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.

MERCY HEALTH SYSTEM CORP 1000 MINERAL POINT AVE JANESVILLE, WI 53548 March 21, 2013
VIOLATION: DISCHARGE PLANNING NEEDS ASSESSMENT Tag No: A0806
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on MR review, review of P&P, and interview with staff (F), in 1 of 5 MR (2), the facility failed to ensure discharge planning is completed to determine patient needs after discharge. This deficiency potentially affects all Pts treated at the facility.

Findings include:

Review on 3/13/13 in the PM of facility policy titled Discharge Planning, last revised 5/11/11, states under 2.0 "The discharge planning evaluation includes the evaluation of the patient's current living environment, functional abilities, capacity fore self-care, availability of caregivers, and use of home health or supportive services. The likelihood of returning to the environment from which the patient entered the hospital is addressed, along with the likelihood of the patient needing post-hospital services and the availability of services."

Pt #2's MR review on 3/13/13 at 2:15 PM revealed Pt #2 was admitted on [DATE] with an acute upper gastric bleed. There is no documentation in the MR of any discharge planning for Pt #2 other than living alone in an apartment. This is confirmed in interview with RNIA F on 3/13/13 at 2:15 PM, adding discharge planning should have been completed for Pt #2.
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on MR review, review of P&P, review of Pt rights that are to be provided upon admission, and interview with staff (B, E and F), in 5 of 5 MRs (1, 2, 3, 4 and 5), the facility failed to ensure patient rights are provided upon admission and include all pt rights. In 2 of 5 MRs (3 and 4) the facility failed to ensure the Pt or their representative was provided and acknowledged receipt of the Medicare Important Notice (IM). This deficiency potentially affects all Pts treated at the facility.

Findings include:

Review on 3/13/13 in the PM of facility policy titled Medicare Beneficiary Notification of Discharge Appeal Rights, reviewed 6/11 states under 3.1. "Initial Notice: Patient Registration. Patient Registration is responsible for the delivery of the Important Message (IM) to all patients admitted to an inpatient level of care. Registration staff will deliver the IM to patients or their representatives in person. Case Management/UR/Nursing. If it is not possible to deliver the IM in person at the time of registration, Case Management, UR or nursing staff will deliver the IM in person, telephonically, via certified mail, or by other electronic means in accordance with CMS regulations..."

Per review of MRs for Pts 1, 2, 3, 4 and 5 on 3/13/13 between 9:50 AM and 3:45 PM, there is no documentation in the MR Pts have received their rights, This is confirmed in interview with RNIA E and F on 3/13/13 at 10:30 AM and between 2:15 PM and 3:45 PM.

Per interview with CNO B on 3/13/13 at 4:15 PM, CNO B said giving the Pts their rights is not documented in the MR. CNO B could no say how the facility assures rights are given to the patients.

Per review on 3/13/13 at 1:00 PM of the facility Pt rights that are to be provided upon admission, the following rights are not included:

The right to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital.

The patient has the right to receive care in a safe setting.

The patient has the right to be free from all forms of abuse or harassment.

The patient has the right to the confidentiality of his or her clinical records.

All patients have the right to be free from physical or mental abuse, and corporal punishment.

All patients have the right to be free from seclusion.

Pt #3's MR review on 3/13/13 at 2:50 PM revealed, Pt #3 was admitted on [DATE]. There is an IM in the MR with no signature, date or time by the Pt or their representative. This is confirmed in interview with RNIA F on 3/13/13 at 2:50 PM, adding the IM notice should have been acknowledged with a signature, date and time.

Pt #4's MR review on 3/13/13 at 3:00 PM revealed, Pt #4 was admitted on [DATE]. There is no IM in the MR. This is confirmed in interview with RNIA F on 3/13/13 at 3:00 PM, adding the IM notice should have been given and acknowledged with a signature, date and time.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on review of facility complaints, review of P&P and interview with staff, in 2 of 6 complaints reviewed (1 and 6) the facility failed to provide a written response to Pt concerns. This deficiency potentially affects all Pts treated at the facility.

Findings include:

Review on 3/13/13 in the PM of facility policy titled Patient Complaint/Grievance Mechanism revised 9/30/11, states under 3.6 "The Health System will provide a response to each complaint. This response may be written or verbal. Whenever possible, the complaint is resolved."

Pt #1's complaint received at the facility via Discharge Phone Call, on 1/31/13 regarding a claim Pt #1 was discharged too early. Outcome of the investigation notes dated 2/3/13 state "Discharge was appropriate." There is no documentation of a send to the Pt with the complaint investigation findings. This is confirmed in interview with CSR J on 3/13/13 at 1:45 PM, and agreed a letter should have been sent to the complainant.

Pt #6's complaint received at the facility via Discharge Phone Call, on 1/17/13 regarding a claim Pt #6 was discharged too early. Outcome of the investigation notes dated 1/29/13 state "patient was ready for discharge." There is no documentation of a send to the Pt with the complaint investigation findings. This is confirmed in interview with CSR J on 3/13/13 at 1:45 PM, and agreed a letter should have been sent to the complainant.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on MR review and interview with staff (B, E and F), in 5 of 5 MRs (1, 2, 3, 4 and 5) the facility failed to ensure consents are timed to prior to administering treatment or procedures. This deficiency potentially affects all Pts treated at the facility.

Findings include:

Per interview with CNO B on 3/13/13 at 10:30 AM the facility does not require a time on the consent to treat forms.

Pt #1's MR review on 3/13/13 at 9:50 AM the consent signed by Pt #1 on 1/29/13 does not have a time. This is confirmed in interview with RNIA E on 3/13/13 at 10:30 AM.

Pt #2's MR review on 3/13/13 at 2:15 PM revealed the consent signed by Pt #2 on 2/24/12 does not have a time. This is confirmed in interview with RNIA F on 3/13/13 at 2:15 PM.

Pt #3's MR review on 3/13/13 at 2:50 PM revealed the consent signed by Pt #3 on 12/29/12 does not have a time. This is confirmed in interview with RNIA F on 3/13/13 at 2:15 PM.

Pt #4's MR review on 3/13/13 at 3:00 PM revealed the consent dated 12/25/12 is not signed by Pt #4 nor representative and is not witnessed by staff for Pt inability to sign. This is confirmed in interview with RNIA F on 3/13/13 at 2:15 PM.

Pt #5's MR review on 3/13/13 at 3:45 PM revealed the consent signed by Pt #5 on 12/29/12 does not have a time. This is confirmed in interview with RNIA F on 3/13/13 at 2:15 PM.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
Based on MR review, interview with Pt #1 and interview with staff (E, I and N), in 1 of 5 MR (1) the facility failed to provide and document hygiene care in the MR, and provide discharge instructions as described in the discharge summary. This deficiency potentially affects all Pts treated at the facility.

Findings include:

Interview with Pt #1 on 2/28/13 at 2:07 PM, Pt #1 stated she was in the hospital from 1/29/13 to 1/31/13 and did not received a bath or shower until the morning of 1/31/13, when given two washcloths, and no towels to clean herself.

Review of Pt #1's MR on 3/13/13, revealed the evening of admission nursing documentation at 9:58 PM indicated Pt #1 was independent with toileting and bathing. On 1/30/13 at 4:30 PM nursing indicated Pt #1 was independent with toileting and bathing. Documentation under Skin Integrity (Adult) Hygiene Care there is one entry on 1/31/13 at 2:54 AM "linen change". There are no other entries related to hygiene between admission on 1/29/13 and discharge on 1/31/13. This is confirmed in interview with RNIA E on 3/13/13 at 10:00 AM.

Per interview with RN I on 3/13/13 at 3:10 PM, she confirmed we worked the night shift on 1/30-1/31/13 and documented the note "linen change". RN I stated the CNAs usually do baths, but could not remember if she assisted or provided a set up for Pt #1 that night.

Per interview with CNA N on 3/13/13 at 12:10 PM, who worked the night shift for 1/30-1/31/13, CNA N stated they usually provide the "Bath in a Bag" heated washing packet to pts or set up with wash cloths, but did not recall Pt #1. CNA N stated they are expected to chart baths under the category Skin Integrity Hygiene Care, and confirmed there was no bath nor refusal of bath documented.

The discharge instructions provided on 1/31/13 at 12:54 PM has a diagnosis listed as Anemia Associated with Blood Loss, no activity restrictions and to contact MD if signs and symptoms of infection. The discharge summary states as the primary diagnosis as Peptic esophagitis with non-bleeding antral ulcers, to see primary MD in 3 days and follow a GERD (gastroesophageal reflux disease) diet. Per telephone interview with CNO B on 3/20/13 at 4:25 PM there are no additional discharge instructions to match the discharge summary instructions.