Based on record review and interview, the facility failed to ensure inappropriate transfers are reported within 72 hours of the event, in 1 of 20 medical records reviewed (1). The cumulative effect of this deficiency potentially affects all patients transferred to the facility. Findings include: The facility failed to report an inappropriate transfer within 72 hours of the event, in 1 of 20 medical records reviewed (1).

Based on record review and interview, the facility failed to report an inappropriate transfer within 72 hours of the event, in 1 of 20 medical records reviewed (1). This deficiency directly affects patient #1 and potentially affects all transfers to the facility. Findings include: Per review of Patient #1's medical record on 10/18/17 at 3:00 PM, it revealed Patient #1 arrived in the Emergency Department on 10/12/17 at 6:32 PM via ambulance with complaints of abdominal pain and cramping. Per the emergency room Record completed by Physician E, Patient #1 was 20 weeks pregnant. The physical exam included palpation of contractions every 2-4 minutes, fetal heart tones of 125-130, and a closed, firm cervix (opening to uterus). The Plan included transfer to another facility that can to obstetric care. Just prior to transfer a vaginal exam revealed the cervix was softening, and the external os (opening at top of vagina) was more open. Per review of the ambulance report dated 10/12/17, it states, "Pt (Patient #1) was walked to the Shell Lake Emergency Department (from jail) where the nurse on staff took Pt blood pressure, made a phone call and then stated to Pt and jail staff that Pt could not be seen there and they may want to call an ambulance to transport Pt. Jail staff stated They walked Pt back to jail where they called (this facility) ED (Emergency Department) and were told that yes (the facility) would accept the Pt." Per interview with Emergency Department Manager C on 10/18/17 at 4:03 PM, Manager C said s/he received a phone call from the nurse that night (10/12/17) who said "I just received a phone call from police and I think it's an EMTALA." Manager C said s/he began investigating the next day. Per telephone interview with Registered Nurse D on 10/18/17 at 4:23 PM, s/he said the deputy had called and said "...Shell Lake would not check out the patient." Per interview with Director of Nursing A and Chief Executive Officer B on 10/18/17 at 2:35 PM, they said "We consulted the legal team, they said we had 72 hours from discovery" Director A said they consulted attorneys on 10/13/17, and left messages with Centers for Medicare and Medicaid Services phone numbers on 10/16/17. Interview on 10/18/17 at 10:13 AM with Registered Nurse K revealed Patient #1 came from jail by foot complaining of contractions. Nurse K said s/he called the physician, who said the patient should be transported to a hospital that does obstetrics. Per interview with Physician J on 10/19/17 at 2:28 PM, s/he was in the clinic when called and told (Patient #1) was 7 months pregnant. Physician J said "I told the nurse to tell (Patient #1) we don't deliver babies anymore. If not in distress, should go to her OB (obstetrician)." Per interview with Deputy H on 10/19/17 at 3:33 PM, s/he walked Patient #1 to the emergency room (about 2 blocks away from jail) because the patient was complaining of severe cramping. Per Deputy H "We were taken into the exam room, the nurse put on a blood pressure cuff, asked how far along she was, her birth date and basic questions...The nurse left the room, came back and out while on the phone...Came back in the room and said 'Well you're gonna have to take her to Rice Lake...safest thing to do, call an ambulance." Deputy H said s/he was "dumbfounded" and walked Patient #1 back to jail, called (this facility) and an ambulance.

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 4 of 20 medical records reviewed (#1, 12, 14 and 16). This deficiency potentially affects all patients that arrive for emergency care at the facility. Findings include: Per review of facility policy titled Emergency Medical Screening Policy, #160-008, revised 8/14, it states "It is the policy of Spooner Health System that all persons seeking emergency care receive an appropriate medical examination and evaluation to determine whether an emergency condition exists...The hospital is not obligated to provide further examination and treatment as may be required to stabilize or treat a patient if an individual (or person acting on the individual's behalf) refuses to consent to the examination and treatment, provided the physician, nurse practitioner, or physician's assistant obtains from the individual (or person acting on the individual's behalf) written informed consent to refuse such examination and treatment...If an individual is in need of a transfer and refuses to consent to the transfer after the practitioner has informed the individual (or person acting on behalf of an individual) of the risks and benefits of such transfer...Staff will take all reasonable steps to secure the individual's (or person acting on behalf of an individual) written informed consent to refuse such transfer. Staff will document the information provided to the individual (or other person) of the risks and benefits of such transfer. The patient's stated reason for refusal is also documented." Patient #1's medical record review on 1/25/17 at 12:20 PM revealed the emergency room Log lists Patient #1 admitted on [DATE] at 11:31 AM with no arrival time or discharge time. The Record of Admission sheet states Patient #1 was admitted in the emergency room on [DATE] at 11:31 AM, and has a discharge date of [DATE] at 11:31 AM. The emergency room Record completed on 1/18/17 states "RN (Registered Nurse) informed patient that (Clinic) had tried to reach (Patient #1) by phone so they could go directly to Rice Lake (sic) so patient could receive orthopedic services as soon as possible. Patient did not (sic)appearred (sic) calm and in no acute distress. dressing (sic) appeared clean, dry and intact. I informed patient that we could see (Patient #1) here even though we do not have orthopedic services available. As I we trying to ensure the patient was aware of (Patient #1's) option the (person ) pushing the wheelchair turned the wheelchair around and informed me (s/he) was taking (Patient #1) to RiceLake (sic) and would explain to patient." The record revealed Patient #1 arrived via wheelchair, was alert and oriented. There is no other documentation of a triage of Patient #1, there is no record of a Medical Screening Exam. The above findings are confirmed in interview with Manager B on 1/16/17 at 12:30 PM, who agreed Patient #1 should have a Medical Screening Exam, before being allowed to leave. Patient #12's medical record reviewed on 1/25/17 at 2:25 PM revealed Patient #12 was triaged on 10/18/16 at 3:10 PM with a complaint of a cough. The emergency room Record states the physician saw Patient #12 at 4:00 PM, there is no documentation of a Medical Screening Exam. The emergency room Log revealed Patient #12 was discharged at 4:20 PM stating "Left Without Being Seen". There are no notes in the medical record indicating why the patient left. This is confirmed in interview on 1/25/17 at 2:25 PM with Manager B, who agreed there should have been a Medical Screening Exam and a note as to why Patient #12 left. Patient #14's medical record reviewed on 1/25/17 at 2:25 PM revealed the triage form has a sticker with the date with Patient #14's name and the date 10/15/16, states at 5:10 PM Patient #14's complaint is "poss (possible) miscarriage" and includes "Left 5:44 PM". The emergency room Log revealed Patient #14 was discharged at 5:44 PM stating "AMA (Against Medical Advice)" and "Left Without Being Seen". There is no emergency room Record indicating the patient was triaged, had a Medical Screening Exam, or why the patient left. This is confirmed in interview on 1/25/17 at 2:25 PM with Manager B, who agreed there should have been a Medical Screening Exam and a note as to why Patient #14 left. Patient #16's medical record reviewed on 1/25/17 at 3:10 PM revealed the emergency room Log stated Patient #16 arrived on 10/16/17 at 6:30 PM and was discharged at 6:50 PM stating "AMA (Against Medical Advice)" and "Left Without Being Seen". There is no emergency room Record indicating the patient was triaged, had a Medical Screening Exam, or why the patient left. This is confirmed in interview on 1/25/17 at 3:10 PM with Manager B, who agreed there should have been a Medical Screening Exam and a note as to why Patient #16 left.

Based on observation, record review and interview, the facility failed to ensure EMTALA signs are in place, in 2 of 2 areas observed (main lobby and Emergency Department); a Medical Screening Exam is performed on patients that arrive at the facility, risks are documented for patients leaving Against Medical Advice and Transfer documents are complete with risks, benefits and physician contact time. 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 2 of 2 observations (main lobby and Emergency Department triage room). See tag C2402. The facility failed to ensure patients received a Medical Screening Exam to rule out a medical emergency upon arrival to the emergency room , in 4 of 20 medical records reviewed(#1, 12, 14 and 16). See tag C2406. The facility failed to ensure risks are explained and documented in patient's medical record if they leave Against Medical Advice, in 3 of 20 medical records reviewed (#6, 9 and 20). See tag C2407. 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 9 of 20 medical records reviewed (#1, 2, 3, 5, 7, 8, 11, 13 and 18). See tag C2409.

Based on record review and interview, 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 8 of 20 medical records reviewed (#2, 3, 5, 7, 8, 11, 13 and 18). This deficiency potentially affects all patients that request emergency treatment at the facility. Findings include: Patient #2's medical record review, on 1/25/17 at 12:43 PM, revealed Patient #2 was transferred to another facility on 1/24/17 at 11:30 PM, due to vomiting blood . The EMTALA Transfer Form, completed on 1/24/17, states "The patient may be a risk for deterioration from or during transport...All transfers have inherent risks of delays or accidents in transit, pain or discomfort upon movement, and limited medical capacity of transport units that my limit available care in the event of a crisis. In addition, this patient's risks of transfer are as follows:" There are no risks listed specific to Patient #2's condition. The above deficient practice was confirmed in interview on 1/25/17 at 12:43 PM with Manager B, who was unaware risks specific to the patient condition should be listed. Patient #3's medical record review, on 1/25/17 at 12:55 PM, revealed Patient #3 was transferred to another facility on 1/24/17 at 1:00 PM, due to surgical bleed from a recent knee surgery . The EMTALA Transfer Form, completed on 1/24/17, states "There is no reasonable likelihood of deterioration from or during transport...All transfers have inherent risks of delays or accidents in transit, pain or discomfort upon movement, and limited medical capacity of transport units that my limit available care in the event of a crisis. In addition, this patient's risks of transfer are as follows:" There are no risks listed specific to Patient #3's condition. There is no documented time of physician to physician contact. The above deficient practice confirmed in interview on 1/25/17 at 12:55 PM with Manager B, who was unaware risks specific to the patient condition should be listed, and the time of physician contact should be documented. Patient #5's medical record review, on 1/25/17 at 1:15 PM, revealed Patient #5 was transferred to another facility on 12/29/16 at 2:01 PM, due to a ruptured bowel obstruction. The EMTALA Transfer Form, completed on 12/29/16 states "The patient may be a risk for deterioration from or during transport...All transfers have inherent risks of delays or accidents in transit, pain or discomfort upon movement, and limited medical capacity of transport units that my limit available care in the event of a crisis. In addition, this patient's risks of transfer are as follows:" There are no risks listed specific to Patient #5's condition. The above deficient practice no documented time of physician to physician contact. This is confirmed in interview on 1/25/17 at 1:15 PM with Manager B, who was unaware risks specific to the patient condition should be listed. Patient #7's medical record review, on 1/25/17 at 1:38 PM, revealed Patient #7 was transferred to another facility on 12/19/17 at 9:20 PM, due to heart attack. The EMTALA Transfer Form, completed on 12/19/17, states "There is no reasonable likelihood of deterioration from or during transport...All transfers have inherent risks of delays or accidents in transit, pain or discomfort upon movement, and limited medical capacity of transport units that my limit available care in the event of a crisis. In addition, this patient's risks of transfer are as follows: deterioration." There are no risks listed specific to Patient #7's condition. There is no documented time of physician to physician contact. The above deficient practice confirmed in interview on 1/25/17 at 1:38 PM with Manager B, who was unaware risks specific to the patient condition should be listed, and the time of physician contact should be documented. Patient #8's medical record review, on 1/25/17 at 1:38 PM, revealed Patient #8 was transferred to another facility on 11/26/17 at 11:41 AM, due to a wrist fracture. The EMTALA Transfer Form, completed on 11/26/17, states "There is no reasonable likelihood of deterioration from or during transport...All transfers have inherent risks of delays or accidents in transit, pain or discomfort upon movement, and limited medical capacity of transport units that my limit available care in the event of a crisis. In addition, this patient's risks of transfer are as follows: deterioration." There are no risks listed specific to Patient #8's condition. There is no documented time of physician to physician contact. The above deficient practice confirmed in interview on 1/25/17 at 1:50 PM with Manager B, who was unaware risks specific to the patient condition should be listed, and the time of physician contact should be documented. Patient #11's medical record review, on 1/25/17 at 2:16 PM, revealed Patient #11 was transferred to another facility on 10/19/16 at 950 PM, due to severe burns. The EMTALA Transfer Form, completed on 10/19/16 states "The patient may be a risk for deterioration from or during transport...All transfers have inherent risks of delays or accidents in transit, pain or discomfort upon movement, and limited medical capacity of transport units that my limit available care in the event of a crisis. In addition, this patient's risks of transfer are as follows:" The above deficient practice no risks listed specific to Patient #10's condition. There is no documented time of physician to physician contact. This is confirmed in interview on 1/25/17 at 2:16 PM with Manager B, who was unaware risks specific to the patient condition should be listed. Patient #13's medical record review, on 1/25/17 at 2:50 PM, revealed Patient #13 was transferred to another facility on 10/17/16 at 9:10 PM, due to body aches and requesting treatment for alcohol use. The EMTALA Transfer Form, completed on 10/17/16 states "The patient may be a risk for deterioration from or during transport...All transfers have inherent risks of delays or accidents in transit, pain or discomfort upon movement, and limited medical capacity of transport units that my limit available care in the event of a crisis. In addition, this patient's risks of transfer are as follows:" There are no risks listed specific to Patient #13's condition, and there are no benefits listed for transferring Patient #13. There is no documented time of physician to physician contact. The above deficient practice confirmed in interview on 1/25/17 at 2:50 PM with Manager B, who was unaware risks specific to the patient condition should be listed. Patient #18's medical record review, on 1/25/17 at 3:15 PM, revealed Patient #18 was transferred to another facility on 10/9/16 at 5:56 PM, due to head trauma. The EMTALA Transfer Form, completed on 10/9/16, states "The patient may be a risk for deterioration from or during transport...All transfers have inherent risks of delays or accidents in transit, pain or discomfort upon movement, and limited medical capacity of transport units that my limit available care in the event of a crisis. In addition, this patient's risks of transfer are as follows:" There are no risks listed specific to Patient #18's condition. The above deficient practice no documented time of physician to physician contact. This is confirmed in interview on 1/25/17 at 12:43 PM with Manager B, who was unaware risks specific to the patient condition should be listed. Per email interview with Chief Nursing Officer G on 1/16/17 at 4:26 PM, there is no policy for completing the EMTALA transfer document.

Based on record review and interview, the facility failed to ensure risks are explained and documented in patient's medical record if they leave Against Medical Advice, in 3 of 20 medical records reviewed (6, 9 and 20). This deficiency potentially affects all patients to request emergency treatment at the facility. Findings include: Patient #6's medical record reviewed on 1/25/17 at 1:26 PM revealed on 12/21/16 Patient #6 requested to leave Against Medical Advice to go to a different facility for admission to treat possible Congestive Heart Failure. The Against Medical Advice form completed on 12/21/16 at 5:50 PM states "This is to certify that I am leaving Spooner Health System at my own insistence and against the advice of the hospital authorities and my attending physician. I have been informed by them of the risks and potential complications of my leaving the hospital at this time." The emergency room Record dictated by the physician on 12/21/16 does not state the risks and potential complications of leaving the facility. This is confirmed in interview with Manager B on 1/25/17 at 1:25 PM, who agrees the physician should document the risks in their dictation. Patient #9's medical record reviewed on 1/25/17 at 2:00 PM revealed on 11/13/16 Patient #9 requested to leave Against Medical Advice refusing to be transferred for treatment of a possible stroke. The Against Medical Advice form that is not timed but dated 11/13/16 states "This is to certify that I am leaving Spooner Health System at my own insistence and against the advice of the hospital authorities and my attending physician. I have been informed by them of the risks and potential complications of my leaving the hospital at this time." The emergency room Record dictated by the physician on 11/13/16 does not state the risks and potential complications of leaving the facility. This is confirmed in interview with Manager B on 1/25/17 at 2:00 PM, who agrees the physician should document the risks in their dictation. Patient #20's medical record reviewed on 1/25/17 at 3:30 PM revealed on 7/30/16 Patient #20 left Against Medical Advice, refusing a scan of his/her head for a laceration. The Against Medical Advice form that is not timed but dated 7/30/16, states "This is to certify that I am leaving Spooner Health System at my own insistence and against the advice of the hospital authorities and my attending physician. I have been informed by them of the risks and potential complications of my leaving the hospital at this time." The emergency room Record dictated by the physician on 7/30/16 does not state the risks and potential complications of leaving the facility. This is confirmed in interview with Manager B on 1/25/17 at 3:30 PM, who agrees the physician should document the risks in their dictation. Per email interview with Chief Nursing Officer G on 1/16/17 at 4:26 PM, there is not a policy for completing the Against Medical Advice document.

Based on observation and interview, the facility failed to ensure EMTALA signs are placed in all lobbies and treatment areas in 2 of 2 observations (main lobby and Emergency Department triage room). This deficiency potentially affects all 6 patients seen in the Emergency Department on day of survey. Findings include: Per observation on 1/25/17 at 10:00 AM, there are no EMTALA signs in the main entrance of the hospital or the emergency room triage room. Per interview with emergency room Manager A on 1/15/17 at 10:00 AM, Manager A was not aware the signs should be in the main lobby and agreed a sign should be in the triage room.