HospitalInspections.org

Based on observation, record review and interviews, this hospital failed to ensure compliance with 42 CFR 489.24 in in 2 of 7 required areas (A2402 Posting of Signs, A2406 Medical Screening Exam).

Findings include:

1) This facility failed to ensure Emergency Medical Treatment and Labor Act (EMTALA) signs are posted in places likely to be noticed by all individuals entering the Emergency Department (ED), receiving treatment in the ED, and Labor and Delivery in 2 of 2 ED areas observed (ED and Obstetrics). See Tag 2402

2) This facility failed to complete an appropriate medical screening exam (MSE) for 1 of 1 patients (Pt #1) who presented to the ED with suicidal ideation. See Tag 2406




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Based on observation and interview this facility failed to ensure Emergency Medical Treatment and Labor Act (EMTALA) signs are posted in places likely to be noticed by all individuals entering the Emergency Department (ED) and receiving treatment in the ED or Labor and Delivery in 2 of 2 ED areas observed (ED and Obstetrics). This deficiency potentially affects all Emergency Department patients including obstetrics patients seeking emergency medical treatment at this facility.

Findings include:

On 10/17/2016 at 1:00 PM, observed no EMTALA signage in the entrance/waiting area in the East entrance of the Emergency Department. There were no EMTALA signs noted in the 9 patient treatment rooms of the Emergency Department while accompanied by Director of Emergency Services D.

On 10/17/2016 at 3:30 PM, observed no EMTALA signage in the entrance of the Obstetrics department (Birth place unit) while accompanied by Lead Specialist of Emergency Department E.

An interview was conducted with Director of Emergency Services D on 10/17/16 at 1:00 PM, at the time of the observation. Director D stated the Obstetrics department does not have a designated Emergency room for Obstetrics patients. Patients would be admitted and examined in an available room depending on presentation of complaint. Lead Specialist of Emergency Department E stated on 10/17/2016 at 3:30 PM during interview that there are no EMTALA signs on the Obstetrics floor.

An interview was conducted with Risk Manager A on 10/17/16 at 3 PM. Risk Manager A stated this facility does not have a policy related to EMTALA sign posting.

Based on record review and interview this facility failed to complete an appropriate medical screening exam (MSE) for 1 of 1 patients (Pt #1) who presented to the Emergency Department (ED) with suicidal ideation. This deficiency potentially affects all Emergency Department patients seeking treatment for mental health concerns.

Findings include:

The facility document titled "Holy Family Memorial - Standard Work- Suicide Precautions" dated 10/2011 was reviewed. This document stated in part "If staff feel at any time a patient is in immediate life threatening danger, the applicable law enforcement agency should be notified and asked to respond to Holy Family Memorial to assess the patient for dangerousness to self and others. Based on this assessment, Manitowoc County Human Services may be contacted for potential mental health detention...Appropriate patient disposition/placement will be determined by Manitowoc Human Services, in conjunction with law enforcement, ED Medical Doctor (MD) and nursing staff. If patient does not meet criteria for a detention, nursing staff should document appropriate plan of care. Staff to document patient safety needs and determines recommendations for treatment. This would include choosing the appropriate setting for these recommendations. When a patient who has been identified as a risk for suicide will be transferred to another facility or discharged from the emergency department, staff should document discussion on suicide prevention/plan of care with referral to appropriate agency. This could include information such as the crisis hotline number, handouts, or safety plan with patient, family or friends, or giving report to accepting facility."

The facility policy titled "Emergency Department Management of Mental Health Patients" dated November 29, 2006 was reviewed. This policy stated in part "Voluntary Admission to Psychiatric Hospital or Other Treatment Facility, Procedure, 1. Patients are assessed for any necessary medical or emergency treatment by the ED physician, nurse practitioner or physician assistant. 2. ED staff will discuss with patient and/or family regarding possible placement in another hospital due to need of placement. 3. The hospital of choice will be contacted for the possible transfer by ED staff..."

Pt #1's Medical Record (MR) was reviewed on 10/17/16. Pt #1 arrived to this hospital on 10/4/16 at 12:01 PM with complaints of suicidal ideation. At 12:05 PM, Registered Nurse (RN) C noted "...said has been taking all (Pt #1's) psych meds as prescribed, but not helping. Said depression is worsening. Denies any suicide attempts today, but has strong thoughts of jumping off a bridge." At 12:06 PM Pt #1 "was placed in room 4 close to nurse's station and under camera monitor due to suicidal ideations. At 12:25 PM RN C documented "Called Manitowoc County Crisis Worker on-call... to report patient requests voluntary admission to Bay Haven in Green Bay and that facility requires county approval for funding before they would consider accepting (Pt #1) there." At 1:15 RN C documented "Phone Manitowoc Police Department. Request officer to come and see patient to determine if (Pt #1) meets criteria for involuntary mental health detention." RN C documented at 1:30 PM "Spoke with (County Human Services) informed that police were contacted. Said County would likely have Newport Home available for patient if police do not place patient in detention. Patient said (pt #1) would be willingly go to Newport Home if offered." RN C documented at 2:30 PM "Officer... states that patient does not meet criteria for Emergency Mental Health Detention. Officer states she phoned (County Human Services) Crisis Worker on call to inform her of disposition. Patient told officer (Pt #1) prefers to go to Sheboygan for voluntary psych services and will plan to go there today. Informed (MD B) of above." Pt #1 was discharged at 2:45 PM by RN C who documented "Aftercares reviewed. Left ED AMB (ambulatory) with steady gait. Waiting for friend to transport home." There is no documentation that Pt #1 was seen by Manitowoc Human Services Crisis Worker or Behavioral Health on call physician for further mental health evaluation before being discharged.

Obtained Pt #1's MR on 10/17/16 from Aurora Sheboygan Memorial Medical Center (receiving hospital). This record indicates Pt #1 presented to their ED on 10/4/2016 at 3:56 PM. ED Notes stated "Pt is sent to the ED from Holy Family Ed from SI (Suicidal Ideation). Pt reports she went to Holy Family ED earlier tonight seeking help for her SI. Pt reports she was medically cleared at Holy Family by (MD B) and was told to drive to ASMMC (Aurora Sheboygan Memorial Medical Center) for inpatient admission. Pt reports SI with a plan to jump off a bridge or overdose on her medications...Pt reports history of 3 past suicide attempts by overdose, with most recent 6 years ago. Pt denies acting on suicidal thought today. Pt reports history of self-harm by cutting, with last cut a few months ago...Pt denies current psychiatrist." Pt #1 voluntarily admitted to inpatient Behavioral Health Unit at 6:05 PM on 10/4/16. Pt #1 was admitted inpatient to the Behavioral Health Unit at 6:05 PM by Psychiatrist F with a diagnosis of "Major Depressive Disorder, recurrent severe without psychotic features."

Interview conducted to MD B on 10/17/16 at 4:15 PM via phone. MD B stated "(Pt #1) was stable for discharge." MD B stated there was no medical contradiction for discharge. (Pt #1) wanted to go to Green Bay and (Pt #1) was given the option to go to a group home instead as Green Bay would not accept. (Pt #1) didn't want to go to any of the options offered. MD B stated (Pt #1) had a friend driving her home and "(Pt #1) was not actively suicidal and stated she was comfortable going home in a car." MD B stated "she was cleared from a medical standpoint." Crisis (Manitowoc Human Services) was consulted as per there process. MD B stated "Psych will never be consulted as they provide zero meaningful info." MD B stated Manitowoc offered her an option which she refused. She was discharged. MD B stated "after the fact, when walking out the door she stated 'maybe I will go to Sheboygan.'" MD B stated Pt #1 was stable to be discharged.

Interview conducted with RN C on 10/17/16 at 12:50 PM. RN C stated Pt #1 was placed in a monitored room. "(Pt #1) came here voluntarily." RN C stated Pt #1 did not meet criteria for involuntary hold but police were called anyway to be on the safe side. RN C also spoke with Human Services. RN C recalled contacting the facility in Green Bay that the patient wanted to be admitted to. That facility would not take her without Human Services (Manitowoc County) funding. RN C stated "it was completely voluntary. At no time did I think she met criteria for involuntary." Human Services gave Pt #1 option of Newport Home if patient wanted to go. RN C stated "Sheboygan has inpatient psych. If we felt she required an admission to inpatient then we would have transferred." RN C stated Pt #1 had community resources already in place along with a councilor and did not need additional resources. RN C stated that neither the RN or the MD felt the patient required admission. RN C stated Pt #1 preferred to go to Sheboygan for voluntary services. Pt #1 didn't want to go to NewPort. RN C stated "I wasn't convinced (Pt #1) was going anywhere when (Pt #1) left." RN C denied any contact with Pt #1's friend who was picking Pt #1 up. RN C stated a suicide/safety contract was not pursued with Pt #1 as all three (RN, MD and Police) were in agreement there was not a concern. RN C states Pt #1 seemed safe to discharge.

Reviewed "HFM (Holy Family Memorial) Monthly Physician Call Schedule" on 10/17/16 at 12:00 PM. On the date in question, October 4th, Doctor G was documented to be on call for Behavioral Health. There is no evidence that Doctor G was consulted for Pt #1. This was confirmed in interview with MD B on 10/17/2016 at 4:15 PM.