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.

Based on record review and interview the facility failed to promote patient rights in a safe environment when a caregiver was allowed to continue to treat patients after an allegation of abuse was made.

See Tag 0145
Based on record review and interview the facility failed to ensure safety of patients after notification of potential abuse against Patient #1 from RN (Registered Nurse) E. This had the potential to affect all patients seen in the Emergency Department by Dr. O from the evening of 9/6/2020 to morning of 9/8/2020.

Review of facility policy "Caregiver Misconduct and Injuries of Unknown Source Investigations and Reporting, AW" last reviewed 2/11/2020, revealed, "The purpose of this policy is to ensure that all patients/clients who receive care from entities owned or operated by Ascension Wisconsin remain safe and respected while receiving the highest level of of quality care and services...In addition this policy is intended to ensure compliance with all applicable State and Federal laws related to the reporting of caregiver misconduct. PROCEDURE: 2. Immediately upon learning of an Incident, steps to ensure that the patient/client is protected from possible subsequent Incident will occur."

Review of facility policy, "Event Reporting, AW" last revised 1/21/2020 revealed, "Response to Events: Patient Events: Any associate who witnesses, discovers, or is involved in a patient event should first ensure that medical treatment is provided and appropriate steps are taken to minimize the immediate potential for a future events. Entry into the ERS (Event Reporting System) should occur as timely as possible and before the end of an individuals shift." Review of the Adverse Safety event log revealed an entry made on 9/7/2020 describing the events of 9/6/2020 and the allegation of provider misconduct. In interview with RN E on 9/30/2020 she stated, "Dr. O was being confrontational with Patient #1 - he kept asking him about drug use. As the patient got more agitated so did Dr. O. I saw Dr. O put his full weight on Patient #1's arm and the patient yelled to stop that it was hurting him. Next thing I know Dr. O was hitting the patient in the face. I told him to leave the room and he did. At the end of my shift, before leaving for home, I entered a safety event. After the event happened, for the rest of the evening, I never let Dr. O be in Patient #1's room alone." When asked if he continued to see other patients RN E answered "Yes."

Patient #1 received lab and x-ray studies and was discharged to home with his father on 9/7/2020 at 5:53 AM. The ED Discharge Summary revealed, "stable condition, nasal fracture, abrasions and contusions... with discharge instructions for follow up with private physician in 2-3 days." Review of the nursing assessment on admission revealed, "bloody drainage noted from both nares (nose opening),nasal deformity noted."

Review of an email from Dr. O sent to his Medical Director Q on 9/7/2020 at 6:28 AM revealed that Dr. O described in his words the events that had occurred and denied ever striking Patient #1. Medical Director Q acknowledged the email and forwarded the message to Risk Management and the Howard Young Chief Executive Officer on 9/7/2020 at 7:41 AM with the message, "Here is Dr. O's recollection of events. I will be at HY (Howard Young) Wednesday if we can meet in person or virtually." Review of the ED (Emergency Department) work schedule for 9/7/2020 revealed that Dr. O worked 7:00 PM 9/7/2020 to 7:00 AM 9/8/2020. This was confirmed in interview with Risk Manager N on 10/7/2020 at 4:00 PM. Risk Manager N stated she did not receive notification of the incident until 9/8/2020 and started her investigation on that day. Confirmed that Medical Director Q had been made aware of the allegation via email on 9/7/2020. Risk Manager N stated that Dr. O was allowed to work because the investigation had not been completed. "They did add additional nursing staff to the 9/7/2020 shift in the ED."

Review of the interview with Dr. O conducted by Risk Manager N on 9/8/2020 at 5:30 AM revealed, "HR (Human Resources) and Dr. Q made the decision earlier to put Dr. O on Administrative leave due to the nature of the incident." In interview with Risk Manager N on 10/7/2020 at 4:00 PM Risk Manager N stated that HR met with their legal team and on 9/11/2020 informed Dr. O that he was terminated.