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MARSHFIELD MEDICAL CENTER - WESTON 3400 MINISTRY PARKWAY WESTON, WI 54476 Aug. 12, 2015
VIOLATION: POSTING OF SIGNS Tag No: A2402
Based on observation and interview, staff at this facility failed to post EMTALA signs in all areas that will be noticed by patients seeking emergency medical treatment in 2 of 2 departments that accept emergency patients (ED and OB). Failure to post appropriate signs has the ability to affect all patients entering these two departments seeking emergency assistance.

Findings include:

A tour of the ED unit, from Pt. entrance to exit, was completed on 8/12/2015 at 9:33 AM accompanied by ED Dir B and QI Specialist A. The two EMTALA signs in the reception area are not readily visible to patients walking in. There is one on the wall to the left of the entry doors-more visible on exit than entrance, and one next to the security room window.

These signs are identical and do not have any bolded type to make it apparent what they are for. They are placed in such a manner that they had to be pointed out for observation during the tour.

The signs do not specify the facility accepts Medicaid patients.

There are no EMTALA signs in the larger waiting room away from the reception area.

In an interview with Dir B during the tour regarding EMTALA signs in the ED treatment rooms, Dir B stated that the treatment rooms in the ED did not have EMTALA signs. There are 15 rooms in total.

Per interview with Dir B on 8/12/2015 at 2:24 PM regarding other areas in the facility that could potentially see emergency patients outside of the ED, Dir B stated that patients could go directly to OB if they are over 24 weeks for an emergent situation. Dir B was unsure if OB had EMTALA signs.

A tour of the OB entrance area was conducted with Dir B on 8/12/2015 at 2:35 PM. No EMTALA signs were observed. Per interview with OB HUC H at 2:35 on 8/12/2015, HUC H was unaware of what an EMTALA sign was and called OB Dir I. HUC H states Dir I said they do not have EMTALA signs.

Per interview with QI Specialist A at 2:45 PM on 8/12/2015, A stated that the triage room in OB does not have EMTALA signs either.
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on observations, interviews and record reviews, this facility failed to comply with the EMTALA regulations found at CFR 489.24 by not having appropriate EMTALA signs in 2 of 2 departments where emergency patients present (ED and OB); not completing full vital signs on patients determined to have an emergent medical condition for 1 out of 20 MR reviewed (Pt. #17); and either not completing a transfer form or not completing risks and benefits on transfer forms for 4 of 4 transferred patients (Pt #10, 14, 17 and 20).

Findings include:

1. The facility failed to have appropriate EMTALA signs in all areas emergency patients present. See A-2402.

2. The ED staff failed to obtain blood pressure measurements on an infant. See A-2406.

2. The ED staff failed to document risks and benefits for transfer patients. See A-2409.

The cumulative effects of these failures has the potential to affect all patients who present for emergency services and/or have a need to be transferred to another facility for care.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on record review ED staff at this facility failed to complete a comprehensive medical screening examination that included blood pressure measurement in 1 of 20 MRs reviewed (Pt. #17).

Findings include:

Pt #17's MR revealed that Pt. #17 presented to the facility's ED on 7/15/2015 at 10:22 PM with complaints of vomiting. Pt. #17 was transferred to another facility for specialty services on 7/16/2015 at 4:38 AM after an ultra sound determined there was pyloric spasm (spasm of the muscular valve that holds food in the stomach until it is ready for the next step in the digestive process) present and not much formula was getting through.

Vital signs (pulse, respirations, temperature, oxygen saturation and weight) were taken at 10:24 PM
Vital signs (pulse, respirations, temperature and oxygen saturation) were taken at 2:49 AM (7/16/2015).
Vital signs (pulse, respirations and oxygen saturation) were taken at 3:43 AM.
Vital signs (pulse, respirations and oxygen saturation) were taken at 4:10 AM.

No blood pressure (BP) was taken/recorded as part of the medical screening examination.

The facility's policy titled, "Emergency Department Protocols," # dated 9/18/2013, was reviewed on 9/13/2015 at 6:45 AM. The policy states in part (on page 14 of 15), "All patients will have a baseline set of vital signs on admission...No BP is required for children under 5 years old."

The facility's policy titled, "Pediatric Emergencies," # dated 6/10/014, was reviewed on 9/13/2015 at 6:50 AM. The policy states in part (on page 2 of 6), "Secondary Assessment: ...2. Obtain full set of vital signs on all pediatric patients... Children under 5 years of age do not need BP assessed unless indicated by condition (i.e. head injury, multiple traumas)."
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, ED staff failed to complete transfer documentation per policy for 4 of 4 ED transferred patients (Pt's #10, #14, #17, #20).
Findings:
Pt #10's MR revealed that Pt. #10 (MDS) dated [DATE] at 10:57 PM with suicidal ideations. Pt. #10 was transferred to another facility for specialty services not offered at this facility. There is no transfer form for Pt. #10 outlining the risks and benefits of transfer. These findings were confirmed in an interview with QI Specialist A on 8/12/2015 at 1:55 PM. QI Specialist A stated that there should be a transfer form but there is not.
Pt #14's MR revealed that Pt. #14 presented to the facility's ED on 6/13/2015 at 9:39 AM with complaints of right face and right hand numbness. Pt. #14 was transferred to another facility for specialty services at 12:24 PM after receiving stabilizing treatment. Pt. #14's Transfer Risk and Consent form does not include individualized risks associated with the transfer. The form states: "Specific risks of my transfer may include ___" and is left blank. The name of the accepting physician and facility is left blank. These findings were confirmed per interview with ED Dir B on 8/12/2015 between 11:30 AM-2:00 PM.
Pt #17's MR revealed that Pt. #17 presented to the facility's ED on 7/15/2015 at 10:22 PM with complaints of vomiting. Pt. #17 was transferred to another facility for specialty services on 7/16/2015 at 4:38 AM after receiving stabilizing treatment. Pt. #17's Transfer Risk and Consent form does not include individualized risks associated with the transfer. The form states: "Specific risks of my transfer may include _____" and is left blank. These findings were confirmed per interview with ED Dir B on 8/12/2015 between 11:30 AM-2:00 PM.
Pt #20's MR revealed that Pt. #20 presented to the facility's ED on 7/24/2015 at 5:26 PM with complaints of abdominal pain. Pt. #20 was transferred to another facility at 7:53 PM for specialty services. Pt. #20's Transfer Risk and Consent form does not include individualized risks associated with the transfer. The form states: "Specific risks of my transfer may include _____" and is left blank. These findings were confirmed per interview with ED Dir B on 8/12/2015 between 11:30 AM-2:00 PM.
Facility policy " Emergency Medical Treatment and Labor Act (EMTALA), CI-18 " dated 6/26/2014, was reviewed on 8/12/2015 at 11:15 AM. The policy states in part: "A Stabilized individual may be Transferred to another facility ...any transfer should occur to an appropriate facility, a determination which requires the use of sound clinical judgment, including assessment of the expected risks and benefits of the Transfer against the risk of the individual. "