The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

WICKENBURG COMMUNITY HOSPITAL 520 ROSE LANE WICKENBURG, AZ 85390 July 13, 2015
VIOLATION: APPROPRIATE TRANSFER Tag No: C2409
Based on review of hospital policies/procedures, hospital documents, medical records and staff interviews it was determined that the hospital failed to implement and enforce their EMTALA/Transfer policies addressing documentation of the explanation of risk of patient transfer and the acceptance of the receiving physician and facility on the patient transfer form for three (3) of thirteen (13) transfer patients (Patient #'s 30, 39 and 40).

The failure to document the risks and acceptance of the patient to the receiving hospital has the potential for delay in care of services when the patient is transferred to another facility and is a violation of the patient's rights when a patient is not explained the risks of the transfer.

Findings include:

Hospital policy titled "Emergency Medical Treatment and Labor Act (EMTALA)" requires: "...A patient with an emergency medical condition will not be transferred to another facility unless:...The other facility agress (sic) to accept the patient; The transfer and it's risks and benefits have been explained to the patient or their representatives...."

Hospital policy titled "Transfer of Patients" requires: "...transferring physician must secure a receiving physician and facility prior to transfer and document it on the transfer form.

Review of Patient #30's medical record revealed the patient was transferred on 01/22/15, for higher level of care (cardiac). The "Request to Transfer/Physician Certification of Transfer Form was found to be incomplete; no risk of transfer was documented.

Review of Patients # 39 and 40's medical record revealed the patients were transferred on 05/05/15, for higher level of care (obstetrical and pediatric). The "Request to Transfer/Physician Certification of Transfer Form" was found to be incomplete; no receiving facility & no accepting physician was documented.

The Chief Nursing Officer (CNO) confirmed during an interview conducted on 07/10/15, that the Request to Transfer/Physician Certification of Transfer Forms were incomplete. The CNO confirmed the forms did not include documentation of the risks of transfer, the receiving facility or the accepting physician.
VIOLATION: EMERGENCY ROOM LOG Tag No: C2405
Based on review of the Emergency Department Logs from January 1, 2015 through July 8, 2015, policies/procedures and interviews with staff, it was determined the hospital failed to include (4) patients (Patient #'s 1, 2, 3,and 4) who arrived at the emergency department (ED) seeking assistance and/or treatment. There is no documentation of the above four (4) patients in the ED central log.

Failing to have a complete ED log may result in a patient not receiving a medical screening examination which could result in harm to a patient.

Findings include:

Hospital policy titled "ER Log Book" requires: "...A control register is continuously maintained and includes at least the following information for every individual seeking care...name, age, sex...date and times of arrival...nature of complaint...disposition and time of departure...."

Patient #1: TARGET CASE: Review of hospital document and RN (employee #11) progress note revealed: Patient #1 was in the magnetic resonance imaging (MRI) on 5/01/15, and began having seizure activity. The patient was non responsive and "shaking." The MRI Technician (employee #22) and ED staff began moving the patient onto a stretcher; the patient then opened his eyes and responded appropriately to questions. The patient was alert and oriented X 4. The patient was transferred to the ED and placed in room #3. Vital signs were stable. The patient complained of neck pain and stated he had a history of post traumatic stress disorder (PTSD) and suffers from panic attacks. The patient refused all treatment, stating his neck no longer hurt and did not want to be seen in the ED.


Patient #2: TARGET CASE: Review of hospital document and Progress Report (NP #6) revealed: Patient #2 was transported to the ED via emergency medical services (EMS) on 2/10/15, with a small laceration to her forehead after a fall on the playground at daycare. The laceration had no active bleeding. The mother arrived to the ED and refused treatment for the child.


Patient #3: TARGET CASE: Review of hospital document for Patient #3, dated 06/13/15, revealed: Two (2) ED Technicians (#'s 13 and 23) greeted the patient. The patient stated she wants to leave her emotionally abusive husband and doesn't know where to go, denies physical abuse and refused a Medical Screening Exam (MSE). The Technician spoke with the PA on duty. The PA determined, without assessing the patient, that if the patient refused the medical exam it would be best to call the police department to intervene. The Police arrived and gave the patient resources and developed a plan with the patient.

ED Tecnicians #'s 13 and 23 confirmed during interviews conducted on 07/0915, that the patient left without being seen and was not placed on the ED log.

Patient # 4: TARGET CASE: Review of hospital document for Patient #4, dated 06/13/15 revealed: the patient arrived in the ED for treatment of leg swelling after a stent placement. The ED Technician (employee #23) placed the patient in room #8 and instructed the patient to get undressed and change into a gown. The patient responded "I am not putting that on." The ED Technician advised the patient that she could bring him a blanket but he must take his pants off and put the gown on so his leg could be evaluated. The patient walked out of the ED.

Technician #23 confirmed during an interview conducted on 07/09/15, that the patient left the ED after refusing to change into the gown and was not placed on the ED log.


Patient # 5: TARGET CASE: reportedly arrived in the ED on 9/26/14, requesting his alcohol (ETOH) level be checked. Reportedly the patient was informed by the RN that ETOH is not checked here and patient left. The ED log for 9/26/14 did not reflect this patient.

Interviews with staff could not substantiate that this patient ever arrived to the ED.


Review of the central log dated 2/09/15 through 2/11/15, 4/30/15 through 5/2/15, and 06/12/15 through 06/14/15, revealed no documentation of Patient # 1, 2, 3 and 4's name and no documentation of the above patient's disposition.


The CNO reviewed and signed the hospital documents for Patients 1, 2, 3 and 4. The CNO documented on the hospital documents "staff acted appropriately. No further action needed."

The CNO confirmed in interviews conducted on 7/8/15, 7/9/15, 7/10/15 and 7/13/15 that patients are not placed on the ED log if they refuse to be seen. She stated that a hospital document is filled out instead. The CNO confirmed in an interview that Patient#1, 2, 3 and 4 were not on the ED log.

The CNO also confirmed that a facility document report was filled out and the progress note written by RN #19 was attached to the facility document for Patient # 1. She confirmed that the progress note was not entered into a medical record for Patient # 1.

The CNO confirmed that a facility document report was filled out and the progress note written by FNP #6 was attached to the facility document for Patient # 2. She confirmed that the progress note was not entered into a medical record for Patient # 2.

The CNO confirmed in an interview that Patient # 3 was only seen by the ED Technicians and that she did not see that as an issue. She stated that this was within their scope of practice.

The ED Supervisor confirmed in an interview conducted on 7/8/15, that all patients should be recorded on the ED Log when they arrive as well as their disposition according to the facility policies and procedures. She also confirmed that Patient # 1, 2, 3, and 4 should have been recorded on the Dedicated ED Log.
VIOLATION: MEDICAL SCREENING EXAM Tag No: C2406
Based on review of hospital policy and procedure, hospital documents and staff interviews, it was determined that the hospital failed to provide a medical screening exam for (4) patients (Patient #'s 1, 2, 3,and 4) who presented to the ED.

This failure could result in the potential harm for a patient with an emergency medical condition.


Findings include:


Hospital policy titled "Emergency Medical Treatment and Labor Act (EMTALA)" requires: "...hospital will provide a medical screening exam by a physician or credentialed Nurse Practitioner, or Physician's Assistant, within a "reasonable" amount of time after arrival/triage...determines whether the person has an emergency medical condition...."

Patient #1: TARGET CASE: was transported to the emergency department (ED) from the MRI on 5/01/15 with seizure activity.

Patient #2: TARGET CASE: transported to the emergency department (ED) via EMS on 2/10/15 with a laceration to her forehead.

Patient #3: TARGET CASE: arrived in the emergency department (ED) on 6/13/15 seeking assistance for emotional abuse by spouse.


Patient # 4: TARGET CASE: arrived in the ED for treatment of leg swelling after stent placement.

There was no documented evidence to confirm the above patients (1, 2, 3 and 4) received a medical screening examination per hospital policy.

The CNO confirmed in interviews conducted on 7/8/15, 7/9/15, 7/10/15 and 7/13/15 that patients # 1, 2, 3, and 4 did not have documentation of a medical screening exam nor did the above patients have a medical record.

The ED Supervisor confirmed in an interview conducted on 7/8/15, that all patients should have a medical record for each visit to document the visit and their disposition according to the facility policies and procedures. She also confirmed that Patient # 1, 2, 3, and 4 did not have documentation of a medical screening exam.