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ASPIRUS RIVERVIEW HOSPITAL & CLINICS INC 410 DEWEY ST WISCONSIN RAPIDS, WI 54495 Oct. 27, 2016
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on record review and interview the facility failed to ensure compliance with EMTALA regulations in provision of medical screening examination for 1 of 21 patients (Patient #1). Failure to provide medical screening examination has the potential to affect all patients presenting in an emergency.

Findings include:

The facility failed to perform a medical screening examination for 1 of 21 patients reviewed. See A2406.

The facility failed to explain risks of leaving against medical advice for 1 of 4 patients reviewed. See A2407.

The facility failed to document the risks and benefits of transfer for 4 of 5 patients reviewed. See A2409.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on record review and interview, facility staff failed to perform a medical screening exam for 1 of 21 patients presenting to the Emergency Department (Patient #1).

Findings include:

Facility policy "Physician and Mid-Level Coverage in the Emergency Department" No. 04 dated 9/27/2016 states in part: "All patients coming to the ED are routinely seen by the MD provider. In addition, these patients and all non-regularly scheduled patients will receive a medical screening examination unless a Refusal of Medical Assessment and Treatment form is signed. A Medical Screening Exam (MSE) will include chief complaint, vital signs, general appearance, mental status, and a symptom-specific assessment."

The facility's EMTALA education states: "Triggers for EMTALA: ...When an individual requests, or has a request made on his or her behalf for medical care for an emergency medical condition on hospital property, the medical screening examination and necessary stabilization will begin in accordance with the emergency department's protocols."

Review of the pre-hospital care report from the EMS service, dated 10/5/2016, describes emergency services were dispatched to Patient #1's nursing home after the patient was found not breathing and without a pulse. The EMS report documents resuscitative efforts began at 2:14 PM. The patient's circulation returned and the ambulance departed with the patient at 2:34 PM. The narrative note states: "Patient was transported to Riverview and a report was given prior to arrival, along with accepting room. Once Med 1 pulled into the garage at Riverview, a HUC informed the EMS crew that the Patient #1 was not going to be accepted here due to the lack of a cardiologist and that Med 1 was to drive to St. Joe's Hospital in Marshfield."

During an interview on 10/26/2016 at 12:05 PM, ED MD E gave the following account of the events that occurred on 10/5/2016: "we got an ambulance call, [Patient #1] coded in the field and had spontaneous return of circulation...we had a similar situation a few days before, we stabilized the patient and sent them to a higher level of care, stopping at us delays treatment." ED MD E stated the facility does not perform cardiac interventions and patients requiring those services have to be transferred. ED MD E stated that it was decided to call EMS and have them transport Patient #1 directly to another facility. ED MD E was then called out of the ED for an inpatient code. ED MD E stated "I did not know [Patient #1] was here or we would not have turned [Patient #1] away...once [the patient] is on our grounds they are our patient, I would have confirmed stability and transferred."

When asked about prior EMTALA training and whether or not the staff recognized sending Patient #1 away as a potential EMTALA violation, ED MD E stated E received "no EMTALA education through the hospital or [contracted entity]." ED MD E went on to state, "I know from doing this a long time, 30 years, that once the patient is here they are our patient."

During an interview on 10/26/2016 at 12:30 PM, ED PA (Physician Assistant) F stated after the call came "someone commented 'does the [Patient #1] need to come here or can they be diverted?'" ED PA F stated ED MD E confirmed [Patient #1 could be diverted] and then ED MD E "got called out for a code." When the ambulance arrived, "I went out to tell them to go to Marshfield...I told them '[ED MD E] wanted you to divert to Marshfield.'" ED PA F stated F talked to the 2 medics in the back of the ambulance and saw them bagging Patient #1. ED PA F stated "I did not know what had been communicated between [ED MD E], the ambulance and the hospital."

When asked about prior EMTALA training and whether or not the staff recognized sending Patient #1 away as a potential EMTALA violation, ED PA F stated the hospital EMTALA training was "very minimal" consisting of "a few papers to read." ED PA F stated "in retrospect, yes, I should have [examined the patient]."

During an interview on 10/26/2016 at 1:15 PM, Paramedic G stated "we were in the trauma room getting ready to receive [Patient #1] and someone said 'run down and tell the ambulance to go to Marshfield.'" Paramedic G stated G was going to call on the radio but the ambulance had already arrived at the facility, G reports telling the medics "the doctor wants you to go to Marshfield because you said [Patient #1] is stable." Paramedic G stated G then went inside the ED to get ED PA F and ED Director H.

When asked about prior EMTALA training and whether or not the staff recognized sending Patient #1 away as a potential EMTALA violation, Paramedic G stated "I didn't think it was a violation because [Patient #1] was not physically in our department." When shown the EMTALA education provided to all ED staff in September 2015, Paramedic G stated "I'm not familiar with the slides, but I'm sure I did it [the training]." G stated staff had been given additional training on 10/25/2016 and "I know if a patient is within 250 yards they are required to have an MSE [medical screening exam]."

During an interview on 10/26/2016 at 10:45 AM, Chief Medical Officer D stated Patient #1 should have received a medical screening exam and been transferred out "if things would have went like they were supposed to."
VIOLATION: STABILIZING TREATMENT Tag No: A2407
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, facility staff failed to provide risks and benefits associated with treatment for 1 of 4 patients (Patient #8) leaving the Emergency department against medical advice (AMA).

Findings include:

Facility policy "Safety of Patient Who Leave Against Medical Advice (AMA) and Patient Elopement" No. 53 dated 7/13/2016 states: "Any patient may refuse treatment to the extent permitted by law and shall be informed of the medical consequences of the refusal...Risks of leaving will be fully explained by the attending physician."

Per medical record review performed on 10/26/2016 at 3:00 PM, Patient #8 (MDS) dated [DATE] at 8:34 AM with a chief complaint of abdominal pain. Orders for lab work were complete and ultrasound revealed bilateral ovarian cysts. Patient #8 was provided a prescription for pain medication with instruction to follow up with Patient #8's primary care provider. The ED log lists Patient #8's discharge disposition as "AMA" at 12:02 PM. Patient #8's medical record contains a signed AMA form dated 9/24/2016 at 12:02 PM. There is no documentation in the patient's medical record as to why the patient left AMA or what treatment/exams the patient refused. There is no evidence that risks of leaving AMA were explained to the patient.

The above finding was confirmed at the time of the review with Chief Medical Officer D. D stated "it isn't clear" what medical advice was provided to the patient, what the risks were or that they were explained to the patient.
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the facility staff failed to document detailed risks and benefits of transfer from the Emergency Department (ED) to another facility for 4 of 5 transferred patients reviewed (Patient #2, Patient #3, Patient #5, Patient #6).

Findings include:

Facility policy "Interfacility Transfers" No. 20 dated 8/26/2016 states: "All transfers to outside facilities: ...C. The transferring physician completes the Physician Assessment and Certification for Transfer Form stating that, based upon the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual...from being transferred. This certification contains a summary of the risks and benefits."

Patient #2 (MDS) dated [DATE] at 9:14 AM with shortness of breath. At 11:58 AM, Patient #2 was transferred to another facility. Patient #2's transfer records do not include a summary of the risks and benefits of the transfer to the patient.

Patient #3 (MDS) dated [DATE] at 5:36 AM with flank pain. At 11:06 AM, Patient #3 was transferred to another facility. Patient #3's transfer records do not include a summary of the risks and benefits of the transfer to the patient.

Patient #5 (MDS) dated [DATE] at 1:26 AM with chest pain. At 9:30 AM, Patient #5 was transferred to another facility. Patient #5's transfer records do not include a summary of the risks and benefits of the transfer to the patient.

Patient #6 (MDS) dated [DATE] at 9:06 AM with foot pain. At 11:46 AM, Patient #6 was transferred to another facility. Patient #6's transfer records do not include a summary of the risks and benefits of the transfer to the patient.

The above findings were confirmed by interview at the time of the review on 10/26/2016 at 1:35 PM with Chief Medical Officer D. Chief Medical Officer D stated the forms include standard risks and benefits listed and the provider is expected to mark the risks and benefits that apply to the patient, or write them in.