Marshfield Medical Center - Eau Claire

“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: 44431 Based on record review and interview the facility failed to assess vital signs every 15 minutes for1 (Patient #1) of 3 patients triaged at an ESI (Emergency Severity Index) level of 1 or 2, failed to reassess vital signs and pain within 15 minutes following administration of pain medication for 1 (Patient #1) of 8 patients who received pain medication and failed to assess vital signs with in 1 hour of discharge for 1 (Patient #1) of 11 patient records reviewed; and failed to complete and document nurse to nurse handoff for 5 (Patient #1, #6, #7, #8 and #10) patients in a total universe of 11 medical records reviewed. Findings: A review of the facility policy last revised 09/23/2025 titled, “Standard of Practice for Emergency Department-Urgent Care Department Policy,” revealed, “Purpose statement: This standard of Practice applies to any patient requiring and seeking care at an emergency/urgent care department with [facility name]...The nurse should collect and document subjective and objective data...to ensure completeness of assessment and concise communication of findings to other health care providers...all patients will have a baseline set of vital signs recorded...Triage category, ESI 1 and 2: a minimum of every 15 minutes after baseline....All patients will have vital signs taken at time of discharge...Blood Pressure...If any patient is hemodynamically (blood circulation) compromised, as evident by hypertension or hypotension, reassess and document every 15 minutes or more frequently as needed...Facilitation of Care:..The RN will assure handoff communication and appropriate means of care for any transport needs of patients...bedside shift report between nurses within the department is the expectation...Admission and Discharge...The RN will ensure appropriate hand off of care.” A review of Pt. #1’s medical record revealed he arrived at the ED on 05/04/2026 at 3:14 PM and was triaged at 3:48 PM with an ESI level of 2. Initial vital signs were obtained at 3:30 PM and reassessed every 15 minutes until 6:45 PM. Pt. #1 was discharged at 8:36 PM. There was no evidence of additional vital signs or nursing assessments completed for nearly 2 hours prior to discharge. Initial pain assessment was documented at 3:26 PM and with a score of “6” on a 1-10 pain severity scale. There was no documentation of pain interventions. At 3:35 PM, Pt. rated pain at a “7.” There was no documentation of interventions or additional pain assessment until 5:47 PM (over 2 hours later) when Pt. #1 received 4 mg of Morphine IV. There was no reassessment of pain following the administration of Morphine until 6:37 PM (nearly an hour later) when Pt. #1 rated his pain a “9.” There was no documented pain interventions until 7:28 PM when Pt. #1 received 50 mcg. Fentanyl IV. There were no additional pain assessments or interventions documented. Pt. #1 was discharged at 8:36 PM by RN (Registered Nurse) S. There was no documentation of a nurse to nurse handoff at the change of shift. Pt. #6 was admitted to the ED on 05/19/2026 at 9:10 AM after falling at home and breaking the right hip. Pt. #6 was transferred to a higher level of care on 05/20/2026 at 9:51 AM. There was no documentation of a nurse to nurse handoff at the time of transfer/discharge from the ED. Patient #7 was admitted to the ED on 05/16/2026 at 11:57 AM as a Code 2 trauma. Pt. #7 was transferred to surgery from the ED at 1:47 PM. There was no documentation of a nurse to nurse handoff at the time of transfer/discharge from the ED. Pt. #8 was admitted to the ED on 05/17/2026 at 11:49 AM with weakness, fatigue and unable to walk. Pt. #8 was admitted to the inpatient nursing unit at 4:20 PM. There was no documentation of a nurse to nurse handoff at the time of transfer/discharge from the ED. Pt. #10 was admitted to the ED on 05/04/2026 at 10:13 AM with weakness, vomiting, low blood pressure, triaged at an ESI of 2. Pt. #10 was admitted to the inpatient nursing unit at 3:38 PM. There was no documentation of a nurse to nurse handoff at the time of transfer/discharge from the ED. An interview was conducted on 06/17/2026 at 8:30 AM with Triage RN J who stated, “When IV pain medications are given the patient should be reassessed 15 minutes after the medication is given. When asked if vital signs are taken before an ED patient is discharged, J stated, “Yes within the last hour before they are discharged.” On 06/17/2026 at 10:51 AM in an interview with ED Manager C when asked why Pt. #1’s last set of vitals was taken at 6:45 PM and no vital signs were taken after the administration of the IV Fentanyl, ED Manager C said, “They should have had another set of vitals. There was also no handoff documented between shifts and there should have been.””

“STANDARD TAG FOR OUTPATIENT SERVICES CFR(s): 482.54 Standard-level Tag for §482.54 Condition of Participation: Outpatient Services If the hospital provides outpatient services, the services must meet the needs of the patients in accordance with acceptable standards of practice. This Standard is not met as evidenced by: 44431 Based on record review and interview the facility failed to implement a safe and effective discharge plan for 1 (Patient #1) of 11 ED records reviewed. Findings: A review of the facility policy last revised 02/05/2026 titled, “Admission and Discharge of Emergency Department Patient Process--[Facility Name],” revealed, “...Discharge of Emergency Department patients...physician will inform primary RN or charge nurse patient is ready for discharge and will provide:...Follow up Plan..Discharge instructions including....follow--up plan and new medications will be sent home with the patient...Patient will be escorted to waiting room or entrance by Emergency Room staff.” A review of Pt. #1’s ED physician history and physical on 05/04/2026 at 5:30 PM revealed, “History of Present Illness:...This patient is largely bedbound and lives alone at home. he was discharged from the VA inpt (inpatient) rehabilitation center...about 5 days ago...Review of systems:...positive for fever chills fatigue and malaise....pain ....in abdomen surrounding his suprapubic site...Patient had lumbar (back) surgery 3 months ago. Pertinent for weakness and immobility of the lower extremities....Medical Decision Making: Infection suspected...for skin and soft tissue infection. Patient presented with complaint of weakness and fatigue. He had a spinal surgery...back in February. He was discharged and went to a inpatient rehab...He was there 2 months and was discharged 5 days ago. Apparently patient was discharged to home to be by himself which was his request. on (sic) today’s evaluation...he does have superficial skin infection around this suprapubic insertion site but no evidence of deep abscess. Placed him on p.o. (oral) antibiotics for the superficial skin infection. I did tell the patient that if he does not feel that he is going to be able to stay at home by himself long--term need to discuss with his case manager ...whether or not he should be in the nursing home setting.” A review of Pt. #1’s medical record revealed Pt. #1 was discharged to the lobby by wheelchair on 05/04/2026 at 8:36 PM. There was no nursing assessment documented prior to discharge. There was no evidence discharge instructions were reviewed with Pt. #1 or that he understood the instructions and plan. A review of Pt. #1’s medical record nurses note on 05/05/2026 at 7:30 AM revealed, “Pt. states he thinks he left rehab too soon and he can’t take care of himself at home.” A review of Pt. #1’s 2nd ED record revealed Pt. #1 remained in the ED lobby all night and at 09:00 AM on 05/05/2026 was re--triaged at an ESI level 4 and returned to a bed in the ED to assess skin status and off--load pressure from sitting in the lobby in a wheelchair all night. A review of the Case Management note on 05/05/2026 at 9:00 AM revealed, “Received a phone call from [Name] at the [Facility Name] who states [Pt. #1] had been sitting in the waiting room since 8:30 PM last night and she was concerned about pressure ulcers. She states that she would like him in a bed because he has been sitting in a wheelchair without a pressure relieving cushion.” A review of the ED doctor note on 05/05/2026 at 9:10 AM revealed, “Chief Complaint: Pt waiting for ride home from ER was discharged last night...History of Present Illness: This is a 58 year old male, wheelchair-bound with neurogenic (loss of bladder control) bladder and suprapubic catheter, who is brought back into the emergency department room to offload in a cot from the waiting room (seated in wheelchair overnight) subsequent to emergency department visit yesterday evening with ultimate discharge home. It is reported by nursing staff that patient had declined multiple options to return home offered by nursing staff overnight, which is why he remained in our waiting room. Patient uses a contracted ambulance company...to return home; however, I am advised there was no way to facilitate this overnight. With concern that patient had been sitting in wheelchair for extended period of time, it was felt best that he be roomed again to prevent skin breakdown.” An interview was conducted on 06/17/2026 at 8:30 AM with Triage RN J who was working the night Pt. #1 was seen in the ED. When asked why Pt. #1 was discharged to the lobby without a ride home, RN J said, “He was calling a friend for a ride. We don’t have a lot of options after 8PM . I offered to arrange an ambulance ride, but he didn’t want to pay out of pocket.” On 06/17/2026 at 10:31 AM an interview was conducted with ED Manager C who stated, “We didn’t know an ambulance was coming, this was not the doctor’s plan, [Pt. #1] arranged his own ride for discharge.””

“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: 41126 Based on record review and interview, facility staff failed to inform patients of their Medicare discharge rights upon discharge for 1 of 4 Medicare-eligible inpatients (Patient #1). Findings include: Review of Patient #1’s medical record revealed an admission for pneumonia on 11/28/2023 and discharge on 12/1/2023. There was no Important Message from Medicare in the medical record at discharge. In an interview with Quality Manager A on 1/16/2024 at 1:55 PM Quality Manager A confirmed that there was not a second Important Message from Medicare.”

“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: 41126 Based on interview and record review the facility failed to ensure that patient needs are met by ongoing assessments for 1 of 2 patients (Patient #1) with extended Emergency Department wait times and boarding status. Findings include: Review of the facility policy titled, “Standards of Nursing Practice Policy - Emergency/Urgent Care Department” dated 11/9/2022 document ID: KT2N6QC5SZE5-3-2854 revealed, “Purpose Statement: This Standard of Practice applies to any patient requiring and seeking care at an emergency/urgent care department with MCHS (Marshfield Clinic Health System)...3.2 Vital Signs: a. All patients will have a baseline set of vital signs recorded. Frequency of vital signs will be determined by initial triage category and patient acuity: ...Triage category ESI 3: a minimum of every 1 hours (sic) after base line...” Review of Pt. #1’s medical record revealed a triage note at 1:10 PM on 11/28/2023. The next notation in the ED record is at 5:00 PM on 11/28/23 when a doctor exam is requested. Vital signs are recorded at 1:28 PM in triage and then again at 5:10 PM. Triage note revealed an ESI (Emergency Severity Index - level 1 (most urgent) to level 5 (least urgent) of 3. On 1/16/2024 at 9:10 AM in an interview with Triage Nurse E, Nurse E stated that they try to get out and check on patients but sometimes are too busy to do so. On 1/16/2024 at 9:05 AM in an interview with ED Manager C when asked what the expectation was for reassessment of patients in the ED waiting room Manager C stated that he expected that the reassessment policy be followed and that vital signs be taken as indicated in the policy and documented. “It appears that didn’t happen with this patient. Once a patient is made an inpatient or placed in a boarder status then we need to care for them along with other ED patients until a bed is available.” The medical record revealed that Patient #1 was boarded in the ED awaiting an inpatient bed for approximately 15 hours from approximately 8:30 PM 11/28/2023 when decision to admit was made, to admission to the nursing unit on 11/29/2023 at 1:30 PM. There is no evidence that vital signs were conducted every hour per policy and no documentation of care provided from 11/28/24 at 11 PM, until 11/29/24 at 10:16 AM (11 hours and 16 minutes later) when a float nurse was assigned to the ED to care for 2 boarder patients.”

“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: 41126 Based on record review and interview, the facility failed to follow policy and procedures for removal of high fall risk interventions on 1 of 3 patients (Pt. #1) with a high fall risk score and failed to document ongoing care of a patient (#1) who was boarded overnight in the Emergency Department. Findings include: Review of facility policy titled, “Fall Prevention Policy - Acute Care and Emergency Department” dated 10/5/2022 Document ID: KT2N6QC5SZE5-3-2206, revealed, “...3.2 Morse Fall Prevention Measures (Adults) (used to predict a patient’s likelihood of falling by evaluating individual risk factors) a. Morse Fall risk assessments occur: ...every 12 hours, after a change in clinical condition and as deemed necessary by a Registered Nurse, high fall risk interventions MAY NOT be discontinued until the adult inpatient scores less than a 45 on the Morse Fall Risk Assessment for 24 consecutive hours...for adult inpatients with a fall risk score of 45 or less interventions may be implemented based on nurses discretion...” In the complaint received 12.28.2023 the complainant, a family member, had concerns about the fall precautions being removed too soon due to Patient #1’s diagnosis of dementia. Review of Pt. #1’s medical record revealed a Morse Fall Risk assessment on 11/29/2023 upon admission to the 4th floor at 4:00 PM. The scoring revealed, “No history of past falls, secondary diagnosis, bedrest, weak gait, oriented, fall risk band applied and a score of 45. - On 11/29/2023 at 9:30 PM the fall risk assessment revealed a score of 60, “forgets limitations” bed exit alarm is documented. - The medical record revealed a fall risk score of 45 on 11/30/2023 at 4:00 PM with the assessment of “oriented” and “standard precautions in place”. Per review of the facility Fall Prevention Policy standard precautions include, “bed in low position, nonslip footwear, call light placed within reach, floors free of clutter, adequate lighting, purposeful hourly rounding. Review of the interview the attending RN had with Manager D on 12/27/2023 revealed, “The RN stated that she reassessed the patient in the morning and got a 45 due to the patient no longer forgetting limitations and being alert and oriented x 4 and able to follow commands. RN is unable to remember when she turned the bed alarm off but did so knowing that the patient was following commands, was a lower fall risk and had family in the room.” The high fall risk interventions should have been in place after a patient scores 45 or less for 24 consecutive hours. On 1/16/2024 at 2:00 PM in an interview with Quality Director A, Director A confirmed that per policy the bed alarm should have remained in place for 24 hours. Based on record review there is not any documentation to support that the patient was attended to during the nighttime hours she was in the ED waiting for an inpatient bed. In an interview with Director of Patient Care Services B on 1/16/2024 at 2:10 PM Director B stated that nurses chart by exception so he/she wouldn’t expect to see anything documented if nothing was done for the patient. “I can see how if it’s not charted it didn’t happen enters in though.””