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.

RIVER FALLS AREA HOSPITAL 1629 E DIVISION ST RIVER FALLS, WI 54022 Oct. 16, 2018
VIOLATION: PATIENT CARE POLICIES Tag No: C1006
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview the facility failed to follow hospital policies and procedures to ensure patients safety by failing to follow restraint policy and procedures in 2 of 7 patients (Patient # 1 and # 10) who presented in police custody with an emergency medical crisis requesting care in the Emergency Department in 23 medical records reviewed.

Findings include:

Record review of System-wide Policy: "Restraints/Seclusion - Management of Violent and/or Self-Destructive Behavior # SYS-PC-NEC-003 dated 8/2018 revealed Prohibited Restraints include "weapon... handcuffs..... applied by law enforcement officials for custody, detention, and public safety reason are not permitted to be used as restraints... restraint interventions for use by hospital staff to restrain patients ...The use of restraint...must be based on a comprehensive, individualized assessment...and not driven by a diagnosis ... Before initiation or renewal of an order for restraint or seclusion, RN must complete a comprehensive individualized assessment of the patient ...An order is required for the implementation of restraint ...the patient must be assessed face-to-face by a practitioner within one hour of the initiation...Minimally, every two hours trained staff will document... Physicians ... authorized to order restraint ... must have a working knowledge of hospital policy regarding the use of restraint."

Review of Patient #1's medical record on 10/10/2018 at 9:43-11:12 AM with Patient Care Manager Emergency Department (ED) C, revealed Patient # 1 was admitted on [DATE] in police custody on a Chapter 51 hold (person with mental illness who is held against their will as they are in danger of harming themselves or others) for medical clearance. ED nursing note 9/25/18 at 1:40 AM revealed "Patient has a belt handcuffed in the front, this was applied by Officers". The patient was restrained with police handcuffs for greater than 7 hours, from 1:40 AM to 9:10 AM, without a RN comprehensive individualized assessment or a physician order and the facility did not follow hospital policy that prohibits the use of handcuffs. On 9/25/18 at 9:10 AM use of "locked restraints" (undefined) on right and left ankles and waist belt were documented "A transfer belt restraint was applied to pt's upper extremities to accommodate his/her handcuffs." Restraint order written at 10:08 AM. No restraint checks from 1:40 AM, when the first use of restraint was documented, until 9:10 AM when the first comprehensive individualized assessment of Patient #1 was completed. First face to face physician evaluation was completed at 10:09 AM, 8 hours and 39 minutes after first restraint was noted by RN.

Review of Patient #8's medical record on 10/11/2018 at 12:40 PM with ED RN I revealed Patient #8 presented in custody of the police 7/08/18 at 8:03 PM with a chief complaint of intentional overdose. Nurses notes 7/08/18 at 8 PM revealed "Agitated, Anxious." Nurse's note dated 7/08/18 at 8:21 PM revealed "Patient uncooperative, security called... Police officer was going to put patient in handcuffs." There was no comprehensive individualized assessment by a RN or physician order for a restraint documented.

On 10/10/2018 at 9:43-11:12 AM an interview was conducted with ED RN I during review of Patient #1's medical record. ED RN I stated "we don't consider police handcuffs to be a restraint."
VIOLATION: COMPLIANCE WITH 489.24 Tag No: C2400
Based on observation, record review and interview, the facility failed to ensure compliance with EMTALA (Emergency Medical Treatment and Active Labor Act) regulations in 4 of 11 required areas (Sign Posting, Appropriate Medical Screening, Delay in Examination or Treatment, and Appropriate Transfer).

Findings include:

The facility failed to ensure signage is posted in all patient care areas. See tag C2402.

The facility failed to provide an appropriate medical screening examination. See tag C2406.

The facility failed to appropriately transfer a patient. See tag C2408.

The facility delayed treatment. See tag C2409.
VIOLATION: POSTING OF SIGNS Tag No: C2402
Based on observation, record review and interview, the facility failed to ensure Emergency Medical Treatment and Labor Act (EMTALA) signs are posted in all treatment areas patients may be waiting for emergency treatment, in 1 of 1 observation of 4 of 5 treatment rooms (exam rooms #2, 3, 4 and 5).

Findings include:

On 10/10/2018 at 9:21 AM during tour of Emergency Department, observed treatment rooms 2, 3, 4 and 5 did not have EMTALA signage.

Review of policy AllinaHealth System-wide Policy Emergency Medical Treatment and Labor Act (EMTALA) #SYS-PC-EMCC-001 page 4 Signs "Signs must be conspicuously posted in any entrances, emergency department and places likely to be noticed by persons waiting for examination."

On 10/10/2018 at 9:21 AM during tour of Emergency Department, Quality/Risk Manager A confirmed there are no EMTALA signs in the treatment rooms.

On 10/10/2018 at 1:17 PM during an interview with Director of Patient Care B, B stated they did not believe they needed EMTALA signs in the treatment rooms, "we have them in places where the patients come in."
VIOLATION: MEDICAL SCREENING EXAM Tag No: C2406
Based on record review and interview, the facility failed to provide an appropriate medical screening examination within the capability of the hospital's emergency department in 1 of 7 patients (Patient #1) presenting in police custody with an emergency psychiatric crisis in 23 medical records reviewed.

Findings include:

Review of department policy "Emergency Detention" #RF-ED-001 date 7/2016 revealed on Page 3 C. What to Do: "Document in the patient's medical record both: a) Criteria justifying Emergency Detention and b) Law enforcement and on-call crisis worker response. 1) Persons under a Chapter 51.15 Emergency Detention ...Law Enforcement is responsible to request a County Crisis worker, or contracted employee, to complete a patient evaluation to determine necessity of transfer. The crisis worker will determine if the patient needs inpatient psychiatric evaluation or if the patient may be discharged ... 3) The crisis worker may determine the patient can be discharged ."

Record review of Response Plan dated 9/24/18 (not timed) written by crisis worker N revealed "meets criteria for Chapter 51.15 emergency detention (person with mental illness who is held against their will as they are in danger of harming themselves or others). Two possible beds were located "If neither hospital will take [Patient #1] this worker will be contacted to further assist."

Record review of "Mobile Crisis Assessment" signed 9/25/2018 at 4:36 AM by mobile crisis worker N revealed mobile crisis worker N determined Patient #1 met criteria for a Chapter 51.25 hold evidenced by "mental health symptoms clearly present and threats toward [his/herself] and others were reported and [his/her] behaviors suggest [s/he] would continue to be aggressive toward others and [s/he] was currently a danger to [his/herself] and others by being aggressive towards police. Client's active delusions and refusal of help is also evidence that [s/he] was experiencing impaired judgment throughout assessment."

Review of policy "ED Stabilization and Nursing Ongoing Assessment" #SYS-PC-EMPC-CG-003 dated 11/07/17 revealed "Utilizing the ED Stabilization and Reassessment Scale - The Stabilization Scale has levels 1 (Life Threatening) through 5 (Least Urgent) that mimic the Emergency Severity Index [ESI] criteria ... the nurse will adjust the assigned stabilization level as a patient's status changes or as the level of care increases or decreases." ED Stabilization and Reassessment Scale under Level 2 (Emergent) under "Ongoing Assessment Guideline" with guidelines including "Vital Signs: at a minimum every 30 minutes & before discharge or transfer" and "Focused Assessment; at a minimum every hour".

Review of Patient #1's medical record with Patient Care Manager Emergency Department (ED) C, ED nursing notes dated 9/24/18 at 5:53 PM revealed Patient #1 arrived in the Emergency Department (ED) with [R] who shares concerns that her/his child "isn't right in the head" and would like him/her to be seen and treated in the ED. Before being seen, Patient #1 exited the building and the community Police Department was notified.

Review of Patient #1's ED medical record, second visit revealed Patient #1 returned to the ED 9/24/18 at 9:08 PM escorted by police under a Chapter 51 hold. 9/24/18 at 9:36 PM nursing notes revealed Emergency Severity Index was Level 2. Vitals signs were completed at 9:36 PM: pulse 72, respiratory rate 26, refused temperature, blood pressure, weight and height. On 9/24/18 9:55 PM blood oxygen level was 100%, blood pressure was elevated "162/98 (Patient was flexing)" height 5'11", weight 195 pounds. 9/25/18 at 12:18 AM patient "refused repeat vital sign assessment." 9/25/18 at 9:10 AM comprehensive assessment was normal except Psycho-Social behavior revealed "Angry; argumentative; irrational; irritable; impulsive." 9/25/18 at 9:27 AM refused vital signs.

ED (Emergency Department) Triage Note 9/24/18 at 10:16 PM revealed "Patient is agitated and aggressive toward staff nurse. Security called at (9:10 PM). Patient is refusing all test or examinations at this time." ED nursing note dated 9/24/28 at 10:45 PM revealed "Patient has agreed to have blood drawn 8 times then refused once lab and nurse come to bedside. Patient is extremely argumentative with staff members and police."

ED nursing note dated 9/25/18 at 1:40 AM revealed "Patient is spitting ... screaming profane words, verbally abusive to police and hospital staff. Patient has a belt handcuffed in the front, this was applied by Officers." ED nursing note dated 9/25/18 at 9:53 AM revealed at 8:30 AM "RN (Registered Nurse) called a Code Green" (call for assist indicating patient is combative). 9:10 AM Patient #1 "threw his breakfast yelling... RN called a second Code Green." The Emergency Severity Index Level remained 2 throughout visit, no other vital signs or comprehensive reassessments were completed as required by hospital policies and procedures. There was no updated psychiatric evaluation.

On 10/16/18 at 9:05 AM during interview with contracted Emergency Mental Health Service (EMHS) T, Director/Call Center Coordinator Y, Y stated at times the EMHS will reassess, but EMHS T was not asked by River Falls Area Hospital or law enforcement to reassess Patient #1 "due to the concerns presented with [his/her] psychosis."

On 10/16/2018 at 12:13 PM during interview with Mobile Crisis Worker N, N stated s/he was "never asked "to reassess Patient #1 "and never offered."

Review of policy "System-wide Medical Staff Policy Template: EMTALA" # SYS-MS-PGCBSC-014 dated 3/03/16, page 3 a. Medical Executive Committee (MEC) "MEC's Responsibility for Emergency Call Plans ... The MEC is responsible for ensuring that the emergency call plans are prepared, maintained and available; that the emergency call plans are sufficiently detailed to identify the physicians who are on-call and available to respond to examine and provide stabilizing treatment for patients who have emergency conditions; and that the emergency call plans meet the emergency coverage needs of the Hospital ...e. Under-Represented Specialties and Subspecialties. "The modified emergency call plan for under-represented specialties ... must also include back-up plans for meeting patient needs ... facilitate the orderly operation of the hospital.. based on pre-established and consistently-applied criteria."

On 10/10/18 at 2:15 PM during interview with Emergency Physician D, D stated Patient #1 was in an acute crisis on admission, his/her condition had not changed, and Patient #1 needed inpatient behavioral health placement and treatment. Emergency Physician D confirmed the facility has Telepsychiatry (psychiatric care provided through videoconferencing) available, but stated s/he did not use it for Patient #1.
VIOLATION: DELAY IN EXAMINATION OR TREATMENT Tag No: C2408
Based on record review and interview, the facility delayed treatment of 1 of 7 behavioral health patients with an emergency psychiatric crisis (Patient #1) requiring inpatient behavioral health treatment in a sample of 23 medical records reviewed.

Findings include:

Record review of contracted Emergency Mental Health Service (EMHS) T "Mobile Crisis Assessment" signed 9/25/2018 at 4:36 AM by mobile crisis worker N, revealed mobile crisis worker N met with Officer SS at police department who "supported an Emergency Detention as client appeared to be struggling with mental health and to be a danger to [him/herself] and others." Patient #1 was agitated and aggressive toward crisis worker N and was determined, by crisis worker N, to meet criteria for a Chapter 51 hold as "[s/he] was currently a danger to [him/herself] and others by being aggressive towards police" and behaviors suggestive that s/he "would continue to be aggressive toward others", with "active delusions" and "impaired judgement". Crisis worker N notified "River Falls Hospital to let them know client was coming for medical clearance for an emergency detention. "At "around 9pm" crisis worker N met Patient #1 at the hospital and "began searching for a bed" for Patient #1. Page 3 revealed "Current medical issues or concerns": "Dr [QQ] or River Falls Hospital...offered to complete a Dr. to Dr. with any hospital that would talk to [him/her] as [his/her] observation that client was medically stable for inpatient [psychiatric] hospitalization ." Crisis worker N notified Dr. QQ and Sergeant RR s/he would call at "7am to check on client's status and to offer additional support."

Review of Patient #1's medical record on 10/10/2018 at 9:43-11:12 AM with Patient Care Manager Emergency Department (ED) C, ED nursing notes dated 9/24/18 at 5:53 PM revealed Patient #1 arrived in the Emergency Department (ED) with [R] who shared concerns that her/his child "isn't right in the head" and would like him/her to be seen and treated in the ED. Before being seen, Patient #1 exited the building and the community police department was notified.

Review of second ED visit dated 9/24/18 at 9:08 PM revealed Patient #1 presented with police escort on a Chapter 51 hold for medical clearance. Response Plan dated 9/24/18 (not timed) written by crisis worker N revealed "meets criteria for Chapter 51.15 emergency detention. ED Nursing Note 9/25/18 at 11:18 AM revealed "Pt discharged into custody of ... law enforcement with handcuffs on." Destination was not documented. Patient #1 was discharged 14 hours 10 minutes after second visit to the Emergency Department.

ED provider note dated 9/25/18 at 6:12 PM by Physician E (21 hours 4 minutes after the patient first presented to the ED) revealed "Behavioral health admission is pending at this time ... Patient presenting with primary psychiatric concern. Patient discharged in police custody."

On 10/16/2018 at 12:13 PM during interview with Mobile Crisis Worker N, N stated s/he was "never asked "to reassess Patient #1 "and never offered."

On 10/10/2018 at 11:34 AM during interview with Manager of Quality/Risk A and Director of Patient Care B, Manager of Quality/Risk A stated s/he was "unsure" of where Patient #1 was taken after discharge of their facility. A and B confirmed Patient #1 was discharged into police custody.

The emergency room discharged Patient #1 into police custody (17 hours and 57 minutes after Patient #1 first presented to the Emergency Department) with no psychiatric treatment or treatment plan, and written discharge instructions that revealed "Seek immediate medical care if: Severe psychotic symptoms present a safety issue (such as an urge to hurt yourself or others)."
VIOLATION: APPROPRIATE TRANSFER Tag No: C2409
Based on record review and interview the facility failed to appropriately transfer 1 of 7 behavioral health patients released into police custody (Patient #1) in a sample of 23 emergency medical records reviewed.

Findings include:

Record review of system-wide policy "Emergency Medical Treatment and Labor Act (EMTALA) # SYS-PC-EMCC-001 dated May 2017 Policy Statement revealed "Compliance with EMTALA is required when an individual presents... with an emergency department, and requests emergency examination or treatment for a medical condition." Page 4 Transfers "Patients who have an emergency medical condition (EMC) will not be transferred from the hospital before the EMC is stabilized, unless the transfer is made according to the requirements for an appropriate transfer, as defined by EMTALA." Definitions, page 7 Stable: "A psychiatric patient is stable when he or she is protected and prevented from injuring or causing harm to self or others... Transfer: Movement (including discharge) of an individual."

Record review of system-wide procedure: "EMTALA Transfer" #SYS-PC-EMCC-001.P1 (no date) revealed "When an individual with an unstable emergency medical condition is transferred from the hospital, the individual must be transferred in accordance with EMTALA requirements. This procedure applies to all transfers from the hospital of individuals who have an unstabilized emergency medical condition... PROCEDURE... A. Transferring Physician... 1. Secure acceptance of transfer from physician at receiving hospital."

Record review of Local Hospital Collaboration/Directive (updated 10-12-16) revealed the emergency mental health services "will utilize the opinions and assessment of hospital staff when making a determination of need" and "crisis staff will stay within their scope of practice."

Record review of Response Plan dated 9/24/18 (not timed) written by crisis worker N revealed "meets criteria for Chapter 51.15 emergency detention."

Record review of "Mobile Crisis Assessment" signed 9/25/2018 at 4:36 AM by mobile crisis worker N revealed mobile crisis worker N determined Patient #1 met criteria for a Chapter 51.25 hold evidenced by "mental health symptoms clearly present and threats toward [his/herself] and others were reported and [his/her] behaviors suggest [s/he] would continue to be aggressive toward others and [s/he] was currently a danger to [his/herself] and others by being aggressive towards police. Client's active delusions and refusal of help is also evidence that [s/he] was experiencing impaired judgment throughout assessment." Page 3 revealed "Current medical issues or concerns": "Dr [QQ] or River Falls Hospital... offered to complete a Dr. to Dr. with any hospital that would talk to [him/her] as [his/her] observation that client was medically stable for inpatient [psychiatric] hospitalization ."

Review of Patient #1's medical record on 10/10/18 at 9:43-11:12 AM with Patient Care Manager Emergency Department (ED) C, ED nursing notes dated 9/24/18 at 5:53 PM revealed Patient #1 came into the ED with [his/her] [R] who shares concerns that her/his child "isn't right in the head" and would like him/her to be seen and treated in the ED. Before being seen, Patient #1 exited the building and River Falls Police Department was notified.

At 9/24/18 at 9:08 PM patient #1 returned to the hospital in police custody, on a Chapter 51 hold for medical clearance. ED provider note dated 9/25/18 at 8:59 AM by Physician E under Medical Decision Making: "I am unable to obtain an accepting provider as a result... [Patient #1] discharged in police custody." ED Nursing Note 9/25/18 at 11:18 AM revealed "Pt discharged into custody of... law enforcement with handcuffs on ... Pt left in police custody."

On 10/10/2018 at 11:34 AM during interview with Manager of Quality/Risk A and ED Medial Director F, A and F confirmed Physician E did not secure acceptance of transfer of Patient #1 from a physcian at a receiving hospital and Physician H discharged Patient #1 into police custody.

On 10/10/18 at 2:15 PM during interview with Emergency Physician D, Physician D confirmed Patient #1 was in an acute mental health crisis on admission, his/her condition had not changed, and Patient #1 needed inpatient behavioral health placement.

Review of Patient #1's Emergency Department record revealed, Patient #1 was discharged to Law Enforcement KK with no psychiatric treatment or treatment plan, and written discharge instructions that revealed "Seek immediate medical care if: Severe psychotic symptoms present a safety issue (such as an urge to hurt yourself or others)."