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Based on record review and interview, the hospital failed to ensure it protected and promoted the rights of its patients, in 6 of 12 patient records reviewed (Patient #'s 1, 2, 3, 7, 10, and 11), in a total sample of 14 patients.

Findings include:

1) The hospital failed to ensure that patient grievances were recorded, investigated and responded to per hospital policy, in 2 of 5 patient grievances reviewed (Patient #'s 1 and 3). (A0119)

2) The hospital failed to ensure that written response letters/notices for patient/patient representative grievances contained the required grievance resolution elements, in 1 of 5 patient grievances reviewed (Patient #2). (A0123)

3) The hospital failed to ensure that patient/ patient representatives without advanced directives were offered or given information about formulation of an advanced directive, in 2 of 5 inpatients reviewed (Patient #'s 7 and 10). (A0132)

4) The hospital failed to ensure that medical orders for physical holds were obtained, in 1 of 2 patients reviewed (Patient # 11). (A0168)

5) The hospital failed to ensure that all patients restrained for violent behavior had a 1 hour face to face evaluation by their LIP (licensed independent practitioner), in 1 of 2 patients reviewed (Patient #11). (A0179)

6) The hospital failed to ensure that staff used to the least restrictive restraint alternatives when applying restraints for violent behaviors, in 1 of 2 patients reviewed (Patient #11). (A0186)

The cumulative effects of these violations of patient's rights resulted the hospital's inability to promote the health, safety and welfare of its patients.

Based on record review and interview, the hospital's governing body failed to ensure that patient grievances were recorded, investigated and responded to per hospital policy, in 2 of 5 patient grievances reviewed (Patient #'s 1 and 3), in a total sample of 14 patients.

Findings include:

The 1/25/18 at 12:40 p.m. record review of " Patient Complaints and Grievances, AW (Ascension Wisconsin), revised 12/5/2017 revealed under "Procedure... B. All complaints and grievances will be documented in the ERS (Event Reporting System). C. The unit /department leader or designee will provide relevant documentation related to the grievance. This includes but is not limited to written statements of patients or persons involved. The unit/department leader or designee will assure the grievance has been recorded into the appropriate area of the ERS ticket...". Under "2. Response to Grievance process" it revealed "A. The unit /department leader or designee will inform the patient of the specific time frame for review and response during initial contact with the patient. Most reviews should be completed with a written response to the patient within 7 days. If more time will be needed, the patient shall be informed of the progress of the investigation, and given a reasonable time frame for completion. The mutually agreed upon timeframe will be documented into the appropriate area of the ERS ticket... G. The final report, including resolution and a copy of written communication to the patient, should be entered in the ERS ticket. H. Regular monitoring of entries into ERS will be conducted. I. Regular reporting to local leadership and senior leaders to assure compliance and facilitate process improvement opportunities."

1) During telephone interview with Patient#1's family members (N, O and P) on 1/23/18 at 4:35 p.m., they confirmed that they had concerns about Patient #1's change in condition on 12/8/17, did not get the appropriate assistance when requesting Patient #1 be transferred to another acute care hospital. Family Member O stated "we never got answers".

Record review of the "Patient Grievance Summary" dated 10/24/17 through 1/24/18 revealed no documented evidence that the family complaints about Patient#1's care were entered into ERS system for review under the hospital's grievance process.

During interview with Patient Relations Representative K on 1/25/18 at 9:20 a.m., K confirmed receipt of voicemails on 12/27/17 and 1/11/18 regarding Patient #1's care at their hospital. K stated that "the ICU nursing Manager L was emailed about the calls on 1/11/18". K confirmed that K did not return calls to the complainant(s) to determine the details of their concerns.

During interview with Critical Care Unit Manager L on 1/25/18 at 2:40 p.m., L stated that Family member N (Health Care Power of Attorney) for Patient #1 spoke to L about "wanting to transfer patient to another hospital". L confirmed the 12/27/17 call was sent to Patient Relations Representative M.

During interview with Nurse Practitioner J, on 1/31/18 at 12:20 p.m., J stated that family did ask "what happened" to cause the change in condition and the code on 12/8/17. J confirmed the complaint inquiry was never formalized through the hospital's complaint process.

During interview with Director of Quality C on 2/1/18 at 2 p.m., C stated that "this complaint was not entered into the hospital's system for formal investigation".

2) Record review of the "Feedback Entry Ticket" revealed a 11/9/17 grievance filed by Patient #3 about #3's medical treatment plan. There was no documented evidence that Patient #3 received notice that the grievance investigation was going to be delayed before 11/22/17. On 11/22/17, Patient #3 received a phone call that told #3 that #3 would get a response letter within 7 days or be contacted by the patient experience team. Record review of the grievance response letter written to Patient #3 was dated 12/4/17. There was no documented evidence that Patient #3 was notified of this delayed response.

During interview with Patient Relations Representative M on 1/25/18 at 10 a.m., M confirmed delay of the grievance response letter, and stated "the doctor that reviewed this case did not respond within the timeframe required".

Based on record review and interview, the hospital failed to ensure that written response letters/notices for patient/patient representative grievances contained the required grievance resolution elements, in 1 of 5 patient grievances reviewed (Patient #2), in a total sample of 14 patients.

Findings include:

The 1/25/18 at 12:40 p.m. record review of " Patient Complaints and Grievances, AW (Ascension Wisconsin), revised 12/5/2017 revealed under "2. Response of Grievance Process... F. ...This notice will be provided in clear language and will include the following information: ...2. Explanation of the steps taken on behalf of the patient to investigate the grievance."

1) Record review of the "Feedback Entry Ticket" revealed that family member Q of Patient #2 filed a grievance on #2's behalf, on 11/3/17 about emergency department care, leaving contact phone number. Review of the grievance response letter dated 11/10/17 revealed this letter was addressed to Patient #2 instead of family member Q. The grievance response letter did not contain the steps taken on behalf of the patient to investigate the grievance.

During interview with RN (Registered Nurse) R, on 1/25/18 at 10:45 a.m., R confirmed that the complaint letter was not addressed to the complainant, and the steps taken to investigate were missing. R stated "it was not added".

Based on record review and interview, the hospital failed to ensure that patient/ patient representatives without advanced directives were offered or given information about formulation of an advanced directive, in 2 of 5 inpatients reviewed (Patient #'s 7 and 10), in a total sample of 14 patients.

Findings include:

The 2/1/18 at 2 p.m. record review of "Advance Directive Assistance", revised June 2014" revealed under "Procedure: A. As part of the admission process, the registered nurse who documents the patient's admission will inquire as to whether or not the patient has an advance directive and will document the response in the medical record. If the patient has not completed an advance directive , the nurse will provide written information to the patient...".

1) Record review of the "1/22/18 (no time given) initial nursing assessment" completed for Patient #7 revealed that the patient did not have an advanced directive on file at the hospital. On 1/25/18 at 8:54 a.m., hospital Case Manager S contacted Patient #7's community case manager and was told that Patient #7 did not have an advanced directive and was "decisional". There was no documented evidence that Patient #7 was given Advance Directive information in order to decide about formulation.

During interview with Quality RN (Registered Nurse) T, who reviewed this medical record on 1/31/18 at 11 a.m., T stated "there is no additional information".

2) Record review of the "1/30/18 at 7:30 p.m. initial nursing assessment" completed for Patient #10 revealed that the patient did not have an advanced directive on file at the hospital. There was no documented evidence that Patient #7 was given Advance Directive information in order to decide about formulation.

During interview with Quality RN (Registered Nurse) T, who reviewed this medical record on 1/31/18 at 12 p.m., T stated "there is no additional information".

Based on record review and interview, the hospital failed to ensure that medical orders for physical holds were obtained, in 1 of 2 patients reviewed (Patient # 11), in a total sample of 14 patients.

Findings include:

The 2/1/18 at 2 p.m. record review of policy "Restraints, revised September 2017" revealed the following: "C. 1. This policy requires that a LIP (licensed independent practitioner) responsible for the care of the patient order a restraint prior to its application...or immediately afterwards (within minutes)."

Record review on 1/31/18 at 2:30 p.m. revealed that Patient #11 had a medical order at 9:12 a.m. on 1/1/18 for "4 point restraints" for "danger to self or others".

The 2/1/18 at 12 p.m. record review of the "Security Department Confidential Incident Report" for Patient #11 revealed that at 9:10 a.m. on 1/1/2018 security staff were called to the emergency room to apply a physical hold to arms and legs of Patient #11 for the application of 4 point Velcro restraints. There was no documented evidence that a medical order was obtained for the physical hold required to apply the 4 point Velcro restraints.

During interview with Quality manager C on 2/1/18 at 3 p.m., C stated "there is no documentation of a medical order for the physical hold by the security staff".

Based on record review and interview, the hospital failed to ensure that all patients restrained for violent behavior had a 1 hour face to face evaluation by their LIP (licensed independent practitioner), in 1 of 2 patients reviewed (Patient #11), in a total sample of 14 patients.

Findings include:

The 2/1/18 at 2 p.m. record review of policy "Restraints, revised September 2017" revealed the following: " C.7. Face to face evaluations requirement for patients placed in restraints for violent or self-destructive behavior: a. When applying restraints for violent/self-destructive (behavior), the LIP (licensed independent practitioner) must see the patient face to face and evaluate the need for restraint within 1 hour after initiation of the intervention".

Record review on 1/31/18 at 2:30 p.m. revealed that Patient #11 had a medical order at 9:12 a.m. on 1/1/18 for "4 point restraints" for "danger to self or others" while in the emergency room. Medical record review revealed that a 1 hour face to face evaluation by an LIP could not be found in the medical record for this restraint application.

During interview with Quality Manager C on 2/1/18 at 3 p.m., C stated "there is no documentation of the LIP's 1 hour face to face evaluation for the 4 point restraints applied on 1/1/18 at 9:12 a.m.".

Based on record review and interview, the hospital failed to ensure that staff used the least restrictive restraint alternatives when applying restraints for violent behaviors, in 1 of 2 patients reviewed (Patient #11), in a total sample of 14 patients.

Findings include:

The 2/1/18 at 2 p.m. record review of policy "Restraints, revised September 2017" revealed the following:"B. 2. Restraints will be implemented in the least restrictive manner."

Record review on 1/31/18 at 2:30 p.m. revealed that Patient #11 had a medical order at 9:12 a.m. on 1/1/18 for "4 point restraints" for "danger to self or others" while in the emergency room. Medical record review revealed on 1/1/18 from 10:09 a.m. through 11:51 a.m., Patient #11 was documented by the nursing staff as "sleeping" while in 4 point restraints.

During interview with Quality Manager C on 2/1/18 at 3 p.m., C confirmed that documentation showed that Patient #11 was sleeping while in 4 point restraint, and stated "I have cautioned the nursing staff about this".

Based on record review and interview, the hospital failed to ensure that it's registered nurses supervised and evaluated the care of it's patients, in 1 of 1 telemetry patients reviewed (Patient #1), in a total sample of 14 patients.

Findings include:

The hospital failed to ensure that the registered nurse evaluated each patient based on their medical and nursing care needs, in 1 of 14 patients reviewed (Patient #1). (A395)

The cumulative effects of these violations of patient's rights resulted the hospital's inability to promote the health, safety and welfare of its patients.

Based on record review and interview, the hospital failed to ensure that each patient received the care based on medical need, in 1 of 1 telemetry patients reviewed (Patient #1), in a total sample of 14 patients.

Findings include:

The 2/1/18 at 2 p.m. record review of "Patient Assessment, revised March 2016" revealed under "Policy: Patient assessment is to determine the care, treatment and services that will meet the patient's initial and continuing needs. Patient needs must be reassessed throughout the course of care, treatment and services."

Medical record review revealed medical diagnosis of Atrial flutter when Patient #1 was admitted at 5:34 p.m. to 4th floor telemetry unit (EKG heart tracing) on 12/5/17 for telemetry monitoring. Hospital admission was stable until 12/8/17 at 1:55 a.m. when patient was noted to have a change in mental status (minimally responsive) after a dose of Lorazepam 2 mg. (milligrams) 2 hours prior. Patient was sent to ICU (intensive care) for closer monitoring at 2:28 a.m. At 8:33 a.m. on 12/8/17, Patient #1 was alert, oriented and back to baseline neurological status but remained to have Atrial flutter with rapid ventricular response. On 12/8/2017 at 1:02 p.m., Patient #1 was transferred back to the 4th floor telemetry unit for continued telemetry monitoring.

The 1/24/18 at 11 a.m. record review of Patient #1's medical "progress note" dated 12/8/17 at 10:42 a.m. revealed that attending Physician D wrote "decided to transfer the patient (#1) to [tele(metry)-heart rhythm monitoring] floor". There was no documented evidence of a written medical order for telemetry monitoring after Patient #1 was transferred from ICU (intensive care) back to the telemetry unit the 12/8/17 at 1:02 p.m.

During interview with Physician D on 1/25/18 at 2:04 p.m., Physician D confirmed that Patient #1 was to be telemetry monitored after returning to 4th floor from ICU (intensive care) 12/8/17.

The 2/1/18 at 1 p.m. record review of "nursing notes" written by RN (Registered Nurse) A revealed on "12/8/17 at 1:19 p.m., At this time, tele(metry), vitals and assessment not completed due to patient refusal". Continued documentation by RN A at 2:30 p.m. on 12/8/17 revealed, "Walked in patient room for rounds and noticed that patient did not appear alert as previous encounter. Patient eyes were open and labored breathing. Writer checked oxygen connections, which were secure. ...Writer asked Physician B to access (sic) the patient. Writer and Physician B entered the room to find patient pulseless and nonbreathing (PNB). CPR (cardiopulmonary resuscitation) started immediately and code (resuscitation alert) was called."

Record review of the "code sheet" revealed a resuscitation code was called on 12/8/17 at 2:30 p.m., and showed resuscitation lasting 40 minutes requiring intubation (breathing tube connected to mechanical ventilation). At 3:34 p.m. the non-responsive patient was transferred back to ICU. Record review revealed that Patient #1 never regained consciousness was neurologically unresponsive with moderate to severe abnormal brain wave activity (EEG) showing encephalopathy and global hypoxic/ anoxic injury with no evidence of "frank" hemorrhage. Patient #1 was removed from life support and expired on 1/12/18 at 6:24 p.m.

During interview with RN A on 2/1/18 at 10:45 a.m. A stated the following:
"On [12/8/2017] at a little after 2 p.m., the assessment was done, tele(metry) was on and vital signs were checked". RN A was asked about the lack of a telemetry strip printing RN A confirmed that when telemetry monitor picks up a heart arrhythmia the machine automatically prints off the rhythm strip however RN A did not have a telemetry strip for 2:30 p.m. on 12/8/17 when Patient #1 was found PNB. There was no documented evidence in the medical record that RN A had connected Patient #1's telemetry monitoring device.

Record review of the "telemetry monitoring strips logged for Patient #1 revealed there was no documented evidence that any heart rhythm (telemetry) monitoring was established on the 4th floor telemetry unit for Patient #1 on 12/8/17 after transfer back to the 4th floor telemetry unit.

During interview with Quality Manager C on 2/1/18 at 2 p.m., C stated "there was no additional documentation regarding the EKG monitoring of Patient #1".