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REEDSBURG AREA MEDICAL CENTER 2000 N DEWEY AVE REEDSBURG, WI 53959 Nov. 14, 2016
VIOLATION: GOVERNING BODY Tag No: C0241
Based on record review and interviews, the facility failed to ensure 1 of 1 staff (Staff A) was licensed and qualified to perform Registered Nurse responsibilities.

Findings include:

Interview on 11/14/2016 at 9:40 AM with Vice President Clinical Practice (VPCP) E stated that Staff A was hired on 5/31/16, but failed to produce her nursing license ten weeks after beginning orientation in the facility. VPCP E then looked at Staff A's hiring file "in early to mid-August" and found discrepancies with Staff A's middle initial and spelling of the last name on the social security card and Wisconsin Driver's license when compared to Staff A's Wisconsin Department of Safety and Professional Services nursing credential search and facility application form. When asked if there was a formal Quality Improvement investigation or Root Cause analysis, VPCP E answered "no."

On 11/14/2016 at 1:15 AM, a record review of Staff A's personnel file showed a different middle initial and spelling of the last name on the Wisconsin Department of Safety and Professional Services licensing search when compared with Staff A's driver's license and social security card.

On 11/14/16 at 9:40 AM, interviewed Hospital President C. When asked if the facility had reported to the State of Wisconsin Office of Caregiver Quality, the response was "no." When asked if the facility had performed a formal investigation of how this had occurred, the response was "no." When asked if they had a policy on verifying staff licensing upon hire, the response was "no." When asked if they developed a policy to prevent staff from misrepresenting themselves or their credentials/license in the future President C replied "no, we sent an email to the leadership staff letting them know that we were tightening up the process already in place, but there is no formal policy on hiring."

On 11/14/16 at 10:00 AM during an interview with Vice President of Staff Development (VPSD) F, VPSD F stated that thorough audits were completed for the time Staff A was employed, 5/31/2016 - 9/4/2016. VPSD F stated Staff A "never really got off orientation. Staff A was only independent on 7/21/2016 and 7/22/2016 for four hour shifts each day before the house supervisor began working intensively with Staff A on a 1:1 basis, before that Staff A was with a preceptor on 1:1."

An 11/14/2016, 11:15 AM record review, the Violation Record-Employee, dated 8/4/16, Staff A did make five medication errors between the dates of 8/2/16 - 8/3/16. 1) Staff A documented giving 2 Immodium, but Staff A had only taken 1 from the Med Drawer, 2) Staff A charted phenytoin was given, but it was not taken from the med drawer, 3) Staff A charted Nonformulary Alinia given but not taken from med drawer, 4) Staff A charted simethicone given before it was taken from the med drawer, and 5) Staff A did not give a schedule xalatan."

A record review of patient audit log on 11/14/2016 at 12:25 PM, revealed Staff A accessed eight charts between the dates of 7/21/2016 and 7/22/2016. Medications were given and skin assessments were performed independently. VPSD F stated that "Staff A's documentation was checked later in the shift by a Registered Nurse since Staff A was still on orientation."

Interview on 11/14/16 at 12:30 PM, Chief Operating Officer (COO) D stated there is no formal policy regarding staff hiring or how the hospital will respond to a situation like this in the future. "Administration is reinforcing what we already have. We discussed this in our 10/18/16 leadership committee meeting and sent the email out to the managers on 8/11/2016." COO D stated "it is on the checklist and the email sent to the managers and leadership at Reedsburg Area Medical Center (RAMC,) I don't think we need a policy."
VIOLATION: ORGANIZATIONAL STRUCTURE Tag No: C0240
Based on record review and interview the facility failed to ensure 1 of 1 (staff A)was licensed before employment.

Findings include:

Staff at this facility failed to ensure policies are developed for the hiring and vetting of potential employees.(see C-241)