Ascension NE Wisconsin - St Elizabeth Campus

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 52395 Based on record review and interview, the facility staff failed to document timely reassessments following administration of pain medications for 5 of 10 patients receiving pain medications (Patients #2, #3, #4, #8, and #10) in a total universe of 10 medical records reviewed. Findings include: A review of the facility’s policy, “Hospital Based Assessment and Documentation Policy,” # 18231547 last reviewed 5/23/2025 revealed, “Data collection: a. Data collection/Reassessment is designed to evaluate the patient’s response to care and interventions and to determine if a change to the plan of care is warranted... c. Additional data collection/reassessments are done when the patient’s diagnosis/condition warrants...” A review of the facility’s policy, “Pain Management Policy, AW,” #13866734 last revised 6/21/2025 revealed, “Purpose/Rationale: The identification and management of pain is an important component of person-centered care. Ascension Wisconsin (AW) respects the patient’s right to have their pain managed. A. Pain is reassessed at a suitable interval following pharmacological and non-pharmacological interventions. B. Timing of reassessment should consider drug, route of administration, dosing interval and the individual patient’s clinical condition. C. Reassessment is not required for schedule nonopioid pain medications.” A review of RN (Registered Nurse) education “AWNE (North East): Joint Commission Always Ready Communications shared with RN’s, Topic: Pain Reassessment,” Date: May 8, 2025 revealed: “Reassessment intervals for pain and sedation: Within 60 minutes after parenteral (IV (in the vein), SubQ (in the subcutaneous tissue) administration, within 120 minutes after enteral (oral or by rectum) administration, Reassess more frequently based on individual patient need and clinical condition e.g. severe, rapidly changing pain and increasing sedation. A: Key Take Away- pain and sedation assessment go hand in hand when opioids are given; one without the other is an incomplete assessment and is not in compliance with policy. A review of Patient #2’s medical record revealed Patient #2 was admitted on 12/04/2025 for cancer-related pain. Patient #2 was a current inpatient on the date of the survey. -On 12/04/2025 at 5:46 PM, Patient #2 received pain medication. There was no reassessment documented until 8:11 PM (2 hours and 25 minutes later). -On 12/08/2025 at 9:36 AM, Patient #2 received pain medication. There was no reassessment documented until 2:00 PM (nearly 4.5 hours later). A review of Pt #3’s medical record revealed Patient #3 was admitted on 12/08/2025 with Acute Cystitis (bladder inflammation) and Hematuria (blood in the urine) and was a current patient. -On 12/8/2025 at 1:58 PM Patient #3 received oral pain medication. There was no reassessment documented until 4:50 PM (2 hours and 52 minutes later). A review of Pt #4’s medical record revealed Patient #4 was admitted on 12/05/2025 with Sepsis-septic shock and was a current patient. -On 12/8/2025 at 03:55 AM Patient #4 received IV pain medication. No reassessment documented until 3:10 PM (11 hrs and 15 minutes later). -On 12/09/2025 at 03:07 AM Patient #4 received oral pain medication. No reassessment documented until 05:00 AM (1 hour and 53 minutes later). A review of Pt. #8’s medical record revealed Pt. #8 was admitted on 11/25/2025 with a PE (blockage in the lung artery) and a current patient. -On 12/06/2025 5:15 PM Pt. #8 received IV pain medication. No pain reassessment until 8:59 PM (3 hours and 44 minutes later). A medical record review was completed on Pt #10’s open medical record on 12/09/2025 at 3:00 PM. Admitted on 12/07/2025 with an admitting diagnosis of upper abdominal pain and was a current patient. -On 12/08/2025 at 01:51 AM Pt #10 received oral pain medication but no reassessment was completed until 05:00 AM (3 hours and 9 minutes later). During an interview on 12/09/2025 at 3:38 PM with RN H, when asked about reassessments after giving pain medication she stated for IV medications it is one hour and for oral medication it is 2 hours. When asked how she remembers to do the follow up documentation she stated, “it’s tricky, I try to use the brain but if I get pulled somewhere the documentation doesn’t always happen.””

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 52395 Based on record review, observation and interview facility staff failed to complete a Medical Screening Exam for 1 of 20 patients (Patient #1) who presented on hospital property requesting treatment in a total sample of 20 medical records reviewed. Findings Include: The facility staff failed to provide a Medical Screening Exam for a patient who presented on hospital property requesting treatment. See Tag A-2406.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 52395 Based on record review, observation and interview facility staff failed to complete a Medical Screening Exam for 1 of 20 patients (Patient #1) who presented on hospital property requesting treatment a total sample of 20 medical records reviewed. Findings Include: A review of Hospital A’s policy titled, “[Facility] Emergency Medical Treatment and Active Labor Act (EMTALA), AW...” last reviewed 04/15/2025 revealed, “...Comes to the Emergency Department ... means an individual: 3. c. Is in a ground or air nonhospital owned ambulance on hospital property for presentation for examination and treatment for a medical condition at a Hospital’s Dedicated Emergency Department... Hospital Property means the entire main campus of the hospital ... An appropriate Medical Screening Exam (MSE) is provided to individuals of any age who present to the Emergency Department or other hospital property requesting or requiring an examination of treatment for a medical condition ... patients who come to a Dedicated Emergency Department requesting examination and treatment will be Triaged and receive a Medical Screening Examination by a QMP (Qualified Medical Provider)...” Observation of Hospital A’s ED (Emergency Department) security footage on 06/21/2025 revealed: 06/21/2025 at 12:06 PM: Ambulance arrived in the ambulance bay at Hospital A with Patient #1 and was wheeled via cot into the ED ambulance hallway with two ambulance drivers and correctional officer (no audio). 06/21/2025 at 12:15 PM: Patient #1 was observed going back into the ambulance via cot and leaving Hospital A via ambulance. There was no observation of staff interacting with Patient #1, ambulance drivers or the correctional officer. A review of Patient #1’s medical record from Hospital A revealed that Patient #1 was a 62-year-old incarcerated male who presented to Hospital A’s ED via ambulance on 06/21/2025 at 12:10 PM (no chief complaint noted) and was marked as “dismissed” on 06/21/2025 at 12:18 PM. A review of the record revealed there was no triage or medical screening provided to Patient #1 at Hospital A. During an interview on 07/29/2025 at 12:51 PM with ED RN (Registered Nurse) E, when asked about Patient #1 and a medical screening exam, ED RN E stated, “Yes the patient should have had a medical screening exam.””