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.

ASCENSION SE WISCONSIN HOSPITAL - ST JOSEPH CAMPUS 5000 W CHAMBERS ST MILWAUKEE, WI 53210 March 22, 2012
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
Based on medical record review, review of hospital medical staff rules and regulations and staff interview, the hospital's governing body failed to ensure that 1 of 1 consulting physician's reviewed (Cardiologist B) performed medical consultations according to hospital bylaws. This has the potential for affect all patients receiving consultations ordered by attending physicians. Actual patient population could not be determined.

Findings include:

The 3/20/12 review of the hospital's "Medical Staff Rules and Regulations-dated 11/11/2011" reflects the following on page 4:
"3. Consultations.
a. Responsibility of Requesting Consultations. The patient's attending is responsible for requesting consultation when indicated...
b. Essentials of a Consultation
i) A satisfactory consultation includes:
(1) A review of the patient's medical record.
(2) A history and physical examination of the patient appropriate to the
clinical circumstances.
(3) A signed opinion by the Consultant in the medical record."

The 3/20/12 review of the hospital's "Medical Staff Rules and Regulations-dated 11/11/2011" reflects the following on page 18:
"c. History and Physical Examination Requirements.
i. Comprehensive History and Physical examination Content:
...(3) Past History: Known allergies, current medications, systems
review, past surgical history, previous hospitalization s...".

The 3/20/12 medical record review of Patient #1 reflects that on 3/7/12 (no time given) consulting Cardiologist B ordered a blood pressure medication (Maxide 37.5/25 mg.) to be given by mouth daily that was currently listed in Patient #1's drug allergy list. There was no documented evidence of risk /benefit by Cardiologist B for ordering this medication. Review of Cardiologist B's dictated consultation records dated 3/5/12 at 5:54 p.m. and 3/6/12 at 7:46 a.m. reflects no documented review of Patient #1's allergies. This section is left blank.

There is no documented evidence that Cardiologist B reviewed Patient #1's allergy listings before ordering this blood pressure medication in accordance with medical staff rules and regulations. The patient was given the medication for 2 days with no adverse significant change in condition.

The above information was verified in interview on 3/20/12 at approximately 4 p.m. by Director of Quality Improvement I.
VIOLATION: PHARMACIST RESPONSIBILITIES Tag No: A0492
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on surveyor observation, review of hospital employee orientation and education files and staff interview, the hospital failed to ensure job orientation documentation was complete for 1 of 3 pharmacist (Pharmacist G) reviewed. This has the potential to affect the 4th floor patient care unit population, which has a bed census of 61.

Findings include:

Surveyor observations were made of Pharmacist G on 3/21/12 at approximately 10:10 a.m. at the decentralized pharmacy workstation on the 4th floor patient care unit. Pharmacist G demonstrated how medical orders for medications were received and transcribed in the pharmacy computer. Pharmacist G was responsible for all medical transcription and pharmacy ordering and scheduling of all patient medication orders for the 4th floor patient care unit at the time of the observation.

The 3/21/12 review of the "Central Pharmacist Training Checklist" of Pharmacist G at approximately 2 p.m. This checklist reflects that 58 training "topics", each reflecting that the trainer pharmacist has "shown" the orientee pharmacist the topic, and that the orientee pharmacist has "exhibited" the skill. Only 30 of the 58 skills were checked as "shown", and only 10 skills were checked as "exhibited". There was no documentation on this checklist to verify that all 58 skills were not required, and there was no signature or date of the trainer pharmacist to verify orientee competency. Dates on the "topics shown" and/or "topics exhibited ranged from "6/29" (sic) to 7/5 (sic)".

The 3/21/12 review of the "Virtual Edge: Print Candidate Profile" reflects that Pharmacist G was hired by the hospital on [DATE] as a "Pharmacist Intern Graduate".

The above information was verified in interview by Director of Pharmacy K, on 3/21/12 at approximately 2:30 p.m., who stated that all pharmacist training records would be reviewed to ensure that they were up-to-date.