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Based on record review and interviews, facility staff failed to ensure all patients on hospital property with an emergency medical condition were documented on an Emergency Department (ED) central log 1 of 13 (Patient #1) who entered the ED on 03/16/2023; 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 1 of 8 (Patient #19) Patients transferred from the ED to another facility in a total universe of 20 medical records reviewed.

Findings include:

The facility staff failed to ensure a patient who presented on hospital property with an emergency medical condition for 1 of 13 Patients (Patient #1) was documented on an ED central log on 03/16/2023. See Tag A-2405.

The facility failed to complete an appropriate medical screening exam for 1 of 20 Patient (Patient #1) who presented to the ED. See Tag A-2406.

The facility failed to fully document risks/benefits for 1 of 8 Patients (Patient #19) who were transferred from the ED to another facility. See Tag A-2409.

Based on record review and interview facility staff failed to ensure all patients who presented on hospital property with an emergency medical condition are documented on an Emergency Department (ED) central log for 1 of 13 Patients (Patient #1) who presented on 03/16/2023 in a total of 20 medical records reviewed.

Findings Include:

A review of the facility's policy titled, "Emergency Medical and Treatment (EMTALA), AW (Ascension Wisconsin)" Policy #8304980, Last Revised Date 07/28/2020 revealed, ""Central Log" is to track the care provided to each individual who comes to the hospital seeking care for an emergency medical condition. "Comes to the Emergency Department" means an individual is considered to have "come to the emergency department" if the individual has: ...2. Has presented on Hospital property, as defined in this section, other than the Dedicated Emergency Department, and requested examination or treatment for what may be an Emergency Medical Condition or has such a request made on his or her behalf."

During an interview on 05/04/2023 at 10:25 AM Administrator D stated, Per letter received from DSPS (Department of Safety and Professional Services) [Patient #1] was walked into the ED entrance on 03/16/2023 at 2:40 AM escorted by Milwaukee Police Department and requested assistance due to suicidal ideations.

Review of the ED Log revealed, Patient #1 presented to the ED on 03/16/2023 at 12:24 AM. There is no documentation on the log indicating Patient #1 re-entered the ED at 2:40 AM.

During an interview on 05/09/2023 at 2:03 PM, Patient Access Representative P stated s/he was working the night of 3/16/2023. Stated remembered Patient #1 coming into the ED via paramedics the first time and was seen by the RN and physician and was discharged from the facility. Patient Access Representative P stated that within a short period of time (like 5 minutes), Patient #1 came back into the hospital doors with two Police Officers. Patient Representative P stated RN B came out and spoke to Patient #1 and the police officers. Stated that Patient #1 then left with the police officers, Patient #1 was never registered on the ED log as s/he did not make it past the registration desk.

During an interview on 05/04/2023 at 10:26 AM Administrator D stated that Patient #1 did not appear on the log as presenting to the hospital again at 2:40 AM, if patients present to the registration desk, they should be placed on the ED Log.

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 the facility's policy titled, "Emergency Medical and Treatment (EMTALA), AW (Ascension Wisconsin)" Policy #8304980, Last Revised Date 07/28/2020 revealed, "1. Medical Screening Examination- Any patient who comes to the Hospital's Dedicated Emergency Department and requests or has a request made on his or her behalf for emergency examination and treatment ...requires examination or treatment for a medical condition, will be provided an appropriate Medical Screening Examination within the capabilities of the Dedicated Emergency Department including ancillary services routinely available to the emergency department to determine whether an Emergency Medical Condition exists regardless of their ability to pay for medical care."

A review of letter that was sent to DSPS (Department of Safety and Professional Services) and the State of Wisconsin was written by Police Officer/Complainant A. The letter referred to 03/16/2023 which explained, at 2:49 AM Patient #1 "was observed sitting on a bench outside the north garage door of the ambulance bay (of hospital). Patient #1 stated was discharged from [Ascension St. Francis Hospital] a little while ago after coming in for suicidal thoughts. [Patient #1] stated that still feels suicidal and feels like jumping off a roof ... [Patient #1] asked if police could take [him/her] somewhere else for assistance. Due to [Patient #1] still being on hospital property, we walked [Patient #1] into the ED entrance and advised staff of [his/her] continued suicidal ideation, and [his/her] continued request for assistance. Hospital staff noted ...that [Patient #1] was at the ED ...earlier in the evening and that [he/she] was treated and was just recently discharged. The ED nurse was contacted. [Registered Nurse (RN) B] came out to the waiting area and stated that [Patient #1] had already been seen and was discharged, and the hospital does not have to see [him/her] again within 24 hours. Police Officer A advised RN B that [Patient #1] is still in crisis, and still requesting help for suicidal ideations with viable plan to kill himself. RN B stated that [he/she] was still not going to readmit [Patient #1]. Police Officer A then walked [Patient #1] out to our squad and conveyed [him/her] at [his/her] request to [MHEC- Mental Health Emergency Center]. [Patient #1] remained at MHEC voluntarily."

A review of Patient #1's medical record revealed Patient #1 did not have a medical screen completed on 03/16/2023 at 2:49 AM when he presented back to the facilities ED with suicidal ideations. Patient #1 was taken to an alternate mental health facility for an evaluation.

During an interview on 05/09/2023 at 2:03 PM, Patient Access Representative P stated s/he was working the night of 3/16/2023. Stated remembered Patient #1 coming into the ED via paramedics the first time, and was seen by the RN and physician and was discharged from the facility. Patient Access Representative P stated that within a short period of time (like 5 minutes), Patient #1 came back into the hospital doors with two Police Officers. Patient Representative P stated RN B came out and spoke to Patient #1 and the police officers. Stated that Patient #1 then left with the police officers, Patient #1 was never registered on the ED log and was not seen by the physician .

An interview was conducted on 05/04/2023 at 8:45 AM with Quality Coordinator C who stated, Patient #1 was seen in the ED on 03/16/2023 at 12:24 AM and was discharged at 2:30 AM. There was no documentation of Patient #1 returning to the ED and requested medical/psychiatric services on 03/16/2023 at 2:49 AM or that a medical screen was completed.

An interview was conducted on 05/04/2023 at 10:30 AM, Administrator D stated that when patients present to the hospital with a complaint, a physician is required to complete a medical screening examination.

Based on record review and interview, facility staff failed to document risks/benefits for 1 of 8 patients (Patients #19) 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 #8304980 titled, "Emergency Medical and Treatment (EMTALA), AW" last revised 07/28/2020 revealed, "Transfers- 2. If a patient is not stabilized, the Hospital may not transfer the patient unless one of the following occurs: a. The individual requests the transfer in writing after being informed of the Hospital's obligation to provide emergency screening and stabilizing treatment and being fully informed of the risks of transferring, or b. The Hospital is unable to provide the treatment necessary to stabilize the patient, and i. A physician signs a certification that based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of medical treatment at another medical facility outweighs the increased risks of the transfer to the patient ..."

A medical record review for Patient #19 revealed, Patient #19 arrived at the facility's ED on 03/17/2023 at 5:13 PM for chief complaint: Suicidal and Alcohol intoxication. The "Physician Documentation" revealed on 03/17/2023 at 5:36 PM, "Patient is medically clear and will be transferred to the [Name of Hospital] for further psychiatric evaluation under the care of the police."

A review of Patient #19's "Transfer Form" from 03/17/2023 at 10:05 PM revealed, "Medical Condition: - (left blank) Diagnosis: intentional self harm; alcohol intoxication. Receiving Facility: [Name of Hospital] Receiving MD: [Name of Physician] Medical Risks: - (left blank)".

During an interview on 05/04/2023 at 9:30 AM, Quality Coordinator C confirmed the findings and stated the medical risks was left blank. When asked if it was expected that risks be included on the transfer form, Quality Coordinator C stated, "Risks should be included on the form, looks like it wasn't completed."