Based on record review and interview, the facility failed to ensure compliance with EMTALA (Emergency Medical Treatment and Active Labor Act) regulations in 3 of 11 required areas: 1) failed to provide appropriate medical screening exam in 1 of 20 patients (Patient # 15), 2) failed to provide policies and procedures to manage emergency department care management plans used assist with decision making when stabilizing treatment is provide in 1 of 3 patient visits (Patient #1), and 3) failed to transfer patients according to the facility's policies and procedures in 3 of 6 patients (Patient # 8, 18 & 20). Findings include: Facility medical staff failed to provide appropriate medical screening exam. See tag 2406 Facility staff failed to provide policies and procedures to manage emergency department care management plans to assist with decision making to provide stabilizing treatment. See tag 2407 Facility staff failed to transfer patients according to the facility's policies and procedures. See tag 2409

Based on record review and interview the facility failed to provide an appropriate medical screening examination to 1 of 20 patients (Patient # 15) in a total sample of 20 medical records reviewed. Findings include: Review of policy titled "Emergency Assessment at UW Health Facilities" #5.1.1 dated 10/19/2015 under IV. Procedure General a. "All patients presenting to a UW Health Emergency Department... will receive a medical screening examination." Review of Emergency Medical Treatment & Labor Act (EMTALA) "Summary of Requirements" dated 2/02/18 revealed "Treatment of patients who "come to the emergency department" requesting examination or treatment" *Provide an appropriate medical screening examination (MSE); *Provide necessary stabilizing treatment to an individual with an emergency medical condition (EMC); * If the hospital does not have the capability or capacity to provide stabilizing treatment or upon request of the patient, provide an "appropriate transfer" of an unstable individual... Important Issues to Keep in Mind... * "Clinically stable" (normal vital signs) is not the same as "stabilized" for purposes of EMTALA. *Patients in labor and patients experiencing psychiatric emergencies, if expressing suicidal or homicidal thoughts or gestures and determined dangerous to self or others, are considered to have an unstable EMC." Review of emergency department (ED) policy #4.0 "Patients Who Leave Before Disposition" dated 7/01/2017 revealed "2.) In the event the patient verbalizes intent to leave prior to seeing APP/MD/DO (Advanced Practice Provider/Medical Doctor/Doctor of Osteopathic Medicine)... if the patient refuses to wait, ED staff asks patient to sign form LWBS# 76 (Record of Patient Who Leaves Before Medical Screening Can Be Performed)... if the patient refuses to sign the form... ED staff will document refusal... notify Administrative Physician and document in Health Link." Patient #15's medical record was reviewed and revealed Patient #15 arrived in the ED in police custody on 2/14/19 at 10:29 PM. The "Patient Care Timeline" at 10:29 PM revealed "Arrival Complaint Suicidal". Vital signs were taken at 10:31 PM. Registered Nurse (RN) note 2/14/19 at 10:32 PM revealed "pt. (patient) asked if [s/he] has plans to harm [her/himself], pt states "If I had a blade I'd cut myself right now". When asked if [s/he] has thoughts of harming others [s/he] states, "It possible."... Pt yelling in triage, "Take me to jail now."... Pt placed in handcuffs in triage... Officer asked how long [s/he] would be in the ED... Pt escalating behaviors. Officers took pt out of the ED." ED note 2/14/19 at 11:24 PM (55 minutes after arrival to ED) revealed "witnessed patient being taken from waiting room." ED Physician S note 2/14/19 at 11:42 PM revealed "informed by nursing that patient was escorted out of the ED in police custody prior to MD eval... I had no contact with this patient." There was no form LWBS# 76 in patient's medical record. On 3/26/19 at 10:10 AM during interview with Director of Emergency Services P, P confirmed Patient #15 did not receive a medical screening exam and that the "record of patient who leaves before medical screening can be performed" form "should have been completed and an incident entered." On 3/26/19 at 3:40 PM during interview with Accreditation and Regulatory Specialist E, E confirmed there was no form LWBS# 76 or incident report completed for Patient #15's Emergency Department visit.

Based on record review and interview the facility failed to provide policies and procedures for management of emergency department care management plans used to assist with decision making to provide stabilizing treatment of Emergency Department patients in 1 of 5 patient visits using an emergency department care management plan (Patient #1) in a total sample of 20 medical records reviewed. Findings include: Review of Emergency Medical Treatment & Labor Act (EMTALA) "Summary of Requirements" dated 2/02/18 revealed "Treatment of patients who "come to the emergency department" requesting examination or treatment" must "Provide necessary stabilizing treatment to an individual with an emergency medical condition (EMC); * If the hospital does not have the capability or capacity to provide stabilizing treatment or upon request of the patient, provide an "appropriate transfer" of an unstable individual... Important Issues to Keep in Mind... * "Clinically stable" (normal vital signs) is not the same as "stabilized" for purposes of EMTALA... patients experiencing psychiatric emergencies, if expressing suicidal or homicidal thoughts or gestures and determined dangerous to self or others, are considered to have an unstable EMC." Review of policy "Suicide Assessment and Prevention #2.4.1 dated 10/26/2015 page 5 B iii d. revealed "If admission is unnecessary but immediate assistance is required to discharge patient into the community, Crisis Intervention of Journey Mental Health may helpful... 24 hours/day... Department of Psychiatry Consult service can be contacted... to assist with this or other plans, as appropriate." Record review of outpatient Psychotherapy Progress Notes dated 3/15/19, not timed, by on-call Licensed Professional Counselor Q revealed Patient #1 had a change in mental status "increased agitation, SI (suicidal ideation) w/plan & action", and was a severe suicide risk. Under "Action taken" revealed "encouraged hospital staff to admit for SI (suicidal ideation) ... Writer also spoke with [Psychologist/complainant A] who strongly agreed. Writer then spoke w/[J] (attending doctor), who stated that [Patient #1] would be assessed by psych. Writer did not receive a call back ... Writer later called back and was told that [Patient #1] was not admitted . Writer called [Patient #1] and spoke w/him/her. S/he was more stable but upset." Patient #1's medical record was reviewed and revealed Patient #1 presented to the Emergency Department (ED) 3/15/19 at 4:08 PM by ambulance from his/her primary care provider's clinic with arrival complaint of suicidal ideation. At 4:11 PM constant supervision was ordered by ED Resident J. At 5:08 PM RN completed the Columbia Suicide Screening which was positive and initiated the constant observation log. ED Attending note dated 3/15/2019 at 4:29 PM revealed possible overdose on gabapentin... planning on overdosing on pills." Psychiatric consult by Resident Psychiatrist K dated 3/15/19 at 5:23 PM revealed "Bio-Psycho-Social Formulation ... presents to the ED for the second time this week requesting admission ... D/c summary from last admission recommends no further hospitalization . Psychiatry Resident K further quotes Consult note 10/22/18 from ED Care Management Plan, last updated 1/23/19, "history of chronic suicidal ideation ... denies changes in [his/her] baseline passive SI (suicidal ideation) ... and an ED treatment plan including "do not admit" and "minimal provider interaction" would be appropriate." The recommendation on the psychiatry consult revealed "1. Do not admit to inpatient psychiatry 2. Patient may go to DCCC (Dane County Care Center) if [s/he] does not feel safe to go home." Addendum by ED Resident J at 6:05 PM (42 minutes after "Psychiatry Consultation Note" was submitted) revealed "I discussed with the therapist on-call for his/her outpatient therapist. [S/he] states that the patient has been decompensating ... Outpatient therapist would like to discuss with psychiatry. I gave psychiatry their number ... they will give [him/her] a call." ED Provider Notes dated 3/22/19 at 9:29 AM by ED Attending M "I am most concerned about his/her suicidal ideation... Disposition: Signed out Pending reevaluation." ED Attending M removed as attending 7:58 PM. Patient with one-on-one suicide precautions through entire ED stay for suicide ideation. There was no documentation that patient #1 felt safe for discharge, no follow-up re-evaluation documented by oncoming ED Resident N, and no social service note to set up services with DCCC. On 3/26/2019 at 8:40 AM during interview with Social Work Manager (SWM) R, SWM R stated if social services would have been requested to assist with outpatient placement, there would have been a note in Patient #1's medical record, "we were not asked" to set up services with DCCC. On 3/26/2019 at 1:25 PM during interview with ED Residents J and N and ED Attending M confirmed they did not know what information was shared after 6:05 PM between Psychiatric Resident K and Patient #1's outpatient care providers.

Based on record review and interview the facility failed to appropriately transfer patients according to the facility's policies and procedures in 3 of 6 patients transferred from the Emergency Department (ED) (Patient #8, Patient #18 and Patient #20) in a total sample of 20 medical records reviewed. Findings include: Review of "Patient Transfer Form Instructions" dated 12/05/18 referring to Patient Transfer Form #UWH 5-DT revealed "These forms should be completed each time a patient is transferred out of a... ED (Emergency Department)... For each transfer out of the ED, complete the following: Patient Transfer Form Part A: Complete Sections 1 and 2 for all transfers." Patient #8's medical record was reviewed and revealed Patient #8 was a [AGE]-year-old who arrived to the ED 2/11/19 at 11:49 AM for suicidal ideation and was transferred to an acute behavioral health facility 2/11/19 at 8:45 PM. Patient Transfer form page 1, section 1, physician/qualified medical person date and time lines are blank. Page 3 Authorizing Signatures, physician box, date and time lines are blank. Patient #18's medical record was reviewed and revealed Patient #18 was a [AGE]-year-old who arrived at the ED 2/28/19 at 8:00 AM with the chief complaint of hallucinations and was transferred to an acute behavioral health facility by ambulance 2/28/19 at 12:57 PM. There was no patient transfer form. Patient #20's medical record was reviewed and revealed Patient #20 was a [AGE]-year-old admitted to the ED 1/16/19 at 1 PM with the chief complaint of suicide attempt and was transferred to an acute behavioral health facility 1/16/19 at 8:42 PM. Patient Transfer Form Page 1 Section 2 of the "Date/time of MD contact" and "Date/time of RN contact" left blank, page 2 section 2 "Time" line blank, Page 3 Authorizing Signatures box, "Print Name", "Relationship" lines are blank and no box was marked for "Patient is: Legal Authority". Patient is a minor. On 3/26/19 at 10:00 AM during interview with Director of Nursing F, F confirmed Patient #8 and Patient #20's transfer forms should be complete, including date, time and authorizing signature information. On 3/26/19 at 11:25 AM during interview with Director of Emergency Services P, P confirmed there was no transfer form in Patient #18's medical record. Director of Emergency Services P confirmed "transfer forms should be completed on all transfers."

Based on observation and interview, the hospital failed to ensure that EMTALA (Emergency Medical Treatment and Labor Act) signage was posted in conspicuous places in the hospital's ED (emergency department) patient waiting areas, in 3 of 3 total waiting rooms (main waiting room, family waiting room and children's hospital waiting room); and in 7 of 11 treatment room observations (triage rooms 1 and 2, patient treatment rooms 7 and 14 and trauma rooms 1, 2 and 3) in a total of 44 hospital ED patient treatment rooms. Findings include: 1) During emergency department waiting room observations, on 9:20 a.m. through 9:45 a.m. on 11/16/17, the EMTALA signage was not conspicuously visible from the registration desk or for seated waiting room patients/families to the right of the registration desk. There was no observed EMTALA signage found in the children's waiting room or the family waiting room. 2) During random observations of the emergency department's patient treatment rooms on 9:20 a.m. through 9:45 a.m. on 11/16/17, there was no EMTALA signage observed in the following rooms: -triage rooms 1 and 2 -treatment rooms 7 and 14 -trauma rooms 1, 2 and 3 During interview with ED Supervisor N on 11/16/17 at 9:30 a.m., N stated that when patient care treatment rooms are open (available), the patient is brought back to the room immediately without being triaged in available triage rooms. N verified that EMTALA signage was not conspicuously visible in the main waiting area, and was not present at all in the family and children's waiting room areas and the treatment rooms observed.

Based on record review and interview, the hospital failed to ensure that medical screening examinations was not delayed, in 1 of 20 patients (Patient #1) presenting to the emergency department. Findings include: Patient #1's medical record review was conducted on 11/15/17 from 11 a.m. through 2:30 p.m. Patient #1's 11/9/17 at 8:03 p.m. through 11/10/17 at 3:09 a.m. ED (emergency department) medical record contained the UW (University of WI Hospitals and Clinic Authority) ED Hospital Encounter (progress and ED notes) and the transferring hospital's "Patient Information" facesheet. The medical record review of Patient #1's UW "Hospital Encounter" dated 11/9/17 (no time given) revealed a "progress notes" written by RN B at 8:03 p.m. on 11/9/17, and stated "Child (Patient #1) with foreign object in throat...Patient can come ground...". Continued medical record review revealed that the UW hospital was faxed a "patient information" facesheet from the transferring hospital at 8:08 p.m. on 11/9/17, which contained emergency contact, insurance, allergy, vital signs and x ray information. The 11/9/17 UW "Hospital Encounter" revealed at 8:18 p.m. that UW RN B contacted UW ED (emergency department) Physician A with information about Patient #1. Patient #1's "Hospital Encounter's ED Notes" revealed on 11/9/17 at 8:18 p.m. that UW Physician H placed telephone call to transferring hospital and documented "...patient is coming by ground transport to be seen by ENT and possibly go to OR (operating room) for removal...". Patient #1's "Hospital Encounter progress note" written by UW RN C at 8:50 p.m. on 11/9/17 revealed "Access Center was notified by admissions that the patient's Illinois Medicaid coverage has not been confirmed for patient coverage at the UW Hospital. The UW Access Center contacted the referring facility at CGH (Community General Hospital in Sterling, Ill.) and informed CGH staff in the ED that the patient may not have any insurance coverage if the patient is transferred for care to the UW hospital. The CGH staff expressed understanding and stated that they would communicate the information to the CGH ED physician." The "progress note" written by UW RN D at 11:36 p.m. on 11/9/17 revealed "received call from UW ENT (ear, nose and throat) resident, Physician E, asking when Patient #1 will arrive. Called referring facility to see if they were able to find a facility in Illinois. They stated that Rockford (hospital) had been contacted and they do not have ENT available tonight. Apparently, they call(ed) report on the patient directly to the UW ED. Stated that the ambulance that came to transport the patient to the UW did not feel comfortable transporting patient and the ED staff contacted their flight program to bring child to the UW. Explained that the patient had Illinois Medicaid and they should try to find a facility in Illinois to take the patient since the family could possibly incur the hospitalization cost. Spoke to (transferring hospital) RN E, the charge nurse at the referring facility. I explained that I would have to have administrative approval to bring patient (Patient #1) in." The "progress note" written by UW RN D at 12:03 a.m. on 11/10/17 revealed "Called UW Access Center Manager F. Explained the situation. Patient is stable, afebrile (temperature not elevated) and not in respiratory distress. Manager F stated need to speak to UW Access Center Director G. Manager F suggested that we reiterate to the referring facility to try to locate a facility in Illinois. (Transferring hospital) charge RN E, asked if we were refusing the patient. Explained it would be better for the family if the patient could be treated in Illinois. Patient condition has not changed since original call." The "progress note" written by UW RN D at 12:16 a.m. on 11/10/17 revealed "Called Access Center Director G. UW Director G reiterated that the patient should be admitted to an Illinois facility." The "progress note" written by UW RN D at 12:20 a.m. 11/10/17 revealed "Spoke with UW Physician H, peds (pediatric) ED attending. Explained situation. Would like to make sure that we don't need on-call hospital administrator included in the decision making process. Spoke with Access Director G again and Director G felt that it was not necessary to contact on-call administrator." The "progress note" written by UW RN D at 12:25 a.m. on 11/10/17 revealed "Contacted referring facility, explained that we were not refusing nor accepting patient. Please try to find a facility in Illinois. If they cannot find another facility, please have the referring MD (medical doctor) call the UW back and we will connect (CGH referring MD) with our (UW) pediatric attending physician." Patient #1's "Hospital Encounter's ED Notes" revealed that UW RN I contacted transferring hospital on [DATE] at 1:40 a.m., and was told by Charge RN E that "patient was still being held at (transferring) hospital". The "progress note" written by UW RN D at 1:49 a.m. on 11/10/17 revealed "Spoke with referring facility, they have not been able to find an Illinois facility that is able to take patient. Explained to referring facility to have referring MD call to speak with our ED attending (physician)." The "progress note" written by UW RN D at 3:05 a.m. on 11/10/17 revealed "Contacted referring facility. Patient was sent to Lurie Children's hospital in Chicago", approximately 6 hours after UW's attending physician accepted Patient #1. The "Hospital Encounter" dated 11/10/17 at 3:09 a.m. revealed under "Discharge Information" that "patient never arrived in ED", but at 3:09 a.m. on 11/10/17 under "Events", the "Hospital Encounter" documented "Patient departed from ED, Patient dismissed." During interview with UW Physician A on 10/15/17 at 2:50 p.m., A stated that A received a telephone call at home from the Access Center, and was told that there was a "physician on the line" about the possible transfer of Patient #1 to UW. A stated that A told transferring hospital that patient "could come here through ED" and "accepted the patient" for transfer to the UW ED, with arrival "sometime after 10 p.m." A stated A called the hospital ENT resident (physician), who was at the hospital, to inform resident of impending transfer. The 11/15/17 at 3:15 p.m. record review of hospital procedure "UWHC-AFCH (University of WI Health Care -American Family Children's Hospital) Access Center Standards of Practice Manual, Topic: EMTALA, revised 7/15/16" revealed "...it may be a violation of EMTALA if a ...receiving hospital delays acceptance of the transfer of an individual with an unstabilized emergency medical condition pending receipt or verification of financial information...It is NOT a violation if the receiving hospital delays acceptance of a transfer of an individual with a stabilized emergency medical condition pending receipt or verification of financial information; EMTALA protection no longer applies once a patient is stabilized." This document stated that the Access Center staff should consider the following when taking referrals or transfers: Ask the referring provider if the patient is currently stable and document this. Consider if the injury or illness is life or limb threatening in nature, if so this patient should be made a priority 1. Determine if the level of care being requested is something that the referring facility can not provide. The 11/15/17 at 3:15 p.m. record review of hospital procedure "UWHC-AFCH (University of WI Health Care -American Family Children's Hospital) Access Center Standards of Practice Manual, Topic: Transfer process: Administrative Considerations, revised 7/8/17" revealed "Factors that are to be considered in the transfer process include but are not limited to the following: Patient Medical Condition, Priority 1: Priority 1 transfers are considered critical in nature. Critical transfers are necessary when the referring facility does not have the capacity or capability to stabilize the patient, and the benefits to the patient of the transfer outweigh the risks. Transfers should be considered a priority 1 when UW has specialized capabilities or facilities that cannot be received at the referring facility. For Priority 1 transfers, it is not appropriate to delay the transfer to obtain insurance/payment information. Priority 2: Priority two transfers are considered non-critical, the patient is in stable condition, and the transfer is not considered emergent in nature. A referral may be considered a priority 2 when that care requested is not considered specialized in nature and is not emergent or life/limb threatening. Priority 2 referrals are for services that can be received elsewhere and are not unique to UW. It is appropriate to obtain insurance verification and approval prior to acceptance for Priority 2 transfers. During interview with RN D on 11/16/17 at 11:45 a.m., D stated that the access center's role was to link transferring physician to appropriate UW physician service, field phone calls for admission to UW and provide triage services for appropriate UW MD contact. D verified the documented information written for Patient #1 on 11/9/17 and 11/10/17 in the "hospital encounter's progress notes". D stated D spoke to the transferring hospital "3-4 times about financial issues", and stated "I did not refuse patient", but thought it "was better to treat child in Illinois rather that incur expenses". D stated that D talked to transferring hospital's RN E about stability of patient and was told that patient was "stable", and needed "emergent" care. D stated that "I know with Illinois Medicaid patients, there can be a huge out of pocket expense". D stated "admission is based on stability and whether we (UW) can take patient." D stated that Patient #1 was classified as a "P2 (priority 2)". D told of previously receiving work emails from supervisors about how to handle out-of-network patients and Illinois Medicaid patients. D stated that D was told that these out-of-network and Illinois Medicaid patients needed prior authorization before being brought into the UW ED unless they were P1 (Priority 1). D stated that D was told that "it would be better if they find a facility in Illinois", and stated "in the past we took every child, this (practice of prior authorization) started within past year". D talked about out-of-network authorization, stating "sometimes this is a challenge at night because there is no one to check out-of-network payer status". D stated "these patients can be held at other (transferring) facilities till morning when (UW) staff come in." When asked if D could identify other medical records where out-of-network patients were "held" due to authorization of out-of-network payer status. D told of not remembering any patient names, and stated "it would be almost impossible" to try to identify these patients through a patient log. The 11/17 17 at 8:30 a.m. record review of the transferring hospital's medical record dated 11/9/17 through 11/10/ 17 for the ED stay for Patient #1 revealed an "ED progress note" written by RN J at 12:26 p.m." ... RN D from UW Madison (called) stating they were concerned about whether or not they would receive payment for their services due to patient having Illinois Medicaid. RN D stated that D did not know if Illinois Medicaid would cover the cost of the transfer. Physician note reviewed and RN D informed that (transferring) Physician K had already attempted to have patient transferred to Rockford Memorial Hospital (RMH) and RMH refused to take patient. Patient is currently stable in no respiratory distress. Physician L aware of situation, and entered a room to speak/update patient's family and flight crew on status of transfer. Health unit coordinator now attempting to transfer to another facility per Physician L". The transferring hospital's ED stay for Patient #1, dated 11/9/17 through 11/10/17, revealed that the nursing triage status was a "4= less acutely ill patient)" at 8:37 p.m. on 11/9/17. The "ED progress note" signed by Physician K at 11/9/17 at 8:24 p.m. and by Physician L on 11/10/17 at 2:20 a.m., stating "Addendum: ...When ambulance arrived to transfer the patient to UW at Madison (WI) they (ambulance personnel) were concerned about possible decompensation (worsening of condition) so they did not feel safe transferring the patient on the ground and recommended air transport. Air transport was contacted and when they arrived and strapped the patient to the bed, we received a call from the UW in Madison who declined acceptance of the patient with recommendations on attempting to transfer the patient to a facility in Illinois for insurance purposes. We attempted Saint Francis (in) Peoria (Illinois), however they did not have a pediatric ENT Physician on-call. I contacted children's hospital in Chicago... After reviewing imaging, the patient has been accepted at the children's hospital in Chicago with accepting physician being Physician M. They are agreeable that air transport is indicated." The transferring hospital's "transfer record" revealed that Patient #1 left the transferring hospital's ED at 2:30 a.m. for Lurie Children's Hospital in Chicago, Illinois. Record review of the "physician assessment and certification form" dated 11/10/17 at 2:14 a.m. (signature illegible) revealed that Patient #1 was in "stable condition".

Based on record review and interview, the hospital failed to ensure compliance with all Emergency Medical Labor and Treatment Act (EMTALA) requirements under 42 CFR 489.20 and 42 CFR 489.24. The hospital failed to ensure that EMTALA (Emergency Medical Treatment and Labor Act) signage was posted in conspicuous places in the hospital's ED (emergency department) patient waiting areas, in 3 of 3 total waiting rooms observed (main waiting room, family waiting room and children's hospital waiting room) and in 7 of 11 patient treatment rooms observed (triage rooms 1 and 2, treatment rooms 7 and 14 and trauma rooms 1, 2 and 3) in a total of 44 hospital ED treatment rooms. The hospital failed to ensure that medical screening examinations were not delayed, in 1 of 20 patients (Patient #1) presenting to the emergency department. Findings include: 1) The hospital failed to ensure that EMTALA (Emergency Medical Treatment and Labor Act) signage was posted in conspicuous places in the hospital's ED (emergency department) patient waiting areas, in 3 of 3 total waiting rooms observed (main waiting room, family waiting room and children's hospital waiting room) and in 7 of 11 patient treatment room observed (triage rooms 1 and 2, treatment rooms 7 and 14 and trauma rooms 1, 2 and 3) in a total of 44 hospital ED treatment rooms. (Reference A2402) 2) The hospital failed to ensure that medical screening examinations were not delayed, in 1 of 20 sampled patients (Patient #1) presenting to the emergency department. (Reference A2408)