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 CENTER - GRAFTON 975 PORT WASHINGTON ROAD GRAFTON, WI 53024 Jan. 3, 2018
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
Based on record review and interview the facility failed to ensure prompt resolution, notification of investigative results of grievance and have a specific time frame for investigation in 1 of 5 grievance investigations reviewed.

Findings include:

The facility policy titled "PATIENT COMPLAINT: HOSPITAL BASED SERVICES INCLUDING ACCREDITED AMBULATORY SURGERY CENTERS" DATED 9/30/16 was reviewed on 1/2/18 at 2:30 PM. This document stated on page 6 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 acknowledgment of the complaint/grievance if possible. The letter must provide the patient with 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. 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."

Facility grievance #PR was reviewed on 1/2/18 at 2:45 PM. Patient #1's family filed the grievance on 9/13/17 in regards to a guidewire being left in Patient #1 after insertion of a central line. Attached to the grievance there is background and investigative notes along with 3 different letters written to the family member that filed the grievance. All 3 of the letters (dated 10/12/17, 11/10/17 & 12/8/17) contain the same letter that stated "Your concerns regarding your father's care remain under review. As we discussed, after the review is complete I will contact you to arrange a time for us to discuss the findings of the review."

An interview was conducted with Clinical Risk Manager A who stated "We are still working on getting all of the pieces put together and investigation done. The plan is to have a sit down meeting with (Patient #1's) family when we have everything wrapped up."
VIOLATION: CONTENT OF RECORD - OTHER INFORMATION Tag No: A0467
Based on record review and interview the facility failed to ensure the medical record was complete including pain assessments and re assessments to determine pain control needs of the patient in 6 of 11 medical records reviewed (Patient #1, Patient #5, Patient #6, Patient #9, Patient #10 and Patient #11).

Findings include:

The facility policy titled "PAIN MANAGEMENT" dated 11/30/16 was reviewed on 1/2/18 at 1:00 PM. This document stated on page 4 under "PROCEDURE" "5.1 Procedures for the assessment of pain. a. Care givers will screen each patient for the presence of pain (yes/no) upon admission. b. Thereafter, patients are monitored for pain by the appropriate caregiver according to the following assessment guidelines; i. Inpatients that deny pain or are not suspected to have pain are assessed daily. ii. For inpatients that report or are suspected to have pain, assessment that is more frequent may be required. The frequency of assessments will depend on patient condition and needs per patient's plan of care...c. If pain is indicated, the appropriate caregiver will complete a pain assessment. The assessment includes the following characteristics/potential contributing factors: i. Onset (establish during initial evaluation) ii. Pain location iii. Pain quality (e.g., sharp, dull, aching) iv. Comfort/function pain score at rest and with activity v. Pain pattern (intermittent or continuous) vi. Aggravating factors (e.g., activity, movement, coughing) vii. Alleviating factors (discussed during history; subsequently reevaluated as an intervention.)" The document continued on page 7 under "c. Evaluate the pharmacological pain interventions, the following general guidelines for reassessment of pain intensity/behavior are recommended: i. Oral medication-reassess pain intensity/behavior within 30-60 minutes of administering an oral pain medication. ii. IV (intravenous) pain medication-reassess pain intensity/behavior within 15-30 minutes of administering an IV pain medication."

Patient #1's medical record was reviewed on 1/2/18 at 3:03 PM. On "Nursing Flowsheet" under "PAIN" registered nurse documented "Pain Assessment Frequency" as "q 4 hours" (every 4 hours). Pain assessment was completed on
8/30/17 at 8:47 PM then at 3:00 AM (six hours later), then at 9:30 AM (six and a half hours later), 12:04 PM then 5:15 PM (five hours later), on 9/3/17 at 8:00 AM then 1:40 PM (five hours later), on 9/4/17 at 7:48 AM then at 1:54 PM (six hours later), at 3:47 PM then 9:17 PM (five and a half hours later), on 9/6/17 at 12:28 AM then 7:53 AM (seven hours later), then 12:56 PM (five hours later), at 4:20 PM then 12:15 AM (almost eight hours later), on 9/8/17 at 11:30 AM then at 8:00 PM (nine hours later), on 9/10/17 at 11:30 PM then at 4:30 AM (five hours later), on 9/17/17 at 3:00 PRN then at 8:00 PM (five hours later), on 9/19/17 at 3:30 PM then at 8:00 PM (four and a half hours later) and on 9/20/17 at 3:00 PM then 8:00 PM (five hours later).

Patient #5's medical record was reviewed on 1/2/18 at 2:11 PM. On "Nursing Flowsheet" under "PAIN" registered nurse documented "Pain Assessment Frequency" as "q 4 hours" (every 4 hours). Pain assessment was completed on 12/24/17 at 10:04 PM then at 3:19 PM (five hours later) and at 6:32 PM then at 1:37 AM (seven hours later).

Patient #6's medical record was reviewed on 1/2/18 at 2:42 PM. On "Nursing Flowsheet" under "PAIN" registered nurse documented "Pain Assessment Frequency" as "q 4 hours" (every 4 hours). Pain assessment was completed on 10/10/17 at 2:59 PM then at 7:47 AM (four hours and 45 minutes later) then at 4:05 PM (eight hours later).

Patient #9's medical record was reviewed on 1/3/18 at 8:00 AM. On "Nursing Flowsheet" under "PAIN" registered nurse documented "Pain Assessment Frequency" as "q 4 hours" (every 4 hours). Pain assessment was completed on 8/13/17 at 2:08 PM then at 8:00 AM (six hours later).

Patient #10's medical record was reviewed on 1/3/18 at 8:20 AM. On "Nursing Flowsheet" under "PAIN" registered nurse documented "Pain Assessment Frequency" as "q 4 hours" (every 4 hours). Pain assessment was completed on 8/7/17 at 9:54 AM then at 4:52 PM (seven hours later), at 11:00 PM then again at 7:52 AM (nine hours later), on 8/10/17 at 9:09 AM then 2:50 PM (five hours and 45 minutes later), on 8/11/17 at 9:00 AM then at 3:59 PM (seven hours later),then at 8:59 PM (five hours later), on 8/12/17 at 12:38 AM then at 7:10 AM (six and a half hours later) and on 8/13/17 at 2:20 AM then at 7:28 AM (five hours later).

Patient #11's medical record was reviewed on 1/3/18 at 8:31 AM. On "Nursing Flowsheet" under "PAIN" registered nurse documented "Pain Assessment Frequency" as "q 4 hours" (every 4 hours). Pain assessment was completed on 8/9/17 at 3:45 PM then at 8:30 PM (seven hours and 45 minutes later), on 8/10/17 at 1:30 PM (17 hours later), 3:22 AM, 8:19 AM (five hours later). On 8/11/17 pain assessment was completed at 12:00 PM then at 5:36 PM (five a half hours later), at 8:00 PM then 1:00 AM (five hours later). On 8/13/17 pain assessment was completed at 3:22 PM then at 8:10 PM (five hours later), on 8/14/17 at 7:00 AM then at 1:09 PM (six hours later), on 8/15/17 at 3:10 PM then 7:59 PM (five hours later) and on 8/16/17 at 3:23 AM then at 8:43 AM (five hours later).

An interview was conducted with Manager of Healthcare Infomatics D on 1/2/18 at 1:30 PM who stated "It is the nurse's judgement based on patient assessment as to how frequent pain assessment is done. If they document q (every) 4 hours than that's when it should be done." The above deficiencies of assessments being completed greater than the 4 hour time intervals documented were confirmed at the time of chart reviews by Manager of Healthcare Infomatics D.