Froedtert Community Hospital

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 29972 Based on record review and interview the facility staff failed to appropriately transfer patients receiving care in the Emergency Department (ED) as per EMTALA (Emergency Medical Treatment and Active Labor Act) in 3 of 20 medical records reviewed (Patient (Pt) #1, 2, 8), in a total sample of 20 medical records reviewed; failed to post EMTALA signage in entrances used by patients seeking treatment in the ED in 3 of 4 hospital entrances observed (ED, Urgent Care, Main Entrance), in a total sample of 4 hospital entrances observed; and failed to have written policies and procedures in place addressing on-call physicians in 1 of 1 EMTALA (Emergency Medical Treatment and Labor Act) policy reviewed (EMTALA), in a total sample of 3 policies reviewed. Findings include: The facility staff failed to appropriately transfer a patient receiving care in the Emergency Department (ED) as per EMTALA. See Tag A-2409. The facility staff failed to post EMTALA signage in entrances used by patients seeking treatment in the ED. See Tag A-2402. The facility staff failed to have written policies and procedures in place addressing on-call physicians. See Tag A-2404.”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 29972 Based on observation, interview, and record review staff failed to post EMTALA (Emergency Medical Treatment and Labor Act) signage in entrances used by patients seeking treatment in the Emergency Department (ED) in 3 of 4 hospital entrances observed (ED, Urgent Care, Main Entrance), in a total sample of 4 hospital entrances observed. Findings Include: Review of policy and procedure #1584 titled, “ED Emergency Medical Treatment and Active Labor Act” last reviewed 06/29/2024 revealed: - “Each department that provides emergency services and any main entrance areas shall post sign in places likely to be noticed by all individuals entering the facility...” Per observations on 10/23/2024 beginning at 10:45 AM, while touring the hospital with Administrator B and Quality Coordinator H, there were no EMTALA signs located in the hospital Main entrance, the Urgent Care entrance, and the ED entrance. Per interview with Administrator B on 10/23/2024 at 11:00 AM, Administrator B confirmed there were no EMTALA signs present at the Main entrance, Urgent Care, and ED entrance; Administrator B stated that patients could potentially come through the Main entrance and Urgent Care entrance when seeking treatment in the ED.”

“ON CALL PHYSICIANS CFR(s): 489.20(r)(2) and 489.24(j)(1-2) §489.20(r)(2) [The hospital (including both the transferring and receiving hospitals), must maintain] a list of physicians who are on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. §489.24(j)(1) Each hospital must maintain an on-call list of physicians on its medical staff in a manner that best meets the needs of the hospital’s patients who are receiving services required under this section in accordance with the resources available to the hospital, including the availability of on-call physicians. §489.24(j)(2)(i) The hospital must have written policies and procedures in place to respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician’s control. §489.24(j)(2)(ii) The hospital must have written policies and procedures in place to provide that emergency services are available to meet the needs of patients with emergency medical conditions if it elects to permit on-call physicians to schedule elective surgery during the time that they are on call or to permit on-call physicians to have simultaneous on-call duties. This Standard is not met as evidenced by: 29972 Based on record review and interview the facility staff failed to have written policies and procedures in place addressing on-call physicians in 1 of 1 EMTALA (Emergency Medical Treatment and Labor Act) policy reviewed (EMTALA), in a total sample of 3 policies reviewed. Findings Include: Review of policy and procedure #1584 titled, “ED Emergency Medical Treatment and Active Labor Act” reviewed on 06/29/2024 revealed, “The hospital will maintain a list of on-call physicians on its medical staff.” There was no other information in the policy addressing on-call physicians. Per interview with Quality Coordinator H and Administrator B on 10/23/2024 beginning at 3:30 PM, Quality H confirmed that the facility did not have a policy and procedure addressing on-call physicians. Per Administrator B, she was not familiar with any hospital policies addressing on-call physicians.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 29972 Based on record review and interview the facility staff failed to appropriately transfer patients receiving care in the Emergency Department (ED) as per EMTALA (Emergency Medical Treatment and Active Labor Act) policy in 3 of 20 medical records reviewed (Patient (Pt) #1, 2, 8), in a total sample of 20 medical records reviewed. Findings Include: Review of policy and procedure #1645 titled, “Nursing Services Management of Patient Transfers...” last reviewed 02/27/2023 revealed, - “An appropriate transfer to a medical facility is a transfer: 1. In which the transferring hospital provides the medical treatment within its capacity which minimizes the risk to the individual’s health...2. In which the receiving facility: a. Has available space and qualified personnel for the treatment of the individual; and has agreed to accept transfer of the individual and to provider appropriate medical treatment. 3. In which the transferring hospital sends to the receiving facility, a. All medical record copies related to the emergency condition...b. Completed Physician’s Certificate of Transfer form...” - “The attending physician is responsible to make the determination of appropriateness of transfer and initiate arrangements with a physician at the receiving hospital.” - “After assessing the patient’s condition and determining the appropriateness and necessity for transfer...the treating physician will discuss transfer risks and benefits with the patient/family to obtain patient/family consent.” - “A physician must sign a certification that based upon information available at the time of transfer, stating that the medical benefits expected from treatment at another facility outweigh the risks of transfer of the individual.” - “After securing an accepting physician and accepting facility for transfer, when assigned bed is available, the transferring registered nurse (RN) and physician must call report to the receiving facility...”- “Ensure transfer of all patient records...” Review of policy and procedure #1584 titled, “ED Emergency Medical Treatment and Active Labor Act” last reviewed 06/29/2024 revealed: - “Staff that suspect an inappropriate transfer or EMTALA violation has occurred must promptly (same day) report the incident to the Manager/Director/Administrative Supervisor.” - “Staff will complete an Incident Report.” Review of Pt #1’s Emergency Department (ED) Patient Care Timeline, revealed that Pt #1 arrived in the ED on 09/08/2024 at 4:59 PM with the arrival complaint of “Hallucinations.” Pt #1 left the ED in police custody on 09/08/2024 at 9:43 PM. Review of RN I’s “ED Triage Note” dated 09/08/2024 at 5:55 PM revealed, “Pt presents to ER (emergency room) with mother reporting hearing voices that are telling him to kill himself, hurt his mom and ‘do other awful things.’ Pt states he feels that someone is trying to take over his brain and put it into theirs. He states that he has a plan of how to hurt himself, specifically putting a toaster into a bath...” Review of Certified Nursing Assistant (CNA) D’s ED “Patient Safety Observation” dated 09/08/2024 at 6:00 PM, revealed that Pt #1 was on “Continuous Observation (1:1).” Review of RN C’s “ED Notes” dated 09/08/2024 at 9:15 PM revealed, “(Pt #1) pacing and not following directions. OCPD (Oak Creek Police Department) called...” Review of RN C’s “ED Notes” dated 09/08/2024 at 9:32 PM revealed, “OCPD handcuffed (Pt #1) and walked out from the department without notified [sic] MD (medical doctor) and RN. Writer walked out in the parking lot and spoke to OCPD and officer came in and stated, ’(Pt #1) is chaptered (Chapter 51--involuntary psychiatric hospital admission) and going to (psychiatric hospital).’ After asking (police officer) provided report. MD notified.” Review of MD G’s “ED Provider Notes” signed on 09/09/2024 at 1:28 AM revealed, “Spoke with mom she doesn’t feel it is safe for patient to go home with them...Spoke with patient he is denying SI (suicidal ideations), HI (homicidal ideations). (Pt #1) admits to auditory hallucinations...Notified police to come see him...Pt is no [sic] voluntary...medically cleared...Police is at bedside evaluated (Pt #1)...Police chaptered patient, and removed him from ER. (Pt #1) was taken to a mental health facility. Police didn’t tell ER staff where patient was going. I didn’t have a chance to do a doc to doc (doctor to doctor conversation with receiving hospital).” Review of nursing progress notes from the receiving hospital (hospital #2) dated 09/08/2024 at 10:31 PM revealed, “It appears that the patient was transferred from (transferring hospital) without a doc to doc or nurse to nurse. Writer contacted (transferring hospital) and spoke to (RN J). (RN J) reports the patient was conveyed to the ED voluntarily with his mother...but then the patient began to request to leave and was pacing so the ED staff contacted police...police arrived and apparently handcuffed the patient and began walking (Pt #1) outside the hospital. The nurse went outside to ask the police where they were taking the patient and the police reported the patient is chaptered and they are coming to (receiving hospital) which is why the doc to doc and nurse to nurse was not completed...” Per interview with CNA D on 10/23/2024 beginning at 3:15 PM, CNA D stated that CNA D was the Sitter in the room with Pt #1 on 09/08/2024 while Pt #1 was in the ED (transferring hospital). CNA D stated that she observed the Police Officer enter Pt #1’s room and tell him to get dressed and that Pt #1 “will have to come with us.” CNA D stated that she observed the Police Officer handcuff Pt #1 and escort him out of the ED. CNA D stated that the ED physician and the nurse assigned to Pt #1 were not aware the Police Officer was taking the patient out of the ED. CNA D stated that she found RN C and informed RN C that the Police Officer left the ED with Pt #1. Per interview with RN C on 10/23/2024 beginning at 4:50 PM, RN C stated that he was informed by staff that the Police Officer was leaving with Pt #1, so RN C ran outside to confront the Police Officer. RN C stated that the Police Officer said he arrested Pt #1 and was taking Pt #1 to a (psychiatric hospital). RN C stated that he and the ED physician informed the Police Officer that he could not take the patient yet, but the officer to did not listen. RN C stated that the Police Officer filled out the Chapter 51 paper work and then left with Pt #1. RN C stated that Pt #1 was medically cleared at the time, but there had not been a Mental Health Team evaluation, no doc to doc, and no RN to RN discussion with the receiving hospital. RN C stated that he did not call the receiving hospital after the Police left with Pt #1. Per interview with Hospital Administrator B while reviewing Pt #1’s ED medical record on 10/23/2024 beginning at 1:05 PM, Administrator B stated that there was no Physician’s Certificate of Transfer form completed as per policy and the ED physician and RN assigned to Pt #1’s care on 09/08/2024 (transferring hospital) did not contact the receiving hospital to discuss transfer before or after the Police Officer removed Pt #1 from the ED. Administrator B confirmed that staff did not complete an Incident Report after the incident as per policy. Administrator B stated that the root cause of this incident was that the Police Officer left with Pt #1 without notifying staff and ensuring the transfer process had been completed as per policy. Administrator B stated that the hospital Director of Security will be meeting with the Police Department to discuss the incident and develop an action plan, but this has not happened yet. Administrator B was unable to provide evidence of an action plan developed and implemented to address the actions of the Police Department and the staff’s response to this incident. Pt #2: Review of Pt #2 ED medical record revealed Pt #2 was a 16 year old who arrived in the ED on 09/26/2024 at 6:47 AM with a chief complaint of Suicidal Thoughts; Pt #2 was transferred to psychiatric hospital on 09/27/2024 at 12:49 AM. Per interview with Administrator B on 10/23/2024 beginning at 2:10 PM, while reviewing Pt #2’s ED medical records (09/26 and 09/27), Administrator B stated that she was unable to find evidence of staff completing the Physician’s Certificate of Transfer form as per policy. Pt #8: Review of Pt #8 ED medical record revealed Pt #8 was a 17 year old who arrived in the ED on 05/07/2024 at 8:46 PM with complaints of Suicidal Thoughts; Pt #8 was transferred to psychiatric hospital on 05/08/2024 at 6:41 AM. Per interview with Administrator B on 10/23/2024 beginning at 2:55 PM, while reviewing Pt #8’s ED medical records (05/07 and 05/08), Administrator B stated that she was unable to find evidence of staff completing the Physician’s Certificate of Transfer form as per policy.”