HospitalInspections.org

An investigation of a possible EMTALA violation (Number TN00032862) was initiated on November 19, 2013 and concluded on November 21, 2013. EMTALA investigative guidelines and procedures were followed. As a result of the investigation, deficient practice was identified at 42 CFR489.20(r)(3) and 42 CFR489.24 (r)(c).

Prior to the survey, you discovered the violation and implemented corrective action that has been effective over the long term. Therefore, we are not proceeding with a termination of your Medicare provider agreement with the Secretary of Health and Human Services.

The administrator was notified on February 20, 2014 by Federal Express overnight mail. A letter and this 2567 were provided.




Based on review of the facility's self-reported documentation , Emergency Department (ED) Central Log, medical record review, review of facility policy, and interview, the facility failed to maintain a ED Central log on each individual who presented to the ED for one patient (#27) of twenty-seven patients reviewed.

The findings included:

Review of facility's self-reported investigation letter dated November 21, 2013, revealed the facility description of the events of an incident "which may represent a potential violation of the Emergency Medical Treatment and Labor Act". Review of the letter revealed on November 11, 2013, between 9:00 p.m., and 10:00 p.m., a 22 month old child (#27) was brought into the ED by the child's parents, who stated the child injured the arm. Further review revealed the Waiting Room Coordinator (WRC), who was a Registered Nurse (RN), had not worked in the ED before, and this was the first time the RN had worked in the ED. The allegation revealed the WRC RN called the Fast Track RN to inquire about the 22 month old child being seen in the Fast Track area. (The Fast Track is a section of the ED where patients with less severe illness/injury are treated.) The Fast Track ED nurse told the WRC the Fast Track section did not screen or examine any patient less than two years old. Continued review revealed the WRC misinterpreted the communication and thought the child was not to be screened or examined at all; and did not refer the child to the regular ED. Further review revealed the WRC told the parent the child could not be seen in the ED. The child's parent filled out a form, and the parent folded the form and put the form in the (named parents) purse and left the ED. Further review revealed the facility watched a video tape recording from the ED and tried to get the tag number on the car but the recording did not reveal the visibility of the car tag. Further review revealed the WRC did not tell the child's parents the facility needed to keep the sign-in sheet for the ED and the facility does not have the child's name or any information.

Review of the ED Central Log revealed no documentation of a 22 month child registered in the ED on November 11, 2013, between the hours of 9:00 p.m. and 10:00 p.m.

Review of the facility's computer patient record documentation, revealed no medical record for a 22 month old child admitted to the ED on November 11, 2013.

Medical record review of twenty-six medical records (including two active medical records) revealed each patient had received a medical screening examination by a licensed medical provider and were entered in the ED Central Log.

Review of facility policy "EMTALA (Emergency Medical Treatment and Labor Act): Tennessee Central Log Policy" last reviewed May, 2013, revealed "...the hospital will maintain a Central Log containing information on each individual who comes to DED dedicated emergency department) seeking assistance, whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred or discharged..."

Review of facility policy "EMTALA Central Log" last reviewed May 2013, revealed "...Emergency Room medical records shall contain the following: Identification data, information concerning the time of arrival, means and by whom transported, pertinent history of the injury or illness to include chief compliant and onset of injuries or illness, significant findings, description of laboratory, x-ray and EKG findings, treatment rendered, condition of the patient on discharge or transfer, diagnosis on discharge and instructions given to the patient or his family..."

Interview on November 21, 2013, at 11:55 a.m., with the ED Director and the ED Clinical Manager, in the ED Clinical Managers Office, confirmed a medical screening was not performed by a licensed medical provider for the patient, no clinical medical record was generated for the patient and the patient was not entered into the ED Central Log.

Interview with the Director of Quality Management and the Risk Manager, on November 21, 2013, at 1:10 p.m., in the Risk Managers office, confirmed a medical screening was not performed by a licensed medical provider for the 22 month old patient (#27), a medical record was not generated for the patient, and the patient was not entered into the ED Central Log.

Based on review of the facility's investigation documentation letter, Emergency Department Central Log, facility documentation, facility policy and procedures, observation and interview, the facility failed to provide a medical screening by a Licensed Medical Professional for one (#27) patient of twenty-seven patients reviewed.

The findings included:

Review of facility's self-reported investigation letter dated November 21, 2013, revealed the facility description of an incident "which may represent a potential violation of the Emergency Medical Treatment and Labor Act".

Review of facility's letter dated November 21, 2013, revealed on November 11, 2013, between 9:00 p.m., and 10:00 p.m., a 22 month old child was brought into the ED by the child's parents, who stated the child injured the arm. Further review revealed the Waiting Room Coordinator (WRC), who was a Registered Nurse (RN #3), had not worked in the ED before, and this was the first time RN #3 had worked in the ED.
The documentation revealed the WRC RN called the Fast Track RN to inquire about the 22 month old child being seen in the Fast Track. (The fast track is a section of the ED in which patients with less severe complaints are seen.) The Fast Track ED nurse told the WRC the Fast Track did not screen or examine any patient less than two years old. Continued review revealed the WRC misinterpreted the communication and thought the child was not to be screened or examined at all. Review revealed the WRC RN did not refer the child to the regular ED. Further review revealed the WRC told the parent the child could not be seen in the ED. The child's parent filled out a form (a sign-in sheet) and after being told the child could not be seen, and the parent folded the form and put the form in the parent's purse and left the ED.

Review of the ED Central Log revealed no documentation of a 22 month child who was registered in the ED on November 11, 2013, between the hours of 9:00 p.m. and 10:00 p.m.

Review of the facility's electronic patient record documentation, revealed no medical record for a 22 month old child admitted to the ED on November 11, 2013.

Review of facility policy, EMTALA; Definitions and General Requirements, last reviewed May, 2013, revealed "...the hospital with an Emergency Department must provide to any individual, including every infant who is born alive, at any stage of development, who comes to the emergency department, an appropriate Medical Screening Evaluation (MSE) within the capacity of the hospital's emergency department, including ancillary services available to the emergency department, to determine whether or not an emergency medical condition (EMC) exits, regardless of the individual's ability to pay...the EMTALA obligations are triggered when there has been a request for medical care by an individual within a dedicated emergency department (DED), when an individual request emergency medical care on hospital property, other than in a DED, or when a prudent layperson would recognize that an individual on hospital property requires emergency treatment or examination, though no request for treatment is made..." Further review revealed "...when a medical screening evaluation is required...an individual MUST receive an MSE within the capabilities of the hospital's DED (dedicated Emergency Department), to determine whether or not an EMC exists...whether or not the treatment requested is explicitly for an emergency condition of (1) the individual comes to a dedicated emergency department of a hospital and a request is made on his or her behalf for examination or treatment for a medical condition..."

Review of the Rapid Regulatory Compliance (facility computer educational training for all clinical hospital employees) revealed "...2.5: Corporate Compliance: Applicable Laws and Regulations...EMTALA...the Emergency Medical Treatment and Active Labor is commonly known as the Patient Anti-Dumping Statute...this statute requires Medicare hospitals to provide emergency services to all patient...whether or not the patient can pay...hospitals are required to (1) Stabilize patients who may have an emergency condition (2) stabilize patients who have an emergency condition..."

Review of an electronic mail (Email), dated November 12, 2013, at 9:26 a.m., from the ED Director to the charge nurses for the ED, and to the Nursing Supervisors, revealed "...the WRC is often the first person a patient presenting for treatment sees...it is imperative that they a full and complete understanding of EMTALA...the ED staff are definitely the experts in this area, and need to be the ones staffing the WRC going forward...we have agreed that any licensed ED associate (nurse, EMT-IV, paramedic) may act as the WRC...student techs may not act as the WRC...if we do receive help from a non-ED (named facility) employee, they need to be utilized in the back...if they are familiar with the ED, they may take a zone (just like we always have)...if not, they need to function as a float nurse/tech...they may transport patients, start IV's, give medications, help take patients to the bathroom, reassess pain, etc..."

Observation on November 20, 2013, at 2:30 p.m., in the ED waiting area, revealed an RN was assigned to the WRC role in the ED. Continued observation revealed the WRC greeted patients upon arrival at the ED, obtained the patients chief complaint and notified the triage nurse of the patient's arrival and chief compliant.

Observation on November 21, 2013, at 9:30 a.m., in the ED waiting area, revealed an RN was assigned to the WRC role in the ED. Continued observation revealed the WRC greeted patients upon arrival at the ED, obtained the patients chief complaint and notified the triage nurse of the patient's arrival and chief compliant.

Interview on November 20, 2013, at 1:45 p.m., with RN #1, in the Emergency Department Waiting Room, revealed all nurses in the ED rotate and do triage in the ED. Continued interview revealed the nurses have cell phones and once a patient comes into the ED for evaluation, the WRC notifies the triage nurse and the triage nurse will do the triage of the patient. Further interview revealed " ...all patients who present to the ED get a medical screening by the physician or the PA..."

Interview on November 20, 2013, at 1:50 p.m., with ED Physician #1, in the Emergency Department, revealed "...any patient who comes into the ED for treatment will get a medical screening by a licensed healthcare provider...the patients are placed in a room during triage by the nurse..."

Interview on November 20, 2013, at 3:20 p.m., with the ED Director, in the ED Director office, revealed "...was called by the ED staff and told a 22 month child had presented to the ED with the parents due to an arm injury...the child had not been seen the ED and the child and parents had left the ED without being seen by a licensed medical provider..." Further interview revealed "...the child's parent put the sign-in sheet in the parents purse and we did not get any demographical information so we don't know who the child was...we do not have a medical record on the patient..." Further interview revealed the facility reviewed the ED video recordings and was unable to get a car tag number or identify the child or the child's parents. Further interview revealed "...I told the staff to document the findings and the next morning the Quality Manager and Risk Manager was notified by me...I notified the CNO (Chief Nursing Officer) and the Assistant CNO..." Further interview revealed "...after talking with CNO...I sent an email to the ED staff and the nursing supervisors...we immediately implemented a policy where no float pool nurses will be assigned to the WRC role in the ED..."

Telephone interview with RN #3, on November 20, 2013, at 3:40 p.m., revealed the nurse was a float pool nurse who was assigned to the ED on November 11, 2013. Continued interview revealed "I had never worked the ED before...this was the first time I had ever worked in the ED...had never triaged before so they assigned me to the waiting room...they told me all I had to do was stamp the sign-in sheet and call the RN and tell them what was wrong with the patient..." Further interview revealed RN #3 did not have access to the ED computer system. Continued interview revealed "...a 22 month old was brought in by the parents who stated the child had an arm injury and they wanted to get the child evaluated..." Further interview revealed "...I stamped the triage sign-in sheet like they told me to...I spoke with (named nurse, RN #4) who was working the Fast Track, and the nurse told me the child could not be seen in the Fast Track due to the extent of the injury and the Fast Track PA said the child could not be seen in the Fast Track area...the nurse hung the phone up..." Further interview revealed "... the RN never told me the ED had two different areas and the child should be taken to the main ED..." Continued interview revealed "...I told the (child's parent) the child could not be seen in the ED and the child's parent stated they had never heard of that..." Further interview revealed "...the child's parent put the sign-in sheet in the parent's purse and left the ED with the child..." Further interview revealed "...RN #4 called me about an hour later and asked me where the child was at...I told RN #4 the child and the parents had left the ED after I told them the child could not be seen in the ED...RN #4 explained to me the process related to Fast Track and the main ED and told me the child should have been triaged and evaluated in the main ED..." Continued interview revealed the RN #3 had completed the hospital required EMTALA training for hospital employees but had not received the ED required EMTALA training. Further interview with RN #3 confirmed the child was never seen by the nurse or a licensed healthcare provider, and therefore a medical screen was not performed.

Telephone interview on November 20, 2013, at 4:10 p.m., with RN #4, revealed the RN was working from 7 PM to 11 PM in the Fast Track section in the Emergency Department on November 11, 2013 (the night of the incident). Continued interview revealed the RN worked in the ED and ED triage area. Further interview revealed the nurse (RN #3) was a float pool nurse that was assigned to the ED...RN #3 did not have access to the EDM (ED computer documentation)...the day shift triage nurse had told RN #3 when a patient came into the ED...get the name and why they are here and then call the triage nurse..." Continued interview revealed "...the WRC called me in the Fast Track area and told me about the patient...I told the nurse we did not see 22 month old patients in the Fast Track and due to the child's compliant...the fast track would not be the appropriate area for the child..." Continued interview revealed "...I talked to (RN #3) in great detail about the different areas in the ED and told the nurse why the child would not be seen in the Fast Track department...I instructed the nurse to call the triage nurse...the physician assistant (PA) assigned to the Fast Track was sitting right beside me and heard me talking and giving instructions to the nurse (RN #3)... Continued interview revealed "...about an hour later I checked the ED tracking board to see where the child went to and noticed a 22 month old was not on the tracking board...this seemed odd to me due to nature of the child's complaint ..." Continued interview revealed "...I called the WRC and asked where the child was...the nurse told me the patient had left the ED with the parents and the nurse (RN #3) had told the parents we would not see the patient...RN #3 did not call the triage nurse..." Further interview revealed "...maybe I should have been clearer about the two departments in the ED..." Continued interview revealed "...I called the charge nurse (RN #5)...and told the charge nurse what had happened and this was a potential EMTALA violation...the charge nurse talked to the WRC and RN #3 told the charge nurse the patient and family had left the ED...the parent had put the sign-in form on the parents purse and a chart was never generated for the child...we did not have any demographical information..." Continued interview revealed "...we called the ED Director at home about the patient leaving..." Further interview revealed float pool nurses usually are oriented to the ED and have access to the EDM..." Continued interview revealed RN #4 had completed the required hospital and ED EMTALA training.

Telephone interview on November 20, 2013, at 4:40 p.m., with RN #5, revealed the RN was working the night shift, as the charge nurse, on November 11, 2013 (the night of the allegation). Continued interview revealed the RN (RN #5) had made the assignments in the ED the night of November 11, 2013 and had assigned RN #3 as the WRC. Further interview revealed "...the nurse was assigned as the WRC because the nurse had never worked in the ED...I told the nurse (RN #3) if a patient came into the ED that needed immediate attention to call the me or the triage nurse...the nurse (RN #3) did not tell me the nurse did not have access to the EDM computer system..." Continued interview revealed "...RN #4 called me and asked me to come over to the Fast Track area...when I went over there RN #4 explained to me what had happened...I went out to ED waiting room and talked to RN #3..." Continued interview revealed "...RN #3 told me the Fast Track nurse had told the nurse the patient could not be seen in the Fast Track and RN #3 had told the patient parent the patient could not be seen...I explained to the RN (#3) the seriousness of the situation and explained the Fast Track and triage system to the nurse..." Further interview revealed the charge nurse went back into the ED...called the nursing supervisor and told the nursing supervisor what had happened...shortly after the nurse (RN #3) was assigned to another area in hospital and did not continue to work as the WRC..." Continued interview revealed "...normally we would just work short and reassign duties if the WRC position was not filled during the shift..." Further interview confirmed the patient was medically screened in the ED. Continued interview revealed RN #5 had completed the required hospital and ED training for EMTALA.

Interview on November 21, 2013, at 9:20 a.m., with the WRC, in the ED waiting room, revealed the WRC role is to meet and greet the patients, enter the patient data into the system and assure the patients get to the appropriate area in the ED. Continued interview revealed "...if a patient comes in with immediate needs...call the triage nurse or the charge nurse..." Continued interview revealed "...the patient enters the Social Security Number into the keypad...we fill the computer screen out regarding the patient's complaint and give the information to the triage nurse..."

Telephone interview on November 21, 2013, at 11:30 a.m., with the Medical Director of the Emergency Department, in the conference room, revealed "...all patients who present to the ED should receive a medical screening by a licensed medical provider..." Further interview revealed "...the patient in question did not see the physician or the PA..."

Interview on November 21, 2013, at 11:55 a.m., with the ED Director and the ED Clinical Manager, in the ED Clinical Managers Office, confirmed a medical screening was not performed by a licensed medical provider for patient #27 and no clinical medical record was generated for the patient.

Interview on November 21, 2013, at 12:20 a.m., with the Assistant CNO (ACNO), in the ACNO office, revealed "...we typically do not assign the float pool nurses to the ED..." Further interview revealed all patients who come into the ED should receive a medical screening by a licensed medical provider. Continued interview revealed "...on November 12, 2013, we implemented a policy where no float pool nurses will assigned as the WRC...the email was sent by the ED Director to the ED staff, Nursing Supervisors and all administration..."

Interview with the Director of Quality Management and the Risk Manager, on November 21, 2013, at 1:10 p.m., in the Risk Managers office, confirmed a medical screening was not performed by a licensed medical provider for the 22 month old patient (#27) and a medical record was not generated for the patient.



Plan of Correction Submitted on 11/21/13 by Quality Director:

1. Immediately (11/12/13) , eliminated the use of Float Pool staff as ED WRC's. (Waiting Room Coordinator) ED charge nurses were notified per e-mail by the ED director about the immediate staffing change for the WRC position. Charge nurses were asked to sign acknowledgement/roster after reading . Goal is to have 100% of CN's complete this review by 11/22 or at time of their next scheduled shift. (if after 11/22).

WRC assignment will be tracked per manual log. Expectation that this will be completed by ED licensed staff when they are in the WRC role. ED Director and/or designee will be responsible for monitoring assignment log on a weekly basis.

2. Nursing (House) Supervisors were also notified of the discontinuation of using float staff in the WRC role in the ED. This communication ws sent on 11/12/13 by the ACNO in the form of an email. Supervisors were requested tp sign the acknowledgement form/roster fter review. Goal is to have 100% of supervisors cmplete this review by 11/22 or at a time f their next scheduled shift.

The ED Director Cnd Chief of Nursing are responsible parties and this will be ompleted by 11/22/13.

3. EMTALA refresher education provided to the ED as of 11/20/13. The ED Director developed refresher education. Topics covered included the MSE requirement, WRC role and overview of government citations and penalties. This education was provided in a self study packet. Expectation is that this will be completed by 11/27/13; all ED staff are requested to complete roster sheet as an acknowledgement of receipt of this information. If staff is not scheduled for work and/or on LOA, they will need to complete this training by the completion of theri next scheduled shift.

4. Annual EMTALA education (approx one hour) is required by all ED licensed staff as well as with Nursing Supervisors. Education reviews all aspects of EMTALA oblications and various modules are followed by written exams. (80% is passing score) This same education is part of the ED orientation process also. The yearly education is required to be completed by 12/31/13. The individuals who were on duty on the day in question have completed this specific EMTALA course for year 2013. The ED Director is responsible for alll Education and the final completion date is 12/31/13.

5. The ED Director created a quick reference sheet of WRC roles/responsibilities and posted them at the WRC desk. The responsibilities are covered in the annual ED licensed staff competencies currently. The ED Director is responsible and the annual ocmpetencies will be completed by 12/31/13.

6. House-wide education EMTALA (focusing on presentation for treatment of medical condition and hospitals obligation) will be provided in December through the hospital education self-study packet distribution. This will be for designated clinical areas. An attendance/completion roster will be used to track compliance/completion of this training. It should also be noted that EMTALA is also covered in annual Healthstream required training-Clinical Rapid Regulations. This training is required to be completed by 12/31/13 and the Director of Hospital Education will be responsible.