The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

ASCENSION EAGLE RIVER HOSPITAL 201 HOSPITAL ROAD EAGLE RIVER, WI 54521 May 3, 2012
VIOLATION: STAFFING AND STAFF RESPONSIBILITIES Tag No: C0970
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on 1 of 10 MR reviewed, 9 of 9 staff interviews, and P&P review by surveyor # , the hospital's medical staff failed to provide quality patient care for Pt. #1 who expired on [DATE].

Findings include:

The hospitals medical staff failed to effectively communicate with each other and nursing staff related to Pt. #1 condition per hosptial P&P, transfer of responsibility and medical needs, failed to ensure that MD (F) saw Pt.#1 within 8 hours of admission to the hospital per medical staff rules and regulations, failed to notify family of patient condition change and admission to the hospital once Pt. #1 was unable to direct his own cares, failed to provide additional testing, treatment or transfer for Pt. #1 when his condition deteriorated without a clear cause per hospital P&P, failed to notify the coroner of an unexplained death and secure an autopsy per hospital P&P, failed to consult with Pt. #1 or family to verify that the DNR and AD on the patients old hospital record was current before writing DNR orders per hospital P&P. See Tag C-257

The cumulative effect of these medical staff failures resulted in the facility's inablitiy to privide safe and optimal patient care.
VIOLATION: RESPONSIBILITIES OF MD AND DO Tag No: C0981
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on 1 of 10 MR reviewed (#1), P&P review, review of medical staff By-Laws and Rules and Regulations, and 9 of 9 staff interviews (D, E, J, G, F, I, K, H, L) by surveyor # , the hospitals medical staff failed to effectively communicate, per hospital P&P, with each other and nursing staff related to Pt. #1 condition, transfer of responsibility and medical needs, failed to ensure that MD (F) saw Pt.#1 within 8 hours of admission to the hospital per medical staff rules and regulations, failed to notify family of patient condition change and admission to the hospital once Pt. #1 was unable to direct his own cares, failed to provide additional testing, treatment or transfer for Pt. #1 when his condition deteriorated without a clear cause per hospital P&P, failed to notify the coroner of an unexplained death and secure an autopsy per hospital P&P, failed to consult with Pt. #1 or family to verify that the DNR and AD on the patients old hospital record was current before writing DNR orders per hospital P&P.

Findings include:
Per P&P review on 5/1/12 in the afternoon, P&P Communication Among Caregivers #1204 and 1204E, the policy directs the following: "To ensure patient safety by using an active communication process during the transfer of patient care and/or communication regarding a change in patient's condition. The primary objective is to provide accurate, clear, and complete information, using interactive communication about a patient's care, treatment, services, current condition, and any recent or anticipated changes. Procedure: a. shift change in nursing units, b. reporting a change in patient condition to a physician or mid-level care provider, e. transferring a patient from an internal level of care to another including admissions from the ED, f. physicians transferring complete responsibility for their patients to another physician (refer to medical staff rules and regulations section A, provision for patient care."

Per review of medical staff rules and regulations (last revised date 5/5/09), medical staff are directed to: "Section A: 9. All patients admitted to the general/medical unit must be seen by the attending physician within eight (8) hours of the time of admission."

Per medical staff P&P "Basic responsibilities of individual medical staff membership" dated 2/4/03, it directs the following: "A. Provide his or her patients with care at the generally recognized professional level of quality and efficiency."

Per review, of medical staff P&P "Autopsy criteria" dated 12/4/07, it directs the following: "1. It is the intention of the medical staff to secure autopsies when appropriate. All deaths meeting the following criteria will be considered for autopsy. Unanticipated death (not related to the natural course of the patient's illness. 2. If the physician does not feel the autopsy is warranted, or the family refuses the autopsy, the physician will document the reasons for not performing the autopsy in the patient chart."

Per review, of hospital P&P "Advance care planning and advance directives" dated 11/10, directs the following: "E. Physician. 5. Review advance directive documents upon admission to the hospital or before discharge to nursing home: discuss preferences with patient or designated healthcare agent/surrogate, if possible, and write appropriate orders for the patient."

Per MR review, on 4/30/12 and 5/1/12, Pt. #1 fell at home about 9:30 AM on 4/17/12. Prior to his fall Pt. #1 was in good health and planning a trip per airplane on Sunday 4/22/12.

Per clinic note review, Pt. #1 saw his primary MD on 3/28/12 to discuss his chronic dependent edema and his need for an electric wheelchair as he is wheelchair bound. His Lasix was increased to 80mg daily with a followup visit scheduled the following Monday.

Per ED nursing notes, dated 4/17/12, Pt. #1 was admitted to the ED at 10:31 AM with presenting complaint of weakness with fall. Triage assessment at 10:40 AM reveals that Pt. #1 appears weak, complains of pain in right leg with breath sounds diminished bilaterally. He is alert, alert to verbal stimuli, reports weakness in right leg since 9:30 AM, range of motion limited in left ankle, right knee and right ankle. Pt. #1 reports weakness in right leg. Per Pt. #1 he stated his leg went out from under him when he got up from the toilet this AM.

Per nursing notes, initial vitals were stable at 110/50, pulse of 70 and respirations at 18 with an oxygen saturation of 90% on room air.

Per ED notes, MD (D) saw Pt. #1 at 10:49 AM Per MD (D). Pt. #1 presented with a contusion, decreased range of motion, and pain that is acute. The complaints affect the lateral aspect of right thigh, lateral aspect of right knee, lateral aspect of right calf, right hamstring, posterior aspect of right knee, right calf, medial aspect of right thigh, medial aspect of right knee, medial aspect of right calf, right quadriceps, right knee and right shin as a result of a fall at home. While standing, the patient is not able to bear weight and not able to ambulate.

Per MD (D) ED notes dated 4/17/12, Pt. #1 respiratory is negative for shortness of breath, cough, sputum production and wheezing. Extremity, positive for pain, swelling, negative for injury or acute deformity, [DIAGNOSES REDACTED] or laceration. Neuro: positive for weakness, patient generally uses a wheelchair, generalized weakness and chronic leg swelling. Constitutional: this is a well developed, well nourished patient who is awake, alert and in no acute distress.

X-rays and laboratory studies were ordered by MD (D) Pt. #1 went to radiology at 11:26 AM for x-rays of his right hip, pelvis, femur and knee which were all negative. Blood samples for laboratory studies were drawn at 11:28 AM and were essentially unremarkable. A urine sample was sent to the lab at 12:35 AM and was normal.

Per nursing notes, Pt. #1 BP was 118/66 with a pulse of 74 and respirations of 18 at 12:49 PM.

Per interview, with MD (D) on 4/30/12 at 2:55 PM, Pt. #1 initially refused pain medication. Pt. #1 latter agreed to pain medication and received Dilaudid 1 mg IV and Zofran 4 mg IV for nausea at 1:17 PM and 1:18 respectively. Per interview, with RN (E) on 4/30/12 at 2:20 PM, she took care of Pt. #1 until shift change at 7:00 PM on 4/17/12. Per (E), she gave the Dilaudid 1 mg IV over 1 minute slowly.

The dose of Dilaudid was validated as 1 mg per Pyxis medication dispensing machine printout dated 4/17/12. Per interview, with Pharmacist (J) on 5/2/12 at 11:45 AM, it is very unusual for a man this size (at 229 pounds) to react to the doses of Dilaudid or Zofran that he got. The Dilaudid dose of 1 mg was appropriate for Pt. #1.

Per RN (D), Pt. #1 was making phone calls off and on while in the ED.

Per nursing notes, Pt. #1 BP was 108/70, with pulse of 78 and respirations of 18 at 2:55 PM. Per RN (E), Pt. #1 was stable, a little drowsy after the Dilaudid, and was checked on frequently by nursing and medical staff since his admission at 10:30 AM.

Per ED notes, MD (D) visited Pt. #1 at 3:55 PM and the decision was made to admit Pt. #1. Per interview, with MD (D) it was for pain control and because he could not ambulate. Per ED notes, MD (D) did a physician consultation with MD (F) who was called at 4:15 PM to discuss Pt. #1 condition and case with admit orders written. Per MD (D) ED notes, MD (F) "will see the patient in inpatient room."

MD (D) admit orders indicated that admission diagnosis was fall, congestive heart failure, failure to thrive. Orders were DNR for code status, IV saline lock, daily weights, and routine vitals, regular diet, fall and aspiration precautions and call MD (F) for further orders. The orders were entered into the MR by MD (D) at 4:45 PM on 4/17/12. Per interview, with MD (D), he saw a previous AD on Pt. #1 MR and ordered the DNR based on that information. Per (D), he did not validate with Pt. #1 if that was his wishes at this time or if the AD dated 8/24/10 was a current and accurate copy prior to admission and writing the order. Per MD (D), he should have validated the patients current wishes before writing DNR orders.

An EKG was done at 4:32 PM and was essentially negative. Lasix 40 mg was given IV per MD orders at 5:10 PM.

Per RN (E), Pt. #1 BP started dropping and was 78/45 with a pulse of 96 and respirations 18 at 5:35 PM. Per (E), she noted Pt. #1 was getting harder to arouse, but did not think it was related to the Dilaudid as it was given 4 hours earlier. Dilaudid has a half-life of 2 1/2 - 4 hours (the time required by the body, tissue, or organ to metabolize or inactivate half the amount of a substance taken in.). Per RN (E), MD (D) was notified at 5:37 PM and an IV bolus was ordered to help increase the BP and oxygen was given per mask at 6 Liters. Pt. #1 head of his bed was lowered into a trendelenburg position.

Per MR review and interview with RN (E), Pt. #1 BP dropped to 76/50 at 5:47. Pt. #1 BP began to increase to 86/48 at 6:33 PM and 91/54 at 6:55 PM. Pulse and respirations were stable. Per RN (E) and MD (D) interview, Pt. #1 was somnolent and hard to arouse so Narcan 0.4 mg IV was ordered to reverse the effects of the Dilaudid and given slowly at 7:00 PM which was 5 and 1/2 hours after the Dilaudid was given. . Per interview, with MD (D), he noted that the patient was becoming harder to awaken so he decided to try Narcan even though it "made no sense why so long after giving it (Dilaudid) that it might cause a drop in blood pressures. Per interview, with MD (D), he felt Pt. #1 had a "good response to the Narcan and he woke up to pre-medication status."

BP at 7:06 PM was 104/47 with a pulse of 98 and respiration of 20.

Per interview, with RN (E), she felt there was little response to the Narcan and fluid bolus. Pt. #1 was still drowsy and hard to arouse. Per (E), at interview on 5/1/12 at 8:00 AM, Pt. #1 took a turn in his condition while in the ED on 4/17/12 and could only be aroused with deep stimulation. No further testing was done in the ED to determine the cause of Pt. #1 condition change, he was not transferred to an acute care hospital for further workups, and was instead admitted to the hospital nursing unit. Per (E), she was told the reason for admission was for strengthening as he was so weak.

Per interview, with RN (G) on 4/30/12 at 3:55 PM, she took over caring for Pt. #1 at 7:00 PM shift change on 4/17/12 from RN (E). At the time, Pt. #1 was able to respond to questions after the Narcan, but did not wake up like you would expect following this reversal agent for Dilaudid. Pt. #1 was still not like he was on admission. In addition, the oxygen mask could not be removed because his oxygen saturations kept dropping. Per RN (G), she had Pt. #1 for 1 hour and 20 minutes and "spent the whole time in that room with Pt. #1." Per (G), Pt. #1 was unresponsive and very difficult to arouse at the time of transfer to the nursing unit. With deep stimulation, he would arouse and be able to answer a yes or no question. and then become unresponsive again Per (G), she was told by RN (E) that patient #1 was being admitted for comfort cares and that is what she told admitting RN (I). Per (G), she told RN (I) that Pt. #1 was not doing well and was not alert. Per RN (G), she failed to document her last nursing assessment of Pt. #1 or her observations the last 1 and 1/2 hours while he was in the ED. In addition, she did not have any contact with MD (D) after she took over cares for Pt. #1. She did not communicate Pt. #1 continued unresponsive state to MD (D) prior to transferring Pt. #1 to inpatient status at 8:45 PM on 4/17/12. The last recorded vitals were at 7:57 PM B/P was 93/51, pulse 93 and respirations 20 with an oxygen saturation of 93% on a non-rebreather mask at 6% at 8:02 PM.

Per interview, with MD (D) on 5/2/12 at 9:15 AM, MD (D) said he was not aware that Pt. #1 was so unresponsive at the time of discharge from the ED and admission to the hospital. Per (D), he admitted Pt. #1 for pain control and to see if he could go back home or need nursing home placement until he could go back home.

Per interviews, with MD (D) and RN's (G) and (E), family was not called to alert them to patient #1 condition change in the ED. Per MD (D), Pt. #1 could direct his own cares at admission so family was not notified. There was no evidence per interview with ED staff or MR review that Pt. #1 family was notified following his condition change at which point he was no longer able to direct his own cares.

There was no evidence from interviews or MR review that RN (G), (E) or MD (D) reported to admitting MD (F) Pt. #1 condition change since MD (D) spoke with him at 4:15 PM. MD (F) was not made aware of the B/P drop at 5:30 PM and Narcan administration at 7:00 PM, with continued unresponsiveness at the time of admission to the hospital. Per interview, with MD (F) on 4/30/12 at 4:00 PM, he did not get an update from ED MD (G) about Pt. #1 condition change that resulted in Pt. #1 becoming unresponsive.

Per interview, with RN (I), she took report about Pt. #1 from ED RN (G). Per RN (I), she was told that he was not doing well, was not alert and was being admitted for "comfort cares only." She then passed on this information to RN (K) who was going to care for Pt. #1 after admission to the nursing unit.

Per interview, with RN (K) on 5/1/12 at 12:00 PM, she thought Pt. #1 had an adverse reaction to Dilaudid and then got Narcan. Per interview, at admission assessment at 8:35 PM, Pt. #1 was non-responsive with only a few groans. He would open his eyes with deep stimulation but could not answer any questions. Per (K), this is how he was when he came from the ED. Per MR notes Pt. #1 was non-verbal on admission and unable to follow directions. RN (K), said she called MD (F) for admission orders at 9:25 PM. Orders received from MD (F), per MR review, were "activity as tolerated, increase oxygen to keep saturations at greater than 90% and plan for nursing home placement on discharge." PM. Per RN (K), she called Pt. #1 daughter, who lives several hours away to help with admission information as Pt. #1 was unresponsive and could not answer any questions. She told the daughter that he got a medication in the ED that made him this way and he got an antidote to reverse that. Per RN (K), MD (F) did not come in to see Pt. #1 until the next day. Per (K), she called MD (F) at 4:15 PM and informed him of Pt. #1 status and that his urine output and B/P were down and that he continued to be unresponsive. Orders received from MD (F) were "vital signs every 4 hours, supportive care." Per RN (K), she was told Pt. #1 was supportive care, comfort, palliative cares only. Per RN (K), she took care of him the whole night and Pt. #1 continued to be unresponsive.

Per nursing notes at 7:30 AM on 4/18/12 per RN (H), Pt. #1 is unresponsive, with edema throughout body, suprapubic catheter not draining well with very concentrated urine. Per interview, with RN (H) on 5/1/12 at 9:50 AM, report given to her by the night nurse made Pt. #1 "sound really bad so she went to see him right away." Per (H), Pt. #1 looked like he was dying. He had a death rattle, was short of breath, and unresponsive. She was told he was comfort cares only. RN (H) updated MD (F) of Pt. #1 condition. RN (H) attempted to contact family and left a message for the daughter at 8:00 AM. Pt. #1 family called back and she told them what was going on. Family were coming in but were 3 1/2 to 4 hours away. . MD (F) arrived around 10:30 AM on 4/18/12 to see Pt. #1 for the first time which was 14 hours after admission to the hospital. Per RN (H), Pt. #1 was unresponsive with no gag reflex. MD (F) told her he was dying but did not say why Pt. #1 was dying.

Per MD (F) progress note dated 4/18/12 at 10:26 AM, MD (F) wrote the following note: "Elderly male presented to emergency room with complaint of weakness. Was in ER for 10 hours attempting to stabilize the patient. Was not transferred due to DNR status and no interventions wanted by family. This AM, patient is entirely unresponsive, death rattle is evident, death is imminent, comfort care only."

There was no evidence found during staff interviews or MR documentation that the family had been contacted and agreed to "DNR status, no interventions and comfort cares only."

Per interview, with MD (F) on 4/30/12 at 4:00 PM, his understanding from MD (D) in the afternoon of 4/17/12 that Pt. #1 was elderly, weak, falling, could not stay at home and needed supportive care and a nursing home. Per MD (F), he stopped by the ED on his way home from clinic hours and peaked in on Pt. #1 who was either asleep or unresponsive. He thought he was going to be transferred because his condition had worsened because he looked bad. This was confirmed per review of Pt. #1 history and physical notes completed by MD (F). Per MD (F), he got a call from nursing staff in the middle of the night and he got the impression that Pt. #1 was too bad to transfer and was made a DNR. He thought Pt. #1 was no different then when he saw him in the ED. Per MD (F), when he first examined the patient on 4/18/12 he was clearly dying. He assumed the patient was a DNR so he did not look for family. When the family came in they were "shocked" by Pt. #1 condition and MD (F) said he was not aware they did not know what was going on.

Per interview, with ED MD (D) on 5/2/12, he said he is not sure why nursing and MD (F) thought Pt. #1 was being admitted for comfort cares only. He was admitted for pain control and to see if he could be discharged home or for further support at a nursing home until he could go home. Per MD (D), when he spoke with MD (F) earlier in the afternoon about Pt. #1 he spoke to him about several patients being admitted that day and one other one was comfort cares only and maybe MD (F) was confused about which patient was for comfort cares.

Per MD record, a CAT (computerized axial tomography) scan was ordered per family request at 4:17 PM on 4/18/12 and was negative for evidence of a stroke or brain bleed. Additional chest-x-rays and laboratory studies were done and showed renal failure but did not explain Pt. #1 change in condition following his admission to the ED. A cardiology consult revealed there was no acute myocardial infarction. Pt. #1 expired on [DATE] at 5:30 AM. Per MD (F), he did not alert the county coroner that they had an unexplained death, request an autopsy or alert the family to this possibility to seek answers to explain Pt. #1 sudden change in condition after admission to the hospital resulting in his death. Per MR review, MD (F) did not document the reason why the coroner was not notified or an autopsy requested of this unexplained death per hospital P&P.

Per interview, with the Chief of Staff and Director of the ED MD (L) on 5/1/12 at 1:50 PM, (L) said the following: "The coroner should have been contacted about Pt. #1 unexplained death and an autopsy requested. Pt. #1 should have been transferred to an acute care hospital and that the family should have been called by both MD (D) from the ED and MD (F) after admission, and that that there should have been a hand-off from MD (D) to MD (F) at the time of admission to the hospital to alert MD (F) to the change in Pt. #1 condition since they last spoke (at 4:15 PM on 4/17/12).