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.

BAY AREA MEDICAL CENTER 3003 UNIVERSITY DR MARINETTE, WI 54143 Nov. 20, 2019
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview the facility failed to ensure that patients at risk for intentional harm to themselves or others were protected in the Emergency Department prior to discharge or transfer in 1 of 8 (Patient #14) patient medical records reviewed involving presentation to the Emergency Department with chief complaints of suicidal ideations in a total universe of 20 records.

Findings include:

The facility policy # 03 titled "Suicide Precautions" last revised 10/2019, revealed, " ...Definitions: Suicide Precautions...Includes 1:1 observation, management of environment, and safety precautions...Plan and Implementation: A. Initiate suicide precautions and 1:1 close observation if assessment of patient indicates patient is a risk based on..the Columbia Suicide Severity Rating Scale in the Emergency Department...1. Suicide precautions and 1:1 close observation may be instituted without a physician order. 2. Suicide precautions may not be discontinued without a physician order...Observer will remain with the patient at all times including during visits with family/friends, physician visits, and off unit testing...Documentation: A. Discontinuation of suicide precautions should only be considered based on physician order or cleared by evaluation from a community mental health agency as no longer dangerous to self or others...C. The observer will document q15 (every 15) minutes on the daily cares/safety flow sheet in the electronic patient chart or on a sheet that will be scanned into the record..."

Patient #14's electronic medical record was reviewed on 11/20/19 at 8:40 AM and revealed the following:

Patient #14 (MDS) dated [DATE] at 8:45 PM, accompanied by law enforcement, with a chief complaint of "Medical Clearance."

At 8:50 PM, "ED (Emergency Department) Triage Notes" revealed, "Patient brought in by police for evaluation of suicidal thoughts. Patient states that he has been having suicidal thoughts for 155 days straight. Has attempting harming (sic) himself...Patient denies any thoughts of harming others."

At 8:56 PM, the Columbia Suicide Severity Rating Scale revealed Patient #14's suicide evaluation as "High Risk." "Suicide Intervention" revealed, "...Interventions - Moderate or High Risk: Constant visual observation...Police officer involvement..."

At 10:21 PM, "ED Notes" revealed, "Adapt (sic, county crisis agency) paged."

At 10:33 PM, "Writer spoke with [first name] from adapt (sic) who will be out shortly to see pt (patient)."

At 10:39 PM, "Suicide Intervention" revealed, "Type of Legal Considerations: Police Hold."

At 11:01 PM, "ED Notes" revealed, "Adapt (sic) at bedside with patient."

On 11/17/19 "ED Provider Notes," signed at 2:23 AM revealed, "Pt (patient) to be transferred to [inpatient psychiatric hospital] to [accepting provider] in serios (sic) condition."

At 3:15 AM, "Departure Condition" revealed, "Departure Mode: In police custody."

At 3:16 AM, 6 hours and 31 minutes after arriving to the Emergency Department, "Discharge Instruction" revealed Patient #14 was transferred to the accepting inpatient psychiatric hospital.

Review of the scanned document titled, "Observation Record...Date: 11/16/19...Status: 1:1 (one to one)" revealed the following:

At 9:00 PM, "Sitter at bedside."

At 9:15 PM, "Sitter at bedside, police at bedside."

At 9:30 PM, 10:00 PM, and 11:00 PM, "Officer at bedside."

On 11/17/19 at 12:00 AM and 1:00 AM, "Adapt at bedside."

At 2:00 AM, "Police at bedside."

1 to 1 observation was not documented every 15 minutes per facility policy. There was no physician order to discontinue 1 to 1 observation, and no documentation to indicate the crisis agency determined Patient #14 was no longer a danger to himself.

During an interview on 11/20/19 at 11:25 AM, VP (Vice President) Nursing A stated, "Even if law enforcement is present, we should still be documenting 15 minute checks; that's what our policy says."
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on record review and interview, the facility failed to define individuals qualified to perform a medical screening examination in 1 of 1 bylaws of the medical staff, failed to complete a thorough medical screening examination (MSE) for 1 of 18 patients (Patient #6) who received a MSE, and failed to ensure appropriate documentation was completed for 1 of 5 patients (Patient # 5) who left against medical advice in a total sample of 20 Emergency Department medical records reviewed.

Findings include:

The facility failed to define individuals qualified to perform a medical screening examination in 1 of 1 bylaws of the medical staff and failed to complete a thorough medical screening examination in 1 of 18 patients. See Tag A-2406.

The facility failed to complete the appropriate documentation for 1 of 5 patients who left the Emergency Department against medical advice. See Tag A-2407.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the facility failed to define which individuals have been determined to be qualified to perform a medical screening exam in 1 of 1 facility bylaws of the medical staff reviewed, and failed to complete a throrough medical screening examination for 1 of 18 patients (Patient #6) out of a total of 20 Emergency Department medical records reviewed.

Findings include:

On 11/19/2019, review of the facility's document titled, "Bylaws of the Medical Staff, Rules and Regulations," signed 6/29/17, revealed no statement defining who was qualified to perform a medical screening exam.

Review of facility policy "EMTALA (Emergency Medical Treatment and Labor Act) Screening and Stabilization and Transfer" last reviewed 1/30/2018 revealed, "...5.1 Medical Screening Examinations: A MSE (Medical Screening Examination) is an examination performed by a physician or a QMP (qualified medical professional) to determine ...whether an EMC (emergency medical condition) (including active labor) exists...A physician or QMP must perform the MSE." There was no definition of which individuals were determined qualified to perform the MSE.

During an interview conducted on 11/20/19 at 12:15 PM, Director of Quality E stated, "I couldn't find anything in the bylaws defining a QMP."

Review of Patient #6's medical record on 11/19/2019 revealed a [AGE] year old who (MDS) dated [DATE] at 4:25PM with complaints of worms and lice. Additional complaints included potential head and shoulder injury as a result of a motor vehicle accident four days prior, and concerns of a family member that Patient #6 may be suffering from alcohol withdrawal. ED provider note revealed, in part, "...Thought content is delusional." "MDM (Medical Decision Making)" revealed, "Discussed getting CT head and x-ray of the left shoulder. Discussed doing blood evaluation. 6:25PM: Patient refuses head CT (x-ray of head), shoulder imaging and lab results. States 'this is a waste of my time, I know I'm not crazy.' Patient reports her husband does not believe her and does not want me to talk with her husband...Pt is discharged against medical advice before evaluation is completed."

An appropriate MSE was not completed to determine the presence of an emergency medical condition.

There was no documentation indicating Patient #6 was informed of the risks of leaving AMA or refusing the medical screening examination. There was an Informed Refusal form in the medical record which was not completed. This was confirmed in interview with ED Manager F at 8:15AM on 11/20/2019.
VIOLATION: STABILIZING TREATMENT Tag No: A2407
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview, facility staff failed to complete the appropriate documentation, per policy, for 1 of 5 Emergency Department patients (Patient #5) who left against medical advice in a total sample of 20 Emergency Department medical records reviewed.

Findings include:

Review of facility policy # 34 titled, "AMA/LWBS -Management of Patient Decisions Against Medical Advice (AMA) Leaving Without Being Seen (LWBS)," last revised 09/2017 revealed, "...To assure, to the extent possible, that patients who leave the hospital, makes transport decisions against medical advice or without being seen do so informed of the related risks and consequences...Procedure C...If the patient expresses the desire to depart AMA, the patient's nurse will present the patient with and ask him/her to sign the Against Medical Advice release Form...The form indicates the patient has been informed of the possible risks and consequences he/she will be taking when leaving against medical advice...the patient is to sign and date the form. A witness signature and date is required also...In the event the patient refuses to sign the release form, the form must be read to the patient in the presence of a witness. The individual reading the contents of the form will document this on the form, as well as sign and date, and have the witness sign and date the form." Review of Attachment A with the policy revealed a one page form with the following headings, "Informed Refusal, Recommendations, Risks, Benefits and Alternatives to Refusal, Reason for Refusal and Informed Refusal/Release from Liability." There were patient and witness signature lines and a line for date/time. The heading Informed Refusal included, in part, check boxes to indicate the following, "Informed Refusal of Treatment, Patient Leaving Hospital AMA, Informed Refusal of Medical Screening Exam/or Left Without Being Seen."

Review of Patient # 5's medical record on 11/19/2019 revealed a [AGE] year old admitted on [DATE] at 12:14PM with a complaint of drug withdrawal, nausea and chest pain. ED provider note revealed, in part, "the patient eloped prior to receiving a second troponin last test which would have medically cleared his chest pain as not likely being cardiac in nature." Medical Record revealed a discharge on 10/17/2019 at 2:38PM. There was no documentation of risks and benefits of leaving AMA and no Informed Refusal form in the medical record. This was confirmed in interview with ED Manager F at 8:18AM on 11/20/2019. ED Manager stated, "this patient is well known to us and has been aggressive to staff in the past. I would not ask my staff to have him sign the form but we should have had two witnesses sign it."