Aspirus Stanley Hospital

“SURGICAL SERVICES CFR(s): If a CAH provides surgical services, surgical procedures must be performed in a safe manner by qualified practitioners who have been granted clinical privileges by the governing body, or responsible individual, of the CAH in accordance with the designation requirements under paragraph (a) of this section. This Condition is not met as evidenced by: 50644 Based on record review, observation and interview, the facility staff failed to complete an update to the pre-operative History and Physical (H&P) within 24 hours of surgery for 2 of 4 surgical patients (Patient (Pt) #7 and #8) requiring an update to the H&P in a total of 20 medical records reviewed; failed to remove contaminated gloves and perform hand hygiene in 1 of 1 surgical patient (Pt. #3) in a total of 7 observations of patient care; failed to maintain the integrity of packaged supplies to prevent possible contamination in 1 of 1 department (Surgery) in a total of 13 departments observed; failed to empty sharps container in 1 of 1 department (Surgery) in a total of 13 departments observed; failed to discard outdated sterile supplies and expired sterile medications in 1 of 1 department (Surgery) in a total of 13 departments observed; failed to provide a Formalin spill kit or Polyform-F as per policy in 1 of 1 department (Surgery) where Formalin was present in a total of 13 departments observed; and failed to complete an operative/procedure note within 24 hours of the procedure being completed per facility policy for 1 of 4 Surgical Patients (Pt. #8) records in a total of 20 patient records reviewed. A review of facility policy #18239417 titled, “Operative/Procedure Note and Immediate Postoperative Notes Policy” last revised 05/2025 revealed, “I. A full operative/procedure note should be documented upon completion of an operative or other high-risk procedure. If a full operative/procedure note is not documented immediately, an immediate postoperative progress note can be entered, and the full report must be completed within 24 hours of the procedure.” Examples of H&P Update not completed: A review of facility policy #18370450 titled “History and Physical Examination Reports Policy” last revised 06/2025 revealed, “...4. For a history and physical completed within 30 days including the 24 hours prior to admission, an update documenting any changes in the patient’s condition is completed within 24 hours after admission, but prior to surgery or a procedure requiring anesthesia services, whichever comes first...B. The update to the H&P can be documented on the H&P progress note, a separate report filed with the H&P; or H &P Update template within Epic. C. The update must indicate: The H&P was reviewed and; The patient was examined for any changes that might be significant to the planned course of treatment and; Any pertinent changes or the absence of changes.” A review of Patient #7’s medical record revealed that Patient #7 was admitted to the facility on 7/30/2025 for a scrotal hydrocelectomy (a surgical procedure to remove a hydrocele, a fluid-filled sac around the testicle) under general anesthesia. The full H&P was completed on 7/17/2025 (13 days prior to the procedure). There was no documented evidence of an update to the H&P within 24 hours prior to the procedure by Surgeon GG. A review of Patient #8’s medical record revealed that Patient #8 was admitted to the facility on 8/29/2025 for an excision of a lipoma (benign (non-cancerous) tumor made up of fatty tissue) under MAC (Monitored Anesthesia Care- conscious sedation). The full H&P was completed on 8/20/2025 (9 days prior to the procedure). There was no documented evidence of an update to the H&P within 24 hours prior to the procedure by Surgeon HH. During an interview on 9/16/2025 at 3:03 PM, Surgery Manager AA confirmed there was no documented evidence in Patient #7 and Patient #8’s medical record and stated that an updated H&P should be done day of surgery. Example of hand hygiene/glove removal not being performed: A review of facility policy #17404137 titled, “Hand Hygiene Policy” last revised 01/2025 revealed, “...Perform hand hygiene with soap and water or alcohol-based hand rub for at least twenty (20) seconds:...A. before direct contact with patients B. Before donning gloves...D. After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings F. If moving from a contaminated-body site to a clean-body site during patient care...H. After removing gloves...” During an observation of care for Patient #3 starting on 9/16/2025 at 9:35 AM in the preoperative room, observed RN G place an intravenous (IV) catheter with gloves on. After the placement, RN G kept on dirty gloves, grabbed her stethoscope from around her neck and completed an assessment. RN G then placed the stethoscope back around her neck, removed dirty gloves, grabbed a new pair of gloves and then placed SCD’s (Sequential Compression Device) on Patient #3’s legs, not completing hand hygiene until removing gloves for the 2nd time and leaving on dirty gloves between dirty and clean tasks. During an observation of care for Patient #3 at 9/16/2025 at 10:06 AM, CRNA (Certified Registered Nurse Anesthestist) J entered Patient #3’s room and completed a heart, lung and airway assessment without performing hand hygiene prior to contact with Patient #3. During an interview on 9/16/2025 at 10:40 AM, Infection Preventionist T stated that the facility follows CDC guidelines and facility policy relating to infection control practices including hand hygiene. Example of maintaining packaged supplies to prevent possible contamination: A review of facility policy #16186308 titled, “Infection Prevention and Control Program” last revised 03/2025 revealed, “A. Limiting unprotected exposure to pathogens throughout the hospital B. Improving compliance with hand hygiene C. Minimizing the risk of transmitting infections with the use of procedures, medical equipment, and medical devices D. Maintaining a sanitary environment to avoid sources and transmission of infections and communicable diseases...” During a tour of the surgery department on 9/16/2025 starting at 11:17 AM, observed the following items being stored outside of their packages with risk of contamination: - 4x4 sponges outside of their packing in 4 out of 4 anesthesia carts observed. -Nasal cannula not in packaging in 1 anesthesia cart. During an interview on 9/16/2025 at 11:30, OR Supervisor H stated, “We shouldn’t have supplies stored outside of its packaging. I will throw them out and remind staff why we don’t do that.” Example of full sharps containers: A review of facility policy #16186308 titled, “Infection Prevention and Control Program” last revised 03/2025 revealed, “The organization has developed specific policies, procedures, or other work processes that address the following:...F. Techniques for storage and disposal of regulated and non-regulated waste.” During a surgery department tour starting on 9/16/2025 at 11:17 AM, observed a full sharps container in OR 2 with needles touching the lid of the container. During an interview on 9/16/2025 at 11:23 AM, OR Supervisor H acknowledged findings and stated that environmental services should be emptying the sharps containers. During an interview on 9/16/2025 at 10:15 AM, EVS Supervisor N stated that the sharps were emptied once a week or when they got full. Examples of expired supplies and medications: A review of facility policy #16276055 titled, “Expired Products/Supplies Policy & Procedure” last revised 07/2024 revealed, “...2.Monthly (or more often as needed), designated staff in each area/department will be responsible to screen sub-inventory and clean supply room locations for expired products.” A review of facility policy #18271794 titled, “Medication Management Policy & Procedure” last revised 06/2025 revealed, “...F. Medication storage areas are inspected monthly by pharmacy staff or delegates and all expired, damaged, or otherwise contaminated medications will be removed by pharmacy...” During a tour of the surgery department starting on 9/16/2025 at 10:33 AM observed the following expired products: -Size 5 LMA with expiration date of 12/13/2024 in the anesthesia cart in OR 1. -Steri-strips with expiration date of 08/2025 x 8 in sterile storage. -0.5% Marcaine with expiration date of 4/2025 x 1 in anesthesia cart in OR 2. -0.5% Marcaine with expiration date of 8/2025 x 2 in anesthesia cart in OR 2. -Succinylcholine with expiration date of 9/7/2025 x 2 in anesthesia cart in OR 2. -6 French intubating stylet x 1 with expiration date of 2/26/2025 in PACU (Post-Anesthesia Care Unit) code cart. -0.9% Sodium Chloride with expiration date of 04/2025 x 2 in PACU code cart. During an interview on 9/16/2025 at 11:17 AM, OR Supervisor H stated that anesthesia is responsible for outdating there carts and supplies, pharmacy takes care of stocking the medications in the carts and surgery staff are responsible for the rest of the supplies in the department. Example of failure to have spill kit for Formalin available: A review of facility policy #18404209 titled, “Formaldehyde Spill Kit” last approved 7/2025 revealed, “1.Distribute/add Polyform-F around the perimeter of the spill to dike the liquid and prevent spreading...” During a facility tour starting on 9/16/2025 at 11:17 AM of the sub sterile area, observed a locked cabinet with specimen containers of Formalin present. During an interview on 9/16/2025 at 11:17 AM, OR Supervisor H was asked if there should be a spill kit for the formalin where she stated, “There should be one stored next to the formalin, but I don’t see it.” Example of delayed post operative note: A review of facility policy #18668669 titled, “Moderate Procedural Sedation Policy” last revised 09/2025 revealed, “...D. Post-Procedure Discharge Criteria...Outpatients should be discharged in the presence of a responsible adult who will accompany them home and be able to report any post procedure complications...” A review of Patient #8’s medical record revealed that Patient #8 was admitted to the facility on 8/29/2025 for an excision of a lipoma (benign (non-cancerous) tumor made up of fatty tissue) under MAC (Monitored Anesthesia Care- conscious sedation). There was no documented evidence of an immediate post operative note, and the postoperative/procedure note was not completed until 9/12/2025 at 7:24 AM by Surgeon HH. During an interview on 9/16/2025 at 8:58 AM, OR Supervisor H stated that the expectation for completion of operative notes/reports are to be completed “day of surgery right after procedure is complete.””

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (iv) Rules for the storage, handling, dispensation, and administration of drugs and biologicals. These rules must provide that there is a drug storage area that is administered in accordance with accepted professional principles, that current and accurate records are kept of the receipt and disposition of all scheduled drugs, and that outdated, mislabeled, or otherwise unusable drugs are not available for patient use. This Standard is not met as evidenced by: 52395 Based on observation, record review and interview the facility failed to dispose of expired supplies and label opened supplies in 2 patient care departments (ED (Emergency Department) and Wound Care) out of a total of 13 patient care departments observed. Findings include: A review of facility policy #16276055 titled, “Expired Products/Supplies Policy & Procedure” last revised 07/2024 revealed, “... For those items that have a shelf life of one year or less, product stickers will be available to provide additional alerts of the product’s impending expiration date...” During a tour and observation of the ED clean supply room on 09/16/2025 at 9:30 AM observed the following expired supply: - “Thora-para 8 French” (Thoracentesis/Paracentesis kit) (procedures to remove fluid from chest and lungs) with an expiration date of 8/31/2025. During an interview on 09/16/2025 at 9:38 AM with Chief Nursing Officer (CNO) B, she stated that she will remove the expired supply. During a tour and observation of the outpatient wound care clinic on 09/16/2025 at 10:10 AM the following supplies were found not labeled upon open and were not labeled with an expiration date: -Two (2) tubes of “Remedy Essentials No Rinse Foam Cleanser” (8 fluid ounces) with no label of date opened or expiration date. -Three (3) bottles of “Vacshe” (wound cleanser) (4 fluid ounces) with no label of date opened or expiration date. During an interview on 09/16/2025 at 10:25 AM with Wound RN DD when asked about the multi-use supplies, she stated that all should be labeled and dated with the date open and expiration date with a sticker.”

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (vi) Procedures that ensure that the nutritional needs of inpatients are met in accordance with recognized dietary practices. All patient diets, including therapeutic diets, must be ordered by the practitioner responsible for the care of the patients or by a qualified dietitian or qualified nutrition professional as authorized by the medical staff in accordance with State law governing dietitians and nutrition professionals and that the requirement of § 483.25(i) of this chapter is met with respect to inpatients receiving post CAH SNF care. This Standard is not met as evidenced by: 52395 Based on observation, interview and record review the facility failed to ensure patients receive safe quality food by failing to ensure that food was labeled upon opening per facility policy and not expired in 2 (main kitchen and inpatient kitchenette) of 2 kitchens observed. Findings include: A review of facility policy #17617292 titled, “Food Receiving & Storage Policy & Procedure” last revised 05/2023 revealed, “... E. Freezers... 2. Foods in units must be labeled, covered and dated or in original boxes to prevent freezer burn...” A review of facility policy #17617288 titled, “Food Preparation Policy” last revised 05/2023 revealed, “... X. All opened food items are dated as to date opened...” During an observation starting on 9/16/2025 at 12:30 PM, observed the following freezer items, Dry Storage Area and Kitchen and Inpatient Kitchenette that had food items not labeled upon open: Freezer: -One (1) package of 15 biscuits (brand unknown) -One (1) ¼ bag “Ore Ida” hashbrowns -One (1) ¼ bag of diced “Brakebush Chicken” -One (1) ½ bag of “Krampholds” cheese curds -One (1) ¾ bag of “Krotzen” french toast -One (1) ½ bag of pancakes (brand and quantity unknown) -One (1) bag of folded cheese omelets (brand unknown) -One (1) bag 50 circular pork sausage patties (brand unknown) -Two (2) ½ bags of french fries (brand unknown) -One (1) ½ bag mixed veggie mix -One (1) ½ package bread sticks (brand unknown) -One (1) ½ package garlic bread (brand unknown) -Nine (9) cauliflower frozen pizza crusts Dry Storage Area and Kitchen: -One (1) ½ bag dried beans -One (1) ½ bag dried peas -One (1) container liquid butter -“Lawry’s” seasoning salt, “Perfect Pinch” Italian seasoning, “Syscol Classic” cooking spray, ground white pepper, ground mustard seed, smoked paprika Inpatient Kitchenette: -Nine (9) tartar sauce packets -Four (4) sugar free syrup containers -Eight (8) original coffee creamers -Nine (9) “Miracle Whip” packets -Eleven (11) mustard packets -Eight (8) mayonnaise packets Inpatient Kitchenette that had expired food items: -Ten (10) sugar free grape jam packets labeled “do not use” by 07/01/2023 -Five (5) “JIF” peanut butter packets labeled “do not use” by 07/01/2023 -Seven (7) regular grape jelly packets labeled “do not use” by 07/01/2023 During an interview on 09/16/2025 at 11:41 AM Cook FF stated that all food should be labeled when it is opened. During an interview on 09/16/2025 at 2:00 PM with CNO (Chief Nursing Officer) B she stated that she would remove the expired items.”

“A standard critical access hospital recertification survey for Life Safety Code compliance was conducted by the Wisconsin Division of Quality Assurance on 09/16/2025 through 09/17/2025. Aspirus Stanley Hospital was found to be in compliance with the following applicable regulations for hospital participation in Medicare-Medicaid: 42 CFR 485.623: Condition of Participation: Physical Plant is MET. 42 CFR 485.623 (d)(1) Standard: Life Safety from Fire is MET. NFPA 101- (2012 Edition) - Life Safety Code was MET. Aspirus Stanley Hospital is a Type II (0,0,0), one-story hospital constructed in March 2003 with a two-story medical office building connected to the hospital; with these occupancies separated by a two-hour occupancy separation wall. The building is fully protected with an NFPA 13-automatic sprinkler system. Aspirus Stanley Hospital is licensed for 24 beds with a census of 3 inpatients during survey. The facility was surveyed under the 2012 Life Safety Code, Chapter 19 for an existing health care occupancy. No Federal deficiencies of the Life Safety Code were cited.”

“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: 47413 Based on record review and interview the facility failed to follow to provide a thorough Medical Screening Exam for 1 of 20 patients (Patient #1) in a total sample of 20 medical records reviewed. The facility failed to provide a Medical Screening Exam to a patient who presented to the Emergency Department and had a change in condition. See Tag 2406.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 47413 Based on record review and interview the facility failed to provide a thorough and complete Medical Screening Exam for 1 of 20 patients (Patient #1) who presented to the ED (Emergency Department) in a total of 20 medical records reviewed. Findings Include: A review of the facility’s policy titled, “EMTALA (Emergency Medical Treatment and Labor Act) Policy” last revised 07/2024 revealed, “... Emergency Medical Condition (EMC): A condition manifesting itself by acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in... with respect to an individual with psychiatric symptoms: a) that acute psychiatric... symptoms are manifested... or b) that individuals are expressing suicidal or homicidal thoughts or gestures and are determined to be a danger to self or others... Medical Screening Exam (MSE): A MSE is the process to determine, within reasonable confidence whether an Individual has an EMC... General Requirements: ... 1. Provide an appropriate MSE to the Individual within the capability of the hospital’s DED (Dedicated Emergency Department) to determine whether or not an EMC exists...” A review of Patient #1’s medical record revealed that Patient #1 was a 42-year-old with a medical history of bipolar disorder and schizophrenia who presented to the facility with a family member on 11/30/2024 at 12:08 AM for suicidal ideation and cuts on her wrists. Patient #1 scored “high risk” on her suicide screening and was placed in a 1:1 observation status upon arrival. Review of the record revealed that ED MD (Medical Doctor) F assessed Patient #1’s cardiovascular status, respiratory status, musculoskeletal status, neurological status and psychiatric status upon arrival to the facility on 11/30/2024 at 12:20 AM. Further review of Patient #1’s medical record revealed county crisis was notified for determination of the need for involuntary psychiatric inpatient placement. Patient #1 refused to speak with crisis staff, Patient #1’s family member spoke with crisis, crisis determined Patient #1 did not meet criteria for an involuntary psychiatric hold requiring inpatient admission, a safety plan was agreed upon and Patient #1 was preparing for discharge. Prior to discharge, Patient #1 became agitated and aggressive, law enforcement was notified, and Patient #1 was placed under arrest and discharged in police custody on 11/30/2024 at 1:40 AM. A review of Patient #1’s medical record revealed the following notes: 11/30/2024 at 12:20 AM by ED MD F: “... Physical Exam: General: [Patient #1] is not in acute distress; Cardiovascular: ... Normal rate and regular rhythm ... Normal pulses ... Normal heart sounds. Pulmonary: ... Pulmonary effort is normal. Abdominal: General: Abdomen is flat ... Musculoskeletal: Comments: A few small scratches/abrasions on her B/L (bilateral) anterior (underneath) wrist from what she said she used. (A knife) very superficial. No suturing needed. The areas were cleaned and a 2*2 gauze placed and covered with tape ... Neurological: ... She is alert ... Psychiatric: She appeared a bit despondent (in low spirits) ... Assessment and Plan: Medical Decision Making: [Patient #1] did not speak with the provider from [Crisis Center], however, [Crisis Center] spoke with [Patient #1’s boyfriend’s cousin] ... [Patient #1] was cleared to go home by [Crisis Center] ... [Patient #1’s boyfriend’s cousin] says he feels safe and comfortable taking her home and having her follow up with Psychiatrist and Social Worker... However, it appeared as if the family member and the patient had a loud conversation in the room and then [Patient #1] became agitated and violent. [Patient #1] started throwing things in the room... She continued to be violent and hitting at the officer and going for her face and hitting at us ... then [Police Officer B] had to tase her a second time and then put the cuffs on... Due to her extreme violent behavior and assault to [Police Officer B] [Patient #1] was placed under arrest and escorted out to police car ...” 11/30/2024 at 1:12 AM by ED RN (Registered Nurse) G: “[Patient #1] became very agitated, throwing equipment, chairs. Swearing at staff, attempted to leave. Police contacted as patient was not safe to go home Patient yelling at police, threatening staff. Provider was hit in the face and glasses knocked off of face.” There was no evidence found of a repeat Medical Screening Exam on 11/30/2024 after 1:12 AM, when Patient #1 had a change in behavioral condition, to determine if an emergent psychiatric condition was present before she was discharged from the facility into police custody.”