/she is doing whether or not he/she washes or sanitizes hands during patient care. During an interview on 09/13/24 at 9:23 A.M., CNA A said he/she washes before and after resident care and sanitizes throughout the day. He/She should sanitize when moving from dirty to clean or before dressing a resident after pericare. During an interview on 09/13/24 at 11:00 A.M., the Director of Nursing (DON) said she would expect staff to perform hand hygiene with glove changes. They don't necessarily have to wash their hands; sanitizer is fine. She would expect staff to perform hand hygiene prior to starting resident care, when going from dirty to clean, and after resident care. Staff should also perform hand hygiene after peri care and prior to personal care, such as dressing or transferring the resident.