HospitalInspections.org

Based on record review and interviews, facility staff failed to provide a medical screening exam to 1 of 20 (Patient #1) Patients presenting to the Emergency Department (ED) and failed to fully document risks/benefits for 4 of 7 (Patient #2, 8, 12, 17) Patients transferred from the ED to another facility.

Findings include:

1. The facility failed to complete an appropriate medical screening exam for 1 of 1 Patient (Patient #1) who presented to the ED. See tag 2406.

2. The facility failed to fully document risks/benefits for 4 of 7 Patients (Patent #2, 8, 12, 17) who were transferred from the ED to another facility. See tag 2409.

Based on record review and interview this facility failed to complete a medical screening exam (MSE) for 1 of 20 patients (Patient #1) who presented to the Emergency Department (ED) with a medical issue.

Findings include:

A review of facility Policy #199290, "AAH (Advocate Aurora Health) EMTALA (Emergency Medical Treatment and Labor Act)" last revised 09/15/2021 revealed, "IV. POLICY A. Hospital staff will provide an appropriate Medical Screening Examination for all individuals that present to the DED (Dedicated Emergency Department) with a medical condition or on the Hospital Campus with an Emergency Medical Condition or is in Labor."

A review of Patient #1's medical record revealed Patient #1 arrived at the facility's ED on 12/04/2022 at 8:27 AM. ED (Emergency Department) Note dated 12/04/2022 at 8:20 AM written by ED RN (Registered Nurse) H revealed, "Patient presented to the ED from urgent care, urgent care attempted to call patient to tell patient to go to Bay Care, Patient's contact was not up to date so they were not able to get in contact with the patient. PSR (Patient Service Representative) took a phone call form urgent care provider that evaluated the patient earlier telling PSR to send the patient to Bay Care if he presented to this ED. PSR sent patient away before communication with nursing staff. No nursing contact was made with patient as patient left the building before this could occur."

An interview was conducted on 01/17/2023 at 2:50 PM with ED MD G. When asked about Patient #1, ED MD G stated, she/he never saw the patient. Stated he/she received a call from Urgent care stating Patient #1 was acutely confused, ataxic (unsteady staggering gait) and falling to the right. ED MD G was waiting for Patient #1 to arrive to the ED. When ED MD G questioned the PSR I about Patient #1, ED MD G was told PSR I received a call and was directed to send Patient #1 to [Name] Hospital.

An interview was conducted on 01/17/2023 at 3:15 PM with ED RN H. When asked about Patient #1, ED RN H stated PSR I came back into the ED and informed her/him that PSR I received a phone call from urgent care and was directed to send Patient #1 to [Name] Hospital. When PSR I informed ED RN H of this information, Patient #1 had already left the ED. ED RN H stated she/he never saw the patient.

An interview was conducted on 01/18/2023 at 8:50 AM with PSR I. When asked if they remembered Patient #1 presenting to the ED, PSR I stated, she/he received a phone call from a PSR at urgent care who stated they had been trying to reach the patient but was not able and if the patient presented to the ED, he/she should be told to go to [Name] Hospital. PSR I stated when Patient #1 arrived to the desk at the ED, the patient was told to go to [Name] Hospital per directives from the urgent care staff.

An interview was conducted on 01/17/2023 at 4:00 PM with Director Of Quality J who stated they were aware of the EMTALA violation related to Patient #1 not receiving a medical screening exam when they presented to the ED on 12/4/2022. Director of Quality J stated PSR I and all other PSR staff were trained on the requirements for a medical screen. The facility staff completed an investigation and re-training of all the staff (including PSR I and all other PSR staff) was done. New protocols were also established for staff to prevent from happening again. Audits have been completed on all transfers to ensure medical screens have been completed, and has been compliant since education was completed. No further instances of directing patients presenting for emergency care to go to a different facility were found in the record reviews of patients presenting after 12/4/2022.

Based on record review and interview, facility staff failed to document risks/benefits for 4 of 7 patients (Patients #2, 8, 12, 17) who were transferred from the Emergency Department to another facility in a total sample of 20 emergency department medical records reviewed.

Findings Include:

A review of the facility's policy #19290 titled, "AAH (Advocate Aurora Health) EMTALA (Emergency Medical and Treatment)," last revised 09/11/2020 revealed, "3. Unstable Patient Transfers: An unstable patient may be transferred if hospital staff provide stabilizing treatment for the patient's EMC (Emergency Medical Condition) within the Capacity and Capabilities of the Hospital and sections a-d below are met: a) A physician certifies the Transfer, or the Transfer occurs upon the request of the patient or a legally responsible person acting on the patient's behalf, as documented on the Patient Transfer Form ("Form"): (1). Transfer with Certification: A physician must certify that the medical benefits expected from Transfer outweigh the risks and describe the reasons for and the potential risks and benefits of the Transfer by completing the applicable areas on the Patient Transfer Form. The date and time of the certification should be close in time to the actual Transfer..."

A review of the facility's policy #68812 titled, "AMCMC (Aurora Medical Center Manitowoc County) Transfer of Patients, Internal and External," last reviewed 09/01/2022 revealed, "G. External Transfers- To another Acute Care Facility 5. The Paient Transfer Form (printed from Epic) will be completed and signed by the physician, RN (Registered Nurse) and patient..."

Patient #2's electronic medical record was reviewed with Lead RN of ED (Emergency Department) B who confirmed the findings:

Patient #2 arrived at the facility's ED on 12/11/2022 at 5:21 PM for suicidal thoughts. The "Physician Documentation" revealed on 12/11/2022 at 6:59 PM, "Clinical Impressions Primary: Suicidal ideation Disposition Transfer to another facility. [Patient #2] should be transferred out to [Name of Hospital]."

A review of Patient #2's "Transfer Form" from 12/11/2022 at 10:55 PM revealed, "Diagnosis: Suicidal ideations Accepting Facility: [Name of Hospital] Accepting Physician: [Name of Physician] Direct Physician-to-Physician contact made?: No ... Risk Statement: (not recorded)".

Patient #8's electronic medical record was reviewed with Lead RN (Registered Nurse) ED (Emergency Department) B who confirmed the findings:

Patient #8 arrived at the facility's ED on 11/30/2022 at 9:34 PM for complaint of not feeling well. The "Physician Documentation" revealed on 12/01/2022 at 12:40 AM, "Clinical Impression ED Diagnosis 1. Perforated viscus Disposition Transfer to another facility. [Patient #8] should be transferred out to [Name of Hospital]."

A review of Patient #8's "Transfer Form" from 12/01/2022 at 1:05 AM revealed, "Diagnosis: Perforated abdominal viscus (wall or gastrointestinal tract ruptures and the enteric contents leak into the peritoneal cavity), ileus versus bowel obstruction Accepting Facility: [Name of Hospital] Accepting Physician: [Name of Physician] Direct Physician-to-Physician contact made?: Yes ... Risk Statement: (not recorded)".

Patient #12's electronic medical record was reviewed with Lead RN (Registered Nurse) ED (Emergency Department) B who confirmed the findings:

Patient #12 arrived at the facility's ED on 08/29/2022 at 12:06 AM for complaint of chest pain. The "Physician Documentation" revealed on 08/29/2022 at 12:18 AM, "Patient here with chest pain. Differential diagnosis includes coronary artery disease including ischemia or infarction, pneumonia, pulmonary embolism (PE) pneumothorax great vessel disease, referred pain ...Disposition: Transfer to [Name of Hospital] by EMS (Emergency Medical Services) for cardiology evaluation."

A review of Patient #12's "Transfer Form" from 08/29/2022 at 1:52 AM revealed, "Diagnosis: Acute Coronary Syndrome Accepting Facility: [Name of Hospital] Accepting Physician: [Name of Physician] Direct Physician-to-Physician contact made?: Yes ... Risk Statement: (not recorded)".

Patient #17's electronic medical record was reviewed with Manager of ED (Emergency Department) A who confirmed the findings:

Patient #17 arrived at the facility's ED on 01/12/2023 at 2:17 PM for complaint of feeling off balance and somewhat foggy from time to time. The "Physician Documentation" revealed on 01/12/2023 at 5:28 PM, "Detailed evaluation undertaken and found her to have a large brain mass ...Disposition Transfer to another facility. [Patient #17] should be transferred out to [Name of Hospital]."

A review of Patient #17's "Transfer Form" on 01/12/2023 at 3:29 PM revealed, "Diagnosis: brain mass with midline shift Accepting Facility: [Name of Hospital] Accepting Physician: [Name of Physician] Direct Physician-to-Physician contact made?: Yes ... Risk Statement: (not recorded)".

During an interview with Lead RN (Registered Nurse) ED (Emergency Department) B on 01/18/2023 at 8:45 AM, when asked if it was expected that risks be included on the transfer form, Lead ED RN B stated, "Risks should be included on the form, looks like it wasn't completed."