Based on record review and interview the facility failed to ensure there are complete medical screening examinations (MSE), failed to include documentation in the pateitn's medical records of understanding the risks of not having an MSE , in 5 of 20 medical records reviewed (#1, 8, 10, 14 and 20); and the facility failed to ensure all patients being transferred have completed transfer documents with listed benefits and/or risks specific to the patient listed in 5 of 5 transfer medical records reviewed (#8, 9, 11, 16 and 17) out of a total 20 medical records reviewed. Findings include: The facility failed to ensure an MSE was performed to determine if there was a medical emergency and/or that documentation was included in the the patient's medical records that the patient understands the risk of not being having an MSE, in 5 of 20 medical records reviewed (#1, 8, 10, 14 and 20). See tag C2406. The facility failed to ensure transfer documents were 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 5 transfer medical records reviewed (#8, 9, 11, 16 and 17), out of a total 20 medical records reviewed. See tag C2409.

Based on record review and interview the facility failed to ensure a Medical Screening Examination (MSE) was performed to determine if there was a medical emergency and/or failed to ensure that documentation was included in the patient's medical records that the patient understands the risk of not being seen for an MSE, in 5 of 20 medical records reviewed (#1, 8, 10, 14 and 20). Findings include: Review of facility policy #EC-002 titled "ED (Emergency Department)/Hospital Diversion", (n.d.) revealed under III. B. "Diversion: Diversion occurs only when the hospital does not have the staff and facilities (resources) to accept additional emergency patients. Conditions that may require diversion include the following: 1. Appropriate inpatient and ED beds are occupied... 2. Current ED staffing resources cannot safely provide patient care due to volume and acuity of patients. 3. Inpatient Labor and Delivery may implement rescue squad diversion of non-high risk maternity patients when there are no inpatient labor beds. If all hospital Labor and Delivery resources in the county are exhausted, the patient should be taken to the nearest emergency department. 4. Critical diagnostic infrastructure is not operational...D. Notification: Notification of when diversion is needed and when the condition no longer exists is conducted by the Nursing Lead and includes: 1. Each EMS (Emergency Medical Service) services (local service area) 2. Dispatch Center appropriate for service area. 3. Other local emergency departments. 4. ED Medical and Clinical Director/Manager if not included in the decision making process. 5. Ensure WI-Trac announcement is posted. E. Log: The clinical director or delegate will maintain a log of diversions for reporting to DHS (Department of Health Services)..." Review of facility policy #RM-0611 titled "Patients Requesting to Leave Against Medical Advice", (n.d.) revealed under H. "Document within the patient's chart the time and date the patient leaves, reason for leaving (if verbalized), and a notation stating release of responsibility form signed or patient's refusal to sign. Additional documentation should include: phone call/conversation with attending physician; conversations about the risks/benefits/alternatives involved in care and decision to leave hospital, notification of family and/or significant other of patient's desire to leave hospital against medical advice." Review of facility policy #GN-009 titled "Screening, Treatment and Transfer (EMTALA)", (n.d.) revealed under IV. A. "Regardless of ability to pay, the sick or injured person receives, within the capabilities of the Hospital's colleagues and facilities, the following: An appropriate medical screening examination...Necessary stabilizing treatment for any emergency medical condition...If necessary, an appropriate and safe transfer to another facility..." Under IV. B. 3. Refusal of Screening and Treatment b. Explain Risks and Benefits. Give the person...an explanation of the risks and benefits...of the examination and/or treatment. c. Note in Record. Describe in the person's EMR (Electronic Medical Record) the examination and/or treatment refused. d. Obtain Written Refusal of Examination/Treatment. Take reasonable steps to obtain the written informed refusal of the examination and/or treatment from the person..." Per telephone interview with Complainant A on 2/7/18 at 4:48 PM, Patient #1 was brought to Hospital I on 2/1/18 at 2:38 PM, via EMS (Emergency Medical Service). Complainant A stated the EMS had called the nearest hospital (K), and told them the patient's symptoms, that the Patient #1 had been found in the closet and had trashed the house. Dr F at Hospital K told the EMS the patient needed an ICU (Intensive Care Unit). Complainant A said Hospital I does not have an ICU. Review of Patient #1's Hospital I medical record, revealed there was an ambulance report, dated 2/1/18 at 12:38 PM, that states "Call type: Stroke/CVA (cardiovascular accident); Resp. (response) Mode: Emergent Immediate; Response Urgency: Immediate...Destination: (Hospital I); Dest. (destination) Determ. (determination): On-Line/On-Scene Medical Direction; Diverted From: (Hospital K). The ambulance report timeline revealed the following: The ambulance was at the Patient's residence at 1:00 PM. The ambulance departed the residence at 1:38 PM The ambulance arrived at Hospital I at 2:13 PM. The ambulance report had no documentation of phone contact with Hospitals I or K. Per interview with the facility Director of Nursing B on 2/12/18 at 10:12 AM, Director B stated there were two open beds in the ED at the time Patient #1 was being transported to Hospital K. Director B said "Dr. F felt the distance was relevant, the ED was at capacity, and believed it was an overdose. They felt it was not an EMTALA and did not call the State Agency." Director B added they have never been on diversion, rather they utilize hospital staff and the hospitalist on call, if needed. Interview on 2/12/18 at 1:29 PM with Sheriff Deputy C, revealed that s/he responded on 2/1/18 to Patient #1's family calling 911 for a possible stroke, and the ambulance crew arrived shortly after s/he did. Deputy C said the patient was combative, but not violent, and didn't think s/he knew where s/he was. Per Deputy C, the EMS called Hospital K and spoke with Nurse E and Dr. F. They ( the paramedics) wanted to go to the closest hospital which was (Hospital K). Deputy C said s/he had a phone conversation with Dr. F, telling her/him they were coming and to get ready. They (Deputy C and EMS) didn't know if it (patient's condition) was medical or psychological, and the doctor made the comment they weren't taking (Patient #1), and were at full capacity. Deputy C said Doctor F told him to take Patient #1 to either Hospital I or Hospital J because they could not handle him/her here. Deputy C provided access to her/his report #18- 8, not dated, which was reviewed on 2/12/18. The report revealed "While in the ambulance speaking with (Patient #1) I was notified that (Hospital K) wanted (Patient #1) transported to Hospital I or Hospital J. I advised (ambulance service) to continue to Hospital K as it was unclear at this time if (Patient #1) was having a medical problem or a psychological problem. While in route to (Hospital K), I spoke with ER (emergency room ) Dr.(Doctor F) to advise (her/him) of the situation. (S/he) stated that they could not handle (Patient #1) at (Hospital K) as they do not have an ICU unit. I began to explain to Dr. F the possible medical condition and s/he told me that the ER unit at (Hospital K) was currently at capacity and they could not take the patient." Per interview with Nurse D on 2/12/18 at 2:01 PM, s/he recalled being really busy on 2/1/18. Nurse D did not speak with the ambulance service, or the deputy, but overheard they were coming. Per Nurse E's interview on 2/12/18 at 2:30 PM, s/he recalled, on 2/1/18, getting a heads up on the ambulance call that a "Patient locked self in a closet and either on meds, or had not taken meds, or too much." Nurse E recalled Dr. F telling them (ambulance service) we don't have the resources and to see if they could get a paramedic intercept to have someone for more monitoring, and specialized care. Nurse E said s/he doesn't remember who, but someone said they were calling on the radio that they were coming here. Nurse E called dispatch to have them call and the deputy called and spoke with Dr. F. Nurse E recalled hearing Dr. F say to take the patient to the closest appropriate facility. Dr. F's interview on 2/12/18 at 3:02 PM, revealed s/he recalled hearing the patient had pinpoint pupil and didn't get a lot of information. The nurse (B) took the call, and thought this was possibly an overdose, if the police were involved. Dr. F said s/he told them to have a paramedic intercept. Per Dr. F, a paramedic intercept does not mean they can't come here, but they like to go to their own hospital. Dr. F recalled the police had called, adding s/he "didn't know what's going on, didn't even know what s/he (Patient #1) had, just needed higher level of service. Dr. F said s/he did not specifically say a hospital, told the officer nearest appropriate hospital. When questioned if a hospitalist was available to help, Dr. F responded "they are supposed to be, but we were busy but managing". When asked about diversion status, Dr. F responded "Pretty rare for us to do that, it would be extraordinary circumstances." Tour of the facility's ED on 2/12/18, 2:30 PM revealed there were seven ED beds. Per review of the facility's ED log, on 2/12/18, provided and confirmed by Nurse G, there was no documentation of Patient #1 at Hospital K. The ED log revealed there were five patients in the facility's ED when Patient #1 was being attended to by the ambulance service, although one, Patient #4, was discharged prior to the ambulance leaving Patient #1's residence. The log revealed the following: Patient #2 arrived at 9:19 AM and was discharged to home at 2:15 PM, with a diagnosis of focal infarction of the brain (stroke). Patient #3 arrived at 11:00 AM and was admitted at 2:38 PM with a diagnosis of a pneumothorax (air between the lung and chest wall). Patient #4 arrived at 12:00 PM and was discharged at 1:15 PM with a diagnosis of cervical strain (neck injury). Patient #5 arrived at 12:00 PM via ambulance,and was discharged at 5:26 PM with a diagnosis of constipation. Patient #6 arrived at 12:29 PM and was discharged at 1:46 PM with a diagnosis of hip pain. An additional Patient (#7) arrived at 1:25 PM, via ambulance and was discharged at 3:50 PM with a diagnosis of abdominal cramping/diarrhea. Per Director B, on 2/13/18 at 12:30 PM, during the day on 2/1/18, there were two nurses scheduled in the ED, D and E, and there were two nurses and a Certified Nurse Assistant in the Med/Surg unit in the hospital, as well as a House Supervisor and a Hospitalist on call. Review of the 2/1/18 Med/Surg census sheet provided by Director B on 2/13/18 at 12:30 PM, revealed there were four patients, between 1:00 PM and 2:15 PM, as follows: One was an observation patient that was changed to admit status on at 3:12 PM, two were discharged at 2:00 PM, one was a short stay surgery admitted at 8:44 AM and discharged in late evening. In addition, there were three outpatient IV procedures: one starting at 12:00 PM for 2 hours, one starting at 2:00 PM for one hour, and another starting at 2:00 PM for a two hour treatment. Telephone interview with Emergency Medical Technician H on 2/14/18 at 11:20 AM, revealed, s/he confirmed the ambulance report adding "While we were trying to settle her/him), dispatch wanted us to call the hospital (Hospital K). We knew what they wanted. All of the EMS know, when we get the number to call." Technician H was referring to being told to go to a different hospital. Technician H stated s/he was unaware of a request to get a Paramedic Intercept. When asked if they have ever been told Hospital K was in diversion status, Technician H said it was never a diversion, adding "We call and they either say nope, take them to Hospital J or Hospital I. If it's a fracture, no ortho on call now or better to go directly to Hospital J instead of us stabilizing and transferring." Technician H was unaware of EMTALA regulations. Patient #8's medical record review on 2/13/18 at 10:15 AM revealed Patient #8, a 17 year old, was brought into the ED on 1/3/18 at 3:29 PM with a complaint of seizures. The ambulance report included that the school staff said "Mom would like (her/him) to go to (Hospital J). EMS did not feel it medically necessary to go to Hospital J and transported to the closest facility." Nursing notes dated 1/3/18 at 3:28 PM reveal "Had a seizure in the ambulance and in the ER. Seizure in the ER lasted approximately 5-10 seconds." The addendum note at 3:46 PM state "(family) do not want patient treated in the ER. They are in ...at (Hospital J) and want to pick (her/him) up and transport (her/him) to (Hospital J) themselves. (Physician) is aware...No further treatment will be completed due to (family's) request." There was no documentation of an MSE in the medical record. There was a Release for Leaving Hospital Against Medical Advice (AMA) document stating a risk for leaving as "improper and untimely treatment for an undiagnosed medical condition", signed by a family member. There was no documentation by the physician of speaking with the patient or family of the risks. This deficiency was confirmed in interview on 2/13/18 at 10:15 AM with Nurse G, who agreed the patient was not seen by the physician. Patient #10's medical record review on 2/13/18 at 10:55 AM revealed Patient #10 arrived in the ED on 1/28/18 at 5:21 PM with a complaint of vomiting. Per ED timeline at 5:38 PM "ED disposition set to LWBS (Left Without Being Seen) before triage". An additional comment, with no time, revealed "Pt aware we (sic) it will be a small wait, room not available. Pt did not want to wait." The ED log for 1/28/18 revealed there were four patients in the ED when Patient #10 arrived. There was no documentation of an MSE, and there was no written refusal to be seen in the medical record. This deficiency was confirmed in interview on 2/13/18 at 10:55 AM with Nurse G, who agreed staff should have had the patient sign a LWBS form. Patient #14's medical record review on 2/13/18 at 11:40 AM revealed Patient #14 arrived in the ED on 12/31/17 at 10:08 AM with a complaint of dental pain. Triage notes dated 12/431/17 at 10:08 AM reveal "Pt is returned for dental pain..." The nursing note at 10:31 AM states "ED Disposition set to LWBS after Triage." The ED log dated 12/31/18 has no other patients in the ED when Patient #14 arrived. There was no documentation of an MSE, and there was no written refusal to be seen in the medical record. This deficiency was confirmed in interview on 2/13/18 at 11:40 AM with Nurse G, who agreed staff should have had the patient sign a LWBS form. Patient #20's medical record review on 2/13/18 at 12:34 PM revealed Patient #20 arrived in the ED on 9/30/17 at 1:34 PM with a complaint of a rash. Nursing notes dated 9/3/0/17 at 15:13 PM reveal "ED disposition set to LWBS before Triage". An additional comment, without a time, revealed "Pt arrived same time as a non stable pt that was unmanageable running throughout ED...Pt went to Urgent Care." The ED log for 9/30/17 revealed there was one patient in the ED who was discharged at 1:51 PM and the unmanageable patient arrived at 1:50 PM. There was no documentation of an MSE, and there was no written refusal to be seen in the medical record. This deficiency was confirmed in interview on 2/13/18 at 12:34 PM with Nurse G, who agreed staff should have had the patient sign a LWBS form.

Based on record review and interview, the facility failed to ensure transfer documents were 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 5 transfer medical records reviewed (#8, 9, 11, 16 and 17), out of a total 20 medical records reviewed. Findings include: Review of facility policy #GN-009 titled "Screening, Treatment and Transfer (EMTALA)", (n.d.) revealed under IV. C. 1. a. "Person Requests Transfer. The person (or a legally responsible person acting on his/her behalf) requests transfer against medical advice after being informed of the Hospital's obligation to provide stabilizing treatment and the risks and benefits of transfer. The request for transfer must be in writing, and must indicate the reason for the request and state that the person is aware of the risks and benefits of the transfer; or b. MSA (Medical Staff Appointee) Certification. The transferring MSA signs a certification before transfer stating that, based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of medical treatment at another medical facility outweigh the risks to the person...The certification must contain a summary of the specific risks and benefits on which it is based...2. Appropriate Transfer. To make an "appropriate transfer" of a person with an emergency medical condition that has not been stabilized, the Hospital must satisfy the requirements in paragraphs a-g below. a. Provide medical treatment...b. Attending MSA contacts the receiving physician at the receiving medical facility prior to transfer to obtain acceptance of the patient. c. Registered nurse contacts the receiving medical facility prior to transfer with the following information: i. Person's name. ii. MSA or Physician accepting transfer. iii. Person's diagnosis. iv. Person's present status. v. Estimated time of arrival if known. vi. Name of transferring physician...e. Use qualified personnel and transportation equipment as required to affect the transfer safely, including using necessary medically appropriate like support measures to minimize risks during the transfer. The transferring MSA determines the method of transfer and necessary accompanying personnel based on the person's medical status, and gives accompanying personnel any orders for care en route...Send with the person to the receiving facility, copies of available medical records, including those presented by the person, related to the emergency medical condition...3. Person's Refusal to Transfer. If a person with an emergency medical condition refuses to consent to a transfer who has been certified by the MSA in accordance with ...this Policy, Hospital colleagues shall do the following: a. Explain Risks and Benefits...b. Note in Electronic Medical Record...c. Person's Written Refusal...d. Obtain Certificate of Transfer.." Patient #16's medical record review on 2/13/18 at 11:35 AM revealed Patient #16 arrived in the Emergency Department (ED) on 11/18/17 with a diagnosis of Confusion: new requires work up. Physician notes indicate Patient #16 wants to go to (Green Bay hospital). The "Transfer Authorization or Refusal" form include the following "Patient Condition at Time of Transfer Patient stabilized, Benefit outweighs risk, There is no reasonable likelihood of deterioration from or during transport Reason for Transfer Qualified clinical personnel or service not available; Other (comment) Benefits of Transfer: MRI (Magnetic Resonance Imaging to detect structural abnormalities); Risks of Transfer: Specific Risks MVA; Inherent Risks Transfers have inherent risks of delays or accidents in transit, pain, or discomfort upon movement, and limited medical capacity of Transport Units." The patient was transported by private car. There were no risks documented specifically to the patient's condition or not having medical support during transport. This deficiency was confirmed during record review on 2/13/18 at 10:20 AM with Nurse G, who agreed the transfer documents did not include risks specifically to the patient's condition and no medical support during transport. Per interview and confirmed with Director B on 2/13/18 at 12:00 PM, the facility has an on site MRI, but it is only staffed "normal hours" Monday through Friday, 8:00 AM to 4:00 PM, no nights or weekends. Patient #16 was in the ED on a Saturday. Patient #17's medical record review on 2/13/18 at 12:05 PM revealed Patient #17 arrived in the ED on 10/13/17 at 2:38 AM with a diagnosis of a heart attack. Nursing notes on 10/13/17 at 3:30 AM revealed "Pt...is refusing transport to (Hospital J) via EMS. Pt stated (s/he) has $10,000 worth of tools and was going to take (her/his) truck home first. Pt was informed of risks but still did not want to be transported. "AMA (Against Medical Advice)" form signed by pt..." The Physician Assistant note dated 10/13/18 states "Patient signed out AMA to "bring (her/his) truck home" and will call a friend to bring (her/him) to (Hospital J)." There is no documentation of physician to physician contact to inform the Hospital J that Patient #17 is coming. There was no refusal of transfer or transfer documents given to the patient to take to the other hospital. There were no risks documented specifically to the patient's condition or not having medical support during transport. This deficiency was confirmed during record review on 2/13/18 at 12:05 P with Nurse G. Patient #8's medical record review on 2/13/18 at 10:15 AM revealed Patient #8, an 17 year old, was brought into the ED (Emergency Department) on 1/3/18 at 3:29 PM with a complaint of seizures. The ambulance report included that the school staff said "Mom would like (her/him) to go to (Hospital J). EMS (Emergency Medical Service) did not feel it medically necessary to go to Hospital J and transported to the closest facility." Nursing notes dated 1/3/18 at at 3:28 PM revealed "Had a seizure in the ambulance and in the ER (emergency room ). Seizure in the ER lasted approximately 5-10 seconds." The addendum note dated 1/3/18 at 3:46 PM state "(family) do not want patient treated in the ER. They are in...at Hospital J and want to pick (her/him) up and transport (her/him) to (Hospital J) themselves. (Physician) is aware...No further treatment will be completed due to parent's request." There is no documentation a physician saw Patient #8. There is a "Release for Leaving Hospital Against Medical Advice (AMA)" document stating a risk for leaving as "improper and untimely treatment for an undiagnosed medical condition.", signed by a family member. There was no documentation by the physician of speaking with the patient or family of the risks. There was no transfer form, no documentation the other hospital was contacted by the physician and no documentation of what medical information was sent with the patient. This deficiency was confirmed during record review on 2/13/18 at 10:15 AM with Nurse G, who agreed the patient was not seen by the physician and transfer documents were not completed. Patient #9's medical record review on 2/13/18 at 10:20 AM revealed Patient #9 arrived in the ED on 1/6/18 at 1:26 PM with a diagnosis of a post-operative infection. The physician notes dictated at 1/6/18 at 3:03 PM include consulting with a physician at hospital the surgery was done who felt Patient #9 should be sent there for antibiotic treatment. The "Transfer Authorization or Refusal" form include the following "Patient Condition at Time of Transfer There is no reasonable likelihood of deterioration from or during transport. Reason for Transfer Hospital: resources not available Benefits of Transfer: Specific Benefits neurosurgery (device removal if needed)/IV Abx (antibiotics) Risks of Transfer: Specific Risks MVA (Motor Vehicle Accident) Inherent Risks Transfers have inherent risks of delays or accidents in transit, pain, or discomfort upon movement, and limited medical capacity of Transport Units." The patient was transported by private car. There were no risks documented specifically to the patient's condition or not having medical support during transport. This deficiency was confirmed during record review on 2/13/18 at 10:20 AM with Nurse G, who agreed the transfer documents did not include risks specifically to the patient's condition and no medical support during transport. Patient #11's medical record review on 2/13/18 at 11:15 AM revealed Patient #11 arrived in the ED on 1/3/18 at 1:27 PM with a diagnosis of Severely Aggressive Behavior. Patient #11 was transferred to a psychiatric hospital via police car. The "Transfer Authorization or Refusal" form include the following "Patient Condition at Time of Transfer Patient stabilized; The patient may be at risk for deterioration from or during transport Reason for Transfer Hospital resources not available; Other (comment) Benefits of Transfer: children's psych Risks of Transfer: Specific Risks MVA (Motor Vehicle Accident) Inherent Risks Transfers have inherent risks of delays or accidents in transit, pain, or discomfort upon movement, and limited medical capacity of Transport Units." The patient was transported by police car. There were no risks documented specifically to the patient's condition or not having medical support during transport. This deficiency was confirmed during record review on 2/13/18 at 10:20 AM with Nurse G, who agreed the transfer documents did not include risks specifically to the patient's condition and no medical support during transport.