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ASCENSION SE WISCONSIN HOSPITAL - ST JOSEPH CAMPUS 5000 W CHAMBERS ST MILWAUKEE, WI 53210 Oct. 16, 2018
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview, the facility failed to ensure that it developed a written policy/procedure/protocol for the use of their sepsis recognition toolkit in the ED (Emergency Department), in 1 of 1 emergency room standards of practice (Sepsis recognition).

Findings include:

During interview with Quality Coordinator A on 10/11/18 at 9:20 a.m., A stated "we (the hospital) do not have a policy that directs nursing or medical staff on how to use the "Adult Sepsis and Septic Shock Management Optimization toolkit."

Record review of the hospital's "Adult Sepsis and Septic Shock Management Optimization toolkit, July 2018" revealed a patient screening tool with four primary criteria: temperature greater than 100.9 degrees Fahrenheit, heart rate greater than 111 beats per minute, respiratory rate greater than 23 breaths per minute and white blood cell count less than 4,000 cells per millimeter squared or greater than 14,000 cells per millimeter squared or 10% immature [DIAGNOSES REDACTED]s. Two of four of the criteria had to be met to result in a "positive" screen that resulted in an additional assessment for organ dysfunction.

During interview with ED Supervisor B on 10/15/18 at 10 a.m., B stated "The nurses use the sepsis screening tool on emergency room admission only." B stated "If the patient is negative for sepsis per the tool's criteria then patient's are not re-screened."

Record review of Patient #1 revealed a ED admission on 7/27/18 at 12:41 a.m. with chest pain, nausea and dizziness. A sepsis screen was conducted at 12:52 a.m. by RN (Registered Nurse) C and found to be negative. At 12:58 a.m., a blood test for the evaluation of Patient #1's white blood cell count was medically-ordered, with results obtained at 1:52 a.m. (18.8 cells per millimeter squared). There was no documented evidence that an additional primary sepsis screen was repeated after the white blood cell count results were obtained at 1:52 a.m. The hospital did not have a written policy/protocol or procedure that allowed for the documentation of repeated primary screenings during the patient's ED stay when status changes occurred or lab test results were reported after the admission sepsis screening process.