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.

UNIVERSITY OF WI HOSPITALS & CLINICS AUTHORITY 600 HIGHLAND AVENUE MADISON, WI 53792 March 26, 2019
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on record review and interview, the facility failed to ensure compliance with EMTALA (Emergency Medical Treatment and Active Labor Act) regulations in 3 of 11 required areas: 1) failed to provide appropriate medical screening exam in 1 of 20 patients (Patient # 15), 2) failed to provide policies and procedures to manage emergency department care management plans used assist with decision making when stabilizing treatment is provide in 1 of 3 patient visits (Patient #1), and 3) failed to transfer patients according to the facility's policies and procedures in 3 of 6 patients (Patient # 8, 18 & 20).

Findings include:

Facility medical staff failed to provide appropriate medical screening exam. See tag 2406

Facility staff failed to provide policies and procedures to manage emergency department care management plans to assist with decision making to provide stabilizing treatment. See tag 2407

Facility staff failed to transfer patients according to the facility's policies and procedures. See tag 2409
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on record review and interview the facility failed to provide an appropriate medical screening examination to 1 of 20 patients (Patient # 15) in a total sample of 20 medical records reviewed.

Findings include:

Review of policy titled "Emergency Assessment at UW Health Facilities" #5.1.1 dated 10/19/2015 under IV. Procedure General a. "All patients presenting to a UW Health Emergency Department... will receive a medical screening examination."

Review of Emergency Medical Treatment & Labor Act (EMTALA) "Summary of Requirements" dated 2/02/18 revealed "Treatment of patients who "come to the emergency department" requesting examination or treatment" *Provide an appropriate medical screening examination (MSE); *Provide necessary stabilizing treatment to an individual with an emergency medical condition (EMC); * If the hospital does not have the capability or capacity to provide stabilizing treatment or upon request of the patient, provide an "appropriate transfer" of an unstable individual... Important Issues to Keep in Mind... * "Clinically stable" (normal vital signs) is not the same as "stabilized" for purposes of EMTALA. *Patients in labor and patients experiencing psychiatric emergencies, if expressing suicidal or homicidal thoughts or gestures and determined dangerous to self or others, are considered to have an unstable EMC."

Review of emergency department (ED) policy #4.0 "Patients Who Leave Before Disposition" dated 7/01/2017 revealed "2.) In the event the patient verbalizes intent to leave prior to seeing APP/MD/DO (Advanced Practice Provider/Medical Doctor/Doctor of Osteopathic Medicine)... if the patient refuses to wait, ED staff asks patient to sign form LWBS# 76 (Record of Patient Who Leaves Before Medical Screening Can Be Performed)... if the patient refuses to sign the form... ED staff will document refusal... notify Administrative Physician and document in Health Link."





Patient #15's medical record was reviewed and revealed Patient #15 arrived in the ED in police custody on 2/14/19 at 10:29 PM. The "Patient Care Timeline" at 10:29 PM revealed "Arrival Complaint Suicidal". Vital signs were taken at 10:31 PM. Registered Nurse (RN) note 2/14/19 at 10:32 PM revealed "pt. (patient) asked if [s/he] has plans to harm [her/himself], pt states "If I had a blade I'd cut myself right now". When asked if [s/he] has thoughts of harming others [s/he] states, "It possible."... Pt yelling in triage, "Take me to jail now."... Pt placed in handcuffs in triage... Officer asked how long [s/he] would be in the ED... Pt escalating behaviors. Officers took pt out of the ED." ED note 2/14/19 at 11:24 PM (55 minutes after arrival to ED) revealed "witnessed patient being taken from waiting room." ED Physician S note 2/14/19 at 11:42 PM revealed "informed by nursing that patient was escorted out of the ED in police custody prior to MD eval... I had no contact with this patient." There was no form LWBS# 76 in patient's medical record.

On 3/26/19 at 10:10 AM during interview with Director of Emergency Services P, P confirmed Patient #15 did not receive a medical screening exam and that the "record of patient who leaves before medical screening can be performed" form "should have been completed and an incident entered."

On 3/26/19 at 3:40 PM during interview with Accreditation and Regulatory Specialist E, E confirmed there was no form LWBS# 76 or incident report completed for Patient #15's Emergency Department visit.
VIOLATION: STABILIZING TREATMENT Tag No: A2407
Based on record review and interview the facility failed to provide policies and procedures for management of emergency department care management plans used to assist with decision making to provide stabilizing treatment of Emergency Department patients in 1 of 5 patient visits using an emergency department care management plan (Patient #1) in a total sample of 20 medical records reviewed.

Findings include:

Review of Emergency Medical Treatment & Labor Act (EMTALA) "Summary of Requirements" dated 2/02/18 revealed "Treatment of patients who "come to the emergency department" requesting examination or treatment" must "Provide necessary stabilizing treatment to an individual with an emergency medical condition (EMC); * If the hospital does not have the capability or capacity to provide stabilizing treatment or upon request of the patient, provide an "appropriate transfer" of an unstable individual... Important Issues to Keep in Mind... * "Clinically stable" (normal vital signs) is not the same as "stabilized" for purposes of EMTALA... patients experiencing psychiatric emergencies, if expressing suicidal or homicidal thoughts or gestures and determined dangerous to self or others, are considered to have an unstable EMC."

Review of policy "Suicide Assessment and Prevention #2.4.1 dated 10/26/2015 page 5 B iii d. revealed "If admission is unnecessary but immediate assistance is required to discharge patient into the community, Crisis Intervention of Journey Mental Health may helpful... 24 hours/day... Department of Psychiatry Consult service can be contacted... to assist with this or other plans, as appropriate."

Record review of outpatient Psychotherapy Progress Notes dated 3/15/19, not timed, by on-call Licensed Professional Counselor Q revealed Patient #1 had a change in mental status "increased agitation, SI (suicidal ideation) w/plan & action", and was a severe suicide risk. Under "Action taken" revealed "encouraged hospital staff to admit for SI (suicidal ideation) ... Writer also spoke with [Psychologist/complainant A] who strongly agreed. Writer then spoke w/[J] (attending doctor), who stated that [Patient #1] would be assessed by psych. Writer did not receive a call back ... Writer later called back and was told that [Patient #1] was not admitted . Writer called [Patient #1] and spoke w/him/her. S/he was more stable but upset."

Patient #1's medical record was reviewed and revealed Patient #1 presented to the Emergency Department (ED) 3/15/19 at 4:08 PM by ambulance from his/her primary care provider's clinic with arrival complaint of suicidal ideation. At 4:11 PM constant supervision was ordered by ED Resident J. At 5:08 PM RN completed the Columbia Suicide Screening which was positive and initiated the constant observation log. ED Attending note dated 3/15/2019 at 4:29 PM revealed possible overdose on gabapentin... planning on overdosing on pills." Psychiatric consult by Resident Psychiatrist K dated 3/15/19 at 5:23 PM revealed "Bio-Psycho-Social Formulation ... presents to the ED for the second time this week requesting admission ... D/c summary from last admission recommends no further hospitalization . Psychiatry Resident K further quotes Consult note 10/22/18 from ED Care Management Plan, last updated 1/23/19, "history of chronic suicidal ideation ... denies changes in [his/her] baseline passive SI (suicidal ideation) ... and an ED treatment plan including "do not admit" and "minimal provider interaction" would be appropriate." The recommendation on the psychiatry consult revealed "1. Do not admit to inpatient psychiatry 2. Patient may go to DCCC (Dane County Care Center) if [s/he] does not feel safe to go home." Addendum by ED Resident J at 6:05 PM (42 minutes after "Psychiatry Consultation Note" was submitted) revealed "I discussed with the therapist on-call for his/her outpatient therapist. [S/he] states that the patient has been decompensating ... Outpatient therapist would like to discuss with psychiatry. I gave psychiatry their number ... they will give [him/her] a call." ED Provider Notes dated 3/22/19 at 9:29 AM by ED Attending M "I am most concerned about his/her suicidal ideation... Disposition: Signed out Pending reevaluation." ED Attending M removed as attending 7:58 PM. Patient with one-on-one suicide precautions through entire ED stay for suicide ideation. There was no documentation that patient #1 felt safe for discharge, no follow-up re-evaluation documented by oncoming ED Resident N, and no social service note to set up services with DCCC.

On 3/26/2019 at 8:40 AM during interview with Social Work Manager (SWM) R, SWM R stated if social services would have been requested to assist with outpatient placement, there would have been a note in Patient #1's medical record, "we were not asked" to set up services with DCCC.

On 3/26/2019 at 1:25 PM during interview with ED Residents J and N and ED Attending M confirmed they did not know what information was shared after 6:05 PM between Psychiatric Resident K and Patient #1's outpatient care providers.
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview the facility failed to appropriately transfer patients according to the facility's policies and procedures in 3 of 6 patients transferred from the Emergency Department (ED) (Patient #8, Patient #18 and Patient #20) in a total sample of 20 medical records reviewed.

Findings include:

Review of "Patient Transfer Form Instructions" dated 12/05/18 referring to Patient Transfer Form #UWH 5-DT revealed "These forms should be completed each time a patient is transferred out of a... ED (Emergency Department)... For each transfer out of the ED, complete the following: Patient Transfer Form Part A: Complete Sections 1 and 2 for all transfers."





Patient #8's medical record was reviewed and revealed Patient #8 was a [AGE]-year-old who arrived to the ED 2/11/19 at 11:49 AM for suicidal ideation and was transferred to an acute behavioral health facility 2/11/19 at 8:45 PM. Patient Transfer form page 1, section 1, physician/qualified medical person date and time lines are blank. Page 3 Authorizing Signatures, physician box, date and time lines are blank.

Patient #18's medical record was reviewed and revealed Patient #18 was a [AGE]-year-old who arrived at the ED 2/28/19 at 8:00 AM with the chief complaint of hallucinations and was transferred to an acute behavioral health facility by ambulance 2/28/19 at 12:57 PM. There was no patient transfer form.

Patient #20's medical record was reviewed and revealed Patient #20 was a [AGE]-year-old admitted to the ED 1/16/19 at 1 PM with the chief complaint of suicide attempt and was transferred to an acute behavioral health facility 1/16/19 at 8:42 PM. Patient Transfer Form Page 1 Section 2 of the "Date/time of MD contact" and "Date/time of RN contact" left blank, page 2 section 2 "Time" line blank, Page 3 Authorizing Signatures box, "Print Name", "Relationship" lines are blank and no box was marked for "Patient is: Legal Authority". Patient is a minor.

On 3/26/19 at 10:00 AM during interview with Director of Nursing F, F confirmed Patient #8 and Patient #20's transfer forms should be complete, including date, time and authorizing signature information.

On 3/26/19 at 11:25 AM during interview with Director of Emergency Services P, P confirmed there was no transfer form in Patient #18's medical record. Director of Emergency Services P confirmed "transfer forms should be completed on all transfers."