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AURORA MEDICAL CTR OSHKOSH 855 N WESTHAVEN DRIVE OSHKOSH, WI 54904 Jan. 11, 2017
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on record review, observation, and interview the facility failed to ensure compliance with EMTALA (Emergency Medical Treatment and Active Labor Act) requirements in 3 of the 7 required areas (Posting of Signs; Medical Screening Exam; Appropriate Transfer).

Findings include:

1) The facility failed to complete an appropriate medical screening exam for 1 of 1 patients (Patient #1) who presented to the Emergency Department with an emergency medical condition. The total patient sample was 20. (Reference A 2406)

2) The facility failed to ensure all patients being transferred from the Emergency Department to an alternate facility had complete and accurate transfer consent forms in 8 out of 17 transferred patients out of a total of 20 medical records reviewed (Patient #3, 8, 11, 14, 15, 17, 19, and 20). (Reference A2409)

3) The facility failed to post EMTALA (Emergency Medical Treatment and Active Labor Act) signs in the emergency department where they are highly visible and likely to be seen by patients waiting for emergency treatment in 1 of 1 area observed where patients receive emergency treatment (Emergency Department). (Reference A 2402)
VIOLATION: POSTING OF SIGNS Tag No: A2402
Based on observation and interview, this facility failed to post EMTALA (Emergency Medical Treatment and Active Labor Act) signs in the emergency department where they are highly visible and likely to be seen by patients waiting for emergency treatment in 1 of 1 area observed where patients receive emergency treatment (Emergency Department). Failure to post EMTALA signs in highly visible places for patients has the potential to affect all patients seeking emergency treatment in this facility.

Findings include:

A tour of the Emergency Department was conducted with Registered Nurse Emergency Department Supervisor C on 1/10/2017 at 9:10 AM.

The following areas were observed to not have EMTALA signs posted:
--The entrance to the Emergency Department.
--The registration/admission area for Emergency Department patients.
--Treatment rooms #8, 11, 15, 16 and 17 (same room but two cots separated by a curtain), and 18.

In the Emergency Department waiting area it was observed that there was one sign posted, 8x10 inch size, that was found by writer and Supervisor C after several minutes of searching. It was located about a foot above and behind a coffee dispensing machine and was difficult to immediately identify as an EMTALA sign.

In an interview with Supervisor C during the tour on 1/10/2017 at 9:10 AM, Supervisor C looked around the emergency room waiting area and stated, "I don't see any signs." Shortly after the sign above the coffee dispensing machine was located.

Upon exit of the building on 1/10/2017 at 3:30 PM accompanied by Director of Risk Management B, the lack of signage in the waiting room areas (entrance, registration/admitting area, and patient waiting area) was again observed. In an interview at this time, Director B stated, "You are right, there should be big visible signs."
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the emergency room physician failed to perform an appropriate Medical Screening examination on 1 of 1 patients diverted for treatment out of a total of 20 medical records reviewed (Patient #1). Failure to perform appropriate medical screening examinations has the potential to affect all patients seeking emergency treatment at this facility.

Findings include:

The facility's policy titled, "EMTALA [Emergency Medical Treatment and Active Labor Act]: Screening, Stabilization and Transfer," #179, dated 12/15, was reviewed on 1/10/2017 at 9:00 AM. The policy states in part, "The Medical Center staff will provide an appropriate medical screening examination for all individuals who may have an emergency medical condition...A MSE [medical screening examination] is an examination performed by a physician or a QMP [qualified medical provider] to determine with reasonable clinical confidence whether an EMC [emergency medical condition] (including active labor) exists."

Per interview with Emergency Department Supervisor, Registered Nurse C, on 1/10/2017 at 8:40 AM, Nurse C stated, "We received an EMS (Emergency Medical System) call about a [Patient #1] with altered mental status. After getting the call, I don't know if it was the hospitalist or who said it, but we were found to have no ICU (intensive care unit) beds [available]. The nurses were getting the emergency bed prepped for the patient. The emergency room doctor (Doctor J) went to the ambulance and saw the patient there. EMS thought the patient was stable enough so the decision to transfer was made. [Doctor J] called the other hospital to let them know the patient was coming. [Doctor J] did not do a proper medical screening exam. That's why it was reported."

Per interview with Quality Manager B on 1/10/2017 at 9:30 AM, an investigation was initiated by Facility #1 and it was discovered that Doctor J, Emergency Department Physician on 12/24/2016, was informed that Patient #1 was en route to the facilty via Emergency Medical Services. Manager B's investigation indicated that Doctor J realized there were no Intensive Care Unit beds available but before Doctor J could contact Emergency Medical Services to take Patient #1 to a neighboring acute care facility (Facility #2) they had already arrived at Facility #1.

Review of Quality Manager B's investigation notes on 1/10/2017 at 9:30 AM revealed that Doctor J then went out to the ambulance, observed Patient #1, and after talking with Paramedics and viewing Patient #1's vital signs that were taken by the Paramedics, directed Emergency Medical Services to take Patient #1 to Facility #2 where there were Intensive Care Unit beds available.

Per medical record review on 1/10/2017 at 10:30 AM, Patient #1 was brought to Facility #1 on 12/24/2016 around 11:00 PM by ambulance. Patient #1 has a history of [DIAGNOSES REDACTED] with brain metastasis and fell at home. A family member called 911 for Emergency Medical Services. Patient #1 was not cooperative with Emergency Medical Services and was sedated with 400 milligrams of Ketamine intramuscularly (Ketamine dosage per protocol for Emergency Medical Services is 4 milligrams per kilogram; Patient #1 weighs 105 kilograms [231 pounds]).

A phone interview with emergency room Charge Nurse I was conducted on 1/10/2017 at 10:43 AM. Nurse I stated, "We got a call about a non-responsive older [Patient #1] who was combative. We briefed the doctor. [Doctor J] said there were no ICU (Intensive Care Unit) beds. I said if you want to divert call now before they get here. A room was prepared for the patient. EMS (Emergency Medical Services) arrived. The tech (emergency room aide) said the doctor went to the garage to divert from us. When I saw the doctor in the hall I asked where that patient was and the doctor said 'Oh I turned them away to go to [other facility]. [Patient #1] was mentating (mentation is the process of using one's mind) so I told them [Patient #1] would be better served over there.' Nurse I stated Doctor J did call Facility #2 after the ambulance left. Nurse I stated, 'I said, [Doctor J] I don't think you can do that.' " Nurse I stated I then contacted the house supervisor with what just happened and a report was started.

The following information was obtained per phone interview with Doctor J on 1/10/2017 at 10:59 AM. Doctor J is currently out of the country and did not have Patient #1's medical record to refer to. "The CT (computerized tomography) was down. We did not have CT scan ability. We did not have the capability to take [Patient #1]. This was not an appropriate facility at the time to handle a potential neurological patient with a bleed, which is what I thought we could have been dealing with given the report I was given. I tried to call Emergency Medical Services back but they pulled in the garage. I called [other Facility] and they said, 'Yes, fine, that's ok.' I sent [Patient #1] from the ambulance bay. I laid eyes on [Patient #1], and vitals per Emergency Medical Services, then let [Patient #1] go because for patient safety it was better to send [Patient #1]. I thought it was dangerous for [Patient #1] to stay here depending on what was going on, thought it was safer this way."
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, staff at this facility failed to, 1. Complete transfer documents outlining risks and benefits of the transfer to the patient, and/or 2. Ensure proper authentication of transfer documents was complete in 8 out of 17 transfers to other facilities out of a total of 20 medical records reviewed (Patient #3, 8, 11, 14, 15, 17, 19, and 20). Failure to obtain complete and authenticated transfer documents has the potential to affect all patients this facility transfers to other facilities.

Findings include:

The facility's policy titled, "EMTALA [Emergency Medical Treatment and Active Labor Act]: Screening, Stabilization and Transfer," #179, dated 12/15, was reviewed on 1/10/2017 at 9:00 AM. The policy states in part, "A physician must certify that the medical benefits expected from Transfer outweighs the risks and describe the reasons for and the potential risks and benefits of the Transfer by completing the applicable areas on the Patient Transfer form [in the electronic medical record]...The date and time of the certification should be close in time to the actual Transfer."

The facility's policy titled, "Medical Records/Patient Health Information," dated 7/27/2015, was reviewed on 1/10/2017 at 10:20 AM. The policy states in part, "All clinical entries in the patient's record shall be legible, accurately dated, timed, and individually authenticated..."

Patient #3's medical record was reviewed on 1/10/2017 at 11:40 AM accompanied by Supervisor C who confirmed the following during the review: Patient #3 was transferred to an alternate facility on 1/5/2017 for cardiovascular operative repair and intensive care unit. The Patient Transfer Form does not include a signature, date, or time from the patient or a family member giving consent for the transfer, nor is there notation as to why a signature was not obtained.

Patient #8's medical record was reviewed on 1/10/2017 at 1:20 PM accompanied by Supervisor C who confirmed the following during the review: Patient #8 was transferred to an alternate facility on 1/9/2017 after a fall and head injury in which a CT (computerized tomography) scan confirmed a cranial bleed. The transfer form does not include what services or expertise is not available at this facility that would necessitate a transfer and the physician's signature on the consent is not authenticated with a time.

Patient #11's medical record was reviewed on 1/10/2017 at 1:40 PM accompanied by Supervisor C who confirmed the following during the review: Patient #11 was transferred to an alternate facility on 11/21/2016 after a family member brought Patient #11 to this facility with altered mental status, diffuse muscle spasms over the previous 24 hours and increase somnolence for 1.5 days. The transfer consent form does not indicate what services/expertise are not available at this facility that would necessitate a transfer and there is no signature from the patient or family member (or indication why one was unable to be obtained) consenting for the transfer.

Patient #14's medical record was reviewed on 1/10/2017 at 2:11 PM accompanied by Supervisor C who confirmed the following during the review: Patient #14 is an [AGE] year old who was transferred to an alternate facility with intractable vomiting and abdominal pain requiring a Pediatric Gastroenterologist. The transfer consent form does not include a date or time family members signed the form, and the physician and nurse's signatures are not authenticated with the time of the signatures.

Patient #15's medical record was reviewed on 1/10/2017 at 2:20 PM accompanied by Supervisor C who confirmed the following during the review: Patient #15 was transferred to an alternate facility after presenting to this facility with a fever and was found to have mandibular osteo[DIAGNOSES REDACTED] (infection of the jaw bone). The transfer consent form does not identify the services/expertise that is not available at this facility that would necessitate a transfer and also does not include the transfer's mode of transportation. The physician's signature is not authenticated with a date or time.

Patient #17's medical record was reviewed on 1/10/2017 at 2:35 PM accompanied by Supervisor C who confirmed the following during the review: Patient #17 was transferred to an alternate facility after presenting to this facility after a fall and increasing weakness to the left arm and leg. The transfer consent form does not identify the services/expertise that is not available at this facility that would necessitate a transfer. The physician's signature is not authenticated with a time.

Patient #19's medical record was reviewed on 1/10/2017 at 2:50 PM accompanied by Supervisor C who confirmed the following during the review: Patient #19 was transferred to an alternate facility after presenting to this facility with a headache of several weeks duration. Patient #19 was found to have an internal carotid artery dissection on CT scan. The transfer form consent is blank and contains no information. The signature page does not include a date or time Patient #19 signed the form, and the physician's signature is not authenticated with a time.

Patient #20's medical record was reviewed on 1/10/2017 at 3:00 PM accompanied by Supervisor C who confirmed the following during the review: Patient #20 was transferred to an alternate facility after presenting to this facility neck pain, swelling, and difficulty breathing. The transfer consent form does not identify the services/expertise that is not available at this facility that would necessitate a transfer. The physician's signature is not authenticated with a time.