Based on observation, record review and interview, the facility failed to ensure EMTALA signs are in place, in 1 of 2 areas observed (Emergency Department); a Medical Screening Exam is performed on patients that arrive at the facility, in 1 of 20 medical records reviewed (#1) and Transfer documents are complete with risks and/or benefits in 5 of 20 medical records reviewed (#3, 9, 16, 17 and 19). The cumulative effect of these deficiencies potentially affect all patients requesting emergency treatment at the facility. Findings include: The facility failed to ensure EMTALA signs are placed in all lobbies and treatment areas in 1 of 2 observations (Emergency Department waiting rooms). See tag A2402. The facility failed to ensure patients received a Medical Screening Exam to rule out a medical emergency upon arrival to the emergency room , in 1 of 20 medical records reviewed(#1). See tag A2406. The facility failed to ensure transfer documents are completed, including risks and/or benefits of the transfer and/or physician to physician contact documented for patients referred to other facilities, in 5 of 20 medical records reviewed (#3, 9, 16, 17 and 19). See tag A2409.

Based on observation and interview, the facility failed to ensure EMTALA signs are placed in all lobbies and treatment areas in 1 of 2 observations (Emergency Department waiting rooms). This deficiency potentially affects all patients seen in the Emergency Department. Findings include: Per observation on 2/27/17 at 3:00 PM, there are no EMTALA signs in two of the three waiting rooms in the Emergency Department. Per interview with Accreditation Manager B on 2/27/17 at 3:00 PM, Manager B confirmed this deficiency and was not aware the signs should be in all the waiting rooms in the Emergency Department.

Based on record review and interview, the facility failed to ensure patients received a Medical Screening Exam to rule out a medical emergency upon arrival to the emergency room , in 1 of 20 medical records reviewed (#1). This deficiency potentially affects all patients that arrive for emergency care at the facility. Findings include: Per review of facility policy titled Obstetrical Patient Care in the Emergency Department Policy NW (northwest) WI (Wisconsin) Region, dated 1/3/17, it states under #1. "All obstetrical patients (antepartum, peripartum, or postpartum) regardless of gestation, who present to the medical center with an emergency medical condition requiring stabilization, will receive such treatment in the Emergency Department...4. All pregnant patients presenting to the Emergency Department equal to or greater than 20 weeks gestation with complaints concerning for active labor or obstetric emergency will be directly transported to Family Birth Center for medical screening exam and stabilization..." Per review on 2/27/17 at 10:30 AM of registration records for Patient #1, it revealed Patient #1 arrived in the Emergency Department on 2/19/17 at 12:05 AM. The record included assignment to room # and a note by Clerk H "02/19/17 00:24:58 (12:24:58 AM) Comment by (Clerk H) l/d (labor and delivery) nurse stated both ob (obstetric) doctors in surgery no one for problematic pregnancy, sent to (other Eau Claire hospital) per ob nurse." This is confirmed in interview with Accreditation Manager B on 2/27/17 at 10:30 AM, adding there were no other records for Patient #1. Per interview on 2/28/17 at 11:25 AM with Registration Clerk H, when Patient #1 arrived with a midwife, who thought the patient had a breech presentation. Clerk H said s/he called labor and delivery (Birth Center) got a room number and doctor assigned. Clerk H said an obstetric nurse came down to take Patient #1 to the Birth Center. Clerk H said s/he observed the nurse stop with the patient in the hall, could not hear what they were saying, and saw the nurse bring the patient back towards the registration desk. Clerk H said s/he was told both Obstetric physicians were in surgery and are "not available". Per Clerk H s/he said "Due to circumstances, called (other Eau Claire hospital) as a courtesy call." Obstetric Nurse E stated in interview on 2/27/17 at 10:15 AM s/he received a call from Registration that there was a patient to be seen in the Emergency Department, who was with a midwife and may have a baby that was breech. Nurse E said the midwife did all the talking, thought the baby was breech due to no progression (with labor). Per Nurse E, while enroute to the Birth Center, s/he received a call from another nurse in the Birth Center saying both physicians can't see the patient. Nurse E said s/he asked them to wait, and told them "We can't have an OB (obstetric physician) safely treat you, but we will transfer you." They did not want to wait saying "OK, we'll go there, our driver is still here" and requested a call be placed to the other hospital. When questioned on the condition of the patient, Nurse E said Patient #1 had one contraction, but was not about to deliver. Per telephone interview with Obstetric Physician F on 2/27/17 at 11:40 AM, s/he was called in to assist with a hemorrhaging patient that required a hysterectomy. Physician F said "We were not very far in (the procedure) when notified of a transfer breech patient coming", Physician F added "I told them (circulator nurse) we are not accepting transfers." When asked if s/he was informed the patient was on the premises, Physician F said s/he was not aware the patient was in the building. The Operating Room Nurse Circulator I said in interview on 2/27/17 at 12:40 PM s/he took the call in the Operating Room, can could not recall if s/he knew Patient #1 was in the building, but stated "Doctor (F) said to tell them they could not admit, I think the word accept was used."

Based on record review and interview, the facility failed to ensure transfer documents are completed with documented risks unique to the patient and/or benefits, in 5 of 20 medical records reviewed (#3, 9, 16, 17 and 19). This deficiency potentially affects all patients that request emergency treatment at the facility. Findings: Per review of facility policy titled Emergency Medical Treatment and Active Labor Act (EMTALA) Policy, dated 5/31/16, it states under Transfer Out 3.c.vii. "Complete the 'Physician Certification of Need for Transfer Medical Necessity Information' form certifying in writing that based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of medical treatment available at another facility outweigh the increased risks to the patient...The certification shall contain a summary of the risks and benefits upon which this decision is based..." Patient #3's medical record review on 2/27/17 at 11:00 AM revealed Patient #3 arrived in the Emergency Department on 11/30/16 at 7:25 PM with a complaint of bleeding at 29-6/7 weeks of pregnancy. Patient #3 was transferred to a facility that could care for a premature infant. The Physician Certification of Need for Transfer completed on 12/1/16 at 12:39 AM, states general transfer risks with no documentation of unique risks related to Patient #3's bleeding and pregnancy. This deficiency is confirmed in interview during record review with Registered Nurse D on 2/27/17 at 11:00 AM. Patient #9's medical record review on 2/17/17 at 11:35 AM revealed Patient #11 arrived in the Emergency Department on 12/1/16 at 5:00 PM with a complaint of high blood pressures with pregnancy at 32 weeks. Patient #9 was transferred to a facility that could provide a higher level of care for the diagnosis of pre-eclampsia (high blood pressures where untreated could result in death). The Physician Certification of Need for Transfer completed on 12/1/16 at 5:10 PM states a general risk of "Medical condition could worsen during transport." There is no documentation of unique risks to Patient #9's pre-eclampsia. This deficiency is confirmed in interview during record review with Registered Nurse D on 2/27/17 at 11:35 AM. Patient #16's medical record review on 2/27/17 at 1:15 PM revealed Patient #16 arrived in the Emergency Department on 11/9/16 at 10:26 AM with a complaint of a fever. Patient #16, a 5 year old, was transferred to a facility that could care pediatrics. The Physician Certification of Need for Transfer completed on 11/9/16 at 1:30 PM, states general transfer risks with no documentation of unique risks related to Patient #16's diagnosis of a fever and receiving chemotherapy. This deficiency is confirmed in interview during record review with Registered Nurse M on 2/27/17 at 1:15 PM. Patient #17's medical record review on 2/27/17 at 1:22 PM revealed Patient #17 arrived in the Emergency Department on 10/3/16 at 8:03 AM with a complaint of seizure. Patient #17, a 10 year old, was transferred to a facility that could care pediatrics. The Physician Certification of Need for Transfer completed on 10/3/16 at 09:15 AM, states general transfer risks with no documentation of unique risks related to Patient #17's diagnosis of shock, seizure disorder and metabolic acidosis (increased acid in the blood). This deficiency is confirmed in interview during record review with Registered Nurse M on 2/27/17 at 1:22 PM. Patient #19's medical record review on 2/27/17 at 1:45 PM revealed Patient #19 arrived in the Emergency Department on 9/17/16 at 2:08 PM with a complaint of a headache. Patient #19, was transferred to a facility for treatment of a brain mass. The Physician Certification of Need for Transfer completed on 10/20/16 at 5:20 PM, states general transfer risks with no documentation of unique risks related to Patient #19's diagnosis of a brain mass, and there are no benefits of the transfer listed. This deficiency is confirmed in interview during record review with Registered Nurse M on 2/27/17 at 1:42 PM. Per interview with Director C, Nurse Administrator K, and Nursing Administrator L on 2/27/17 at 3:20 PM they agree the transfer forms should be complete, including unique risks.