Froedtert South Inc.

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 50644 Based on record review and interview, the facility failed to provide a complete medical screening exam (MSE) that addressed all presenting medical complaints in 1 (Patient #1) of 20 patients with an emergency medical condition in a total of 20 ED (Emergency Department) medical records reviewed. Findings include: A review of facility policy, “10.30 EMTALA [Emergency Medical Treatment and Labor Act]: Medical Screening and Stabilizing Treatment” last revised December 2023 revealed, “...The medical screening exam provided is to be of sufficient scope as to be reasonably intended to determine whether an emergency medical condition exists and includes assessment of the patient based upon presenting complaint(s), chronic condition(s), involved or potentially involved system(s), and all necessary diagnostic tests required to determine the presence or absence of an emergency medical condition...” A review of Patient #1’s medical record revealed Patient #1 presented to the facility’s ED from his Assisted Living Facility (ALF) on 04/24/2026 at 5:22 AM via EMS with an arrival complaint of leg pain. A review of the “ED Timeline” at 5:27 AM revealed, “EMS reported patient called 911 with complaints that a friend was in the basement and was sick. EMS reported nursing was unaware that patient had called 911 and that patient “had to go” due to altered mental status. EMS reported patient has history of manic episodes...Patient reported complaint of left hand pain 10/10 and bilateral numbness in hands...” On 04/24/2026 at 5:31 AM, the chief complaint was updated to, “Psychiatric Problem” and pain assessment revealed Patient #1 reported a pain level of 10 at rest on his left hand on a 0 to 10 scale (0 being no pain, 10 being highest). Triage assessment completed including airway, respiratory, cardiac, peripheral/neurovascular, cognitive and manic behavior assessment. There was no evidence of further pain assessments or interventions completed. On 04/24/2026 at 6:03 AM, “ED Timeline” revealed a Medical Screening Exam (MSE) was completed by ED Physician C. A Urine analysis (UA), 12 lead ECG (electrocardiogram), blood gas, drug screen, metabolic panel, CBC (complete blood count) and magnesium labs were ordered. “ED Note” written by ED RN D at 8:03 AM revealed, “EDT [ED tech] found patient on the floor, patient reports he slid out of bed. [ED Physician C] at bedside to evaluate the patient.” There was no evidence that a nursing assessment was completed to assess for injury or pain following the fall.. A review of “ED Provider Note” written by ED Physician C on 4/24/2026 at 6:03 AM revealed, “...presenting for altered mental status patient is currently awake and alert interactive but appears to be having visual hallucinations. He is somewhat agitated...Workup for his altered mental status was initiated including a CBC CHEM panel magnesium level urinalysis venous blood gas. He does have a history of COPD (chronic obstructive pulmonary disease)...blood gas...consistent with compensated respiratory acidosis. The urinalysis was negative for infection his CBC and CHEM panels were also unremarkable nothing to explain altered mental status. Patient EKG was unremarkable...Due to his agitation we gave him 2.5 mg of IM (intramuscular) Zyprexa (antipsychotic medication) which did seem to calm him down some...patient was getting agitated and he tried to crawl out of bed and he was found on the floor at the foot of the ED cart. He had no complaints of pain or injury. ED techs and myself flipped him and left (sic) him into the bed. I did not find any obvious injury on reassessment...The patient may need adjustments of his mental health medications I do not think he needs to be admitted to the hospital. The patient will return back to his nursing facility for ongoing care...Problems addressed: Mania...Physical exam...patient is confused...Extremities: No cyanosis 1+ bilateral edema...no deformity no long bone or major joint tenderness...has weakness to all extremities...chronic contracture of his left hand...” There was no evidence that Patient #1’s presenting complaint of leg pain was addressed. Patient #1 was discharged from the ED back to the ALF on 04/24/2026 at 9:15 AM. On 04/24/2026 at 2:42 PM (5.5 hours after initial discharge), Patient #1 returned to the ED via EMS with complaints of pain and swelling to the left ankle. “ED Triage Note” on 04/24/2026 at 2:48 PM revealed, “ ...EMS reports that pt was here early this morning and fell, possibly injuring his ankle...” Patient #1 was subsequently diagnosed with a left ankle fracture requiring surgical intervention and was admitted to the facility. It is unclear if the ankle fracture was sustained prior to Patient #1’s initial ED encounter when he presented with “leg pain” or as a result of the fall in the ED. During an interview on 6/23/26 at 9:10 AM, ED Physician N stated that EMTALA means that “any patient presenting needs to be medically stabilized to the best of ability based on presenting symptoms.” He stated that he would verify what workup has been done, what level of care is still needed and if it’s an acute change vs. progressed overtime to determine if a patient can be discharged or needs to be admitted. ED Physician N stated that the purpose of a medical screening exam is to rule in/out an emergent condition based on the information that is offered and stabilized to their medical ability. During an interview with ED RN M on 6/23/26 at 2:31 PM while reviewing Patient #1’s medical record, stated that pain is initially assessed during triage and throughout the ED admission if pain is present. He stated that interventions should be completed and documented prior to intervention and 60 minutes after interventions even non pharmaceutical interventions. ED RN M stated that if pain is present “you need to address it some way.””

“OPO AGREEMENT CFR(s): 482.45(a)(1) Incorporate an agreement with an OPO designated under part 486 of this chapter, under which it must notify, in a timely manner, the OPO or a third party designated by the OPO of individuals whose death is imminent or who have died in the hospital. The OPO determines medical suitability for organ donation and, in the absence of alternative arrangements by the hospital, the OPO determines medical suitability for tissue and eye donation, using the definition of potential tissue and eye donor and the notification protocol developed in consultation with the tissue and eye banks identified by the hospital for this purpose; This Standard is not met as evidenced by: 47413 Based upon record review and interview the facility failed to update and incorporate the required information into their agreement with an Organ Procurement Organization (OPO) for 1 of 1 OPO agreements reviewed. This had the potential to affect any future organ donor and recipients. Findings Include: A review of the facility’s “Organ and Tissue Donor Referral Agreement” last revised 07/01/2015 revealed no definition of imminent death, timely notification, revealed no criteria for referral of individuals whose death is imminent, and revealed no interventions the hospital will utilize to maintain potential organ donor patients. Further review of the agreement revealed there was no current name of the facility or the current name of the organ procurement organization. During an interview on 06/24/2025 at 12:34 PM with Senior Director B, she stated, “This is our written agreement. It looks like there are some missing pieces.””