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.

MAYO CLINIC HLTH SYSTM FRANCISCAN HLTHCARE SPARTA 310 W MAIN ST SPARTA, WI 54656 July 7, 2014
VIOLATION: COMPLIANCE WITH 489.24 Tag No: C2400
Based on observation, record review and interview, the facility failed to ensure EMTALA signed are posted, Pts receive a MSE upon arrival to the ED in 1 of 20 MRs (1), and transfer forms are completed including Pt specific risk of transfer, in 9 of 9 transfer MRs reviewed, out of a total 20 MRs reviewed.

Findings include:

In 1 of 1 observation, the facility failed to ensure EMTALA signs are in the entrances and treatment rooms. See Tag C2402.

In 1 of 20 MRs (1) the facility failed to ensure Pts receive an MSE to rule out a medical emergency. See Tag C2406.

In 9 of 9 MRs (1, 2, 3, 7, 9, 11, 13, 14 and 19) where Pts were transferred, the facility failed to complete a facility to facility transfer consent form and/or provide risks benefits of transfer to the Pt. See Tag C2409.

The cumulative affect of these deficiencies potentially affect all ED Pts seen requiring transfers at this facility.
VIOLATION: POSTING OF SIGNS Tag No: C2402
Based on observation and interview, the facility failed to ensure there are EMTALA signs posted in all entrances and treatment areas, in 1 of 1 observation (ED). This deficiency affects all ED Pts seen at the facility.

Findings include:

Per observation on 7/7/2014 at 8:45 AM with PCS B, there are no EMTALA signs in the ED entrance Main Hospital Entrance or the 10 treatment rooms. In interview with PCS B, B stated, "the signs needed to be updated and have not been hung yet."
VIOLATION: MEDICAL SCREENING EXAM Tag No: C2406
Based on record review and interview, the facility failed to ensure there is a comprehensive MSE completed on Pts arriving in the ED to determine a medical emergency, in 1 of 20 MRs reviewed.

Findings include:

Review on 7/7/14 at 1:00 PM of facility policy titled Emergency Medical Treatment and Labor Act, dated 2/14 states an MSE is "An evaluation by a licensed provider designed to determine whether an individual has an emergency medical condition. A MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether a medical emergency does or does not exist."

Pt #1's MR review on 7/7/14 at 9:45 AM revealed Pt #1 arrived in the ED on 6/27/14 at 2:54 AM with a complaint someone was trying to kill Pt #1. Pt #1 was seen by MD C at 3:00 AM. The MSE included the History of Present Illness as "...roommate was trying to kill (Pt #1). (Pt #1) has a history of polysubstance abuse and bipolar disorder..."

The Past Medical History included comments of Pt #1 receiving Seroquel (to treat schizophrenia) and Clonazepam (to treat panic) a week ago. The Systems Review states "The patient is interested in hospitalization . (Pt #1) usually goes to (another hospital)...says (Pt #1) will allow blood sample." This is not a systems review that includes a head to toe evaluation of bodily functions, to determine any system problems that would arise to a medical emergency.

The Physical Examination includes "dilated pupil, alert... mumbles...Note, we attempted to get blood sample and urine sample, but (Pt #1) could not cooperate to allow either sample to be obtained." There is no evidence of the following components of a physical examination: lung sounds, heart tones, muscular or a skeletal examination to determine if there is a physical condition that would arise to a medical emergency.

There is no neurological examination, or orientation to self, place and time, and there is no evidence of lab work completed to determine if there is a medical emergency.

This is confirmed in interview with PCS B on 7/7/14 at 9:45 AM, stating there should be a complete MSE.
VIOLATION: APPROPRIATE TRANSFER Tag No: C2409
Based on record review and interview with staff, the facility failed to ensure all transferred Pts sign a consent to transfer and/or have risks and benefits explained related to their diagnosis, in 9 of 9 transfer MRs (1, 2, 3, 7, 9, 11, 13, 14 and 19) out of a total 20 MRs reviewed. This deficiency directly affects Pt #1 and potentially affects all Pts transferred to another facility for care.

Findings include:

Per review on 7/7/14 at 1:00 PM of facility policy titled Emergency Medical Treatment and Active Labor Act (EMTALA) dated 2/14, it states under 3.c.viii. related to completing the transfer document "...The certification shall contain summary of the risks and benefits upon which this decision is based and must be signed by the provider."

Pt #1's MR review on 7/7/14 at 9:45 AM revealed Pt #1 arrived in the ED on 6/27/14 at 2:54 AM with a complaint someone was trying to kill Pt #1. This facility has no behavior health unit and due to aggression and pointing a pen at staff, the police were called who volunteered to take Pt #1 to another facility in La Crosse for assessment and treatment in their behavior health unit. Pt #1 was not placed on psychiatric hold. There are no transfer forms that include a consent, explanation of risks and benefits specific to psychosis, mode of transportation or MD to MD contact. Per the MD notes, the La Crosse facility was contacted after Pt #1 left with police, and was then informed there were no beds in their behavior health unit. This is confirmed in interview with PCS B on 7/7/14 at 9:45 AM, stating there should be a transfer form.

Pt #2's MR review on 7/7/14 at 10:00 AM revealed Pt #2 arrived in the ED on 6/22/14 at 5:54 AM with a possible blocked ureter (tube from kidney to bladder). Pt #2's consent to transfer lists the only risks as "Movement could cause increased pain", there are no risks specific to Pt #2's diagnosis. This is confirmed in interview with PCS B on 7/7/14 agreeing the risk listed is too general.

Pt #3's MR review on 7/7/14 at 10:15 AM revealed Pt #3 arrived in the ED on 6/22/14 at 12:15 PM with a complaint of chest pain. The transfer form dated 6/22/14 at 12:50 AM includes checked pre-printed Risks of Transfer as "Medical condition could worsen during transport, Movement could cause increased pain and Transportation risks including weather and road conditions." There are no risks specific to Pt #3's diagnosis. This is confirmed in interview with PCS B on 7/7/14 agreeing the risks listing is general to all conditions.

Pt #7's MR review on 7/7/14 at 10:40 AM revealed Pt #7 arrived in the ED on 5/28/14 at 6:51 PM with a complaint of paralysis and fatigue and required a neurological evaluation. The transfer form completed on 5/28/14 has no risks during transport listed. This is confirmed in interview with PCS B on 7/7/14 at 10:40 AM, agreeing risks should be documented.

Pt #9's MR review on 7/7/14 revealed Pt #9 arrived in the ED on 4/20/14 at 4:59 PM with a complaint of chest pain, and heart attack. The transfer form dated 4/20/14 at 5:48 PM includes checked pre-printed Risks of Transfer as "Medical condition could worsen during transport, Movement could cause increased pain and Transportation risks including weather and road conditions." There are no risks specific to Pt #9's diagnosis. This is confirmed in interview with PCS B on 7/7/14 at 10:50 AM agreeing the risks listing is general to all conditions.

Pt #11's MR review on 7/7/14 at 10:55 AM revealed Pt #11 arrived in the ED on 4/21/14 at 3:28 PM with a complaint of an ankle fracture. The transfer form dated 4/31/14 at 6:30 PM has no risks for transport listed. This is confirmed in interview with PCS B on 7/7/14 at 10:55 AM, agreeing risks should be documented.

Pt #13's MR review on 7/7/14 at 11:05 AM revealed Pt #13 arrived in the ED on 3/23/14 at 3: 51 PM with a complaint of suicide ideation. Pt #13 was place on a psychiatric hold and transported via police to another facility. The transfer form dated 3/23/14 at 5:00 PM includes checked pre-printed Risks of Transfer as "Medical condition could worsen during transport, Movement could cause increased pain and Transportation risks including weather and road conditions." There are no risks specific to Pt #13's diagnosis. This is confirmed in interview with PCS B on 7/7/14 at 11:05 AM agreeing the risks listing is general to all conditions.

Pt #14's MR review on 7/7/14 at 11:10 AM revealed Pt #14 arrived the on 3/23/14 at 9:05 PM with a complaint of vaginal bleeding. The transfer form dated 3/34/14 at 9:45 PM lists the only risk of transport as "Medical condition could worsen during transport". There are no risks specific to Pt #14's diagnosis. This is confirmed in interview with PCS B on 7/7/14 at 11:10 AM, agreeing the risk is too general.

Pt #19's MR review on 7/7/14 at 11:35 AM revealed Pt #19 arrived in the ED on 2/23/14 at 3:31 PM with a complaint of a head injury from a fall. The transfer form dated 2/23/14 at 5:18 PM includes checked pre-printed Risks of Transfer as "Medical condition could worsen during transport, Movement could cause increased pain and Transportation risks including weather and road conditions." There are no risks specific to Pt #19's diagnosis. This is confirmed in interview with PCS B on 7/7/14 at 11:35 AM agreeing the risks listing is general to all conditions.