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.

ST MARYS HOSPITAL SUPERIOR 3500 TOWER AVE SUPERIOR, WI 54880 Feb. 24, 2016
VIOLATION: COMPLIANCE WITH 489.24 Tag No: C2400
Based on record review and interview, the facility failed to ensure transfer form are completed including risk of transfer specific to patient diagnosis, time for accepting physician contact and/or date and time with the doctor signs the document, in 8 of 20 medical records (2, 5, 9, 11, 12, 15, 16 and 17); the transfer of a patient is an appropriate transfer in 2 of 20 medical records (5), and that EMTALA signs are posted in 1 of 1 waiting areas, 1 of 1 entrance and 6 of 11 treatment rooms.

Findings include:

The facility failed to ensure there is a policy addressing completion of the EMTALA transfer form, and that it is legible and complete including risks related to the patient's diagnosis, benefit of transfer and time accepting physician is notified, in 8 of 10 transfer records reviewed (2, 5, 9, 11, 12, 15, 16 and 17) out of a total of 20 medical records reviewedSee Tag C2409.

The facility failed to ensure EMTALA signs are posted in all treatment rooms and waiting areas, in 6 of 11 Emergency Department treatment rooms, 1 of 1 waiting room and 1 of 1 emergency entrance observed. See Tag C2404.

The cumulative affect of these deficiencies potentially affect all 119 Emergency Department Patients seen in the Emergency Department during this survey.
VIOLATION: POSTING OF SIGNS Tag No: C2402
treatment rooms and waiting areas, in 6 of 11 Emergency Department treatment rooms, 1 of 1 waiting room and 1 of 1 emergency entrance observed .

Findings include:

Per tour of the Emergency Department on 2/24/16 at 3:15 PM, it was observed there are no EMTALA signs posted in the Emergency Department entrance, waiting room and in the following treatment rooms: 3, 4, 6, 33, 34 and 35. Per interview during the tour on 2/24/16 at 3:15 PM with Manager A, Manager A was not aware the signs were not posted in the observed areas.
VIOLATION: APPROPRIATE TRANSFER Tag No: C2409
Based on record review and interview, the facility failed to ensure there is a policy addressing completion of the EMTALA transfer form, and that it is legible and complete including risks related to the patient's diagnosis, benefit of transfer, level of care during transport and times of consent and notifying accepting physician, in 8 of 10 transfer records reviewed (2, 5, 9, 11, 12, 15, 16 and 17) out of a total of 20 medical records reviewed.

Findings include:

Per interview on 2/24/16 at 3:15 PM with Manager A a policy on transferring patients could not be located.

Patient #2's medical record review revealed Patient #2 arrived in the Emergency Department on 11/2/15 with a complaint of abdominal pain. Patient #2 was transferred to another facility due to a bowel obstruction. The Transfer Assessment and Certification Hospital to Hospital has illegible Benefits/Reason for Transfer and illegible Risks. The time listed for doctor to doctor contact is illegible. This is confirmed in interview with Emergency Department Manager A on 2/24/16 during record reviews between 10:35 AM and 3:00 PM, adding staff are expected to write clearly on paper documents.

Patient #5's medical record review revealed Patient #5 arrived in the Emergency Department on 10/18/15 with a complaint of a sexual assault. Patient #5 was transferred to another facility due for a sexual assault examination. The Transfer Assessment and Certification Hospital to Hospital has under Benefits/Reason for Transfer "needs sexual assault exam" and states under Risks "MVC (motor vehicle crash), and is not related to the patient diagnosis. There is no time listed for doctor to doctor contact. This is confirmed in interview with Emergency Department Manager A on 2/24/16 during record reviews between 10:35 AM and 3:00 PM, adding this is not an appropriate transfer. Manager A stated medical staff do sexual assault examinations at this facility and there is not need for a transfer.

Patient #9's medical record review revealed Patient #9 arrived in the Emergency Department on 8/3/15 after a fall. Patient #9 was transferred to another facility due to a need for orthopedic surgery. The Transfer Assessment and Certification Hospital to Hospital has under Risks "traffic accident", and is not related to the patient diagnosis. This is confirmed in interview with Emergency Department Manager A on 2/24/16 during record reviews between 10:35 AM and 3:00 PM, agreeing the risks should be related to the patient diagnosis.

Patient #11's medical record review revealed Patient #11 arrived in the Emergency Department on 9/5/15 with a complaint of shortness of breath. Patient #11 was transferred to another facility due to Chronic Obstructive Pulmonary Disease with exacerbation. The Transfer Assessment and Certification Hospital to Hospital has no information under Risks, and there is no date and time the doctor signed the document. This is confirmed in interview with Emergency Department Manager A on 2/24/16 during record reviews between 10:35 AM and 3:00 PM, adding medical staff are to list risks of transfer and have a date and time with their signature.

Patient #12's medical record review revealed Patient #12 arrived in the Emergency Department on 11/2/15 with a complaint of Anorxia. Patient #12 was transferred to another facility due to high potassium levels and renal failure. The Transfer Assessment and Certification Hospital to Hospital has no risks listed. This is confirmed in interview with Emergency Department Manager A on 2/24/16 during record reviews between 10:35 AM and 3:00 PM, adding the medical staff are to list risks of transfer.

Patient #15's medical record review revealed Patient #15 arrived in the Emergency Department on 11/5/15 with a complaint of a finger laceration. Patient #15 was transferred to another facility due to need of open finger fracture repair. The patient was transferred by private car. The Transfer Assessment and Certification Hospital to Hospital states under Risks "decompensation" and does not include risks specific to the patient's diagnosis or lack of medical assistance during transfer. This is confirmed in interview with Emergency Department Manager A on 2/24/16 during record reviews between 10:35 AM and 3:00 PM, agreeing there should be risks related to the patient's diagnosis and not having medical assistance during transfer.

Patient #16's medical record review revealed Patient #16 arrived in the Emergency Department on 11/4/15 with a complaint of dizziness. Patient #16 was transferred to another facility due to need for further evaluation and repeated episodes. The patient was transferred by private car. The Transfer Assessment and Certification Hospital to Hospital states Benefits/Reason for Transfer as "imaging" and Risks as "transfer/decompensation". This is confirmed in interview with Emergency Department Manager A on 2/24/16 during record reviews between 10:35 AM and 3:00 PM, agreeing there should be risks related to the patient's diagnosis and not having medical assistance during transfer, Manager A also stated it benefits should have been more specific related to Magnetic Resonance Imaging that is not available at the facility.

Patient #17's medical record review revealed Patient #17 arrived in the Emergency Department on 12/7/15 with a complaint of abdominal pain. Patient #17 was transferred to another facility due to an incarcerated hernia. The Transfer Assessment and Certification Hospital to Hospital states "surgery" for Benefits/Reason for Transfer and under Risks "worsening condition risks of transfer", and is not specific to the patient's diagnosis. This is confirmed in interview with Emergency Department Manager A on 2/24/16 during record reviews between 10:35 AM and 3:00 PM, agreeing the benefits should be more specific than surgery and risks should be specific to the patient's diagnosis.