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 MARYS HOSPITAL 2251 NORTH SHORE DR RHINELANDER, WI 54501 Sept. 11, 2019
VIOLATION: CONTENT OF RECORD Tag No: A0449
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview the facility failed to follow physician orders in 4 of 10 (Patient #'s 1, 3, 4 & 10) medical records for the ACU unit reviewed in a total number of 10 records reviewed.

Findings include:

The facility policy titled "Process Standard Assessment" ID: 68 last reviewed 4/1/2019 revealed "2. When "routine" vital signs are ordered they are defined as every 4 hours x 48 hours. Then, if stable and afebrile (no fever) for 24 hours, tid (once an 8-hour shift) or as specifically ordered by the physician. 3. More frequent or in-depth assessments will be done as actual or potential problems are identified. 8. The patient can expect to have neurological status assessed utilizing the Glasgow Coma Scale upon admission and at least every 4 hours for the first 24 hours for a newly diagnosed cerebral vascular accident, seizure disorders and head injuries, and other neurological disorders. If after 24 hours they are stable, the patient can expect neurological assessments every 8 hour shift for 24 hours, then discontinued."

Patient #1 was admitted on [DATE] for chief complaint of lightheadedness, had diagnosis of hypertension and acute cerebral vascular accident confirmed by MRI on 7/1/2019. There was documented neurological checks greater than four hours on 7/1/2019 (day of MRI confirmation of stroke) at 10:07 AM and 4:08 PM (six hours later).

Patient #1 had physician admitting orders of vital signs "q (every) 4 hours" on 6/30/2019. On 7/1/2019 vital signs were documented at 1:36 AM, 6:21 AM (five hours later), 1:55 PM (seven hours later), 6:45 PM (5 hours later) and on 7/2/2019 at 1:48 AM then 6:25 AM (five hours later).

Patient #2 was admitted on [DATE] with a diagnosis of "Possible Acute Ischemic Stroke" and hypertension. Physician admitting orders documented "Neuro Checks q 4 hours". Neurological checks were documented on 8/2/2019 at 8:00 AM then 5:50 PM (nine and a half hours later).

Patient #2 had unit vital sign orders of every four hours. Vital signs were documented on 8/1/2019 at 10:29 PM then on 8/2/2019 at 6:00 AM (seven and a half hours later).

Patient #3 was admitted on [DATE] with a admitting diagnosis of "Acute Ischemic Stroke" and discharged to a skilled nursing facility on 6/28/2019. The admission physician orders documented "Neurological checks Every 4 hours." Neurological checks were documented on 6/24/2019 at 4:17 AM then 10:09 AM (six hours later), 7:20 PM (nine hours later), on 6/26/2019 at 12:10 AM then 8:15 AM (eight hours later), on 6/26/2019 at 4:52 PM then 6/27/2019 and at 1:51 AM (nine hours later).

Patient #3 had physician admitting orders of vital signs "q 4 hours". Vital Signs were documented on 6/23/2019 at 6:00 PM then 11:13 PM (five hours later), 5:25 AM then 10:00 AM (four and a half hours later), on 6/25/2019 at 9:33 AM then 2:24 PM (five hours later), on 6/26/2019 at 1:50 AM then 6:10 AM (four and a half hours later), and at 1:38 PM then 6:00 PM (four and a half hours later).

Patient #4 was admitted on [DATE] for stroke and right sided facial drooping and discharged home on 7/10/2019. Admission orders did not specify neurological or vital sign checks frequency unit policy stated as above. Neurological checks were documented on 7/7/2019 at 2:08 PM then 8:30 PM (six hours later), then on 7/8/2019 at 7:30 AM (11 hours later), and at 3:37 PM (eight hours later).

Patient #4 had physician admitting order of vital signs "q 4 hours". Vital signs were documented on 7/7/2019 at 6:57 AM then at 11:30 AM, then 10:00 PM (eleven hours later), on 7/8/2019 at 8:16 AM (ten hours later), at 4:00 PM (eight hours later), and at 10:00 PM (six hours later).

The above findings were confirmed in interview at the time of record review with Manager of Inpatient Care F who stated when asked expectation of vital signs and neurological checks "Yes they were done greater than 4 hours apart and they shouldn't be."

Patient #10 was admitted on [DATE] and discharged on [DATE] for chief complaint of "Syncope with patient needing CPR (Cardio Pulmonary Resuscitation) prior to admission, possible cardiac arrest." Patient #10 left the morning of 9/9/2019 against medical advice and prior to being seen by physician. Admitting orders to "Observation" status on 9/8/2019 documented "Vital signs: Per unit" which were every 4 hours according to facility policy for ACU unit. Vital signs were documented as completed on 9/8/2019 12:37 PM, 6:00 PM (six hours later) 9:43 PM and on 9/9/2019 at 6:18 AM (eight hours later).

The above findings were confirmed in interview at the time of record review with Registered Nurse I who stated when asked expectation of vital signs, "You're right. They should have been done every 4 hours."