Ripon Medical Center

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 50643 Based on record review and interview, the facility failed to maintain an accurate, complete log of patients presenting to the Emergency Department (ED) for 1 of 1 patient (Patient #1) in a total universe of 20 medical records reviewed. Findings include: Review of the Facility’s policy titled “EMTALA (Emergency Medical Treatment and Labor Act)” dated 12/13/2023 revealed, “...A Central Log must be maintained containing information on each individual who comes on the hospital campus requesting assistance or whose appearance or behavior would cause a prudent layperson observer to believe the individual needed examination or treatment. This documentation should occur whether the patient left before a MSE (medical screening exam) could be performed; refused treatment; or was transferred, admitted and treated, stabilized and transferred or discharged. 2. The Central Log may include date of service, the patient logs from the traditional ED, either by director indirect reference, patient logs from any other areas of the hospital that may be considered DEDs (dedicated emergency departments) or other areas where an individual may present for emergency services or receive a MSE, such as Labor and Delivery...” Review of the Adverse Event log “Event #PE2026061018452” revealed, “Event Description: Regulatory made aware of a possible EMTALA violation... on 6/20/26 [Receiving Facility] received (sic) [Patient #1] with complaints of left testicular pain for the last 3.5 hours and that they previously presented to [Originating Facility] ED and was told that there was no ultrasound capability and was sent to ‘Fond du Lac’. [Patient#1] was driven by his mother. [Receiving Facility] searched for [Patient #1] ...and could not find an encounter.” Review of the ED log for 6/20/2026 revealed no encounter or documentation for Patient #1’s visit. During an interview on 7/14/2026 at 11:55 AM ED Manager F stated that it was facility policy that if a patient presented to the facility, there must be an encounter created. During an interview on 7/14/2026 at 4:28 PM, Patient #1’s mother stated that when she and Patient #1 arrived at the Facility’s ED, they waited for about 10 minutes before an RN met with them in the waiting room. Patient #1’s mother stated that the RN told them that they could evaluate them there, but that they would not be able to perform an ultrasound. Patient #1’s mother stated that she then decided to leave the facility and go to Receiving Facility C, as it was in the same healthcare system as they went to at home. Patient #1’s mother stated that she was never asked to sign a LWBS/AMA (left with out being seen/against medical advice) form.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 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: 50643 Based on record review and interview the facility failed to provide a Medical Screening Exam for 1 of 20 patients (Patient #1) who presented to the ED (Emergency Department) in a total of 20 medical records reviewed. Findings include: Review of policy titled “EMTALA (Emergency Medical Treatment and Labor Act)” dated 12/13/2023 revealed, “... A. All ministries shall provide a MSE (Medical Screening Examination) to any individual who comes to the ED of Hospital and requests emergency care regardless of diagnosis, financial status, race, and color, national origin, and/or disability...” During an interview on 7/14/2026 at 4:28 PM, Patient #1’s mother ...stated that Patient #1 presented to the ED on 06/20/2026 for complaint of acute testicular pain. Patient #1’s mother stated the ED Registered Nurse (RN) spoke with them in the waiting room and informed Patient #1 and his mother that they could evaluate the patient but did not have ultrasound capabilities and suggested they instead go to another ED with those capabilities. Patient #1’s mother stated she decided to leave and was not asked to sign a Left Without Being Seen (LWBS)/Against Medical Advice (AMA) form. Review of the ED log for 6/20/2026 revealed no encounter or documentation for Patient #1’s visit. There was no evidence of a Medical Screening Exam being offered or completed. During an interview on 7/14/2026 at 10:08 AM, ED Physician J stated that all patients who present to the ED must be given a MSE. ED Physician J stated that if a patent presented to the ED with testicular pain, it would be important to rule out testicular torsion with a physical exam and ultrasound imaging. ED Physician J stated that if ultrasound services were not available when the patient presented, he would find an accepting physician at a different facility and initiate a transfer. ED Physician J stated that if a patient refused transfer, they would be asked to sign a LWBS/AMA form, and this would be documented in the medical record.”