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 MEDICAL CTR KENOSHA 10400 75TH ST KENOSHA, WI 53142 May 16, 2018
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on record review and interview, the hospital failed to ensure that the RN (registered nurse) reports all changes in patient condition to the attending physician, in 1 of 5 in-patient records (Patient #1). This occurred in a total sample of 21 patients.

Findings include:

Record review of hospital policy, "Number 1016, last reviewed 2/1/2018" revealed " under 4.12 the nurse will notify the Physician or licensed independent practitioner if there are significant changes in the patient's vital signs based on position notification standards unless other parameters are defined in a Physician's order."

Record review on 5/8/18 at 12:10 PM of the "Customer Relations, Unique ID: PR " form revealed that Patient #1's representative filed a grievance on 3/3/18 regarding Patient #1's care during a 2/27/18 through 3/9/18 hospital stay, covering the following areas: "delay in treatment, inadequate care, treatment issues. Review of documentation written by Nursing Director A on 3/3/18 revealed Patient #1's representative told the 1st floor medical-surgical nursing staff that Patient #1 had a change in condition based on behavior changes and headache pain and requested nursing staff inform the attending physician for a medical evaluation. Patient #1's representative stated that nursing staff did not respond in a timely manner. Patient #1's representative told Director A that a phone call was made to a friend (who was a physician) in an attempt to get this friend to contact Patient #1's attending physician, in order to prompt a medical consult.

Record review on 5/8/18 at 1 PM of the "Default Flowsheet Data (2/27/18 at 12 AM -3/2/18 at 11:59 PM) revealed on 2/28/28 at 10:52 AM that RN D documented a change from previous pain status under the dementia pain assessment noting the patient was "moaning and groaning" with a "tense, distressed, fidgeting" posture, which was documented as still continuing at the 3:20 PM nursing assessment (approximately 4 hours later). There was no documented evidence that this change was reported to the admitting physician for evaluation.

Review of the "medical consultation" documentation by Hospitalist E on 2/28/18 at 4:40 PM revealed "Patient... post operatively had initially been doing well but however later started becoming more agitated, confused, trying to pull out lines. Patient showed signs of delirium. Was also complaining of a headache with cough. Non-productive sputum. Patient's (sic) been having a sitter at the bedside last night." The Hospitalist E ordered a immediate CT (computerized tomography) of head. At 7:10 PM on 2/28/18, the findings were "acute infarction (stroke) involving the posterior right temporal and parietal lobes" likely caused by an embolism (blood clot).

Record review of nursing documentation on 2/28/18 from 10:52 AM through 4:40 PM revealed no documented evidence that any nursing staff called the attending physician to report changes in condition or patient representative's medical concerns.

During interview with Chief Nursing Officer F on 5/8/18 at 10:15 AM, F verified that there were "no written notes to confirm that the nursing staff called the attending physician" when patient changes or patient representative's concerns were voiced. There was no documentation to confirm how Hospitalist E was notified to come and evaluate Patient #1.
VIOLATION: CONTENT OF RECORD Tag No: A0449
Based on record review and interview, the hospital failed to ensure that patient's medical records described significant changes in the patient's condition, in 1 of 5 in-patient records (Patient #1). This occurred in a total sample of 21 patients.

Findings include:

Record review of hospital policy, "Number 2131, last reviewed 7/12/2016" revealed under "4.5.b - Pertinent progress notes must be entered at time of the observation and must be sufficient to permit continuity of care and /transfer of the patient. Final responsibility for an accurate description in the medical record of the patient's progress rests with the attending physician".

Record review on 5/8/18 at 12:10 PM of the "Customer Relations, Unique ID: PR " form revealed that Patient #1's representative filed a grievance on 3/3/18 regarding Patient #1's care during a 2/27/18 through 3/9/18 hospital stay, covering the following areas: "delay in treatment, inadequate care, treatment issues. Review of documentation written by Nursing Director A on 3/3/18 revealed Patient #1's representative told the 1st floor medical-surgical nursing staff that Patient #1 had a change in condition based on behavior changes and headache pain and requested nursing staff inform the attending physician for a medical evaluation.

Record review of the "Default Flowsheet Data (2/27/18 at 12 AM -3/2/18 at 11:59 PM) at 5/8/18 at 1 PM revealed on 2/28/28 at 10:52 AM, RN D documented a change from previous pain status under the dementia pain assessment noting the patient was "moaning and groaning" with a "tense, distressed, fidgeting" posture, which was documented as still continuing at the 3:20 PM nursing assessment while Patient #1's family was present.

Record review of nursing documentation on 2/28/18 from 10:52 AM through 4:40 PM revealed no documented evidence that any nursing staff responded to Patient #1's representative's concerns or documented any attempts to reach attending physician to report potential significant changes.

During interview with Chief Nursing Officer F on 5/8/18 at 10:15 AM, F verified that there were "no written notes to confirm that the nursing staff called the attending physician" when patient changes or documented patient representative's concerns when voiced. There is no documentation to confirm how Hospitalist E was notified to come and evaluate Patient #1.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation and interview, the hospital failed to follow aseptic infection control techniques in 2 of 2 hospital nursing service areas observed (medication pass and hemodialysis services). This occurred in 2 of 2 patients observed (Patient #'s 12 and 13) for nursing services practices in a total sample of 21 patients.

Findings include:

1) Observations on 5/9/18 9:47 AM of medication administration to Patient #12 in Room 109 revealed that RN (Registered Nurse) G did not wipe the table surface of the COW (computer on wheels) used to prepare Patient #12's medication which was being stored in patient's room. RN G failed to hand wash, after using the computer's name-band scanning device which was stored at the back of the computer, before putting on clean gloves used to administer medications.

During interview with Chief Nursing Officer F on 5/9/18 at 3 PM, F verified "nurses are suppose to use aseptic technique, hand wash between glove change and use clean surfaces to prepare meds".

2) Observations on 5/9/18 of RN H performing discontinuation of dialysis by fistula on Patient #13 in Room 105 revealed patient's room signage for contact isolation precautions. RN H failed to place a clean drape under the left arm before removing dialysis venipuncture needles and holding venipuncture sites individually until bleeding was stopped. RN H failed to use aseptic technique to remove vascular access needles and provide hemostasis (stop bleeding) on a clean surface.

During interview with Magnet Program Manager I on 5/9/18 at 2:45 PM, I verified "the removal of dialysis needles was a clean process and required a clean surface".
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on record review and interview, the facility failed to ensure that a thorough investigation of the grievance details was completed before sending a resolution response letter to complainants, in 4 of 5 patient grievances reviewed (Patient #'s 1, 2, 3 and 5). This occurred in a total sample of 21 patients.

Findings include:

Hospital policy "Number 99, Patient Complaint: Hospital based services including accredited ambulatory surgical centers, last reviewed 3/2/18" documented under "7.5- acknowledge the complaint via telephone or sending a letter of acknowledgement within 7 days of receipt of the complaint/grievance..., 7.6- Investigate the complaint/grievance and request input from those involved, as needed. 7.7- Come to a resolution and send a resolution letter to the patient within 30 days of acknowledgement of the complaint/grievance if possible. The letter must provide the patient with a written notice of its decision that contains the name of the facility contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion...".

1) Record review on 5/8/18 at 12:10 PM of the "Customer Relations, Unique ID: PR " form revealed that Patient #1's representative filed a grievance on 3/3/18 regarding Patient #1's care during a 2/27/18 through 3/9/18 hospital stay, covering the following areas: "delay in treatment, inadequate care, treatment issues, treatment not provided, unexpected complication and unexpected outcome". As of 5/8/18, there was no documented evidence that the details of Patient #1's grievance had been investigated.

During interview with Risk Management Director B on 5/8/18 at 12:10 PM, B stated "...we're waiting on results of a root cause analysis", B stated "root cause analysis data is privileged information, and cannot be shared with anyone".

2) Record review on 5/8/18 at 12:10 PM of the "Customer Relations, Unique ID: PR " form revealed that Patient #2 filed a grievance on 3/25/18 regarding "delay in treatment" while in the emergency department. Review of the complaint response letter attached to this form dated 4/5/18 revealed medical record review and staff interviews were conducted to investigate the patient's allegations. There was no documented evidence of date and time of record review or the date and time or who was interviewed as part of this investigation. There was no documented evidence that an investigation was conducted per the complaint response letter or per hospital policy.

During interview with Risk Management Director B on 5/8/18 at 12:10 PM, B stated "I do not have documented details of what was done to investigate this complaint."

3) Record review on 5/8/18 at 12:10 PM of the "Customer Relations, Unique ID: PR " form revealed that Patient #3's family member filed a grievance on 3/13/18 regarding "treatment issue, unexpected outcome". Review of the complaint response letter attached to this form dated 4/30/18 revealed medical record review, staff interviews and referral for physician review were conducted to investigate the patient's allegations. There was no documented evidence of date and time of record reviews or dates and time of interviews, with outcome of the findings. There was no documented evidence that an investigation was conducted per the complaint response letter or per hospital policy.

During interview with Risk Management Director B on 5/8/18 at 12:10 PM, B stated "I do not have documented details of what was done to investigate this complaint."

4) Record review on 5/8/18 at 12:10 PM of the "Customer Relations, Unique ID: PR " form revealed that Patient #5's family member filed a grievance on 12/14/17 regarding "insufficient physician communication". Review of the complaint response letter attached to this form dated 1/24/18 revealed that "staff discussion" was conducted to investigate the allegations. There was no documented evidence of who was part of this "staff discussion, the time or date when it took place and what was discussed. There was no documented evidence that the complaint was provided to the physician in question for review/comments. There was no documented evidence that an investigation was conducted per the complaint response letter or per hospital policy.

During interview with Risk Management Director B on 5/8/18 at 12:10 PM, B stated "I do not have documented details of what was done to investigate this complaint."

During continued interview with Risk Management Director B on 5/8/18 at 12:10 PM, B stated that the unit managers/department heads usually handle the investigation and respond to complainants, and stated "we do not always review investigative details" to ensure thoroughness.
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
Based on record review and interview, the facility failed to ensure that it provided patients/ patient representatives filing grievances with a timely response, in 1 of 5 patient grievances (Patient #1). This occurred in a total sample of 21 patients.

Findings include:

Hospital policy "Number 99, Patient Complaint: Hospital based services including accredited ambulatory surgical centers, last reviewed 3/2/18" documented under "7.5- acknowledge the complaint via telephone or sending a letter of acknowledgement within 7 days of receipt of the complaint/grievance..., 7.6- Investigate the complaint/grievance and request input from those involved, as needed. 7.7- Come to a resolution and send a resolution letter to the patient within 30 days of acknowledgement of the complaint/grievance if possible... However, depending on the nature and complexity of the complaint, this time period may be extended as needed to allow adequate time to fully resolve the patient's concerns." Review of this hospital policy revealed no documented evidence of a time frame for resolution of a complaint that requires extended investigation to ensure that it is completed as soon as possible.

During interview with Risk Management Director B on 5/8/18 at 12:10 PM, B revealed that a time frame for an extended investigation was not set in policy nor in practice.

Record review on 5/8/18 at 12:10 PM of the "Customer Relations, Unique ID: PR " form revealed that Patient #1's representative filed a grievance on 3/3/18 regarding Patient #1's care during a 2/27/18 through 3/9/18 hospital stay, covering the following areas: "delay in treatment, inadequate care, treatment issues, treatment not provided, unexpected complication and unexpected outcome". Email communications with Patient #1's representative revealed that the complainant sent an email on 3/27/18 detailing concerns voiced to Director of Nursing/Case Management A on 3/3/18. On 4/25/18, the complainant emailed Risk Management Director B to check the status of the investigation. There was no documented evidence that as of 5/8/18 (2 months and 5 days later) and this grievance had been investigated and resolved.

During interview with Risk Management Director B on 5/8/18 at 12:10 PM, B stated "a resolution letter or verbal notice has not been given to the complainant yet."
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on record review and interview, the facility failed to ensure that it provided patients/patient representatives filing grievances with a written notice of the investigative resolution, in 1 of 5 patient grievances (Patient #1). This occurred in a total sample of 21 patients.

Findings include:

Record review on 5/8/18 at 12:10 PM of the "Customer Relations, Unique ID: PR " form revealed that Patient #1's representative filed a grievance on 3/3/18 regarding Patient #1's care during a 2/27/18 through 3/9/18 hospital stay, covering the following areas: "delay in treatment, inadequate care, treatment issues, treatment not provided, unexpected complication and unexpected outcome". Email communications with Patient #1's representative revealed that the complainant sent an email on 3/27/18 detailing concerns voiced to Director of Nursing/Case Management A on 3/3/18. On 4/25/18, the complainant emailed Risk Management Director B to check the status of the investigation. There was no documented evidence that as of 5/8/18 (2 months and 5 days later) this grievance had been investigated and resolved.

During interview with Risk Management Director B on 5/8/18 at 12:10 PM, B stated "a resolution letter had not been sent to the complainant".

Record review of hospital policy "Number 99, Patient Complaint: Hospital based services including accredited ambulatory surgical centers, last reviewed 3/2/18" documents under "7.7- Come to a resolution and send a resolution letter to the patient within 30 days of acknowledgement of the complaint/grievance if possible. The letter must provide the patient with a written notice of its decision that contains the name of the facility contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion."
VIOLATION: MEDICAL STAFF RESPONSIBILITIES Tag No: A0358
Based on record review and interview, the hospital failed to ensure their physicians completed a H&P (History and Physical) examination within 24 hours of the patient's admission, in 1 of 5 in-patient hospital admissions (patient #1). This occurred in a total sample of 21 patients.

Findings include:

Record review on 5/7/18 at 2:30 PM revealed that Patient #1 was admitted to the 1st floor medical-surgical unit as an in-patient on 2/27/18 at 8:45 PM. There was no documented evidence of a H&P completed within 24 hours after admission.

During interview with Chief Medical Officer C on 5/8/18 at 9:30 AM, C stated that "the H&P was not done or updated after the hospital admission, it should have been done."