University of WI Hospitals & Clinics Authority

“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 the facility staff failed to ensure the nursing staff perform pain reassessments after giving a pain medication intervention to ensure safe and effective pain management in 5 of 10 medical records reviewed (Patient (Pt) #1, 4, 5, 8, 9), in a total sample of 10 medical records reviewed. Findings Include: Review of policy and procedure 3.5.5 titled, “Pain Management: Screening, Assessment, and Reassessment” effective date August 5, 2020 revealed: - “Following an intervention, the patient should be reassessed for pain relief, side effects, or other adverse event produced by the intervention.” - “Reassessment of pain is ongoing. Reassess after each intervention and with each additional report of pain in a timely and comprehensive manner appropriate to the circumstances to ensure safety and efficacy.” - “Patients that can verbalize pain or answer question independently...should have a comprehensive pain assessment. Assessments components may include: a. Quality, onset, location, duration...d. An acceptable level of pain...e. Intensity of the patient’s pain rating on a scale (e.g.,0 to 10, mild-moderate-severe).” - “The minimum documentation of a comprehensive pain assessment includes: Frequency, Location, Intensity, and Quality.” Review of Pt #1’s medical record revealed Pt #1 was admitted to the hospital on 09/15/2025 for Laparoscopic Distal Pancreatomy (partial removal of the pancreas) and Splenectomy (removal of the spleen); Pt #1 was discharged home on 09/20/2025 at 2:50 PM. Review of Pt #1’s pain medication orders revealed Hydromophone (Dilaudid) 2-4 milligrams (mg) PO (by mouth) every 4 hours PRN (as needed) for pain. Pt #1 was on a continuous Dilaudid Epidural Nerve Block infusion from 09/15/2025 until it was stopped on 09/19/2025 at 11:26 AM. Review of Pt #1’s Medication Administration Record and Pain assessment flow sheets revealed: -On 09/19/2025 Pt #1 was given Dilaudid 2 mg PO at 11:03 AM and the Dilaudid Epidural infusion was stopped at 11:26 AM. There was no documented evidence of nursing staff completing a pain assessment/reassessment to ensure the medication intervention was safe and effective until 9:00 PM, 9 hours and 57 minutes later. -On 09/19/2025 Pt #1 was given Dilaudid 2 mg PO at 3:29 PM. There was no documented evidence of nursing staff completing a pain assessment/reassessment until 9:00 PM, 5 hours and 31 minutes later. -On 09/20/2025 Pt #1 was given Dilaudid 2 mg PO at 12:57 AM. There was no documented evidence of staff completing a pain reassessment until 9:00 AM, 8 hours and 3 minutes later. -On 09/20/2025 Pt #1 was given Dilaudid 4 mg at 5:37 AM. There was no documented evidence of staff completing a pain assessment and reassessment until 9:00 AM, 5 hours and 23 minutes later. Review of Pt #4’s medical record revealed Pt #4 was admitted to the hospital on 11/30/2025 with Leukocytosis (abnormally high white blood cells), Sepsis (blood infection), and Polycystic Kidney Disease; Pt #4 was a current patient at the time of medical record review. Review of Pt #4’s Medication Administration Record and Pain assessment flow sheets revealed: -On 12/01/2025 Pt #4 was given Oxycodone (narcotic pain medication) 10 mg PO at 10:13 AM. There was no documented evidence of nursing staff completing a pain reassessment to ensure the medication intervention was safe and effective until 3:00 PM, 4 hours and 47 minutes later. -On 12/01/2025 Pt #4 was given Oxycodone 10 mg PO at 10:56 PM. There was no documented evidence of nursing staff completing a pain reassessment until 12/02/2025 at 5:15 AM, 6 hours and 19 minutes later. -On 12/02/2025 Pt #4 was given Oxycodone 10 mg PO at 8:21 AM. There was no documented evidence of nursing staff completing a pain reassessment until 3:00 PM, 6 hours and 39 minutes later. -On 12/02/2025 Pt #4 was given Oxycodone 10 mg PO at 9:21 PM. There was no documented evidence of nursing staff completing a pain reassessment until 7:45 AM, 10 hours and 24 minutes later. Review of Pt #5’s medical record revealed Pt #5 was admitted to the hospital on 12/01/2025 for a hernia repair and breast reconstruction post mastectomy; Pt #5 was a current patient at the time of medical record review. Review of Pt #5’s Medication Administration Record and Pain assessment flow sheets revealed: -On 12/02/2025 Pt #5 was given Oxycodone 10 mg PO at 1:18 AM. There was no documented evidence of nursing staff completing a pain reassessment to ensure the medication intervention was safe and effective until 8:30 AM, 7 hours and 12 minutes later. -On 12/02/2025 Pt #5 was given Oxycodone 10 mg PO at 4:26 PM. There was no documented evidence of nursing staff completing a pain reassessment until 9:00 PM, 4 hours and 34 minutes later. Review of Pt #8’s medical record revealed Pt #8 was admitted to the hospital on 10/01/2025 due to a motor vehicle accident; Pt #8 was discharged on 10/06/2025 at 1:00 PM. Review of Pt #8’s Medication Administration Record and Pain assessment flow sheets revealed: -On 10/02/2025 Pt #8 was given Intravenous (IV) Dilaudid 0.4 mg at 2:05 AM. There was no documented evidence of nursing staff completing a pain reassessment to ensure the medication intervention was safe and effective until 6:00 AM, 3 hours and 55 minutes later. -On 10/02/2025 Pt #8 was given Intravenous (IV) Dilaudid 0.4 mg at 9:51 AM. There was no documented evidence of nursing staff completing a pain reassessment until 3:45 PM, 5 hours and 54 minutes later. Review of Pt #9’s medical record revealed Pt #9 was admitted to the hospital on 08/25/2025 due to hip pain; Pt #10 was discharged on 08/26/2025 at 5:20 PM. Review of Pt #9’s Medication Administration Record and Pain assessment flow sheets revealed: -On 08/25/2025 Pt #9 was given Oxycodone 10 mg PO at 4:40 PM. There was no documented evidence of nursing staff completing a pain reassessment to ensure the medication intervention was safe and effective until 9:00 PM, 4 hours and 20 minutes later. -On 08/25/2025 Pt #9 was given Oxycodone 10 mg PO at 2:17 AM. There was no documented evidence of nursing staff completing a pain reassessment until 6:17 AM, 4 hours later. Per interview with Nurse Manager D (Acute Care) on 12/04/2025 beginning at 10:54 AM, Manager D stated that nursing staff should do a comprehensive pain reassessment within an hour after giving a pain medication intervention. Manager D stated that staff should document interventions in the medical record. Manager D stated that she expects the staff to follow the Pain Management policy.”

“PATIENT RIGHTS: REVIEW OF GRIEVANCES CFR(s): 482.13(a)(2) [The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance.] The hospital’s governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. This Standard is not met as evidenced by: 50643 Based on record review and interview the facility failed to follow the process outlined in the complaint/grievance policy to acknowledge and investigate 1 complaint/grievance in a total of 3 complaints/grievances reviewed. Findings Include: A review of the facility’s policy titled, “Responding to Patient/Family Complaints and Grievances,” effective 1/31/21 revealed, “ ...Staff members should make every effort to promptly address patient complaints ... A staff member who receives a grievance about patient care or service is required to inform their manager of the grievance ... The Patient Relations Department will notify patients of their rights, inform them of the grievance process, and set up a timeline of up to 45 days for completion of the grievance process ...” A review of the facility’s policy titled, “Patient Rights and Responsibilities,” effective 7/10/24 revealed, “ ...Patients, their guardians or family members who feel that their concerns have not been adequately addressed should contact the Department of Patient Relations ... Inquires will be reviewed in a timely manner and resolved whenever possible ...” A review of the “Patient Relations voicemail log” revealed a voicemail from Complainant A on 5/30/25 at 11:00 AM which revealed, “Calling regarding the care my mother [Patient #1] received. Would like her care reviewed that resulted in her death. Would like to make sure this also does not happen to anyone else.” There was no additional documentation including acknowledgment, investigation, follow-up or resolution as of 6/10/25 (date of survey). An interview was conducted on 6/10/25 at 2:35 PM with Patient Relations (PR) Director E. When asked what the expected initial response time was for initial contact made after grievances were made, PR Director E stated that the expectation is that contact is made within 1 to 2 business days.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 50644 Based on record review and interview, facility staff failed to provide a notice of patient rights in 9 out of 10 patients’ (Patients #1, 2, 3, 4, 5, 6, 7, 8, and 10) medical records reviewed in a total universe of 10 patient medical records. Findings include: Review of facility’s policy #1.2.21, “Patient Rights and Responsibilities,” dated 7/10/2024 revealed, “It is the responsibility of the admitting/registration staff, in collaboration with the patient care staff, to provide a copy of Patient’s Rights and Responsibilities to patients or their legal guardians upon admission to the hospital.” Review of Patient #1’s medical record revealed Patient #1 had a colon screening on 5/31/2024. There was no evidence of patient rights being reviewed with or given to Patient #1. Review of Patient #2’s medical record revealed Patient #2 had a sigmoid colonoscopy on 5/31/2024. There was no evidence of patient rights being reviewed with or given to Patient #2. Review of Patient #3’s medical record revealed Patient #3 had a colon screening on 5/31/2024. There was no evidence of patient rights being reviewed with or given to Patient #3. Review of Patient #4’s medical record revealed Patient #4 had a diagnostic colonoscopy on 5/31/2024. There was no evidence of patient rights being reviewed with or given to Patient #4. Review of Patient #5’s medical record revealed Patient #5 had a colon screening on 5/23/2024. There was no evidence of patient rights being reviewed with or given to Patient #5. Review of Patient #6’s medical record revealed Patient #6 had a colonoscopy/esophagogastroduodenoscopy (a procedure that allow a doctor to examine the upper gastrointestinal tract) on 5/23/2024. There was no evidence of patient rights being reviewed with or given to Patient #6. Review of Patient #7’s medical record revealed that Patient #7 had an esophagogastroduodenoscopy on 4/24/2024. Further review revealed no evidence of patients’ rights being reviewed with or given to Patient #7. Review of Patient #8’s medical record revealed Patient #8 had a colonoscopy on 11/8/2023. There was no evidence of patient rights being reviewed with or given to Patient #8. Review of Patient #10’s medical record revealed Patient #10 had a colonoscopy on 7/30/2024. There was no evidence of patient rights being reviewed with or given to Patient #10. During an interview on 10/01/2024 at 10:02 AM, Patient #11 was asked if they were given their patient rights. Patient #11 stated, “I don’t think so.” During an interview on 10/01/2024 at 10:57 AM, Patient #12 was asked if they were given their patient rights. Patient #12 stated, “No one said anything about them.” During an interview on 10/01/2024 at 12:00 PM, Manager D was asked how patient rights are provided to the patient and/or representative. Manger D stated, “Nothing is given to the patients here.” During an interview on 10/01/2024 at 12:50 PM, Registration Staff O was asked what paperwork is signed and gone over with patients upon registration. Registration Staff O stated, “We go over HIPPA (Health Insurance Portability and Accountability Act) and assignment of benefits...No patient rights are discussed here.” During an interview on 10/01/2024 at 1:00 PM, Regulation Specialist E stated, “Patient rights are given to patients when they initially establish care as an inpatient to the hospital. They are hung up on the walls by the elevators.””

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 29963 Based on record review and interview, the facility staff failed to inform patients of whom to contact to file a grievance for 9 of 10 patients’ (Patients 1, 2, 3, 4, 5, 6, 7, 8, 10) medical records in a total universe of 10 medical records reviewed. Finding include: A review of facility policy #1.2.21 titled, “Patient Rights and Responsibilities,” effective date, July 10, 2024, revealed, “B. Responsibility: 1. It is the responsibility of employees, medical staff, students, and volunteers to acknowledge and respect these patient rights and ensure that patients receive adequate information describing their rights. 2. It is the responsibility of the admitting/registration staff, in collaboration with the patient care staff, to provide a copy of Patient’s Rights and Responsibilities to patients or their legal guardian upon admission to the hospital... A. Patient Rights Forms are located on UW Health’s intranet and public internet sites ... III. Key Policy Elements A. Patients or their authorized representative are informed of their rights in advance of furnishing or discontinuing care whenever possible. At the time of admission (sic) patients to the hospital (sic) patients will receive a copy of their Patient Rights and Responsibilities and at the time of new patient registration in the clinics, within a reasonable period.” A review of facility form titled, “Notice of Privacy Practices” form is undated, revealed, “This information describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. Your Rights: When it comes to your health information, you have certain rights. This section explains your right and some of our responsibilities to help you ... File a complaint if you feel your rights have been violated. You can complain if you feel we have violated your rights by contacting us using the information on page (no page number is listed) . You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W. Washington D.C. 20201, calling (877) 696-6775, or visiting www.hhs.gov/ocr/privacy/hippa/complaints/. We will not retaliate against you for filing a complaint.” The facility did not provide any forms that reference how a patient can file a quality of care complaint to the facility. During an interview on 10/01/2024 at 12:00 PM, Manager D was asked how patient rights are provided to the patient and/or representative. Manger D stated, “Nothing is given to the patients here.” During an interview on 10/01/2024 at 1:00 PM with Regulation Specialist E, when asked how the patient would know who to contact if they had a complaint, Regulation Specialist E stated there is a website on UW Health that patients can access the information to file a complaint. When asked how the patient would know to look on the website, she stated she was not sure.”