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Based on review of Tennessee Code Title 63, hospital policies, hospital documents, personnel file review, medical record review and interview, the hospital failed to ensure an appropriate medical screening exam (MSE) was performed by qualified medical personnel (QMP) to determine if an emergency medical condition (EMC) existed for 19 of 20 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 and 20) sampled patients who presented to the emergency department (ED) seeking medical treatment. The failure of the hospital to ensure a QMP performed an appropriate and ongoing MSE to validate the existence of an EMC resulted in Patient #1 leaving the hospital at 11:30 PM. Patient #1 returned to the hospital via Emergency Medical Services at 2:07 AM in full respiratory/cardiac arrest with cardiopulmonary resuscitation (CPR) in progress.

Refer to A 2406.

Based on review of Tennessee Code Title 63, hospital policies, Medical Staff By-Laws/Rules and Regulations, hospital documents, personnel file review, medical record review and interview, the hospital failed to ensure an appropriate medical screening exam (MSE) was performed by qualified medical personnel (QMP) to determine if an emergency medical condition (EMC) existed for 19 of 20 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 and 20) sampled patients who presented to the emergency department (ED) seeking medical treatment.
The failure of the hospital to ensure a QMP performed an appropriate and ongoing MSE to validate the existence of an EMC resulted in Patient #1 leaving the hospital at 11:30 PM. Patient #1 returned to the hospital via Emergency Medical Services at 2:07 AM in full respiratory/cardiac arrest with cardiopulmonary resuscitation (CPR) in progress.

The findings included:

1. Review of the 2010 Tennessee Code Title 63 - Professions of the Healing Arts, Chapter 7 - Nursing, Part 1 - General Provisions" revealed, "...63-7-130. Practice of professional nursing defined... (b)... the practice of professional nursing does not include acts of medical diagnosis or the development of a medical plan of care and therapeutics for a patient..."

2. Review of the hospital's "EMERGENCY MEDICAL TREATMENT" policy revealed, "...The purpose of this policy is to set forth the requirements of the federal Emergency Medical Treatment and Labor Act (EMTALA)...Any individual who comes to the emergency department ...and requests examination or treatment for a medical condition is entitled to and will receive an appropriate medical screening examination performed by individuals qualified to perform an examination to determine whether an emergency medical condition exist ...DEFINITION...Emergency medical condition...A medical condition manifesting itself by acute symptoms of sufficient severity...such that the absence of immediate medical attention could reasonably be expected in result in...Placing the health of the individual ...in serious jeopardy...Serious impairment to bodily functions...Serious dysfunction to any bodily organ or part...Medical screening examination...The process required to reach within reasonable clinical confidence, the point at which it can be determined whether or not an emergency medical condition exists...The Board approves who is qualified to conduct medical screening examinations...Qualified medical personnel (QMP)...Refers to non-physician individuals defined by the hospital's medical staff bylaws or rules/regulations and approved by the hospital's Board of Trustees to perform the medical screening examinations...Triage...A sorting process to determine the order in which patients will be provided a medical screening examination by a physician or QMP...WHO MAY PERFORM THE MEDICAL SCREENING EXAMINATION...Medical screening examinations must be performed by individuals who are...Determined qualified and granted privileges by hospital medical staff bylaws and rules/regulations and who are approved by the hospital's Board of Trustees...Functioning within the scope of their license and privileges granted and are in compliance with state law..."

Review of the hospital's "MEDICAL SCREENING POLICY" revealed, "...All patients who present to the Emergency Room will receive a medical screening evaluation by a qualified medical person to determine whether an emergency condition exists. This screening may be done by a Physician, Nurse Practitioner, Physician's Assistant, or a qualified Registered Nurse [RN] with advance training...All Licensed nursing personnel will be evaluated for competency for designation as a QMP on hire during the orientation process and as deemed necessary thereafter..."

Review of the hospital's "TRIAGE" policy revealed, "...The purpose of Triage is to determine the severity of an emergency medical condition, where in the ED [emergency department] the patient should be placed, and the order in which the ED physician should see each patient...All patients presenting to the ED will be assessed and triaged into the following three categories...Level I: Emergent: Conditions requiring immediate attention by appropriate medical/clinical personnel. The disorder is acute and potentially life threatening...Examples of emergent conditions include...Cardiac chest pain and acute dyspnea and/or cyanosis...Level II: Urgent...Conditions which do not require immediate medical intervention, but require ongoing assessment and intervention...Examples of urgent condition include, but are not limited to...Nonspecific chest pain, irregular pulse, palpitations or pleuritic chest pain...Level III: Non-Emergent...Disorder is non acute or minor in severity..."

Review of the hospital's ED policy titled Chest Pain - Cardiac revealed, "All patients presenting with chest pain will be promptly triaged and treated in the following manner when indicated:...Notify the Physician when warranted...Place patient on O2 at 2 lts [liters] or otherwise directed by physician...Heparin lock and heparin flush (IV fluids as indicated) and flush..."

Review of the hospital's "VITAL SIGNS" policy revealed, "...It is the policy of this hospital that vital signs will be taken on all patients presenting to the emergency room for treatment as part of the triage process, and thereafter at a frequency appropriate to the patient presentation or per provider orders..."

3. Review of the hospital's "MEDICAL STAFF BY-LAWS/RULES AND REGULATIONS" approved on 7/27/17 revealed, "...Appointees of the Staff shall accept responsibility for emergency service care in accordance with emergency service policies and procedures...Emergency service policies and procedures shall be approved by the emergency services committee, the Staff and the Trustees...Each patient's emergency medical record shall be signed by the practitioner in attendance who is responsible for its clinical accuracy..."

Review of the hospital's "MEDICAL STAFF BY-LAWS/RULES AND REGULATIONS" approved on 7/27/17 revealed, "...COMMITTEE: GOVERNING BOARD MEETING...DATE: 12-08-2011...A called Board Meeting was conducted at 10:30 AM to discuss and approve the following...The medical staff also reviewed the QMP skills checklist and agreed these criteria were adequate for the ER [emergency room] RN [Registered Nurse]. The QMP skills checklist was approved for use and it was approved to perform upon hire and to be reviewed annually. This will be monitored thru QAPI [quality assurance performance improvement] by the GB [governing body]..."

4. Review of the hospital's "EMERGENCY DEPARTMENT COMPETENCY" form revealed, "...RN-ED Medical Screening Exam Competency...QUALIFICATIONS/EDUCATION-A minimum of 6 months Emergency Department and/or Medical Surgical Experience..."

5. Review of the personnel files revealed the "EMERGENCY DEPARTMENT COMPETENCY" was completed for the staff on the following dates:
Director of Nursing (DON) 12/30/13.
RN #1 6/14/13.
RN #2 12/23/13.
RN #3 11/17/13.
RN #4 12/3/13.
RN #5 11/12/13.
RN #6 was not completed.
There was no documentation for competency evaluation for RN #7.

Review of the personnel files for Nurse Practitioner (NP) #2 revealed "...Nurse Practitioner Protocol...Primary Supervising Physician: [ED Physician #1]...Consultation with Supervising Physicians: The nurse practitioner will maintain open communication with the supervising physicians either in person or by telephone as needed...In the event of a life threatening emergency, the nurse practitioner will institute CPR [cardiopulmonary resuscitation] and run the code until the arrival of a physician or the patient is transferred to higher level of care...Date...01-16-18..."

Review of the personnel file for RN #2 revealed, "...JOB DESCRIPTION...JOB TITLE: ER Nurse...JOB SUMMARY: Provide professional nursing care to medically ill and traumatized patients of various criticality. Use triage to determine the patient's level of severity/priority...ESSENTIAL FUNCTIONS...Able to monitor the hemodynamic status of the patient and correctly interpret results...Maintain accurate and continued nursing documentation including patient history, condition, vital signs, treatment, response to intervention and change of status...Teach the patient based on identified learning needs; evaluate the effectiveness of the patients learning. Include the family in the teaching as appropriate. Review written discharge instructions with the patient or responsible party...Accurately triage patients..."

6. Medical record review revealed Patient #1 was a 54 year old female who presented to the ED on 2/7/18 at 9:55 PM with a chief complaint of chest pain.

The Triage Assessment dated 2/7/18 at 9:58 AM documented B/P (blood pressure) 171/83, Pain Scale: 10 (on a scale of 1-10 scale with 10 being the most painful), Manner of Arrival, privately owned vehicle (POV) with Chief Complaint (CC): Chest pain (CP), Triage Level, III (Non-Emergent).

RN #2 performed the MSE at 10:05 PM and documented a 54 yr (year) old female ambulatory to ER (emergency room) c (with) c/o (complaint of) chest pain that started about 7 PM tonight, described as being in center of chest with some nausea and no vomiting. There was no documentation a physician was notified or consulted. At 11:30 PM, RN #2 documented the patient was discharged (DC) home c instructions given. The MSE was completed by RN #2 on 2/7/18 at 10:05 PM. Nurse Practitioner (NP) #2 was notified of patient being in the ED at 10:05 PM and Patient #1 was seen by NP #2 at 10:20 PM. RN #2 determined an emergency medical condition did not exist prior to Pateint #1 being seen by the treating provider, NP #2.

RN #2 documented the following vital signs on the Ongoing Vital Signs form on 2/7/18 at 11:08 PM: B/P 126/79, Pulse 89, oxygen saturation (O2 sat) 98%. This set of vital signs was taken 73 minutes after the initial vital signs were taken. There were no documentation any other vital signs were taken throughout Patient #1's emergency department (ED) visit on 2/7/18. There was no documentation the patient's vital signs were taken upon discharge.

The Pain Assessment form dated 2/7/18 revealed the following: 9:55 PM, pain on admision, 10; goal for pain, 0; 11:30 PM, pain intensity at discharge, 5. There was no documentation of any other pain assessment throughout Patient #1's ED visit on 2/7/18.

Patient #1 received the following medications on 2/7/18: Aspirin 325 milligrams (mg) by mouth and Nitroglycerin (NTG) paste 1/2 inch to chest wall at 10:00 PM. Patient #1 also received pepcid 20 mg PO at 10:50 PM. NP #2 signed the medication orders on 2/7/18 at 11:20 PM. There was no documentation of a reassessment of Patient #1's pain or nausea or the effectiveness of the medications.

NP #2 documented on the ED Provider Record the time in was 10:20 PM with CC of localized sub-sternal, continuous, sharp-stabbing chest pain, worse c laying down. NP #2 documented Patient #1 had tenderness of the sternum (breastbone) c palpitations; Primary Diagnosis: Chest pain, Diabetes Mellitus type II (DM) with Patient #1 discharged home in stable condition. Provider Signature was documented as printed name of ED Physician #1 and signed name of Nurse Practitioner (NP) #2), completed 2/7/18 at 11:20 PM.

The electrocardiogram (EKG) dated 2/7/18 at 10:05 PM documented the following computer-generated information at the top of the page: Diagnosis Information: Sinus Rhythm - no Acute ST symbols for elevation or depression, Larged PtfV1, QS Wave in lead V1, Inverted T Wave (V1, V2), Report Confirmed by [blank]. There was no documentation ED Physician #1 reviewed and confirmed the EKG report.

Review of an EMS report dated 2/8/18 revealed EMS arrived at Patient #1's home at 1:26 AM. The EMS report documented the patient was unresponsive, asystole on the cardiac monitor and CPR was started. The EMS report documented, "Upon arrival was met at door by Pt [patient] husband stated Pt just left [name of Hospital] with Chest Pain and Shortness of Breath less than two hours ago. Husband stated Pt went to ER with Chest Pain and Shortness of Breath and stated everything came back OK and the Dr [doctor] sent her home. Husband stated when she got home she all of a sudden got short of breath and started having chest pain then gurgling at the mouth and then went unresponsive. EMS found white female sitting on couch in night gown. Pt head was slumped over to right side. Skin pale and warm. Pt was apneic [no respirations]. No radial or carotid pulse..." EMS documented Patient #1 was placed on the stretcher and started chest compressions. The patient was transported to and arrived at the hospital ED on 2/8/18 at 2:07 AM. The EMS Report documented upon arrival to [name of Hospital] the patient was transferred to a hospital ED bed. EMS documented, "Chest compressions and ventilations where [were] continued by EMS crew in ER due to hospital ER not having no staff in ER to help. EMS crew help until [NP #2] had EMS stop. Pt care was then signed over to [named RN #2]." The EMS Report documented the time of the transfer of care was at 2:10 AM.

The Triage assessment written by RN #2, dated 2/8/18 and no time documented Patient #1 arrived by EMS at 2:10 AM with Chief Complaint of CPR in progress, Triage Level I.

RN #2 performed the MSE at 2:20 AM and Documented Patient #1 was transported to the hospital from home via EMS with CPR in progress. Patient #1 had no vital signs upon arrival to the hospital. The MSE was completed by RN #2 on 2/28/18 at 2:20AM. RN #2 documented NP #2 was notified a of the patient being enroute to the hospital. Patient #1 was seen by NP #2 at 2:10 AM. At 5:20 AM, RN #2 documented Patient #1's body was released to (named) funeral home. RN #2 determined an emergency medical condition did not exist prior to being seen by treating provider, NP #2.

NP #2 documented on the ED Provider Record dated 2/8/18 and timed 2:10 AM Patient #1 was unresponsive, cool to touch, cyanotic/ash color from chest-to-face, pupils fixed-dilated, no pulse, no spontaneous respirations, asystole on the cardiac monitor; Patient #1 was Pronounced Deceased 2:20 AM on 2/8/18 with Immediate Cause of Death - Myocardial Infarction (MI).

7. During a telephone interview on 3/28/18 at 9:07 AM, Patient #1's husband stated Patient #1 was discharged and was told by the hospital staff "we can't find anything wrong with you... would like to see you spend the night so we can monitor you... never mentioned [she] was on the verge of heart attack... I wasn't told what to watch for [signs or symptoms of impending heart attack]..." He stated he and Patient #1 went to bed when they got home and Patient #1 got sick three times, and vomited. Patient #1's husband stated Patient #1 was seen in the ED by NP #2. He further stated, "I do not think [there was] a doctor on staff or on call... nobody mentioned she might be having a heart attack..."

During a telephone interview on 3/28/18 at 10:45 AM, EMS Personnel #1 stated NP #2 and RN #2 were in the ED when the ambulance arrived with Patient #1. EMS Personnel #1 stated EMS continued with performning CPR after arrival to the ED while RN #2 administered medications ordered by NP #2. EMS Personnel #1 stated it was common practice for EMS to perform CPR in the ED due to the lack of ED staff. EMS Personnel #1 stated RN #2 and NP #2 did not participate in performing chest compressions or providing ventilation with the ambu bag.

During an interview in the conference room on 3/28/18 at 11:38 AM, NP #1 stated nurses in the ED should recheck vital signs in 5 or 10 minutes for a patient who presented with chest pain and had a systolic blood pressure of 170 or higher. When asked about the two sets of vital signs taken for Patient #1 on 2/7/18 (at 9:55 PM and 11:08 PM), NP #1 stated, "...that's not acceptable..."

During an interview in the conference room on 3/29/18 at 6:42 AM, RN #2 reviewed Patient #1's medical record dated 2/7/18 and stated she had checked the wrong box which documented Patient #1 did not have an emergency medical condition. RN #2 confirmed she only documented Patient #1's vital signs on 2/7/18 at 9:55 PM and 11:08 PM. When asked about the hospital's policy for taking vital signs of a patient with chest pain, RN #2 stated, "...I don't think we really have a policy...probably should have taken more often..."

During an interview in the conference room on 3/29/18 beginning at 9:15 AM, ED Physician #1 stated he was not present in the ED during the attempted resuscitation of Patient #1. ED Physiciain #1 stated when a NP is covering the ED, there is always a physician available by phone. ED Physician #1 stated the NP usually calls if he (physician) is needed in the ED. ED Physician #1 was asked if he was notified Patient #1 was in the ED. He looked though the text message log in his cell phone and stated, "[I] got a text from [named NP #2] at 2:33 AM... [reading from cell phone] 54 year old brought in with CPR in progress, had been down greater than 1 hour, DOA [dead on arrival], cause of death, MI..." When ED Physician #1 was asked what time did he come to the ED to see Patient #1, he stated it may have been the next morning before he got to the hospital to view Patient #1. He stated, "I don't rush in." ED Physician #1 further stated he used the NP's time of death as the official time of death. When ED Physician #1 was asked if NP could pronounce death in the ED in TN, he stated, "I don't know."

7. Medical record review revealed Patient #2 presented to the ED on 3/10/18 at 5:40 PM with a chief complaint of chest pain.

The Triage assessment dated 3/10/18 at 5:45 PM documented B/P: 168/89, Pain Scale: 10, Triage Level...II [Urgent].

RN #6 performed the MSE at 5:50 PM and documented Patient #2 presented to ER c/o chest pain, rated at 10 on 0-10 VPS (verbal pain scale) radiating into armpit area. The mid left chest area had constant pain, not relieved and worse with exertion, bilateral lower extremity (BLE) with nonpitting edema. There was no documentation a physician was notified or consulted. At 8:20 PM, RN #6 documented Patient #2 will be transported by emergency medical flight services. The MSE was completed by RN #6 on 3/10/18 at 5:50 PM. NP #2 was notified of patient being in the ED at 5:50 PM and Patient #2 was seen by NP #2 at 5:50 PM. RN #6 determined an emergency medical condition did not exist prior to Patient #2 been seen by the treating provider, NP #2.

NP #2 documented on the ED Provider record the time in was 5:50 PM with chief complaint of chest pain radiating to the left arm, onset 1 hour prior to arrival (PTA), described as heavy pressure. NP #2 further documented EKG results, chest xray (CXR) results and lab results. NP #2 documented he consulted with Hospital #3, and the provider at Hospital #3 agreed to accept the patient for further evaluation and treatment. NP #2 documented Patient #2 was in stable condition and transferred to Hospital #3 via (named air EMS). NP #2 completed the ED Provider record at 7:50 PM. The patient was transferred to Hospital #3 due to the need of a higher level of care at 8:20 PM. The transfer document was not signed by a physician.

During an interview in the conference room on 3/13/18 at 8:10 AM, the Director of Nursing (DON) confirmed RN #6 had not been evaluated for competency to perform a MSE. The DON stated RN #6 performed the MSE under the direction of the provider. There was no documentation in the medical record RN #6 performed the MSE under the direction of the provider.

8. Medical record review revealed Patient #3 presented to the ED on 3/10/18 at 12:50 PM with a chief complaint of chest pain.

The Triage assessment dated 3/10/18 at 12:55 PM documented BP: 123/70, Pain Scale: 8, Triage Level III (Non-Emergent].

RN #6 performed the MSE at 1:00 PM , and documented Patient #3 presented to ER with c/o CP in the left chest area rated as 8 (pain scale level), nonradiating & stays in same area. Exertion makes worse and nothing makes better. Patient #3 has shortness of breath (SOB) with exertion and these signs/symptoms (S/S) started about 10 AM. Patient #3 was noted to have bilateral wheezing and 2+ BLE edema. At 1:30 PM, RN #6 documented Patient #3 was transferred to Hospital #2 by ground EMS. The MSE was completed by RN #6 on 3/10/18 at 1:00 PM. NP #2 was notified of patient being in the ED at 1:00 PM and Patient #3 was seen by NP #3 at 1:00 PM. RN #6 determined an emergency medical condition did not exist prior to Patient #3 being seen by the treating provider, NP #2.

NP #2 documented on the ED Provider record the time in was 1:00 PM with chief complaint of chest pain, shortness of breath and edema. The chest pain was described as sub-sternal, dull, onset 2 hours PTA, and radiates to mid-back. NP #2 further documented EKG results, CXR and lab results. NP #2 documented he consulted with Hospital #2, and the provider at Hospital #2 agreed to accept Patient #3 for further evaluation and treatment. NP #2 documented Patient #3 was in stable condition, even though a work up for chest pain was never completed. Patient #3 was transferred to Hospital #2 via ambulance. The patient was transferred to Hospital #2 due to the need of a higher level of care, even though they were capable of providing this higher level of care, at 3:30 PM. A physician did not sign the transfer documentation.

9. Medical record review revealed Patient #4 presented to the ED on 2/28/18 at 2:30 PM with chief complaints of chest pain, left arm pain and left jaw pain.

The Triage assessment dated 2/28/18 at 2:33 PM documented B/P: 155/102, Pain Scale: 9/10, Triage Level...II (Urgent).

RN #4 performed the MSE at 2:40 PM and documented Patient #4 presented to ER, ambulatory with c/o chest pain and Left (L) arm pain/L jaw pain with onset this AM with c/o nausea/vomiting (n/v), smells of alcohol and states drinking gin for several days. At 6:05 PM, RN #4 documented Patient #4 was discharged to exit, ambulatory with friend. The MSE was completed by RN #4 on 2/28/18 at 2:40 PM. NP #1 was notified of patient being in the ED at 2:45 PM and Patient #4 was seen by NP#1 at 3:00 PM. RN #4 determined an emergency medical condition did not exist prior to Patient #4 being seen by treating provider, NP #1.

NP #1 documented on the ED Provider record the time in was 3:00 PM with chief complaint of chest pain, patient smells strong of alcohol (ETOH) fumes. NP #1 documented the patient had a history of MI a few months ago with stent placement. NP #1 documented CXR results and lab results. NP #1 documented Patient #4 was discharged home in stable condition with diagnoses of Atypical Chest Pain and Intoxication.

10. Medical record review revealed Patient #5 presented to the ED on 2/25/18 at 8:55 PM with chief complaints of chest pain, left arm pain and neck pain.

The Triage assessment dated 2/25/18 at 9:00 PM documented BP: 143/68, Pain Scale: 4/10, Triage Level, III (Non-Emergent).

RN #1 performed the MSE at 9:10 PM and documented Patient #5 presented to the ED with c/o L arm/neck described as feeling numb and achy with some pressure in his chest for 4 hrs. Patient #5 stated he became sweaty while sitting this afternoon. At 10:45 PM, RN #1 documented Patient #5 was ambulatory and discharged home with his wife. The MSE was completed by RN #1 on 2/25/18 at 9:10 PM. NP #2 was notified of patient being in the ED and Patient #5 was seen by NP #2 at 9:20 PM. RN #1 determined an emergency medical condition did not exist prior to Patient #5 being seen by the treating provider, NP #2.

NP #2 documented on the ED Provider record the time in was 9:20 PM with chief complaint of chest pain. NP #2 further documented EKG results, CXR and lab results. The patient was discharged home in an unstable condition.

11. Medical record review revealed Patient #6 presented to the ED on 2/24/18 at 12:45 AM with a chief complaint of chest pain.

The Triage assessment dated 2/24/18 at 12:50 AM documented, B/P: 151/85, Pain Scale: 4/10, Triage Level.II (Urgent).

RN #1 completed the MSE at 1:00 AM and documented Patient #6 presented to the ED with CP with onset in the epigastric region since 5:00 PM. Patient #6 went to bed at 10:00 PM feeling "hot" with CP and rated 1/10, woke at midnight diaphoretic with CP 4-5/10. At 6:15 AM RN #1 documented Patient #6 was discharged home. The MSE was completed by RN #1 on 2/24/218 at 1:00 AM. NP #2 was notified of patient being in the ED at 1:05 AM and Patient #6 was seen by NP #2 at 1:15 AM. RN #1 determined an emergency medical condition did not exist prior to Patient #6 being seen by the treating provider, NP #2.

NP #2 documented on the ED Provider record the time in was 1:15 AM with chief complaint of chest pain described as dull sub-sternal chest pain. NP #2 further documented EKG results, CXR and lab results. NP #2 documented Patient #6 was discharged home in a stable condition. The patient was discharged home at 6:15 AM.

12. Medical record review revealed Patient #7 presented to the ED on 2/23/18 at 3:40 PM with chief complaints of body aches and right-sided chest pain.

The Triage assessment dated 2/23/18 at 3:45 PM documented Pain Scale: 3, Triage Level III (Non-Emergent].

RN #3 performed the MSE at 3:50 PM and documented Patient #7 presented to the ED with c/o right side CP described as constant. At 6:30 PM, RN #3 documented Patient #7 was discharged home. The MSE was completed by RN #3 on 2/23/18 at 3:50 PM. NP #2 was notified of patient being in the ED at 3:55 PM and Patient #7 was seen by NP #2 at 4:00 PM. RN #3 determined an emergency medical condition did not exist prior to Patient #7 being seen by treating provider, NP #2.

NP #2 documented on the ED Provider record the time was 4:00 PM with chief complaint of weakness and chest pain. NP #2 documented the patient had weakness in both arms, and unable to grasp and hold onto anything; chest pain in unspecific in right side of chest for 2 weeks. NP #2 further documented EKG results, lab and CXR results. NP #2 documented Patient #7 was stable and discharged home. The patient was discharged home at 6:30 PM.

13. Medical record review revealed Patient #8 presented to the ED on 2/20/18 at 9:30 AM with a chief complaint of syncopal episode.

The Triage assessment dated 2/20/18 at 9:32 AM documented BP: 134/81, HR 88, Pain Scale: 4, Triage Level II (Urgent).

RN #4 performed the MSE at 9:40 AM and documented Patient #8 presented to the ER, ambulatory with assistance with chief complaint of syncopal episode at Post Office. Patient #8 stated he became diaphoretic/SOB, passed out, and stated he had chest pain prior to arrival. At 12:30 PM, RN #4 documented Patient #8 was transferred to Hospital #2 via stretcher per EMS. The MSE was completed by RN #4 at 9:40 AM. NP #1 was notified of patient being in the ED and Patient #8 was seen by NP #1 at 9:40 AM. RN #4 determined an emergency medical condition did not exist prior to being seen by the treating provider, NP #1.

NP #1 documented on the ED Provider record the time in was 9:40 AM with chief complaint as syncopal episode, not feeling great this AM, and a "little SOB." NP #1 documented EKG results as well as lab. NP #1 documented Patient #8 was stable and to be transferred to Hospital #2 via EMS with primary diagnosis of Atrial Fibrillation (A-fib), new onset with rate control. The patient was transferred to Hospital #2 due to need of a higher level of care at 12:30 PM.

14. Medical record review revealed Patient #9 presented to the ED on 2/20/18 at 9:17 AM with a chief complaint of chest pain prior to arrival.

The Triage assessment dated 2/20/18 at 9:20 AM documented, Pain Scale: 4/10, Triage Level...II (Urgent).

RN #4 performed the MSE at 9:25 AM and documented Patient #9 presented to ER per [named EMS] stretcher with c/o Chest pain prior to arrival, becoming diaphoretic with mid epigastric pain. At 2:00 PM, RN #4 documented Patient #9 was discharged, ambulatory with wife. The MSE was completed by RN #4 at 9:25 AM. NP #1 was notified of patient being in the ED and Patient #9 was seen by NP #1 at 9:30 AM. RN #4 determined an emergency medical condition did not exist prior to being seen by treating provider, NP #1.

NP #1 documented on the ED Provider record the time was 9:30 AM with chief complaint of chest pain below the sternum, history of MI in 2017, had been out feeding cattle and became SOB. NP #1 documented the EKG on arrival showed no ST changes. NP #1 further documented CXR and lab results. NP #1 documented Patient #9 was in stable conditionn and discharged home.

15. Medical record review revealed Patient #10 presented to the ED on 2/18/18 at 11:35 AM with a chief complaint of chest pain.

The Triage assessment dated 2/18/18 at 11:40 AM documented Pain Scale: 9, Triage Level III (Non-Emergent).

RN #6 performed the MSE at 11:45 AM and documented Patient #10 presented to ER with c/o Right (R) sided Chest Pain rated at 9 on 0-10 VPS, nonradiating and c/o lower back pain at same scale. Patient #10 stated it hurts worse with deep breathing. At 1:00 PM, RN #6 documented Patient #10 ambulated to exit with discharge paperwork in hand. The MSE was completed by RN #6 at 11:45 AM. ED Physician #2 was notified of patient being in the ED and Patient #10 was seen by ED Physician #2 at 11:45 AM. RN #6 determined an emergency medical condition did not exist prior to being seen by treating provider, ED Physician #2.

ED Physician #2 documented on the ED Provider record the time in was 11:45 AM with chief complaint of Myalgia and Left sided chest wall pain (illegible) since this AM. ED Physician #2 further documented the patient has stents; the patient complaints of precordial chest discomfortand having a dull aching pain over left (illegible). The patient was discharged from hospital with diagnoses of Atypical Chest Pain, Myalgia, and Upper Respiratory Infection.

16. Medical record review revealed Patient #11 presented to the ED on 2/2/18 at 9:40 AM with chief complaints of contractions and labor pain.

The Triage assessment dated 2/2/18 at 9:45 AM documented Pain Scale: 8, Triage Level II (Urgent).

The DON performed the MSE at 9:45 AM and documented Patient #11 presented to the ED, ambulatory, stating 'I thing I am in labor,' 23 weeks into pregnancy, Fetal Heart Tones (FHT) 140, No Bloody Show - No drainage, Contractions every 8-10 mins (minutes) lasting 1-2 mins. The Nurse was unable to feel contractions. Patient #11 states this is her 1st Baby, but 2 mo (months) early. At 12:00, the DON documented Patient #11 was discharged, ambulatory with discharge paperwork in her hand. The MSE was completed by the DON on 2/2/18 at 9:50 AM. NP #1 was notified of patient being in the ED at 9:55 AM and Patient #11 was seen at 10:00 AM. The DON determined an emergency medical condition did not exist prior to being seen by the treating provider, NP #1.

NP #1 documented on the ED Provider record the time was 10:00 AM with chief complaint of possible contractions, 2nd pregnancy. NP #1 documented Patient #11 was at work and started with contractions. The patient thinks she may have passed mucous plug this AM then about an hour later, felt like she had a contraction, then started having low back pain. NP #1 documented she was unable to feel any abdominal muscle contractions, no dilation, no bloody show. NP #1 documented she consulted with the Patient #11's personal physician. NP #1 documented Patient #11 was discharged home in stable condition with diagnosis of Contraction possible and low back pain.

17. Medical record review revealed Patient #12 presented to the ED on 1/26/18 at 9:40 AM with a chief complaint of chest pain with increased pain with movement.

The Triage assessment dated 1/26/18 at 5:45 PM documented Pain Scale: 3, Triage Level III (Non-Emergent).

RN #3 performed the MSE at 5:50 PM and documented Patient #12 presented to the ED with c/o Left side CP, denies radiation but has increased pain with movement. At 6:36 PM patient was discharged home per RN #3. The MSE was completed by RN #3 on 1/26/18 at 5:50 PM. NP #2 was notified of patient being in the ED at 5:55 PM and Patient #12 was seen by NP #2 at 6:00 PM. RN #3 determined an emergency medical condition did not exist prior to Patient #12 being seen by the treating provider, NP #2.

NP #2 documented on the ED Provider record the time in was 6:00 PM with chief complaint of Left lower chest pain, occurring off and on since this AM. The pain is described as intermittent, gra