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.
|WAUKESHA MEMORIAL HOSPITAL||725 AMERICAN AVE WAUKESHA, WI 53188||April 16, 2013|
|VIOLATION: OPERATING ROOM POLICIES||Tag No: A0951|
|Based on record review, policy and procedure (P&P) review the hospital failed to ensure complete orders were received prior to completing surgical procedure in 4 of 10 surgical cases reviewed. This had the potential to affect all patients having surgery during the survey, 4/15/2013 = 27 and 4/16/2013 = 29.
On 4/16/2013 a review of pt's #5, 7, 8 and 10 records were completed with Clinical Informatics (CI) F.
At 12:20 PM a review of pt. #5's record was completed. The record showed pt. #5 had right hip surgery on 4/15/2013. The physician order does not have a physician signature.
At 12:28 PM a review of pt. #7's record was completed. The record showed pt. #7 had a laparoscopic appendectomy on 2/20/2013. There is no physician order.
At 12:37 PM a review of pt. #8's record was completed. The record showed pt. #8 had left knee surgery on 2/12/2013. The physician order does not have a physician signature.
At 12:51 PM a review of pt. #10's record was completed. The record showed pt. #10 had laparoscopic hernia surgery on 2/18/2013. There is no physician order, only a case request.
The above findings were cinfirmed with CI F at the time of review.
Review of P&P titled Orders for Patient Care, dated 7/2012 was completed on 4/17/2013 at 2:30 PM. The P&P states in part 2) All other patient care orders shall contain the following: d. Name and/or signature of the prescriber.