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.

ST NICHOLAS HOSPITAL 3100 SUPERIOR AVE SHEBOYGAN, WI 53081 Sept. 23, 2019
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on record review and interview staff failed in its resolution of a grievance, to provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion in 2 out of a total sample of 4 grievance files reviewed.

Findings
Review of facility policy "System Complaint/Grievance" last revision date 7/25/2019 under 2. Investigation c. it states in part,"all documents related to complaints/grievances (letters from the complainant/grievant, acknowledgement and resolution letters, investigation documents) shall be scanned and attached to the complaint/grievance file in the electronic complaint/event management reporting system." Review of grievance file # 8 entered date 4/18/2019 revealed the statement, "hand written note sent." There was no note or resolution letter in the file. The file had a resolution date documented as 4/25/2019. Review of grievance file # 7 entered date 7/31/2019 revealed a letter to the complainant asking for him/her to contact the facility for discussion. There was no resolution letter in the file. The file had a resolution date of 7/29/2019.

Interview with Risk Manager C on 8/19/2019 at 3:15PM confirmed the two files did not have resolution letters and stated "I didn't know our policy said they had to have the letters in the file."
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on record review, observation and interview, 1. The facility failed to provide stablizing treatment for 1 out of a total sample of 20 patients reviewed. 2. Staff failed to ensure that all areas where emergency patients are treated have EMTALA signs regarding their rights in 1 of a total sample of 2 departments observed (Emergency Department)

Findings include:

Facility staff failed to ensure all areas where emergency patients are treated have EMTALA signs. See tag A2402.

Facility staff failed to provide stabilizing treatment prior to discharge . See tag A2407
VIOLATION: POSTING OF SIGNS Tag No: A2402
Based on observation, record review and interview, the facility failed to ensure EMTALA signs are posted in all patient waiting and emergency treatment areas in 2 of 3 patient care areas (Emergency Department Entrance, Triage, and Patient Treatment Areas).

Findings include:

On 8/19/2019 at 10:05AM during a tour of the Emergency Department area accompanied by ED RN D, EMTALA signage was observed in the main entrance and in the waiting room. No signage was noted in the patient triage room or any of the observed patient treatment rooms. This includes treatment/exam rooms 1, 2, 3, 4, 5, 7, 8, 9, 10, 11, 12 in the department out of a total sample of 15 - three rooms were occupied by patients, room #6 is radiology. ED RN D stated "there are no signs in those rooms either." This was confirmed in interview with Quality Staff B at 10:40AM who stated "we have never had signs in our rooms, we have them in the waiting room."

Review on 8/19/2019 of facility Policy Screening Treatment and Transfer (EMTALA) policy # GN-009 last reviewed 5/02/2017 revealed under E. 4. Notification/Communication, "the hospital shall post signs throughout the ED and Labor and Delivery (entry, waiting room, registration area, and exam, treatment and triage rooms), as well as in the general hospital entryways and registration areas." This verbiage was confirmed with Quality Staff B on 8/19/2019 at 4:00PM.
VIOLATION: STABILIZING TREATMENT Tag No: A2407
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, staff failed to provide stablizing treatment prior to discharge in 1 of 20 patients reviewed (Patient #1) in a total sample of 20.

Findings include:

Patient #1's medical record was reviewed on 8/18/2019 at 11:30AM accompanied by Emergency Department (ED) Nurse D and again reviewed on 9/23/2019 at 9:45AM by surveyor . Review of the medical record revealed Patient #1 (MDS) dated [DATE] at 10:41AM with chief complaint of chest pain, nausea/vomiting, headache, history of alcohol abuse and a fall 2 days prior where the patient hit the back of the head. Patient complained that the headache was related to the fall and he/she was worried about that injury. Patient requested admission for alcohol detoxification and depressive symptoms. Patient #1 was triaged at 10:44AM and seen by the ED MD H at 10:46AM. ED MD H ordered labs, including alcohol level, an EKG, chest x-ray and a CT scan of the head without contrast. Patient revealed to ED MD H, "a history of withdrawal seizure last year, and states he/she is concerned that he/she lives alone and could have that again."

Labs revealed an elevated blood alcohol level of 0.390 (reference range <0.010), normal chest x-ray and EKG, head CT impression, "8mm x 9mm left frontal lobe lesion. Suspect changes are present atypical [DIAGNOSES REDACTED] (a usually benign vascular tumor derived from blood vessel cell types). Subacute frontal lobe hemorrhagic contusion can have similar appearance although this is considered less likely. Surveillance imaging may be helpful. Follow-up MRI on a nonemergent basis may be helpful."

Medical record review revealed vital signs documented at 10:57AM, 11:00AM, 11:30AM, noon, 12:30PM, 12:45PM, 1:00PM, and 1:15PM. At 1:53PM patient's disposition was documented as "observation". Patient #1 received intravenous fluids and electrolye replacements. Nurses notes revealed a nursing assessment in triage, a note that patient was given "food and drink" at 1:30PM, a note at 2:52PM, "resting comfortably", and a discharge time of 5:10PM.

Medical record review revealed that the facility attempted to secure a transfer to the Aurora behavioral health unit but the transfer was declined as Aurora stated, "they do not accept pure medical detox from another facility that has capability to detox medically." Interview with Director A at 3:00PM confirmed that St. Nicholas Hospital does admit and care for patients with a diagnosis of [DIAGNOSES REDACTED]"handed off to the oncoming provider, ED provider I, stating that Patient #1 was not in withdrawal, was medically stable for discharge, and was in need of a substance abuse program."

Patient #1 was discharged with instructions to "go straight to Aurora for medical treatment." The patient was discharged to a friend and transported by private vehicle. There was no transfer paperwork in the medical record. The last vital signs were documented at 1:15PM; there was no documentation that the patient was not actively withdrawing at the time of discharge, no neurological checks or physical assessments. Review of the medical record did not document any discharge instructions or needed follow-up for the abnormality seen on the CT scan.