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.

COMMUNITY MEMORIAL HOSPITAL W180 N8085 TOWN HALL RD MENOMONEE FALLS, WI 53051 Sept. 24, 2020
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 follow their policies and procedures by failing to ensure that each patient or patient's representative received their patient's rights in 4 of 11 medical records (Patients #1, #5, #6 or #7) and failed to ensure that "An Important Message from Medicare" (IM) was reviewed by the patient or patient's representative within 2 days of admission in 3 of 8 medical records meeting requirements to receive the IM (Patient #1, #5 & #6) in a total sample of 11 medical records reviewed.

Findings include:

Review of policy "Patient Rights and Responsibilities" #FH-COM.067 dated 12/04/2018 revealed "The Hospital will inform each patient, or when appropriate, the patient's representative... of the patient's rights. Whenever possible, this notice will be provided before providing or stopping care."

Review of policy "Important Message from Medicare" # -011, not dated, under policy #1 revealed "Within 48 hours of the date of inpatient admission [facility] must issue the IM (Important Message from Medical Notice) and obtain the signature of the Medicare beneficiary or his/her representative to indicate that he/she received and understood the Notice." Under procedure, initial notice "the HUC (health unit clerk) staff will be responsible for delivering the IM to the patient/patient representative within 48 hours of the patient's inpatient admission. 2. When the signature of the Medicare beneficiary or his/her representative has been obtained to indicate that he/she received and representative. 3. A copy of the IM Notice will be retained and filed in the patient's legal healthcare record... The entire Notice should be read."

Review of Patient #1's medical record revealed Patient #1 was admitted on [DATE] at 3:30 PM through the Emergency Department with acute on chronic congestive heart failure and transferred to the ICU 7/13/20. There was no documentation that the patients rights or the IM were given to the patient or the patient's representative during this hospitalization .

Review of Patient # 5's medical record revealed Patient #5 was admitted to the Modified Care Unit through the emergency room on [DATE] at 10:17 AM with a Pulmonary Embolus, transferred to the ICU, and discharged home on 7/13/20. There was no documentation that patient rights or the IM were given to the patient or the patient's representative during this hospitalization .

Review of Patient #6's medical record revealed Patient #6 was admitted [DATE] with recurrent septic arthritis, was transferred to the ICU 6/24/20, and expired 7/05/20. There was no documentation that patient rights or the IM were given to the patient or the patient's representative during this hospitalization .

Review of Patient #7's medical record revealed Patient #7 was admitted [DATE] through the Emergency Department for a drug overdose, was tranferred to ICU on 6/17/20, and expired 6/25/20. There was no documentation that patient rights were given to the patient or the patient's representative during this hospitalization .

On 9/22/20 at 8:10 AM during interview with Director of Risk Management D, Director D confirmed there was no signed IM for Patient #1 for his current hospitalization .

On 9/22/20 at 3:40 PM during interview with Director of Risk Managment D, Vice President of Patient Care Services B, Director of Nursing Administration F, and Quality Coordinator E, E stated patient rights are in the admission packet which is given to the patient or patient's representative on admission and documented by the admitting nurse. E confirmed the admission packet was "not addressed" by the staff in the medical record for Patients #1, #5, #6 or #7, and there was no signed IM for Patient #1, #5 and #6.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview, the facility failed to notify the patient/patient representative that he/she has the right to file a complaint with the State agency and failed to provide the telephone number for the State agency in 1 of 1 intensive care unit information packets. The facility also failed to notify the patient/patient representative, on admission, that they have the right to seek review by the QIO (Quality Improvement Organization) for quality of care issues in 3 of 8 medical records (Patient #1, #5 & #6) meeting requirements to receive the IMM (Important Message from Medicare) in a total sample of 11 medical records reviewed.

Findings include:

Review of the Intensive Care Unit admission packet revealed booklet titled "Your Stay at [this facility]" page 9 under patient Rights "Patients have a right to report any unresolved issues regarding care, safety, treatment and services to [regulating agency]. There is no telephone number or address to report a grievance with the state agency.

Review of the Intensive Care Unit admission packet revealed pamphlet titled "ICU Visitor's Guide" under problem solving revealed "If there are concerns regarding care during your time here, please utilize the following resources." There is no telephone number or address to report a grievance with the state agency.

Review of policy "Patient Grievance Reporting and Investigation" # -118 dated 9/22/2018 revealed "Grievance: A grievance is a written or verbal complaint (when the complaint is not resolved at the time of the complaint by staff present) by a patient or patient's representative regarding the patient's care." Under Policy C revealed "If at any time a Medicare beneficiary expresses to the hospital a desire to refer a concern to the Quality Improvement Organization... the hospital will offer assistance to the patient and provide such assistance when requested."

Review of policy "Important Message from Medicare" # -011, not dated, under policy #1 revealed "Within 48 hours of the date of inpatient admission [facility] must issue the IM (Important Message from Medical Notice) and obtain the signature of the Medicare beneficiary or his/her representative to indicate that he/she received and understood the Notice." Under procedure, initial notice "the HUC (health unit clerk) staff will be responsible for delivering the IM to the patient/patient representative within 48 hours of the patient's inpatient admission. 2. When the signature of the Medicare beneficiary or his/her representative has been obtained to indicate that he/she received and representative. 3. A copy of the IM Notice will be retained and filed in the patient's legal healthcare record... The entire Notice should be read."

Review of Patient #1's medical record revealed Patient #1 was admitted on [DATE] at 3:30 PM through the Emergency Department with acute on chronic congestive heart failure. There was no documentation that the IMM was given to the patient or the patient's representative during this hospitalization .

Review of Patient # 5's medical record revealed Patient #5 was admitted to the Modified Care Unit through the emergency room on [DATE] at 10:17 AM with shortness of breath and hemoptysis (vomiting blood), was diagnosed with a Pulmonary Embolus, transferred to the ICU and discharged home on 7/13/20. There was no documentation that the Important Message from Medical Notice was given to the patient or the patient's representative during this hospitalization .

Review of Patient #6's medical record revealed Patient #6 was admitted [DATE] with fever, chills for follow-up of recurrent septic arthritis. There was no documentation that the Important Message from Medical Notice was given to the patient or the patient's representative during this hospitalization .

On 9/22/20 at 8:10 AM during interview with Director of Risk Management D, Director D confirmed there was no signed IMM for Patient #1 for his current hospitalization , she "was not aware" if complainant A was notified of her right to contact the Quality Improvement Organization (QIO), and confirmed that administration did not offer assistance to the patient or patient's representative to contact the QIO.
VIOLATION: PATIENT RIGHTS: ADVANCED DIRECTIVES Tag No: A0132
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview the facility failed to assist with formulating advanced directives in the form of a health care power of attorney in 1 of 11 Intensive Care Unit patient medical records reviewed (Patient #5) in a total sample of 11 medical records reviewed.

Findings include:

Review of policy "Advance Directives" # -014, not dated, under procedure A revealed "The patient/significant other is asked on admission by a registered nurse whether s/he has an Advance Directive. This information is documented in the electronic medical record... D. When the competent adult patient wishes to initiate a Health Care Power of Attorney and/or Living Will during the course of a hospitalization , the forms may be obtained from Nursing, Social Services or Spiritual Services and must be signed by the patient and... a copy is maintained in the patient's medical record."

Review of Patient #5's medical record revealed patient #5 was a [AGE]-year-old admitted [DATE] with shortness of breath and hemoptysis (throwing up blood) and was discharged [DATE]. Case manager note dated 7/10/20 at 11:05 AM revealed patient "does not have a HCPOA (health care power of attorney) and is interested in completing one. SW (social worker) notified." There was no HCPOA or documentation in the medical record that the social worker assisted with initiation of patient #5's HCPOA.

On 9/23/20 at 3:05 PM during interview with Quality Coordinator E following medical record review, E confirmed there was no documentation that a social worker had assisted with initiation of a living will or HCPOA in Patient #5's medical record.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on record review and interview the nursing staff failed to complete appropriate assessments by failing to follow it's policies and procedures when titrating a sedative/narcotic infusion in 4 of 6 intensive care unit patients receiving a sedative/narcotic infusion (Patient #1, #2, #7 and #10 ) in a total of 11 intensive care unit patients medical records reviewed.

Findings include:

On 9/22/20 at l:50 PM during interview with Director of Critical Care/Emergency Services G, Director G stated they follow the American Nurse's Association (ANA) and American Association of Critical Care Nurses (AACN) standards of nursing practices.

Review of the facilities standards and guidelines titled "Expanded Standards of Nursing Care Intensive Care Unit," not dated, under Assessment - AACN (American Association of Critical Care Nurses) Standard of Care I, revealed "RASS assessment (Richmond Agitation - sedation scale) is performed: *Every hour when a sedative/narcotic infusion is being titrated *RASS Goals (0 to -1) is maintained unless provider notified and order changed... * Every 4 hours for patients receiving non-titrating sedative/narcotic infusion."

Review of Patient #1's medical record revealed Advanced Practice Nurse Practitioner (APNP) J ordered a continuous intravenous infusion of propofol (sedative/narcotic infusion) 7/20/20 at 10:24 AM to be titrated "to reach and maintain goal" ended 7/22/20 at 6:22 AM. There was no RASS assessment for tititration documented according to policy on 7/20/20 at 1 PM, 2 PM, 3 PM, 4 PM, 5 PM, 6 PM, 9:30 PM, 10:30 PM, 11:30 PM, 7/21/20 at 1 AM, 2 AM, 3 AM, 5 AM, 6 AM, and 7/22/20 at 11:30 AM, 12:30 PM, 1:30 PM, 2:30 PM, 9:15 PM, 10:15 PM, 11:15 PM, 1:30 AM, 2:30 AM, 3:30 AM or 5:30 AM.

Review of Patient #2's medical record revealed APNP J ordered a continuous intravenous infusion of propofol (sedative/narcotic infusion) 8/24/20 at 3AM to be titrated "to reach and maintain goal" "titration goal RASS 0 to -1" ended 8/26/20 at 4:52 AM. There was no RASS assessment for titration documented according to policy on 8/25/20 at 9:15 AM, 11 AM, 1 PM, 2 PM, 3 PM, 9 PM, 10 PM, 11 PM or 8/26/20 at 12 AM, 1 AM, 2 AM, or 3 AM.

Review of Patient #7's medical record revealed MD K ordered a continuous intravenous infusion of dexmedetomidine (sedative/narcotic infusion) 6/17/20 at 8 PM to be titrated "to reach and maintain goal" ended 6/18/20 at 9:21 AM. There was no RASS assessment for titration documented according to policy on 6/17/20 at 9 PM, 10 PM, 11 PM, 6/18/20 at 2 AM, 6 AM or 7AM.

Review of Patient #10's medical record revealed MD L ordered a continuous intravenous infusion of propofol (sedative/narcotic infusion) 8/20/20 at 8:28 PM to be titrated "to reach and maintain goal" "titration goal RASS 0 to -1" ended 8/21/20 at 2 AM. There was no RASS assessment for titration documented according to policy on 8/20/20 at 9:30 PM or 8/21/20 at 1:30 AM.

On 9/22/20 at l:50 PM during interview with Director of Critical Care/Emergency Services G, Director G stated a RASS assessment (sedation level) is done more frequently for patients receiving a sedative/narcotic infusion "per our nursing standards" and confirmed "I will need to review this" when showed charting of Patient #1, #2, #7 and #10's medical records.