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AURORA MEDICAL CTR KENOSHA 10400 75TH ST KENOSHA, WI 53142 Feb. 8, 2012
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on hospital record review, patient interview and Hospital A staff interviews, review of Hospital A's EMTALA policies and procedures, Hospital A failed to ensure that 1 of 21 sampled patients (Patient #1), who came into the Emergency Department requesting medical treatment, had an appropriate medical screening exam to rule out emergency medical conditions.

Findings include:

The 2/6/12/review of Hospital A's "Policy #179, effective 5/08, revised 12/11, states under "II. Policy Statement" that:
"Medical Center staff will provide an appropriate medical screening examination for all individuals who may have an emergency medical condition or are in labor and who present at a Medical Center location served by the Medical Center staff. In addition, if Medical center staff conclude that a patient has an emergency medical condition or is in labor, such patients will receive necessary stabilizing treatment within the capability and capacity of the Medical Center and Medical Center staff...".

Interview with Patient #1 by telephone on 2/6/12 at approximately 4:30 p.m. reflects that Patient #1 came up to the Emergency Department registration desk of Hospital A on 1/21/12 between 11 p.m. and 12 midnight and told the receptionist at the desk she "needed to see a doctor" because she "was not sure she was feeling her baby move". Patient #1 stated that the receptionist asked some questions, and then she spoke with a nurse who telephoned the OB (obstetrical) unit nurse. Patient #1 stated that she spoke directly by telephone with a OB nurse, who stated "since she was seen by a doctor a few days ago, and that because she was 5 months pregnant that she would not feel (fetal) movement at 5 months (21 weeks)''. Patient #1 stated that she "said OK" and hung up the phone. Patient #1 stated that she was upset, and told the nurse on the phone and the nurse and receptionist at the desk that she "just wanted them to tell me if they hear a heartbeat". Patient #1 stated that the nurse at the registration desk showed concern for her and stated "just go to St. Catherine's". Patient #1 stated that she went to Hospital B for treatment. Hospital A did not perform a medical screening exam.

At exit interview on 2/8/12 at approximately 3:30 p.m., it was verified by AO (Administrative Officer) G, RMC's B and C that Hospital A had no medical record documentation of Patient #1 ever being in the hospital or the emergency department seeking care on 1/21/12/or 1/22/12, and it was verified that they had no documented evidence of performing a MSE (medical screening exam) to rule out an emergency medical condition occurring in Patient #1.
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on hospital record review, patient interview and Hospital A and Hospital B staff interviews, review of Hospital A's EMTALA policies and procedures, Hospital A failed to ensure that they were in compliance with all EMTALA Requirements under 42 CFR 489.20 and 42 CFR 489.24, This occurred in 1 of 21 sampled patients (Patient #1), who presented to the emergency department seeking emergency medical care.

Findings include:

1) Patient #1 came into the emergency department registration desk of Hospital A at approximately 11:30 p.m. on 1/21/12, seeking medical treatment to determine the viability of her approximate 21 week old fetus. e. Hospital A failed to register and track care of this patient seeking emergency treatment in their central log. (Reference A2405)

2) On 1/21/12 at approximately 11:30 p.m., Patient #1, who was seeking emergency medical treatment to determine the viability of her approximate 21 week old fetus, went to Hospital A. Hospital A failed to provide an appropriate medical screening exam for Patient #1. (Reference A2406)


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VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
Based on record review of Hospital A's emergency department central log, patient interview, Hospital A staff interviews and review of hospital EMTALA policies and procedures, Hospital A failed to ensure that they registered all persons who came into their emergency department seeking care into a central log system. This occurred in 1 of 21 sampled patients (Patient #1), who presented to the emergency department seeking emergency medical care/ treatment.

Findings include:

1) Interviews with Hospital A's RMCs (Risk Management Coordinators) B and C on 2/6/12 at approximately 4:15 p.m. reflects that they have searched the central admission logs for evidence of registration for Patient #1 on 1/21/12 and 1/22/12, and cannot find any evidence that Patient #1 came into their hospital for the above dates.

Record review of the central log on 2/6/12 at approximately 4:15 p.m. showed no entry for Patient #1. on 1/21/12/or 1/22/12.

Interview with Patient #1 by telephone on 2/6/12 at approximately 4:30 p.m. reflects the following:
Patient #1 states that she came into the emergency department at Hospital A on 1/21/12 between 11 p.m. and 12 midnight and told the receptionist at the desk she "needed to see a doctor" because she "was not sure she was feeling her baby move". Patient #1 stated that the receptionist asked her name, birth date and how many weeks pregnant she was, and wrote it down on a piece of paper. Patient eventually presented to Hospital B.

RMCs B and C verified that Patient #1 had sought emergency room treatment/ care on the night of 1/21/12, had talked with ED triage nurse E and OB nurse F, and had not been registered, had not been centrally logged or had not been seen as a patient by their emergency room or OB clinic by medical or nursing staffs for a medical screen. RMC's B and C verified that they had no documentation of the hospital staff's encounter with Patient #1 on 1/21/12 or 1/22/12.