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.

WAUKESHA MEMORIAL HOSPITAL 725 AMERICAN AVE WAUKESHA, WI 53188 July 10, 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 2 of 11 required areas: 1) Appropriate Medical Screening Examination and 2) Stabilizing Treatment.

Findings include:

Facility failed to provide an appropriate medical screening examination to determine whether or not an emergency medical condition existed. See tag 2406

Facility failed to ensure patients who presented to the emergency room with an emergency medical condition received stabilizing treatment to ensure patient's safety. See tag 2407
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on record review and interview the medical staff failed to provide an appropriate medical screening examination to determine whether or not an emergency medical condition existed by failing to follow hospital policies and procedures that are consistent with applicable State law in 2 of 3 patients who left without being seen (Patient #6 & #8) and 1 of 2 patients who left against medical advice (Patient #18) in a total of 19 medical records reviewed.

Findings include:

Review of the facility policy titled "Emergency Detention Involuntary Commitment under Mental Health Act" last review date 9/13/2016 Purpose revealed "Provide guidelines for the emergency detention and/or involuntary commitment of individuals." Policy 1) a. "Emergency Detention or Involuntary Commitment is appropriate when an individual is mentally ill ...) A substantial probability of physical harm to himself or herself, manifested by evidence of recent threats of, or attempts at suicide." Under Procedure 2) "Treatment Director... responsibilities. a) Determine whether to detain. Upon delivery of the individual to the hospital, .. shall determine ... whether the individual shall be detained."

Review of policy titled "Against Medical Advice (AMA) Patient Leaving" last review date of 8/16/2016 under documentation a) All patients ... requesting to leave AMA shall be asked to sign a release form that states the risks and potential complications of leaving the facility ... b) ...If the patient ... refuses to sign the form ...the form should be filled out, read to the patient, and witnessed by the health care personnel present, and the statement "Signature Refused" shall be written on the patient signature line ... Nursing staff should document in the patient's record ... whether the appropriate form was signed."

Patient #6's medical record was reviewed and revealed Patient #6 presented to the Emergency Department 6/14/19 at 4 AM themselves requesting mental health evaluation and admission. RN H's nursing note (NN) dated 6/14/19 at 5 AM revealed "does not want inpatient mental health assistance ... declines additional evaluation/intervention." Discharge disposition in ED log "Left Without Being Seen - After Triage". No explanation of the risks and benefits of the examination and treatment or request to sign refusal form documented. No refusal of examination or treatment form in medical record.

Patient #8's medical record was reviewed and revealed Patient #8 presented to the Emergency Department 6/13/19 at 3:55 PM by ambulance, Emergency Medical Service (EMS) Pre-Hospital Report Form dated 6/13/19, not timed, revealed chief complaint "faint/lightheaded" hand-written in, EMS Interventions "court room at jail" hand-written in. Provider note (PN) by ED Physician I dated 6/13/19 at 4:16 PM revealed "left without being seen." NN dated 6/13/18 at 4:33 PM by RN J revealed "Patient became increasing agitated and walked out." Discharge disposition in ED log "Left Without Being Seen - Before Triage." No explanation of the risks and benefits of the examination and treatment or request to sign refusal form documented. No refusal of examination or treatment form in medical record.

Patient #18's medical record was reviewed and revealed Patient #18 presented to the ED 6/18/18 at 7:32 PM by ambulance in police custody for medical clearance. ED Provider note by Physician K dated 6/18/18 at 9:18 PM revealed "refused physical examination or work-up at this time." Discharge disposition in ED log "AMA". Discharge disposition Page 1 "Discharge Information" dated 6/18/19 at 9:22 PM revealed "Home Or Self Care". No request to sign refusal form documented. No refusal of examination or treatment form in medical record.

On 7/10/19 at 8:11 AM during interview with VP Critical Care/Specialty Services B, VP B stated when a patient is refusing a medical screening or leaving against medical advice VP B stated it is "not in our practice" to have the RN sign a refusal form prior to discharge or document their refusal, and confirmed there were no refusal of treatment forms in the patient's medical records.
VIOLATION: STABILIZING TREATMENT Tag No: A2407
Based on record review and interview the facility failed to ensure patients who presented to the emergency room with an emergency medical condition (EMC) received stabilizing treatment to ensure patient's safety within it's capability prior to 1 of 4 patients discharged home (Patient #1) and failed to follow hospital policies and procedures that are consistent with applicable State law in 1 of 2 patients who left against Medical advice (Patient #19) in a total of 19 medical records reviewed.

Findings include:

Review of the facility policy titled "Emergency Detention Involuntary Commitment under Mental Health Act" last review date 9/13/2016 Purpose revealed "Provide guidelines for the emergency detention and/or involuntary commitment of individuals." Policy 1) a. "Emergency Detention or Involuntary Commitment is appropriate when an individual is mentally ill ...) A substantial probability of physical harm to himself or herself, manifested by evidence of recent threats of, or attempts at suicide." Under Procedure 2) "Treatment Director... responsibilities. a) Determine whether to detain. Upon delivery of the individual to the hospital, .. shall determine ... whether the individual shall be detained."

Review of policy titled "Emergency Medical Treatment and Active Labor Act (EMTALA) reviewed last 2/08/2019 under definitions "Transfer: The movement (including the discharge) of a patient ... page 5 #2 "Voluntary Withdrawal. If an individual refuses to consent to treatment to stabilize an emergency medical condition ...b) ... Give the individual ... an explanation of the risks and benefits ... of the examination and treatment ... d) Obtain Written Refusal of Examination or Treatment. Take all reasonable steps to obtain the written informed refusal of the examination or treatment from the individual ... 4) ... On discharge of a stable patient, patients will be given written discharge instructions."

Review of policy titled "Against Medical Advice (AMA) Patient Leaving" last review date of 8/16/2016 under documentation a) All patients ... requesting to leave AMA shall be asked to sign a release form that states the risks and potential complications of leaving the facility ... b) ...If the patient ... refuses to sign the form ...the form should be filled out, read to the patient, and witnessed by the health care personnel present, and the statement "Signature Refused" shall be written on the patient signature line ... Nursing staff should document in the patient's record ... whether the appropriate form was signed."

Patient #1's medical record was reviewed and revealed Patient #1 presented to the Emergency Department 6/08/19 at 11:07 AM by ambulance for medical clearance, overdose, and suicidal ideation's. Provider note by Physician C on 6/08/19 at 11:05 revealed "decision was made to discharge the patient ... patient became very aggressive and threatening ... local police were contacted." NN dated 6/08/19 at 11:06 AM by RN G revealed "escorted from emergency department" by police. Discharge disposition in ED log "Discharge". There was no reassessment completed by a qualified provider to determine if Patient #1 was stable prior to discharge. Discharge instructions were in the medical record but there was no indication they were given to Patient #1.

Patient #19's medical record was reviewed and revealed Patient #19 presented to the ED 6/29/19 at 10:02 PM by ambulance in for alcohol intoxication, suicide ideation. Ambulance report dated 6/29/19 at 9:45 PM chief complaint revealed "ETOH requesting detox." Provider note by Physician Assistant L dated 6/29/19 at 11:02 PM revealed "[s/he] decided [s/he] no longer wants to stay ... Police were contacted given [his/her] reports of SI" (suicide ideation). NN dated 6/29/19 at 11:03 PM by RN M revealed "Police were contacted d/t (due to) patient's SI." Discharge disposition in ED log "AMA". Discharge disposition Page 1 "Discharge Information" dated 6/29/19 at 11:29 PM revealed "Home Or Self Care". No explanation of the risks and benefits of the examination and treatment or request to sign refusal form documented. No refusal of examination or treatment form in medical record.

Patient #19's medical record was reviewed and revealed Patient #19 presented to the ED 6/30/19 at 8:17 AM by ambulance intoxicated stating he is suicidal. Blood alcohol 0.391 on 6/30/19 at 9:18 AM. ED note by RN N on 6/30/18 at 8:36 AM revealed "informed the PT (patient) that if [s/he] continues to yell police will be called." ED note 6/30/19 at 9:41 AM by RN N revealed "asking for help, "I need Ativan, I am withdrawing.",,, [s/he does not know what [s/he] wants, to stay or go."ED NN by RN N at 6/30/19 at 9:59 AM revealed "Tried to review DC (discharge) instructions ... did not want to listen." Provider note by Physician O on 6/30/19 at 10:08 AM revealed "insisted on leaving at this time." Discharge disposition in ED log "AMA". No request to sign refusal form documented. No refusal of examination or treatment form in medical record.

On 7/09/19 at 12:43 PM during interview with Vice President (VP) Critical Care-Specialty Services B, VP B stated the discharge status was indicated as discharged for Patient #1 as they "didn't have another option."

On 7/10/19 at 11:40 AM during a telephone interview with ED Physician C, Physician C could not say if s/he would have had Patient #1 reassessed, stating Patient #1 had "no place to stay" and social service was still working with her/him. Physician C confirmed, discharge instructions were not given to the Patient #1 prior to discharge.

On 7/10/19 at 8:11 AM during interview with VP Critical Care/Specialty Services B, VP B stated when a patient is refusing a medical screening or leaving against medical advice VP B stated it is "not in our practice" to have the RN sign a refusal form prior to discharge or document their refusal, and confirmed there were no refusal of treatment forms in the patient's medical records.