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ASCENSION SE WISCONSIN HOSPITAL - ST JOSEPH CAMPUS 5000 W CHAMBERS ST MILWAUKEE, WI 53210 Dec. 22, 2020
VIOLATION: CONTRACTED SERVICES Tag No: A0083
Based on record review and interview, the facility administration failed to ensure that the contracted Dialysis Services follow the facility's policies and procedures to ensure a safe environment by failing to complete adverse patient events in 1 of 10 patients demonstrating threatening behavior towards staff (Patient #1) in a total of 10 medical records reviewed.

Findings include:

Record review of the contracting dialysis policy titled "Patient Refusal of Services" #7-01-03, last review date 9/2019, under Purpose revealed "To verify that the patient is adequately informed of the risks of their action or non-action in relation to a medical order and to verify documentation of communication with the patient informing him/her that the hospital/facility cannot assume further responsibility related to his/her actions." Under policy revealed "The licensed teammate will intervene whenever a patient refuses to follow a medical order related to the Acute Services scope of practice... the Acute Services teammate will follow the policies and procedures concerning refusal of treatment of the hospital/facility in which acute services are provided."

Review of policy titled "Patients Leaving Against Medical Advice/Elopement" # 79 last revised 2/2019 under procedure leaving against medical advice revealed "The Physician should advise the patient of the risks of leaving AMA... the risks and potential complications in the medical record and/or on the AMA form."

Record review of hospital policy titled "Event Reporting" # 26 last revised 1/2020 under Purpose/Rationale revealed "The intention is to: Reduce events which cause, or have notational to cause, serious harm or injuries to patients." Under Definitions revealed "Events: any happening or occurrence... that is inconsistent with routine operations... Other adverse outcomes such as elopements." Under procedure, Response to Events, Patient Events revealed "Entry into the ERS (Event Reporting System) should occur as timely as possible and before the end of an individual's shift.

Record review of e-mail dated 11/16/2020 at 11:40 AM from contracted Dialysis Services, Regional Operations Director (ROD) F to Nursing Director (ND) G revealed "We are having more behavioral issues" with Patient #1.

Record review of e-mail dated 11/16/2020 at 12:30 PM from ND G to ROD F revealed "Does she have an active behavioral contract?"

Review of Patient #1's medical record revealed. Patient #1 had been coming to this facility through the Emergency Department (ED) for hemodialysis since 7/13/2020. Patient #1 began exhibiting paranoia and threatening behaviors with the ED and the contracted dialysis staff in November 2020. On 11/09/2020 the patient became verbally abusive with the ED staff and left without receiving hemodialysis treatment. On 11/13/2020 at 12:15 PM Dialysis Registered Nurse (RN) note revealed patient became "agitated" "didn't feel safe...ran out of the facility... security was called." On 11/16/2020 at 11:47 AM ED Provider note revealed "Patient is acting paranoid ... left while being prepped for dialysis ... eloped," Dialysis RN note 11/16/2020 at 12:32 PM revealed "pt ripped the needles out of the tech's hand." 11/24/2020 at 1:00 PM Dialysis nurse note revealed "Demanded to be taken off HD (hemodialysis) with 1hr25min remaining." There was no behavioral contract documented.

On 12/08/2020 at 1:20 PM during an interview with contracted Administrator of Dialysis E, Administrator E stated she started this job 3 weeks ago, she "can't recall" when she was made aware of Patient #1's dissatisfaction with the Dialysis Unit, and 11/16/2020 was the first time she was made aware of Patient #1's behavior concerns. E stated she was not aware if there was a behavioral contract with Patient #1, and confirmed the contracted dialysis staff had not completed any safety event reports on Patient #1.

On 12/08/2020 at 4:27 PM during an interview with Quality Management Director P, Director P confirmed there were no complaints, grievances, or safety events on Patient #1 in their systems.

Record review of Dialysis Services Behavioral/Patient Complaints and Security Event # 9 Event Date 11/16/2020 involving Patient #1 under Entered Date revealed "12/09/2020." Brief Factual Description revealed "patient snatched capped needles out of Tech hands ... The Nurse ... asked the patient to cooperate with the treatment. Patient refused treatment and got up and walked out." Under actions taken revealed "Notified Social Worker."

Record review of Dialysis Services Behavioral/Patient Complaints and Security Event # 6, Event Date 11/27/2020 involving Patient #1 under Entered Date revealed "12/09/2020." Brief Factual Description revealed "Aprox 1 hour into treatment ... asked to be taken off the machine that she didn't want anymore treatment. Treatment was discontinued ... Patient left while being verbally abusive to staff."

On 12/09/2020 at 3:52 PM during interview with contracted Dialysis Services, Regional Operations Director (ROD) F, ROD F stated, after identification that there were no incident reports completed by staff on Patient #1, he followed up with staff and completed Security Event # 9 and # 6.

On 12/09/2020 at 8:00 AM during an interview with Nursing Director (ND) G, ND G stated she was first notified, by e-mail, of Patient #1's behavioral issues on 11/16/2020 by the Contracted Dialysis Services Regional Director F. ND D stated she had a meeting scheduled to discuss Patient #1's behavior with Regional Director F on 12/09/2020 but it was rescheduled.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on record review and interview, the facility's administrative staff failed to provide a safe environment by failing to follow policies and procedures to promptly identify and facilitate a behavior conference to ensure the patient's understanding of the facility's expectations and consequences for the patient's actions in 1 of 1 patients receiving a medical screening through the Emergency Department and hemodialysis on the contracted Dialysis Unit who exhibited paranoid and threatening behavior to staff (Patient #1) in a total of 10 medical records reviewed of patients receiving hemodialysis on the contracted Dialysis Unit.

Findings include:

Record review of the contracting dialysis policy titled "Patient Refusal of Services" #7-01-03, last review date 9/2019, under Purpose revealed "To verify that the patient is adequately informed of the risks of their action or non-action in relation to a medical order and to verify documentation of communication with the patient informing him/her that the hospital/facility cannot assume further responsibility related to his/her actions." Under policy revealed "The licensed teammate will intervene whenever a patient refuses to follow a medical order related to the Acute Services scope of practice... the Acute Services teammate will follow the policies and procedures concerning refusal of treatment of the hospital/facility in which acute services are provided."

Review of policy titled "Patients Leaving Against Medical Advice/Elopement" # 79 last revised 2/2019 under procedure leaving against medical advice revealed "The Physician should advise the patient of the risks of leaving AMA... the risks and potential complications in the medical record and/or on the AMA form."

Record review of policy titled "Patient Rights and Responsibilities # 85, last revised 3/2020, under Procedures, "Patients have the right," page 3, #22 to be "informed in writing about hospital policies and procedures for initiation, review, and resolution of patient complaints."

Record review of this facilities policy titled "Patient Complaints and Grievances" # 38 last revised 8/2019 under Definitions, What is a patient grievance revealed "verbal complaint that is made to the hospital by a patient... regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present)."

Record review of e-mail dated 11/16/2020 at 11:40 AM from contracted Dialysis Services, Regional Operations Director (ROD) F to Nursing Director (ND) G revealed "We are having more behavioral issues" with Patient #1.

Record review of e-mail dated 11/16/2020 at 12:30 PM from Nursing Director G to Regional Operations Director (ROD) F revealed "Does she have an active behavioral contract?"

Record review of this facility's policy titled "Disruptive Patient/Visitor Management" # 75 last approved 4/2019 under Patient/Visitor Rules of Conduct revealed "In an effort to provide a safe and healthy environment" unacceptable behaviors "that are disruptive or pose a threat" are not allowed in the facility listing "use of verbally abusive and threatening language." Under Procedure is a list of seven actions that should be taken "depending on the situation." Action #4 Behavior Conference and Agreement "Leader/designee facilitates a behavior conference... Patient is counseled regarding expectations for behavior... informed of the consequences of persistent inappropriate behavior ... a behavior agreement ... is prepared by the leader/designee and signed by both the leader and the disruptive person ... a copy of the Behavior Agreement is given to patient ... and original copy placed in front of chart."

Review of Patient #1's medical record revealed. Patient #1 had been coming to this facility through the Emergency Department for hemodialysis since 7/13/2020. Case Manager U note dated 7/24/2020 at 9:29 AM revealed "received... referral to assist the patient in locating another outpatient local dialysis center to continue her treatment." Emergency Department nurse note dated 8/12/2020 at 9:05 AM revealed "Pt (patient) expresses frustration... Not sure what the barrier is to being able to go to another center." Emergency Department Social Worker D's note dated 8/26/2020 at 12:14 PM revealed "Pt wanted to discuss why her doctor hadn't moved her to another site... Informed Pt (patient)... unable to address prior issues."

Patient #1 began exhibiting paranoia and threatening behaviors with the ED and the contracted dialysis staff in November. Nephrologist A note dated 11/24/2020 at 12:53 PM under Diagnosis/Plan revealed "continue HD (hemodialysis) MWF" (Monday, Wednesday and Friday)." Between 11/09/2020 and 12/04/2020 with the potential for 12 MWF hemodialysis procedures, Patient #1 experienced 14 missed occurrences for properly receiving hemodialysis. She discontinued her hemodialysis early four times (11/13/2020, 11/16/2020, 11/27/2020 and 12/01/2020), left without receiving hemodialysis twice (11/09/2020 and 12/04/2020), showed up on Tuesday rather than MWF twice (11/24/2020 and 12/01/2020) and did not show for treatment seven times (11/11/2020, 11/18/2020, 11/20/2020, 11/23/2020, 11/25/2020, 11/30/2020 and 12/02/ ). Nephrologist A note dated 12/01/2020 at 2:08 PM under Plan revealed "Continue same." Case Management note dated 12/01/20, at 1:59 PM revealed "asked to "speak with Social Worker and you never come" ... wants a new dialysis unit... explained... no [outpatient dialysis facility's] will take her d/t (due to) her prior behaviors ... she denies that she ever did anything blames the unit for bad behaviors toward her. Pt (patient) states that [this facility] dialysis has refused her treatment several times lately ... stated she wanted to fire her nephrologist and get a new one." There was no behavior contract to ensure patient understood the behavior expectations when presenting to the Emergency Department for hemodialysis, or the risks of her not receiving hemodialysis due to her paranoid and threatening behavior.

On 12/09/2020 at 8:00 AM during an interview with Nursing Director (ND) G, ND G stated she "assumed" there was a behavior contract between the Dialysis Unit and Patient #1 to "prevent escalation" of Patient #1's behaviors due to her past history, but stated she was first notified, by e-mail, of Patient #1's behavioral concerns at this facility on 11/16/2020 by the contracted Dialysis Services Regional Director F. ND D stated a meeting was planned for 12/11/2020 to discuss Patient #1's behavioral issues.

On 12/09/2020 at 8:33 AM during a telephone interview with Nephrologist (Dr.) A, Dr. A stated he has "begged" Patient #1 to control her behavior and get back on her psych medications, but she does not see it as her problem. Dr. A stated that there is no "formal arrangements" with this facility for Patient #1's hemodialysis treatments.

On 12/09/2020 at 3:52 PM during an interview with contracted Dialysis Services, Regional Operations Director (ROD) F, ROD F confirmed there was not a behavior contract between the Dialysis Unit and Patient #1.

On 12/10/2029 at 8:32 AM during interview with Emergency Department Medical Director (MD) Q, MD Q stated "it was brought to my attention" in August, that Patient #1 was receiving hemodialysis on the contracted Dialysis Unit due to her past behavior in an outpatient facility and he was "unaware" of a behavior contract for Patient #1.

On 12/10/2020 at 11:20 AM during interview with Social Worker (SW) D, SW D stated she did not discuss Patient #1's behaviors related to hemodialysis on the Dialysis Unit, the expectations during her hemodialysis treatments, or the risks of not receiving hemodialysis on the Dialysis Unit. SW D stated she was "not aware" of a behavioral contract with Patient #1, stating "the nursing staff would do that" referring to the Emergency Department and the Dialysis Unit nursing staff.