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Based on review of medical staff rules and regulations, review of facility policies, review of Tennessee Code Annotated 63-7-103 (Tennessee Practice of Professional Nursing), medical record reviews, and interviews, the facility failed to provide a Medical Screening Examination (MSE) by a Qualified Medical Provider (QMP) for 3 patients (#36, #37, and #40) of 40 Emergency Department (ED) patients reviewed.


Refer to A-2406 for failure to provide a medical screening examination.

Based on review of medical staff rules and regulations, review of facility policies, review of Tennessee Code Annotated 63-7-103 (Tennessee Practice of Professional Nursing), medical record reviews, and interviews, the facility failed to provide a Medical Screening Examination (MSE) by a Qualified Medical Provider (QMP) for 3 patients (#36, #37, and #40) of 33 Emergency Department (ED) patients reviewed.

The findings included:

Review of the facility's "...Medical Staff Rules and Regulations..." revised September 2015, revealed "...The screening of individuals seeking emergency medical care in the Emergency Department for the purposes of determining whether the individual has an emergency medical condition that requires stabilizing treatment, shall be done by the Emergency Department physician, or by an appropriately credentialed Physician Assistant and/or Nurse Practitioner working within the practitioner's approved scope of practice under the supervision of an Emergency Department physician. In the case of pregnant patients in possible labor, the medical screening examination shall be done by registered nurses with special competence in obstetrics in consultation with an obstetrician..."

Review of facility policy "...Emergency Medical Treatment & Active Labor Act (EMTALA) Guidelines..." last revised 7/2017, revealed "...A Medical Screening Examination (MSE) will be performed for any individual that...presents on hospital property and requests examination or requires treatment for what may be an emergency medical condition...Medical screening examinations are provided regardless of diagnosis...If a Non-physician QMP [Qualified Medical Provider] determines a woman is in false labor, a physician must certify the diagnosis by telephone consultation or by actually examining the patient..."

Review of facility policy "...Medical Screening Examination of the Obstetric Patient..." last reviewed 7/0216, revealed "...Qualified Obstetrical Evaluator as defined by the OB Medical Staff...A registered nurse with a minimum of 2 years experience as an Obstetrical Nurses or equivalent hospital approved in writing by the chairman of the OB Dept [department] to evaluate obstetrical patients in the absence of the immediate attendance of a licensed physician..."

Review of the Tennessee Code Annotated 63-7-103 "...Title 63 Professions of the Healing Arts...Nursing...General Provisions..." dated 2016, revealed "...professional nursing includes...(A) Responsible supervision of a patient...(B) Promotion, restoration and maintenance of health or prevention of illness of others...(C) Counseling, managing, supervising and teaching of others...(D) Administration of medications and treatments as prescribed by a licensed physician...or nurse authorized to prescribe...(E) Application of such nursing procedures as involve understanding of cause and effect...(F) Nursing management of illness, injury or infirmity...(b) the practice of professional nursing does not include acts of medical diagnosis or the development of a medical plan or care..." Continued review did not specify Registered Nurses (RN) were permitted to complete Medical Screening Examinations under the Tennessee Nurse Practice Act.

Medical record review of an Emergency Department (ED) Triage note revealed Patient #36 arrived in the ED at Hospital B on 7/31/18 at 11:04 PM for complaint of (c/o) "...39 weeks pregnant with vaginal bleeding..." Continued review revealed no documentation a MSE was completed in the ED, but was transferred to the OB department at 11:16 PM.

Medical record review of the OB Triage documentation dated 7/31/18 at 11:16 pm revealed Patient #36 was admitted to Obstetric (OB) department. Further review revealed the patient was assessed by a Registered Nurse (RN) on 7/31/18 at 11:37 PM and on 8/1/18 at 12:49 AM. Continued review on 8/1/18 at 1:16 AM revealed "...[physician] Called and updated on pts [patients] arrival, c/o vaginal bleeding; SVE [sterile vaginal exam] 1.5 [centimeters] [dilatation]...60 [%] [effacement-thinning of cervix]...station -3 [fetal station-position of baby] with scant brown bleeding noted on glove. Ctx [contraction] q [every] 5-8 minutes...Ok to dc [discharge] home..." Further review revealed the patient was discharged home on 8/1/18 at 1:33 AM. Continued review revealed no documentation Patient #36 received a MSE by any provider other than a RN.

Medical record review of the OB Triage documentation revealed Patient #37 was admitted to OB Triage at Hospital B on 7/9/18 at 12:26 PM for c/o of "...EGA [estimated gestational age] 38.3 [38 weeks and 3 days]...abd [abdominal] pain since yesterday evening..." Continued review at 12:32 PM revealed the patient was assessed by a RN and "...dilatation 0.5 [centimeters]...effacement 50...station -3..." Continued review at 1:40 PM revealed "...[physician] notified of the pts C/O HX [complaint and history], Reactive FHR [fetal heart rate] VS [vital signs] VE [vaginal exam] pt vagaled [heart rate slowed] on her back and felt better when turned on her side...Pt is in touch with her OB...is going to follow up with him..." Further review revealed the patient was discharged at 2:00 PM. Continued review revealed no documentation Patient #37 received a MSE by any provider other than a RN.

Medical record review of the OB Triage documentation revealed Patient #40 was admitted to OB Triage at Hospital B on 12/3/18 at 11:41 PM for EGA 38.7 and c/o "...contractions worsening..." Continued review at 11:55 PM revealed "...Cervix Dilation 3...Effacement 50...Station -3..." Further review revealed on 12/4/18 at 1:00 AM revealed "...Uterine Contraction Frequency [every] 3-6 [minutes]..." Continued review revealed the patient was discharged on 12/4/18 1:10 AM. Further review revealed no documentation Patient # 40 received a MSE by any provider other than a RN.

Interview with RN #1 at Hospital B on 12/11/18 at 3:27 PM, in the administrative conference room, confirmed physical examinations of patients with OB related symptoms were performed by an RN. Continued interview confirmed some patients were not examined by any provider other than the designated OB triage RN.

Interview with RN #2 at Hospital B on 12/11/18 at 10:00 AM, in the OB staff work room, confirmed RNs performed physical examinations on patients with OB related symptoms. Continued interview confirmed some patients were not examined by any provider other than the designated OB triage RN.

Interview with the Manager of the Child Birth Center at Hospital B on 12/11/18 at 4:00 PM, in the administrative conference room, confirmed the MSE for Patients #36, #37, and #40 were provided by RNs. Further interview confirmed Patients #36, #37, and #40 were not been seen by any other providers prior to discharged from Hospital B.