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.

AMERY HOSPITAL & CLINIC 265 GRIFFIN STREET EAST AMERY, WI 54001 June 28, 2018
VIOLATION: EMERGENCY SERVICES Tag No: C0880
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, interview, and record review, the hospital failed to ensure patients seeking emergency department care are appropriately triaged in 3 of 12 patient chart reviews (Patients #1, 7, and 11), failed to ensure development of policies in 4 of 4 areas within the Emergency Department (Quality, Emergencies, Urgent Care, and Registration) and failed to carry out an annual evaluation of active and closed clinical records in 1 of 1 periodic evaluation projects to ensure quality care in the Emergency Department.

Findings include:

Review of policy titled "Patient Reassessment and Reassessment Chart" Policy #41, failed to include healthcare standards of practice used to develop this policy to ensure it was current and followed standards of practice, had no date of origination, and did not have review dates.

On 6/28/2081 at 3:50 PM during interview, Vice President of Patient Care A and Vice President of Ambulatory Services B, confirmed the emergency service did not have a Standard for Emergency Care and Triage Policy available.

Additional emergency service policies reviewed:

Review of Policy titled "AHC (Amery Hospital & Clinic) Clinic RN (Registered Nurse) -- Telephone Advice, policy # CS/RN - 01 failed to include healthcare standards of practice used to develop this policy to ensure it was current and followed standards of practice, had no date of origination, or dates it was updated and reviewed.

Review of policy titled "Suicide Precautions" policy #63 failed to include healthcare standards of practice used to develop this policy to ensure it was current and followed standards of practice, had no date of origination, or dates it was updated and reviewed.

Review of the hospital's electronic health record system "Emergency Navigator" with the ED Nurse Manager F on 6/28/2018 at 7:55 AM confirmed, during the interview, the required options included: Arrival Charting, Chief Complaint, Quick Assessment, Triage Notes, ED Notes, Allergies, Vitals, Legal/Communication/Safety, Triage Complete, Home Medication, History, Immunizations, Screening, Quick Questions but nurses are not completing this documentation in the drop down boxes for the Arrival information, Arrival Charting, Chief Complaint, Quick Assessment, Legal/Communication/Safety, Home Medication, History, Screening, or Quick Questions.

During an interview with Vice President of Patient Care A on 6/28/2018 at 9:05 AM and review of Patients #2, 3, 4, 5 & 6, whose records failed to include: Vitals, Legal/Communication/Safety, Home Medication, History, Screening, or Quick Questions drop-downs.

On 6/28/2018 at 3:50 PM during an interview Vice President (VP) of Patient Care A, stated their organization does not have emergency department standard of practice or standardized Emergency Department and nursing policies. VP Patient Care A confirmed that they do not have written policies for triage of Emergency Department, nursing assessment of an Emergency Department patient on admission, or medication reconciliation. (Also see C-271)

On 6/28/2018 at 5:35 PM, observed a combined entrance for "Patient/Visitor", "Ambulance" and "Emergency Services" (see photos attached in Aspen). The entrance to the facility had a long desk with the words "Registration" above it and four registration desks. There was no hospital registration staff behind the registration desk marked "EMERGENCY REGISTRATION THIS WINDOW".

On 6/28/2018 at 9:05 AM during an interview Patient Access Clerk (PAC) E stated that someone was always behind the registration desk "24/7". PAC E stated registration covers both urgent care and emergency services. If patients come in when the Urgent Care was open and do not have an appointment, patients are given the choice of where they want to be seen. PAC E stated they use "the red list" for guidance, but had no specific training to determine who goes to urgent care and who goes to emergency services. PAC E provided the red list titled "Symptoms Indicating Need for Triage". PAC E confirmed the patients who walked in without appointments were not triaged by a licensed professional at the registration desk unless the Patient Access Clerk called the nursing line when they had questions. PAC E confirmed s/he had no specific medical or triage training.

Review of Patient # 1's medical record revealed, Patient #1 came into the registration area and an appointment was entered for Urgent Care by Patient Access Clerk L on 10/20/2017 at 1:35 PM. Patient #1 was a [AGE]-year-old who stated s/he was in a motor vehicle accident last night and had back pain. Patient #1 was seen in the Urgent Care by Physician Assistant K on 10/20/2017 at 1:40 PM, was treated with Toradol injection (for pain), a Vistaril injection (for anxiety), given 2 Percocet tablets (for pain), discharged from Urgent Care 10/20/2017 at 3:48 PM and instructed to follow-up with primary care physician. Progress notes by Physician Assistant K started on 10/20/2018 at 1:40 PM, filed on 10/20/18 at 4:04 PM, under Assessment/Plan revealed, "patient was demonstrating extreme drug seeking behavior ... extremely anxious with me and demanding more for pain." Patient was discharged from Urgent Care 10/20/2017 at 3:48 PM. There is no documentation that Patient #1 was triaged by a registered nurse on arrival. After discharge Patient #1 went into a bathroom, locked the door, and cut his/her throat with a box cutter. On 10/20/2018 at 4:39 PM patient #1 was admitted to the Emergency Department by Patient Access Clerk X for suicide attempt. An unsuccessful attempt was made to control Patient #1's bleeding in the Emergency Department and Patient #1 was transferred to a trauma center by helicoper and eventually expired.

Patient #7's medical record revealed Patient #7 was registered for an Urgent Care on 6/28/2018 at 10:19 AM by Patient Access Clerk E complaining of "fever/sweats/headache." There was no documentation of the degree of the patient's temperature or severity of the patient's pain documented at the time the appointment was made. There was no documentation that the patient caller was transferred directly to Registered Nurse for triage as per hospital policy.

Patient #11's medical record revealed Patient #11 was registered for an Urgent Care visit on 11/25/2017 at 11:32 AM by Patient Access Clerk Q, with Doctor P. Notes documented by Patient Access Clerk Q revealed "swollen glands sore throat hard to swallow X 3 days fever also." There was no documentation of the degree of the patient's temperature. Patient #11 was checked in to Urgent Care on 11/25/2017 at 12:27 PM by Patient Access Clerk O with the chief complaint of "dysuria" (pain on urination), however there was no documentation that patient #11 was transferred directly to Registered Nurse for triage as per hospital policy. (Also see C-294).

On 6/28/2018 at 7:55 AM during an interview, Emergency Department Nurse Manager F stated, when asked if s/he had done any emergency service audits on patient medical records, "not officially".

On 6/28/2018 at 12:35 PM during an interview, Quality Director H stated a peer review and suicide risk analysis of Patient #1's hospitalization on [DATE] was completed. Quality Director H confirmed there were no findings from the peer review, no outcome from the suicide risk analysis, and no documented incident report stating " Legal Risk told us to do peer review on this case only and that was what we did." (Also see C-333)

The cumulative effects of these systematic failures resulted in the facility's inability to ensure the emergency services provided standardized quality health in a safe environment.
VIOLATION: PATIENT CARE POLICIES Tag No: C1006
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on record review and interview, the hospital failed to ensure development of policies in 4 of 4 areas with the Emergency Departments (Emergency Department, Quality, Urgent Care, and Registration).

Findings include:

Review of policy titled "Patient Reassessment and Reassessment Chart" Policy #41, revealed there were no listed healthcare standards of practice referenced for the development of this policy, there was no date of origination, no date this policy was updated or reviewed.

On 6/28/2018 at 7:55 AM during an interview, ED Nurse Manager F confirmed the Emergency Department did not have a standard for emergency health care or emergency triage policy available.

Review of the hospital's electronic health record system "Emergency Navigator" with the ED Nurse Manager F on 6/28/2018 at 7:55 AM revealed staff are to document the following information: Arrival Information, Chief Complaint, Triage Plan, Arrival Charting to include Suicide Assessment, Prehospital Treatment, Language Assistance, Infectious Disease screening, Pain, Allergies, Vitals, Glascow Coma Scale (to assess awareness), Medication Reconciliation, Medical History, Surgical History, Social History which consists of alcohol, drug, and tobacco use, Family History, Fall Risk, Suicide Screening, Violence Assessment, Advance Directives, Devices/Implants/Pumps, and Religious Beliefs/Values.

Review of medical records for patient #2, 3, 4, 5 & 6 revealed the electronic health record for patients 2, 3, 4, 5 & 6 were incomplete. All five emergency department records failed to include a suicide or falls assessment, Patient #3 had no medication reconciliation, social history with alcohol or tobacco use, Patient #4 was missing medication reconciliation, social history of tobacco use, and vital signs.

Review of Policy titled "AHC (Amery Hospital & Clinic) Clinic RN (Registered Nurse) -- Telephone Advice, policy # CS/RN - 01 (not dated) revealed under Procedure, #1 "Patient Access team [registration] will... route messages to PCP's [primary care providers] care team or Clinic RN" (registered nurse) ... The call will be addressed by either an MA [Medical Assistant] or RN [Registered Nurse]. There were no references used for the development of this policy or dates of origination or review.

Review of Patient #1, 7, and 11's medical record revealed Patient #1, 7, and 11 were not referred to a licensed medical staff. Unlicensed registration staff determined patient # 1, 7 and 11 would be seen in urgent care.

Review of policy titled "Suicide Precautions" policy #63 revealed no emergency or mental health care standards of practice were referenced for the development of this policy, and had no date of origination, or dates it was updated or reviewed.

Review of the attendance education "Suicide Prevention 2018 Annual Mandatory Education" confirmed not all staff completed the annual suicide prevention training.

On 6/28/2018 at 1:50 PM during an interview, Quality Director W and Vice President (VP) Patient Care A stated that all nursing staff and physician assistants were required to complete the Suicide Prevention Education annually. Quality Director W confirmed that annual Suicide Prevention Education was mandatory, but could not provide a written policy.

Review of Patient #1s medical record from Urgent Care revealed no licensed staff triage documented, however Patient #1, a [AGE] year old white male, was sent to urgent care on 10/20/2017 to be seen after complaining about being in a motor vehicle accident the day before. Urgent Care visit was completed by Physician Assistant (PA) K on 10/20/2017 at 1:40 PM. PA K discussed with ED physician Y that patient #1 had drug seeking behaviors and history of chronic pain. Patient #1 was treated and discharged [DATE] at 3:48 PM. No documentation was found to address or treat Patient #1 for thoughts of suicide.

Review of Patient #1's medical record from Emergency Department admission revealed after discharge from Urgent Care, Patient #1 went into a bathroom, locked the door, and cut his/her throat with a box cutter. On 10/20/2018 at 4:39 PM patient #1 was admitted to the Emergency Department by Patient Access Clerk X for suicide attempt. An unsuccessful attempt was made to control Patient #1's bleeding in the Emergency Department and Patient #1 was transferred to a trauma center by helicoper and eventually expired.

On 6/28/2018 at 1:50 PM during an interview, Vice President (VP) Patient Care A confirmed that Physician Assistant K had never completed the Suicide Prevention Education.

On 6/28/2018 at 7:55 AM during an interview, Emergency Department Nurse Manager F stated there were no written policies on nursing assessments and could not provide the policy "Standard for Emergency Care and Triage Policy" referred to in the "Patient Reassessment and Reassessment Chart Policy" #41. F stated that the expectation was for the registered nurses to complete the Emergency Department Navigator on each patient entirely. F stated that s/he had identified that nursing electronic health record documentation was not consistently completed.

On 6/28/2018 at 9:30 AM during an interview, Patient Access Director G stated that patients were given a choice to be seen in the Emergency Department or Urgent Care. G confirmed there were no written policies for registration of a patient to the Urgent Care or Emergency Departments.

On 6/28/2018 at 3:50 PM during an interview Vice President (VP) of Patient Care A and VP of Ambulatory Services B, VP Patient Care A stated their organization was aware the emergency department lacked standardization of healthcare practices and standardized emergency healthcare policies. Both VP Patient Care A and VP Ambulatory Services confirmed that they do not have written policies for triage urgent care or emergency services, nursing assessment for the emergency department, patient admission documentation, and medication reconciliation.
VIOLATION: NURSING SERVICES Tag No: C1046
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, interview, and record review, the hospital failed to ensure patients seeking Emergency Department care are appropriately triaged in 3 of 12 patient (Patients #1, 7, and 11) and 2 of 2 patients interviewed in Urgent Care (Patient #7 and 8).

Findings include:

On 6/28/2018 at 5:35 PM, observed a combined entrance for "Patient/Visitor", "Ambulance" and "Emergency Services" (photos attached in ASPEN). The entrance to the facility had a long desk with the words "Registration" above it and four registration desks. There was no hospital registration staff behind the registration desk marked "EMERGENCY REGISTRATION THIS WINDOW".

On 6/28/2018 at 9:05 AM during an interview Patient Access Clerk (PAC) E stated that someone was always behind the registration desk "24/7" marked EMERGENCY REGISTRATION. PAC E stated patients were given the choice of where they want to be seen (urgent care or emergency services). PAC E stated they use "the red list" for guidance. PAC E provided the red list titled "Symptoms Indicating Need for Triage". PCA E stated s/he did not have any specific medical training. PAC E confirmed the patients who walked in without appointments were not triaged by licensed staff unless the Patient Access Clerk called the nursing line when they had questions.

On 6/28/2018 at 9:05 AM during an interview with Patient Access Clerk (PAC) E who was sitting behind the area marked Emergency Registration desk, E stated that someone was always behind the registration desk "24/7" marked EMERGENCY REGISTRATION. PAC E stated Urgent Care hours were 10 AM - 7 PM Monday through Friday and 9AM to 1 PM Saturday and Sunday. If patients come in when the Urgent Care was open and do not have an appointment, patients were given the choice of where they want to be seen. PAC E stated they use "the red list" for guidance. PAC E provided the red list titled "Symptoms Indicating Need for Triage". PCA E stated s/he did not have any specific medical training. PAC E confirmed the patients who walked in without appointments were not triaged by a Registered Nurse or other medically trained person unless the Patient Access Clerk called the nursing line when they had questions.

Review of record titled "Symptoms Indicating Need for Triage" revealed a typed message beginning with the word NOTE bolded "Please familiarize yourself with these symptoms to best determine whether it is an emergent or nonemergent call." Listed under Emergent: " warm transfer caller directly to RN [Registered Nurse] for triage" was "Fever... adult 103 or greater...Headache - worst ever or vomiting... Swollen face/Throat... Urination-Inability to urinate."

Review of Policy titled "AHC (Amery Hospital & Clinic) Clinic RN (Registered Nurse) -- Telephone Advice, policy # CS/RN - 01 (not dated) on 6/28/2018 at 9 AM revealed under Procedure, #1 "Patient Access team will... route messages to PCP's [primary care providers] care team or Clinic RN" (registered nurse) ... The call will be addressed by either an MA [Medical Assistant] or RN [Registered Nurse].

Review of job description of the Patient Access Clerk revealed , Department : Patient Access Registration/Scheduling Final Approval: Manager of Patient Access, Date Approved: left blank, Date revised: left blank. Under Essential Duties as Applicable revealed "Accurately and appropriately schedules patients.... 4. Other duties and responsibilities... Answer incoming calls for facility, and warm transfer if transfer is needed." Under Education/Experience: "Education: High School Diploma or equivalent, Experience: 2 years related office experience."

On 6/28/2018 at 9:40 AM during an interview with Patient Access Clerk J, J stated when patients call to access their services or when they walk in without an appointment, " I triage them according to our online CMP" (Care Model Process). They are asked who they want to see, the reason why they want to be seen, their symptoms, and we use the online CMP and Triage List for guidance. They have a RN (Registered Nurse) "Red Line" we can forward to the Registered Nurse if they have any questions on where they should be seen, and after hours and weekends they can forward the call to their after-hours nurse line. Patient Access Clerk J confirmed not all patient calls listed under Emergent/Urgent on the Triage List are sent directly to an RN for triage as instructed in the Care Model Process phone triage instructions.

Patient # 1's medical record revealed Patient #1 was a [AGE]-year-old who came into the facility stating s/he was in a motor vehicle accident last night, had back pain, and wanted to be seen. Patient #1 was triaged by registration (Access Clerk L) and sent to urgent care to be seen by Physician Assistant K on 10/20/2017 at 1:35 PM. Patient #1 was assessed, treated, and discharged [DATE] at 3:48 PM by Physician Assistant K who documented patient #1 was drug seeking and instructed to follow-up with primary care physician. On 10/20/2017 at 4:12 PM patient was found in the bathroom, s/he had cut his/her throat with a box cutter and later died .There was no documentation that Patient #1 was triaged by a registered nurse when presenting at the registration desk. There was no documentation of a suicide assessment.

Patient #7's medical record revealed Patient #7 was registered for an Urgent Care visit per policy on 6/28/2018 at 10:19 AM by Patient Access Clerk E complaining of "fever/sweats/headache." There was no documentation of the degree of the patient's temperature or the severity of the patient's headache documented at the time the appointment was made. There was no documentation that the patient caller was transferred directly to Registered Nurse for triage per policy.

Patient #11's medical record revealed Patient #11 was registered for an Urgent Care visit with Doctor P, on 11/25/2017 at 11:32 AM by Patient Access Clerk Q, notes "swollen glands sore throat hard to swallow X 3 days fever also." There was no documentation of the degree of the patient's temperature. Patient #11 was checked into facility on 11/25/2017 at 12:27 PM by Patient Access Clerk O with the chief complaint of "dysuria" (pain with urination). There was no documentation that the patient caller was transferred directly to Registered Nurse for triage per policy.

On 6/28/2018 at 9:30 AM during an interview Patient Access Director G stated that patients were given a choice to be seen in the Emergency Department or Urgent Care and confirmed there was no written policy for admission of a patient to the Urgent Care or Emergency Departments.

On 6/28/2018 at 3:50 PM during an interview with Vice President Ambulatory Services B, B stated that there were no written policies for patient triage. B confirmed that all patients are not triaged by medically trained staff and that they do not have a written triage policy.
VIOLATION: PERIODIC EVALUATION OF PATIENT RECORDS Tag No: C0333
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview, and record review, the hospital failed to carry out an annual evaluation of both active and closed clinical records to ensure quality care in the Emergency Department in 1 of 1 Emergency Departments.

Findings include:

Review of policy titled "Patient Reassessment and Reassessment Chart" Policy #41, with no date, under 3.7 Emergency Department: a. "An adult assessment will be completed by the RN [Registered Nurse] upon patient presentation, the content of which is defined by the EMR [Electronic Medical Record] through the "ED [Emergency Department] Navigator."

Review of the required electronic medical record documentation in the Emergency Navigator with ED Nurse Manager F on 6/28/2018 at 7:55 AM included suicidal assessments of all Emergency Department patients.

Patient # 1's medical record revealed Patient #1 was a [AGE]-year-old who came into the facility stating s/he was in a motor vehicle accident last night, had back pain, and wanted to be seen. Patient #1 sent to urgent care on 10/20/2017 at 1:35 PM. Patient #1 was assessed, treated, and discharged [DATE] at 3:48 PM by Physician Assistant K who documented patient #1 was drug seeking and instructed to follow-up with primary care physician.

On 10/20/2017 at 4:12 PM patient was found in the bathroom, s/he had cut his/her throat with a box cutter and later died .There was no documentation that Patient #1 was triaged by a registered nurse when presenting at the registration desk. There was no documentation of a suicide assessment.

Emergency Department medical record review of patients #2, 3, 4, 5 & 6 revealed no suicide assessments were documented.

On 6/28/2018 at 7:55 AM during an interview Emergency Department Nurse Manager F, F stated the expectation was for the Emergency Department Registered Nurses to complete the Emergency Department Navigator on each patient completely which would include a suicide assessment of each ED patient. When asked if s/he had done any audits or record reviews, ED Manager F stated "not officially".

On 6/28/2018 at 10:10 AM during an interview, Chief Medical Officer (CMO) Z confirmed suicide assessments are not required for urgent care patients and was not aware of the suicide assessment requirements for ED patients.

On 6/28/2018 at 12:35 PM during an interview, Quality Director H stated a peer review and suicide risk analysis of Patient #1's hospitalization on [DATE] had been completed by the facility and Quality Director H confirmed there were no findings. Quality Director H stated there was no documentation of the peer review or suicide risk analysis available.