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.

MERCY HEALTH SYSTEM CORP 1000 MINERAL POINT AVE JANESVILLE, WI 53548 July 20, 2016
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on record review, observation, and interview the facility failed to ensure compliance with 42 CFR 489.24, in 3 of the 7 required areas (A2402-Posting of Signs; A2406-Medical Screening Exam; A2407-Stabilizing Treatment).

Findings include:

1) The facility failed to complete an appropriate medical screening exam (MSE) for 1 of 6 (#1) patients (pts.) who presented to the Emergency Department (ED) with suicidal ideations, failed to document the actual time of the MSE for 3 of 20 pts (#2, 3 and 4), and failed to continuously monitor 4 of 6 (#1, 3, 5 and 6) pts with suicidal ideations. The total patient sample was 20. (Reference A 2406)

2) The facility failed to ensure all patients presenting to the Emergency Department (ED) receive stabilizing treatment before being discharged for 1 of 20 ED records reviewed (Pt 1). (Reference A 2407)

3) The facility failed to ensure Emergency Medical Treatment and Labor Act (EMTALA) signs are posted in places likely to be noticed by all individuals entering the Emergency Department (ED), receiving treatment in the ED, and Labor and Delivery in 5 of 9 areas observed (ED Entrance, ED patient rooms, Main Hospital Entrance, Main Hospital Registration/Admitting, Labor and Delivery patient rooms). (Reference A 2402)
VIOLATION: POSTING OF SIGNS Tag No: A2402
Based on observation, record review, and interview, staff failed to ensure Emergency Medical Treatment and Labor Act (EMTALA) signs are posted in places likely to be noticed by all individuals entering the Emergency Department (ED), receiving treatment in the ED, and Labor and Delivery in 5 of 9 areas observed (ED Entrance, ED patient rooms, Main Hospital Entrance, Main Hospital Registration/Admitting, Labor and Delivery patient rooms). This could potentially impact all patients who seek treatment in the Emergency Department and Labor and Delivery.


Findings Include:

Review of Policy and Procedure titled, "EMTALA Screening, Treatment, & Transfers of Patients" last reviewed 5/25/2016 states, "The Hospital must post signs throughout the ED (entry, waiting room, registration area, and exam, treatment and triage rooms), as well as in the general Hospital entryways and registration areas, and the labor and delivery entry, waiting, exam and registration areas."


Observations on 7/19/2016:

Beginning at 9:25 AM during tour of the ED, Labor and Delivery, and Hospital Registration/Admitting area observed the following:

-No EMTALA sign posted in ED entrance
-No EMTALA signs posted in ED patient rooms
-No EMTALA signs posted in Main hospital entrance and main admitting and registration area
-No EMTALA signs posted in Labor and Delivery patient rooms

Per observation, EMTALA signs are posted across from ED room 4, across from ED room 1 and 2 facing the supply cabinet, next to the ambulance bay, and on wall near nurses station hidden behind a supply cart. These signs are not in areas easily accessible and visible to patients receiving treatment in the ED. Per observation of Labor and Delivery rooms 3220 and 3219 no EMTALA signs were posted.

Per interview with ED Director "C" at the time of the tour, "C" stated there are no signs posted in the ED rooms where patients receive an examination and treatment. "C" confirmed no signs are posted in any of the Labor and Delivery rooms, "C" stated patients presenting to the ED who are greater than 20 weeks pregnant and having issues related to pregnancy are sent directly to a Labor and Delivery patient room for examination and treatment. "C" confirmed there are no signs posted in the main Hospital entrance and main Hospital Registration/Admitting area.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on record review and interview, the facility failed to complete an appropriate medical screening exam (MSE) for 1 of 6 (#1) patients (pts.) who presented to the Emergency Department (ED) with suicidal ideations resulting in that patient's death by suicide after discharge from the ED, failed to document the actual time of the MSE for 3 of 20 pts (#2, 3, and 4), and failed to continuously monitor 4 of 6 ( #1, 3, 5 and 6) pt with suicidal ideations. On 8/18/16 at 12:35 pm these findings resulted in an Immediate Jeopardy. A total of 20 patients were included in the sample. The Immediate Jeopardy was cited at 42 CFR 489.23(a).

Findings include:

Review of Policy and Procedure titled, "EMTALA Screening, Treatment, & Transfer of Patients" last reviewed 5/25/2016 states the following:
"The triage nurse will triage and prioritize patients. (Triage alone does not constitute a medical screening exam). Based on their acuity and room availability, patients will be directed either to an examination room or to the ED triage room and then placed in a room as it becomes available... Regardless of the order of patients established by triage, all patients must be given an appropriate medical screening examination to determine if an emergency medical condition exists and treated to stabilize the condition or transferred, in accordance with this policy."

Review of Policy and Procedure titled, "Suicidal Patients; MHTC Emergency Department" last reviewed 1/15/13 states as follows:

-If Patient is felt to have imminent potential risk for suicide the patient should be placed in a room that can be directly observed by staff or Security at all times. Security will be notified and should report to the ED. If security is unavailable, direct observation of patient will be performed by staff.
-Documentation of patient observations will be performed every 15 minutes.
-This documentation will be sent to Medical Records for scanning and will become a part of the patient's medical record.
-Psychiatric Services should be consulted and assist with evaluation and disposition of the patient.

#1
Review of Patient (Pt) 1's medical record (MR) revealed Pt 1 arrived in the ED on 5/23/16 at 11:31 AM with chief complaint documented as "(Pt 1's) desire to end his life".

Per review of Pt 1's nursing notes and assessments, Suicide Risk Assessment completed on 5/23/16 at 11:49 AM and revealed a "Yes" answer to the question "Does the patient have a history of suicide attempt or ideation". "Actions taken to address Suicide Risk" is listed as "None beyond standard unit procedures; Clothing removed; Request Psychiatrist consult".

Further review of Pt 1's ED Provider Notes including History and Physical dated 5/23/16 at 11:52 am revealed, "Patient reports that (Pt 1) has a previous suicide attempt by overdosing on his medications. However patient reports today (Pt 1) is not overdosed on any medications or pills or drugs." ED provider notes further revealed, "Patient does not have a definitive plan in place at this time however he reports overdosing on a bunch of pills is a possible option...Patient reports that (Pt 1) would like to be admitted to the hospital before (Pt 1) does something that (Pt 1) regrets."

Review of Pt 1's ED Physicians Psychiatric assessment documented on 5/23/16 at 11:52 am revealed that Pt 1 "Exhibits a depressed mood", "Expresses suicidal ideations", and "Expresses suicidal plans". Per "ED Course" documentation at 11:52 am, "Patient will be placed under suicide precautions here in the emergency department.", "Patient is medically cleared for behavioral health evaluation."

Further review of Pt 1's ED course documented at 11:52 AM reveals at 11:40 AM Pt 1 walked out of the exam room in underwear, removed underwear, then proceeded to attempt to walk out of the ED naked. Pt 1 was intercepted by a couple of nurses and brought back to the exam rooom and covered up.

Review of Pt 1's MR revealed a Suicide risk assessment documented on 5/23/16 at 11:49 AM and a Safety/coping assessment documented at 11:56 AM. Further review of the same record revealed there was no documentation of Pt 1 being continuously monitored and observed while on suicide precautions between 11:52 AM and 1:50 PM (as per policy, "Suicidal Patients; MHTC Emergency Department").

Per Social Worker "D's" progress notes documented on 5/23/16 at 2:36 PM, "D" revealed the following, "SW (social worker) approached (Pt 1 ' s) room and observed the pt leaving (Pt 1 ' s) room unclothed holding a blanket. Pt was observed having trouble keeping (Pt 1 ' s) eyes open....(Pt 1) kept eyes shut and was mumbling incoherent statements that were inaudible." Per "D ' s" documentation, Pt 1 would not respond to "D's" questions. "D" then told staff to call Crisis and have them assess Pt 1 for involuntary treatment. "D" then left the ED to consult with the psychiatrist on call, when "D" came back to ED to follow up with Pt 1 ' s assessments, "D" observed Pt 1 had been discharged .

Interview with ED Physician "G" on 7/19/2016 beginning at 2:20 PM, revealed "G" stated when developing a plan of care for patients who present with suicidal ideations, "G" relies heavily on the evaluation and suggestions from the behavioral health team including the social worker and Psychiatry consult to determine best course of action. When asked had "G" spoken to the social worker, the Crisis team, or Pt 1 ' s case manager in regards to Pt 1 "G" responded "No". "G" felt that Pt 1 ' s case manager could better assist Pt 1 in the outpatient setting. "G" felt Pt 1 was stable enough to be discharged to follow-up with Pt 1's case manager immediately following discharge from ED.

Per interview with Social Worker "D" on 7/20/16 beginning at 12:35 PM, "D" revealed Registered Nurse "F" (assigned to Pt 1) and ED Physician "G" did not contact "D" to discuss discharge plan prior to discharging Pt 1 home. "D" stated normally when patients present to ED with suicidal ideation and are uncooperative and not answering questions, the interdisciplinary team normally gets Crisis team and Police Department involved to assess a patient for potential involuntary admission. The Crisis team consists of trained mental health professionals from the County Human Services Department who assess patients and work in conjunction with the police department to determine if patient's qualify for police holds and involuntary admissions.

Per interview with Director of ED "B" on 7/20/16 at 1:05 PM, "B" revealed the Crisis team did not come to ED to assess Pt 1 prior to being discharged home.

Review of Patient 1's ED record revealed Patient 1's MR lacked documentation that Pt 1 received a comprehensive MSE that included a psychiatric assessment by a Mental Health Professional to determine if Patient 1 was experiencing a Psychiatric Emergency Medical Condition.

Per mandatory death report #2805 submitted by Rock County Human Services Department to the Wisconsin Department of Quality Assurance/Behavioral Health Certification Section, Pt 1 commited suicide at approximately 10:30 PM on 5/23/16 by jumping off a bridge.

#2
Review of Patient 2's 6/27/16 "ED Events" log revealed the following timeline:

-4:12 PM: Arrived in ED, triage started, patient roomed in ED, assigned nurse
-4:17 PM: Triage completed
-4:25 PM: Labs ordered
-4:26 PM: Assigned Physician
-4:38 PM: Labs ordered
-5:52 PM: Patient discharged (Home, against medical advice)

Review of Patient 2's MR revealed no documentation of the actual time of Patient 2's MSE to determine if Patient 2 is experiencing an emergency medical condition. Patient 2's ED Event Log did not list the "First Provider Evaluation" time to indicate the actual time of the MSE.

#3
Review of Patient 3's 5/7/16 "ED Events" log shows the following timeline:

-5:26 PM: Patient arrived in ED
-5:29 PM: Assign physician
-5:29 PM: Provider first Contact
-5:32 PM: Triage Started, patient roomed
-5:34 PM: Assign nurse
-5:46 PM: labs ordered
-7:13 PM: Remove attending
-7:13 PM: Assign attending, Provider First Contact
-9:08 PM: Patient discharged (to Psychiatric Hospital)

Review of Patient 3's ED record revealed no documentation of the actual time of Patient 3's MSE to determine if Patient 3 is experiencing an Emergency Medical Condition. Patient 3's ED Event Log did not list the "First Provider Evaluation" time to indicate when the MSE was performed.

Per Pt 3's ED record, Pt 3 was placed on suicide precautions due to expressing suicidal thoughts and plan. Per Pt 3's ED nursing notes, Suicide Risk assessment was documented at 5:37 PM and Safety/coping assessment documented at 5:45 PM. Between 5:45 PM and time of discharge at 9:08 PM there was no documentation of Pt 3 being continuously monitored and observed while on suicide precautions (as per policy, "Suicidal Patients; MHTC Emergency Department").

#4
Review of Patient 4's 5/14/16 "ED Events" log shows the following timeline:

-5:39 PM: Patient arrived in ED
-5:40 PM: Patient roomed, triage started
-5:41 PM: Labs ordered
-5:43 PM: Assign physician; Provider First Patient Contact
-8:11 PM: Remove Attending
-8:17 PM: Assign Physician; Provider First Patient Contact
-10:55 PM: Patient discharged (Psychiatric Hospital)

Review of Patient 4's MR revealed no documentation of the actual time of Patient 4's MSE to determine if Patient 4 was experiencing an Emergency Medical Condition. Patient 4's ED Event Log did not list the "First Provider Evaluation" time to indicate the actual time of the MSE.

#5
Per Pt 5's MR, Pt 5 arrived in the ED on 1/31/16 at 12:52 AM with complaint of suicide attempt and was placed on suicide precautions. Per Pt 5's MR, Suicide Risk assessment documented on 1/31/16 at 1:00 AM and Safety/Coping assessment documented on 1/31/16 at 1:13 AM. Further review of Pt #5 s MR revealed there was no documentation Pt 5 was being continuously monitored and observed while on suicide precautions between 1:13 AM and time of discharge 3:12 AM on 1/31/16 (as per policy, "Suicidal Patients; MHTC Emergency Department").

#6
Per review of Pt 6's MR, Pt 6 arrived in ED on 5/22/16 at 5:16 PM with complaints of suicidal ideation's. Social Worker progress notes documented on 5/22/16 at 7:04 PM revealed, "(Pt 6) brought in by PD (police department) after walking into police station stating (Pt 6) was suicidal. Pt still having suicidal thoughts with plan to jump of a bridge..."

Review of Pt 6's ED "Flowsheet" dated 5/22/16 revealed no documentation of nursing staff performing a Suicide Risk Assessment. Further review of Pt #6s MR reveals there was no documentation of Pt 6 being continuously monitored and observed while on suicide precautions between 5:45 PM and time of discharge at 8:29 PM on 5/22/16 (as per policy, "Suicidal Patients; MHTC Emergency Department").

Per interview with Registered Nurse "E" on 7/19/2016 beginning at 1:05 PM, "E" revealed Security observes patients on suicide precautions, if security is unavailable then the Registered Nurse or ED Technician should be continuously monitoring and observing patients and document these observations at least every 15 minutes in the patients MR.

Per interview with Director of ED "C" on 7/19/2016 beginning at 1:05 PM, "C" revealed Security should document these observations on the "Patient Observation Monitoring Flowsheet" as per policy, and these flowsheet should be scanned into the patients MR.

Per interview with ED Director "C" on 7/20/16 beginning at 9:45 am, "C" revealed the date and time on the ED Provider Note (History and Physical) indicates the time the assessment was documented, not necessarily the actual time of the assessment. "C" stated the MSE is represented by "First Provider Evaluation" time documented on the ED Event log. "C" stated physicians should be documenting time of "First Provider Evaluation" which indicates the actual time of the MSE. "C" stated "First Provider Contact" time on the ED Event log, does not indicate that a MSE has been done.

Per interview with Director of Quality "H" on 7/20/2016 beginning at 1:05 PM, "H" revealed during Department of Emergency Medicine Meeting on 4/27/2016, medical staff discussed requiring ED physicians to document First Provider Evaluations (MSE) in real time. Per "H" this new process was effective as of May 2016 and physicians were informed of new process via email. "H" stated the plan to monitor for compliance was to review random samples of 120 ED records quarterly; approximately 40 ED records monthly. As of 7/20/2016 "H" was unable to provide an acceptable plan addressing compliance with new documentation process including evidence of MR audits being performed.
VIOLATION: STABILIZING TREATMENT Tag No: A2407
Based on record review and interview the facility failed to ensure all patients presenting to the Emergency Department (ED) receive stabilizing treatment before being discharged in 1 of 6 in a total sample of 20 ED records reviewed (Pt 1). Pt 1 committed suicide on 5/23/16 at approximately 10:30 PM, this could potentially impact all patients seeking emergency mental health treatment in the ED.

Findings Include:

Review of Policy and Procedure titled, "EMTALA Screening, Treatment, & Transfer of Patients" last reviewed 5/25/2016 states, "...(Hospital) recognizes the right of the patient to receive, within the capabilities of the Hospital's Staff and facilities...Necessary stabilizing treatment for an emergency medical condition (including treatment for psychiatric and substance abuse patients). "To stabilize mean with respect to an emergency medical condition, that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during transfer of the patient. A person is also stable when it is determined within reasonable clinical confidence that the patient has reached the point where his or her continued care could be reasonably performed as an out patient...provided the patient is given a plan for appropriate follow-up care with discharge instructions. Psychiatric patients are considered stable whey they are protected and prevented from injuring or harming themselves or others.

Review of Policy and Procedure titled, "Suicidal Patients; MHTC Emergency Department" last reviewed 1/15/13 states,

-If Patient is felt to have imminent potential risk for suicide the patient should be placed in a room that can be directly observed by staff or Security at all times. Security will be notified and should report to the ED. If security is unavailable, direct observation of patient will be performed by staff.
-Documentation of patient observations will be performed every 15 minutes.
-This documentation will be sent to Medical Records for scanning and will become a part of the patient's medical record.
-Psychiatric Services should be consulted and assist with evaluation and disposition of the patient.

Review of Patient 1's medical record (MR) shows Patient (Pt) 1 arrived in the ED on 5/23/16 at 11:31 am with chief complaint documented as "(Pt 1's) desire to end his life"; Pt 1 departed from the ED at 1:50 PM, prior to receiving discharge instructions.

ED Provider Notes including History and Physical dated 5/23/16 at 11:52 am revealed, "Patient reports that (Pt 1) has a previous suicide attempt by overdosing on his medications. However patient reports today (Pt 1) is not overdosed on any medications or pills or drugs." ED provider notes further state, "Patient does not have a definitive plan in place at this time however he reports overdosing on a bunch of pills is a possible option...Patient reports that (Pt 1) would like to be admitted to the hospital before (Pt 1) does something that (Pt 1) regrets."

Per ED Physicians Psychiatric assessment documented on 5/23/16 at 11:52 am Pt 1 "Exhibits a depressed mood", "Expresses suicidal ideations", and "Expresses suicidal plans".

Per "ED Course" documentation on 5/23/16 at 11:52 am, "Patient #1 will be placed under suicide precautions here in the emergency department.", "Patient (#1) is medically cleared for behavioral health evaluation." Further review of the same document revealed that on 5/23/16 11:40 AM Pt 1 walked out of the exam room in underwear, removed underwear, then proceeded to attempt to walk out of the ED naked. Pt 1 was intercepted by a couple of nurses and brought back to the exam romm and covered up.


ED physician note documented on 5/23/16 at 2:41 PM revealed Pt #1, "Prior to final disposition patient eloped from the emergency department. The plan is for the patient to follow-up with his caseworker immediately after discharge from the emergency department."

Review of Pt 1's MR dated 5/23/16 revealed no documentation providing evidence of an ED Physician re-assessment of Pt 1's Suicidal Ideations to determine if Pt 1's symptoms had resolved and if Pt 1 was stable prior to discharge home.

Per interview with ED Physician "G" on 7/19/2016 beginning at 2:20 PM, "G" revealed when developing a plan of care for patients who present with suicidal ideations, "G" relies heavily on the evaluation and suggestions from the behavioral health team including the social worker and Psychiatry consult to determine best course of action. When asked had Pt 1 informed "G" that Pt 1 was no longer having suicidal ideations, "G" responded "No". When asked had the Registered Nurse "F" (Pt 1's assigned nurse) informed "G" that Pt 1 was no longer having suicidal ideations, "G" responded "No", When asked had "G" spoken to the social worker, the Crisis team, or Pt 1's case manager in regards to Pt 1 no longer having suicidal ideations, "G" responded "No". "G" stated Pt 1 would not respond to social workers questions in the ED; however, Pt 1 agreed to speak to case worker on the phone in the ED so "G" felt that Pt 1's case manager could better assist Pt 1 in the outpatient setting. "G" felt Pt 1 was stable enough to be discharged to follow-up with Pt 1's case manager immediately following discharge from ED. "G" was unable to provide evidence of Pt 1's symptoms of suicidal ideations being resolved.

Per Social Worker "D's" progress notes documented on 5/23/16 at 2:36 PM, "D" revealed the following, "SW (social worker) approached (Pt 1's) room and observed the pt leaving (Pt 1's) room unclothed holding a blanket. Security redirected the (Pt 1) to his room and SW entered the room and introduced (D). Pt was observed having trouble keeping (Pt 1's) eyes open....(Pt 1) kept eyes shut and was mumbling incoherent statements that were inaudible." Per "D's" documentation, Pt 1 would not respond to "D's" questions so "D" asked another nurse to come in and attempt to ask Pt 1 questions; Pt 1 still would not respond. "D" then told staff to call Crisis and have them assess Pt 1 for involuntary treatment. "D" then left the ED to consult with the psychiatrist on call, when "D" came back to ED to follow up with Pt 1's assessments, "D" observed Pt 1 had been discharged .

Per interview with Social Worker "D" on 7/20/16 beginning at 12:35 PM, "D" revealed Registered Nurse "F" (assigned to Pt 1) and ED Physician "G" did not contact "D" to discuss discharge plan prior to discharging Pt 1 home. "D" stated normally when patients present to ED with suicidal ideation's and are uncooperative and not answering questions, the interdisciplinary team normally gets Crisis team and Police Department involved to assess patient for potential involuntary admission. The Crisis team consists of trained mental health professionals from the County Human Services Department who assess patients and work in conjunction with the police department to determine if patient's qualify for police holds and involuntary admissions.


Per interview with Director of ED "B" on 7/20/16 at 1:05 PM, "B" revealed the Crisis team did not come to ED to assess Pt 1 prior to being discharged home.

Per review of Pt 1's nursing notes and assessments, Suicide Risk Assessment completed on 5/23/16 at 11:49 AM and revealed "Yes" to the question "Does the patient have a history of suicide attempt or ideation". "Actions taken to address Suicide Risk" is listed as "None beyond standard unit procedures; Clothing removed; Request Psychiatrist consult".

Pt 1's "Safety and Coping" assessment documented on 5/23/16 at 11:56 AM states, "Verbalized Emotional State" is listed as "Suicidal Thoughts". Safety actions taken are listed as "belongings removed; Pt placed in gown; curtain open with door closed".

Pt 1's Registered Nurse documentation on 5/23/16 at 1:49 PM revealed "Pt leaves with all belongings, clothing on. Does not take D/C (discharge) instructions with (Pt 1)."

Review of Pt 1's 5/23/16 ED MR revealed no evidence of documentation showing patient observation being performed every 15 minutes ensuring patient safety between 11:31 AM and 1:50 PM (as per policy, "Suicidal Patients; MHTC Emergency Department"). Pt 1's 5/23/16 ED record revealed no documentation of a re-evaluation of the suicide risk assessment to determine if Pt 1's symptoms had resolved and if Pt 1 was stable for discharge home.

Per interview with Registered Nurse "F" on 7/19/2016 beginning at 2:20 PM, "F" revealed patients in suicide precautions should be directly observed and staff should be documenting checks every 5 to 15 minutes.

Review of Pt 1's MR revealed no documentation of these safety checks for Pt 1.

Further interview with Registered Nurse F on 7/19/2016 beginning at 2:20 PM, "F" revealed Pt 1 presented with suicidal ideations and was requesting to be admitted . Pt 1 would not respond to "F's" question asking if Pt 1 was currently suicidal, so "F" called Crisis team and was put in touch with Pt 1's case worker who Pt 1 agreed to talk to in the room. Pt 1 then spoke with Pt 1's case worker who told "F" that Pt 1 is ok to discharge from hospital to come see case worker. "F" informed ED Physician "G", and "G" agreed with plan and "G" wrote the discharge orders. "F" stated Pt 1 would not answer any questions prior to discharge so "F" was unable to confirm if Pt 1 was still experiencing symptoms of suicidal ideations.

During the interview on 7/19/2016 beginning at 2:20 PM, "F" confirmed "F" did not discuss the plan to discharge Pt #1s from hospital with social worker.

Per mandatory death report #2805 submitted by Rock County Human Services Department to the Wisconsin Department of Quality Assurance/Behavioral Health Certification Section, Pt 1 commited suicide at approximately 10:30 PM on 5/23/16 by jumping off a bridge.