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 COLUMBIA ST MARY'S HOSPITAL MILWAUKEE 2323 N LAKE DR MILWAUKEE, WI 53211 Nov. 19, 2018
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on record review and interview, the hospital failed to ensure that patient responses to nursing care were assessed in 2 of 10 behavioral health patients (7 and 8); and failed to ensure a focused health system assessment of the chief complaint(s) was conducted, in 2 of 13 (3 and 19) emergency department patients. This occurred in a total sample of 21 patients.

Findings include:

Record review of hospital policy "Assessment-Reassessment-Patient, ID: 11, last revised 5/2017" revealed "Each patient's care begins with an assessment to determine his or her initial needs and, as care proceeds, reassessments identify the individual's response to care provided... Emergency Department/Urgent Care... 2. D. Focused (nursing) assessments will be done for each patient based on established standards and guidelines to identify needs, plan and initiate care, and evaluate effectiveness of interventions."

1) Record review of Patient #7's "11/8/18 at 3:29 p.m. Behavioral Med Progress Note-RN (Registered Nurse)" by RN F revealed no documented evidence of assessed response to nursing actions conducted for the nursing diagnoses of "Admission/Depression/Anxiety" and "Impaired Respiratory Status related to Asthma".

2) Record review of Patient #8's "11/12/18 at 4:51 p.m. Behavioral Med Progress Note-RN" by RN G revealed no documented evidence of assessed response to nursing actions conducted for the nursing diagnoses of "Nutrition Management related to Diabetes Mellitus."

During interview with Behavioral Lead RN C on 11/14/18 at 11:20 a.m., C stated "they (response) are supposed to be filled in by the nurse".

3) Record review of Patient #19's "Patient Summary Report" revealed patient presented to the ED (Emergency Department) on 10/15/18 at 4:18 p.m. for evaluation of Altered Mental Status. Record review of the 10/15/18 at 5 p.m. ED focused nursing assessment revealed all "Review of Systems" assessment areas were not completed for this patient.

During interview with ED Manager D on 11/14/18 at 10:20 a.m., Manager D stated "Review of systems for the focused area(s) should be completed by the ED nurse".

4) Record review of the "Patient Summary Report" revealed that Patient #3 came to the ED on 5/22/18 at 7:14 p.m. with ETOH intoxication. The "ED Nursing Progress Note" by ED RN J at 7:42 p.m. revealed "patient fell forward out of wheelchair onto the ground in triage, did not appear to lose consciousness, was not having seizing motions, able to follow directions to stand self up and get back into chair, instructed to patient (sic) need to wait until room is available... , states understanding, waited less than 5 minutes and ambulated with steady gait out front to smoke a cigarette." RN J documented that when patient was called at 7:57 p.m. and at 8:29 p.m. on 5/22/18, there was no response (patient left without medical screening).

There was no documented evidence that RN J assessed and documented details of fall from wheelchair (whether wheelchair was locked, whether patient tripped over foot petals). There was no documented evidence that RN J asked Patient #3 if there was any injury or described how patient landed on floor to determine if patient needed a neurological exam or orthopedic exam to rule out injury. There is no documented evidence of how intoxicated Patient #3 was since there was no documented evidence that patient was alert, oriented and could answer questions coherently before leaving without a completed nursing triage assessment or MSE.

During interview with ED Manager D on 11/15/18 at 4:05 p.m., D stated that "There is no added information that could be identified."
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on record review and interview, the hospital failed to ensure that patient care plans were developed based on patient need, in 2 of 10 patients (5 and 9); and failed to ensure that care planned goals/outcomes were measurable, in 4 of 10 patients (7, 8, 9 and 10). This occurred in a total sample of 21 patients.

Findings include:

Record review of hospital policy "Documentation-Progress Notes-Focus Charting, ID: 99, last revised 3/2107, In-patient Behavioral Medicine ONLY:" revealed under "2. The nursing care plan will reflect psychiatric and medical problems being addressed during each hospital stay." and "4. Short term goals must be included in the nursing care plan. Goals and outcomes must be stated in measurable terms."

Behavioral Health Unit
1) Record review of ED (Emergency Department) records revealed Patient #5 came into the ED on 11/9/18 with complaint of Suicide Ideation, and blood alcohol of .125 gm/dl. (grams per deciliter), an abnormally high result. The patient was admitted initially to a medical unit due to cardiac issues found in the ED. Record review of the "11/10/18 at 4:24 p.m., Hospitalist progress note" revealed under "Plan... Mental Illness-Transfer to in-patient psych when bed available... ETOH (alcohol) abuse/transaminitis (abnormal liver function)-Monitor. Encourage cessation. Trend." Record review of the "Physician Information Sheet" revealed that Patient #5 was admitted to the hospital's in-patient BHU (Behavioral Health Unit/psych unit) on 11/11/18 at 1:35 p.m.

During interview with Patient #5 on 11/12/18 at 10:45 a.m., Patient #5 revealed use of alcohol when stressed with mental health problems. Patient #5 stated "I want the hospital to help, since the doctor told me I had a bad liver 2 days ago".

Record review of Patient #5's BHU "Patient Plan of Care" revealed no documented evidence of a care plan for ETOH monitoring or cessation.

During interview with BHU Lead RN C on 11/14/18 at 11:20 a.m., C stated "We did not do a care plan for ETOH cessation".

2) Record review of Patient #7's BHU "Patient Plan of Care" revealed no documented evidence of measurable goals ("outcome") for the following care plans: the "11/8/18-Increased Depression times 1 week; the 11/18/18-Anxiety, increased anxiety and outbursts and the 11/8/18-Respiratory Status, impaired gas exchange".

During interview with RN C on 11/14/18 at 11:20 a.m., C stated "These care plan outcomes are not measurable".

3) Record review of Patient #8's BHU "Patient Plan of Care" revealed no documented evidence of measurable goals ("outcome") for the following care plans: the "11/4/18-Recent increase in Depression related to financial and family stressors; 11/4/18-Reports of Suicidal Ideation with thoughts of not wanting to live with outcome goal of stabilization of patient from suicide thoughts and 11/13/18-Depression/Safety with outcome goal of decrease depression of agitation."

During interview with BHU Lead RN C on 11/14/18 at 11:20 a.m., C stated "These care plan outcomes (goals) are not measurable."

4.a.) Record review of Patient #9's "11/12/18 at 11:16 a.m. Psychiatric Evaluation" revealed under "Plan: given (onset of) psychosis while on Risperidone, patient agrees to trial Invega. Will not resume pro-psychotic meds, Amantadine, Vyvanse, Wellbutrin until psychosis controlled..."

Record review of Patient #9's BHU "Patient Plan of Care" revealed no documented evidence of a care plan for evaluation of medication effectiveness.

During interview with BHU Lead RN C on 11/14/18 at 3:20 p.m., C stated "We did not do a care plan for medications effectiveness."

4.b.) Record review of Patient #9's BHU "Patient Plan of Care" revealed no documented evidence of measurable goals ("outcome") for the following care plan: the "11/11/18-Suicidal Ideation with outcome goal of stabilization of patient from suicide thoughts."

During interview with BHU Lead RN C on 11/14/18 at 3:20 p.m., C stated "The care plan outcome is not measurable."

5) Record review of Patient #10's BHU "Patient Plan of Care" revealed no documented evidence of measurable goals ("outcome") for the following care plan: the "11/12/18-Depression with outcome goal of patient will have less Depression by 11/14/18."

During interview with RN C on 11/14/18 at 4 p.m., C stated "The care plan outcome is not measurable."
VIOLATION: CONTENT OF RECORD Tag No: A0449
Based on record review and interview, the hospital failed to ensure that BHU (Behavioral health Unit) nursing staff documented patient's aggressive behavior events requiring a hospital security staff response, in 2 of 4 events (9/6/18 at 2:14 p.m. and 9/11/18 at 3:03 p.m.); and failed to ensure that security officers responding to BHU nursing service calls to assist in the provision of patient care and treatment documented event details per hospital policy, 2 of 4 security calls (9/6/18 at 2:14 p.m. and 9/11/18 at 3:03 p.m.).

Findings include:

Hospital policy "Assistive Response for Aggressive Behavior, ID: 13, last revised 12/2017" revealed under "Policy... For difficult patients, associates may consult with other hospital department staff and resources, i.e. Behavioral Health Services, Administrative Representatives, Security, Patient Representatives, Spiritual Care, Clinical Nurse Specialists or Case Managers... 10. Documentation... B. All instances of patients displaying aggressive behaviors and the factors that led to the behaviors must be charted within the patient's medical record. C. Upon completion of the aggressive person situation, security will complete a Security Incident Report and forward to Risk Management, who will assure that a debriefing is done after the event."

1) Record review of the hospital's "Security Services Dispatch Log" for the BHU revealed that on 9/6/18 at 2:14 p.m. security services was dispatched to the BHU "Disorderly/Combative Patient- Requested Security to room 5112-2, patient wants to leave and is getting agitated." The log documents that security staff spent 12 minutes in the BHU. There was no documented evidence of a written security incident report. There was no documented evidence the BHU RN documented incident about security response and their actions to assist in calming the patient. The patient was not identified on the security log report or in the hospital's written response provided by Quality Director A on 11/14/18.

2) Record review of the hospital's "Security Services Dispatch Log" for the BHU revealed that on 9/11/18 at 3:03 p.m. security services was dispatched to the BHU "Disorderly/Combative Patient- Requested Security to Unit, Patient is trashing room and now requesting to leave unit." The log documents that security staff spent 43 minutes in the BHU. There was no documented evidence of a written security incident report. There was no documented evidence the BHU RN documented incident about security response and their actions to assist in calming the patient. The patient was not identified on the security log report or in the hospital's written response provided by Quality Director A on 11/14/18.

During interview with Quality Director A on 11/14/18 at 9:15 a.m., A stated "We cannot find nursing or security documentation for these two events."
VIOLATION: ORGANIZATION AND DIRECTION Tag No: A1101
Based on record review and interview, the hospital failed to ensure the ED (Emergency Department) followed hospital directives (policies), in 2 of 13 ED patients (4 and 13); and failed to ensure that appropriate patient follow-up was performed when necessary medical screening services were not provided during ED stay in 1 of 2 sexual assault patients (1). This occurred in a total sample of 21 patients.

Findings include:

Hospital policy "Patients Leaving Against Medical Advice/Elopement, ID: 46, 8/2018" revealed "A. Risks of leaving AMA (against medical advice) should be reviewed as soon as a patient indicates their intent to leave. If a patient continues to wish to leave AMA every attempt should be made to have a physician review the risks with the patient... D. Upon patient request or declaration of intention to leave AMA, the patient care team will assess the patient's physical and cognitive state." "Documentation requirements for all AMA departures and elopements: 1. All information related to the patient's AMA discharge shall be gathered and documented in the patient's health record, including, but not limited to: a. The patient's verbatim statement about why he or she wants to leave AMA, b. Contact or attempts to contact physician, c. Risks disclosed to the patient...". "3. Complete the AMA form used by the facility where the patient is being treated."

1) Record review of the "Patient Summary Report" revealed that Patient #13 came to the ED on 5/23/18 at 8:58 p.m. requesting a psychiatric evaluation. The "ED Nursing Progress Note" by ED RN (Registered Nurse) J at 11:23 p.m. revealed "Patient walks out of room and requests discharge papers, encouraged to wait and talk to MD (medical doctor) for full evaluation. Patient requesting to speak to someone about psych (sic) concerns, denies suicidal or homicidal ideation." The next progress note written by RN J at 11:28 p.m. revealed "Patient no longer in department, left without being seen".

There was no documented evidence that ED RN J attempted to have Patient #13 sign AMA (against medical advice) paperwork, or informed Patient #13 about the potential risks of leaving without a completed MSE (medical screening examination).

2) Record review of the "Patient Summary Report" revealed that Patient #4 presented to ED on 10/4/18 at 2:10 p.m. with complaints of Suicidal Ideation. The "ED Nursing Progress Note" by ED RN M at 3:11 p.m. on 10/4/18 revealed "Patient ambulated around the unit twice... Patient then stated I'm not staying here man. MD (Medical Doctor) aware."

There was no documented evidence that ED RN M attempted to have Patient #4 sign AMA (against medical advice) paperwork, or informed Patient #4 about the potential risks of leaving without a MSE (medical screening examination).

During interview with ED Manager D on 11/15/18 at 4:05 p.m., D stated that "There is no added information that could be identified for these patients."

3) Record review of the "Emergency Note ED, dated 9/8/18 at 11:09 a.m." by ED Physician H revealed Patient #1 received a MSE (Medical Screening Exam) after a sexual assault on 9/8/18. Physician H documented under "Impression and Course" that "Patient #1 left ED without prescription for HIV prophylaxis. I called patient multiple times but no answer and answering machine full. Will try to contact patient tomorrow."

Record review of the "ED Nursing Progress Note" dated 9/8/18 at 12:31 p.m. written by ED RN (Registered Nurse) I revealed "Patient given discharge instructions all questions answered. No Intravenous to remove, patient knows to go to Sinai (Hospital) for SANE (sexual assault evidence collection examination)."

There was no documented evidence that the hospital made any other attempts to contact Patient #1, or attempted to contact the hospital to which Patient #1 was referred to for the SANE to alert them or patient of the missed prescribed medication.