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MAYO CLINIC HEALTH SYSTEM IN EAU CLAIRE 1221 WHIPPLE ST EAU CLAIRE, WI 54703 Oct. 3, 2013
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on interviews and record reviews, the hospital, for 3 of 29 registered Emergency Department (ED) patients and 1 unregistered ED patient, failed to ensure compliance with 489.24, specific to tag A-2406, appropriate medical screening examination.

Findings include:

For 3 of 29 registered ED patients reviewed (Patients #26, #7, #5) and 1 unregistered ED patient (Patient #10), the hospital failed to provide an appropriate medical screening examination (MSE) in order to determine if an emergency medical condition (EMC) existed.

The cumulative affect of this deficiency potentially affect all ED patients from 08/23/13 (Patient #26) through the end of the survey on 10/03/13. The ED sees an average of 2,526 patients per month, as determined by the number of emergency cases seen per month for the preceeding 6 months.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interviews, record reviews, review of policies/procedures, review of a police report and review of another hospital's Emergency Department (ED) record, the hospital failed, for 3 of 29 registered ED patients reviewed (Patients #26, #7, #5) and 1 unregistered ED patient (Patient #10), to provide an appropriate medical screening examination (MSE) in order to determine if an emergency medical condition (EMC) existed.

Findings include:

Observation during an ED tour on 10/01/13 from 11:55 a.m. to 12:50 p.m. identified the hospital had 1 triage room, 23 emergency room s (including 1 monitored with a camera, used for behavioral health patients) and 6 observation rooms.

Per interview with Medical Director of the ED (MD/ED) J on 10/02/13 at 11:25 a.m., it was stated the hospital's ED was normally staffed with 2 physicians and 1 Nurse Practitioner or Physician Assistant.

Per interview with SED A on 10/03/13 at 2:45 p.m., it was stated that anyone who presents with a psychiatric complaint is automatically given a triage of 2-Emergent.

Per review on 10/02/13 of the hospital policy/procedure, Number 419, "Emergency Services," last revised 10/11, the following was included, "...Consistent with the requirements of the Emergency Medical Treatment and Active Labor Act (EMTALA). All patients who come to the Emergency Department requesting care will receive a medical screening examination and the necessary treatment to stabilize an emergency medical condition without unnecessary delay and without regard to the patient's ability to pay..."

Per review on 10/02/13 of the hospital policy/procedure, Number 100, "TRIAGE IN THE EMERGENCY DEPARTMENT," last revised 01/11, the following was included, "It is the policy...to triage patients upon arrival and provide medical screening exams and stabilizing treatment of emergency medical conditions. The Emergency Severity Index (ESI) triage system will be used to determine acuity and order of examination...A triage assessment will be conducted by a Registered Nurse (RN) to determine patient acuity...The ED provider will perform a medical screening exam for all patients who present for emergency care to the emergency department...Once patients have been triaged, the triage nurse will place patients in an appropriate treatment room and inform the primary nurse of placement...Assign patient acuity using the five-tier Emergency Severity Index (ESI)...ESI levels 1 and 2 patients will be triaged to the appropriate patient care area for immediate and continued reassessment...ESI level 3 patients who are required to wait in the waiting room will be reassessed at least every 20 minutes until evaluated by a provider...Behavioral Health Emergencies...Assess for safety and suicidal ideations on the ED Behavioral Health Screen/Safety Assessment as soon as possible...Any patient brought to the department on an emergency detention (Chapter 51) hold or with a positive response on the ED Behavioral Health Screen/Safety Assessment will be assigned ESI Level 2 and taken immediately to a room and security staff notified for continuous observation..."

Per review on 10/03/13 of the hospital's ESI 5-LEVEL SYSTEM, undated, provided by RN, Supervisor of the ED (SED) A, it was identified, "5 levels-acuity is determined by the stability of vital functions and potential for life, limb or organ threat...1=Resuscitation...2=Emergent...3=Urgent...4=Non-Urgent...5=Less Urgent..."

Per review on 10/01/13 of the hospital policy/procedure, "Bedside Registration Procedure," last revised 11/08/12, the following was included, "...Bedside registration information and signatures for treatment and billing may be gathered from the patient and/or accompanying family, based on the condition of the patient..."

Per review on 10/02/13 of the hospital policy/procedure, "Discharge Against Medical Advice (AMA) Patients Refusal of Care," last revised 07/05/12, the following was included, "...patients, who refuse care and request discharge against the physician's advice, will be considered discharged against medical advice (AMA)...If the patient is in the hospital building or grounds, the physician or nurse will...Determine why the patient wishes to leave or is refusing treatment...Explain...risks or complications that may result from the patient's refusal pf care...Attempt to persuade the patient to comply with recommendations...Alternative treatment and follow up should be discussed, as appropriate to the patient's condition...If the patient is, intoxicated...The patient may be discharged in the care of responsible family members or, the patient may be temporarily prevented from leaving until the patient demonstrates he/she is no longer impaired...Documentation of the AMA process is recorded in the patient's record...If the patient refuses to sign the form, it should be completed anyway and read to the patient...then be placed in the patient's medical record...The patient should be encouraged to return...if their condition worsens or they change their mind..."

1) Per review of Patient #26's ED record on 10/02/13 at 4:40 p.m., the following was identified related to a presentation to the ED on 08/23/13.
-At 11:18 p.m., the patient presented to the ED, at the front desk accompanied by police. Per registration notes obtained through Supervisor of Patient Services (SPS) B, the patient was registered with signs/symptoms stated as, "PSYCH" at 11:18 p.m. and

-at 11:41 p.m., was discharged , having left without being seen.

Per a note written by RN, Behavioral Health Liaison (BHL) C on 08/23/13 at 11:50 p.m., "Patient was a potential admit and registered, was accessing chart to gain information prior to seeing patient but was transferred by law enforcement before being assessed to (another Eau Claire hospital)l who had beds available for admission." RN, Supervisor of the ED (SED) A confirmed there was no triage/assessment thus no ESI assigned and no MSE completed on the patient.

The police report related to this incident was reviewed on 10/07/13 which included the following, "...While in contact with (Patient #26), she repeated several times that she didn't wish to go to the hospital, nor would she go willingly. Due to these comments, she was placed in handcuffs to ensure her safety along with others...After arriving at Mayo, (Patient #26) was ushered into the emergency room check in area. Upon making contact with the receptionist, she was advised that (Patient #26) was going to be admitted as a Chapter 51. During the check in process, a nurse advised that Mayo no longer had room available for (Patient #26), and she would need to go to (another Eau Claire Hospital). While in contact with (the other Eau Claire Hospital) (Patient #26) was checked in by the receptionist. Contact was made with a nurse after receiving information that (the other Eau Claire Hospital) could receive (Patient #26). The ER (emergency room ) nurse was informed that (Patient #26) was check in, but would be transferred over to (another Eau Claire hospital). She replied that (the other Eau Claire hospital) was aware of the transfer and that (Patient #26) was free to be transferred..."

Per interview with Director of Inpatient Behavioral Health (DBH) D on 10/03/13 at 11:55 a.m., it was confirmed there was only 1 male bed available on the inpatient Behavioral Health unit on the evening of 08/23/13.

Per interview with RN, Chief Executive Officer/Vice President Administration (CNO/VP) E on 10/02/13 at 5:20 p.m., this incident had been reviewed by the hospital's legal department who determined the police dispatch called (the police officer with Patient #26) and advised that (the other Eau Claire hospital) had available beds while Mayo Hospital did not. There was no further explanation as to why Patient #26 did not receive an MSE after presenting to the ED at Mayo Hospital per hospital policy/procedure.

2) Per review of Patient #7's ED record on 10/02/13 at 10:57 a.m., the following was identified related to a presentation to the ED on 09/14/13.
-At 4:47 p.m., the patient presented to the ED, at the front desk and per registration notes obtained through SPS B, the patient was registered with signs/symptoms stated as, "BEHAVIORAL HEALTH" at 4:47 p.m. There was no evidence that a physician or other appropriate ED provider ever "took charge" of the patient's care.

-At 4:51 p.m., the triage assessment was completed by RN K and included the following, "states he needs his clozaril dose increased, states he feels he is having trouble with thought processes, anxious...Alone...Private vehicle..." The nurse also completed a Behavioral Health Screen/Safety Assessment that identified the patient was depressed. SED A confirmed the patient was assigned an ESI (acuity level) of 2 (Emergent). Per interview with SED A during the record review, SED A stated it could be assumed that Patient #7 was triaged in the triage room and then asked to wait in the waiting area, for an ED room to become available.

-At 5:34 p.m., a communication note entered by RN K stated, "pt (patient) left waiting room, returned, stated he was fine and wanted to leave, security and staff told pt room was ready, pt left, ambulatory, no distress."

-At 5:36 p.m., a communication note entered by RN K stated, "pt told we were readying room for him, while readying room pt left waiting area."

-At 5:37 p.m., a communication note entered by RN K stated, "pt returned to waiting area, states he doesn't want to be seen, advised he should stay and needs eval (evaluation) by MD (physician), pt left."

-At 5:39 p.m., Patient #7 was discharged , "Left Without Being Seen" and discharge instructions were printed for Patient #7 (they are unsigned as the patient left without being seen by the physician).

An "ED Arrival By Hour" form was reviewed on 10/02/13 which identified the following for the number of patients who arrived at the ED (registered) on 09/14/13 prior to and during Patient #7's visit to the ED: from 3:00 p.m. to 4:00 p.m. = 8; from 4:00 p.m. to 5:00 p.m. = 2; from 5:00 p.m. to 6:00 p.m. = 7.

Patient #7 did not receive continued reassessment per the hospital policy/procedure, "ESI levels 1 and 2 patients will be triaged to the appropriate patient care area for immediate and continued reassessment...ESI level 3 patients who are required to wait in the waiting room will be reassessed at least every 20 minutes until evaluated by a provider..." The triage assessment was completed (initiated) at 4:51 p.m. There is no documentation to determine when the assessment was completed, how long Patient #7 waited in the waiting room, nor if he was reassessed if he waited over 20 minutes for an MSE (Patient #7 had an ESI level of 2 thus he should had even more frequent reassessment per hospital policy/procedure).

Patient #7 did not receive an MSE after presenting to the ED at Mayo Hospital per hospital policy/procedure and there was no AMA form completed for the patient as per hospital policy/procedure.

Patient #7 returned to the ED on 09/16/13 at 3:17 p.m. with the following ED report per Physician L: "...concern about paranoid schizophrenia...does have a history of this and has been noncompliant...today took his clothes off and ran through the neighborhood...does work in a group home...appears to be a threat and needs inpatient management and help...the patient did agree to stay although he has been changing his mind throughout the afternoon...The goal would be to get a Chapter 51 detention..." The patient was subsequently admitted , voluntarily, as an inpatient on 09/16/13.

3) Per review of Patient #5's ED record on 10/02/13 at 10:17 a.m., the following was identified related to a presentation to the ED on 09/19/13.
-At 12:23 p.m., the patient presented to the ED, at the front desk and per registration notes obtained through SPS B, the patient was registered with signs/symptoms stated as, "DEPRESSION" at 12:23 p.m.

-At 12:25 p.m., the ED provider, Physician F was notified that Patient #5 had presented to the ED and "took charge" of the patient's care (as explained by SED A in interview on 10/02/13 during the 10:17 a.m. review of Patient #5).

-At 12:30 p.m., the triage assessment was completed by RN G and included the following, "been depressed for months. here today crying and feeling like he can't "take it anymore." says he recently lost his home and has no support. binge drinks daily. drank today...Alone...Mode of Arrval ED: Private vehicle..." The nurse also completed a Behavioral Health Screen/Safety Assessment that identified the patient was depressed, had thoughts of harming himself, had (previous) suicide attempts and had the current self destructive behavior of binge drinking. SED A confirmed the patient was assigned an ESI (acuity level) of 2 (Emergent).

Per interview with SED A on 10/03/13 at 2:45 p.m., it was stated that anyone who presents with a psychiatric complaint is automatically given a triage of 2-Emergent.

-At 12:55 p.m., the primary RN assigned to the patient, RN H, completed a full systems assessment which included a Behavioral Health Screen/Safety Assessment that identified the patient was depressed, but had no thoughts of harming himself, had no (previous) suicide attempts and did not have any current self destructive behaviors (a contradiction to the above triage assessment).

-At 1:15 p.m., a security log (presented by hospital administration on 10/03/13 and reviewed at that time) identified, "intoxicated male (Patient #5) left ED AMA (against medical advice). Pt. (patient) had driven himself from Bloomer (to the ED). Unable to locate."

-At 1:41 p.m., Patient #5 was discharged , "Left Without Being Seen."

-At 2:51 p.m., discharge instructions were printed for Patient #5 (they are unsigned as the patient had previously left without being seen by the physician).

-At 3:04 p.m., Social Worker (SW) I documented, "Met with pt. in ED to discuss options for addressing his persistent alcohol abuse and attendant mood symptoms. Pt. was pacing, emotional labile, and intoxicated. SW left the room to consult with MD regarding anxiety symptoms, and pt. eloped from the dept (department). Pt. did admit to driving to ED from Bloomer after consuming alcohol, so security was notified. SW did contact dispatch, who stated that he would send ECPD (the city police), but without a vehicle description, law enforcement has a limited ability to respond. Unfortunately, since the pt. left without notice, no one witnessed him leaving the premises in his vehicle. Security was not able to visualize the pt. getting into his vehicle. SW did contact Bloomer PD (police department) dispatch to notify that pt. is intoxicated and driving his vehicle." It was unclear when SW I met with the patient and when SW I consulted with the physician.

-At 4:46 p.m., Physician F documented, "...(Patient #5)...presenting to the ED with anxiety and depression. He reports this has been an ongoing and worsening issue for the past few months...just can't take it anymore...binge drinking daily...history of past suicide attempts, and has thoughts of harming himself...would like something today for anxiety. He has no other medical complaints. The patient did leave the facility by his own decision before I was able to assess him...I had ordered labs (Comprehensive Metabolic Panel, Complete Blood Count, Urine Drugs of Abuse, Ethanol Level) fluid (unclear what was ordered) and medication (unclear what was ordered) for this patient. When I went to evaluate the patient he was not present Nursing reports that the patient was intoxicated and driving and so police were notified that he left the ED. At no point that I evaluate this patient myself unfortunately...I have reviewed the chart and agree that the record accurately reflects my personal performance of the history, physical exam, medical decision making, and emergency department course for this patient."

An "ED Arrival By Hour" form was reviewed on 10/02/13 which identified the following for the number of patients who arrived at the ED (registered) on 09/19/13 prior to and during Patient #5's visit to the ED: from 10:00 a.m. to 11:00 a.m. = 5; from 11:00 a.m. to 12:00 p.m. = 3; from 12:00 p.m. to 1:00 p.m. = 3; from 1:00 p.m. to 2:00 p.m. = 8.

The record did not identify whether Patient #5 occupied a regular ED room or the ED room monitored with a camera, used for behavioral health patients. The physician ordered lab, fluids and medication for Patient #5 without performing an MSE. Patient #5 did not receive an MSE after presenting to the ED at Mayo Hospital per hospital policy/procedure.


4) Per interview with SED A, CNO/VP E and Director of ED (DED) M on 10/01/13 at 3:35 p.m., this hospital had no record of Patient #10 being registered at the ED on 09/04/13 or 09/05/13.

However, on 09/05/13, an ED nursing assessment from another acute care hospital in Eau Claire included the following, "PT (Patient) states he went to (another acute care Eau Claire hospital) prior to coming here to get some help told by a info person (the other Eau Claire hospital) couldn't help him and that they would help him call a cab to bring him to the ER (of the Eau Claire hospital he subsequently presented) last noc (night) pt was in a car accident...checked out by EMS (emergency medical services) and was taken home by police..states he didn't sleep well lst noc took Alprazolam..today has felt quesy (queasy) and chilled..."

There was no evidence available, per interviews or documentation, to explain why Patient #10 did not receive an MSE after presenting to the ED at Mayo hospital on [DATE], per hospital policy/procedure.