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.

MARSHFIELD MEDICAL CENTER - WESTON 3400 MINISTRY PARKWAY WESTON, WI 54476 July 22, 2021
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview and record review the facility failed to ensure patients and the patient's family were aware of being video monitored in 6 of 8 records reviewed with video monitoring (Pt #1, 6, 7, 8, 9, 10) in a total sample of 10 records.

Findings include:

Review of policy and procedure titled, "Continuous Video Monitoring Using the AvaSys System Policy" last revised 01/07/2021 revealed, "The AvaSys System uses mobile, wireless monitors that allow trained video monitoring technicians to observe and speak with patients over video and audio feed in real time. The system is intended to help reduce patient falls, decrease costs related to observer use, and increase the safety of patients." Per policy, it is the nursing staffs responsibility to "Notify the patient and family that video monitoring has been initiated", "Staff may utilize the Video Monitoring brochure for family education."

Per interview with Registered Nurse (RN) M on 07/22/21 beginning at 10:45 am, RN M stated that staff should inform patient and family of video monitoring and document this education in the patient's medical record in the "Environmental Safety Management" section.

Review of Pt #1's medical record revealed Pt #1 was admitted to the facility on [DATE] at 11:28 am for evaluation of altered mental status. Review of Pt #1's "Treatment Consent" dated 06/04/21 revealed Pt #1 had an "Activated POA (Power of Attorney)" responsible for making Pt #1's health care decisions. Review of Pt #1's "Individual Observation Record" dated 06/04/21 at 10:08 pm revealed Pt #1 was "admitted to VM (video monitoring) at 2056 (8:56 pm)." Per review of Pt #1's medical record there was no documented evidence of the RN informing Pt #1 and Pt #1's family (POA) of video monitoring being initiated as per policy.

Review of Pt #6's medical record revealed Pt #6 was admitted to the facility on [DATE] at 9:46 pm. Review of Pt #6's "Individual Observation Record" dated 07/15/21 2:04 pm revealed Pt #6 was on video monitoring. Per review of Pt #6's medical record there was no documented evidence of the RN informing Pt #6 of video monitoring being initiated as per policy.

Review of Pt #7's medical record revealed Pt #7 was admitted to the facility on [DATE] at 1:33 pm with diagnosis of elevated heart rate and history of dementia. Review of Pt #7's "Treatment Consent" dated 07/12/21 revealed Pt #7 had an activated POA. Review of Pt #7's "Individual Observation Record" dated 07/13/21 at 6:03 am revealed Pt #7 was "admitted to VM @ 0019 (12:19 am)." Per review of Pt #7's medical record there was no documented evidence of the RN informing Pt #7 and Pt #7's family (POA) of video monitoring being initiated as per policy.

Review of Pt #8's medical record revealed Pt #8 was admitted to the facility on [DATE] at 9:00 pm for diagnosis of fall and history of dementia. Review of Pt #8's Advanced Directive revealed, Pt #8 had an activated POA for healthcare responsible for making Pt #8's healthcare decisions. Review of Pt #8's "Individual Observation Record" dated 07/19/21 at 2:17 am revealed Pt #8 was on video monitoring. Per review of Pt #8's medical record there was no documented evidence of the RN informing Pt #8 and Pt #8's family (POA) of video monitoring being initiated as per policy.

Review of Pt #9's medical record revealed Pt #9 was admitted to the facility on [DATE] at 9:46 am with chest pain and history of psychotic disorder. Review of Pt #9's "Treatment Consent" dated 06/06/21 revealed Pt #9 had an activated POA for healthcare responsible for making Pt #9's healthcare decisions. Review of Pt #9's "Individual Observation Record" dated 06/08/21 at 2:12 am revealed Pt #9 was on video monitoring. Per review of Pt #9's medical record there was no documented evidence of the RN informing Pt #9 and Pt #9's family (POA) of video monitoring being initiated as per policy.

Review of Pt #10's medical record revealed Pt #10 was admitted to the facility on [DATE] at 3:19 pm for alcohol detoxification. Review of Pt #10's "Individual Observation Record" dated 06/14/21 at 2:04 am revealed Pt #10 was on video monitoring. Per review of Pt #10's medical record there was no documented evidence of the RN informing Pt #10 of video monitoring being initiated as per policy.

Per interview with POA N on 07/22/21 at 1:45 pm, POA N stated he/she was not aware of Pt #7 being on video monitoring. POA N stated he/she visited Pt #7 on Monday and Tuesday and seen the equipment in the room but was never told by staff what the equipment was for.

Per interview with Nurse Manager E on 07/22/21 at 1:50 pm, E stated staff should be informing patients and family that they are on video monitoring and evidence of this education should be documented in the patient's medical record.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on interview, record review and observations the facility failed to follow a hospital-wide infection prevention program that followed Centers for Disease Control (CDC) infection control guidelines to prevent the spread of COVID-19. Staff failed to post signs and observe social distancing in 1 of 1 staff break room observed (1st floor) and failed to ensure all staff screen for COVID-19 symptoms prior to working in 1 of 1 employee COVID-19 screenings reviewed (Housekeeper H).

Findings Include:

Review of the CDC guidelines "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic" last updated on 02-23-21 revealed the following recommendations:

1. Establish a process to ensure everyone (patients, healthcare personnel, and visitors) entering the facility is assessed for symptoms of COVID-19, or exposure to others with suspected or confirmed SARS-CoV-2 infection and that they are practicing source control (facemask).
2. Post visual alerts at the entrance and in strategic places.
5. Physical distancing (maintaining at least 6 feet between people) is an important strategy to prevent SARS-CoV-2 transmission.

Per observations while on facility tour with Director G at 07/21/21 at 1:35 pm, observed the staff break room on the first floor. Per observations, 5 staff members were sitting at 2 round tables and were approximately 3 feet apart. Per observations no visible signs were posted addressing occupancy limits and social distancing.

Per interview with Infection Preventionist C 07/22/21 at 9:45 am, C stated the manager on the unit should decide how many staff should be in the break room at one time based on size. Per C based on measurements and floor plan the 1st floor staff break room should have a limited occupancy of 4 people. C stated signs should be posted with the maximum capacity limits and social distancing reminders.

Review of email correspondence from Incident Command to unit managers dated 08/03/21 at 4:21 pm (provided by Infection Preventionist C) revealed the "Subject" of the email was "Incident Command request: Lunch and break room social distancing." Per email, "When reviewing positive employees with COVID-19, it was found that eating together in the lunchroom or break rooms was the main cause of employee to employee exposure" "To assist in decreasing this hazard, Infection Preventionist is requesting regional incident commanders conduct an assessment of lunchroom and break room spaces..." Per email staff should determine maximum capacity and "post signs to enforce maximum capacity guidelines". Per email, staff should "remove and space chairs in break and lunch rooms to allow for 6 feet of space between employees."

Per interview with Housekeeper H on 07/21/21 at 1:45 pm, when asked about employee COVID screening, H responded, "I don't think we do anything specific for screening."

Per Interview with Director D on 07/21/21 at 3:05 pm, D stated Housekeeper H started a few months ago and has not received training on the employee COVID screening process. Director D stated that D has no record of H completing employee COVID screening. D stated that H must have been "overlooked." Per interview with D, All housekeeping staff should be filling out the "Employee Symptom Log" for COVID screening before every shift.