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Based on hospital policy review, medical record review and interview, the hospital failed to ensure all patients presenting to the hospital's Emergency Department (ED) seeking medical treatment were provided an appropriate medical screening examination (MSE) for 1 of 21 (Patient #1) sampled patients, failed to ensure stabilizing treatment was provided to 1 of 21 (Patient #1) sampled patients presenting to the Emergency Department (ED) seeking medical care for pain. The hospital failed to ensure the risks and benefits of examination and treatment were explained to and documented for all patients presenting to the ED seeking medical care and leaving against medical advice (AMA) for 1 of 21 (Patient #13) sampled patients.

The findings included:

1. Medical record revealed Patient #1, a 73-year-old male, presented to the Hospital's ED on 10/29/2024 at 1:53 PM via Emergency Medical Services (EMS) with complaint of chest pain and all over pain. Patient #1 did not receive laboratory testing for troponin (troponin is a protein found in heart muscle cells that is released into the blood when the heart is damaged; a troponin test measures the amount of troponin in the blood to help diagnose heart attacks and assess the extent of heart damage) to rule out a heart event prior to discharge. Patient #1 reported his pain as moderate/5 on a scale from 0-10. Patient #1 was not administered any medications for his pain prior to discharge.
Cross Refer to 2406 and 2407.

2. Medical record revealed Patient #13, an 87-year-old female, presented to the ED on 12/1/2024 at 10:59 AM via private vehicle with complaints of dizziness for 2 days and generalized weakness. Patient #13 had an abnormal electrocardiogram, and elevated troponin levels. Patient #13 decided to leave the ED against medical advice, while awaiting a hospital bed for admission. The ED Physician failed to document the discussion of the risks versus benefits for remaining at the hospital for further evaluation.
Cross Refer to 2407.

Based on hospital policy review, medical record review and interview, the hospital failed to ensure all patients presenting to the hospital's Emergency Department (ED), seeking care for an emergency medical condition (EMC) received an appropriate and on-going medical screening examination (MSE) within the capabilities of the hospital for 1 of 21 (Patient #1) sampled patients.

The findings included:

1. Review of the hospital policy "EMTALA [Emergency Medical Treatment and Active Labor Act] Tennessee Medical Screening Examination and Stabilization" revised 12/2023 revealed, "The policy reflects guidance under EMTALA and associated state laws only. PURPOSE: To establish guidelines for providing appropriate medical screening examinations (MSE) and any necessary stabilizing treatment or an appropriate transfer for the individual as required by EMTALA...POLICY: An EMTALA obligation is triggered when an individual comes to the dedicated emergency department (DED) and 1. The individual or a representative acting on the individual's behalf requests an examination or treatment for a medical condition; or 2. A prudent layperson observer would conclude from the individual's appearance or behavior that the individual needs an examination or treatment of a medical condition...PROCEDURE 1. When an MSE is required. A hospital must provide an appropriate MSE within the capability of the hospital's emergency department including ancillary services routinely available to the DED, to determine whether or not and EMC exists to any individual...who requests such an examination...An MSE shall be provided to determine whether or not the individual is experiencing a EMC...An MSE is required when: a. The individual comes to the DED of a hospital and a request is made by the individual or on the individual's behalf for examination and treatment of a medical condition including where i. the individual requests medication to resolve or provide stabilizing treatment for a medical condition....3. Extent of the MSE...b. definition of MSE. An MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC or not. It is not an isolated event. The MSE must be appropriate to the individual's presenting signs and symptoms and the capability and capacity of the hospital...e. Extent of MSE varies by presenting symptoms...i. Depending on the individual's presenting symptoms, an MSE can involve a wide spectrum of actions, ranging from simple process involving only a brief history and physical...to a complex process that also involves ancillary studies and procedures such as (but not limited to) lumbar punctures, clinical laboratory tests, CT scans and other diagnostic tests and procedures..."

2. Review of the Emergency Medical Services (EMS) trip report dated 10/29/2024 revealed Patient #1, a 73-year-old male called for EMS for complaints of chest pain. The EMS narrative revealed, "...responded to [Bus Company] station for Chest Pain. Arrived to find male sitting upright on bench, patient advised he had generalized body pains for the last 3 months, was seen [named another hospital] yesterday for chest pain and discharged to [homeless shelter]. Patient took 324 mg [milligrams] ASA [aspirin] prior to our arrival, advised he has nitro [nitroglycerin - medication used to treat and prevent chest pain] but has not taken any today. Pt [patient]...advised he is aching all over and feeling worn out...Vitals recorded. 12 lead [electrocardiogram test that shows electrical activity of the heart] shows a sinus tach [tachycardia - the heart is beating faster than 100 times per minute]. Pt [patient] refused Nitro at this time. Transported to [named Hospital #1] no incidents." The EMS report revealed the unit arrived at Hospital #1 at 1:50 PM and care was transitioned to Hospital #1's ED staff.

3. Patient #1's ED record at Hospital #1 revealed a 73-year-old male who presented to the Hospital's ED on 10/29/2024 at 1:53 PM via EMS with complaint of "pain all over".

Triage was initiated at 2:07 PM with the stated complaint "PAIN ALL OVER", and chief complaint "Chest Pain". The subjective assessment by Nurse #2 revealed, "EMS stated that patient was picked up from [Bus Company] bus station. Pts initial call was for chest pain but stated he hurt all over when EMS arrived." Patient #1 reported his pain as moderate and rated it 5 on a scale of 0-10 with 0 being no pain and 10 being the worst pain.

The MSE was initiated at 1:54 PM by ED Physician #1 with the chief complaint recorded as "generalized pain". ED Physician #1's History and Present Illness note revealed, "This is a 73-year-old patient with reported history of hypertension, DVT [deep vein thrombosis] and anticoagulated on Xarelto [medication to prevent blood clotting], also reports a history of chronic pain and used to be on pain management, visiting from [named state], brought in from [Bus Company] bus station reportedly for stated complaint of not feeling well, occurring over the past several days...Patient reports he hurts from head to toe, denies shortness of breath, vision disturbances, any facial/extremity tingling/numbness or weakness."

There were no troponin laboratory orders for Patient #1. (Troponin is a protein found in heart muscle cells that is released into the blood when the heart is damaged. A troponin test measures the amount of troponin in the blood to help diagnose heart attacks and assess the extent of heart damage).

Patient #1 was discharged from Hospital #1 by ED Physician #3 on 10/29/2024 at 4:49 PM.

4. During an interview on 12/17/2024 at 12:35 PM, Nurse #2 verified she provided care to Patient #1 in the ED on 10/29/2024. Nurse #2 stated she did recall Patient #1, that he initially refused to have an IV started, but later agreed. Nurse #2 stated she drew labs for BMP, CMP and Troponin after getting Patient #1's intravenous (IV) access started, however the physician made the determination about what orders and lab testing would be completed for each patient in the ED.

During an interview on 12/17/2024 at 12:46 PM, the Director of Quality verified there were no orders for troponin for Patient #1.

During an interview on 12/17/2024 at 3:01 PM, Nurse #3, a Clinical Coordinator in the ED, stated a troponin was typically drawn for all patients who reported chest pain. Nurse #3 stated there were no nurse driven protocols in the ED. Nurse #3 stated the nurses draw labs and wait for the providers to put orders in. Nurse #3 stated the ED Physician determine what labs to order.

During a telephone interview on 12/17/2024 at 2:31 PM, ED Physician #2 stated Patient #1 complained of generalized pain all over and not chest pain. When asked if she would order an EKG on a patient who reported generalized weakness, she stated, "on an elderly patient who reported feeling weak, they often get an EKG." When asked why no Troponin was ordered, ED Physician #2 stated that would be a better question for ED Physician #1 because he initiated the MSE for Patient #1.

During a telephone interview on 12/17/2024 at 3:18 PM, ED Physician #1 stated he did not recall Patient #1. When asked what protocols he follows for a patient who presented to the ED with reports of chest pain, ED Physician #1 stated, "EKG, Chest X-ray and cardiac markers." ED Physician #1 stated he did have access to the electronic medical record for Patient #1 and he did not see any orders for troponin for Patient #1 on 10/29/2024. ED Physician #1 stated Patient #1 reported generalized pain all over as his chief complaint during the MSE, not chest pain.

Based on policy review, medical record review and interview, the hospital failed to ensure stabilizing treatment was provided to 1 of 21 ( Patient #1) sampled patients presenting to the Emergency Department (ED) seeking medical care for pain and failed to ensure the risks and benefits of examination and treatment was explained and documented to all patients presenting to the ED seeking medical care and leaving against medical advice (AMA) for 1 of 21 (Patient #13) sampled patients.

The findings included:

1. Review of the hospital policy "EMTALA [Emergency Medical Treatment and Active Labor Act] Tennessee Medical Screening Examination and Stabilization" last revised 12/2023 revealed," The policy reflects guidance under EMTALA and associated state laws only. PURPOSE: To establish guidelines for providing appropriate medical screening examinations (MSE) and any necessary stabilizing treatment or an appropriate transfer for the individual as required by EMTALA...POLICY: ...6. Refusal to Consent to Treatment a. Written Refusal- Partial Refusal of Care or Against Medical Advice. If a physician or QMP [Qualified Medical Person] has begun the MSE or any other stabilizing treatment and an individual refuses to consent to a test, examination or treatment or refuses any further care and is determined to leave against medical advice, after being informed of the risks and benefits and the hospital's obligations under EMTALA, reasonable attempts should be made to obtain a written refusal to consent to examination or treatment using the form provided for that purpose or document the individual's refusal to sign the Patient Refusal of Care or the Against Medical Advice form...7. Stabilizing Treatment Within Hospital Capability The determination of whether an individual is stable is not based on the clinical outcome of the individual's medical condition. An individual has been provided a sufficient stabilizing treatment when the physician treating the individual in the DED has determined, within reasonable clinical confidence, that no material deterioration of the condition is likely ...a. Stable. The physician or QMP providing the medical screening and treating the emergency has determined within reasonable clinical confidence that the EMC that caused the individual to seek care in the DED has been resolved although the underlying medical condition may persist ..."

Review of the hospital policy "Pain Assessment and Reassessment, Management and Documentation" revised 3/2023 revealed, "PURPOSE: To establish an approach to pain management consistent with patient needs, preferences and rights and within organizational ICARE/ PROMISE values. POLICY : [named Hospital #1] respects patient's right to pain management ...[named Hospital #1] assesses. reassesses and manages its patient's pain consistent with scope of care treatment, services and the patient's condition ...[named Hospital #1] treats the patients pain or refers the patient to treatment if necessary ..."

Review of the hospital policy "Discharge of Patient Against Medical Advice (AMA)" last revised 01/2012 revealed, "PURPOSE: To insure [ensure] that the patient and/or guardian have been informed and acknowledge understanding of risks involved in refusal to accept offered medical treatment/services. POLICY: The patient and/or guardian will be advised of the risks and benefits involved in leaving the medical center against medical advice relative to his or her medical condition. PROCEDURE: 1. If a patient or guardian wishes to sign out of the medical center against medical advice, the administrative supervisor of nursing and the patient's physician are to be notified immediately. 2. If the physician (or nurse in the absence of the physician) has explained all the risks involved in the patient's refusal of medical treatment, as well as all the benefits involved in his/her remaining a Release of Responsibility for Discharge form is to be signed by the patient...and witnessed by two nurses or a nurse and physician..."

2. Medical record review for Patient #1 revealed a 73-year-old male who presented to the hospital's ED via Emergency Medical Services on 10/29/2024 at 1:53 PM with complaints of chest pain and generalized all over pain.

Triage was initiated at 2:07 PM with the stated complaint "PAIN ALL OVER", and chief complaint "Chest Pain". The subjective assessment at 3:12 PM, by Nurse #2, revealed "EMS [Emergency Medical Services] stated that patient was picked up from [Bus Company] bus station. Pts [Patient's] initial call was for chest pain but stated he hurt all over when EMS arrived." At 3:14 PM, Patient #1 reported his pain as moderate and rated it 5 on a scale of 0-10 with 0 being no pain and 10 being the worst pain. There was no documentation that Patient #1's pain was assessed from his arrival at 1:53 PM to the pain assessment conducted at 3:14 PM (1 hour 21 minutes).

The MSE was initiated at 1:54 PM by ED Physician #1 with the chief complaint recorded as "generalized pain". ED Physician #1's History and Present Illness note revealed, "This is a 73-year-old patient with reported history of hypertension, DVT [deep vein thrombosis] and anticoagulated [use of medication to prevent blood clotting] on Xarelto [medication to prevent blood clotting], also reports a history of chronic pain and used to be on pain management, visiting from [named state], brought in from [Bus Company] bus station reportedly for stated complaint of not feeling well, occurring over the past several days ...Patient reports he hurts from head to toe..."

Review of ED Physician #1's Medical Decision-Making Notes revealed, "The patient presents with vague and stated complaint of generalized pain."

There was no treatment provided to Patient #1 to address his pain reported as 5 on a scale of 0-10.

Patient #1 was discharged from Hospital #1 by ED Physician #2 on 10/29/2024 at 4:49 PM. There was no documentation Patient #1's pain was reassessed after the time of the initial pain assessment documented at 3:14 PM to the time of his discharge at 4:49 PM (1 hour 35 minutes).

During an interview on 12/17/2024 at 12:35 PM, Nurse #2 verified the patient was not administered any pain medication in the ED.

During an interview on 12/17/2024 at 12:46 PM, the Director of Quality verified there were no orders for pain medication to address Patient #1's pain.

During a telephone interview on 12/17/2024 at 2:31 PM, ED Physician #2 stated Patient #1 complained of generalized pain all over and not chest pain. ED Physician #2 verified Patient #1 was not administered any pain medications in the ED on 10/29/2024.

During a telephone interview on 12/17/2024 at 3:18 PM, ED Physician #1 stated he did not recall Patient #1. When asked if Patient #1's pain was addressed, ED Physician #1 stated he signed out and transitioned the care for Patient #1 to ED Physician #2.

2. Medical record review for Patient #13 revealed a 87-year-old female who presented to the ED on 12/1/2024 at 10:59 AM via private vehicle with complaints of dizziness for 2 days and generalized weakness. Triage was initiated at 11:05 AM. The MSE was initiated at 11:10 AM. ED Physician #3 documented the patient presented for dizziness and weakness occurring for several days. Troponin (Troponin is a protein found in heart and skeletal muscles that helps regulate calcium and muscle contraction. In medical terminology, troponin levels in the blood can indicate heart damage or injury. Troponin levels are within normal limits are 0-54) labs revealed slightly elevated levels at 11:21 AM-55 and at 12:34 PM-59. An electrocardiogram (EKG- a test that measures electrical activity of the heart) report resulted at 11:58 AM revealed a sinus rhythm with a 1st degree AV block (is a minor arrhythmia that occurs when electrical signals from the atria (top chambers of the heart) to the ventricles (bottom chambers of the heart)are delayed), a non-specific intraventricular block (is a conduction disorder that causes a widened QRS complex on an electrocardiogram), T wave abnormality (refers to an unusual appearance of the T wave, which represents ventricular repolarization, indicating potential issues like myocardial ischemia).

Review of ED Physician #3's Clinical Impression note revealed, "Patient presents for generalized weakness, she does not report any chest pain or shortness of breath, denies any significant past cardiac history, her EKG is abnormal but does not appear significantly changed from prior and does not appear to meet STEMI (medical term for heart attack) criteria, her troponin is very mildly elevated and slightly up trending, will admit to the hospitalist for further work up, trend troponins, cardiology consult."

A nurse note dated 12/1/2024 at 3:11 PM revealed, "Pt [patient] opted to go home against medical advice despite explaining the risks. [named ED Physician #3] explained possible life-threatening incident if Pt will go AMA Patient Still signed AMA form."

Review of the Informed Refusal for Partial Refusal of Care and AMA form revealed ED Physician #3 did not document the risks and benefits explained to Patient #13, in the AMA section of the form.

Review of ED Physician #3's provider note did not document discussion with Patient #13 regarding the risks and potential outcomes of leaving the ED AMA .

During a interview on 12/17/2024 at 11:50 AM, Nurse #1 verified she cared for Patient #13 in the ED on 12/1/2024. Nurse #1 verified she had signed page 1 of the AMA form for Patient #13, along with ED Physician #3. When asked who was required to complete page 2 of the AMA form specifically the risks and benefits section, Nurse #1 stated she did not know what to write there, and the ED Physician completed that section.

The Assistant ED Medical Director called the surveyor on 12/18/204 at 8:27 AM and reported ED Physician #3 was not available for interview because he was sleeping. The Assistant ED Medical Director stated he was familiar with the case and felt comfortable answering questions about Patient #13. The Assistant ED Medical Director verified the risks and benefits section was not completed on the AMA form for Patient #13 but stated ED Physician #3 had documented the discussion in his notes. The surveyor explained there was no documentation in ED Physician #3's notes. The Assistant ED Medical Director asked for time to review the notes a requested to telephone the surveyor back, as he was driving.

During a subsequent telephone interview on 12/18/2024 at 8:59 AM, the Assistant ED Medical Director stated he was unable to find any documentation about a discussion regarding risks and benefits with Patient #13 by ED Physician #3. The Assistant ED Medical Director stated, "The nurse documented it but he [ED Physician #3] did not." The Assistant ED Medical Director stated that was an area for improvement and he did expect physicians to document discussions with patients before they leave the ED AMA.