HospitalInspections.org

Based on record review and interview, the facility staff failed to obtain and accurately document "Consent for Treatment and Financial Agreement" for 2 of 5 patients (Patients #2, and #3) seeking care in the ED (Emergency Department) in a total universe of 10 records reviewed.

Findings include:

The facility policy titled "Patient Rights and Responsibilities" #7808885 last reviewed 3/2020, revealed: "PROCEDURE: [Facility Name] provides compassionate, personalized care to all. Patients (or support person) have the right, consistent with laws and regulations to: 4. Make informed decisions and provide consent about their care, treatment and services, unless they are unable to do so. Except in emergencies, patient consents or the consent of the patient representative shall be obtained before treatment is administered."

Patient #2's medical record reviewed with ED (Emergency Department) Manager H revealed, Patient #2 was a 68 year-old who presented to the ED on 5/1/2021 at 11:40 AM with a chief complaint of left flank pain. Patient #2 was evaluated and treated in the ED. There was no documented "Consent for Treatment and Financial Agreement" in Patient #2's medical record for this visit.

Patient #3's medical record reviewed with with ED Manager H revealed, Patient #3 was a 43 year-old who presented to the ED via ambulance on 5/1/2021 at 10:26 PM with a chief complaint of respiratory arrest. Patient #3 was evaluated and treated in the ED then admitted to the Intensive Care Unit for asthma exacerbation. There was no documented "Consent for Treatment and Financial Agreement" in Patient #3's medical record for this admission.

During an interview on 5/21/2021 at 9:30 AM with ED Manager H stated "The consent to treat is not completed for Patient #2 and #3."

Based on record review and interview, the facility staff failed to accurately document "Competency Review" coaching, counseling and/or corrective action/s for 4 of 7 Sterile Processing staff (Staff AA, DD, FF and GG) during their Orientation period receiving a '1' rating (Needs Improvement) in the Central Sterile Processing Department in a total universe of 11 personnel records reviewed.

Findings include:

The facility policy titled "Competency Policy, AW" last updated 8/1/2018 revealed,"SCOPE: [Facility Name] associates employed in Wisconsin. This policy applies to associates and contingent workers. It does not apply to practitioners credentialed and granted privileges through Medical Staff Office procedures. PURPOSE: The purpose of this policy is to outline the process for assessing associate and contingent worker performance and planning development and remedial plans of associates. POLICY STATEMENT: It is the policy of [Facility Name] to ensure that active associates and contingent workers are qualified and competent in the performance of their job duties. POLICY:....E. Leadership will assess each responsibility/behavior according to departmental processes (i.e. competency assessment checklist)."

The facility policy titled "Associate Coaching, Counseling, and Corrective Action" last updated 8/1/2018 revealed, ".....Leaders are responsible for communicating performance and behavioral expectations to associates, providing training and development for their associates, and, as appropriate, correcting performance or behavior. PROCEDURE/GUIDELINES.....C Associate coaching, counseling and when necessary corrective actions. Leaders may use, as appropriate, a variety of Performance Management and Corrective Action approaches to address the specific nature of each concern. The goal is to identify and resolve problems as early as possible through timely and effective communications with associates....E. Coaching Session(s)-Informal: This action is not part of the formal process and may be undertaken with any associate whose performance or behaviors are inconsistent with organizational expectations. 1. Informal coaching sessions are the preferred initial step for correction when the associate has no prior performance or behavioral problems, and the infraction or deficiency seems minor and easily correctable. 2. The Manager should establish a continuing dialogue with the associate concerning performance expectations. If an associate's performance or behaviors do not meet or exceed organizational expectations, a manager may attempt to remedy the deficiency with documented informal coaching. 3. All informal coaching sessions should be documented on a Coaching Feedback Form and kept in the associate's departmental file."

Review of the Orientation "Competency Review" Checklist for Sterile Processing revealed, "Competency Levels: 1=Needs Improvement, 2=Competent, 3=Excels."

Review of Orientation "Competency Review" Checklist for Sterile Processing Tech AA revealed, "1" ratings under "Case Carts, Clinics, Sterilization and Immediate Use Sterilization" on 10/5/2020 with no coaching, counseling and/or corrective action documented.

Review of the Orientation "Competency Review" Checklist for Sterile Processing Tech DD revealed, "1" ratings under "Immediate Use Sterilization and Clinics" on 10/5/2020 with no coaching, counseling and/or corrective action documented.

Review of the Orientation "Competency Review" Checklist for Sterile Processing Tech FF revealed, "1" ratings under "Case Carts, Clinics, and Immediate Use Sterilization" on 10/5/2020 with no coaching, counseling and/or corrective action documented.

Review of the Orientation "Competency Review" Checklist for Sterile Processing Tech GG revealed, "1" rating under "Immediate Use Sterilization" on 1/4/2021 with no coaching, counseling or and/or corrective action documented.

During an interview with Sterile Processing Manager J on 5/20/2021 at 12:30 PM, when asked who does staff training in the Central Sterile Processing Department, J stated "I do the training and also the leads can train, staff also work with an assigned preceptor and we also have an assigned educator on 2nd shift." When asked when Sterile Processing staff complete the Orientation Competency Review and have a '1' rating (Needs Improvement), is there follow-up, J stated "We work with them until they are trained." When asked if there is documentation of coaching, counseling and/or corrective action/s, J stated "There is no documentation."

During an interview with Senior Director of Operations Resource Group K on 5/21/2021 at 9:10 AM, when asked what the expectation is for staff training, K stated "There is a preceptor assigned as needed, we do have a trainer on 2nd shift and there are 'leads' to train on 1st and 2nd shift as well; we work as a team to train. All people involved in training can sign-off on the training they've witnessed." When asked if there is documentation for employees needing additional coaching, counseling and/or corrective action to meet the competency expectations, K stated "One of the areas of concern we can improve on is documentation. We have a new Orientation sheet from a different facility that we will be putting in place, we will start ensuring that people needing help will be trained and documented." When asked if a '1' rating (Needs Improvement) would raise concern on a Orientation Competency review, K stated "We believe that more training should be done if they are getting a '1' rating on their competency reviews, there needs to be documentation what was done to resolve."

During an interview with Sterile Processing Lead Z on 5/21/2021 at 11:15 AM, when asked if he/she does training for new hires in the Central Sterile Processing Department, Z stated "Yes, I do training for staff and I am a preceptor-I also train students. We also have a trainer on 2nd shift." When asked if it would raise concern that a staff member had a '1' rating (Needs improvement) after going through the Orientation Competency Review, "Yes, that is a concern." When asked what the process is if he/she found staff had a '1' rating on Orientation or Yearly Competency Reviews, Z stated "I would re-train them and let our Manager J know." When asked if he/she would document anywhere that an employee needed coaching, counseling and/or corrective action/s, Z stated "Manager J would do all the documentation."