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 ST LUKES MEDICAL CENTER 2900 W OKLAHOMA AVE MILWAUKEE, WI 53215 March 21, 2013
VIOLATION: DELIVERY OF DRUGS Tag No: A0500
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on facility complaint documentation, patient and staff interview and facility policy, the hospital failed to ensure that all medications brought from home were identified and secured by qualified hospital staff. This occurred in 1 of 1 patients (Patient #1) using home medications during an observational hospital stay, in a total sample of 7 patients; having the potential to affect the total patient population of 237 patients.

Findings include:

The 3/18/13 review of hospital complaint form "Case Information-PR Event # 3" documents that Patient #1's hospital parish Nurse C filed a complaint by email with the hospital on [DATE] about observational status hospital stay on 1/11/13 to 1/15/13, and security of home medication brought with her during that hospital stay. The complaint documents the patient's home medications "were put on the counter in her room. Her prn Ativan (anti-anxiety medication) was pinned the board. When patient was able to walk, she placed her meds in her bedside table (safer)."

On 3/19/13 at approximately 8:45 a.m., Manager of Inpatient Pharmacy L was interviewed, and stated that she reviewed Patient #1's medical record and could not identify that a qualified hospital individual had made identification of the medications brought in by this patient on the 1/11/13 for this observational hospital stay. Manager L stated review of the medication administration record shows that the only medication used from this patient's home medications was Potassium Chloride (mineral supplement) used 1/12/13 through 1/15/13.

The 3/20/13 review of Policy No: 2012 effective 11/08, states under "III. A. 3 and 4. Medications brought from home must be positively identified by a qualified individual such as: physician, physician assistant, registered nurse or a pharmacist. If necessary, identification of the medication must be made on the pharmacist. If necessary, identification of the medication must be made on the basis of identifying marks on the medication form itself. Visual identification of the medications physical integrity should be performed as well. Medications deemed to not be used in the hospital are to be returned to the patient's family or the patient to be removed from the facility, If the medication(s) cannot be given to the patient's family, the medications will be stored and returned to the patient upon discharge..."

Patient #1 was interviewed on 3/21/13 at 1 p.m. and stated that she brought her medications from home as requested by the hospital on [DATE], and stated that when she got to her room the medications were put on the counter and the IV Ativan and syringes were put in a plastic ziplock bag and pinned to the board in her room.
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of hospital complaint documentation, hospital policy and patient and staff interviews, the hospital failed to ensure that complaints lodged by 5 of 5 patients in the complaint survey sample (Patient #'s 1, 2, 3, 4 and 5) were investigated within the hospital policy timeframes or had documentation of notification that the investigation would take longer than expected timeframes. This occurred in a total sample of 7 patients, inclusive of 2 inpatient observations, and has the potential to affect the total hospital census of 237.

Findings include:

The 3/20/13 review of "Policy 99, revised 1/2010" states under "V. H" that a Level 2 complaint /grievances are written or verbal complaints that cannot be resolved at the time of the complaint by the staff present, is postponed for later resolution, is referred to other staff for resolution, requires investigation, and /or requires further actions for resolution. Under "VII.B", the policy states the level 2 complaint/grievance coordinator or decision-making body or individual or designee will respond in writing to the complainant, patient, or patient representative within 7 business days after the complaint's filing with Aurora Health Care. All attempts will be made to meet the 7 day requirement but if not met reasons for not meeting it will be documented.

1) The 3/18/13 review of the "Case Information-PR Event # 3" documents that Patient #1's hospital parish Nurse C filed a complaint by email with the hospital on [DATE] about observational status hospital stay and security of home medication brought with her during that hospital stay. This document states the department assigned to investigate the complaint was not given this complaint until 3/1/13. As of 3/20/13, the hospital cannot provide any documentation to show that this complaint was investigated, or that the complainant received documentation within the required timeframe.

AVP A was interviewed on 3/19/13 at approximately 5 p.m. and stated that PCM B spoke to Patient #1 on 1/14/13 about the admission criteria and observation status. AVP A stated that she knew the hospital received the complaint about the medications on 2/7/13 by the parish Nurse C, but had no further information/documentation to offer to show the hospital did an investigation or responded to the Patient #1 per hospital policy.

Patient #1 was interviewed on 3/21/13 at 1 p.m. and stated that she was aware that the parish nurse had filed a complaint on her behalf, but that no one from the hospital had contacted her about the investigation or resolution of the medication issue as of this date.

2) The 3/18/13 review of the "Case Information-PR Event # 9" documents that Patient #2 made a verbal complaint on 12/17/12 to hospital Staff D that during a hospital stay on 11/29/12 and 11/30/12 that she was "rudely and roughly treated" by a nursing assistant on the night shift. The actions taken document that this complaint was referred to the department manager, risk management and service recovery, and that a verbal acknowledgement to complaint would be done. On 3/6/13 the complaint was documented as closed by Hospital Staff E, after Staff E called Patient #2 on 3/6/13 and "spoke with Patient #2 to offered apology. This document stated this complaint was reported to PCM F (department manager) on 2/5/13. There is no documented evidence on this form that an investigation of patient care allegations was done within the required timeframe. There was no documented evidence on this form that Patient #2 received information stating the investigation would be delayed past the 7 day timeframe set in the hospital policy.

PCM F was interviewed on 3/19/13 at approximately 4 p.m. and states that she received the complaint, and called Patient #2 on 3/2/13 to get the details of the allegation. PCM F stated that she has not contacted Patient #2, by phone or either in writing, to extend this complaint investigation or resolve it.

Patient #2 was interviewed on 3/21/13 at 1:30 p.m. and stated that she talked with PCM F on 3/2/13, and that PCM F promised to call her back on the following Tuesday. Patient #2 states that she has no received no further telephone calls or written information about her complaint from the hospital since 3/2/13.

3) On 3/18/13 at approximately 1:51 p.m. PCM H was interviewed about an complaint investigation initiated on 2/18/13 for Patient #3, who received care on his in-patient unit on 2/26/13 through 2/17/13. PCM H stated that he telephoned the patient's daughter (complainant) on 2/19/13 regarding the concerns she had about her mother's care. PCM H stated that he investigated all the concerns and interviewed staff involved, and had written a report of his findings after the investigation was conducted on 2/20/13. PCM H stated hat he had not contacted the complainant (Patient #3's daughter) after the investigation was conducted to give her the details of the investigation or tell her that the investigation timeframe had to be extended.

Patient #3's daughter was interviewed on 3/21/13 at approximately 3:30 p.m., and stated that she has not received any information about the complaint investigation results either verbally or in writing.

4) The 3/18/13 review of the "Case Information-PR Event # 9" documents that Patient #4 made a telephone call to the hospital to complaint of infection control issues regarding a needle injection and insensitive and/or rough handling during a 7/28/12 visit to the ED. Documentation on this form by ED Mgr. I on 1/31/13 indicates that the case is open and that the "ED MD aware as case presented as a MetaStar letter. ED CNS aware of patients concerns about bandage." The results stated that the CNS discussed findings with with ED RN, and education was provided. this document stated that no further action was needed from ED Mgr., Quality aware and following." As of 3/20/13, the hospital cannot provide any documentation to show the timeline of this complaint investigation or any documented evidence that the patient was contacted within the hospital policy timeframe.

AVP A was interviewed on 3/19/13 at approximately 5 p.m., and stated that no additional information could be found for this patient.

Patient #4 interviewed on 3/21/13 at approximately 4 p.m., and stated that he has not received any information about the complaint investigation results either verbally or in writing.

5) The 3/20/13 review of the "Case Information-PR Event # 8" documents that Patient #5's sister/ patient representative (Complainant #9) sent a letter to the hospital, that was received on 1/24/13, stating she wanted to file a grievance against the hospital on behalf of Patient #5. The complaint alleges that Patient #5 did not get appropriate treatment when she came to the ED. Under "Initial actions taken" it documents "referred to department manager, written acknowledgement to complainant, written acknowledgement to patient and /or family.

On 3/20/13, a letter was written by Risk Manager J to Complainant #9 thanking her for her complaint and stating the team would review her concerns was presented to this surveyor. The letter was dated 1/25/13, but there was not proof of mailing, and reflects no timeframe of resolution. Attached to this letter, was another letter dated 3/19/13 (43 days later), stating that investigation was completed and that the hospital shared the complainant's concerns and wanted to arrange a conference call to go over the details.

Risk Manager K was interviewed on 3/20/12 at approximately 2 p.m. and agreed that the initial letter did not give a timeframe of resolution as hospital policy states, and stated that the second letter did not meet the policy timeframes for resolution.

Complainant #9 was interviewed on 3/21/13 at approximately 4:40 p.m., and stated that she received the initial letter stating that they had received her complaint, but has not received or heard anything from the hospital as of 3/21/13 either verbally or in writing about there investigation.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of hospital complaint documentation, hospital policy, patient and staff interview, the hospital failed to ensure that complaints lodged by 5 of 5 patients in the complaint survey sample (Patient #'s 1, 2, 3, 4 and 5) were provided with written notification of the decision, including contact name, investigative steps, grievance results and completion date. This occurred in a total sample of 7 patients, inclusive of 2 inpatient observations, and has the potential to affect the total hospital census of 237.

Findings include:

The 3/20/13 review of "Policy 99, revised 1/2010" states under "V. H" that a Level 2 complaint /grievances are written or verbal complaints that cannot be resolved at the time of the complaint by the staff present, is postponed for later resolution, is referred to other staff for resolution, requires investigation, and /or requires further actions for resolution. It continues that "all level 2 complaints will result in a written response to the complainant, unless the complainant does not want a written response sent. The decision-making body, individual, or designee, will write the complainant and include the Level 2 complaint's resolution decision, including the name of the decision-making body, individual or designee, any steps taken on behalf of the complainant, patient or patient representative to investigate or review the complaint, outcomes of the investigation, and the date of completion."

1) The 3/18/13 review of the "Case Information-PR Event # 3" documents that Patient #1's hospital parish Nurse C filed a complaint by email with the hospital on [DATE] about observational status hospital stay and security of home medication brought with her during that hospital stay. As of 3/20/13, the hospital cannot provide any documentation to show that this complaint was investigated, or that the above resolution information was given to the complainant.

AVP A was interviewed on 3/19/13 at approximately 5 p.m. and stated that the hospital has no further information/documentation to offer to show the hospital did an investigation or responded to the Patient #1 per hospital policy.

Patient #1 was interviewed on 3/21/13 at 1 p.m. and stated that she was aware that the parish nurse had filed a complaint on her behalf, but that no one from the hospital had contacted her about the investigation or resolution of the medication issue as of this date.

2) The 3/18/13 review of the "Case Information-PR Event # 9" documents that Patient #2 made a verbal complaint on 12/17/12 to hospital Staff D that during a hospital stay on 11/29/12 and 11/30/12 that she was "rudely and roughly treated" by a nursing assistant on the night shift. There is no documented evidence on this form that an investigation of patient care allegations was done, or that Patient #2 received written resolution information.

PCM F was interviewed on 3/19/13 at approximately 4 p.m. and states that she received the complaint, and called Patient #2 on 3/2/13 to get the details of the allegation and began and investigation, but as of 3/19/13 has not finished it. PCM F stated that she has not contacted Patient #2, by phone or either in writing, to extend this complaint investigation or resolve it.

Patient #2 was interviewed on 3/21/13 at 1:30 p.m. and stated that she talked with PCM F on 3/2/13, and that PCM F promised to call her back on the following Tuesday. Patient #2 states that she has no received no further telephone calls or written information about her complaint from the hospital since 3/2/13.

3) On 3/18/13 at approximately 1:51 p.m. PCM H was interviewed about an complaint investigation initiated on 2/18/13 for Patient #3, who received care on his patient unit on 2/26/13 through 2/17/13. PCM H stated that he telephoned the patient's daughter (complainant) on 2/19/13 regarding the concerns she had about her mother's care. PCM H states that the complainant had concerns about medication administration, patient incontinence care and droplet isolation. PCM H stated that he investigated all the concerns and interviewed staff involved, and had written a report of his findings after the investigation was conducted on 2/20/13. PCM H stated hat he had not contacted or written the complainant (Patient #3's daughter) after the investigation was conducted to give her the details of the investigation per policy.

Patient #3's daughter was interviewed on 3/21/13 at approximately 3:30 p.m., and stated that she has not received any information about the complaint investigation results either verbally or in writing.

4) The 3/18/13 review of the "Case Information-PR Event # 9" documents that Patient #4 made a telephone call to the hospital to complaint of infection control issues regarding a needle injection and insensitive and/or rough handling during a 7/28/12 visit to the ED. As of 3/20/13, the hospital cannot provide any documentation to show the complaint has been investigated or written resolution was provided to the patient as per policy.

AVP A was interviewed on 3/19/13 at approximately 5 p.m., and stated that no additional information could be found for this patient.

Patient #4 interviewed on 3/21/13 at approximately 4 p.m., and stated that he has not received any information about the complaint investigation results either verbally or in writing.

5) The 3/20/13 review of the "Case Information-PR Event # 8" documents that Patient #5's sister/ patient representative (Complainant #9) sent a letter to the hospital, that was received on 1/24/13, stating she wanted to file a grievance against the hospital on behalf of Patient #5. The complaint alleges that Patient #5 did not get appropriate treatment when she came to the ED. Under "Initial actions taken" it documents "referred to department manager, written acknowledgement to complainant, written acknowledgement to patient and /or family.

On 3/20/13, a letter, dated 1/25/13, was written by Risk Manager J to Complainant #9 thanking her for her complaint and stating the team would review her concerns was presented to this surveyor. The review of this letter reflects that there is no timeframe for resolution given to Complainant #9. Attached to this letter, was another letter dated 3/19/13 (43 days later), stating that investigation was completed and that the hospital shared the complainant's concerns and wanted to arrange a conference call.

Risk Manager K was interviewed on 3/20/12 at approximately 2 p.m. and agreed that the initial letter did not give the details of resolution as the hospital policy states.

Complainant #9 was interviewed on 3/21/13 at approximately 4:40 p.m., and stated that she received the initial letter stating that they had received her complaint, but has not received or heard anything from the hospital as of 3/21/13 either verbally or in writing about there investigation.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on review of hospital complaint documentation, hospital policy, patient and staff interview, the hospital failed to ensure that all patient complaints of abuse are thoroughly investigated in a timely manner to protect patients from all forms of abuse. This occurred in 1 of 1 patient complaints alleging physical abuse (Patient #2) in a total sample of 5 patient complaints reviewed. This occurred in a total sample of 7 patients, and has the potential to affect the total census of 237 patients.

Findings include:

The 3/18/13 review of the "Case Information-PR Event # 9" documents that Patient #2 made a verbal complaint on 12/17/12 to hospital Staff D that during a hospital stay on 11/29/12 and 11/30/12 that she was "rudely and roughly treated" by a nursing assistant on the night shift. The actions taken document that this complaint was referred to the department manager, risk management and service recovery, and that a verbal acknowledgement to complaint would be done. Continued documentation on 3/6/13 shows the complaint was closed by Hospital Staff E, after Staff E called Patient #2 on 3/6/13 and "spoke with Patient #2 to offered apology. Will provide maid service for housekeeping times 1 as a courtesy. Also advised patient if (patient) had concerns about outstanding bills that (patient) should give me a call and I would see what I could do". This document stated this complaint was reported to PCM F (department manager) on 2/5/13. There is no documented evidence on this form that a thorough and timely investigation of these patient care allegations were done.

PCM F was interviewed on 3/19/13 at approximately 4 p.m. and states that she received the complaint, and called Patient #2 on 3/2/13 to get the details of the allegation. PCM F stated that she looked at the schedule yesterday (3/18/13) and by description from the complainant identified 3 NAs that could potentially have cared for Patient #2 on 11/29/12 and 11/30/12 . PCM F stated that she has only interviewed 1 of the 3 NAs identified as yet. PCM F stated that interview was conducted on 3/18/13, and that NA G denied the allegation. PCM F stated that the investigation was not finished. PCM stated that she had not received any training on how to conduct a caregiver investigation (patient allegation of abuse against a hospital staff member) and was not aware of any hospital policy timeframes for this investigation. PCM F stated that she is "not familiar" with Wisconsin Caregiver Misconduct regulations and reporting laws.

The 3/20/13 review of "Policy No: Adm-502, revised 6/00" states that the purpose of this policy is to provide guidance to all levels of employees in responding to a patient's claim of any type of misconduct by an employee, physician, resident-physician, student, contracted staff, volunteer, visitor or other patient." Under "V. Investigation", it documents "an internal investigation will occur immediately upon receiving the patient's account of the event. Pending the outcome of the investigation, the leader of the alleged in collaboration with Human Resources will determine if any disciplinary actions will be appropriate." Under "A. Leader/ Clinical Nurse Specialist or Nurse Clinician Role/ Responsibility" it documents "When possible, obtain a written statement from the accused immediately after being notified of the allegation and remove the accused from responsibilities that would put him/her in contact with or view of the patient /accuser. If appropriate, remove the accused from all patient contact by placing the accused on an investigatory suspension." Under "VI. Notification" it documents "1. Employees who may be accused of abuse or neglect of a patient ...will be notified that the incident will be reported to the Department of Health and Family Services (Wisconsin Caregiver Misconduct Bureau)."

Patient #2 was interviewed on 3/21/13 at 1:30 p.m. and stated that she talked with PCM F on 3/2/13 giving details of the abuse allegations. Patient #1 stated that she feels that the "rough treatment" given while rolling and turning during toileting, when she was on flat bedrest after back surgery on 11/29/12 and 11/30/12 harmed her and led to her not recovering as planned.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on facility incident documentation, medical record review and staff interview, the facility failed to ensure that 1 of 1 patients (Patient #2) received a re-evaluation of fall risk after surgery. This occurred in 1 of 1 patients having in-patient surgery in a total patient sample of 7, and has the potential to affect 237 patients.

Findings include:

The 3/19/13 review of the "Incident Manager" report filed by RN M on 12/12/12 documents Patient #2's fall from bed on 12/9/12 at 11:45 a.m. The narrative description "per the nursing assistant, NA set patient up on the side of the bed to wash up. NA left room to give pt. privacy. Pt. then tried to stand up, knowing her right leg gives out sometimes, which it did and pt. fell . Bed alarm was not on, but NA was right outside the room and heard pt. fall. Pt. did not have any injuries and said that she did not hit her head." Under "event information" it documents that a fall risk assessment was performed on admission and within 12 hours of the fall. Under "at time of the fall" it documents that this patient has not fallen within the past 30 days.

Review of the computerized medical record with Clinical Nurse Specialist Director N on 3/19/13 at approximately 5:30 p.m. reflects the patient was admitted on [DATE] for elective back surgery performed on 11/29/12. Review of the admission Morse fall risk scale puts the patient risk of fall at a score of 35 on 1/29/12 at 7 p.m. through 12/10/12 at 12:25 a.m. This fall risk assessment was re-evaluated at 11:07 a.m. on 12/10/12 when the fall risk score was recorded as 95 (higher number = higher risk of falls). Review of the inpatient discharge summary by surgeon on 12/10/12 at 2:29 p.m. documents that after surgery the patient was placed on flat bedrest, with gradually HOB increases beginning 12/2/12 and was not released to get out of bed until 12/3/12.

Director N stated in interview on 3/19/13 at 5:45 p.m. that the Morse Fall scale should have been re-assessed on 12/3/12 when the patient was allowed to get out of bed.