HospitalInspections.org

Based on review of facility policy, review of facility Medical Staff Rules and Regulations, medical record review, and interview, the facility failed to provide stabilizing treatment for 1 patient (#30) of 32 medical records reviewed.

For documentation purposes:

Facility A is Tennova Healthcare-Jefferson Memorial Hospital which is located at 110 Hospital Drive, Jefferson City, TN 37760.

Facility B is Fort Sanders Regional Medical Center located at 1901 W Clinch Avenue, Knoxville, TN 37916 (located 28 miles from Facility A).

Refer to A-2407 for failure to provide stabilizing treatment.

Based on facility policy review, review of facility Medical Staff Rules and Regulations, medical record review, and interview, the facility failed to provide stabilizing treatment for 1 patient (#30) of 32 medical records reviewed.

The findings included:

Review of facility policy "Emergency Medical Treatment and Patient Transfer" dated 9/2/13 revealed "...Emergency Medical Treatment and Labor Act ("EMTALA")...a medical condition manifesting itself by acute symptoms of sufficient severity...the absence of immediate medical attention could reasonably be expected to result in...placing the health of the individual...in serious jeopardy...serious impairment to bodily functions...serious dysfunction of any bodily organ or part...Medical Screening Examination...whether or not an Emergency Medical Condition exists...such screening must be done within the Hospital's Capacity and Capability and available personnel...including on-call physicians...Medical Screening Examination is an ongoing process and the medical records must reflect continued monitoring based on the patient's needs and continue until the patient is either Stabilized or Appropriately Transferred...Non-Emergent means based on an appropriate Medical Screening Examination...Qualified Medical Personnel has determined that the patient does not have an Emergency Medical Condition...On-Call list...defines those physicians who are "on-call" for duty after the initial Medical Screening Examination to provide further evaluation and/or treatment necessary to stabilize an individual with an Emergency Medical Condition..."

Review of "Medical Staff Rules and Regulations" dated December 2016, revealed "...Emergency Services...organization and coverage...emergency service has coverage 24 hours a day by qualified contracted physicians...in order to supplement...basic coverage in the Emergency Room...call lists shall be developed to provide...backup assistance...in-house coverage...provide the various specialists that are needed to supplement...provide comprehensive patient care..."

Medical record review revealed Patient #30 presented to the Emergency Department (ED) at Facility A on 9/24/17 at 4:05 PM with a complaint of abdominal pain for 1 month, weakness, and vomiting.

Medical record review of an ED nurse's triage note at Facility A dated 9/24/17 at 4:08 PM revealed the patient was triaged with an Emergency Severity Index (ESI) of a level 2 (Emergent high risk of deterioration or signs of a time-critical problem) and presented with complaints of right side/flank pain, which radiated to the right upper quadrant (RUQ). Further review revealed the patient reported she had pain on and off for 1 month and would vomit after eating certain foods. Continued review revealed the patient rated her pain as an 8 on a scale of 1 to 10.

Medical record review of an ED Nurse's Assessment at Facility A on 9/24/17 at 4:27 PM revealed the patient's pain score remained at a level of 8 and her vital signs were: Pulse 101, Respiratory Rate 16, Blood Pressure 132/71, Temperature 98.2 degrees, and Pulse Oximetry 100%.

Medical record review of a laboratory report at Facility A dated 9/24/17 at 4:31 PM revealed the following abnormal laboratory results: White Blood Cells (WBC) 12.3, Hemoglobin (HGB) 7.1, Hematocrit (HCT) 26.3, Aspartate Aminotransferase (AST test for liver disease) 204, Alkaline Phosphatase (ALK test for liver disease) 350, Lipase 555 (test for pancreas or liver damage), and Albumin (test for kidney disease) 3.1.

Medical record review of an ED Nurse's Note at Facility A dated 9/24/17 at 4:39 PM revealed "...pain reassessment...remains unchanged at this time..." Continued review revealed no documentation of interventions for the patient's pain.

Medical record review of an ED Physician's Documentation at Facility A dated 9/24/17 at 4:47 PM revealed "...abdominal pain in the right upper quadrant...onset...several weeks now...intermittent...symptoms...radiate...anorexia...nausea...symptoms...sharp...symptoms...aggravated by food...severity of pain...was moderate in the emergency department...has not experienced similar symptoms in the past..."

Medical record review of an ED Physician's Documentation at Facility A dated 9/24/17 at 5:32 PM revealed "...NS [normal saline, solution of salt and water] 0.9% [percent] 1000 ml [milliliters]...IV [intravenous] rate...bolus [given rapidly]..."

Medical record review of a radiology diagnostic report at Facility A dated 9/24/17 at 5:33 PM revealed "...US [ultrasound] abdomen...abd [abdomen] pain...right upper quadrant ultrasound...2 rounded...solid-appearing lesions...largest...located centrally in the right lobe of the liver...measures...7.2 cm [centimeters]...smaller lesion...left lobe of...liver...measures...1.6 cm..."

Medical record review of a radiology diagnostic report at Facility A dated 9/24/17 at 5:54 PM revealed "...CT [commuted tomography] abdomen pelvis without contrast...right-sided abdominal pain abdomen only for 1 month...vomiting...back pain...a 1.1 cm low-density nodule present...anterior left lung base abutting the diaphragmatic pleura axial...scattered coronary artery calcifications...liver...enlarged...with...round areas of low density...suspicious for liver lesions...a lesion involving much...right lobe...liver...measures up to 9.9 cm...large lesion or multiple confluent lesions involving...left lobe of...liver...diffusely enlarged...overall low in density...irregular nodular...wall thickening medial mid ascending colon...with adjacent pedunculated mass projecting off...medical wall of...ascending colon...mass measures about 4.7 cm x 2.8 cm...cystic mass centered...left of midline in the pelvis measuring up to 9 cm...posterior to the uterus...suspicious for malignancy involving the ascending colon with eccentric nodular wall thickening...adjacent soft tissue mass...several low-density lesions throughout...enlarged liver suspicious for diffuse hepatic metastatic disease...1.1 cm pulmonary nodule in the left lung base...suspicious for a metastatic nodule...9 cm cystic lesion in the pelvis...suspect an ovarian cystic mass...discussed with [ED Physician #1] in the ER [emergency room]..."

Medical record review of an ED physician's documentation from Facility A dated 9/24/17 at 6:15 PM revealed "...data reviewed...vital signs...nurses notes...lab test result(s)...radiologic studies...CT scan...ultrasound...discussed with patient that it appears she has metastatic colon CA [cancer] with mets [metastasis] to the liver...will refer to [named on-call General Surgeon]...[and] to oncology..."

Medical record review of an ED Physician's Documentation from Facility A dated 9/24/17 at 6:16 PM revealed "...Disposition...Patient's condition represents a certified medical emergency...condition is stable...discharge instructions...Iron Deficiency Anemia...Metastatic Cancer...Colon Mass...prescriptions for Colace 100 mg [milligrams]...Ferrous Sulfate 325 mg...Levsin [antispasmodic] 0.125 mg oral tablet...follow up...[named on-call General Surgeon]...when...next available...appointment...reason...recheck today's complaints...follow up...[named Oncologist]...when...next available appointment...reason...recheck today's complaints...problem is an ongoing problem...symptoms are unchanged..."

Medical record review of an ED Physician's Documentation from Facility A dated 9/24/17 at 6:30 PM revealed "...patient left the ED..."

Medical record review from Facility A revealed no documentation the ED Physician contacted an Admitting Physician, the on call General Surgeon, or the Oncologist for a consult on Patient #30.

Medical record review from Facility B revealed Patient #30 presented to the ED on 9/24/17 at 9:19 PM (2 hours and 49 minutes later after discharge from Facility A) with a chief complaint of abdominal pain.

Medical record review of an ED Nurse's Triage and Nursing History note at Facility B dated 9/24/17 at 9:26 PM revealed "...ESI level...3 Urgent...Pulse...114...temperature...99 F..."

Medical record review of an ED Physician's Note at Facility B dated 9/24/17 at 9:30 PM revealed "...c/o abdominal pain onset 2 days ago...states she was evaluated at [Facility A] today...dx [diagnosis] with colon mass...symptoms are constant...symptoms generalized throughout the abdomen...complains of vomiting...complains of nausea...anxious...tachycardic...2/6 systolic ejection murmur...has vomiting...has nausea...has abdominal pain...has fever..."

Medical record review of a laboratory report for Patient #30 at Facility B dated 9/24/17 at 9:45 PM revealed "...WBC [white blood cells]...14.7...H [high]...hemoglobin...6.9 C [critical]...hematocrit...24.7 L [low]...urinalysis...protein...30 mg [milligrams]/dl [deciliter] A [abnormal]...Iron...17 mcg [micrograms]/dl L...platelet count...582 H...WBC urine...78 A...RBC [red blood cells] urine...5 A...hepatic panel...alkaline phosphatase...317 H...AST ...110 H...Albumin...3.4 gm/dl L...Vitamin B12...> [greater than] 2000 pg [pictogram]/ml H...CO2 [carbon dioxide]...16 L...Glucose...128 mg/dl H...Creatinine...1.5 mg/dl H...Lipase...119 H..."

Medical record review of a Physician's order at Facility B dated 9/24/17 at 11:14 PM revealed "...Type and screen...STAT [immediately]...RBCs keep ahead...STAT...Transfuse 1 unit of blood product...STAT...transfuse in ED..."

Medical record review of an ED Physician's Care note at Facility B dated 9/24/17 at 11:17 PM revealed "...primary diagnosis...acute anemia...metastatic intraabdominal cancer...acute renal insufficiency...disposition decision is admit..."

Medical record review of a physician's order at Facility B dated 9/25/17 at 12:04 AM revealed "...transfuse 1 unit of blood product...STAT...transfuse in patient room..." Continued review revealed unit of blood was sent to the ED for transfusion at 12:15 AM.

Medical record review of an admitting Physician's History and Physical at Facility B dated 9/25/17 at 12:13 AM revealed "...chief complaint...abdominal pain and weakness...she [patient] tells me she is short of breath and is very weak...increasingly concerned...went to [Facility A] emergency department today...patient was given IV fluids...instructed to come to [Facility B] where oncology services were held...symptomatology...moderate and constant...decreased appetite...has lost about 30 pounds over 6 months without attempting...found to be tachycardic [rapid heart rate] at a rate of 114...hemoglobin at 6.9...typed and crossed...order to transfuse a unit of blood at this point...hemoglobin...abnormal range...she has right-sided back pain...radiate over to the right flank area...assessment and plan...ascending colon mass suspicious for malignancy with metastasis likely to the liver and lungs...will be admitted...pelvic ultrasound...general surgery...oncology will be consulted...acute blood loss anemia...assume acute kidney injury...most likely secondary to the blood loss...creatinine [level of kidney function] is at 1.5...tachycardia secondary to acute blood loss anemia...neutrophilic leukocytosis [abnormally high WBCs]...secondary to ascending colon mass...1.1 cm [centimeter] left lung base pulmonary nodule...9 cm cystic lesion in the pelvis...liver lesions x 2 with elevated transaminase level [suggestive of liver damage]...metabolic acidosis [buildup of acid in the body related to kidney function] with a bicarb [bicarbonate buffer in the blood stream] of 16 and an anion gap [indicative of metabolic acidosis] at 23...elevated lipase [indicate of liver abnormalities]...generalized asthenia [weakness]...abdominal pain/flank pain to the right side...deep vein thrombosis [blood clot] prophylaxis...Pyuria [white blood cells]...suspect she has a urinary tract infection...start her on broad spectrum antibiotics..." Continued review revealed Patient #30 was admitted with the following diagnoses: Malignant Neoplasm of Colon, Acute Post-hemorrhagic Anemia, Acute Kidney Failure, Acidosis, Secondary Malignant Neoplasm of Unspecified Lung, and Secondary Malignant Neoplasm of Liver and Intrahepatic Bile Duct.

Medical record review of a Physician's Progress Note at Facility B dated 9/25/17 at 7:35 AM revealed a Rapid Response Team (team of health care providers who respond to hospitalized patients with early signs of deterioration on non-intensive care units to prevent respiratory or cardiac arrest) was called to the patient's room for "...management of SVT [Supraventricular Tachycardia]...colon mass concerning...malignancy...severe anemia...was receiving transfusion of 2nd unit of PRBCs [packed red blood cells]...HR...160-170...transfer [to ICU]..."

Telephone interview with Patient #30's daughter on 10/3/17 at 8:39 AM revealed "...I took my mom to [Facility A] for back pain and weakness...she could barely walk...they did a CT scan...blood work...ultrasound...doctor told us she had cancer...she needed to consult an oncologist...wrote a prescription for iron and stool softeners...we took her to [Facility B]...they admitted her immediately...gave her I think 4 units of blood...did surgery...they discovered she had a heart attack...a kidney doctor has seen her...she's still there at [Facility B]..."

Interview with the ED Nursing Director at Facility A on 10/3/17 at 2:10 PM, in the conference room, revealed pain assessments are completed when patients are admitted to the ED, after pain medications or other interventions are administered to assess the effectiveness of the intervention, and before a patient was discharged. Further interview revealed other forms of interventions staff can use to relieve pain included warm blankets, ice packs, and repositioning the patient. Continued interview confirmed the nursing staff was expected to notify the physician of the patient's pain score and symptoms and to document physician notification, interventions, and effectiveness of the interventions.

Interview with Registered Nurse (RN) #1 at Facility A on 10/3/17 at 3:30 PM, in the ED breakroom, revealed "...I triaged her [Patient #30]...at the front desk...put her in the room..." Continued interview revealed the patient had a Pain Score of 8.

Interview with RN #2 on 10/3/17 at 3:49 PM, in the ED breakroom, confirmed interventions for pain should be documented and "...I don't see anything [documented]..."

Interview with RN #3 at Facility A on 10/3/17 at 4:15 PM, in the ED breakroom, revealed he was not the primary nurse for Patient #30 but had seen the patient in the ED. Further interview confirmed the patient's pain score remained an 8 and there was no documentation the physician was notified of the pain score or of the interventions implemented.

Telephone interview with ED Physician #1 at Facility A on 10/4/17 at 7:38 AM revealed he was the physician who treated Patient #30 on 9/24/17. Further interview revealed the patient was experiencing abdominal pain after eating for over 1 month. Continued interview revealed the CT scan showed Colon Cancer with metastasis to the liver and the patient was anemic, but because the patient did not have symptoms of bleeding such as "...bloody bowel movements...it [anemia]...didn't happen overnight...was a chronic problem..." Continued interview revealed a blood transfusion was not ordered for Patient #30 because the patient's Hgb was greater than 7 (Hgb was 7.1) and she was not symptomatic. Further interview revealed the on call surgeon was not consulted "...because [named on call general surgeon] was quick to get patients in..." Further interview revealed Patient #30 was discharged to home and was to follow up with the surgeon and an oncologist.

Interview with the Chief Nursing Officer at Facility A on 10/4/17 at 8:52 AM, in the conference room, confirmed "...I expect the nurses to document pain scores...and if they [patients] have pain to let the physician know...if the physician doesn't order anything the nurses are to complete an intervention and document what they did and follow up if the intervention helped the patient..."

Telephone interview with the Chief of Staff and Medical Radiology Director at Facility A on 10/4/17 at 9:30 AM revealed "...I will be honest lab values is a little lost on me...I would think he [Physician #1] would consult the physician [on call] and they would decide if the patient needed to be admitted for surgery or more tests or if they can be discharged..."

Interview with the Nurse Manager of the Intermediate Care Unit (IMC) and the Assistant Nurse Manager of the IMC at Facility B on 10/4/17 at 2:30 PM, in the IMC Unit, revealed Patient #30 was a current patient and had a diagnosis of Stage 4 Colon Cancer with Metastasis. Continued interview revealed the patient was transferred from the Oncology floor to the unit after a rapid response was called.

Interview with RN #4 at Facility B on 10/4/17 at 2:39 PM, in the IMC Unit, revealed Patient #30 was currently in the IMC Unit and was receiving nothing by mouth (NPO) and was on Total Parenteral Nutrition (tube feedings). Continued interview revealed the patient had 2 closed suction drains on her right side, which contained moderate amounts of serosanguinous (yellowish color with small amounts of blood) drainage. Further interview revealed the patient's had an indwelling urinary catheter and her urine output was low.

Interview with Patient #30 on 10/4/17 at 2:45 PM, in the patient's room at Facility B, revealed the patient went to the ED at Facility A and was told by the ED physician "...You've got cancer..." Further interview revealed she was discharged with 3 prescriptions and the names and phone numbers of doctors to call for follow up appointments. Continued interview revealed the patient did not receive anything for pain while she was at Facility A and the pain had not gotten any better before she was discharged. Further interview revealed the patient was not advised of her abnormal lab results.

Interview with Nurse Practitioner #1 at Facility B on 10/4/17 at 3:05 PM, in the conference room, revealed Patient #30 was seen at Facility A earlier in the day before presenting to Facility B. Continued interview revealed he recalled there was "...concern with malignancy and metastasis and the patient had lost 20-30 pounds over the past couple of months...had back pain...was significantly anemic, and had abdominal tenderness...[Patient #30 was]...worried and uncomfortable..." Further interview confirmed Patient #30 had an Emergency Medical Condition (EMC) and was admitted to Facility B.

Telephone interview with Physician #2, Internist at Facility B, on 10/4/17 at 3:20 PM revealed Patient #30's complained of feeling tired and was experiencing abdominal and back pain for some time. Continued interview revealed a rapid response was called because the patient developed a cardiac arrhythmia.

Telephone interview with Physician #3, General Surgeon at Facility B, on 10/4/17 at 3:35 PM, revealed Patient #30 had a mass totally obstructing the cecum (pouch connecting the small and large intestines) and "...whole liver...full of tumor...pelvic mass..." Continued interview revealed the patient went to surgery the following day (9/26/17) for a Right Hemicolectomy (surgical procedure to remove one side of the colon) and Primary Anastomosis (surgical procedure to reconnect portions of the large intestine). Further interview revealed the General Surgeon felt Patient #30 had an Emergency Medical Condition (EMC).

Telephone interview with Physician #4, Oncologist at Facility B, on 10/4/17 at 3:40 PM revealed he reviewed Patient #30's medical records from Facility A and they indicated the patient was Anemic, had a Colon Mass, and Abnormalities of the Liver. Continued interview revealed it was "...obvious she probably had a malignancy...the large pelvic mass was...removed..." Further interview revealed the patient had Stage 4 Colon Cancer with extensive Metastasis to the liver.

Telephone interview Physician #5, Cardiologist at Facility B, on 10/4/17 at 3:48 PM revealed Patient #30 experienced Supraventricular Tachycardia (abnormally fast heart rhythm) with a heart rate of 180 beats per minute. Continued interview revealed Patient #30 had an EMC and needed to be admitted to the hospital.

Telephone interview with ED Physician #6 at Facility B on 10/4/17 at 4:00 PM, revealed Patient #30's Lipase was elevated and Sodium Bicarbonate was decreased. Further interview revealed the creatinine level was 1.5 (normal female range 0.5 to 1.1 milligrams) and Hgb was 6.9 (normal female range 12.0 to 15.5 grams). Continued interview revealed Patient #30 had an EMC and needed to be admitted to the hospital.