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Based on review of Tennessee Code Annotated 63-7-103 (Tennessee Practice of Professional Nursing), review of medical staff bylaws, review of facility policies, medical record review, and interviews, the facility failed to provide a Medical Screening Examination by a Qualified Medical Provider for 2 patients (#27 and #28) of 30 Emergency Department (ED) patients reviewed.

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

Based on review of Tennessee Code Annotated 63-7-103 (Tennessee Practice of Professional Nursing), review of medical staff bylaws, review of facility policies, medical record review, and interviews, the facility failed to provide a Medical Screening Examination (MSE) by a Qualified Medical Provider (QMP) for 3 patients (#27 and #28) of 30 Emergency Department (ED) patients reviewed.

The findings included:

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.

Review of "Medical Staff Bylaws of Southern Tennessee Regional Health System - Winchester and Sewanee" adopted March 30, 2000, revealed, "...Any individual, who presents to the hospital property or premises, with a request for care, will be provided a medical screening examination to determine if a medical emergency condition exists. The exam may be performed by the Emergency Department physician in the Emergency Department or in the case of an obstetrical patient, by a Qualified Medical Person (designated Obstetrical Registered Nurse) in the Childbirth Center..."

Review of the facility's policy, "LL.026, EMTALA - Medical Screening and Treatment of Emergency Medical Conditions" approved 12/4/13 revealed "...any individual who comes to the Hospital Property or Premises requesting an examination or treatment is entitled to and shall be provided an appropriate Medical Screening Examination performed by a physician or other Qualified Medical Person...Qualified Medical Person or Personnel, or QMP, means an individual other than a licensed physician who has demonstrated current competence in the performance of Medical Screening Examinations and been approved by the main Hospital provider's governing board as qualified to administer one or more types of Medical Screening Examinations...The categories of non-physician practitioners who may be designated as QMPs is set forth in the Medical Staff Bylaws..."

Review of the facility's policy titled "Assessment of Obstetrical Patients in the Emergency Department, 1-600-9.16" last reviewed 8/2015 revealed, "...Obstetrical patients at more than 20 weeks gestation, with a chief complaint related to the pregnancy are transported to the Childbirth Center. The qualified medical person in the Childbirth Center performs a Medical Screening Examination..."

Medical record review revealed Patient #27 arrived at the ED on 9/27/17 at 2:45 PM with complaint of nausea, high heart rate, and lower back pain.

Medical record review of a nurse's flow sheet dated 9/27/17 at 2:58 PM revealed "...G1P0 [first pregnancy] 21 Y.O. [21 years old] PATIENT OF DR [named obstetrician] IS AMBULATORY TO OB [obstetrics] FLOOR FOR COMPLAINTS OF FEELING LIKE PASSING OUT AT WORK. PT [patient] STATES SHE GOT HOT NAUSEATED, AND HAS BACK PAIN. PT DENIES LOF [leaking of amniotic fluid], VAGINAL BLEEDING AND STATES POSITIVE FM [fetal movement] EDD [estimated delivery date] 10/25/17. PT IS 36 WEEKS TODAY..." Continued review at 3:12 PM revealed the patient was placed on a fetal monitor and had a vaginal exam by the RN at 3:28 PM. Further review at 3:30 PM revealed "...DR [named obstetrician] IS NOTIFIED OF PT'S ARRIVAL TO FLOOR WITH COMPLAINTS OF FEELING LIKE SHE WAS GOING TO PASS OUT AT WORK, NAUSEATED, AND BACK PAIN. MD [medical doctor] IS UPDATED ON VITAL SIGNS, FHR [fetal heart rate] PATTERN, AND SVE [sterile vaginal exam]. MD ORDERS R/O [rule out] LABOR PUSH FLUIDS AND TYLENOL..." Continued review at 5:22 PM revealed "...DR ...IS CALLED AND NOTIFIED OF FHR PATTERNS, CTX [contractions] PATTERN, AND TYLENOL ADMINISTRATION. MD ORDERS UA [urinalysis] AND CBC [complete blood count]..." Further review at 6:30 PM revealed "...DR...IS UPDATED ON FHR PATTERN, CTX PATTERN, LABS AND SVE UNCHANGED. MD ORDERS TO DISCHARGE PT HOME TO F/U [follow up] WITH HIM AT NEXT APPT [appointment]..." Continued review at 7:56 PM revealed "...Patient discharged to 'HOME'..." Further review revealed no documentation the patient was examined by a physician or any practitioner other than the Registered Nurse.

Medical record review revealed Patient #28 presented to the hospital on 9/29/17 at 9:50 AM for a complaint of dizziness at home.

Medical record review of a Nurses Flow Sheet dated 9/29/17 at 9:50 AM revealed the patient was triaged with "...G1P0 [first pregnancy] 38 Y/O PT [38 year old patient]...AMBULATED TO LD [labor and delivery] C/O [complaining of] LIGHT HEADEDNESS AND DIZZINESS THAT STARTED THIS MORNING...DENIES ANY LOF OR VAGINAL BLEEDING...CONFIRMS FETAL MOVEMENT..." Further review at 10:00 AM revealed "...DR. [named obstetrician] NOTIFIED OF PT ARRIVAL. ORDERS RECEIVED..." Further review revealed the patient was placed on a fetal monitor at 10:00 AM. Continued review at 11:38 AM revealed "...UDPDATED DR...ON PT STATUS. ORDER RECEIVED TO D/C [discharge] HOME..." Further review at 3:01 PM revealed "...Patient discharge to 'HOME'..." Further review revealed no documentation the patient was examined by a physician or any practitioner other than the Registered Nurse.

Interview with the Interim OB Director on 10/3/17 at 3:00 PM, in the administrative conference room, revealed facility practice was for an OB RN, who had completed facility competencies in OB, to be designated as a QMP. Further interview confirmed Patients #27 and #28 were not provided a MSE by a physician or any other non-physician practitioner other than the RN.