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.

INDIANHEAD MEDICAL CTR 113 4TH AVE SHELL LAKE, WI 54871 Oct. 20, 2017
VIOLATION: COMPLIANCE WITH 489.24 Tag No: C2400
Based on record review and interview the facility failed to ensure there are complete medical screening examinations in 1 of 20 medical records reviewed (#1); and failed to ensure all transfer have completed transfer documents with listed benefits and/or risks specific to the patient listed in 9 of 17 transfer medical records reviewed (1, 3, 6, 8, 11, 12, 13, 17 and 18) out of a total 20 medical records reviewed. The cumulative effect of these deficiencies potentially affect all patients treated at the facility.

Findings include:

The facility failed to ensure a Medical Screening Examination wass performed to determine if there was a medical emergency in 1 of 20 medical records reviewed (#1). See tag C2406.

The facility failed to ensure obstetric patients were appropriately transferred in 1 of 1 obstetric patient record (#1) out of a total 20 medical records reviewed; and failed to ensure transfer documents were completed, including risks and/or benefits of the transfer and/or physician to physician contact documented for patients referred to other facilities, in 9 of 17 transfer medical records reviewed (#1, 3, 6, 8, 11, 12, 13, 17 and 18), out of a total 20 medical records reviewed. See tag C2409.
VIOLATION: MEDICAL SCREENING EXAM Tag No: C2406
Based on record review and interview the facility failed to ensure a Medical Screening Examination was performed to determine if there was a medical emergency in 1 of 20 medical records reviewed (#1).

Findings include:

Review of the facility policy titled Emergency Department Medical Screening on 1/12/15, revealed "The Registered Nurse (RN) is delegated by the Medical Staff to perform medical screening exams and to provide patient care in the Emergency Department only if: the RN is on site and immediately available when an individual comes to the CAH's emergency department and requests examination or treatment; the RN has training and experience in emergency care; and the nature of the request for medical care is within the scope of practice of an RN and consistent with applicable Wisconsin State Law and (facility's) bylaws." Under Medical Screening Exam is states "all laboring patients are considered unstable and thereby deemed to have an emergency medical condition...the RN completing the medical screen will assess document blood pressure, heart rate, respiratory rate, temperature, present illness or injury, severity of symptoms, possibility of labor, past medical history, present medications, allergies."

Review of the facility policy titled Assessment and Transfer of OB (Obstetric) Patients, effective 9/24/15, revealed under Procedure "4. a. OB Screening Exam i. LMP/EDC (last monthly period/estimated date of conception), how many weeks (performed by RN) ii. History of gravida (pregnancies) and para (live deliveries, aborted) (performed by RN) iii. Brief history of prenatal care/primary MD (physician) and clinic/any ultrasounds (performed by ED RD) iv. Complaint OB related, contractions onset and frequency (performed by RN) v. Exam by physician may include: fundal height, fetal heart tones, cervical check, contractions palpated, ferning exam (test for amniotic fluid) for rupture of membranes...6. If ED physician feels patient needs to be discharged to or transferred to a different facility, you may want to have the discussion with the primary provider on where to transfer the patient or follow these guidelines: a. Less than 34 weeks, closest facility is Duluth, Twin Cities, or Marshfield. b. 34-36 weeks, closet (sic) facility is Eau Claire and Duluth. c. 36 weeks and up, closest facility is Rice Lake and Cumberland. 7. While patient is in the ED here..suggested labs include: a. Blood type, b. UA (urine analysis) c. Ferning exam for rupture membranes...d. Hemogram...e. Any other labs requested by accepting facility. 8. If transfer is needed: a. Automobile if considered safe based on findings from medical screening exam and the physician has discharged the patient. b. EMS (Emergency Medical System) basic, they my request a nurse for transfer...9. Report will be called to receiving facility."

Patient #1's medical record review on 10/19/17 at 11:20 AM revealed Patient #1 arrived in the emergency room (ER) on 10/12/17 at 5:50 PM with a complaint of cramping. Registered Nurse E documented at 5:54 PM, Patient #1's pain level was a 5 out of 10, acute and in the location of the abdomen. A set of vital signs is documented at 5:55 PM as blood pressure 145/103, pulse 95 and respirations 18. There is no documentation of breath sounds or palpation of the abdomen. The notes at 5:50 PM state "Patient presents to the ER under the care of Washburn jail with complaints of cramping since about 5 pm tonight. (S/he) noticed vaginal discharge the past few days. No active bleeding, (patient's) water has not broke. (S/he) has been pregnant before. (Patient's) due date is December (sic) 21st. Patient is crying, (s/he) stated (s/he) doesn't have a clock at the jail but (s/he) thinks (Patient's) contractions are about 2-3 minutes apart, unrelieved by positioning or walking." At 5:55 PM nursing notes state "Dr. F stated we do not do OB (obstetric) care here and to tell the jail to send (patient) to Rice Lake or where (patient's) OB doctor is. Discharge without being seen. Advised the officer to call the ambulance for transport, to transport to facility with OB capabilities such as Rice Lake."
There is no documentation in the medical record of fetal heart tones, palpation of contractions, vaginal exam or lab work.

Per interview with Administrator B and emergency room Manager C on 10/19/17 at 10:13 AM, they confirmed Patient #1 arrived by foot complaining of contractions, the nurse did an initial assessment and called Physician F who said Patient #1 should be transported to a hospital that does OB. Patient #1 returned to jail, and they learned an ambulance was called who took the patient to Spooner.

Per interview via telephone with Registered Nurse E on 10/19/17 at 11:15 AM, Nurse E confirmed the above medical record findings, and that Physician F did not come, although answered the phone right away when called. Nurse E stated s/he did not give discharge instructions, "they just walked out."

Per interview via telephone with Physician J on 10/19/17 at 2:28 PM, s/he was in the clinic when called and told Patient #1 was 7 months pregnant. Physician F said "I told the nurse to tell (Patient #1) we don't deliver babies anymore. If not in distress, should go to her OB (obstetrician)."
VIOLATION: APPROPRIATE TRANSFER Tag No: C2409
Based on record review and interview, the facility failed to ensure obstetric patients were appropriately transferred in 1 of 1 obstetric patient record (#1) out of a total 20 medical records reviewed; and failed to ensure transfer documents were completed, including risks and/or benefits of the transfer and/or physician to physician contact documented for patients referred to other facilities, in 9 of 17 transfer medical records reviewed (#1, 3, 6, 8, 11, 12, 13, 17 and 18), out of a total 20 medical records reviewed.

Findings include:

Review of the facility Competency Statement: 18E-3 Transfer of patient to another facility (n.d.) revealed " I. Care of Patient A. Stabilize the patient per Doctor's orders...B. Retrieve patients (sic) history... II. Transfer Protocol: A. Call facility of MD (physician)'s choice and Doctor B. Call for the transport of MD's choice...C. Initiate Transfer Packet...4. Have Doctor sign forms after risks & benefits have been explained...E. Document physicans (sic) order for transfer on ER (emergency room ) form or Doctors (sic) order sheet..."

Review of the facility policy titled Assessment and Transfer of OB (Obstetric) Patients, effective 9/24/15, revealed under Procedure "4. a. OB Screening Exam i. LMP/EDC (last monthly period/estimated date of conception), how many weeks (performed by RN-Registered Nurse) ii. History of gravida (pregnancies) and para (live deliveries, aborted) (performed by RN) iii. Brief history of prenatal care/primary MD (physician) and clinic/any ultrasounds (performed by ED-Emergency Department RN) iv. Complaint OB related, contractions onset and frequency (performed by RN) v. Exam by physician may include: fundal height, fetal heart tones, cervical check, contractions palpated, ferning exam (test for amniotic fluid) for rupture of membranes...6. If ED physician feels patient needs to be discharged to or transferred to a different facility, you may want to have the discussion with the primary provider on where to transfer the patient or follow these guidelines: a. Less than 34 weeks, closest facility is Duluth, Twin Cities, or Marshfield. b. 34-36 weeks, closet (sic) facility is Eau Claire and Duluth. c. 36 weeks and up, closest facility is Rice Lake and Cumberland. 7. While patient is in the ED here..suggested labs include: a. Blood type, b. UA (urine analysis) c. Ferning exam for rupture membranes...d. Hemogram (examination of blood)...e. Any other labs requested by accepting facility. 8. If transfer is needed: a. Automobile if considered safe based on findings from medical screening exam and the physician has discharged the patient. b. EMS (Emergency Medical System) basic, they my request a nurse for transfer...9. Report will be called to receiving facility."

Patient #1's medical record review on 10/19/17 at 11:20 AM revealed Patient #1 arrived in the emergency room (ER) on 10/12/17 at 5:50 PM with a complaint of cramping. Registered Nurse E documented at 5:54 PM, Patient #1's pain level was a 5 out of 10, acute and in the location of the abdomen. A set of vital signs is documented at 5:55 PM as blood pressure 145/103, pulse 95 and respirations 18. There is no documentation of breath sounds, palpation of the abdomen. The notes at 5:50 PM state "Patient presents to the ER under the care of Washburn jail with complaints of cramping since about 5 pm tonight. (S/he) noticed vaginal discharge the past few days. No active bleeding, (patient's) water has not broke. (S/he) has been pregnant before. (Patient's) due date is December (sic) 21st. Patient is crying, (s/he) stated (s/he) doesn't have a clock at the jail but (s/he) thinks (Patient's) contractions are about 2-3 minutes apart, unrelieved by positioning or walking." At 5:55 PM nursing notes state "Dr. F stated we do not do OB (obstetric) care here and to tell the jail to send (patient) to Rice Lake or where (patient's) OB doctor is. Discharge without being seen. Advised the officer to call the ambulance for transport, to transport to facility with OB capabilities such as Rice Lake."

There was no transfer completed including physician to physician contact which was confirmed in interview with Director of Nursing D on 10/19/17 at 3:10 PM, who agreed the patient should have been transferred to to a faciltiy that does obstetrics.

Patient #3's medical record review on 10/19/17 at 4:00 PM revealed Patient #3 arrived in the ER on 9/20/17 at 11:03 AM with a complaint of confusion, nausea and headaches and diagnosis of leukocytosis (increased white cells). The emergency room Report, dated 9/20/17 states that after consulting with Eau Claire physician "felt to be safest to continue further evaluation at (Eau Claire hospital) as the source for the leukocytosis is not completely clear in this setting. Will send (patient) with a copy of (patient) CT (computed tomography) scan and (patient) lab results and this dictation. Nursing notes dated 9/20/17 at 2:10 PM state "D/C (Discharge) Condition Good, D/C to Trans (transfer) is checked, Mode: Wheelchair is checked, Discharge Instruction: to (Eau Claire hospital). The ER Patient Instructions state "Please have your (family member) drive you to (Eau Claire hospital) today for further treatment. you (sic) will be on the 5th floor. Dont (sic) take your coumadin (blood thinner) dose today."

There is no transfer document in file with risks of transfer by private car, or benefits of transfer, and no signed consent form for transfer by the patient, or family member, and physician. This was confirmed in interview with Director of Nursing D on 10/19/17 at 4:00 PM, who agreed there should be transfer documentation with risks and benefits, signed by the patient and physician.

Patient #6's medical record review on 10/19/17 at 4:15 PM revealed Patient #6 arrived in the ER on 9/22/17 at 4:15 PM following an All Terrain Vehicle accident and head injury. The EMTALA Certification of Transfer form has a sticker over the date and time of completion and there is no time for the signatures of physician and family member for consent of transfer. There are no benefits of transfer listed on the document. The document states the risk of transfer is "Deterioration en route". There are no risks listed specific to Patient #7's condition. This was confirmed in interview with Director of Nursing D on 10/19/17 at 4:15 PM, who agreed there should be transfer documentation should include risks specific to the patient condition.

Patient #8's medical record review on 10/19/17 at 4:33 M revealed Patient #8 arrived in the ER on 9/2/17 at 8:58 AM with a complaint of chest pain and diagnosis of heart attack. The EMTALA Certification of Transfer completed on 9/2/17 at 9:46 AM has no benefits of transfer listed. The document states the risk of transfer is "Death" and "Deterioration en route". There are no risks listed specific to Patient #8's condition. There This was confirmed in interview with Director of Nursing D on 10/19/17 at 4:33 PM, who agreed there should be transfer documentation should include benefits and risks specific to the patient condition.

Patient #11's medical record review on 10/19/17 at 4:50 PM revealed Patient #11 arrived in the ER on 8/18/17 at 1:57 PM with a complaint of chest pain, and diagnosis of heart attack. The EMTALA Certification of Transfer completed on 8/18/17 at 2:30 PM states the risk of transfer is "Deterioration en route". There are no risks listed specific to Patient #11's condition. This was confirmed in interview with Director of Nursing D on 10/19/17 at 4:52 PM, who agreed there should be transfer documentation should include benefits and risks specific to the patient condition.

Patient #12's medical record review on 10/19/17 at 4:55 PM revealed Patient #12 arrived in the ER on 8/11/17 at 10:10 PM with a complaint of chest pain and diagnosis of high blood pressure emergency. The EMTALA Certification of Transfer completed on 8/12/17 at 1:46 AM has no benefits or risks of transfer listed. This was confirmed in interview with Director of Nursing D on 10/19/17 at 4:55 PM, who agreed there should be transfer documentation should include benefits and risks specific to the patient condition.

Patient #13's medical record review on 10/20/17 at 7:30 AM revealed patient #13 arrived in the ER on 8/3/17 at 12:02 PM ankle injury and was unresponsive upon arrival. The diagnosis was altered level of consciousness, hypoxia (low oxygen in blood), low blood pressure, and acute renal failure. The EMTALA Certification of Transfer completed on 8/3/17 at 1:48 PM has the risk of transfer as "Deterioration en route". There are no risks listed specific to Patient #13's condition. This was confirmed in interview with Director of Nursing D on 10/20/17 at 7:35 AM, who agreed there should be transfer documentation should include risks specific to the patient condition.

Patient #17's medical record review on 10/20/17 at 7:55 AM revealed Patient #17 arrived in the ER on 6/27/17 at 12:45 PM with a complaint of vision difficulty after a fall and diagnosis of partial blindness and head injury. The EMTALA Certification of Transfer completed on 6/27/17 at 4:09 PM has no benefits of transfer listed. The document states the risk of transfer is "Deterioration en route". There are no risks listed specific to Patient #17's condition. There This was confirmed in interview with Director of Nursing D on 10/20/17 at 7:55 AM, who agreed there should be transfer documentation should include benefits and risks specific to the patient condition.

Patient #18's medical record review on 10/20/17 at 8:00 AM revealed Patient #18 arrived in the ER on 6/24/17 at 8:36 PM with a complaint of high blood pressure and chest pain. The emergency room Report gives a diagnosis of chest pain. The EMTALA Certification of Transfer completed on 6/24/17 at 11:33 PM has the risk of transfer as "Deterioration en route". There are no risks listed specific to Patient #18's condition. This was confirmed in interview with Director of Nursing D on 10/20/17 at 8:00 AM, who agreed there should be transfer documentation should include risks specific to the patient condition.