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.

THEDACARE MEDICAL CENTER-WAUPACA 800 RIVERSIDE DRIVE WAUPACA, WI 54981 Feb. 24, 2015
VIOLATION: RECORDS SYSTEM Tag No: C1116
Based on record review and interview, the facility failed to ensure there is complete documentation of nursing assessments and/or MD notification, in 5 of 10 MRs reviewed (5, 6, 7, 8 and 10).

Findings include:

On 2/24/15 between 2:00 p.m. and 3:10 p.m. the following records were reviewed with DON A and CM C:

Pt #6's MR review revealed Pt #6 arrived in the ED on 1/2/15 at 7:47 p.m., with a complaint of swollen leg. There is no documentation of the MD being notified the Pt was in the ED. This was confirmed by CM C on 2/24/15 at 2:08 p.m., who agreed the time should be documented in the MR.

Pt #7's MR review revealed Pt #7 arrived in the ED on 1/2/15 at 6:33 p.m., with a complaint of sore throat. There is no documentation of the MD being notified the Pt was in the ED. There is no documentation of a nursing assessment, including Pt's complaint,other than vital signs. This was confirmed by CM C on 2/24/15 at 2:45 p.m., who agreed these should be documented in the MR.

Pt #8's MR review revealed Pt #8 arrived in the ED on 1/2/15 at 6:05 p.m. with a complaint of a respiratory infection. There is no documentation of the MD being notified the Pt was in the ED. This was confirmed by CM C on 2/24/15 at 2:55 p.m., who agreed the time should be documented in the MR.

Pt #10's MR review revealed Pt #10 arrived in the ED on 1/2/15 at 7:39 p.m. with a complaint of a rash. There is no documentation of the MD being notified the Pt was in the ED. There is no documentation of a nursing assessment, including Pt's complaint, other than vital signs. This was confirmed by CM C on 2/24/15 at 3:07 p.m., who agreed these should be documented in the MR.






Pt. #5's closed ED MR was reviewed on 2/24/2015 at 2:55 p.m. accompanied by DON A who confirmed the following findings:

Pt. #5 arrived at the ED on 1/5/2015 at 5:17 p.m. The MD was notified that there was a new patient to be seen at 6:23 p.m. Pt. #5 was roomed into one of the ED rooms at 6:43 p.m. and, according to the ED log, left against medical advice at 7:50 p.m.

There is no documentation indicating that nursing completed a triage assessment or nursing assessment or that the MD completed a medical screening examination. There is also no form signed by Pt. #5 for leaving against medical advice.

In an interview with DON A on 2/24/2015 at 3:10 p.m., DON A stated, "There should be some sort of documentation in the record to indicate that this patient was taken back to a room in the ED but there is not."