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.

ROGERS MEMORIAL HOSPITAL 34700 VALLEY RD OCONOMOWOC, WI 53066 Jan. 13, 2021
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 hospital failed to ensure patients and their guardian receive their rights and responsibilities upon admission in 1 of 20 inpatients (Patient #1) in a total of 20 medical records reviewed.

Findings include:

Record review of policy titled "Admission Registration" #15-015-1218, dated 12/15/2018 under procedure revealed "The intake specialist will discuss and review all admission forms with the patient/guardian." The intake specialist will review and sign the Consent for Treatment, Patent Rights and any other necessary admission forms... page 3, G. Signatures on the Consents for Admission #2 revealed "Children between the ages of 14 & [AGE] years old are required to sign all admission documents."

Review of Patient #1's medical record revealed Patient #1 was 17-years-old, admitted voluntarily 5/29/2020. "Consent for Treatment & Financial Agreement" dated 5/29/2020, not timed, with all areas for Patient's initials, Guardian's initials, and Guarantor's initials blank. Patient Signature, Parent/Legal Guardian Relation to Patient, and Witness Signature lines blank. Patient #1 was readmitted [DATE] voluntarily and the "Consent for Treatment & Financial Agreement" was not initialed, timed or witnessed.

During interview 12/21/2020 at 1:40 PM with Executive Director of Clinical Services E, E confirmed on admission, the admission staff read through the consent, initial the Patient Rights and Consent for Treatment forms, and have the patient sign, date, time the form with a witness signature stating "they try" to have patient's sign the admission paperwork, but it depends how they come in.
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 investigate and provide a written response to 2 of 3 patient grievances reviewed (Patient #2 and Patient #10) from grievance log dated June 2020 thru December 22, 2020.

Findings include:

Review of policy titled Patient Grievance Procedure #04-041-0219 dated 12/01/2019 under Grievance Definition revealed "Any formal or informal written or verbal complaint by a patient, or the patient's representative regarding patients care... a patient care complaint... that can not be "resolved at the time of the complaint... will be assigned to the program's client rights specialist." Under Procedure revealed "the client rights specialist or designee will then investigate and provide a written response within 30 business days from the [DIAGNOSES REDACTED]il filing of the grievance... Once the investigation is complete, the Clients Rights Specialist must prepare a written response/letter describing the facts gathered during the investigation, the application of any appropriate laws and rules to those facts, and a determination as to whether the grievance was founded or unfounded."

Record review of incident report # dated 10/23/2020 at 11:15 AM, entered 12/22/2020 at 10:55 AM, completed 12/23/2020 at 10:57 AM revealed Patient # 2 wrote her concerns down, gave them to the therapist who filed them in Patient #2's medical record. Patient #2's concerns were not investigated until 12/22/2020.

Record review of response letter to grievance # , dated 12/22/2020 was sent 60 days after the incidents occurred.

Record review of incident report # dated 11/29/2020 at 5:30 AM, entered 11/30/20 at 9:39 AM revealed patient #11 "walked up to [Patient #10], placed his hands on her shoulders, threw her down to the ground and began to hit her." Under Classification of Incident with Injury - Intentional by Other and Physical Aggression checked, "Risk Assessment Detail" with nothing checked, Physical Injury/Trauma with nothing checked. Under Incident report investigation action log Activities revealed "Patient/Staff Assessed for Physical & Emotional Safety (Immediate action taken, separated if needed, injuries treated, statements obtained) Date Completed 11/29/20" Incident report action log item #3, specific reference of actions taken, revealed "Peer restriction ordered (11/30/20), X-Ray ordered (11/30/20)." Medical record orders revealed "XR (x-ray) Wrist 2 View Unilateral" dated 11/30/2020 at 12:56 AM and order for "Peer restriction" dated 11/30/2020 at 4:38 PM, greater than 32 hours after the altercation. Under Incident /FollowUp revealed "Investigation complete" dated 12/07/2020 at 11:34 AM.

Record review of incident report # dated 11/30/2020 at 5:30 PM, entered 11/30/20 at 6:12 PM, completed 12/21/20 at 8:01 AM revealed family complained Patient #10 "did not get a head to toe assessment and wrist x-ray... after the physical altercation... why the male peer was not removed immediately from the facility after punching [Patient #10], and why there was no staff in the group room when the altercation occurred." Was Event Substantiated "yes" was marked. Under Contributing Factors Physical environment and P&P (policies and procedures) not followed were marked. Under Incident reviewed marked complete dated 12/10/20 at 11 AM revealed "RNs (registered nurse) coached about importance of putting pts (patients) on the medical board to see the provider if pt (patient) complains of pain after an altercation... No further." Under Incident FollowUp marked complete on 12/21/20 at 8:00 AM revealed "Upon investigation, policy was not followed and patient was not referred for consult/assessment by medical staff... Mother's concern regarding the handling of patient's injury is validated." There was no follow-up of complainants concerns regarding staffing or peer removal from site documented.

Record review of response letter to grievance # , dated 12/14/2020, did not include the concerns regarding the male peer who was not removed immediately from the facility after punching [Patient #10] or why there was no staff in the group room when the altercation occurred.

On 1/07/2021 at 10:48 AM during interview with Executive Director of Clinical Services C, Director C stated they are "moving to a better system" more clear "to make the connection better," on what has been done, when they review the incident. Director C confirmed there is no further follow-up documented in the incidents requested.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on record review and interview the facility failed to ensure informed consent was signed before administering psychotropic medications in 2 of 20 patient receiving psychotropic medications (Patient #2 and #3) in a total of 20 medical records reviewed.

Findings include:

Record review of policy titled "Informed Consent for Use of Medications" # -0419 dated 4/15/19 under General Information revealed "the duty to obtain informed consent requires two steps: 1. Providing the information to the patient... 2. Obtaining written consent for medication prior to medication administration."

Review of Patient #2's medical record revealed Medication Administration consent signed 10/22/2020 at 11:49 AM, first dose of Prozac (a psychotropic medication) administered 10/22/2020 at 9:02 AM.

Review of Patient #3's medical record revealed Medication Administration consent signed 6/04/2020 at 1:22 PM, first dose of Pristiq (a psychotropic medication) administered 6/04/2020 at 9:32 AM.

On 1/12/2021 at 2:06 PM during interview with Executive Director of Nursing G, Director G confirmed the informed consents were not signed before staff administered Patient #2 and #3 their psychotrophic medications.
VIOLATION: DISCHARGE PLANNING- TRANSMISSION INFORMATION Tag No: A0813
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview, the facility failed to ensure social workers arranged complete follow-up of outpatient services to ensure patient's outpatient treatment goals were met in 2 of 9 patients receiving outpatient follow-up (Patient #1 and #3) in a total of 20 medical records reviewed.

Findings include:

Record review of policy titled Treatment Planning" #04-057-0419 dated 4/01/2019 under Discharge Planning revealed "The discharge plan will be formulated in terms of key variables for aftercare, obstacles and action plan in obtaining post-hospital care... the social service staff... will be accountable, to ensure that the patient family, or other community advocate has made arrangements in a timely fashion.... Unmet goals should transfer to the next level of care. e. The discharge plan will be finalized, and the treatment team will work with the patient, physician, and family to set up all resources by targeted date of discharge."

Record review of policy "Discharge Planning/Patient Advocacy" #06-210-0917, dated 9/25/17 under Guidelines revealed "The expectation will be that each patient will have an appointment with a provider who can assess for patient safety within five (5) days of discharge."

Review of Patient #1's medical record revealed Patient #1 was a [AGE]-year-old voluntary admit on 5/29/2020 due to unusual behavior, talking to himself, pacing with unpredictable outbursts of aggression. Family Support Session note dated 6/02/2020 at 10:00 AM under Discharge plan (tentative) revealed "discussed the CORE program following discharge as they would be able to help pt (patient) manage with psychosis and other long term case management following his 18th birthday." Patient Care Note dated 6/02/2020 at 7:01 PM revealed "at 3:40 PM patient was outside with his group when he proceeded to climb and jump the fence... at 1840 (6:40 PM) police returned patient to the hospital." Psychiatrist note dated 6/03/2020 at 2:30 PM revealed "based on the unlikelihood of further benefit to be gained from continued inpatient care... We discussed the deferred prosecution program which (Patient #1) will enter following discharge which will proceed for 9 months, mandating compliance with treatment... goal to prevent hospitalization ."

Follow-up appointments were listed in another county 90 miles away from Patient #1's home address. Patient was discharge 6/04/2020. There was no social service documentation confirming admission into the deferred prosecution program or transfer of care to another county.

On 10/06/2020 Patient #1 was voluntarily readmitted with worsening symptoms of psychosis. His medications were changed due to side effects of previous injection, and he was discharged on [DATE]. Discharge Planning note dated 10/15/2020 revealed "Patient is connected with wraparound services. SW (social worker) in contact with..., patients CM" (case manager). Discharge Summary Documents dated 10/16/2020 at 12:53 PM revealed Follow-up with Dr. (N) 11/06/2020 at 12:00 PM, 21 days after discharge. There was no appointment with a provider who can assess for patient safety within five (5) days of discharge.

Review of Patient #3's medical record revealed Patient #3 was a [AGE]-year-old voluntary admit on 6/02/2020 for suicidal ideation with a plan and was discharged [DATE]. Licensed professional counselor (LPC) note dated 6/08/2020 at 2:34 PM revealed "Pt (patient) reports she would be open to a referral for PHP." (Partial Hospital Program). Last psychiatrist note dated 6/11/2020 at 12:42 PM under Plan revealed "Continue inpatient for safety... Contact patient's friend... regarding removal of the medications and blades from the house." LPC note dated 6/11/2020 at 3:02 PM revealed patient "remains unwilling to involve her husband... The therapist asked the friend if he was willing to dispose of items and he asked to talk with Patient #3, who became tearful "then whispered "(expletive) you" into the phone and hung up... eventually stated she needed to make a plan... Pt then ... made another call, placed phone on speaker... asking a friend... to "supervise"... her friend... agreed to supervise... but reports he will not be in WI (Wisconsin) until Sunday night as he is currently in MN (Minnesota)." The therapist note revealed...the situation would be discussed with attending and treatment team would come to a conclusion." Last Nursing note dated 6/12/2020 at 11:33 AM under Depression and Anxiety, score was 7 (high-unmanageable). Suicidal Ideation/Risk for revealed "2 (low-manageable)." Last safety plan updated was documented 6/11/2020 at 1:56 PM. Patient was discharged Friday, 6/12/2020 at 2:28 PM. There was no social service note or discharge instructions documented after 6/11/2020 regarding removal of medications and blades from Patient #3's house.

On 12/21/2020 at 1:40 PM during interview with Executive Director of Clinical Services E, Director E stated she was not aware of what the deferred prosecution program was and confirmed there was no documentation by social services coordinating outpatient services for Patient #1 for the 6/04/2020 discharge. Director E stated their goal is to have an appointment with a provider who can assess for patient safety within five days of discharge, stating "the services are not always available."

On 12/22/20 at 11:40 AM during an interview with Executive Director of Clinical Services E, when asked if there was a plan to obtain the contraband from Patient #3's home prior to discharge or if the safety plan was updated with Patient #3 prior to discharge, Director E stated "I can't confirm or deny that."
VIOLATION: Treatment Plan Tag No: A1640
Based on record review and interview, facility staff failed to ensure that all staff persons involved in the development of patient's interdisciplinary comprehensive treatment plans signed the plans as per facility policy in 6 of 20 patients with interdisciplinary treatment plans (Patient #1, #8, #13, #14, #15 and #18) in a total of 20 medical records reviewed.

Findings include:

The facility policy titled "Treatment Planning" #04-057-0419 last reviewed on 4/1/2019 under Purpose revealed "Treatment plans are necessary to guide the multidisciplinary treatment team as they attempt to assist the patient in their recovery and return to a less restrictive treatment environment." Under Master Treatment Plan Formation revealed "The Master Treatment Plan is completed by the attending physician, psychologist, registered nurse, social service staff." Under Treatment Plan Signatures revealed "The Treatment Plan Signature Sheet (HIM-139) should be signed by the patient, parent/guardian, and all staff members attending or reviewing the staffing and treatment plan... The attending physician's/psychologists' signature on the Master Treatment Plan indicates that he/she reviewed the treatment plan... The SOCIAL WORKER... will review... with the patient and/or guardian, ensuring participation in the development and understanding of goals and interventions and they must obtain the patient/guardian's signature."

Review of Patient #1's medical record revealed Patient #1 was on the adolescent inpatient unit from 5/29/2020 to 6/04/2020. There was no documented signature on the Master Treatment plan by by a Social Worker or Registered Nurse. The Physician did not sign the plan until 6/24/2020.

Review of Patient #8's medical record revealed Patient #8 was on the adolescent inpatient unit from 12/09/2020 to 12/22/2020. There was no documented signature on the Master Treatment plan by the Registered Nurse.

Review of Patient #13's medical record revealed Patient #13 was on the adult inpatient unit from 11/16/2020-11/24/2020. There was no documented signature on the Master Treatment Plan by a Physician or Psychiatrist.

Review of Patient #14's medical record revealed Patient #14 was on the adult inpatient unit from 10/28/2020-11/2/2020. There was no documented signature on the Master Treatment Plan by a Registered Nurse or of the patient/legal guardian.

Review of Patient #15's medical record revealed Patient #15 was on the adult inpatient unit from 12/26/2020-1/1/2021. There was no documented signature on the Master Treatment Plan by a Registered Nurse.

Review of Patient #18's medical record revealed Patient #18 was on the adult inpatient unit from 12/5/2020-12/15/2020. The Master Treatment Plan electronic signature by the physician was dated 12/30/2020 (15 days after the patient was discharged ).

An interview was conducted with Executive Director of Compliance C and Executive Director of Nursing G on 1/12/2021 at 2:00 PM who, when asked, the expectation of signatures on the "Treatment Sheets" for Master Treatment Plans Executive Director of Compliance C stated "Usually they are hand signed by everyone involved in doing the treatment plan but because of the pandemic a lot of the staffings are being done as "telemedicine" so there are electronic signatures that are captured in the electronic medical record." When reviewed the above missing and/or late electronic signatures on the medical records Executive Director of Compliance C stated "I agree with you they are not there and they should be."