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.

COLUMBUS COMMUNITY HOSPITAL 1515 PARK AVE COLUMBUS, WI 53925 Feb. 5, 2016
VIOLATION: COMPLIANCE WITH 489.24 Tag No: C2400
Based on record review and interview, the facility failed to ensure transfer and against medical advice forms are completed including risk of transfer specific to patient diagnosis, dates and times for accepting physician contact and date/or times with signatures, in 11 of 20 medical records (1, 2, 4, 5, 7, 9, 11, 14, 17, 19 and 20).

Findings include:

The facility failed to ensure patents leaving against medical advice documents include date and/or time risks are discussed on the Against Medical Advice form, in 1 of 4 medical records where patient left against medical advice (#5) out of a total 20 medical records reviewed.
Tag C2407.

The facility failed to ensure the EMTALA transfer form is complete including risks related to the patient's diagnosis, mode of transport, level of care during transport and times of consent and notifying accepting physician, in 10 of 10 transfer records reviewed (1, 2, 4, 7, 9, 11, 14, 17, 19 and 20) out of a total of 20 medical records reviewed. See Tag C2409.

The cumulative affect of these deficiencies potentially affect all 108 Pts seen in the Emergency Department during this survey.
VIOLATION: STABILIZING TREATMENT Tag No: C2407
Based on record review and interview the facility failed to ensure patents leaving against medical advice documents include date and/or time risks are discussed on the Against Medical Advice form, in 1 of 4 medical records where patient left against medical advice (#5) out of a total 20 medical records reviewed.

Findings include:

Per interview with Manager A on 2/4/16 at 11:26 AM via email, there is no specific policy for completing the forms for patients leaving against medical advice.

Patient #5's medical record review revealed Patient #5 arrived in the Emergency Department on 10/15/15 at 9:58 PM with a complaint of chest pain. Per the physician notes Patient #5 had a history of heart bypass surgery and reported having "recurrent chest pain for weeks". After having blood work an electro cardiogram and X-ray completed the physician states in the notes "Likely will need to be transferred to (a Madison hospital) where his cardiologist who has treated (Patient #5) is familiar with ...case. Patient refusing admission stating (Patient #5) wants to go home and 'will talk to (own) regular doctor next week before making other decisions' I stressed the patient (sic) that given (Patient #5's) tenuous medical situation that the only way (Patient #5'll) be able to leave the hospital would be to sign out AGAINST MEDICAL ADVICE...".

The Release From Responsibility For Discharge form signed by the physician has no time, and Patient #5's signature has no date and time.

The above findings are confirmed in interview with Manager B during record review on 2/3/16 between 12:00 PM and 4:30 PM, adding all signatures should have a date and time attached.
VIOLATION: APPROPRIATE TRANSFER Tag No: C2409
Based on record review and interview, the facility failed to ensure the EMTALA transfer form is complete including risks related to the patient's diagnosis, mode of transport, level of care during transport and times of consent and notifying accepting physician, in 10 of 10 transfer records reviewed (1, 2, 4, 7, 9, 11, 14, 17, 19 and 20) out of a total of 20 medical records reviewed.

Findings include:

Review of facility policy titled Medical Screening, Stabilization and Transfer Plan, dated 6/15, states under Emergency Medical Condition requiring further treatment and/or higher level of care: "The patient/family must be informed of the risks and benefits of transfer, the 'EMTLALA (Emergency Medical Treatment and Labor Act) Transfer form must be signed by the patient or responsible person...Physician Certification: The physician has informed the patient/family and certifies in writing that the benefits of transfer outweigh the potential risks to the patient..."

Review of facility policy titled Emergency Department Specific Plan for Providing Care, dated 3/15, states under Medical Screening, Stabilization and Transfer: "...The risks, benefits and alternatives of the impending transfer are shared and understood by the patient/family and documented as such prior to transfer."
The follow medical records were reviewed between 12:00 PM and 4:30 PM on 2/3/16 with Manager B:

Patient #1's medical record review revealed Patient #1 was transferred to another facility for higher level of care on 10/8/2015 after being found unresponsive. Per the EMTALA (Emergency Medical Treatment and Labor Act) Form: Patient Consent/Refusal, Patient Request/Physician (or QMP (Qualified Medical Personnel)) Certification, completed on 10/8/15, there is no time when the physician contacted the accepting physician nor time the physician signed the form, no date and time the Registered Nurse signed the form, no documentation of type of transport, what portions of the medical record was sent with the patient and date and time the representative signed the consent.

Patient #2's medical record review revealed Patient #2 was transferred to another facility for higher level of care on 7/13/15 after suspected seizure. Per the EMTALA (Emergency Medical Treatment and Labor Act) Form: Patient Consent/Refusal, Patient Request/Physician (or QMP (Qualified Medical Personnel)) Certification, completed on 7/13/15, there is no documented benefit of the transfer, no time when the physician contacted the accepting physician nor time the physician signed the form, no time the Registered Nurse signed the form, no documentation of type of transport, what portions of the medical record was sent with the patient and time the representative signed the consent.

Patient #4's medical record review revealed Patient #4 was transferred to another facility for pediatric care on 2/1/16 due to pneumonia. Per the EMTALA (Emergency Medical Treatment and Labor Act) Form: Patient Consent/Refusal, Patient Request/Physician (or QMP (Qualified Medical Personnel)) Certification, completed on 2/1/16, there is no time when the physician contacted the accepting physician and the risks documented state "deterioration reroute" and is not specific to the patient's diagnosis of pneumonia.

Patient #7's medical record review revealed Patient #7 was transferred to another facility for higher level of care on 11/2/15 complaint of breathing problems and new diagnosis of cancer. Per the EMTALA (Emergency Medical Treatment and Labor Act) Form: Patient Consent/Refusal, Patient Request/Physician (or QMP (Qualified Medical Personnel)) Certification, completed on 11/2/15, there is no risk of transfer documented, and the benefits state "higher level of care", there is no time when the physician contacted the accepting physician nor time the physician signed the form, and what portions of the medical record was sent with the patient.

Patient #9's medical record review revealed Patient #9 was transferred to another facility at patient request for insurance and for higher level of care on 11/21/15 for chest pain . Per the EMTALA (Emergency Medical Treatment and Labor Act) Form: Patient Consent/Refusal, Patient Request/Physician (or QMP (Qualified Medical Personnel)) Certification, completed on 11/21/15, there is no risk of transfer documented, and the benefits state "cardiac", and there is no time when the physician contacted the accepting physician, and no mode of transportation designated by the physician.

Patient #11's medical record review revealed Patient #11 was transferred to another facility for due to equipment or services not available on 12/2/15 , Patient #11 is pregnant and complains of a headache. Per the EMTALA (Emergency Medical Treatment and Labor Act) Form: Patient Consent/Refusal, Patient Request/Physician (or QMP (Qualified Medical Personnel)) Certification, completed on 12/2/15, there is no time when the physician contacted the accepting physician. The mode of transport is "car" and "self", the risks documented state "MVC (motor vehicle crash) and deterioration reroute" and is not specific to the patient's diagnosis of headache and pregnancy, nor does it address risk of not having medical help available reroute new to transport by private car. There are no vital signs documented, no time the Registered Nurse signed the form, and time the representative signed the consent.

Patient #14's medical record review revealed Patient #14 was transferred to another facility at patient request due to insurance on 7/31/15 after pneumonia and lung mass. Per the EMTALA (Emergency Medical Treatment and Labor Act) Form: Patient Consent/Refusal, Patient Request/Physician (or QMP (Qualified Medical Personnel)) Certification, completed on 7/31/15, the risk of transfer is illegible, and the benefits are illegible, there is no time when the physician contacted the accepting physician and what portions of the medical record was sent with the patient.

Patient #17's medical record review revealed Patient #17 was transferred to another facility for gynecological care on 7/26/15 for vaginal bleeding post hysterectomy. Per the EMTALA (Emergency Medical Treatment and Labor Act) Form: Patient Consent/Refusal, Patient Request/Physician (or QMP (Qualified Medical Personnel)) Certification, completed on 7/26/15, state under Risk of Transfer "none", there is no time when the physician contacted the accepting physician and no signature, date and time of the physician.

Patient #19's medical record review revealed Patient #19 was transferred to another facility for equipment or services not available "cath" (catheter) on 12/22/15 for complaint of chest pain and need of cardiac catheterization. Per the EMTALA (Emergency Medical Treatment and Labor Act) Form: Patient Consent/Refusal, Patient Request/Physician (or QMP (Qualified Medical Personnel)) Certification, completed on 12/22/15, the risk of transfer states "MVC", the benefits state "cath", there is no time when the physician contacted the accepting physician, no mode of transportation designated by the physician, what portions of the medical record was sent with the patient and no time the representative signed the consent.

Patient #20's medical record review revealed Patient #20 was transferred to another facility for equipment and services not available care on 1/8/16 for hand surgery due to a fracture. Per the EMTALA (Emergency Medical Treatment and Labor Act) Form: Patient Consent/Refusal, Patient Request/Physician (or QMP (Qualified Medical Personnel)) Certification, completed on 1/8/16, state under Risk of Transfer "crash", there are no risks specific for patient's diagnosis, and the records sent states X-ray disc.

The above findings were confirmed in interview with Manager B on 2/3/16 during the record reviews between 12:00 PM and 4:30 PM. Manager B stated nursing staff are to ensure completeness, dates and times, and physicians are responsible for reason, risk, benefits and documenting receiving hospital's acceptance times. Manager B stated staff should be writing on the transfer form if this is an EPIC electronic record available to the receiving hospital, or checking what records were sent with the patient.