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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 8 patients (#1, #3, #5, #6, 14, #17, #25 and #28) of 31 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 8 patients (#1, #3, #5, #6, #14, #17, #25, and #28) of 31 Emergency Department (ED) patients reviewed.

The findings included:

Review of Medical Staff Rules and Regulations, last revised 3/2018, revealed "...Article V1: In the cases 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 "...labor means an individual who is admitted with latent or early phase of labor...A woman experiencing contractions is in true labor unless a physician, certified nurse mid-wife, or other qualified medical person acting within his or her scope or practice as defined in hospital medical staff bylaws and state law, certifies that, after a reasonable time of observation, the woman is in false labor..." Further review revealed "...Medical Screening Examination [MSE] is defined as the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an emergency medical condition [EMC] or not...Stabilized: means with respect to an EMC that no material deterioration of condition is likely, with reasonable medical probability, to result from or occur..." Further review revealed "...MSE will be conducted by a QMP who is determined by the Governing Body of the hospital. Non physician QMP's may conduct specific MSE's...within the scope of practice of the QMP...if a non-physician QMP determines a woman is in false labor, a physician must certify the diagnosis by telephone consultation or by actually examining the patient before the diagnosis of false labor is confirmed. Consultation with the physician should be documented in the patient's medical record..."

Review of facility policy "Triage" last revised 5/2016, revealed "...Registered Nurse [RN] competent in the assessment of obstetrical patients...assess the patient's chief complaint...perform complete assessment of patients including vital signs, fetal heart rate and uterine contractions, cervical exam if needed...obtain NST [non-stress test] [test to determine the infants heart rate, movement and uterine contractions] on all patients 28 weeks or greater...the attending physician will be notified after the initial assessment unless earlier notification is warranted...the attending physician will decide the disposition of the patient from the triage unit..."

Review of facility policy "Medical Screening of the Obstetrical Patient" dated 12/2016, revealed "...a physician or a QMP will perform a MSE for all patients who presents to the dedicated Labor and Delivery Unit for emergency care. An Obstetric RN with demonstrated competency can act as a QMP in the Labor and Delivery to perform a medical screening for labor status..."

Review of Facility Policy "Medical Screening Assessment of the Obstetric (OB) Patient," last reviewed 7/16/18 revealed "...a registered nurse with at least 2 years' experience in Obstetrical Department...approved in writing by the chairman of the Department of Obstetrics to evaluate obstetrical patients in the absence of the immediate attendance of a physician..." (The date the policy was originally issued and/or last revised was not documented. The last reviewed date of 7/16/18 occurred after the incident).

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 revealed Patient #1 was admitted Hospital A on 6/4/17 at 1:42 PM with a chief complaint of cramping and abdominal pain. Continued review revealed the patient was discharged home on 6/4/17 at 2:27 PM (45 minutes later).

Medical record review of an OB Nursing Triage record from Hospital A dated 6/4/17 at 1:42 PM revealed the patient presented with complaints of abdominal pain and cramping since earlier that morning (6/4/17). Further review revealed "...vaginal exam: dilatation [opening of the cervix] 1.0 cm [centimeters]...effacement [thinning of the cervix] 50%...Station [measurement of how far the baby has descended into the pelvis] -4..."

Medical record review of the Discharge Summary from Hospital A dated 6/4/17 at 2:27 PM revealed "...precautions to return given...follow-up on 6/9/17 if not needed to be seen sooner...follow-up with OB/GYN..." Continued medical record review revealed no documentation a physician completed the MSE for Patient #1.

Review of Hospital B's "EMERGENCY SIGN-IN SHEET" (ED log) dated 6/4/17 at 5:20 PM revealed Patient #1 presented to the ED at Hospital B for complaint of "...severe abdominal pain/pregnant..."

Medical record review of the OB Triage form from Hospital B dated 6/4/17 at 5:54 PM revealed Patient #1 "...Arrived By...Ambulatory...Arrived From...Home...EGA [estimated gestational age]...23.1 [weeks]..." Further review at 5:59 PM revealed "...pt states she was at [Hospital A] today about 1pm and they didn't check her urine or cervix. She states she was instructed to take Tylenol for abdominal pain and discharged..." Further review at 6:12 PM revealed "...Vaginal Exam...Dilatation 8.0-9.0 [centimeters]...exam by [Registered Nurse #1 and Physician #1]...Membranes Status...intact bulging in vagina..."

Medical record review of a Physician's Progress Note from Hospital B dated 6/4/18 (no time) revealed "...Called to room...vag BBOW [vaginal bulging bag of waters]...cvx [cervix] 7 cm [centimeters]...NST [non-stress test] [monitoring of fetal heart rate, fetal movement, and contractions] reassuring...no bleeding...transport [Hospital C]..." Further review revealed Patient #1 was administered Magnesium Sulfate (drug to slow down labor) 6 grams intravenously (IV) on 6/4/18 at 6:16 PM, Betamethasone (steroid to improve the infant's lungs prior to birth) 12.5 milligrams intramuscular at 6:33 PM, and Penicillin (antibiotic) 5 million units IV at 6:33 PM. Continued review revealed Patient #1 left Hospital B via ambulance at 6:35 PM.

Medical record review from Hospital C revealed Patient #1 was admitted on 6/4/17 at 7:13 PM with diagnosis of 23 Weeks and 4 Days Pregnancy in Labor and Breech (baby positioned feet first) Presentation. Further review revealed "...23 weeks and 4 days gestation...had complaints on 6/4 [2017] at 11:00 am of abdominal pain. She was seen at [Hospital A] and discharged. The patient then went to [Hospital B] and found to be 8-9 cm dilated. She was transferred to [Hospital C]...Due to breech presentation and no measurable cervix, she was prepped and sent to the OR [operating room]...She had general for anesthesia and she delivered on 6/4/17 at 2031 hours [8:31 PM] a viable female infant...[Hospital D] attended the delivery. The infant (Infant A) lived approximately 3 hrs..." Further review revealed the patient was discharged home on 6/7/17.

Medical record review revealed Infant A was admitted to Hospital D on 6/4/17 at 8:54 PM. Continued review revealed the infant was born 6/4/17 at 8:37 PM with a gestational age of 23 weeks and was unable to maintain her oxygen saturations and had severe respiratory acidosis (condition where the lungs are unable remove carbon dioxide produced by the body). Further review revealed the infant was intubated (insertion of a breathing tube) and started on an oscillator (breathing machine that delivers very small breaths at a very high rate) and shortly after her admission to the NICU (Neonatal Intensive Care Unit) the infant continued to have bradycardia (slow heart rate) and expired on 6/5/17 at 2:36 AM.

Interview with Labor and Delivery RN #1 from Hospital A on 12/10/18 at 4:00 PM, in the conference room, revealed "...the initial triage information for the patient [Patient #1] is incomplete. If I saw a 1 centimeter dilatation and 50% effacement on a patient who was 23 weeks pregnant, I would be concerned and would certainly make the physician aware..."

Interview with the Labor and Delivery Nurse Manager from Hospital A on 12/11/18 at 2:15 PM, in the conference room, revealed "...the nurse performs the vaginal exam and calls the doctor with the findings. The physician would then give any additional orders for the patient and make the decision if the patient is stable for discharge...I do not see any documentation the nurse called the doctor...there is no documentation the physician examined the patient while she was in the OB triage..."

Interview with Labor and Delivery RN #2 at Hospital A on 12/12/18 at 9:10 AM, in the conference room, revealed Patient #1 presented to the OB Triage from the emergency department (ED) with abdominal pain and cramping which started earlier in the morning. Further interview revealed "...she [Patient #1] stated her membranes had not ruptured and I did not see any evidence of the rupture of the membranes. I performed a vaginal exam on the patient and she was 1 centimeter dilated, 50% effaced, and stationed at -4. She did not have any bleeding and no drainage was observed. I placed the patient on the Toco monitor [device used to monitor for fetal heart beat and uterine contractions] and obtained Doppler [device used to detect heart tones] FHT's [fetal heart tones]...they were 140 BMP [beats per minute]..." Continued interview revealed "...[named OB/GYN] was on-call...I showed the strips and the Antepartum record to [named OB/GYN physician]...he did not see the patient...any patient who had dilatation and effacement needs to be monitored...I did not ask [named OB/GYN physician] to go in and see the patient..."

Interview with the Director of Surgery and Family Birthing from Hospital A on 12/12/18 at 1:10 PM, in the conference room, confirmed the MSE on Patient #1 was performed by a RN and the physician did not examine the patient or provide a MSE for the patient.

Interview with the Senior Risk Manager at Hospital A on 12/12/18 at 1:40 PM, in the conference room, revealed the facility had not performed a formal investigation related to the incident and no action plan was implemented, but the facility did identified documentation issues.

Telephone interview with the Corporate Risk Manager at Hospital A on 12/12/18 at 2:50 PM revealed "...we reviewed the patient's medical record and found no issues other than lack of documentation by the nurse. We interviewed the nurse and she said she had spoken with the physician about the patient's presentation. The nurse stated she did not think the patient had any signs of premature labor...there is no documentation the physician evaluated the patient..." Further interview revealed "...we were notified by [Hospital B] the patient [Patient #1] had presented to the ED and was found to be in premature labor requiring a transfer to [Hospital C] for delivery. After the delivery, the baby was transported to [Hospital D] where the baby expired..."

Interview with the Chief Nursing Officer at Hospital A on 12/12/18 at 2:25 PM, in the conference room, confirmed the physician did not see the patient and the physical examination of Patient #1 was performed by the OB triage nurse.

Interview with Physician #1 at Hospital A on 12/12/18 at 3:00 PM, in the conference room, revealed Patient #1 presented to the OB Triage from the ED with abdominal pain and cramping. Further interview revealed "...reportedly the patient got better and went home from triage. I might have seen the patient in the office but I am not sure. The nurse may have told me about the patient but I cannot remember...I did not see the patient...a patient 1 centimeter dilated and 50% effaced is not a typical finding for a 24 week expectant mother..."

Telephone interview with Patient #1 on 12/13/18 at 2:40 PM revealed the patient complained of abdominal pain which felt like menstrual type pain and the pain started 6/4/17 while she was at work. Continued interview revealed she presented to Hospital A and was taken to the OB Triage for evaluation. Further interview revealed "...the pain was 8 [on scale to 10, with 10 being the worst pain]...the nurse came in the room and asked me if I could get a urine specimen...I could not at that time...the nurse placed a monitor around my abdomen area...I don't remember them checking the baby's heartbeat..." Further interview revealed "...the nurse never checked my cervix or performed a vaginal exam while I was at [Hospital A]...she did not look at my vaginal area...the nurse came back into the room no later than an hour later and asked me if I could get a urine specimen and I could not. A few minutes later she came in the room and told me she had spoken with the doctor on call and he thought I may be constipated. She told me to drink fluids and take some Tylenol for the pain and said they were going to discharge me home...there was never a vaginal exam performed and I never saw a physician while at [Hospital A]..." Continued interview revealed the patient was discharged home and on 6/4/17 at approximately 5:00 PM she went to Hospital B because the abdominal pain was not getting better. Further interview revealed she was examined by a nurse and a physician (at Hospital B) and found to be 9 cm dilated and then was transferred to (Hospital C) where a Caesarean Section was performed. Continued interview revealed the baby (Infant A) was transferred to (Hospital D) in critical condition and expired on 6/5/17.

Medical record review revealed Patient #3 was admitted to Hospital A on 6/16/17 at 8:49 AM for complaint of "...upper abdominal pain...pain score of 5 [moderate]...21 weeks [EGA]..." Continued review of the OB Triage form revealed the patient was at high risk for Placenta Previa (condition where the placenta lies low in the uterus and partially or completely covers the cervix). Further review revealed the patient was assessed by a RN at 9:13 AM and the RN "...spoke with [named physician] reguarding [regarding] performing SVE [sterile vaginal examine] due to pt [patient] states has previa and not supposed to be checked. Ordered not to check pt...to monitor and give GI [gastrointestinal] cocktail for heart burn due to pt c/o nausea and upper abd [abdominal] pain..." Further review at 10:29 AM revealed "...spoke with [named physician]..." Continued review revealed the patient was discharged home 6/16/17 at 10:36 AM. Further review revealed no documentation Patient #3 received a MSE by any provider other than a RN.

Medical record review revealed Patient #5 was admitted to Hospital A on 6/25/17 at 12:56 AM for complaint of "...contractures...nausea...27 weeks [EGA]..." Further review of the OB Triage form revealed the patient was assessed by a RN at 1:12 AM. Further review at 1:55 AM revealed "...[physician] notified of status update...fetal status...labor status...membrane status...uterine activity...lab/diagnostic study..." Continued review revealed the patient was discharged home on 6/25/17 at 2:03 AM. Continued review revealed no documentation Patient #5 received a MSE by any provider other than a RN.

Medical record review revealed Patient #6 was admitted to Hospital A on 8/17/18 at 11:40 AM for complaint of "...abdominal pain...pain score of 5...21 weeks [EGA]..." Continued review revealed no documentation the physician was notified. Further review revealed the patient was assessed by a RN at 12:00 PM and was discharged home on 8/17/18 at 1:08 PM. Continued review revealed no documentation Patient #6 received a MSE by any provider other than a RN.

Medical record review Patient #14 was admitted to Hospital A on 7/11/18 at 2:49 AM for complaint of "...abdominal pain...pain score of 7 [severe]...23 weeks [EGA]..." Continued review revealed the patient was assessed by a RN at 2:49 AM. Further review at 4:33 AM revealed "...[physician] notified of pain...test results...SVE...orders received..." Further review revealed the patient was discharged home on 7/11/18 at 4:35 AM. Continued review revealed no documentation Patient #14 received a MSE by any provider other than a RN.

Medical record review revealed Patient #17 was admitted to Hospital A on 11/4/18 at 11:21 AM with a complaint of "...has not felt baby move since yesterday..." Continued review revealed the EGA was 20 week. Further review revealed "...11:55 [AM] cervix 0 cm...0% effacement...12:09 PM: dr.[doctor] notified..." Continued review revealed the patient was discharged home on 11/4/18 at 12:14 PM. Further review revealed no documentation Patient #17 received a MSE by any provider other than a RN.

Medical record review revealed Patient #25 was admitted to Hospital A on 6/26/18 at 3:15 PM for complaint of decreased fetal movement. Continued review revealed the EGA was 31 weeks. Further review revealed the patient was assessed by a RN at 3:19 PM and the patient was placed on a fetal monitor. Continued review revealed the patient was discharged home on 6/26/18 at 4:20 PM. Further review revealed no documentation Patient #25 received a MSE by any provider other than a RN.

Medical record review Patient #28 was admitted to Hospital A on 12/4/18 at 1:47 PM for complaint of "...abdominal pain...35 2/7 weeks [EGA]..." Continued review revealed the patient was assessed by a RN at 1:45 PM. Further review at 3:25 PM revealed "...no vaginal change occasional ctx [contraction] lasting 30 secs [seconds]...orders to DC [discharge] home..." Continued review revealed the patient was discharged home on 12/4/18 at 3:38 PM. Further review revealed no documentation Patient #28 received a MSE by any provider other than a RN.

Interview with the Nurse Manager on 12/11/18 at 2:30 PM, in the conference room, confirmed there was no documentation the doctor or other QMP completed a MSE for Patients #1, #3, #5, #6, #14, #17, #25, and #28.