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.

AURORA LAKELAND MEDICAL CENTER W3985 COUNTY ROAD NN ELKHORN, WI 53121 Feb. 28, 2012
VIOLATION: PATIENT RIGHTS: PRIVACY AND SAFETY Tag No: A0142
Based on MR review, review of P&P and interview with staff, in 1 of 8 MR reviewed (# 2) the facility failed to ensure the correct Pt information including full name and birth date upon admission and confirmed prior to treatments per policy. This deficiency directly affected 1 Pt (#1) and potentially affected 159 Pts treated on the dates of the event and 157 Pts during the survey.

Findings include:

Facility policy reviewed on 2/27/12 at approximately 3:30 PM titled Patient Identification Policy dated 12/07 states under C. "Prior to the administration of medications or blood products, taking blood samples and other specimens for clinical testing or providing any other treatment, procedure or direct care service, patient identification will be verified by: 1. Using, at minimum, the two patient identifiers of : name and date of birth...III. A. When verbally verifying the name with the patient, do not state the name and ask the patient to confirm it. B. Verification without wristband present: Ask the patient to state and/or spell his/her name and another identifier: 1. First identifier: Please state and/or spell your name for me (John Jones)...2. Second identifier: What is the date of your birth? (May X, 19XX). C. Verification with the wrist band present: Actively involve the patient and family as needed. 1. First identifier: Name on wrist band (must match name on medication administration record, blood bag, etc.) 2. Second identifier: Date of birth on wristband (must match date of birth on medication administration, record, blood bag, etc.) IV. B. Proper identification must occur at the time of wristband placement and information must be verified with patient/family/significant other..."

Per surveyor review of the Pt #1 ER MR on 2/27/12 at 2:00 PM, Pt #1 arrived in the ER, via ambulance, on 2/21/12 at 11:41 PM with complaint of chest and abdominal pain. The ER MR was set up under Pt #2's name and birth date. This is confirmed in interview with PAR C on 2/28/12 at 7:20 AM, adding that she obtained this information from the P that transported Pt #1 to the facility. PAR C said in interview Pt #1 was referred to with Pt #2's first name, and there was no correction by Pt #1. PAR C said as soon as the error was discovered, when the consent form was ready for signing, approximately 1:15 AM on 2/22/12, the corrections to the MR were immediately completed.

The ER order sheet had one label with Pt #1's information covering a label with Pt #2's name. The orders included EKG, Xray, blood draw and a Verbal Order for MS. This was confirmed in interview with RM A on 2/27/12 at approximately 3:30 PM.

The ER log reviewed on 2/27/12 at approximately 3:00 PM revealed Pt #2's name registered as an admit on 2/21/12 at 11:41 PM, and Pt #1's name registered as an admit on 2/22/12 at 1:17 AM. There are no other Pts admitted between 2/21/12 at 12:00 AM to 2/22/12 at 11:59 PM with a same or similar name. The Face sheets with Pt #1's name and Pt #2's name reflect the same admit times as on the ER log. This is confirmed in interview with RM A on 2/27/12 at approximately 3:30 PM.

Per surveyor telephone interview with RN D on 2/27/12 at 3:20 PM, RN D confirmed when verifying the correct Pt prior to treatments, only the last name and allergies are confirmed.

Per surveyor interview with RN E on 2/28/12 at 7:32 AM, there was no wristband on Pt #1, when the blood draw was done, and confirmed the Pt's identification was not confirmed prior to the draw.

Surveyor telephone interview with P O on 2/28/12 at 10:51 AM, confirmed bringing Pt #1 to the ER via ambulance, and giving the information that related to Pt #2's name to the PAC. P O stated in interview he received the information from the first responders.

Per interview with HIM L on 2/22/12 at approximately 10:30 AM, the MR for Pt #2 was corrected to reflect "deceased " after the discovery of the Pt #1 being registered correctly. Per HIM L, Pt #2 died a couple months ago and the record had not been updated in the computer system.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation, tour, review of facility documents and interview with staff, in 3 of 3 interviews (B, R and G) the facility failed to ensure staff follow safe practices that prevent and control potential cross contamination, and ensure the safety of staff and patients, per policy. This deficiency potentially affected all 6 patients present in ER during the tour and a total of 157 patients treated during the survey.

Findings include:

Per tour and observation in the ER on 2/27/12 at 1:00 PM to 2:00 PM the following was observed by surveyor :

The clean supply room had an open Foley catheter kit, allowing an unsterile item for patient use. This was confirmed during tour at 1:10 PM with EMR B.

The soiled utility room was not secured and contained an open large gray bin half full of medication vials, intravenous bags, and syringes with varying amounts of medication still present, and a sharps container. This was confirmed during tour at 1:10 PM with EMR B.

Two portable supply carts were used for medication preparation, administration and taking blood samples. The used items were removed, and the cart was placed in position ready for use with the next patient, without cleaning potentially contaminated surface. This was discussed with EMR B at 1:45 PM.

At 1:40 PM, RN H who obtained blood from Pt #9 in treatment room #7 handled the filled blood tubing without gloves allowing for self contamination. The tubes were placed in a non-biohazard bag and handed to another RN to take to the laboratory. RN H was not observed washing after placing the blood tubing in the bag. This was discussed with EMR B at 1:45 PM.

At about 1:40 PM RN K entered and exited trauma room 11 including touching the privacy curtain, without the benefit of washing her hands. This was discussed with EMR B at 1:45 PM

Per interview with H F on 2/27/12 at 1:15 PM, H F said the large gray bin in the soiled room was filled by her emptying the small black containers by the Pyxis into the gray bin, stating "I just empty it (black hazardous container) rather than call the janitor to change it out". In interview, H F did not know if there were extra black hazardous waste containers available. The black container next to the Pyxis is labeled RCRA Hazardous Waste, and was not secured to prevent injury during disposal of items or spill.

Interview with EVS supervisor F on 2/22/12 at 1:30 PM the black container labeled RCRA Hazardous is supposed to be sealed when full and removed to the janitor closet for pick up. EVS supervisor F stated there are plenty of extra containers and they should not be dumped into the large container. EVS supervisor S confirmed during interview the soiled room was unsecured, and that all EVS staff had keys.

EVS supervisor F provided meeting minutes from 1/27/2012 with the EVS staff, that revealed discussion on the black hazardous waste containers and soiled rooms needed to be secure.
VIOLATION: SECURE STORAGE Tag No: A0502
Based on tour of the ER and interview with staff, in 1 of 1 tour the facility failed to ensure crash carts are not accessible to unauthorized patients and staff. This deficiency potentially affects all 6 patients in the ER at the time of the tour and 69 Pt treated in the ER during survey.

Findings include:

Per surveyor tour of the ER on 2/27/12 between 1:10 PM, Trauma room 8 and Cardiac room 4 contained one crash cart each with a breakaway lock. Per interview with EMR B on 2/27/12 at 1:10 PM, the breakaway locks were confirmed, and Pts and/or Pts family members are left alone in the rooms with curtains closed. This practice allows for unauthorized access to medications.