Ascension Columbia St Marys Hospital Milwaukee

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 51278 Based on record review and interview, the facility staff failed to reaassess fall risk after a fall for Pt. #1, failed to assess patient after a fall for Pt. #6 and failed to assess fall risk for Patients #7 and 10 per facility policy in 4 of 10 (#1, 6, 7 and 10) medical records reviewed in a total universe of 10 medical records reviewed. Findings include: Review of the facility’s policy “Fall Prevention, AW,” #16329940 dated 8/1/2024 “II. Department specific prevention interventions: A. Emergency Department: a. From point of entry to discharge, patients in (facility name) acute care facilities and emergency departments/ trauma centers will be assessed and reassessed for fall risk. b. A fall risk assessment, and reassessment will be completed and documented on every patient utilizing an approved, evidence based, and age-appropriate fall risk screening tool: i. As part of an initial assessment ii. With any change in patient clinical condition, including after fall... g. The patient/ family/ caregiver will be educated on standard fall precautions, fall prevention interventions, and activity limitations. i. All education will be documented...h. The RN will implement patient-specific fall prevention interventions based on the fall risk assessment and clinical judgement ... Fall Management: I. In the event of a fall the RN should: A. Immediately assess the adult inpatient for the following: 1. Neurologic changes...2. Review physical assessment findings, which include cardiovascular symptoms (e.g., vital signs)...” Pt. #1 Review of Pt. #1’s “Patient Care Timeline” from 6/19/2026 at 8:42 AM to 6/19/2026 at 3:22 PM revealed Pt. #1 presented to the ED (Emergency Department) with low potassium. Review of Pt. #1’s “Patient Care Timeline” revealed at 9:04 AM Pt. #1’s “Kinder Fall Risk Assessment” (A screening method for triage nurses to identify a patient at risk for falls) score: Low fall risk. Review of Pt. #1’s “Patient Care Timeline” revealed at 10:55 AM, “Pt asked to go to the restroom. Pt removed from monitor and IV meds to go to the rest room. Pt education on going to the restroom and locking mechanism. Pt understood and asked for privacy. Writer stepped away as pt stated she is ok going to the restroom. Pt called out for help and was heard. Writer went to the rest room and was found on floor, Pt stated she tripped over her EKG leads. Pt had no complaint of head injury, however, have complaint of leg and arm pain towards left side.” Review of Pt. #1’s “Patient Care Timeline” from 6/19/2026 at 8:42 AM to 6/19/2026 at 3:22 PM revealed Pt. #1 did not have a Kinder fall assessment completed after fall charted at 10:55 AM. ED Manager E confirmed Pt. #1 did not have a Kinder fall assessment charted post fall per policy. An interview with ED Manager E on 9/2/2026 at 2:15 PM, she stated post fall assessments should be completed per policy as stated for inpatient falls. Pt. #6 Review of Pt. #6’s “Patient Care Timeline” from 4/7/2026 at 3:17 PM to 4/8/2026 at 11:35 AM revealed Pt. #6 presented to the ED (Emergency Department) for a Transient Cerebral ischemic attack (a temporary blockage of blood flow to a part of the brain). Review of Pt. #6’s “Patient Care Timeline” revealed at 3:26 PM Pt. #6’s “Kinder Fall Risk Assessment” score: High fall risk, no fall interventions charted. Review of Pt. #6’s “Patient Care Timeline” revealed “ED Notes” dated 4/8/2026 at 1:27 AM “Pt continuing to refuse to remain in bed and refusing vitals. Pt also attempting to ambulate in hall and enter other patient’s room. Redirected back to bed in room” Review of Pt. #6’s “Patient Care Timeline” revealed “ED Notes” dated 4/8/2026 at 2:58 AM “MD paged as pt changed out of gown and into street clothing stating that she was not sure where she was and wanted to go home.” Review of Pt. #6’s “Patient Care Timeline” revealed “Assessment” dated 4/8/2026 at 3:00 AM “Fall: WITHOUT injury.” Review of Pt. #6’s “Patient Care Timeline” revealed “ED Note Addendum dated 4/8/2026 at 3:04 AM “Pt attempted to ambulate by self while hospital staff was in other treatment room. (city name) PD (police department) was in the ER with separate pt and witnessed pt fall ...Teaching was reinforced. Pt was placed in inpatient bed in position of comfort, with grippy socks, back in yellow gown, bed alarm on, and yellow wrist band.” Review of Pt. #6’s “Patient Care Timeline” revealed on 4/8/2026 at 3:16 AM “Kinder Fall Risk Assessment” score: “High Fall Risk. Fall Interventions Initiated: Fall risk armband provided; Instruct patient to ask for assistance when getting out of chair or bed; Non-slip footwear; bed/chair alarm; Communicate recent fall and /or risk of harm during handoff.” Review of Pt. #6’s “Patient Care Timeline” revealed “ED Notes” on 4/8/2026 at 3:36 “VSM (video safety monitoring) in place.” Review of Pt. #6’s “Patient Care Timeline” revealed on 4/8/2026 at 4:15 AM vital signs were charted (1 hour and 15 minutes after post fall documentation). An interview with Clinical Nurse Leader F on 9/2/2026 at 3:20 PM, she confirmed post fall assessments should be completed per policy as stated for inpatient falls. Pt. #7 Review of Pt. 7’s “Patient Care Timeline” from 6/19/2026 at 9:12 AM to 6/19/2026 at 5:05 PM revealed Pt. #7 presented to the ED with Atrial Fibrillation (irregular heart beat) and Dizziness. Clinical Nurse Leader F confirmed Pt. #7 did not have a fall assessment charted during the ED visit. Pt. #10 Review of Pt. #10’s “Patient Care Timeline” from 7/27/2026 at 10:30 PM to 7/28/2026 at 6:20 AM revealed Pt. #10 presented to the ED after a fall. Clinical Nurse Leader F confirmed Pt. #10 did not have a fall assessment charted during the ED visit.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 29972 Based on record review and interview, facility staff failed to perform nursing assessments, interventions, and evaluate patient skin care needs to prevent skin breakdown in 4 of 10 medical records reviewed (Patient (Pt) #1, #3, #5, #8); failed to ensure that nursing care plans were initiated as per policy to address skin/wound care needs and interventions in 4 of 10 medical records reviewed (Pt #2, #3, #7, #10); failed to ensure nursing care plans are kept current and updated based on patient assessments in 3 of 10 medical records reviewed (Pt #1, #3, #10); and failed to ensure that nursing interventions are implemented based on ongoing assessments of patient care needs in 3 of 10 medical records reviewed (Pt #1, #3, #10), in a total sample of 10 medical records reviewed. Findings Include: The facility staff failed to perform nursing assessments, interventions, and evaluate patient care needs to prevent skin breakdown. See Tag A-0395. The facility staff failed to ensure that nursing care plans were initiated as per policy to address skin/wound care needs and interventions; failed to ensure nursing care plans are kept current and updated based on patient assessments; and failed to ensure that nursing interventions are implemented based on ongoing assessments of patient care needs. See Tag A-0396.”

“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: 29972 Based on record review and interview, facility staff failed to perform nursing assessments, interventions, and evaluate patient skin care needs to prevent skin breakdown for 4 of 10 patients (Patient (Pt) #1, #3, #5, #8), in a total sample of 10 medical records reviewed. Findings Include: Review of policy and procedure #18006238 titled, “Ascension Wisconsin Pressure Injury Risk Assessment & Prevention” last revised 04/17/2025 revealed: - “The Braden Scale is a tool used to assess a patient’s risk for developing pressure injuries. It evaluates six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. A person that scores 18 or lower on the scale is considered to be at risk for skin breakdown.” - “A pressure injury is localized damage to the skin and underlying tissue, primarily occurring over a bony prominence, caused by prolonged pressure, shear, or friction. Pressure injuries commonly occur in individuals with limited mobility...” - “HAPI (hospital acquired pressure injury) risk assessment should be conducted using the Braden Scale for predicting pressure sore risk.” - “Skin assessments should be conducted at a minimum of the following: A. Admission B. Every Shift...” - “HAPI prevention interventions should be tailored to address specific risks identified during the HAPI risk and skin assessments and as recommended in the...algorithm.” - “Interventions aligned with Braden Subscaled scores less than 3. A. Sensory perception recommendations...iii. Sacrum: Consider application of multi-layer foam dressing with silicone adhesive...B. Moisture/Incontinence management recommendations. i. Single layer, breathable, high absorbency incontinence pads: no incontinence briefs in bed. ii. Cleanse skin using non-alkaline cleansers, apply moisture barrier...iv. apply moisture to dry skin...C. Activity recommendations...iv. Sacrum/lower buttocks: Consider application of multi-layer foam dressing with silicone adhesive. D. Mobility recommendations...iv. Sacrum: Consider application of multi-layer foam dressing with silicone adhesive. v. consider use of high specification reactive foam or reactive air mattress/overlay...F. Friction & Shear recommendations...iii. Sacrum: Apply multi-layer foam dressing with silicone adhesive to minimize friction/shear...” Review of policy and procedure #12500967 titled, “Management of Skin breakdown” last revised 10/10/2022 revealed: - “Patients with existing skin breakdown on admission or that develop skin breakdown during their hospital stay will be treated with established evidenced-based interventions.” - “Measure wound and document at minimum every 4 days.” - “Assess wound with every dressing change including skin surrounding wound, and document both assessment and dressing change.” - “If WOC RN (Wound Care Registered Nurse) consult has been completed, complete wound care as ordered per recommendations.” Review of policy and procedure #18231547 titled, “Hospital Based Assessment & Documentation...” last revised 05/23/2025 revealed: - “Each discipline documents their interventions and the patient’s response to these interventions in the patient’s health record.” Review of Pt #1’s medical record revealed Pt #1 was a 63 year old admitted to the inpatient Intensive Care Unit (ICU) on 03/06/2025 at 6:27 PM after having a “Whipple” procedure (surgical operation that removes the head of the pancreas, the first part of the small intestine, and sometimes a portion of the stomach, gallbladder, and common bile duct) for pancreatic cancer. Pt #1 was placed on comfort cares and passed away at the hospital on 06/03/2025 at 3:08 PM. Review of Pt #1’s Discharge Summary dated 06/03/2025 at 1:36 PM revealed on 03/23/2025 Pt #1 became hypotensive (low blood pressure) and tachycardic (fast heart rate) and was intubated (breathing tube inserted for breathing) in the ICU. Per the Discharge Summary, on the evening of 03/23/2025 Pt #1 returned to Surgery for active bleeding from previous surgical site. Pt #1 remained on ventilation (breathing machine) after surgery and underwent a tracheostomy for respiratory failure and ventilator dependence. Review of Pt #1’s ICU admission skin assessment on 03/06/2025 at 8:00 PM revealed Pt #1’s buttocks was red, foam dressing applied. Review of Pt #1’s Braden score from 03/06/2025 through 05/23/2025 revealed Pt #1’s Braden score ranged from 12 to 16 (at risk for skin breakdown) throughout the inpatient stay. Review of Pt #1’s skin/wound assessments revealed the redness to Pt #1’s buttocks on admission (03/06/2025) worsened to an unstageable pressure injury measuring 5 cm x 10 cm x 1.5 cm (05/09/2025). Review of Pt #1’s wound flowsheets revealed, “Deep Tissue Injury (DTI) Bilateral Buttocks” was “first assessed” on 03/25/2025 at 12:00 AM (19 days after admission). Review of Pt #1 Wound Care progress notes from 03/25/2025 to 05/23/2025 revealed: -03/25/2025 3:55 PM: “Hospital acquired DTI across bilateral buttocks measuring 4 (length in centimeters) x 7 cm (centimeters) (width) with non blanchable deep purple tissue...Writer applied Allevyn boarder foam...Pt is at risk for skin breakdown due to decreased mobility, moisture, friction/shear, inadequate nutrition. Goals of Treatment:...Prevent skin breakdown, Manage incontinence...Recommendations: Wound Care to Bilateral Buttocks...1. Cleanse with peri wipes...2. Apply Allevyn boarder foam...3. Assess under dressing every shift...4. Change dressing every other day, PRN (as needed) soiling...Preventative Measures:...5. Utilize incontinence management as needed: Cleanse with: Soap and water, Sage Barrier Wipes. Apply: Critic-Aid Clear (barrier cream)...Frequency: PRN with Incontinence...6. Only remove soiled layer of barrier cream, reapply to ensure frosting like consistency.” -04/1/2025 at 10:45 PM: “Hospital acquired DTI across bilateral buttocks measuring larger 4 x 7 cm (to) 6 x 9 cm with non blanchable deep purple tissue...Writer applied Allevyn boarder foam” (Recommendations and Preventative Measures same as 03/25/2025). -04/04/2025 at 1:58 PM: “Apply Desitin to wound bed BID (twice daily).” -04/22/2025 at 12:35 PM: “Wound Care to Bilateral Buttocks: 1. Cleanse with soap and water...2. Apply Medihoney to wound bed...3. Cover with Allevyn...4. Change and assess q (every) day and PRN with saturation.” -04/29/2025 at 12:50 PM: “Hospital acquired DTI across bilateral buttocks is now an unstageable pressure injury measuring 5 (cm) x 10 (cm) x 0.5 cm (depth) which is starting to evolve revealing red moist tissues.” -05/02/2025 at 10:38 PM: “Hospital acquired DTI across bilateral buttocks is now an unstageable pressure injury measuring 5 x 10 x 1 cm...Wound Care to Bilateral Buttocks...1. Cleanse with soap and water...2. Apply Santyl (wound ointment) to wound bed...3. Cover with Allevyn...4. Change and assess q (every) day and PRN with saturation.” -05/09/2025 at 1:43 PM: “Hospital acquired DTI across bilateral buttocks is now an unstageable pressure injury measuring 5 x 10 x 1.5 cm...Wound Care to Sacrum...1. Cleanse with soap and water...2. Apply Santyl to wound bed...3. Moisten Hydrofera Blue (antibacterial foam dressing) with NS (normal saline), cut to fit wound and apply to wound bed...4. Cover with Allevyn...5. Change and assess q day and PRN with saturation.” -05/23/2025 at 1:59 PM: “Wound Care to Sacrum...1. Cleanse with soap and water...2. Apply wet to dry dakins (solution) to wound beds...3. Cover with Allevyn or ABD (abdominal) pad...4. Change and assess q day and PRN with saturation.” Review of Pt #1’s “Deep Tissue Injury (DTI) Bilateral Buttocks” wound flowsheets from 03/25/2025 through 05/23/2025 revealed: -On 03/28/2025 to 04/01/2025 (5 days), 04/12/2025 to 04/15/2025 (4 days), 04/20/2025 to 04/23/2025 (3 days), nursing wound documentation revealed “No dressing in place” and “Open to air.” This was inconsistent with Wound Care orders to “Cover with Allevyn (foam dressing).” -On 03/26/2025 to 04/01/2025 (7 days), 04/12/2025 to 04/15/2025 (4 days), 04/20/2025 to 04/22/2025 (3 days), 04/26/2025 to 04/29/2025 (4 days), and 05/10/2025, there was no documentation of cleansing of the wound and/or treatment interventions completed as per Wound Care orders. -On 03/26/2025, 03/27/2025, 04/26/2025 to 05/02/2025 (7 days), 05/06/2025, 05/07/2025, 05/10/2025 to 05/13/2025 (4 days), and 05/16/2025 to 05/19/2025 (4 days), there was no documentation of a comprehensive wound assessment for this pressure injury as per Wound Care orders (daily with dressing change). Review of Pt #1’s “Hygiene” flowsheets from 03/25/2025 through 05/20/2025 revealed there were no “Skin” interventions documented on 03/26/2025, 03/28/2025 to 03/30/2025 (3 days), 04/01/2025, 04/05/2025, 04/09/2025 to 04/13/2025 (5 days), 05/08/2025, 05/09/2025, 05/12/2025 to 05/17/2025 (6 days), 05/19/2025, and 05/20/2025. Per review of Pt #1’s “Infectious Disease” physician progress note dated 06/02/2025 at 8:32 AM, on 05/31/2025 the buttock wound culture revealed growth of “Enterococcus faecium (bacteria)” and “Candida auris (yeast).” Per the “Infection Disease” note, Pt #1’s blood cultures on 05/30/2025 showed Enterococcus Faecium (same as wound cultures). The Infectious Disease physician progress note “Assessment” revealed, “VRE (Vancomycin-resistant Enterococcus) bacteremia (blood stream infection)...multiple potential sources including...necrotic buttock ulcer...” Pt #3: Review of Pt #3’s medical record revealed Pt #3 was admitted to the inpatient ICU on 06/03/2025 at 5:00 AM with Acute Encephalopathy (brain dysfunction that causes change in mental status); Pt #3 was an inpatient at the time of the medical record review on 06/12/2025 at 8:40 AM. Review of Pt #3’s Braden score from 06/03/2025 to 06/11/2025, revealed Pt #3’s Braden score ranged from 11 to 16 (at risk for skin breakdown) throughout the inpatient stay. Review of Pt #3’s “Stool” assessment nursing flowsheets revealed documentation that Pt #3 was incontinent of stool on 06/06/2025 (3:00 PM, 8:00 PM), 06/07/2025 (12:00 AM, 4:00 AM, 2:00 PM), 06/08/2025 (8:00 AM, 12:00 PM, 4:00 PM, 7:36 PM), 06/09/2025 (12:00 AM), 06/10/2025 (12:00 PM, 2:25 PM, 4:00 PM, 10:44 PM), 06/11/2025 (2:00 AM, 10:33 PM), and 06/12/2025 (2:00 AM). Review of Pt #3’s “Hygiene” flowsheets from 06/06/2025 through 06/11/2025 revealed there was no documentation of “Skin” interventions (i.e. incontinence cleanser, barrier cream, moisturizer) addressing Pt #3’s risk for skin breakdown due to moisture from incontinence. Review of Pt #3’s “Skin” nursing flowsheets from 06/06/2025 to 06/11/2025 revealed there was no documentation of staff initiating preventative wound/skin interventions as per policy; including but not limited to, barrier cream, incontinence cleanser, moisture wicking incontinence pads, and preventative foam dressing. Review of Pt #3’s “Wound Care” nurse progress note dated 06/11/2025 at 10:39 AM, revealed Wound Care was consulted for a wound to buttocks (not present on admission). Per “Wound Care” note, “Buttocks: partial thickness shearing throughout, in total measuring 8 (cm) x 10 (cm) x 0.1 cm. Wound bed 20 % pink moist tissue, 10 % peeling skin, 70 % fragile intact skin. Scant serous (clear to yellow fluid) drainage, increased moisture throughout related to stool/urinary incontinence.” Review of Pt #3’s nursing skin assessments on 06/11/2025 and 06/12/2025 revealed documentation of “WDL (within defined limits)” on 06/11/2025 at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 8:00 PM, and 06/12/2025 at 12:00 AM. This was inconsistent with the Wound Care nurse assessment on 06/11/2025. Pt #5: Review of Pt #5’s medical record revealed Pt #5 was admitted to the inpatient ICU on 06/09/2025 at 3:44 PM with an Intracranial Hemorrhage (brain bleed); Pt #5 was an inpatient at the time of the medical record review on 06/12/2025 at 10:28 AM. Review of Pt #5’s nursing flowsheets revealed on 06/09/2025 at 3:45 PM, Pt #5’s Braden score was “12”. Review of Pt #5’s Wound flowsheets revealed a “Skin tear” on Pt #5’s back was first assessed on 06/09/2025 at 9:00 PM. Review of Pt #5’s “Wound” flowsheets from 06/09/2025 through 06/12/2025 revealed there was no documentation of nursing assessments and treatment interventions for the “Skin tear” wound. Review of the “Wound” flowsheets revealed “No dressing in place” was documented on 06/09/2025, 06/10/2025, and 06/11/2025. Review of Pt #5’s “Stool” assessment nursing flowsheets revealed documentation that Pt #5 was incontinent of stool on 06/10/2025 (4:00 PM, 8:00 PM), 06/11/2025 (12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, and 4:00 PM), and 06/12/2025 (8:00 AM). Review of Pt #5’s “Hygiene” flowsheets from 06/09/2025 through 06/12/2025 revealed there was no documentation of “Skin” interventions addressing Pt #5’s risk for skin breakdown due to moisture from incontinence. Pt #8: Review of Pt #8’s medical record revealed Pt #8 was admitted to the inpatient ICU on 06/06/2025 at 11:30 AM with Metabolic Encephalopathy and Acute Kidney Injury; Pt #8 was an inpatient at the time of the medical record review on 06/12/2025 at 11:00 AM. Review of Pt #8’s nursing flowsheets revealed on 06/06/2025 at 11:45 AM, Pt #8’s Braden score was “13”. Review of Pt #8’s “Wound” nursing flowsheets revealed a “Red moist scab + hypopigmented (light area) vs. resolving pressure injury area” to the coccyx; the wound was first identified on 06/06/2025 at 6:32 AM (prior to inpatient admission). Per review of “Wound” flowsheets from 06/06/2025 through 06/11/2025, only “Intact” was documented for the “Wound Assessment (s).” There was no documentation of a comprehensive nursing assessment describing the appearance of the wound. “Wound” flowsheets revealed “Open to Air” documented for “Dressing.” There was no documentation of nursing staff applying a preventative foam dressing to protect the wound as per policy. Review of Pt #8’s “Stool” assessment nursing flowsheets revealed documentation that Pt #8 was incontinent of stool on 06/12/2025 (1:01 AM, 11:36 AM), 06/10/2025 (4:29 AM, 10:49 AM, 4:18 PM), 06/09/2025 (12:43 AM, 6:33 AM, 11:12 AM, 12:27 PM, 9:24 PM), 06/08/2025 (12:25 AM, 5:55 AM, 12:10 PM, 5:27 PM), and 06/07/2025 (8:49 PM). Review of Pt #8’s “Hygiene” flowsheets from 06/06/2025 through 06/12/2025, revealed there was no documentation of “Skin” interventions addressing Pt #8’s risk for skin breakdown due to moisture from incontinence. Per interview with ICU Clinical Nurse Specialist (CNS) F, while reviewing medical records on 06/11/2025 beginning at 12:00 PM, CNS F confirmed the findings and stated that staff should be documenting a wound assessment every shift or as per wound care orders. CNS F stated that staff should peel back the preventative foam dressing and assess the skin underneath at least every shift. CNS F stated that staff should document wound and skin interventions in the nursing flowsheets. CNS F stated that documenting “Intact” would not be considered sufficient for a wound assessment. Per interview with ICU Manager H on 06/12/2025 at 1:17 PM, Manager H stated nursing staff should initiate preventative skin interventions when the Braden scale is less than 18. Per Manager H, nursing staff should provide interventions such as repositioning, skin barrier cream, incontinence cleanser, and preventative foam dressings to protect the skin. Per interview with Wound Care manager G on 06/12/2025 beginning at 1:20 PM, Manager G stated nursing staff should be cleansing skin tears with soap and water and applying a foam dressing to the wound. Manager G stated that nursing staff should apply a preventative foam dressing on skin at risk for a pressure injury.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 29972 Based on record review and interview the facility staff failed to ensure that nursing care plans were initiated as per policy to address skin/wound care needs and interventions in 4 of 10 medical records reviewed (Patient (Pt) #2, #3, #7, #10); failed to ensure nursing care plans are kept current and updated based on patient assessments in 3 of 10 medical records reviewed (Patient (Pt) #1, #3, #10); and failed to ensure that nursing interventions are implemented based on ongoing assessments of patient care needs in 3 of 10 medical records reviewed (Pt #1, #3, #10), in a total of 10 medical records reviewed. Findings Include: Review of policy and procedure #18231547 titled, “Hospital based Assessment & Documentation Policy” Last revised 05/23/2025 revealed: - “As patient care needs are identified, it is the responsibility of the healthcare team to prioritize the care and service delivered to assure that the patient’s needs are met.” - “A care plan has individualized patient priorities, expected outcomes with target dates, and appropriate interventions.” - “Members of the healthcare team revise the plans and goals for care, treatment, and services, based on the patient’s needs.” - “The...initial plan of care should be completed within 24 hours.” - “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.” Pt #1: Review of Pt #1’s medical record revealed Pt #1 was a 63 year old admitted to the inpatient Intensive Care Unit (ICU) on 03/06/2025 at 6:27 PM after having a “Whipple” procedure (surgical operation that removes the head of the pancreas, the first part of the small intestine, and sometimes a portion of the stomach, gallbladder, and common bile duct) for pancreatic cancer. Pt #1 was placed on comfort cares and passed away at the hospital on 06/03/2025 at 3:08 PM. Review of Pt #1’s “Care Plans” revealed the “Skin Integrity Impairment Risk” care plan was opened on 03/07/2025. Review of Pt #1’s “Wound” flowsheets revealed, “Deep Tissue Injury (DTI) Bilateral Buttocks” was “first assessed” on 03/25/2025 at 12:00 AM (19 days after admission). Per review of Pt #1’s skin care plan, there was no documented evidence of nursing staff updating and/or revising the skin/wound care plan to ensure patient care needs were met, after developing a pressure injury while in the hospital. Review of Pt #1’s “Deep Tissue Injury (DTI) Bilateral Buttocks” wound flowsheets from 03/25/2025 through 05/23/2025 revealed: -On 03/26/2025 to 04/01/2025 (7 days), 04/12/2025 to 04/15/2025 (4 days), 04/20/2025 to 04/22/2025 (3 days), 04/26/2025 to 04/29/2025 (4 days), and 05/10/2025, there was no documentation of cleansing of the wound and/or treatment interventions completed as per Wound Care orders. -On 03/26/2025, 03/27/2025, 04/26/2025 to 05/02/2025 (7 days), 05/06/2025, 05/07/2025, 05/10/2025 to 05/13/2025 (4 days), and 05/16/2025 to 05/19/2025 (4 days), there was no documentation of a comprehensive wound assessment for this pressure injury as per Wound Care orders (daily with dressing change). Pt #1’s “Skin integrity Impairment Risk” care plan was not kept current due to a lack of ongoing assessments and evaluations of Pt #1’s “Deep Tissue Injury Bilateral Buttocks” wound, to ensure Pt #1’s skin/wound needs were being met as per policy. Pt #2: Review of Pt #2’s medical record revealed Pt #2 was admitted to the inpatient ICU on 06/09/2025 at 2:13 PM with Chronic Obstruction Pulmonary Disease (COPD); Pt #2 was an inpatient at the time of the medical record review on 06/12/2025 at 8:40 AM. Review of Pt #2’s “Care Plans” revealed the “Skin Integrity Impairment Risk” care plan was opened on 06/09/2025 (no time). There were no skin interventions documented in the care plan. Pt #3: Review of Pt #3’s medical record revealed Pt #3 was admitted to the inpatient ICU on 06/03/2025 at 5:00 AM with Acute Encephalopathy (brain dysfunction that causes change in mental status); Pt #3 was an inpatient at the time of the medical record review on 06/12/2025 at 8:40 AM. Review of Pt #3’s “Care Plans” revealed the “Skin Integrity Impairment Risk” care plan was opened on 06/05/2025 (no time) (2 days after admission). The skin plan of care was not initiated within 24 hours of admission as per policy. Review of Pt #3’s “Wound Care” nurse progress note dated 06/11/2025 at 10:39 AM revealed Wound Care was consulted for a wound to buttocks (not present on admission). Per “Wound Care” note, “Buttocks: partial thickness shearing throughout, in total measuring 8 (cm) x 10 (cm) x 0.1 cm. Wound bed 20 % pink moist tissue, 10 % peeling skin, 70 % fragile intact skin. Scant serous (clear to yellow fluid) drainage, increased moisture throughout related to stool/urinary incontinence.” Per review of Pt #3’s “Skin” care plan, there was no documented evidence of nursing staff updating and/or revising the skin/wound care plan to ensure patients care needs are met after developing a wound to the buttocks while in the hospital. Review of Pt #3’s nursing skin assessments on 06/11/2025 and 06/12/2025 revealed documentation of “WDL (within defined limits)” on 06/11/2025 at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 8:00 PM, and 06/12/2025 at 12:00 AM. This was inconsistent with the Wound Care nurse assessment on 06/11/2025. Review of Pt #3’s “Skin” nursing flowsheets from 06/06/2025 to 06/11/2025 revealed there was no documentation of staff initiating preventative wound/skin interventions as per policy; including but not limited to, barrier cream, incontinence cleanser, moisture wicking incontinence pads, and preventative foam dressing. Pt #3’s “Skin integrity Impairment Risk” care plan was not kept current due to a lack of ongoing assessments and evaluations of Pt #3’s buttock wound to ensure Pt #3’s skin/wound needs are being met as per policy. Pt #7: Review of Pt #7’s medical record revealed Pt #7 was admitted to the inpatient ICU on 06/08/2025 at 11:41 PM with Gastrointestinal Hemorrhage; Pt #7 was an inpatient at the time of the medical record review on 06/12/2025 at 10:45 AM. Review of Pt #7’s “Care Plans” revealed the “Skin Integrity Impairment Risk” care plan was opened on 06/09/2025 (no time). There were no skin interventions documented in the care plan. Pt #10: Review of Pt #10’s medical record revealed Pt #10 was admitted to the inpatient ICU on 05/28/2025 at 2:49 PM with a spinal cord injury; Pt #10 was an inpatient at the time of the medical record review on 06/12/2025 at 12:30 PM. Review of Pt #10’s “Care Plans” revealed the “Skin Integrity Impairment Risk” care plan was opened on 05/30/2025 (no time). There were no skin interventions documented in the care plan. Pt #10’s “Skin Integrity Impairment Risk” care plan was not initiated within 24 hours of admission as per policy. Review of Pt #10’s “Wound” flowsheets revealed a “Sacrum Fissure” was first assessed on 06/02/2025 (5 days after admission). There was no documented evidence of nursing staff updating and/or revising the skin/wound care plan to ensure patient care needs are met after developing a wound to the sacrum while in the hospital. Per interview with Clinical Nurse Leader J on 06/11/2025 beginning at 2:00 PM, Nurse J stated that the skin care plans should be updated and/or revised when a wound develops or when there is deterioration of an existing wound. Nurse J stated that a skin impairment care plan should be opened when there is an actual wound. Nurse J stated that the nurse should add interventions to the care plan document.”

“LABORATORY SERVICES CFR(s): 482.27 The hospital must maintain, or have available, adequate laboratory services to meet the needs of its patients. The hospital must ensure that all laboratory services provided to its patients are performed in a facility certified in accordance with Part 493 of this chapter. This Condition is not met as evidenced by: 29972 Based on record review and interview staff failed to follow protocol and notify the responsible medical professional of critical lab results when the Registered Nurse and Charge Nurse were unable to be reached as per policy; and staff failed to document who was notified of the critical lab results and the time they were notified in 1 of 10 patient critical lab values reviewed (Patient (Pt) #1), in a total sample of 10 medical records reviewed. Findings Include: Staff failed to follow protocol and notify the responsible medical professional of critical lab results when the Registered Nurse and Charge Nurse were unable to be reached as per policy. See tag A-0582. Staff failed to document who was notified of the critical lab results and the time they were notified. See tag A-0582.”

“ADEQUACY OF LABORATORY SERVICES CFR(s): 482.27(a) The hospital must have laboratory services available, either directly or through a contractual agreement with a certified laboratory that meets the requirements of part 493 of this chapter. This Standard is not met as evidenced by: 29972 Based on record review and interview staff failed to follow protocol and notify the responsible medical professional of critical lab results when the Registered Nurse was unable to be reached as per policy and staff failed to document who was notified of the critical lab results and the time they were notified in 1 of 10 patient critical lab values reviewed (Patient (Pt) #1), in a total sample of 10 medical records reviewed. Findings Include: Review of policy and procedure titled, “Critical Test Results Communication Policy” last revised 02/23/2022 revealed the following: -Critical Results and Values: “A test result with an abnormal finding that may represent a life-threatening situation. These values/interpretations require timely notification to the provider to ensure appropriate care for the patient.” - “I. Diagnostic/testing departments will call critical results/tests directly to the ordering/covering provider or to a responsible licensed caregiver...” Review of policy titled, “...Laboratory Policy: Critical Result Reporting (no date)” revealed the following: - “Responsible Licensed Caregiver: The licensed practitioner who will assume responsibility for acting upon the critical result or test. This includes: Physician, Physicians Assistants, Nurse Practitioners, Advanced Practice Nurse Prescribers, or health care professionals that have authority to write orders within their credentials...” - “Authorized Personnel: These personnel can take the verbal communication of critical tests or values from the laboratory and will notify the appropriate Responsible Licensed Caregiver. This includes:...Registered Nurses (RN)...” - “The critical value/test notification...has been designed to ensure timely communication of critical values and test to an authorized personnel or responsible, licensed caregiver. Every attempt will be made to provide notification as soon as the result is available in the laboratory...” - “Critical Results for Inpatient and Emergency Department (ED)/Urgent Care Patients...A. Results will be communicated to authorized personnel who are accountable for communication to the responsible licensed caregiver or directly to the responsible licensed caregiver. 1. In the event the authorized personnel assigned to the patient or the responsible licensed caregiver are unavailable, the value may be given to another authorized personnel or responsible licensed caregiver.” - “B. When contact cannot be established with an authorized personnel or responsible licensed caregiver, repeat the call...C. If successful contact cannot be established after this repeat call or authorized personnel/responsible licensed caregiver will not take the result, communicate the result to the on-call nurse/house supervisor/manager. D. If successful contact cannot be established with the nurse/house supervisor after multiple attempts (three), notify the on-call physician for that department...E. If successful contact cannot be established with the on-call hospitalist or they will not take the result, notify the hospital department chair/medical director for help identifying the right clinician who can triage the issue to the ED or another clinical environment. F. If the department chair is not available, escalate to the VPMA (Vice President of Medical Affairs) and/or Chief of Staff of the hospital for help identifying the right clinician who can triage the issue to the ED, or another clinical environment.” - “Documentation of Notification: A. Documentation of Critical Result...Notification in the...Medical Record: 1. Records must show prompt notification of a critical value or test to the appropriate, authorized personnel or responsible licensed caregiver. 2. All attempts for notification will be documented. 3. The documentation must be placed on the critical result that is being communicated...” Review of Pt #1’s Critical Care physician progress notes from 05/24/2024, revealed that Pt #1 was a 82 year old who “presented to the hospital on 05/09/2024 after being found down at his home with confusion. (Pt #1) was diagnosed with a UTI (urinary tract infection) and obstructive uropathy (blockage of urinary flow) causing acute kidney injury...Patient was reportedly doing ok this AM (05/11/24) and actually had a sitter d/t (due to) his confusion. (Pt #1) was sleeping when he was found to be unarousable and pulseless. A code was called. When the medical team arrive patient was in asystole (no pulse)...prolonged code lasting 40 minutes...Called lab during the code as no morning BMP (Basic Metabolic Panel) had resulted and were told K (Potassium) was 6.5 (normal 3.5-5.1). Aggressively treated the K. Intubated. Eventually achieved ROSC (return of spontaneous circulation--pulse) and transferred to ICU (Intensive Care Unit).” Review of Pt #1’s Adverse Event reported on 05/11/2024 at 1:16 PM revealed on Medical Surgical floor 7 East, “Patient was located in room 7201, overhead page received for a medical emergency at approximately 1030 this morning...Pt was coded (received cardiopulmonary resuscitation--CPR) and ROSC (return of spontaneous circulation--pulse) at approximately 1120. Per Dr...at bedside pt had noted critical potassium in addition to creatinine noted from morning labs...Delay in lab results resulting in sentinel event, results not received till code was in progress.” Review of Pt #1’s Laboratory Downtime Requisition form revealed Labs ordered for a Metabolic Panel (includes Potassium) to be drawn “Next AM” (routine) on 05/11/2024 at 6:00 AM. Lab collection Date and Time on the form is blank. Review of Pt #1’s 05/11/2024 (6:00 AM) Lab results revealed a Potassium of 6.5 (normal 3.5-5.1) “Completed” on 05/11/2024 at 10:42 AM. Review of the “Comments” on the Lab results revealed that in regard to the “Critical K (potassium) result,” staff “Tried calling 3 times-No answer.” There was no documentation of who was called and the time of each call as per policy. Per interview with Lab Manager D on 06/06/2024 beginning at 3:15 PM, Manager D stated that for inpatient critical results, staff do not contact the Provider (Responsible Licensed Caregiver) because they do not have a Volcera (communication device carried by RNs) and are harder to get in touch with. Manager D stated that Lab staff call the RN’s Volcera 3 times and if they do not answer, Lab staff would call the Charge Nurse. Per interview with Lab Director E and Manager D on 06/11/2024 at 1010 AM, Manager D stated that Lab G did not follow the critical results reporting process as per policy beyond contacting the Charge RN.”

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 42046 Based on staff interview and record review from 05/10/2024 through 05/14/2024, the Ascension Columbia St Mary’s Hospital failed to construct, install, and maintain the building systems to ensure safety of patients. Findings include: The facility was found to contain the following deficiencies. K711 - Evacuation and Relocation Plan S948 - Other Physical Environment - Fire Report-1.-124.36 As a result of these deficiencies, 42 CFR Subpart CFR 482.41 Condition of Participation: Physical environment was NOT MET See K-tags for details of the specific findings.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 29972 Based on record review and interview staff failed to develop and implement a comprehensive corrective action plan and monitor the action plan for compliance in 1 of 1 adverse events reviewed (Patient (Pt) #1); in a total sample of 1 adverse event reviewed. Findings Include: Review of policy and procedure titled, “Event Reporting” last revised 03/14/2023 revealed the following: - “The leader or designee of the department/nursing unit/medical group site whereby an event occurs is responsible for initiating investigation action, follow-up of all events, and tracking/trending of all events which occurred within...” - “Specific events will be reviewed by the Safety Event Review Team (SERT) or SERT sub-team to determine the need for investigation or Root Cause Analysis (RCA) completion.” Review of policy and procedure titled, “Fire Plan and Fire Risk Assessment--Surgical Services and Procedural Areas” last approved 04/11/2023 revealed the following: - “All aerosols, tinctures, and other flammable compounds will not be used in the presence of an ignition source.” - “Alcohol based skin prep solutions must be allowed to dry for at least 3 minutes...” Review of policy and procedure titled, “Electrosurgery” last reviewed 06/12/2022 revealed the following: - Policy Statement: “To provide guidance to perioperative personnel for the use and care of electrosurgical equipment...The expected outcome is the patient is free from signs and symptoms of electrical injury.” Review of Pt #1’s incident report revealed on 02/28/2024 (no time), “Physician Assistant (PA B)...was applying Cavilon Barrier film (protects skin from irritation) for Wound Vac Dressing around the surgical site. Before the Cavilon was able to dry, (Surgeon A) used the Bovie at the surgical site which caused a fire. The entire surgical site caught fire and a small portion of the surgical drape, which lasted approx (approximately) 5 seconds. (PA B) and (Surgeon A) put out the fire with sterile towels which were at the field. (Surgeon A) and (PA B) examined the patient for injury and did not note any new injuries. Both (Surgeon A) and (PA B) finished putting on patient dressing and surgery was finished...” Per interview with PA B on 05/10/2024 beginning at 1:27 PM, PA B stated that the surgical fire occurred after Pt #1’s procedure had ended. PA B stated that Surgeon A completed Pt #1’s wound debridement and PA B was prepping the skin to place a Wound Vac over the surgical site. PA B stated that she/he applied the barrier film (flammable when wet) to the surgical site and before it could dry, Surgeon A proceeded to use the Bovie Pen to stop a small bleed and this resulted in a “flash” fire. PA B stated that there is a risk for fire when the Bovie Pen (heat source) comes in contact with a flammable substance. PA B stated that there was no formal education/reinforcement provided and that the team talked about the incident and determined the Bovie would be taken “off the field” when using skin prep; PA B stated, “a verbal discussion was sufficient.” Per interview with Surgeon A on 05/10/2024 beginning at 5:10 PM, Surgeon A stated that PA B was applying skin prep for the placement of a Wound Vac and Surgeon A noticed there was bleeding coming from Pt #1’s surgical site. Surgeon A attempted to use the Bovie Pen to stop the bleeding and this “sparked a fire.” Surgeon A stated, “I don’t know what I was thinking.” Per Surgeon A, Surgeon A and PA B put the fire out with wet surgical towels and the patient was unharmed. Surgeon A stated that after the incident an action plan was developed for the Operating Room (OR) nurse to be responsible for unplugging the Bovie Pen when alcohol based skin prep was being applied to prevent an incident like this from occurring again. Per interview with Director of Surgery C on 05/10/2024 beginning at 2:16 PM, Director C was informed of the incident immediately. Director C stated that she/he met with leadership, Quality, and Safety and determined that staff should unplug the Bovie Pen until the skin prep is dry. Director C stated that this was shared with staff (Registered Nurse (RN), First Assistants, Surgical Technicians) during safety huddles and a staff meeting. When asked if all staff were educated on the new process, Director C stated, “We were able to catch the majority of staff.” Per Director C, she/he did not keep track of who attended the huddles. Director C stated that no formal education went out to the Surgeons/Providers; per Director C, the staff meeting and staff huddles captured the First Assistants, RNs, and Surgical Technicians. Director C stated that there is no documentation of staff conducting audits and monitoring to ensure that the OR staff are compliant with the new process. Per interview with Quality Manager F on 05/10/2024 beginning at 3:13 PM, Manager F stated a Safety Event review team conducted a review of the incident (Nursing leadership, Provider leadership, Safety, Risk Management, and Quality) and the team determined that based on the facts a RCA was not necessary. Per Quality Manager F, the facility is unable to release the meeting minutes showing documented evidence of this incident review and investigation due to being protected information. Review of the Daily OR Safety Huddles from 03/01/2024, 03/04/2024, 03/08/2024, 03/11/2024, and 03/12/2024 revealed documentation to “turn off” and/or “unplug” the Bovie Pen when applying skin prep using a “lollipop” (Chlorprep stick/swab--alcohol based skin prep); there was no documentation of which staff attended the Safety Huddles. There was no documentation of the education addressing the use of the Cavilon Barrier Film used for Wound Vac skin prep. Review of the “Associate Meeting” power point slides dated 03/14/2024 revealed, “Reminder: Unplug bovie when using prep (skin prep)-do not plug it in until the dry time has elapsed. This is to prevent surgical fire.” Review of the staff meeting attendance sheet revealed 11 RN’s and 12 Surgical Technicians/First Assistants did not sign off as being in attendance for this meeting. There was no documentation of the education addressing the use of the Cavilon Barrier Film used for Wound Vac skin prep. Per email correspondence with Quality Manager H on 05/13/2024 at 3:40 PM, when asked if all Surgeons and Providers who use the Bovie Pen during surgery have been informed of this incident and educated on the new process, Manager H responded that there was no documented evidence that this was shared with all Surgeons and Providers.”

“LIFE SAFETY FROM FIRE CFR(s): 482.41(b) Life Safety from Fire This Standard is not met as evidenced by: 42046 Based on staff interview and record review from 05/10/2024 through 05/14/2024, the Ascension Columbia St Mary’s Hospital failed to construct, install, and maintain the building systems to ensure safety of patients. Findings include: The facility was found to contain the following deficiencies. K711 - Evacuation and Relocation Plan S948 - Other Physical Environment - Fire Report-1.-124.36 As a result of these deficiencies, 42 CFR 482.41(b) Standard: Safety from Fire was NOT MET See K-tags for details of the specific findings.”

“OPERATING ROOM POLICIES CFR(s): 482.51(b) Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. This Standard is not met as evidenced by: 29972 Based on observation, record review, and interview surgery staff failed to ensure skin antiseptic (non-alcohol) was applied as per manufacturer’s guidelines to ensure effective skin antisepsis prior to a surgical procedure in 1 of 1 surgery observation (Pt #2), in a total sample of 1 observation of surgery. Findings Include: Review of the manufacturer’s guidelines for Bactoshield CHG (Chlorhexidine Gluconate) 4% (non-alcohol skin prep) revealed, “Patient Preoperative skin preparation: Apply product liberally to surgical site and swab for at least 2 minutes and dry with a sterile towel...Repeat procedure for an additional 2 minutes and dry with a sterile towel.” On 05/10/2024 beginning at 2:00 PM, while observing Pt #2’s surgical procedure in the operating room (OR), observed Circulating Registered Nurse (RN) E applying skin antiseptic (CHG) to Pt #2’s back prior to Pt #2’s surgery. RN E applied the skin prep for 2 minutes then draped the patient; RN E did not dry the skin with a sterile towel and repeat the steps to ensure proper skin antisepsis as per the manufacturer’s guidelines for use. During interview with Surgery Director C on 05/14/2024 beginning at 12:30 PM, Director C observed Pt #2’s surgery on 05/10/2024 and confirmed that RN E did not apply the skin antiseptic as per manufacturer’s guidelines. Director C stated that OR staff should following the manufacturer’s guidelines for use when applying skin antiseptic and ensure skin prep is dry before draping.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 41126 Based on record review and interview the facility failed to ensure patients receive care in a safe setting consistent with sound nursing practice in 1 of 10 medical records reviewed (Pt. (patient) #1) and failed to follow policy in the reporting of an abnormal finding on x-ray in 1 of 10 medical records reviewed (Pt. #6). Findings: Patient discharged with intact IV catheter Review of facility policy titled, “Patient Rights and Responsibilities, AW (Ascension Wisconsin)” dated 3/14/2020 revealed, “Procedure: ...#11. Receive compassionate, personal care, consistent with sound medical and nursing practice in a clean, safe and secure environment...” Review of Pt. #1’s medical record revealed he was discharged at approximately 12:25 PM on 1/23/2024. The medical record revealed a nurses note that was dated 1/23/204 at 2:43 PM, “Shift Summary: ...Patient pulled out IV and walked down hallway towards elevator because he wanted to wait for niece to pick him up downstairs in the main lobby and not his room.” The record revealed that the patient became unresponsive in the lobby at approximately 1:05 PM and resuscitation efforts were unsuccessful. Review of the facility policy titled “Intravenous (IV) Therapy- Invasive Lines, AW (Ascension Wisconsin)” dated 12/21/2023 revealed no policy statements regarding removal of intravenous catheters at discharge. On 2/13/2024 at 9:40 AM in the interview with CVICU (Cardiovascular Intensive Care Unit) Manager F, Manager F stated, “As far as the IV, he (Pt. #1) told the nurse that he had taken the IV out and (RN P) believed him. Of course, we routinely remove IV catheters at discharge.” The RN believed that he had discontinued his own IV however did not verify. The patient was discharged from the ICU (intensive care unit) with an intact capped IV catheter in place. Unreported abnormal finding on x-ray Review of facility policy titled, “Critical results Reporting for Medical Imaging” dated 10/21/2021 revealed, “Policy: Critical results and critical tests results will be reported by the Radiologist to a licensed caregiver authorized to make clinical decisions or his/her designee within one (1) hour of findings. Critical results would be defined as any study with an abnormal finding in which the clinician needs to make a decision in the care of the patient within 24 hours (i.e. prior to receiving the typed dictated report).” Review of Pt. #6’s medical record revealed a portable chest x-ray was ordered by the ICU Intensivist Physician Assistant on 12/13/2023 for hypoventilation (breathing that is too shallow or too slow) likely due to splinting from post-op pain citing needs a CXR (chest x-ray) has not had one postoperatively yet.” The medical record revealed that the CXR was ordered at 2:00 PM and completed and read at 4:44 PM. The report “X-ray Chest Portable: Patient Communication” in the medical record revealed, under Impression, “1. There is a radiopaque ribbon over the RIGHT upper quadrant abdomen. Its exact location is otherwise indeterminate on the basis of this study. It may be overlying or post surgical but will need CLINICAL CORRELATION TO EXCLUDE A RETAINED FOREIGN BODY SUCH AS A SPONGE...” The x-ray was read with a finding of a potential retained foreign body with a note indicating that clinical correlation was necessary to confirm the findings. No notification to the provider of the potential critical finding was made by the Radiologist.”

“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: 29963 Based on record review and interviews, facility staff failed to communicate with a physician (at the receiving hospital) who would agree to accept a transfer and the medical care for 1 of 9 (Patient #1) Patients transferred from the Emergency Department (ED) to another facility in a total universe of 20 medical records reviewed. Findings include: 1. The facility failed to communicate with a physician who would agree to accept a transfer and medical care of a patient transferred from the ED to another facility. See tag 2409.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 29963 Based on record review and interviews, facility staff failed to communicate with a physician (at the receiving hospital) who would agree to accept a transfer and the medical care for 1 of 9 (Patient #1) Patients transferred from the Emergency Department (ED) to another facility in a total universe of 20 medical records reviewed. Findings Include: A review of facility Policy #13744813 “Emergency Medical Treatment and Active Labor Act (EMTALA), AW (Ascension Wisconsin),” last revised 06/01/2023 revealed, “Transfers: c. A patient should only be transferred when one of the situations in 2. above exist, and the transfer meets all the following requirements (a. Transfer is then appropriate): ii. The receiving facility has available space and qualified personnel for the treatment of the patient and has agreed to accept transfer of the patient and to provide appropriate medical treatment; and iii. Medical records related to the patient’s medical condition are provided to the receiving facility, and iv. The transfer is completed through the appropriate medical personnel and utilizing the appropriate equipment for the patient. Prior to transfer, the [Transfer Form] must be completed.” A review of Patient #1’s medical record revealed Patient #1 arrived at the facility’s ED on 12/19/2023 at 6:01 PM. ED “Triage Note” dated 12/19/2023 at 6:09 AM written by ED RN (Registered Nurse) J revealed, “Pt. arrived to ED via BELL [ambulance service] in police custody for AMS [Altered Mental Status] with suspected drug ingestion. Police report pt. breaking through window at pt. home today. Pt. is spitting at police and EMS[Emergency Medical Services] and ED staff; police placed a spit mask on pt. Pt. is not responding to questions.” A review of Patient #1’s “Medical Screen Exam” written by ED MD (Medical Doctor) I dated 12/19/2023 at 9:30 PM revealed, “Patient arrives extremely agitated. S/he was spitting at staff and taunting other patients. S/he was chemically sedated with 5 of Versed [sedative] due to significant agitation. Following this, further workup was performed. I did a thorough skin exam and found no lacerations that would need repair. Lab workup obtained which was overall reassuring with the exception of the CK [creatine kinase- used to help diagnose and monitor injuries and diseases that damage skeletal muscles] slightly over 2000. S/he was given an IV[intravenous] and given a liter of fluids. There was no evidence of an AKI [Acute Kidney Injury] on his/her metabolic panel. CK was down trending. Patient did recover and became alert and oriented x 4 with agitation resolved. S/he was placed on a Chapter 51 hold by MPD [Milwaukee Police Department] due to him being a threat to himself. S/he is otherwise medically cleared and was discharged in police custody to [receiving hospital] ... Disposition: Discharged.” A review of Patient #1’s “ED Notes” in ED RN J on 12/19/2023 at 9:58 PM revealed, “Writer called [receiving hospital] in attempt to give nurse to nurse report, put on hold. Writer told that pt. was not in system yet. MD notified and MD informed writer that EMTALA and doc to doc report not needed. MPD at bedside for transportation to [receiving hospital], D/C [discharge] paperwork reviewed with MPD.” A review of Patient #1’s medical record for the ED visit on 12/19/2024 did not include a “MD Documentation-EMTALA form” completed. ED MD I discharged Patient #1 from the facility into police custody under a Chapter 51 hold. During an interview on 02/13/2023 at 9:06 AM, the medical record review findings were discussed with and confirmed by with ED Director E who stated the physicians are expected to call the receiving facility to obtain a verbal agreement to accept transfer of the patient and to provide appropriate medical treatment. ED Director E also stated, the EMTALA form should be completed.”