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.

THE MONROE CLINIC 2005 5TH STREET MONROE, WI 53566 April 30, 2013
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on MR review, and interview with staff(C and B), in 20 of 20 MR (1 through 20), tour and observation, the facility failed to ensure MRs include MD MSE time, transfer forms are completed including Pt specific risk of transfer, MD to MD consent for transfer and EMTALA signs are missing.

Findings include:

In 1 of 1 tour, and interview with staff the facility failed to ensure an EMTALA signs are in the patient/family waiting room, lobby and treatment rooms. See Tag A2402.

In 17 of 20 MR, the facility failed to ensure MD MSE time is documented in the MR. See Tag A2406.

In 1 of 6 MRs, where Pts were transferred, the facility failed to complete a facility to facility transfer with MD to MD contact and acceptance of receiving facility, and providing risks benefits of transfer to the Pt. See Tag A2409.

The cumulative affect of these deficiencies potentially affect all 52 ED Pts seen at this facility the day of survey.
VIOLATION: POSTING OF SIGNS Tag No: A2402
Based on tour of the ED and interview with staff (B and C), in 1 of 1 tour the facility failed to ensure EMTALA signs are posted in entrance, waiting areas and treatment rooms. This deficiency potentially affects all 52 ED Pts seen at this facility the day of survey.


Findings include:

Per tour of the ED on 4/29/13 at 11:00 AM with DON B and RN C there are no EMTALA signs in the ED entrance, waiting room or treatment rooms. Tour of patient treatment rooms #9, 10, 15, 16 and 17 did not have EMTALA signs.

Per interview with DON B and RN C on 4/29/13 at 11:00 AM, none of the treatment rooms have EMTALA signs.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on MR review, and interview with staff(B, C and G), in 1 of 18 MR with a MSE(1), out of a total 20 MRs reviewed, the facility failed to ensure the MSE is complete to rule out emergency need. In 17 of 18 MR with a MSE (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 12, 13, 15, 17, 18, 19 and 20), out of a total 20 MRs, the facility failed to ensure the MSE time is documented. This deficiency potentially affects all 52 ED Pts seen at this facility the day of survey.

Findings include:

Pt #1's MR review on 4/29/13 at 10:00 AM, revealed Pt #1 arrived in the ED at 7:26 PM with a complaint of "Psychiatric Problem". The HPI by MD G dated 4/18/13 at 1:10 AM states "The patient is currently exhibiting strange behavior and the (family member) is concerned for both (Pt #1's) own health and the possibility that he may harm himself. The (family member) is also concerned for the well being of his family because of (Pt #1's) behavior...The (family member) is also concerned that he may be under the influence of some medications and/or marijuana...I further learned that the patient has a possible history of oxycodone (narcotic) abuse in the past. The patient is very easily agitated at this time." The RS includes "Positive for hallucinations and agitation. The patient is nervous/anxious and is hyperactive." The PE includes "Very anxious. Very easily agitated...Patient hallucinating (comments on seeing people through other peoples eyes). Very easily agitated. Speaking in third person. Denies suicidal ideation Abnormal judgment."

The ED course note by MD G (n.d.) states "The patient had an unremarkable emergency room course. Because the patient was having hallucinations as well as showing signs of being easily agitated I treated (Pt #1) with Haldol (antipsychotic) 10 mg intramuscular before any further workup. Local enforcement was further contacted and they discussed the patient with no (sic) local crisis services. My initial intention was to perform blood work on the patient as well as a urine drug screen but before this could be completed the police came to me and stated that the patient was amenable to going to a psychiatric facility for voluntary admission. When I went back to the patient's room the father states that he wished to take him to (a Madison hospital) for voluntary admission. Patient is then discharged out of our facility and encouraged to proceed to that hospital."

An HPI addendum completed by MD G on 4/19/13 at 6:43 PM has the following information "The patient is brought to our facility at this time to be evaluated for strange behavior at home which has the father concerned...The (family member) tells me that (Pt #1) has been having on going issues/exacerbations of his psychiatric problems for the past 3 weeks. I am able to review the patient's notes in our computer and did appears that he has been under the care of (MD) since 2008 for Depression, Psychosis, Tobacco Use Disorder and Unspecified Psychosis. I also see mention of some medication non-compliance and marijuana usage. Patient is currently getting treatment with Rispridone and Wellbutrin and the (family member) tells me (family member) is uncertain if the patient is actually taking (Pt #1's) meds. When I enter the room the patient is lying face down in the bed and speaking to me from that position. The nurse expressed to me that the patient was agitated but I see no obvious signs of this. The (family member) further expressed to me that he is concerned about the patient not getting appropriate treatment for (Pt #1's) most recent exacerbations...The patient answers that he is not suicidal. The (family member) also comments on (Pt #1's) marijuana usage that (family member) feels is the inciting source for (Pt #1's) behavior...There is no mention of the patient seeing things of (sic) hearing voices. The patient is talking quickly and (Pt #1's) responses to me are going off on numerous tangents but overall he has been pleasant to deal with and accepting of be here for medical care. I lastly ask the (family member) about the patient sleeping last night and it appears that (Pt #1) only slept for 2-3 hours."

The RS, attached to addendum dated 4/19/13, states "Positive for agitation. The patient is nervous/anxious and is hyperactive." The PE attached to the addendum dated 4/19/13, states "Awake and alert. Very anxious....Mild agitation and very anxious. Denies hearing voices. Denise suicidal ideation Flat Affect (no distinct facial expression)".

The ED course note by MD G on 4/19/13 states "..(the Pt) was very accepting to treatment. Soon after meeting with the patient and seeing (Pt's) level of anxiety I gave (Pt #1) Haldol 1 mg to try and calm (Pt) down before any further workup. Local law enforcement was then called and I discussed with the patient and (family member) about helping get him to a psychiatric facility for care. Local law enforcement soon arrived and discussed their recent visits with (Pt) at their home. I then had further discussion with them and was made aware that (county services) were also contacted and plans were agreed with the patient and (family member) to leave our facility and seek out yesterday (sic) self admission to a psychiatric facility...My initial intention was to perform blood work on the patient as well as a urine drug screen but before any further plans were made for care but (sic) the family was wishing to leave at this time and accepting of this plan I allowed them to be discharge out of the ER...Patient is then discharged out of our facility and invited to return with any problems."

The addendum dated 4/19/13 no longer included the following statements from the original HPI dated 4/18/13 "...the (family member) is concerned for both (Pt #1's) own health and the possibility that (Pt #1) may harm (Pt's) self. The (family member) is also concerned for the well being of (family member's) family because of (Pt #1's) behavior...The (family member) is also concerned that (Pt #1) may be under the influence of some medications and/or marijuana...The patient is very easily agitated at this time." The RS with the 4/19/13 addendum, no longer contained the statements "Positive for hallucinations..."; and the PE with the 4/19/13 addendum, no longer contains the statement "Very easily agitated...Patient hallucinating (comments on seeing people through other peoples eyes). Very easily agitated. Speaking in third person...abnormal judgement."

The ED course addendum from 4/19/13 no longer included the statement "Because the patient was having hallucinations as well as showing signs of being easily agitated ...Local enforcement was further contacted and they discussed the patient with no (sic) local crisis services...Patient is then discharged out of our facility and encouraged to proceed to that hospital."

There is no documented labwork in the MR to Pt #1 of drugs that could potentially result in emergency treatment.

Per interview with MD G on 4/30/13 at 8:29 PM, MD G recalled Pt #1 was very anxious, not suicidal and "was not himself". MD G said (family member) wanted psychiatric care, and MD G was trying to facilitate some help. Regarding giving Pt #1 Haldol, MD G stated the RNs felt (Pt #1) "may lash out, they were fearful (Pt) would act out if anyone came near" MD G said Pt #1 was speaking in the third person and not in reality. When asked about not having the labs drawn, MD G said there was no concern for acute drug use. MD G recalled being comfortable discharging the patient. MD G acknowledged removing and changing statements from the ED notes in the MR for Pt #1's visit, adding "They didn't fit in what I was trying to convey. I usually do not write notes that long."

Examples of MSE not timed:

Per review of MR #'s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 12, 13, 15, 17, 18, 19 and 20 on 4/29/13 between 10:00 AM and 4:30 PM, there is no time documented when the MSE is done. This is confirmed in interview with DON B and RN C on 4/29/13 at 4:30 PM. RN C said in interview on 4/29/13 at 10:30 AM, the EMR system does not have a way to automatically document the MSE time and MDs currently are not documenting when they do the MSE.
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
Based on MR review, interview with C A and interview with staff (B, C and G), interview with SAC (H), in 1 of 6 MRs with a transferred Pt (Pts #1) out of a total of 20 MRs reviewed the facility failed to complete a facility to facility transfer with MD to MD contact, receiving facility acceptance and providing risks benefits of transfer to the Pt. This deficiency potentially affects all 52 ED Pts seen at this facility the day of survey.

Findings include:

Pt #1's Monroe Clinic MR review on 4/29/13 at 10:00 AM, revealed Pt #1 arrived in the ED at 7:26 PM with a complaint of "Psychiatric Problem". The ED course note by MD G (n.d.) states "The patient had an unremarkable emergency room course. Because the patient was having hallucinations as well as showing signs of being easily agitated I treated (Pt #1) with Haldol (anitpsychotic) 10 mg intramuscular before any further workup. Local enforcement was further contacted and they discussed the patient with no (sic) local crisis services. My initial intention was to perform blood work on the patient as well as a urine drug screen but before this could be completed the police came to me and stated that the patient was amenable to going to a psychiatric facility for voluntary admission. When I went back to the patient's room the (family member) states that (family member) wished to take (Pt #1) to (Madison hospital) for voluntary admission. Patient is then discharged out of our facility and encouraged to proceed to that hospital."

Discharge instructions documented in the EMR state "Patient and (family member) are going to (Maidson hospital) for self committal and treatment of underlying psychosis. Please see attached education materials entitled "Psychosis" for more information regarding your visit today." There are no education materials attached to the EMR.

The Teaching documented on 4/17/13 at 8:34 PM states "Discharge instructions performed 'Y', Instructions given to: Patient; (family member); Teaching comments AVS and KRAMES (education) sheets given and reviewed". There are no attached copies of the discharge instructions, with Pt acknowledgment, to insure Pt #1 and (family member) understood the instructions.

Per interview with CNO B and RN C, on 4/29/13 at approximately 4:30 PM, discharge instructions are not scanned into the EMR, nor signed by the Pt to acknowledge receipt.

Per (Madison hospital)'s MR review on 4/29/13 at 8:30 AM, the HPI completed 4/17/13 at 10:27 PM states "...(Pt #1) presents to the ED via private vehicle for evaluation of a psychiatric problem....(family member) initially took the patient to Monroe Clinic tonight. (Pt #1) was given Haldol injection at Monroe because he was being uncooperative and "loud". (family member) thinks the patient may have used marijuana recently...The patient was then sent here to (Madison hospital) for "self committal."..No physician, nurse, or social worker was contacted here. Pt was transferred here via private vehicle. Per (family member), (family member) was told to come to SMH ED for admission." The ED course notes state "No beds are available here but they were sent here for admission without an accepting physician or contact made with the ED or psychiatry..."

There are no transfer documents for Pt #1 to go to (Madison hospital). There is no documented instruction to Pt #1 and (family member) of risk of transport by private car to another facility. Per interview with C A on 4/26/13 at 11:20 AM, Pt #1 arrived at (Madison hospital)'s ED with no transfer paperwork, there was no MD to MD contact that reflects (Maidson hospital)'s accepted the Pt. Per C A, when the MR from this facility was received, there was documentation they knew Pt #1 was coming to (Madison hosptial) after discharge.

Per interview with MD G on 4/30/13 at 8:29 AM, MD G stated the (family member) was willing to leave with the Pt and requested to leave. MD G stated there was only communication between PD, family member and MD G once it was decided Pt #1 would go to (Madison hospital). MD G stated he discharged Pt #1 into the care of (family member), but knew he was going to (Madison hospital).

Per interview with SAC H on 4/30/13 at 10:55 AM, SAC H said only the names of three hospitals were provided to Pt #1's (family member). SAC H said there were no phone calls made to ensure an open bed was available, and no phone numbers given to (family member).