HospitalInspections.org

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 review, and interviews, the facility failed to provide a Medical Screening Examination (MSE) by a Qualified Medical Provider (QMP) for 4 patients (#1, #5, #9, and #13) of 30 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 4 patients (#1, #5, #9, and #13) of 30 patients reviewed.

The findings included:

Review of the 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 obstetric, 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...MSE will be conducted by a QMP [Qualified Medical Provider] 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 infant's 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 [L&D] Unit for emergency care. An Obstetric [OB] RN with demonstrated competency can act as a QMP in the Labor and Delivery Unit to perform a medical screening for labor status..."

Review of Facility Policy Medical Screening Assessment of the Obstetric Patient dated 7/16/18 revealed "...a RN with at least 2 years' experience in Obstetrical Department...approved by the chairman of the Department of Obstetrics to evaluate obstetrical patients in the absence of the immediate attendance of a physician..."

Review of facility policy Triage last revised 5/2016, revealed "...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 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 were permitted to complete Medical Screening Examinations under the Tennessee Nurse Practice Act.

Medical record review revealed Patient #1 was admitted to the facility on 9/20/18 at 2:05 AM with a complaint of "Contractions" and was transported to the L& D unit for triage at 2:11 AM. Further review revealed the patient left the facility Against Medical Advice (AMA) on 9/20/18.

Medical record review of the fetal monitor (used to detect fetal heart rate and uterine contractions) dated 9/20/18 revealed the patient was placed on the monitor at 2:31 AM and the fetal rate was 120 beats per minute and the patient's contractions were 2-3 minutes apart.

Medical record review of a Women's Health (L&D) form for Patient #1 dated 9/20/18 at 3:03 AM revealed a spontaneous delivery was performed by RN #3. Further review revealed "...Delivery Type: Vaginal...Delivery of Head...9/20/18 3:03 [AM] [58 minutes after arrival]...Placenta Delivery 9/20/18 3:08 [AM]..." Continued review revealed "...no antepartum [period prior to delivery] notes have been documented..." Further review revealed an admission assessment for Patient #1 was documented on 9/20/18 at 4:10 AM (2 hours and 5 minutes after arrival). Continued review revealed no documentation the physician was advised of Patient #1's arrival prior to delivery of the infant.

Medical record review of a Physician's Admission History and Physical dated 9/20/18 at 3:20 AM revealed "...26 year old...presents complaining of labor, 6 cm [centimeters] dilatation. Promptly became complete and delivered spontaneous by attending RN...no acute distress...vulva has a very superficial abrasion not requiring suturing..."

Medical record review of a Physician's Progress Note dated 9/20/18 at 3:27 AM revealed "...History of Subutex [medication used for opiate addiction] 16 mg [milligrams] a day...patient underwent a spontaneous vaginal delivery controlled by RN..."

Medical record review of a Nurse's Note dated 9/20/18 at 1:56 PM revealed "...discussed with patient, wanting to be discharged. Called [named physician] who states she will be seen again tomorrow, can leave AMA, patient decided to leave AMA, discussed consents with patient. Patient signed out AMA..."

Telephone interview with RN #1 on 1/10/19 at 12:05 PM revealed "...I had heard [named Labor and Delivery Nurses] talking about the patient being 6 centimeters dilated but I was not sure what was going on in the room. I took the Pitocin [medication used to induce labor] into the room and heard them telling the patient to push..."

Interview with the Director of Surgery and Women's Health on 1/10/19 at 2:05 PM, in the conference room, confirmed the MSE prior to delivery was completed by the RN for Patient #1.

Interview with the Director of Surgical Services and Women's Health on 1/10/19 at 2:25 PM, in the conference room, confirmed there was no documentation in the medical record of a vaginal assessment on Patient #1 and no documentation the physician was notified of the patient's arrival.

Telephone interview with RN #2 on 1/10/19 at 2:30 PM revealed "...I was told by the nurse the patient was 6 centimeters dilated when she came into the triage room. Another nurse passed me in the hallway and asked me if knew they were pushing in the room. I was not aware of this so I stepped into the room and saw [RN #3] telling the patient to push and they had her [Patient #1] up in the stirrups...I asked [RN #3] if she thought the physician should be called...she looked at me and said 'yes you can call the doctor'...I looked at the monitor and then I saw [RN #3] with gloves on and was preparing the perineum for delivery...she was telling the patient to push. I called the physician [unsure of time] and told him they were pushing with the patient and he said he would be right there...once I got back into the room the delivery was taking place. I helped [RN #3] clamp the cord and she delivered the placenta. The baby was fine and had no complications..." Further interview revealed "...after the delivery [named physician] arrived...he asked [RN #3] if he needed to check the patient and she said 'No'...I told him he needed to check the patient and he did...the secretary told me that she heard [RN #3] tell the physician that her goal was to deliver the baby before he got there..."

Telephone interview with RN #3 on 1/10/19 at 2:45 PM revealed "...the patient was out of control when she arrived on the unit...she was in pain and appeared to be in active labor...she was 6 centimeters dilated...[RN #4] told me she thought the patient was going deliver so we took her to room 24...we placed her on her left side and started oxygen on her...[RN #4] instructed the patient with breathing...I put on my gloves and told the patient not to push but she was far along...delivery was imminent...I checked the patient and she was fully dilated...I performed the delivery...I don't know when the physician was called. [RN #1] came into the room and asked if [named physician] was aware and asked me if I wanted her to call him...I told her to call the doctor. The patient delivered at 3:03 AM [58 minutes after the patient's arrival]..." Further interview confirmed there was no documentation of an initial assessment of Patient #1 and no documentation the physician was notified of the patient's arrival.

Telephone interview with RN #4 on 1/10/19 at 3:00 PM revealed "...I came into the triage room and the patient [Patient #1] was out of control and was pushing...I performed the vaginal examination on the patient in triage and she was 6 centimeters dilated...we moved her to room 24 and started an IV [intravenous line] on the patient. The whole situation went very quick...[RN #3] was with the patient and hooked her up to the monitor...I thought the physician had been called...she [RN #3] said the patient was 6 centimeters [dilated] in triage and I thought she [RN #3] was charting everything...[RN #1] came into the room and [RN #3] told her to call the doctor. The physician arrived a few minutes after the patient delivered and examined the patient. The patient did not have any lacerations and did not require sutures..."

Telephone interview with the former L&D Nurse Manager (NM) on 1/10/19 at 3:35 PM revealed the NM received an e-mail from another staff member that stated Patient #1 was coached by RN #3 to push and to promote delivery of the infant and that the physician was not called until the patient was already in the stirrups for delivery and after the RN was asked if the physician should be called. Further interview revealed "...the patient apparently presented to the unit and was 6 centimeters dilated and had been in labor since the day before. Our investigation revealed there was no documentation of a vaginal examination or the patient's dilatation or effacement...[or no documentation] the physician was notified of the patient's admission...the nurse [RN #3] said she did the vaginal examination in triage and the patient was 6 centimeters dilated...they moved the patient from triage to the labor room and prepared the room for delivery...[RN #1] came into the room and asked her [RN #3] if she wanted her to call the doctor...the patient delivered vaginally and had no complications. The physician arrived after the delivery and examined the patient...the patient did not have any lacerations and did not require any suturing...the placenta had already been delivered by the time the physician arrived..." Further interview confirmed there was no documentation of a patient assessment or vaginal examination prior to delivery and no documentation the physician was notified of the patient's admission.

Telephone interview with Physician #1 on 1/10/19 at 4:40 PM revealed the nursing staff notifies the physician once the vaginal examination was performed and the assessment was completed on a patient. Further interview confirmed "...I was not present for the delivery [Patient #1]...the patient delivered before I arrived. Someone called me and told me...I told them I was on my way and she delivered while I was in transit...I am not sure what time they called me...once I arrived I checked the patient...she did not have any lacerations and did not require any suturing..."

Medical record review revealed Patient #5 was admitted to the facility on 9/5/18 at 6:04 AM with complaints of "...sharp lower abd [abdominal] pains...started x [times] 1 hour...pt [patient] is 33 wks [weeks] pregnant...states she is under a lot of stress...believes has caused her to miscarry in the past, worried about baby..." Continued review revealed the patient was assessed by an RN on 9/5/18 at 6:30 AM and 8:12 AM. Further review revealed "...[named physician] notified at 8:13 AM..." Continued review revealed the patient was discharged home on 9/5/18 at 8:16 AM (2 hours and 12 minutes after arrival). Further review revealed no documentation Patient #5 received a MSE by any other provider other than an RN.

Medical record review revealed Patient #9 was admitted to the facility on 10/29/18 at 10:35 PM for a complaint of "...contractions and ? [questionable] SROM [spontaneous rupture of membranes]..." Further review revealed the patient was assessed by a RN on 10/29/18 at 10:47 PM and the patient's estimated date of delivery was 11/1/18. Continued review revealed the patient was discharged home on 10/29/18 at 11:47 PM (1 hour and 12 minutes after arrival). Further review revealed no documentation Patient #9 received a MSE by any other provider other than a RN.

Medical record review revealed Patient #13 was admitted to the facility on 12/27/18 at 1:30 AM with a chief complaint "...lower abd pain into lower right side of back..." Continued review revealed the estimated gestational age was 30 weeks. Further review at 1:34 AM revealed"...[named physician] called informed pt. here...c/o [complaints of] abd pain radiating to rt [right] lower back, no complications...orders received...[2:30 AM]...pt. unable to drink, paged [named physician] for orders and update..." Continued review revealed the patient was discharged home on 12/27/18 at 7:59 AM (6 hours and 29 minutes after arrival). Continued review revealed no documentation Patient #13 received a MSE by any other provider other than an RN.

Interview with RN #5 and the Director of Surgery and Women's Health on 1/10/19 at 2:05 PM, in the conference room, confirmed the RN completed the MSE for Patient #5, #9, and #13.