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Based on record review and interview, the hospital failed to ensure it provided patients/patient representatives with a written grievance response containing the required regulatory elements, in 3 of 6 (Patients #23, 24, 25) patient grievance files reviewed out of a total sample of 6 complaint and grievance files reviewed.

Findings include:

On 9/12/19, review of the facility policy titled, "Patient Grievance, Bill Amendments, and Grievance Appeals Process," last revised 07/2018 revealed, " ...II. Policy: It is the policy of [facility] to effectively respond to patient's or patient's representatives grievances (concerns or complaint) as they occur, and to conclude investigation and follow-up within a maximum of 7 days of a reported concern or complaint ...III. Procedure: (See attachment Patient Feedback Workflow) ...D ...the first step is to contact the patient/patient representative to assure clarity of the grievance and to inquire regarding expectations for resolution. This should occur as soon as possible, optimally within 1 day of grievance receipt ...E. During the contact for clarity, the patient/patient representative should be informed of the expected timeline for follow-up with a proposed action plan, generally not to exceed 7 days unless highly complex ...G. Once the investigation is complete, the patient/patient representative should be contacted to discuss the action plan...H. If the patient/ patient representative does not verbalize that the grievance was resolved to his/her satisfaction and the concern is at a medium or high classification, a letter should be sent summarizing the concern and action plan and including information on filing a grievance appeal...I. If the grievance was at a low classification or the patient/patient representative has signified satisfaction with an action plan for a medium or high classification grievance, the patient should be sent a 'Patient Grievance Confirmation' letter."

Review of the attached document containing an algorithm titled, "Patient Feedback Workflow" revealed, "Leadership follow-up: Contact grievant ASAP (within 24 hours/one business day) to assure clarity. Complete investigation and action plan within one week. Contact grievant. Document follow-up in Feedback Event."

On 9/12/19 at 3:00 PM, the facility's electronic complaint files were reviewed and revealed the following:

Review of Patient #23's grievance file titled, "Healthcare Safetyzone...Event Number 34275," revealed the complaint was received via personal contact and entered on 4/20/19 at 3:53 AM. Further review revealed the first follow up contact was made with Patient #23's family member on 5/9/19 at 2:30 PM, 19 days after the receipt of the complaint. A written confirmation letter was also dated 5/9/19.

Review of Patient #24's complaint file titled, "Healthcare Safetyzone...Event Number 34553," revealed the grievance was received via telephone and entered on 7/10/19 at 1:46 PM. Further review revealed the first follow up contact attempt was made on 7/22/19 at 2:09 PM, 12 days after the receipt of the complaint, and a message was left for the patient. Contact with Patient #24 was documented on 8/2/19 at 1:10 PM, 23 days after the receipt of the complaint. A written confirmation letter was also dated 8/2/19..

Review of Patient #25's complaint file titled, "Healthcare Safetyzone...Event Number 34650," revealed the grievance was received via telephone and entered on 8/14/19 at 1:07 PM. Further review revealed a written confirmation letter sent by the facility was dated 9/11/19, 28 days after the receipt of the complaint.

During an interview on 9/12/19 at 3:30 PM, when asked about the expected timeframe for sending the follow-up letters per facility policy, Quality Director B stated, "Yes, I agree that the grievance letters weren't sent within 7 days."

Based on record review and interview the facility failed to ensure that patients at risk for intentional harm to themselves or others were protected in the Emergency Department prior to discharge or transfer in 1 of 5 (Patient #22) patient medical records reviewed involving presentation to the Emergency Department with chief complaints of suicidal ideations in a total universe of 22 records.

Findings include:

The facility policy titled "Suicide Precautions" last reviewed 07/2018, revealed, " ...Definitions: Suicide Precautions: Includes 1:1 observation, management of environment, and safety precautions. Plan and Implementation: A. Initiate suicide precautions and 1:1 close observation per physician orders or per RN if assessment of patient indicates patient is a risk based on admission depression screening. 1. Suicide precautions and 1:1 close observation may be instituted prior to securing a physician order if nursing staff assess patient to be at risk. The order will follow as soon as practical precautions are in effect. C. All suicidal patients will be placed on 1:1 close observation.....Notify the provider of the patient with suicide risk."

Patient #22's electronic medical record was reviewed on 9/13/19 at 8:45 AM and revealed the following:

Patient #22 presented to the emergency room on 09/11/2019 at 10:01 PM with a chief complaint of shortness of breath and chest pain.

The Columbia Suicide Severity Rating Scale completed at 10:10 PM revealed Patient #22's suicide evaluation as "high risk."

The "ED Provider note" dated 09/12/2019 at 1:12 AM revealed, " ...He/she has numerous health problems which has been contributing to him/her feeling very depressed and recently suicidal. He/she is currently suicidal and tonight his/her significant other had to take a knife away from him/her. He/she tells me he/she 'keeps his/her knives sharp.' He/she says that would be his/her plan, or he/she would use his/her cross bow."

On 09/12/2019 at 1:17 AM, "ED note" revealed, "contacted Marinette dispatch for an officer to do an EM1 (emergency psychiatric hold) screening."

At 1:28 AM "Marinette dispatch at bedside."

At 1:39 AM "Marinette police calling Northwest Connections. (On-call for ADAPT)" (county crisis center).

At 5:28 AM, "Discharged to Winnebago Mental Health with law enforcement."

There was no documented order for suicide precautions or 1:1 sitter or evidence that suicide precautions or a 1:1 sitter was initiated, per facility policy, during the emergency room stay.

During an interview with ED Manager D on 09/13/2019 at 10:20 AM when asked what about the process when a patient comes in with suicidal ideations and a Columbia Suicide Severity Rating (CSSR) of high risk, ED manager D stated, "We would have 1:1 sitter with the patient even if there is family present."

During an interview with VP Nursing C on 09/13/2019 at 11:30 AM stated "It looks like we didn't follow our policy on this one."

Based on observation, record review and interview, the facility failed to have EMTALA law signage posted conspicuously in 4 of 7 patient care areas (Emergency Department (ED) Waiting Room, ED Triage, ED Patient Treatment Areas, and Labor and Delivery Triage) out of a total of 7 patient care areas observed, and failed to appropriately transfer patients according to the facility's policies and procedures in 2 of 20 patients (Patients #1, #22) presenting the the Emergency Room with behavioral health chief complaints in a total sample of 22 medical records reviewed.

Findings include:

The facility failed to have EMTALA law signage posted conspicuously in 4 of 7 patient care areas (Emergency Department (ED) Waiting Room, ED Triage, ED Patient Treatment Areas, and Labor and Delivery Triage). See Tag A2402.

The facility failed to appropriately transfer patients according to the facility's policies and procedures in 2 of 20 patients (Patients #1, #22) presenting the the Emergency Room with behavioral health chief complaints. See Tag A2409.

Based on observation, record review and interview, the facility failed to ensure EMTALA signs are posted in all patient waiting and emergency treatment areas in 4 of 7 patient care areas (Emergency Department (ED) Waiting Room, ED Triage, ED Patient Treatment Areas, and Labor and Delivery Triage) out of a total of 7 patient care areas observed.

Findings include:

On 9/12/2019 at 12:44 PM, during a tour of the Emergency Department (ED) area accompanied by ED Manager D, Paramedic F, and President E, EMTALA signage was observed in the ED Main Entrance alcove. No signage was noted in the ED waiting room or patient triage room. 14 of 14 ED treatment rooms were occupied. During an interview at the time of the tour, 9/12/19 at 12:44 PM, ED Manager D and President E stated, "We do not have signs in any of the rooms or in triage. We've never had them anywhere but at the entrance. We did not have them in the rooms at the old hospital, either."

On 9/13/19 at 10:32 AM, during a tour of the Labor and Delivery department accompanied by President E, Director H, and Manager I, EMTALA signage was observed outside the locked entrance to the Labor and Delivery department and in the "Family Lounge" waiting room. No signage was observed in the room identified by Director H and Manager I as the Labor and Delivery Triage room.

On 9/12/2019, review of of facility policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)," last revised 05/2017 revealed, "...Definitions:...Proper Documentation and Signage: The hospital will prepare and maintain proper documentation and signage as required by EMTALA, as well as comply with other EMTALA requirements...Procedure:...Signage: The hospital shall post signs within the ED, as well as in the general hospital, and the Labor and Delivery entry. The signs must state the rights of individuals under EMTALA and that the hospital participates in the Medicare program."

Based on record review and interview, the facility failed to appropriately transfer patients according to the facility's policies and procedures in 2 of 20 patients presenting the Emergency Room with behavioral health chief complaints (Patients #1, #22) in a total sample 22 medical records reviewed.

Findings include:

Review of the facility policy #3478077 titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)," last revised 05/2017 revealed, "...B. Transfer the patient. Appropriate transfer of the patient to another medical facility must be conducted in accordance with the hospital transfer policy. If the patient is transferred to another facility, a Certificate of Transfer will be completed...Transfer of an Unstable Patient...B. Physician/QMP Certification: The transferring physician/QMP signs a certification before transfer stating that, based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of medical treatment at another medical facility outweigh the risks to the patient...In addition to the physician/QMPs Certificate of Transfer, hospital staff should also attempt to obtain the patient's informed consent to transfer whenever possible...F. 'Transfer' means the movement (including the discharge) of a patient outside the hospital's facilities at the direction of any person employed by (or affiliated or associated, directly or indirectly with) the hospital, but does not include such a movement of a patient who has been declared dead, or who leaves the facility without the permission of any such person."

Review of facility policy #6038171 titled, "Transfer of Patient to Another Hospital," last revised 04/2019 revealed, "...Procedure: A. Physician will initiate orders to transfer patient. B. Receiving facility will call staff to confirm acceptance of patient and provide room assignment. Give patient care report at this time if appropriate...E. Obtain written consent from patient on Patient Transfer form (EMTALA form). 1. If patient is EM-1 (involuntary psychiatric commitment) there is no need to obtain EMTALA consent. F. Have physician sign: 1. Physician Certification Statement for Ambulance Services. 2. Patient Transfer Form (EMTALA form)...Documentation: Document appropriately in electronic health record."

Review of facility policy #2835891 titled "MENTAL HEALTH/SUBSTANCE ABUSE INVOLUNTARY AND VOLUNTARY REFERRALS, "last revised 10/2016 revealed, "III. PROCEDURE: 2. Assessment of Mental Health needs can generally be performed when an individual has a blood alcohol level of 0.1 or less. Inquire if the patient is currently under a providers care and contact the individual if possible. If not currently being treated, contact on-call crisis workers: Menominee County Residents: Northpointe Healthcare (906) 863-7841 for assessment in MI (Michigan) if patient is deemed safe to be discharged from the ER and able to meet the crisis worker in MI. If a MI county resident is a risk to self or others, Marinette Law Enforcement should be called for EM1 issuance and they will then call ADAPT to come to BAMC (facility) and assess the patient. Marinette County Residents: ADAPT (715) 732-7760 will evaluate all patients from WI (Wisconsin) at BAMC."

The facility algorithm titled "BAMC Mental Health Crisis Flow," dated 09/06/2016 revealed, "Michigan Resident regardless of where incident occurred-Arrives with Menominee Law: NO-Patient Receives Medical Screening Exam by ED MD-Call Marinette PD for EM1 Screening-EM1 Placed?-No, Voluntary-Refer to Northpointe for follow-up the next business day. If YES, Involuntary-ADAPT Case."

Patient #1's electronic medical record was reviewed on 9/12/19 and revealed the following:

Patient #1 was brought into the emergency room by his/her mother on 9/6/19 at 10:54 AM after having "bizarre" behavior in school. The "Arrival Complaint" was documented as "Poss (possible) Med (medical) Clearance."

On 9/6/19 at 11:02 AM, "ED Triage Notes," completed by a Registered Nurse, revealed, "Patient in the waiting room yelling and talking in incomprehensible sentences. States he/she has not slept and that is the reason for his/her behavior. Says he/she smoked pot but is not under the influence of other substances. Reading piece of paper that he/she states he/she wrote last night."

At 11:04 AM, the "Neurological Flowsheet" revealed, "Verbal Response: Confused conversation." The "Triage Plan Flowsheet" revealed, "Triage Plan: Patient Acuity: Urgent."

At 11:08 AM, the "Suicide Eval/Intervention" flowsheet revealed, "denies thoughts of self harm or helping (typo, should be "hurting") others." No Columbia Suicide Screening evaluation was documented.

At 11:24 AM, "Orders" revealed, "1:1 patient (Suicide)."

At 1:49 PM, "ED Notes" revealed, "Calling Northpointe (Michigan crisis agency) to get a case worker to talk to [Physician Assistant J]."

At 1:55 PM, "Observation Record" revealed, "Provider talking [with] Northpointe Behavioral Medicine (Michigan crisis agency)." No further documentation is found within Patient #1's medical record regarding who Physician Assistant J spoke to at the Michigan crisis agency or what was discussed in the conversation.

At 2:21 PM, "ED Vital Signs" revealed, "patient d/c (discharge) immediately to Northpointe (Michigan crisis agency) - no last set of vitals gotten - patient is climbing on chairs and ED furniture. Patient manically talking about the 'meaning of life.' D/C instructions given to [Patient #1's family member] who is taking right to Northpointe."

Patient #1 was diagnosed in the Emergency Department with Acute Psychosis and discharged at 2:23 PM. "Discharge Disposition" revealed, "Home or Self Care." Discharge Destination revealed, "Not Going To Other Hc (healthcare) Provider." "Discharge Provider" revealed, "None." Review of the discharge instructions titled, "After Visit Summary" revealed, "Caregiver to transport patient immediately to Crisis hotline officials in MI (Michigan). Seek law enforcement assistance if patient becomes combative."

There is no documentation of the consultation with Northpointe crisis in the ED Physician Assistant notes, and no documentation of Northpointe's acceptance to evaluate Patient #1. There is no evidence that transfer documents or information was provided to Northpointe upon Patient #1's discharge.

Patient #22's electronic medical record was reviewed on 9/13/19 at 8:45 AM and revealed the following:

Patient #22 presented to the emergency room on 09/11/2019 at 10:01 PM with a chief complaint of shortness of breath and chest pain.

The Columbia Suicide Severity Rating Scale completed at 10:10 PM revealed Patient #22's suicide evaluation as "high risk."

The "ED Provider note" dated 09/12/2019 at 1:12 AM revealed, " ...He/she has numerous health problems which has been contributing to him/her feeling very depressed and recently suicidal. He/she is currently suicidal and tonight his/her significant other had to take a knife away from him/her. He/she tells me he/she 'keeps his/her knives sharp.' He/she says that would be his/her plan, or he/she would use his/her cross bow."

On 9/12/19 at 1:12 AM, "ED Provider Notes" revealed, "...Decision Making...3:02 AM Awaiting voluntary psychiatric placement possibly at Winnebago Mental Health. 5:08 AM Pt (patient) accepted at Winnebago by [Physician Assistant] / [Medical Doctor]...Transfer via law enforcement to Winnebago Mental Health."

On 09/12/2019 at 1:17 AM, "ED Notes" revealed, "contacted Marinette dispatch for an officer to do an EM1 screening."

At 1:28 AM, "Marinette dispatch at bedside."

At 1:39 AM, "Marinette police calling Northwest Connections. (On-call for ADAPT)" (county crisis center).

At 2:00 AM, "...Patient is wanting to voluntarily check [him/herself] in to a psychiatric facility..."

At 2:50 AM, "Information faxed to Winnebago Behavioral per request for intake."

At 5:06 AM, "...Winnebago Mental Health called and stated that patient is accepted."

At 5:09 AM, "Patient Transfer Form" revealed, "Section I. Physician Certification...Diagnosis: suicidal ideation. Accepting facility: Winnebago Mental Health. Accepting physician: [Physician Assistant name] / [Medical Doctor name]. Direct physician to physician contact made? No. Reason direct contact not made: not requested by accepting facility. Reason for/Benefits of transfer: Specialty services/expertise not available at this facility. Services/expertise not available: psychiatry. Mode of transfer with appropriate personnel: Law enforcement. Section II. Physician Certification, Transfer Risks & Consent...Is the patient stable? Yes (see corresponding Physician Statement). Was this an emergency medical condition? This patient had an emergency medical condition, received necessary stabilizing treatment, and is now stable."

At 5:12 AM, "Section III. Patient Information at Time of Transfer...Sent with patient: ED Transfer Summary; EKG; Face Sheet; Imaging Films."

At 5:28 AM, "ED Notes" revealed, "Discharged to Winnebago Mental Health with law enforcement." "Discharge Instruction" revealed, "Discharge Date/Time: 09/12/2019 0528 (5:28 AM). Discharge Disposition: Psychiatric Hospital. Discharge Destination: Winnebago Mental Health Institute. Discharge Provider: None."

There was no evidence that Patient #22's informed consent to transfer was obtained, and there were no specified benefits or risks of transfer documented, per facility policy.

During an interview on 9/12/19 at 12:56 PM, when asked about the facility's process for patients presenting with a psychiatric emergency, ED Medical Director G stated, "We assess the patient and do a medical screen. If we determine there is a psychiatric emergency and the patient is from Wisconsin, we contact the police for a chapter (legal hold). If the police determine the patient should be chaptered, they contact crisis - ADAPT is the crisis agency for Wisconsin. If they determine an admission is necessary, they find an inpatient facility for us to transfer the patient to. If they don't feel the patient needs inpatient admission, they instruct us to discharge the patient or they have a sort of halfway house they might send the patients to. If the patient is from Michigan, if they are in custody of the Michigan police, then we do a medical clearance. If the patient is stable, we contact the Michigan crisis agency (Northpointe). They will not come to the hospital to assess patients. They usually have us discharge the patient to the custody of the police, who will transport the patient to Northpointe for evaluation and certification of placement. If the patient is from Michigan and has not been previously seen by Northpointe and not in custody of law enforcement, we will do a medical screen. If there is an emergency identified, we will contact the police, who will come and evaluate the patient, contact ADAPT, who then contacts Northpointe. ADAPT will not come to the hospital to evaluate Michigan patients. If the patient is here during the day - during normal business hours - and they are medically clear, we contact Northpointe who tells us to discharge the patient and have them go right to their office. If patients walk in here, it doesn't matter where they are from." ED Manager D stated, "If the patient is actively suicidal or threatening, ADAPT will see the patients, but it is a struggle. We are currently working on setting up telepsych services through Aurora, which would take the county out of it. This should be live by the end of October. If the patient is voluntary, there is no need to contact crisis or the police. We find an accepting facility and discharge the patient."

During an interview on 9/13/19 at 10:20 AM, when asked if it was expected that details or follow up from a conversation with crisis was documented in the medical record, Director J stated, "In a perfect world, yes, but sometimes it's just documented as a conversation took place." When asked how patients who are transferred to an inpatient psychiatric facility are transported, Director J stated, "Those transfers are almost always a discharge to police custody and they transport the patient."

A telephone interview was conducted with Physician Assistant J on 9/13/19 at 11:04 AM. When asked about determining appropriateness of transport mode for patients being discharged to the Michigan crisis agency for further evaluation, Physician Assistant J stated, "If the family can transport the patient and are comfortable with transporting the patient, then they usually go by private auto. The police will not transport if the patient is not determined to be an immediate risk." When asked about the conversation with Northpointe which was documented in Patient #1's medical record, Physician Assistant J stated, "I can't remember who I talked to or what the details of the conversation were. I know I did talk to someone from there. The nurses spoke with them too. I was back and forth talking with [Patient #1's family member] multiple times, and spoke with him/her privately regarding his/her comfort with driving the patient."

During an interview on 9/13/19 at 11:30 AM, when asked about the contact with Northpointe regarding Patient #1 on 9/6/19, ED Manager D stated, "I know it was [crisis worker's first name] who called back. He/she told our PCT (Patient Care Technician) to send [Patient #1] right over." When asked where this was documented, ED Manager D stated, "I know it's not documented in the record."