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 ST FRANCIS HOSPITAL 3237 S 16TH ST MILWAUKEE, WI 53215 Feb. 24, 2020
VIOLATION: LICENSURE OF PERSONNEL Tag No: A0023
Based on record review and interview the facility failed to ensure that all staff in the Emergency Department possessed a current license and listed on the State of Wisconsin Nurse Aide Registry according to state law to work as a Certified Nursing Assistant in 1 (Emergency Department Technician 2 E) of 10 Emergency Department Technician employee files reviewed.

Findings include:

The facility job description titled "Job Description As of February 24, 2020 Job Title: Emerg (Emergency) Dept (department) Tech (technician) II SetID: WIMI1 Job Code: 3" was reviewed on 2/24/2020. This document revealed "Minimum Qualifications Licensure/Certification/Registration: Required Credential(s): Certified BLS (Basic Life Support) Provider credentialed from the American Heart Association (AHA) obtained prior to hire date or job transfer date. One or more of the following: License Emergency Medical Tech credential from the state of Wisconsin obtained prior to hire date or job transfer date. Certified Nursing Assistant credentialed from the state of Wisconsin, and in Wisconsin Nurse Aide Registry with eligibility to work within a hospital setting."

Beginning in 1990 the federal government required all states to establish a "Registry" of persons who were eligible to work as a nurse aide in federally regulated facilities. Federal regulations require all states to keep such a list. Federal and State regulations require that a person's name is entered on the Wisconsin Nurse Aide Registry only after satisfactorily completing both a Wisconsin approved 1. Nurse aide training program, or basic nursing course for professional nurses or licensed practical nurses, and 2. Competency evaluation program. A person may also transfer from another state nurse aide registry if that person meets all requirements of the Wisconsin Nurse Aide Registry.

State of Wisconsin Department of Human Services Chapter 129 states "(30) (a) "Nurse Aide" means a person, regardless of the person's title, who provides routine client-related services under the supervision of a registered nurse or license practical nurse. "Nurse aide" includes any of the following: 1. Any person on the registry. 2. Any person providing nursing or nursing-related services to clients. 3. Any person who has successfully completed a training program under s. DHS 129.07 and a competency evaluation program under s DHS 129.08. 4. Any person employed to provide nursing or nursing-related services, or employed within the last 24 months as a nurse aide by a health care provider. 5. Any person eligible to be included on the registry under s. 146.40 Stats. (44) 'Registry' means the department's record of all persons who are eligible to be employed by a health care provider, and who have either: (a) Successfully completed a training and and competency evaluation program. (b) Met the eligibility requirements under s. DHS 129.09 (5) to be included in the registry."

Emergency Department Technician 2 E (ED Tech 2) personnel file was reviewed on 2/24/2020 at 1:00 PM. ED Tech E was hired on 8/18/2014 as a Certified Nursing Assistant for the Emergency Department. ED Tech 2 E gave the facility a certificate that indicated completion of a Nursing Assistant class in his previous state of Arizona. There was no documented proof of licensing in the state of Arizona as a Certified Nurses Aide. There was no documented proof of licensing in the state of Wisconsin as a Certified Nurses Aide and ED Tech E was not listed on the Wisconsin State Certified Nurses Aide registry as required by state and federal law to work as a Certified Nurses Aide in a hospital facility.

An interview was conducted with the State of Wisconsin Nurse Aide Program Coordinator O on 2/25/2020 who stated "When I called Arizona they couldn't find anything on him. There is nothing to prove that he has or had an active license."

An interview was conducted with Quality Coordinator B, Emergency Department Manager D and Director of Inpatient Services C at the time of the above listed personnel file. Emergency Department Manager D when asked where ED Tech E's license was stated "I don't know. I don't see it."
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview the facility failed to ensure that consent for treatment signatures were obtained on all Emergency Department patients or their representatives in 5 (Patient #'s 3, 4, 5, 6 & 7) of 10 out of a total of 10 emergency department medical records reviewed.

Findings include:

The facility policy titled "Consent for Treatment & Financial Agreement" # 88 was reviewed on 2/24/2020. This document revealed "Purpose: It is the policy of R1 and Ascension Wisconsin to support the patient or his/her representative to obtain their "Consent for Treatment and Financial Agreement" when patients are accessing services. The purpose of this policy is to ensure that appropriate consent is obtained for patients accessing services and to define the consistent process to follow in the collection of signatures on the Inpatient and Outpatient Consent for Treatment & Financial Agreement document. The Consent for Treatment and Financial Agreement signature is obtained by registration staff and/or staff of departments where patients present for services: -With each episode of care for all other services including, emergency room , inpatient, surgical services including GI (gastrointestinal) services and observation. Signature on the Form: The patient's signature is always obtained when the patient is of legal age ([AGE] years old) and able to sign."

Patient #3's medical record was reviewed on 2/24/2020 at 9:55 AM. Patient #3 was seen in the emergency department on 12/22/2019 requesting medication refills. There was no documented "Consent for Treatment" in Patient #3's medical record for this visit.

Patient #4's medical record was reviewed on 2/24/2020 at 10:10 AM. Patient #4 was seen in the emergency department on 1/1/2020 for suicidal ideations. There was no documented "Consent for Treatment" in Patient #4's medical record for this visit.

Patient #5's medical record was reviewed on 2/24/2020 at 10:30 AM. Patient #5 was seen in the emergency department on 1/1/2020 for suicidal ideations. There was no documented "Consent for Treatment" in Patient #5's medical record for this visit.

Patient #6's medical record was reviewed on 2/24/2020 at 10:30 AM. Patient #6 was seen in the emergency department on 1/2/2020 for altered mental status due to sepsis. There was no documented "Consent for Treatment" in Patient #6's medical record for this visit.

Patient #7's medical record was reviewed on 2/24/2020 at 11:15 AM. Patient #7 was seen in the emergency department on 1/31/2020 for hypertension. There was a documented "Consent for Treatment" in Patient #7's medical record for this visit but no signature present.

An interview was conducted with Quality Coordinator B, Emergency Department Manager D and Director of Inpatient Services C at the time of the above listed chart reviews. Emergency Department Manager D when asked if Consent for Treatment was present in electronic medical records of patient's listed above stated "No. I don't see them."