HospitalInspections.org

Based on 6 of 30 records reviewed (#4,5,6,12,14,19), staff interview and facility policies the hospital failed to ensure nursing care plans were updated.

Findings include:

Examples by surveyor 18816:

Patient (Pt) #4's medical record (MR) review by surveyor 18816 on 5/8/12 at 8:15 AM revealed the Treatment Plan (TP) initiated on Pt #4's admission date of 3/26/12 include 6 problems identified pertaining to Pt #4's eating disorder. Of these problems, 1 was developed 1 week after admission, 4/4/12; and 1 problem had 4 additional interventions on 3/31/12. There are no other changes to the goals or interventions. Per review of Staff Meeting notes, dated 4/2/12, 4/9/12, 4/16/12 and 4/30/12, they indicate "continued need" or "continues to struggle", with no additional interventions to assist Pt #4's achievement of the goals. This is confirmed in interview with Clinical Education Specialist (CES) C on 5/8/12 at 8:15 AM.

Pt #5's MR review by surveyor 18816 on 5/8/12 at 8:30 AM revealed the TP initiated on Pt #5's admission date of 4/22/12 included 8 problems identified pertaining to Pt #5's eating disorder. Of these problems, 1 was developed 2 days after admission, 4/12/12, and 1 was developed 7 days after admission, on 4/29/12; 3 interventions were added to 1 goal on 5/4/12. There are no other changes to the goals or interventions. Per review of Staff Meeting notes, an undated note states "Patient has been struggling...", with no additional interventions to assist Pt #5's needs. This is confirmed in interview with CES C on 5/8/12 at 8:30 AM.

Pt #6's MR review by surveyor 18816 on 5/8/12 at 11:00 AM revealed the TP initiated on Pt #6's admission date of 2/26/12 included 4 problems identified pertaining to Pt #6's eating disorder. Of these problems, 1 included 2 updated intervention on 2/29/12, 3 days after admission; and 1 updated intervention on 3/2/12, 5 days after admission. There are no other changes to the goals or interventions. Per review of Staff Meetings notes, dated between 3/5/12 and 4/30/12, they indicate "Patient continues to struggle", with no additional intervention to assist Pt #6's need. This is confirmed in interview with CES C on 5/8/12 at 11:00 AM.


26711

Findings by Surveyor #26711:

An interview with RN L was conducted on 5/7/2012 at 12:15 p.m. RN L stated that care plans (treatment plans) are initiated by the admitting nurse according to the diagnosis/problem the patient comes in with. RN L indicated that staff cannot change the problem to individualize it to the patient.

MR reviews were completed by Surveyor #26711 on 5/7/2012 between 9:30 a.m. and 5:40 p.m. with the assistance of Clinical Informatics Manager (CIM) H.

Pt. #12 is a 5 year old admitted on 3/27/2012 and discharged on 4/4/2012. On 3/27/2012 the following problem was put on Pt. #12's TP: Health maintenance related to management of psychiatric condition. The 4th goal under this problem states: [Pt. #12] will verbalize understanding of current medication regimen including rationale and potential side effects. The 5th goal under this problem states: [Pt. #12] will develop a post discharge relapse prevention plan for safety prior to discharge. Both of these goals were marked as being achieved on 4/4/2012 (the day of discharge). When asked about the realistic achievement of these goals for a 5 year old, CIM H stated they were not realistic for a 5 year old and that this particular problem (health maintenance) is assigned to almost every patient who is admitted to the facility.

Pt. #12's second problem reads as: At risk for outward aggressive behaviors-thoughts or actions that verbally or physically intimidate others, property damage or cruelty to animals. Three goals under this problem were updated with specific negative behaviors demonstrated by Pt. #12, however on 3/30/12 and 4/2/12 Pt. #12 was taken to the "Quiet Room," at least one of these times for locked seclusion, and these episodes are not noted on the TP. Findings were confirmed during the MR by CIM H.

Pt. #19 is a 13 year old admitted on 4/30/2012. Pt. #19's TP has 5 problems and 40 goals that were assigned on 4/30/2012. Out of these 40 goals there was one updated on 5/1/2012 and one was individualized to identify specific behaviors of Pt. #19. The rest of the goals remain in the standardized computer format and and are not individualized to the patient. Findings were confirmed during the MR by CIM H.



05409

Per medical record review of Pt. #14 by Surveyor #05409 beginning at 2:44 p.m. on 5/8/12, review of the treatment plan revealed that the following problems were identified and says %NAME% instead of pt. #14's name in the goal sections: Anxious behaviors, Health maintenance, Knowledge Deficit, Self Care Deficit, and School Functioning, These findings were verified during this record review while CIM (Clinical Informatics Manager) H reviewed the records with Surveyor #05409.

Based on observation and 1 of 1 staff interview (I), this hospital does not ensure that unauthorized individuals at one of two inpatient facilities do not have access to information in patient records. Failure to secure medical records from unauthorized staff has the potential to affect all patients who received services in the facility including the 12 patients discharged the night before the observation (5/7/12) whose medical records would have been in the Health Information office.

Findings by Surveyor #26711:

In an interview with Manager (Mgr) M on 5/8/2012 at 7:35 a.m., Mgr M indicated that housekeeping staff clean the Health Information department in the Milwaukee location on second shift after staff have left so as not to disturb them. Mgr M states, "[staff member] will stick [members] head in and see if its ok to go in to clean, if someone is still there [member] will go do something else and come back later."

A tour of the Health Information (HI) department in Milwaukee was conducted on 5/8/2012 at 8:30 a.m. accompanied by Health Information Specialist (HIS) I and Manager (Mgr) J.

In a room identified by HIS I as the room where physicians come to sign their work, there were several stacks of closed records with physician's names on signs identifying the stacks for the individual physicians. HIS I identified a stack of records on a desk as those being set out for Medical Doctor (MD) P on 5/7/2012 but the MD did not come in that day so the records will stay on that desk, or may be moved to the open shelf by the other MD's unsigned records for MD P to sign.

HIS I confirmed that housekeeping staff are present in the HI department after hours when HI staff are not there.

Based on 24 of 30 records reviewed (#1 -10,12,14,16 -19,22,23,25,26 -30), interview with staff and review of facility policies the hospital failed to ensure medical record entries were complete.

Findings include:
Findings by Surveyor #26711:

Patient Safety Rounds

The facility's policy titled, "Safety Rounds & Suicide Precautions," with a revision date of 8/17/2009, was reviewed by Surveyor #26711 on 5/9/2012 at 12:00 p.m. The policy states under Procedure, #5 states in part, "At change of shift, staff from both shifts will make rounds together to verify each patient's safety status during transition."
In a subsequent revision dated 5/1/2012 the policy states in part, Procedure, #2. "Armband should only be checked on the night shift (2300 [11:00 p.m.] ) if patient is awake; indicate on the form 'NA' if not awake." And #5 states in part, "At change of shift, staff from both shifts will make rounds together to verify each patient's safety status during transition. Check patient armband and picture at 0700 [7:00 a.m.] and 1500 [3:00 p.m.] ).

MR reviews were completed by Surveyor #26711 on 5/8/2012 between 9:30 a.m. and 5:40 p.m. with the assistance of Clinical Informatics Manager (CIM) H.

The abbreviation "NA" is not on the Patient Safety Rounds Log legend for use as an abbreviation during safety checks.

Pt. #12 was admitted on 3/27/2012 and discharged on 4/4/2012. Pt. #12 had a physician order for safety checks to be done every 15 minutes and these were to continue through the time of discharge. Out of 14 change of shift time periods where two staff were to verify the activity and identity of Pt#12, it was completed by two staff once. CIM H verified the safety checks were not completed per policy. Also on Pt. #12's safety rounds log there are 84 entries identified by a diagonal line indicating the staff members initials. These initials do not appear on the staff signature sheet as a caregiver for this patient. CIM H verified that if this diagonal line is initials it is not on the signature sheet.

Pt. #19 was admitted on 4/30/2012. Pt. #19 has a physician order for safety checks to be done every 15 minutes. Out of 14 change of shift time periods where two staff were to verify the activity and identity of Pt#19 from 4/30/12 through 5/6/2012, there were no occasions where two staff completed the rounds together. CIM H verified the safety checks were not completed per policy.

Pt. #22 was admitted on 5/2/2012. Pt. #22 has a physician order for safety checks to be done every 15 minutes. Between 5/6/12 and 5/7/12 there were 4 change of shift time periods where two staff were to conduct rounds together. According to the safety log there were no joint rounds made. These findings were verified by CIM H during the MR review.

Pt. #25 was admitted on 5/4/2012. Pt. #25 has a physician order for safety checks to be done every 15 minutes. Between 5/4/12 and 5/7/12 there were 6 change of shift time periods where two staff were to conduct rounds together. According to the safety log there were no joint rounds made. These findings were verified by CIM H during the MR review.

Pt. #26 was admitted on 5/1/2012. Pt. #26 has a physician order for safety checks to be done every 15 minutes. Between 5/1/12 and MR review, there were 10 change of shift time periods where two staff were to conduct rounds together. According to the safety log there were no joint rounds made. These findings were verified by CIM H during the MR review.
Also on Pt. #26's safety rounds log there are 11 entries that are not initialed by a staff member and 5 that have an abbreviation for a activity or location not on the legend key.

Pt. #27 was admitted on 5/2/2012. Pt. #27 has a physician order for safety checks to be done every 15 minutes. Between 5/4/12 and 5/8/12 there were 8 change of shift time periods where two staff were to conduct rounds together. According to the safety log there were 4 times when joint rounds were not made. These findings were verified by CIM H during the MR review.

Pt. #28 was admitted on 5/2/2012 and discharged on 5/8/2012. Pt. #28 has a physician order for safety checks to be done every 15 minutes. Between 5/2/12 and 5/8/12 there were 10 change of shift time periods where two staff were to conduct rounds together. According to the safety log there were no joint rounds made. These findings were verified by CIM H during the MR review.

Pt. #29 was admitted on 5/2/2012. Pt. #29 has a physician order for safety checks to be done every 15 minutes. Between 5/2/12 and 5/7/12 there were 10 change of shift time periods where two staff were to conduct rounds together. According to the safety log there were no joint rounds made and on one occasion there is no indication that anyone did a change of shift check on 5/4/12. These findings were verified by CIM H during the MR review.

Findings by surveyor #20878

Pt. #9 was admitted on 02/20/2012. Pt. #9 has a physician order for safety checks to be done every 15 minutes. On 02/22/12, 02/23/12 and 02/24/12 at 7:00 AM there was a change of shift where two staff were to conduct rounds together. According to the safety log there was no joint round made and no indication that the armband and photograph were confirmed for identification. These findings were verified by QA director B during the MR review.

Pt. #10 was admitted on 02/29/2012. Pt. #10 has a physician order for safety checks to be done every 15 minutes. On 03/01/12 at 7:00 AM and 3:00 PM there was a change of shift where two staff were to conduct rounds together. According to the safety log there was no joint round made and no indication that the armband and photograph were confirmed for identification. These findings were verified by QA director B during the MR review.


05409

Patient Safety Rounds sheets reviewed by Surveyor #05409 between 8:52 a.m. on 5/8/12 through 1:12 p.m. on 5/9/12 revealed the following:

Medical record review of Pt. #14 with CIM (Clinical Informatics Manager H) beginning at 2:44 p.m. on 5/8/12 revealed that #14 was admitted on 5/7/12. Pt. #14 had a physician order for 15 minute checks. Change of shift checks were not verified by 2 staff as per policy for 3 of 4 shift changes.

Medical record review of Pt. #16 with CIM H beginning at 3:25 p.m. on 5/8/12 revealed that #16 was admitted on 5/4/12 and had an order for 15 minute checks. Change of shift checks were not verified by 2 staff as per policy for 4 of 7 shift changes.

Medical record review of Pt. #17 with CIM H beginning at 4:10 p.m. on 5/8/12 revealed that #17 was admitted on 5/2/12 and had 15 minute checks ordered. Change of shift checks were not verified by 2 staff for 8 of the 11 change of shift checks.

Medical record review of Pt. #18 with CIM H beginning at 11:45 a.m. on 5/8/12 revealed that #18 was admitted on 5/3/12 and 15 minute checks ordered. Change of shift checks were not verified by 2 staff as per policy for 6 of 7 change of shift checks. A progress note dated 5/6/12 at 7:42 p.m. states, "Patient states she hit her head on the bed, re-injured, ice provided, area looked shiny and increased in size." When Surveyor #05409 inquired further details about the event, CIM H had Manager Q investigate.
At 3:15 p.m. Manager Q produced a note that Q had written after consulting with Pt. (Patient) #18. The progress note was dated 5/8/12 at 3:00 p.m. and stated that pt. #18 told Q that on 5/6/12 #18 was sitting at group with arms crossed and put head down on arms leading to the bump on head landing on arm. Manager Q said that the documentation at 7:42 p.m. on 5/6/12 was incorrect.

Medical record review of Pt. #23 with CIM H beginning at 4:37 p.m. on 5/8/12 revealed that #23 was admitted on 5/3/12. Orders contained 15 minute checks on 5/8/12. The initial change of shift check at 7:00 a.m. was not verified by 2 staff as per policy.

Medical record review of PT. #30 beginning at 1:12 p.m. on 5/9/12 revealed that 15 minute checks from 4/1/12 through the morning of 4/28/12 were not verified by 2 staff as per policy for 81 of 82 change of shift checks.


18816

Examples by surveyor 18816 on progress notes:

Patient (Pt) #3's medical record (MR) review by surveyor 18816 on 5/8/12 at 9:45 AM revealed there is a progress note on 5/7/12 that is not timed. This is confirmed in interview with Clinical Education Specialist (CES) C on 5/8/12/ at 9:45 AM.

Pt #5's MR review by surveyor 18816 on 5/8/12 at 10:00 AM revealed there are progress notes written on 5/5/12 and 5/6/12 that are not timed. This is confirmed in interview with CES C on 5/8/12 at 10:00 AM.

Pt #6's MR review by surveyor 18816 on 5/8/12 at 11:00 AM revealed there are progress notes written on 4/14/12 that are not timed. This is confirmed in interview with CES C on 5/8/12 at 11:00 AM.

Pt #8's MR review by surveyor 18816 on 5/8/12 at 10:10 AM revealed there are progress notes written on 5/7/12 that are not timed. This is confirmed in interview with CES C on 5/8/12 at 10:10 AM.


Examples by surveyor 18816 on Medical Examinations (ME):

Pt #3's MR review by surveyor 18816 on 5/8/12 at 7:45 AM revealed Pt #1 was admitted on 5/5/12. The ME dated 5/6/12 is not timed when done to ensure it is written within 24 hours per staff by-laws. This is confirmed in interview with CES C on 5/8/12 at 7:45 AM.

Pt #4's MR review by surveyor 18816 on 5/8/12 at 8:15 AM revealed Pt #4 was admitted on 3/26/12. The ME dated 3/27/12 is not timed when done to ensure it is within 24 hours per staff by-laws. This is confirmed in interview with CES C on 5/8/12 at 8:15 AM.

Pt #5's MR review by surveyor 18816 on 5/8/12 at 8:30 AM revealed Pt #5 was admitted on 4/22/12. The ME dated 4/23/12 is not timed when done to ensure it is within 24 hours per staff by-laws. This is confirmed in interview with CES C on 5/8/12 at 8:30 AM.

Pt #6's MR review by surveyor 18816 on 5/8/12 at 11:00 AM revealed Pt #6 was admitted on 3/26/12. The ME dated 3/10/12 is not completed within 24 hours per staff by-laws. This is confirmed in interview with CES C on 5/8/12 at 11:00 AM.

Pt #7's MR review by surveyor 18816 on 5/8/12 at 10:10 AM revealed Pt #7 was admitted on 5/5/12. The ME dated 5/6/12 is not timed when done to ensure it is within 24 hours per staff by-laws. This is confirmed in interview with CES C on 5/8/12 at 10:10 AM.

Examples by surveyor #20878 on Medical Evaluation:

Pt. #10's record contained a medical evaluation transcribed on 03/01/2012 which was signed by the physician but was lacking a date or time associated with the signature. This was confirmed per interview with QA director on 05/08/12 at 2:00 PM.


Examples by surveyor 18816 on Psychiatric Evaluations (PE):

Pt #1's MR reviewed by surveyor 18816 on 5/7/12 at 3:00 PM revealed the PE does not include the Pt's intelligence, strengths or weaknesses. This is confirmed in interview with CES C on 5/7/12.

Pt #2's MR reviewed by surveyor 18816 on 5/7/12 at 3:55 PM revealed the PE does not include the Pt's weaknesses. This is confirmed in interview with CES C on 5/7/12 at 3:55 PM.

Pt #3's MR reviewed by surveyor 18816 on 5/7/12 at 7:45 AM revealed the PE does not include the Pt's weaknesses. This is confirmed in interview with CES C on 5/7/12 at 7:45 AM.

Pt #4's MR reviewed by surveyor 18816 on 5/7/12 at 8:15 AM revealed the PE does not include the Pt's weaknesses. This is confirmed in interview with CES C on 5/7/12 at 8:15 AM.

Pt #5's MR reviewed by surveyor 18816 on 5/7/12 at 8:30 AM revealed the PE does not include the Pt's weaknesses. This is confirmed in interview with CES C on 5/7/12 at 8:30 AM.

Pt #6's MR reviewed by surveyor 18816 on 5/7/12 at 11:00 AM revealed the PE does not include the Pt's weaknesses. This is confirmed in interview with CES C on 5/7/12 at 11:00 AM.

Pt #7's MR reviewed by surveyor 18816 on 5/7/12 at 1:45 PM revealed the PE does not include the Pt's weaknesses. This is confirmed in interview with CES C on 5/7/12 at 1:45 PM.

Examples by surveyor #20878 on Psychiatric Evaluations:

Pt. #10's record contained a psychiatric evaluation transcribed on 03/01/2012 which was signed by the physician but was lacking a date or time associated with the signature. This was confirmed per interview with QA director on 05/08/12 at 2:00 PM.

Based on 4 of 30 records reviewed (#1,3,6 and 8), staff interview and facility policy review, the hospital failed to ensure verbal orders were authenticated.

Findings include:

Examples by surveyor 18816:

Patient (Pt) #1's medical record (MR) review by surveyor 18816 on 5/8/12 at 10:30 AM revealed there are verbal orders (VO) written between 5/4/12 and 5/6/12 that are not authenticated by the Medical Doctor (MD) with a signature, date and time. This is confirmed in interview with Clinical Education Specialist (CES) C on 5/6/12 at 10:30 AM.

Pt #3's MR review by surveyor 18816 on 5/8/12 at 9:45 AM revealed there is a VO written with no date or time and not authenticated by the MD with a signature, date or time. This is confirmed in interview with CES C on 5/8/12 at 9:45 AM.

Pt #6's MR review by surveyor 18816 on 5/8/12 at 10:45 AM revealed there is a VO written on 5/2/12 that is not authenticated by the MD with a signature, date or time. This is confirmed in interview with CES C on 5/8/12 at 10:45 AM.

Pt #8's MR review by surveyor 18816 on 5/8/12 at 10:50 AM revealed there is a VO written between 5/5/12 and 5/6/12 that are not authenticated by the MD with a signature, date or time. This is confirmed in interview with CES C on 5/8/12 at 10:50 AM.

Based on tour, review of policy and procedures and interview with staff, in 1 of 1 interview (D) the facility failed to ensure food items are dated when open and/or prepared for use, and stored in a sanitary manner; in 1 of 1 interview (D), the facility failed to ensure kitchen dishes, glassware and pitchers are stored in a sanitary manner; and based on observation and interview with staff, in 1 of 1 interview (D) the facility failed to ensure the water is hot enough to sanitize dishes.

Findings include:

Per surveyor 18816 review on 5/7/12 at 3:00 PM of facility policy titled Food Purchasing, Receiving & Storage dated 8/24/09, states under Storage 1. "Food is covered, dated and labeled to protect the food...3. To avoid contamination of bulk, stored food, bulk containers are sealed, labeled and dated. Scoops are not stored in the bins. 4. Frozen items are maintained in 0 (degrees) to minus 20 (degrees)...7. All refrigerated food not stored in the product's original container or package in which it was originally obtained, is stored in a tightly covered, see thu [sic] container, labeled and dated. 8. All refrigerated food items are sealed, labeled and dated....Once the original case/package has been opened, Dining Services staff documents an 'open date'...10. All dry storage/canned food items are sealed, labeled and dated...Once the original case/package has been opened, Dining Services staff documents on 'opened date'."

Per tour of the facility kitchen with Dietary Manager (DM) on 5/7/12 between 11:35 AM and 12:45 PM, the following was observed by surveyor 18816:

Dry goods:

Bran flak bag is open with no date.
Mixed nuts were out of original packaging and not labeled and dated.
There were 4 cracker packages with expiration dates of 10/24/11.
A styrofoam bowl is in the sugar bin.

On food prep counter:

A container of brown granulated substance is not labeled or dated.
Two trays of cookies partially covered.

Freezer items:

A frozen yogurt cup had a broken rim allowing for potential contamination.
Veggie burgers had no received or opened date.
Blueberries had no received or opened date.

Refrigerated items:

Walk in refrigerator:

Dill dip container was opened 5/1. Per DM D during tour it should be discarded after 5 days.
Three bags of shredded cheese are not dated when opened.

Examples of storage of dishes:

Per surveyor 18816 review on 5/7/12 at 3:00 PM of facility policy titled Sanitation dated 12/13/07, it states under 4.n. "No personal items will be stored in unauthorized areas...7.f. All kitchen counter, tables, drawers and shelves will be maintained in a clean condition at all times."

Per surveyor 1886 observation of dishwashing on 5/7/12 at approximately 12:00 PM there is a jacket, garbage bags, a personal drinking cup and unopened personal hygiene item on a slotted shelf containing clean glasses, pitchers, with soup/cereal bowls on the shelf below. Dietary Manager (DM) D removed the items when told of their existence on 5/7/12 at 12:00 PM, and did not wash the shelf or have the potentially contaminated dishes washed. At 12:15 PM, baking pans were observed on the shelf where the jacket had been, along with the potentially contaminated dishes.

Examples of sanitizing dishes:

Per surveyor 18816 review on 5/7/12 at 3:00 PM of facility policy titled Sanitation dated 12/13/07, it states under 5.c. "The wash water should have a temperature of 150 (degree) F or above. The rinse water should be 180 (degree) F to 195 (degrees) F."

On 5/7/12 at 12:00 PM surveyor 18816 observed staff washing dishes, after three trays of dishes had passed through the automatic dishwasher, this surveyor noted the gauge for the rinse water was not hotter than 150 degrees. Per interview with Dietary Manager D, on 5/7/12 at 12:00 PM the water should the 180 or above for the sanitizing cycle.

Based on observation, staff interviews and review of maintenance documents, during a tour of the facility on 5/7/12, 5/10/12 and 5/11/12 the facility did not construct and maintain the building systems to the 2000 edition of the Life Safety Code of the National Fire Protection Association (NFPA). Refer to the full description of the deficient practices at the cited K-tags under the appropriate building.

Findings include:

The Rogers Memorial Hospital survey consisted of (7) Buildings:

Building #1 is the original structure in 1906 with 5 additions in 1911-12, 1920, 1921, 1939 & 1958 located in Oconomowoc, WI had seven (7) deficiencies: K-11 Separation Walls, K-12 Building Construction, K-22 Exit Access, K-33 Exit Components, K-51 Fire Alarm Installation, K-62 Sprinkler Inspections, and K-130 Miscellaneous.
Building #2 is a 2-story structure originally built in 1988 and Occupied as New Construction in 2000, with a 2-story addition in 2009-2010 located in West Allis, WI had two (2) deficiencies: K-62 Sprinkler Inspections, and K-130 Miscellaneous.
Building #3 is a 3-story structure built in 2005 and occupied in 2006 located in Oconomowoc, WI had four (4) deficiencies: K-22 Exit Access, K-62 Sprinkler Inspections, K-130 Miscellaneous, and K-147 Electrical.
Building #6 is a Storage Occupancy (S-1) located in the Lower Level of the Experimental Therapy (ET) Building and separated by 2-hour construction from the rest of the IP & ET Building located in Oconomowoc, WI had no K-tag deficiencies.
Building #7 is the Gymnasium (A-1) located on the 1st Floor of the Experimental Therapy (ET) Building and separated by 2-hour construction from the rest of the IP & ET Building located in Oconomowoc, WI had no K-tag deficiencies.
Building #8 is a 3-story structure and Tunnel / Link built from 2010-2012 and Occupied in 4 Phases. December 2011 (Lower Level of ET), March 7, 2012 (1st Floor ET), April 18, 2012 (Tunnel / Link), May 8, 2012 (Inpatient Sleeping), located in Oconomowoc, WI had five (5) deficiencies: K-18 Corridor Doors, K-25 Smoke Barriers, K-29 Hazardous Areas, K-38 Egress, and K-130 Miscellaneous.
Building "MA" is a 4 story clinic structure built in 1989 with a Type II (000) class of unprotected steel frame construction, located in Madison, WI had one (1) deficiency: K-130 Miscellaneous

This includes deficiencies cited in: A-701 Maintenance, A-709 Life Safety from Fire and A-722 Facilities.

The cumulative effect of these environment deficiencies resulted in the hospitals inability to ensure a safe environment for all patients, staff, and visitors.

Based on observation during a meal delivery with staff, in 1 of 1 observation, the facility failed to ensure integrity of floors to prevent potential injury from falls which has the potential to affect all patients, visitors and staff. The facility also failed to have doors free of damage which occured in 1 of 10 smoke compartments, and had the potential to affect 20 of the 78 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:

During a meal tray delivery on 5/7/12 at 11:50 AM with Dietary Manager D, the hallway called "the tunnel" had carpet tiles with edges and corners up allowing for potential misstep and fall.


05409

Findings by Surveyor #18107:

On 05/07/2012 at 2:07 pm surveyor #18107 observed in Building #2, the I.P. Adult & Geriatric Unit - SC-4 smoke compartment on the 2nd floor in the Exam Room #2622, that a portion of the door was damaged and in need of repair. The door was delaminating near the edges of the door and the delamination would effect the fire-rating of the door to the corridor. This door damage renders this door surface porous and non-cleanable for a hospital environment. This observed situation was not compliant with 42 CFR 482.41(a). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Environmental Srvcs Mgr.) and staff C (Senior Director of Finance).

On 05/07/2012 at 2:10 pm surveyor #18107 observed in Building #2, the I.P. Adult & Geriatric Unit - SC-4 smoke compartment on the 2nd floor in the Patient Room #2608, that a portion of the door was damaged and in need of repair. The door was delaminating near the edges of the door and the delamination would effect the fire-rating of the door to the corridor. This damage renders this door surface porous and non-cleanable in a hospital environment. This observed situation was not compliant with 42 CFR 482.41(a). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Environmental Srvcs Mgr.) and staff C (Senior Director of Finance).




18107

Based on observation, staff interviews and review of maintenance documents, during a tour of the facility on 5/7/12, 5/10/12 and 5/11/12 the facility did not construct and maintain the building systems to the 2000 edition of the Life Safety Code of the National Fire Protection Association (NFPA). Refer to the full description of the deficient practices at the cited K-tags under the appropriate building.

Findings include:

The Rogers Memorial Hospital survey consisted of (7) Buildings:

Building #1 is the original structure in 1906 with 5 additions in 1911-12, 1920, 1921, 1939 & 1958 located in Oconomowoc, WI had seven (7) deficiencies: K-11 Separation Walls, K-12 Building Construction, K-22 Exit Access, K-33 Exit Components, K-51 Fire Alarm Installation, K-62 Sprinkler Inspections, and K-130 Miscellaneous.
Building #2 is a 2-story structure originally built in 1988 and Occupied as New Construction in 2000, with a 2-story addition in 2009-2010 located in West Allis, WI had two (2) deficiencies: K-62 Sprinkler Inspections, and K-130 Miscellaneous.
Building #3 is a 3-story structure built in 2005 and occupied in 2006 located in Oconomowoc, WI had four (4) deficiencies: K-22 Exit Access, K-62 Sprinkler Inspections, K-130 Miscellaneous, and K-147 Electrical.
Building #6 is a Storage Occupancy (S-1) located in the Lower Level of the Experimental Therapy (ET) Building and separated by 2-hour construction from the rest of the IP & ET Building located in Oconomowoc, WI had no K-tag deficiencies.
Building #7 is the Gymnasium (A-1) located on the 1st Floor of the Experimental Therapy (ET) Building and separated by 2-hour construction from the rest of the IP & ET Building located in Oconomowoc, WI had no K-tag deficiencies.
Building #8 is a 3-story structure and Tunnel / Link built from 2010-2012 and Occupied in 4 Phases. December 2011 (Lower Level of ET), March 7, 2012 (1st Floor ET), April 18, 2012 (Tunnel / Link), May 8, 2012 (Inpatient Sleeping), located in Oconomowoc, WI had five (5) deficiencies: K-18 Corridor Doors, K-25 Smoke Barriers, K-29 Hazardous Areas, K-38 Egress, and K-130 Miscellaneous.
Building "MA" is a 4 story clinic structure built in 1989 with a Type II (000) class of unprotected steel frame construction, located in Madison, WI had one (1) deficiency: K-130 Miscellaneous

The cumulative effect of these environment deficiencies resulted in the hospitals inability to ensure a safe environment for all patients, staff, and visitors.

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 and State Regulations. The facility did not have a building that complied with State regulations that were in effect when the space was built. This deficiency occurred in 1 of the 9 smoke compartments, and had the potential to affect any maintenance or workman that had to provide maintenance to the Air Handling Unit located on the Roof or any maintenance to the exterior and roof of the Experimental Therapy building.

FINDINGS INCLUDE:
On 05/10/2012 at 10:08 am surveyor #18107 observed and during a review of facility documents (building plans) the facility failed to install a system that was designed and maintained in accordance with federal and state requirements that were in effect at the time of construction. A roof access hatch to the HVAC equipment located on the Experimental Therapy Roof exposed maintenance and other workmen since they were within a distance of 3'-0" to toilet and other product-conveying outlets, which does not meeting the 2009 edition of the International Mechanical Code section 501.2.1(2) and section 501.2.1.1 Exhaust discharge. This observed situation was not compliant with 42 CFR 482.41(c). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (CFO), staff B (Senior Director of Finance) and staff C (Environmental Srvcs Mgr).


18816

Based on tour of the facility and interview with staff, in 1 of 1 tour the facility failed to ensure there is a call light in all bathrooms.

Findings include:

Per surveyor 18816 tour of the seclusion room near the Adult Unit on 5/7/12 between 1:00 PM and 2:00 PM, the bathroom does not have a call light to obtain help in an emergency. This was confirmed in interview with Clinical Education Specialist C on 5/7/12 between 1:00 PM and 2:00 PM.

During the environmental tour of the West Allis location from 7:35 a.m. to 8:45 a.m. on 5/8/12 accompanied by Infection Control Coordinator N, Surveyor #05409 observed the following:

On the 2nd floor in the exam room by Day room 2621, the bathroom in the exam room lacks a call light and can be locked from the inside. This poses a potential for safety as patients could not alert staff for help and could potentially harm themselves behind the locked door. This was verified by Infection Control Coordinator N.

Based on observation, interview with 5 of 5 staff and review of facility policies, the hospital failed to control potential spread of infection. This has the potential to affect all patients in the hospital.

Findings include:

Examples by surveyor 18816:

Per surveyor 18816 review on 5/7/12 at 3:00 PM of facility policy titled Hand-washing dated 12/13/04 for Dining Service staff it states under 1.f. "Turn off the wash faucet using a paper towel, to prevent recontamination."

On 5/7/12 between 11:35 AM and 11:50 AM kitchen staff was observed washing hands three times using her bare hands to turn off the faucet rather than a paper towel per facility policy.

On 5/8/12 between 9:05 AM and 9:45 AM the following was observed by surveyor 18816 during a medication pass:

Registered Nurse (RN) E was observed completing giving medications to a patient, left the consultation room, obtained water, asked the next patient into the consultation room and administered medications without the benefit of washing between patients. RN E called in the next patient to the consultation room and administered medications without the benefit of washing between patients. RN E went to the nursing station, obtained hand cleansing gel, asked the next patient into the consult room. RN E washed, administered medications, handled a nicotine patch removed from the patient, and handled new nicotine patch to the patient. RN E place the old path in the now empty foil packet, left to dispose of the patch in the medication room, and without the benefit of washing. RN E administered medications to three more patients, in their rooms, without washing prior to entering or upon leaving the rooms.

Examples by surveyor 18816 from environment tour:

Per surveyor 18816 tour of the Adult Unit on 5/7/12 at 1:00 PM, there is an open sterile water bottle in the Medical Examination room; cold packs under the sink in the Medication Room; and the wall has paint torn off from the wall next to the seclusion bathroom. These were confirmed in interview with Clinical Education Specialist (CES) C on 5/7/12 at 1:00 PM.

Per surveyor 18816 tour of the Eating Disorder Unit on 5/7/12 at approximately 1: 45 PM, there were cold packs under the sink in the Medication Room. This was confirmed in interview with CES C on 5/7/12 at 1:45 PM.

On 5/8/12 between 9:05 AM and 9:45 AM Registered Nurse (RN) E was observed taking a laptop into three patient rooms, to administer medications, setting the laptop down on the bedside table and/or window sill and did not clean the laptop prior to leaving the patient rooms.

Per surveyor 18816 tour of the Child Adolescent Unit on 5/8/12 at 11:15 AM there were two bags of soiled linen in the clean linen room. This was confirmed with CES C on 5/8/12 at 11:15 AM.

Per surveyor 18816 tour of the off site Day Treatment facility located at 406 Science Dr, Madison, WI, on 5/9/12 between 9:00 AM and 9:20 AM with Clinical Education Specialist (CES) C, and Director G, the following was observed:

There were boxes of supplies directly on the floor in the storage room off the lobby.

The glucometer is not designated for use for multiple patients and has no control solutions to do daily control checks. Per interview with Registered Nurse F on 5/9/12 at 9:10 AM, there are no control solutions or check sheet for the glucometer.


26711

Findings by Surveyor #26711:

A tour of the Milwaukee facility's Environmental Services areas was conducted on 5/8/2012 from 7:50 a.m. until 8:15 a.m. accompanied by Manager (Mgr) M. During this tour the janitor closest's on first and second floor were included.

Room 1058, a carpeted clean supply closet, had a build up of dust and debris under the metal shelving unit. Whole sheets of white paper were also on the floor under the cabinet.

Room 1093, janitor supply closet, contained clean supplies in the same area as the hopper used to discard used and dirty water from the mop bucket, and also vacuum cleaners that can harbor dust mites and bacteria. Also noted was a build up of dust and dirt in the ceiling vent.

Room 2630, janitor supply closet, contained clean supplies in the same area as the hopper used to discard used and dirty water.

Mgr M confirmed findings at the time of discovery on 5/8/2012.


Findings by Surveyor #18107:

Surveyor #18107 toured the Milwaukee location on 5/7/2012 from 10:30 a.m. until 5:30 p.m. with Mgr M. The following findings are from this tour and were confirmed by Mgr M at that time :
Exam room 26 and 22 - doors are de-laminating
Patient room 2608 - door is de-laminating
Consult/office 1032 - damaged ceiling tiles; water damage and mold growing
Exam room 1037 - no hand-washing lavatory nor hand gel
Experiential Therapy-Art studio - stained ceiling tiles








05409

RN P was observed giving medication to patient #31 as follows:
At 12:10 p.m. on 5/9/12 Surveyor #05409 observed RN P talking on the phone, holding handset, manipulating a chart at the nursing desk then go into the medication room and reached into pocket of pants and remove keys to open medication drawer on the adolescent unit at the Oconomowoc location without cleansing hands. At 12:11 p.m. RN proceeded to remove 2 packages of pills, and opened the pills into Pt. #31's hand without washing hands or applying hand gel.

Based on 4 of 30 medical records reviewed (#4,5,6 and 8) and staff interview the hospital failed to assure discharge planning was documented.

Findings include:

Examples by surveyor 18816:

Patient (Pt) #4's medical record (MR) review by surveyor 18816 on 5/8/12 at 8:15 AM revealed there is no documented discharge planning since admission on 3/26/12. This is confirmed in interview with Clinical Education Specialist (CES) C on 5/8/12 at 8:15 AM.

Pt #5's MR review by surveyor 18816 on 5/8/12 at 8:30 AM revealed there is no documented discharge planning since admission on 4/23/12. This is confirmed in interview with CES C on 5/8/12 at 8:30 AM.

Pt #6's MR review by surveyor 18816 on 5/8/12 at 11:00 AM revealed there is no documented discharge planning since admission on 2/26/12. This is confirmed in interview with CES C on 5/8/12 at 11:00 AM.

Pt #8's MR review by surveyor 18816 on 5/8/12 at 10:10 AM revealed there is no documented discharge planning since admission on 5/5/12. This is confirmed in interview with CES on 5/8/12 at 10:10 AM.

Based on record review and staff interviews, the facility failed to assure that Psychosocial Assessments for 15 of 16 active sample patients (A1, A2, A3, A4, A6, A7, A8, B1, B2, B3, B4, B5, B6, B7and B8) contained conclusions and recommendations that described the anticipated social work roles in treatment and discharge planning. This failure results in a lack of input to the treatment team about the endeavors of the social work staff.

Findings include:

A. Record Review

All of the Psychosocial Assessments (A1 dated 5/04/2012; A2 dated 5/04/2012; A3 dated 5/05/2012; A4 dated 5/02/2012; A6 dated 5/07/2012; A7 dated 4/19/2012; A8 dated 5/05/2012; B1 dated 5/01/2012; B2 dated 4/10/2012; B3 dated 5/02/2012; B4 dated 5/01/2012; B5 dated 5/04/2012; B6 dated 5/03/2012; B7 dated 5/02/2012 and B8 dated 4/29/2012) lacked a description of the social worker's role in treatment and discharge planning.

B. Staff Interview

On 5/09/2012 at 9:05AM, the Director of the Social Work Department was shown the Psychosocial Assessments of Patients B1, B2, B3 and B4 as examples of the deficiency noted in all the Psychosocial Assessments. The Director agreed that the Psychosocial Assessments lacked any description of what the efforts of the social work staff would be in treatment or discharge planning.

Based on record review and interview, the facility failed to insure that the Master Treatment Plans (MTPs) for 16 of 16 active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, B1, B2, B3, B4, B5, B6, B7, and B8) included substantiated diagnoses. Absence of substantiated diagnoses on patients' Master Treatment Plans compromises the ability of the treatment team to identify specific psychiatric and physical problems and plan effective treatment during the current hospitalization.

Findings include:

A. Record Review (MTP dates in parentheses)

None of the following16 active sample patients' treatment plans included substantiated diagnoses (plan dates in parentheses): A1 (5/3/2012), A2 (5/2/2012), A3 (5/4/2012), A4 (5/1/2012), A5 (5/3/2012), A6 (5/6/2012), A7 (4/18/2012), A8 ( 5/4/2012), B1 (4/30/2012), B2 (4/9/2012), B3 (4/30/2012), B4 (4/30/2012), B5 (5/3/2012), B6 (5/3/2012), B7 (4/30/2012), and B8 (4/27/2012).

B. Interview

On 5/9/12 at 11:30AM, the Clinical Information Manager acknowledged that diagnoses are not included in patients' treatment plans.

Based on record review and interview, the facility failed to develop Master Treatment Plans (MTPs) that included individualized specific interventions for 16 of 16 active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, B1, B2, B3, B4, B5, B6, B7 and B8). The listed interventions were generic tasks which lacked a specific focus. This deficient practice results in treatment plans that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment.

Findings include:


A. Record Review (MTP dates in parenthesis)


1. Patient A1


The MTP (5/3/12) listed the following generic and routine function for the problem "Health maintenance related to management of psychiatric condition": "Treatment team will monitor quality of sleep."

2. Patient A2
The MTP (5/2/12) listed the following generic and routine function for the problem "At risk for suicide": "Treatment team will assist (Patient) in identifying positive coping mechanisms."

3. Patient A3

The MTP (5/4/12) listed the following generic and routine function for the problem "At risk for self-harm-verbal, physical expression, thoughts, intent, or plan for self-harm": "Treatment team will provide assignments."

4. Patient A4

The MTP (5/1/12) listed the following generic and routine function for the problem "At risk for suicide": "Treatment team will conduct safety rounds as indicated by physician order."

5. Patient A5

The MTP (5/3/12) listed the following generic and routine function for the problem "Depressed mood characterized by significant loss, severe or prolonged stress, unresolved conflict, chronic fear/anxiety or ager that leads to inability or decreased performance of ADL's": "Treatment team will provide assignments."

6. Patient A6

The MTP (5/6/12) listed the following generic and routine function for the problem "Depressed mood characterized by significant loss, severe or prolonged stress, unresolved conflict, chronic fear/anxiety or ager that leads to inability or decreased performance of ADL's": "Treatment team will provide assignments."

7. Patient A7

The MTP (4/18/12) listed the following generic and routine function for the problem "At risk for suicide": "Treatment team will assess (Patient) for safety."

8. Patient A8

The MTP (5/4/12) listed the following generic and routine function for the problem "Body image disturbance--a distorted perception of body that elicits feelings of negative self-worth": "Treatment team will administer and monitor effectiveness of prescribed sleep meds."

9. Patient B1

The MTP (4/30/12) listed the following generic and routine function for the problem "At risk for self-harm behavior - verbal, physical expression, thoughts, intent or plan for self-harm": "Treatment team will provide a safe and secure place for (Patient) to process feelings away from the group milieu."

10. Patient B2

The MTP (4/9/12) listed the following generic and routine function for the problem "Altered behaviors related to eating disorder thought patterns as evidenced by binge eating, purging, restricting or misuse of medications/supplements for the purpose of controlling their weight and intake": "Treatment team will review assignments."

11. Patient B3

The MTP (4/30/12) listed the following generic and routine function for the problem "Altered thought process- impaired contact with reality as evidence by disorientation, altered behavior patterns, altered mood states, impaired ability to perform self-maintenance activities, altered sleep pattern, altered perceptions": "Treatment team will minimize situations that provoke anxiety."

12. Patient B4

The MTP (4/30/12) listed the following generic and routine function for the problem "Depressed mood characterized by significant loss, severe or prolonged stress, unresolved conflict, chronic fear/anxiety or ager that leads to inability or decreased performance of ADL's": "Treatment team will acknowledge and reinforce positive statements made by (Patient)."

13. Patient B5

The MTP (5/3/12) listed the following generic and routine function for the problem "Poor impulse control - inability to self-restrain compulsive or impulsive behaviors": "Treatment team will provide positive feedback to (Patient) for on task behavior."

14. Patient B6

The MTP (5/3/12) listed the following generic and routine function for the problem "Health maintenance related to management of psychiatric condition": "Treatment team will encourage (Patient) to use self-identified interventions."

15. Patient B7

The MTP (4/30/12) listed the following generic and routine function for the problem "At risk for suicide": "Treatment team will conduct safety rounds as indicated per physician order."

16. Patient B8

The MTP (4/27/12) listed the following generic and routine function for the problem "School functioning - risk for interrupted school functioning": "Treatment team will encourage and support (Patient) to enhance class attendance."

B. Staff Interviews

1. In an interview on 5/9/12 at 10:05AM, when asked if the listed interventions on the MTPs were specific, Social Worker 1 replied "no."

2. In an interview on 5/9/12 at 4:40PM, when asked about the quality of treatment plans, the Vice President of Nursing stated, "Every survey we get talked to about treatment plans."

Based on record review and interview, the facility failed to ensure that the name and discipline of staff persons responsible for specific aspects of care were listed on the Master Treatment Plans of 16 of 16 active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, B1, B2, B3, B4, B5, B6, B7 and B8 ). This practice results in the facility's inability to monitor staff accountability for specific treatment modalities.

A. Record Review (MTP dates in parenthesis)

1. Patient A1 (5/3/2012)

The MTP included no staff names or disciplines for the listed intervention: "Treatment team will monitor quality of sleep,"

2. Patient A2 (5/2/2012)

The MTP included no staff names or disciplines for the listed intervention: "Treatment team will assist (Patient) in identifying positive coping mechanisms."

3. Patient A3 (5/4/2012)

The MTP included no staff names or disciplines for the listed intervention: "Treatment team will provide assignments."

4. Patient A4 (5/1/2012)

The MTP included no staff names or disciplines for the listed intervention: "Treatment team will conduct safety rounds as indicated by physician order."

5. Patient A5

The MTP included no staff names or disciplines for the listed intervention: "Treatment team will provide assignments."

6. Patient A6

The MTP included no staff names or disciplines for the listed intervention: "Treatment team will provide assignments."

7. Patient A7

The MTP included no staff names or disciplines for the listed intervention: "Treatment team will assess (Patient) for safety."

8. Patient A8

The MTP included no staff names or disciplines for the listed intervention: "Treatment team will administer and monitor effectiveness of prescribed sleep meds."

9. Patient B1

The MTP included no staff names or disciplines for the listed intervention: "Treatment team will provide a safe and secure place for (Patient) to process feelings away from the group milieu."

10. Patient B2

The MTP included no staff names or disciplines for the listed intervention: "Treatment team will review assignments."

11. Patient B3

The MTP included no staff names or disciplines for the listed intervention: "Treatment team will minimize situations that provoke anxiety."

12. Patient B4

The MTP included no staff names or disciplines for the listed intervention: "Treatment team will acknowledge and reinforce positive statements made by (Patient)."

13. Patient B5

The MTP included no staff names or disciplines for the listed intervention: "Treatment team will provide positive feedback to (Patient) for on task behavior."

14. Patient B6

The MTP included no staff names or disciplines for the listed intervention: "Treatment team will encourage (Patient) to use self-identified interventions."

15. Patient B7

The MTP included no staff names or disciplines for the listed intervention: "Treatment team will conduct safety rounds as indicated per physician order."

16. Patient B8

The MTP included no staff names or disciplines for the listed intervention: "Treatment team will encourage and support (Patient) to enhance class attendance."

B. Staff Interview

1. In an interview on 5/9/12 at 10:05a.m., when asked which specific member of the treatment team was responsible for documenting on interventions that have the "treatment team" identified as being responsible, Social Worker 1 stated, "I don't know."

2. In an interview on 5/9/12 at 4:40p.m., when asked about the quality of treatment plans, the Vice President of Nursing stated, "Every survey we get talked to about treatment plans."

Based on record review, staff interview and hospital policy review, the Medical Director and the Director of Nursing failed to assure that hospital staff was able to manage aggressive patient behaviors without recourse to law-enforcement aid for treatment issues and milieu management. Specifically the facility failed to de-escalate and control aggressive behavior for 3 of 4 discharged child and adolescent patients whose uncontrolled behavior required police intervention (C1, C2 and C3), and 1 of 1active adult patients whose aggressive behavior resulted in police being called prior to de-escalation (C4). In addition, during a sample period in April 2012, staff were unable to deescalate 2 of 5 discharged child and adolescent patients (C5 and C6) in spite of the patients' prolonged episodes of inappropriate behavior, which resulted in seclusion and/or restraint. Interviews revealed staff were not adequately trained to deescalate these patients. These failures result in the potential for injury to both patients and staff. (Refer to B139).

Based on document review and interviews, the facility failed to ensure adequate numbers of qualified professional and supportive staff to provide active treatment. Specifically the facility failed to de-escalate and control aggressive behavior for 3 of 4 discharged child and adolescent patients whose uncontrolled behavior required police intervention (C1, C2 and C3), 1 of 1 active adult patients whose aggressive behavior resulted in police being called prior to de-escalation (C4), and 2 of 5 discharged child and adolescent patients whose aggressive behavior resulted in seclusion and/or restraint during April 2012 (C5 and C6). Staff were not adequately trained to de-escalate and control aggressive behavior. Failure to de-escalate/control aggressive patient behavior can disrupt the milieu and can result in patient injury.

Findings include:

A. Specific patient findings

1. Patient C1 was a young adolescent admitted on 6/07/2011. Review of the Patient/Visitor Incident Reporting Form dated 6/18/2011 revealed documentation that Patient C1 became aggressive at 9a.m. The Patient Care Notes (RN), dated 6/18/2012 at 6:14p.m. and attached to the incident report, documented that Patient C1 became "severely aggerssive [sic] both physcailly [sic] and verbally." According to the incident report, the patient was cursing and "feeding off of and provoking neagtive [sic] behaviors of other peers." Patient C1's behavior was also described as "running up and down the hallways, singing sexually explict [sic] songs." The report said that the patient's behavior escalated to jumping over the nurses' desk, going into the nurses' station and trying to enter the medication room. The patient and a peer "grabbed the gurney at the beginging [sic] of the hall and began racing it down the hall" yelling obscenities. The patient "punched a female staff memeber [sic] in the chest" and the police were called. The police placed the patient in hand cuffs and transported to "the juvienle [sic] dentation center." The incident report further stated that the patient's "belongings were sent with patient along with medications."


2. Patient C2 was an adolescent admitted on 6/13/2011. Review of the Patient/Visitor Incident Reporting Form dated 6/18/2011 revealed documentation that Patient C2 became aggressive at 9a.m. The Patient Care Notes (RN) dated 6/18/2011 at 3:57p.m. and 4:20p.m., which were attached to the incident report, summarized the incident. According to the notes, Patient C2 was "hyperverbal...pacing the dayroom and hallways, jumping on furtinure [sic] and having very poor boundires [sic]." The patient was reported as "antognizing [sic] staff, touching thier [sic] arm and yelling 'poor boundires' [sic]." Patient C2's behavior continued to escalate with verbal threats and cursing. The patient was described as "unable to attend any programming because of the manic behaviors," and was told by the staff "to go to (patient's) room and calm down so (patient) could join the rest of the peers." The patient refused to go to (patient's) room, and with peers was "running in the hallway throw [sic] toy balls all over....grabbing clip boards and even walked into the nurses [sic] station in an attempt to raid the medication room." The police were called after the patient jumped on a gurney and attempted to run into staff. The patient was handcuffed and taken to "the juvienle [sic] center."

3. Patient C3 was an adolescent admitted on 3/21/2012. Review of the Patient/Visitor Incident Reporting Form dated 3/27/2012 revealed documentation that Patient C3 became aggressive at 8:40a.m. The Patient Care Notes (RN) dated 3/27/2012 at 10:05p.m., which were attached to the incident report, summarized the incident. According to the notes, Patient C3 became aggressive while making a phone call at the nurses' desk and "...put feet on desk, tilted chair back. Patient took cup of water and threw it across desk." The patient then ended the call and "...came behind the nurses [sic] desk, charging staff." Staff attempted to de-escalate by offering a bottle of water which had "...worked as a distraction in previous times" and patient was also offered, "resting in bed and night time meds." Patient C3's behavior continued to escalate as evidenced by throwing the tape dispenser across the room and "picked up computer monitor and slammed it on nurses [sic] desk. Patient then picked up printer and attempted to slide it off nurses [sic] desk." Patient C3's aggressive behavior continued and was recorded as "Patient punched and kicked staff numerous times while smiling." The patient then "...laid [sic] on back and began pulling electric wires from computer monitor and attempted to put them around (his/her) neck." When asked by staff what they could do to help, Patient C3 responded "I like this. This is fun." The patient was escorted to the "comfort room" (unlocked seclusion). When offered a ball that was used as a "theraputic [sic] tool " in the comfort room, Patient C3 "...took ball and threw it at staff in an aggressive way." The patient then "...took sandal off foot and threw it at staff." The patient continued to "punch and kick and charge staff" and at that point "locked seclusion was attempted but could not safely be initiated." This behavior continued for "...approximately 15 minutes" when the police were called. When the police arrived, Patient C3 was "discharged to police."

4. Patient C4 was a middle aged person admitted on 5/07/2012. The Patient/Visitor Incident Reporting Form dated 5/07/2012 revealed documentation that Patient C4 became aggressive at 2:30p.m. The Patient Care Notes (RN) dated 5/07/2012 at 4p.m., which were attached to the incident report, summarized the incident. The notes state that upon admission to the Adult Unit, Patient C4 "...immediately became angry, loudly yelling ...(RN and MD) attempted to de-escalate (Pt). (Pt) cont (continued) to be angry...(Pt) began to leap and forcefully kick locked unit door numerous times, (Pt) forcefully punched several doors." The notes stated that support staff was called to the unit and the police were called. At that point, the patient "...agreed to go into day room with (MD)" and "...was agreeable to taking meds." Because of apparent injury to hand, "X-ray ordered for (Pt's) r (right) hand that immediately had swelled/bruised after (Pt) hit doors."

5. Patient C5 was an adolescent admitted on 4/17/12. The patient was secluded from 2:30p.m. to 3p.m. on 4/27/12. The RN progress note from the medical record on 4/17/12 at 3:51p.m. documented the following: "Patient has demonstrated physical/verbal aggression towards staff and peers throughout the shift. This morning patient went after a little kid from the child unit after the child flipped [him/her] the bird. Patient spent time 1:1 [sic] with unit manager in her office after this first incident and was given a one time dose of Seroquel 25mg at 1100 [11:00am]. During ET [experiential therapy] group this afternoon (1330) [1:30p.m.], patient became verbally and physically aggressive towards an adolescent [peer] in the art room. (Patient) accused this peer of changing the radio station and said something to (peer) which resulted in (peer) using some foul language against [him/her]. [Patient] stood on the top of the tables hovering over the peer, threatening to fight [peer]. At some point during this, [patient] managed to throw a pair of scissors at the peer. Per ET staff, the scissors missed the peer and hit the wall. Patient remained on top of the table refusing to come down with several attempts from staff. [Patient] paced back and forth on the table and threw markers (twice) outside into the hallway, attempting to hit peer even though he wasn't no longer out in the hall. [Patient] eventually came down from the tables after some staff was asked to leave, as it appeared patient was thriving off the attention from staff during the code green [signal that extra staff help was needed for disruptive patient. Patient was given [his/her] scheduled Seroquel 50mg a little early (approximately 1335) [1:25p.m.] due to [his/her] escalating behaviors. Shortly after ET group, patient disclosed in Social Services group that [s/he] 'felt like killing someone.' Patient attacked [his/her] third peer during this group. [Patient] was unprovoked and punched a disabled...adolescent peer in [his/her] face three times and knocked [him/her] out of [his/her] wheelchair. [Patient] was placed in the open quiet room to maintain the safety of others. Staff remained with [her/him], [s/he] didn't express any remorse and was laughing. Given Zyprexa Zydis [sublingual] 10mg one time at 1417 [2:17p.m.]. Patient came out the open quiet room and attempted to trash the nurses station. [S/he] threw cups, paper and plastic spoons from snack [sic] onto the floor. Patient was locked [in the seclusion room] from 1430 to 1500.[2:30p.m.-3p.m.] "

The patient was subsequently "transferred to Milwaukee County Mental Health Complex for a higher level of care."

6. Patient C6 was a young child admitted on 3/27/12. According to Seclusion/Restraint reports in the medical record, the patient was restrained on 4/02/12 with a manual hold at 9:30a.m., again at 9:50a.m. and then was secluded at 10a.m. The RN progress note in the medical record on 4/02/12 at 3:45p.m. documented the following: "...Patient agitated when directed to join peers, staff for morning goals group. Eloped from unit at 0925 [9:25a.m.] as outside maintenance personnel were doing work on magnetic entry door to unit. Patient went to cafeteria. In cafeteria, patient agitated, tipping chair, aggressive towards staff present. Patient kicking, hitting, attempting to bite, spitting on staff present. Staff placed patient in children's control position at 0930 [9:30a.m.] to assist patient in calming, maintain safety of staff present and reduce risk of injury related to property destruction. Patient remained agitated despite staff efforts to identify acceptable resolution. Staff offered patient 1:1 [1 staff, 1 patient], quiet time in alternate location, telephone call to grandmother or father, snack or beverage of choice. Patient initially declined options, then requested 'strawberry water.' Patient calmed at 0945 [9:45a.m.], agreed to walk to unit with staff. Upon exiting cafeteria, patient refused to move from hallway. As uninvolved staff exited cafeteria, patient ran back into cafeteria where [s/he] resumed destructive and aggressive behaviors. At 0950 [9:50a.m.], staff elected to place patient in escort [manual hold] position for return to unit. Upon return to unit, patient engaged in behaviors including throwing books from shelf, attempts to hit and kick staff. Alternatives again offered, including call to family active play, time outdoors on patio, play money. Staff reinforced behavioral expectations, verbalized limits to aggressive and destructive behaviors. Patient behaviors escalated, ...patient resumed physically aggressive behaviors kicking, hitting, scratching staff, attempting to bite, and spitting, Writer initiated locked seclusion at 1000 [10a.m.] for safety of patient and staff as less restrictive efforts failed. Patient sat on seclusion room floor, made verbal threats to choke self with hands...Patient agreed to refrain from aggressive behaviors within 10 minutes, seclusion room door opened at 1010 [10a.m.]..."

B. Interviews

1. In interview on 5/8/2012 at 1p.m., the Vice President for Nursing stated that Police are called to the unit "to assist with a patient staff cannot manage."

2. In a confidential interview on 5/09/2012 at 2:45p.m., a staff member stated that once the police arrive on the unit they (the police) "make the decision about whether to put (patient) in seclusion or if they will arrest them."

3. During the State surveyor exit conference on 5/09/12 at 3:15p.m., the Team Leader stated that in the management of aggressive behavior classes "there was not a lot of 'hands on' training."

4. In a discussion of seclusion and restraint on 5/09/12 at 3:45pm, the Director of Nursing stated "Our training has been to do blanket holds and manual holds." The Quality Improvement Director added that all staff had just received CPI [management of aggressive behavior] training; and they were just adjusting to the new approach of dealing with patients out of control.

5. In interview on 5/09/2012 at 4:30p.m., RN3 stated that police were called to the Child and Adolescent Unit approximately 6-10 times a year. RN3 explained that the police were "sometimes there to help de-escalate (a patient) and sometimes to take a patient off the unit." RN3 further stated that even though the police worked with the staff, "they (police) were in control."

6. In an interview on 5/10/2012 at 10:15a.m., the Vice President for Nursing verified that even though police did not have to intervene in the control of Patient C4's aggressive behavior on 5/07/2012, four police officers did respond and entered the patient care unit.

C. Policy

Review of the "CODE GREEN- Assault without Weapon" policy dated 12/31/06 revealed guidelines for calling the police. Specifically, the policy states, "In the event of a serious and threatening situation, the manager or house supervisor will authorize and direct a staff member to CALL 911." The policy did not give the definition of "a serious and threatening situation."

Based on record review and staff interview, it was determined that the Medical Director failed to ensure that patients had Master Treatment Plans that contained all required elements. Also, the Medical Director failed to assure that hospital staff were able to manage aggressive patient behaviors. Specifically, the Medical Director failed to:


I. Ensure that Substantiated Diagnoses were present on Master Treatment Plans. This failure results in the treatment team members not being able to conceptualize what the patient specific diagnoses are. (Refer to B120).


II. Ensure that individualized treatment interventions were present on Master Treatment Plans. This failure results in a lack of patient specific interventions appropriate to the problems of each patient. (Refer to B122).

III. Ensure that responsible team members for selected interventions were identified on Master Treatment Plans. This results in a lack of clarity as to which treatment team member is responsible for the selected interventions. (Refer toB123).

IV. Ensure that aggressive behaviors of patients were managed by hospital staff. This failure results in the need to request non-hospital staff (law enforcement officers) arrive on the units to assist in patient management issues, and/or exposes patients to harmful situations when patients are not deescalated or removed by clinical staff to a safer environment in a timely manner. (Refer to B139).

Based on document review and interviews, the Director of Nursing (DON) failed to ensure adequate numbers of qualified nursing professional and supportive nursing staff to provide active treatment. Specifically the DON failed to ensure that staff were adequately trained to de-escalate and control aggressive behavior for 3 of 4 discharged child and adolescent patients whose uncontrolled behavior required police intervention (C1, C2 and C3), 1 of 1active adult patients whose aggressive behavior resulted in police being called prior to de-escalation (C4) and 2 of 5 discharged child and adolescent patients whose aggressive behavior resulted in seclusion and/or restraint during April 2012 (C5 and C6). Failure to de-escalate/control aggressive patient behavior can jeopardize patient safety and disrupt the milieu, potentially preventing therapeutic active treatment. It also can result in patient injury.

Findings include:

A. Specific patient findings:

1. Patient C1 was a young adolescent admitted on 6/07/2011. Review of the Patient/Visitor Incident Reporting Form dated 6/18/2011 revealed documentation that Patient C1 became aggressive at 9a.m. The Patient Care Notes (RN), dated 6/18/2012 at 6:14p.m. and attached to the incident report documented that Patient C1 became "severely aggerssive [sic] both physcailly [sic] and verbally." According to the incident report, the patient was cursing and "feeding off of and provoking neagtive [sic] behaviors of other peers." Patient C1's behavior was also described as "running up and down the hallways, singing sexually explict [sic] songs." The report said that the patient's behavior escalated to jumping over the nurses' desk, going into the nurses' station and trying to enter the medication room. The patient and a peer "grabbed the gurney at the beginging [sic] of the hall and began racing it down the hall" yelling obscenities. The patient "punched a female staff memeber [sic] in the chest" and the police were called. The police placed the patient in hand cuffs and transported to "the juvienle [sic] dentation center." The incident report further stated that the patient's "belongings were sent with patient along with medications."

2. Patient C2 was an adolescent admitted on 6/13/2011. Review of the Patient/Visitor Incident Reporting Form dated 6/18/2011 revealed documentation that Patient C2 became aggressive at 9a.m. The Patient Care Notes (RN) dated 6/18/2011 at 3:57p.m. and 4:20p.m., which were attached to the incident report, summarized the incident. According to the notes, Patient C2 was "hyperverbal...pacing the dayroom and hallways, jumping on furtinure [sic] and having very poor boundires [sic]." The patient was reported as "antognizing [sic] staff, touching thier [sic[ arm and yelling 'poor boundires' [sic]." Patient C2's behavior continued to escalate with verbal threats and cursing. The patient was described as "unable to attend any programming because of the manic behaviors," and was told by the staff "to go to (patient's) room and calm down so (s/he) could join the rest of the peers." The patient refused to go to (patients) room, and with peers was "running in the hallway throw [sic] toy balls all over....grabbing clip boards and even walked into the nurses [sic] station in an attempt to raid the medication room." The police were called after the patient jumped on a gurney and attempted to run into staff. The patient was handcuffed and taken to "the juvienle [sic] center."

3. Patient C3 was an adolescent admitted on 3/21/2012. Review of the Patient/Visitor Incident Reporting Form dated 3/27/2012 revealed documentation that Patient C3 became aggressive at 8:40 a.m. The Patient Care Notes (RN) dated 3/27/2012 at 10:05p.m., which were attached to the incident report, summarized the incident. According to the notes, Patient C3 became aggressive while making a phone call at the nurses' desk and "...put feet on desk, tilted chair back. Patient took cup of water and threw it across desk." Patient then ended the call and "...came behind the nurses [sic] desk, charging staff." Staff attempted to de-escalate by offering a bottle of water which had "...worked as a distraction in previous times" and patient was also offered, " resting in bed and night time meds." Patient C3's behavior continued to escalate as evidenced by throwing the tape dispenser across the room and "picked up computer monitor and slammed it on nurses [sic] desk. Patient then picked up printer and attempted to slide it off nurses [sic] desk." Patient C3's aggressive behavior continued and was recorded as "Patient punched and kicked staff numerous times while smiling." The patient then "...laid on back and began pulling electric wires from computer monitor and attempted to put them around (his/.her)neck." When asked by staff what they could do to help, Patient C3 responded "I like this. This is fun." The patient was escorted to the "comfort room" (unlocked seclusion). When offered a ball that was used as a "theraputic [sic] tool " in the comfort room, Patient C3 "...took ball and threw it at staff in an aggressive way." The patient then "...took sandal off foot and threw it at staff." The patient continued to "punch and kick and charge staff" and at that point "locked seclusion was attempted but could not safely be initiated. " This behavior continued for "...approximately 15 minutes" when the police were called. When the police arrived, Patient C3 was "discharged to police."

4. Patient C4 was a middle aged person admitted on 5/07/2012. The Patient/Visitor Incident Reporting Form dated 5/07/2012 revealed documentation that Patient C4 became aggressive at 2:30p.m. The Patient Care Notes (RN) dated 5/07/2012 at 4p.m., which were attached to the incident report, summarized the incident. The notes state that upon admission to the Adult Unit, Patient C4 "...immediately became angry, loudly yelling...(RN and MD) attempted to de-escalate (Pt). (Pt) cont (continued) to be angry...(Pt) began to leap and forcefully kick locked unit door numerous times, (Pt) forcefully punched several doors." The notes state that support staff was called to the unit and the police were called. At that point, the patient "...agreed to go into day room with (MD)" and "...was agreeable to taking meds." Because of apparent injury to hand, "X-ray ordered for (Pt's) r (right) hand that immediately had swelled/bruised after (Pt) hit doors."

5. Patient C5 was an adolescent admitted on 4/17/12. According to information in the Seclusion/Restrain documentation forms, patient C5 was secluded from 2:30p.m. to 3p.m. on 4/27/12. The RN progress note from the medical record on 4/17/12 at 3:51p.m. documented the following: "Patient has demonstrated physical/verbal aggression towards staff and peers throughout the shift. This morning patient went after a little kid from the child unit after the child flipped [another young patient] the bird. Patient spent time 1:1 [sic] with unit manager in [unit manager's] office after this first incident and was given a one time dose of Seroquel 25mg at 1100 [11a.m.]. During ET group this afternoon (1330) [1:30p.m.], patient became verbally and physically aggressive towards an adolescent [patient] in the art room. ]Patient] accused this peer of changing the radio station and said something to [peer] which resulted in [peer] using some foul language against [patient]. [Patient] stood on the top of the tables hovering over the peer, threatening to fight [peer]. At some point during this, [patient] managed to throw a pair of scissors at the peer. Per ET [experiential therapy] staff, the scissors missed the peer and hit the wall. Patient remained on top of the table refusing to come down with several attempts from staff. [Patient] paced back and forth on the table and threw markers (twice) outside into the hallway, attempting to hit peer even though [peer] wasn't no [sic] longer out in the hall. [Patient] eventually came down from the tables after some staff was asked to leave, as it appeared patient was thriving off the attention from staff during the code green [signal that extra staff help was needed for disruptive patient]. Patient was given [her/his] scheduled Seroquel 50mg a little early (approximately 1335) [1:25pm] due to ...escalating behaviors. Shortly after ET group, patient disclosed in Social Services group that [s/he] 'felt like killin someone.' Patient attacked [the] third peer during this group. [Patient] was unprovoked and punched a disabled ...adolescent peer in [the] face three times and knocked [disabled adolescent] out of [a] wheelchair. (Patient) was placed in the open quiet room to maintain the safety of others. Staff remained with [patient], [who] didn't express any remorse and was laughing. Given Zyprexa Zydis [sublingual] 10mg one time at 1417 [2:17p.m.]. Patient came out the open quiet room and attempted to trash the nurses [sic] station. [Patient] threw cups, paper and plastic spoons from snack [sic] onto the floor. Patient was locked [in the seclusion room] from 1430 to 1500.[2:30p.m.-3.00p.m.]"

The patient was subsequently "transferred to Milwaukee County Mental Health Complex for a higher level of care."

6. Patient C6 was a young child admitted on 3/27/12. According to Seclusion/Restraint reports in the medical record, the patient was restrained on 4/02/12 with a manual hold at 9:30a.m., again at 9:50a.m. and then was secluded at 10a.m. The RN progress note in the medical record on 4/02/12 at 3:45p.m. documented the following: "...Patient agitated when directed to join peers, staff for morning goals group. Eloped from unit at 0925 [9:25a.m.] as outside maintenance personnel were doing work on magnetic entry door to unit. Patient went to cafeteria. In cafeteria, patient agitated, tipping chair, aggressive towards staff present. Patient kicking, hitting, attempting to bite, spitting on staff present. Staff placed patient in children's control position at 0930 [9:30a.m.] to assist patient in calming, maintain safety of staff present and reduce risk of injury related to property destruction. Patient remained agitated despite staff efforts to identify acceptable resolution. Staff offered patient 1:1 [1 staff, 1 patient], quiet time in alternate location, telephone call to grandmother or father, snack or beverage of choice. Patient initially declined options, then requested 'strawberry water.' Patient calmed at 0945 [9:45a.m.], agreed to walk to unit with staff. Upon exiting cafeteria, patient refused to move from hallway. As uninvolved staff exited cafeteria, patient ran back into cafeteria where [s/he] resumed destructive and aggressive behaviors. At 0950 [9:50a.m.], staff elected to place patient in escort [manual hold] position for return to unit. Upon return to unit, patient engaged in behaviors including throwing books from shelf, attempts to hit and kick staff. Alternatives again offered, including call to family active play, time outdoors on patio, play money. Staff reinforced behavioral expectations, verbalized limits to aggressive and destructive behaviors. Patient behaviors escalated, ...patient resumed physically aggressive behaviors kicking, hitting, scratching staff, attempting to bite, and spitting. Writer initiated locked seclusion at 1000 [10a.m.] for safety of patient and staff as less restrictive efforts failed. Patient sat on seclusion room floor, made verbal threats to choke self with hands...Patient agreed to refrain from aggressive behaviors within 10 minutes, seclusion room door opened at 1010 [10a.m.]..."

B. Interviews

1. In interview on 5/8/2012 at 1p.m., the Vice President for Nursing stated that Police are called to the unit "to assist with a patient staff cannot manage."

2. In a confidential interview on 5/09/2012 at 2:45p.m., a staff member stated that once the police arrive on the unit they (the police) "make the decision about whether to put (patient) in seclusion or if they will arrest them."

3. During the State surveyor exit conference on 5/09/12 at 3:15p.m., the Team Leader stated that in the management of aggressive behavior classes "there was not a lot of 'hands on' training."

4. In a discussion of seclusion and restraint on 5/09/12 at 3:45p.m., the Director of Nursing stated "Our training has been to do blanket holds and manual holds." The Quality Improvement Director added that all staff had just received CPI [management of aggressive behavior] training; and they were just adjusting to the new approach of dealing with patients out of control.

5. In interview on 5/09/2012 at 4:30p.m., RN3 stated that police were called to the Child and Adolescent Unit approximately 6-10 times a year. RN3 explained that the police were "sometimes there to help de-escalate (a patient) and sometimes to take a patient off the unit." N3 further stated that even though the police worked with the staff, "they (police) were in control."

6. In an interview on 5/10/2012 at 10:15a.m., the Vice President for Nursing verified that even though police did not have to intervene in the control of Patient C4's aggressive behavior on 5/07/2012, four police officers did respond and entered the patient care unit.

C. Policy

Review of the "CODE GREEN Assault without Weapon" policy dated 12/31/06 revealed guidelines for calling the police. Specifically, the policy states, "In the event of a serious and threatening situation, the manager or house supervisor will authorize and direct a staff member to CALL 911." The policy did not give the definition of "a serious and threatening situation."