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.

COLUMBIA ST MARYS HOSPITAL OZAUKEE 13111 N PORT WASHINGTON RD MEQUON, WI 53097 July 2, 2019
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview the facility failed to ensure that each patient or patient's representative signed for receiving the patient's rights (in the consent to treat) in 5 of 10 medical records (Patient #'s 1, 2, 3, 4 & 5) and that "An Important Message from Medicare" was reviewed and signed by patient or patient's representative within 2 days of admission per facility policy in 2 of 10 medical records (Patient #2, & 3) in a total universe of 10.

Findings include:

The facility document "CONDITIONS OF TREATMENT" revealed "PATIENT RIGHTS AND RESPONSIBILITIES: I acknowledge that I have received a copy of Ascension Columbia St. Mary's Patient's Rights and Responsibilities Brochure."

The facility policy titled "Important Message from Medicare (IM)" ID # 26 last reviewed on 6/2019 was reviewed. This document revealed under "PURPOSE/RATIONALE: To ensure compliance with the Centers for Medicare & Medicaid Service (CMS) regulation, AW facilities shall appropriately notify all inpatient Medicare beneficiaries about their discharge appeal rights using the "Important Message from Medicare About Your Rights Form" ("IM"). POLICY: The IM shall be delivered to inpatients within two (2) calendar days of admission or at preadmission, but not more than seven (7) calendar days before admission, the follow-up copy of the IM shall be delivered as far in advance as possible before discharge, but no more than (2) calendar days before the day of discharge. If the follow-up notice is delivered on the day of discharge, the patient must be given at least four (4) hours prior to discharge to consider their right to request a QIO review. Retained copies must be placed in the patient's medical record. Initial Delivery of the Important Message from Medicare: 1. The Patient Access Department/designee shall discuss the IM with patients and/or the patient's representative and obtain his/her signature acknowledging their receipt and understanding of the information. The original signed form is placed in the patient's medical record. A copy of the IM is provided to the patient or patient's representative. 2. For inpatients that are not seen by Patient Access, the IM is directed to the appropriate nursing unit/designee for distribution and completion with the other admission paperwork by assigned personnel. Delivery of Follow-up Important Message: 1. Within no more than two (2) days prior to discharge, the appointed designee will communicate to the Medicare beneficiary and/or representative his/her inpatient rights on discharge. The appointed designee will provide the follow-up IM and obtain the patient or representative's signature. The original signed copy of the follow-up notice shall be given to the patient or representative. The signed copy shall be placed in the medical record."

Examples of consent to treat:

Review of Patient #1's medical record revealed Patient #1 was admitted to the facility on [DATE] with admitting diagnosis of acute hypoxic respiratory failure and was discharged on [DATE]. There was no documented consent for treatment in Patient #1's medical record.

Review of Patient #2's medical record revealed Patient #2 was admitted on [DATE] with increased shortness of breath and congestive heart failure and discharged on [DATE]. There was no documented consent for treatment in Patient #2's medical record.

Review of Patient #3's medical record revealed Patient #3 was admitted on [DATE] with a cardiac arrhythmia and potential pacemaker placement and discharged on [DATE]. There was a documented consent for treatment in Patient #3's medical record that had no date.

Review of Patient #4's medical record revealed Patient #4 was admitted on [DATE] with pneumonia and discharged on [DATE]. There was a documented consent for treatment in Patient #4's medical record that had a staff signature but no date.

Review of Patient #5's medical record revealed Patient #5 was admitted on [DATE] with pneumonia and discharged on [DATE]. There was no documented consent for treatment in Patient #5's medical record.

Examples of An Important Message from Medicare:

Review of Patient #3's medical record revealed Patient #3 was admitted on [DATE] and discharged on [DATE]. There was no documented "Important Message from Medicare (IMM)" in Patient #3's medical record given prior to discharge.

Review of Patient #4's medical record revealed Patient #4 was admitted on [DATE] and discharged on [DATE]. The admission IMM was documented as signed by the patient on 1/8/2019 (6 days after admission). There was no documented IMM in Patient #4's medical record given prior to discharge.

The above findings were confirmed in interview with RN Manager of AAU/ICU F and Quality Improvement G at the time of record reviews.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on record review and interview the facility failed to ensure the patient is notified of grievance investigation resolution, per facility policy in 1 of 5 grievance investigations reviewed. This deficiency directly affects Patient #1.

Findings include:

The facility policy # 00 "Patient Complaints and Grievances" last reviewed 4/2018, reveals under G. "once the grievance has been resolved, the department leader will provide a written notice of the resolution to the patient/guardian who filed the grievance. This notice will be provided in clear language and will include the following information: 1. Name of a hospital contact person. 2. Explanations of steps taken on behalf of patient to investigate the grievance. 3. Results of grievance investigation process. 4. If appropriate, identify the action plan for improvement. 5. Date the investigation was completed. 6. Contact information of the agency to whom the patient may appeal if still unsatisfied. 7. Response letters must be sent EVEN if appropriate staff members meet with the patient and family members and resolved the grievance during discussions (phone or in person)."

Per phone call with Patient #1 on 6/25/2019 at 10:50AM patient stated that she did not receive any follow up from Risk Management.

During interview with Risk Manager D on 7/1/2019 at 12:50 PM Risk Manager D confirmed that this incident would be classified as a grievance. Risk Manager D, when asked about follow up with Patient #1, stated "it looks like we didn't provide any follow up."
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on record review and 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 in 1 of 1 patient complaints. (Patient #1)

Findings include:

The 7/2/2019 review of facility policy # 69 Abuse or Neglect - Suspected last revised 4/2017 states under 5. Suspected Elder Adult-At-Risk 2.B. "Any heath care professional who suspects evidence of Elder-at-Risk criteria will immediately document evidence in the patient's medical record. Examples of tangible evidence would be: malnutrition, unexplained injuries, bruises, or burns..."

In phone interview with Patient #1 on 6/25/2019 at 10:50AM he/she confirmed that no exam or police contact was offered or provided.

There was no documented evidence that the hospital offered or provided an exam or report to local police after the alleged incident.