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ASCENSION OUR LADY OF VICTORY HOSPITAL 1120 PINE ST STANLEY, WI 54768 Sept. 23, 2013
VIOLATION: COMPLIANCE WITH 489.24 Tag No: C2400
Based on review of ED (Emergency Department) policy, medical record review, and staff interviews, the hospital failed to ensure compliance with EMTALA regulations 489.24. The hospital failed to provide a complete medical screening for 2 of 20 pts. (Patients) sampled (Pts. #1 and #2). This has the potential to affect all pts. who enter the ED.

Findings include:

The ED did not provide a complete medical screening for pts. #1 and #2 who entered the ED.

The cumulative affect of this deficiency potentially affects all 66 ED and Urgent Care Pts. who entered the ED during the survey.

See findings for tag C-2406.
VIOLATION: MEDICAL SCREENING EXAM Tag No: C2406
Based on review of ED policies, medical record reviews, review of physician note, and staff interviews (A, C, B), the hospital failed to provide complete and appropriate medical screening examination for 2 of 20 pts. sampled (Pts. #1 and #2) who entered the ED. This has the potential to affect all pts. who enter the ED. The hospital averages 227 patients per month in their ED in the past 6 months.

Findings include:

Policy/Procedure entitled "EMTALA" last revised 2/07 states the following: "A. All persons who present to the emergency department seeking treatment must receive a medical screening exam within the capability of the hospital to determine if an emergency medical condition exists."

Policy #CI-18 last revised 9/1/12 entitled, "Emergency Medical Treatment And Labor ACT (EMTALA)" states the following under #1 policy statements, "It is the policy of the Hospital Organizations who are subject to EMTALA to provide any individual who comes in the Emergency Department of the Hospital Organization with an appropriate Medical Screening Examination."

1.) Per interview with Hospital President A and Risk Management Specialist C at 1:15 p.m. on 9/19/13, A admitted that another hospital had telephoned A on 9/16/13 stating that their physician felt our hospital had an EMTALA violation and gave A the name of Pt. #1. A described the events for Pt. #1 who presented in the hospital ED on 9/10/13. Pt. #1, accompanied by private caregiver, had seen an eye doctor in the community who recommended that Pt. #1 should have an MRI (Magnetic Resonance Imaging). Per A, "There was a gap." Per A, Dr. B, who saw Pt. #1 in the ED, did not document appropriately; and requested Dr. B dictate a note of his evaluation of Pt. #1 after the fact. A admitted in interview that it is their hospital policy that anyone seen in the ED should be screened. A said that A concurred that a thorough screening exam was not done for Pt. #1 when presented in their ED on 9/10/13.

During interview with C on 9/19/13, C said that Pt. #1 presented to the ED registration requesting an MRI. Pt. #1 had a piece of paper in one hand. ED RN D looked at the paper and informed Pt. #1 that the hospital did not have a mobile MRI at the hospital on that day, which was Tuesday, 9/10/13. RN D then spoke with Dr. B who requested D bring Pt. #1 into the ED. Dr. B did not provide a medical screen to Pt. #1, but looked into Pt. #1's left eye. No ED record was generated.

In review of the physician note A had Dr. B write on 9/17/13, stated that Dr. B saw Pt. #1 on 9/10/13 after Pt. #1 presented at the registration desk requesting an MRI. Dr B wrote that B had checked Pt. #1's left eye and pulse. Dr. B wrote, "I suggested that it may be best to just go to a facility that could provide him the needed studies." Pt. #1's caregiver and Pt. #1 understood that this could potentially represent a stroke. Caregiver of Pt. #1 said would take Pt. #1 to another hospital.

During interview with Dr. B at 3:15 p.m. on 9/19/13, when asked to summarize what occurred on 9/10/13 when Pt. #1 was seen in the ED, B replied, "Everything is written on my form. I have nothing else to say." When further prompted to describe the evaluation, Dr. B said had checked Pt. #1's eyes and pulse and did a visual. There was potential for a stroke. B further explained that visual meant a general visualization of the patient appearance and that Pt. #1 needed further evaluation. B stated Pt. #1 was given the option to be evaluated here or go elsewhere where Pt. #1 could get an MRI. Felt Pt. #1 was potentially having a stroke. B concluded, "No other focal symptoms were displayed. It could be Lyme disease for all I know."

2.) Per medical record review of Pt. #2 on the morning of 9/23/13, the following was noted: Pt. #2 presented to the ED at 7:51 p.m. on 8/25/13 complaining of urinating blood. Dr. E did not document what screening examination was done. A complete screening examination is not documented .

During an interview with Risk Manager C at 2:05 p.m. on 9/23/13, when asked about the screening examination for Pt. #2, C replied " No", it was not a good screening and " agreed " it was incomplete.