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 reviews, and interviews, the facility failed to provide a Medical Screening Examination (MSE) by a Qualified Medical Provider (QMP) for 2 patients (#21 and #30) of 34 Emergency Department (ED) patients reviewed.

Refer to A-2406 for failure to provide a medical screening examination.

Based on medical record review and interviews, the facility failed to report a suspected EMTALA violation for 1 patient (#1) of 34 Emergency Department (ED) patients reviewed.

The findings included:

Medical record review revealed Patient #1 presented to Hospital A (document contained in the medical record at Hospital C) on 6/4/17 at 12:53 PM for complaints of cramping and abdominal pain. Further review revealed the patient was pregnant and was triaged in the Obstetrics (OB) unit by a Registered Nurse (RN).

Medical record review of an OB Triage record from Hospital A (document contained in the medical record at Hospital C) dated 6/4/17 at 1:42 PM revealed "...Monitor Mode...External...Fetal Assessment...140 via Doppler [device used to listen to fetal heart tones]...Pain Scale...5...Vaginal Exam...Dilatation...1.0 [cm]...Effacement...50 [%]...Station...-4 [position of baby in the pelvis]..." Continued review revealed no documentation the RN contacted the physician regarding Patient #1. Further review revealed no documentation the patient was examined by any provider other than the RN. Continued review revealed Patient #1 was discharged home on 6/4/17 at 2:27 PM (1 hour and 34 minutes after arrival).

Medical record review of the OB Triage record from Hospital B (document contained in the medical record at Hospital C) dated 6/4/17 at 5:54 PM revealed "...Arrived By...Ambulatory...Arrived From...Home...EGA [estimated gestational age]...23.1 [weeks]..." Further review at 5:59 PM revealed "...pt [patient] 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..." Continued review at 6:12 PM revealed "...Vaginal Exam...Dilatation [opening of cervix] 8.0 [to] 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 (document contained in the medical record at Hospital C) dated 6/4/18, not timed, revealed "...Called to room...vag BBOW [vaginal bulging bag of waters]...cvx [cervix] 7 cm...NST [non-stress test] [monitoring of fetal heart rate, fetal movement, and contractions] reassuring...no bleeding...transport regional [Hospital C]..." Further review revealed the patient 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 (mg) injected intramuscular at 6:33 PM, and Penicillin 5 million units IV at 6:33 PM. Further review the patient left Hospital B for transferred to Hospital C via ambulance at 6:35 PM.

Medical record review revealed Patient #1 was admitted to Hospital C on 6/4/17 at 7:13 PM with diagnosis including 23 week and 4 day Pregnancy, in Labor and Breech Presentation (the baby's buttocks and/or feet positioned to be delivered first). Further review revealed the patient was 10.0 centimeters (cm) dilated (opening of the cervix), 100% effaced (thinning of the cervix) and had bulging membranes into the vagina. Continued review revealed "...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 lived approximately 3 hrs..." Further review revealed the patient was discharged home on 6/7/17.

Medical record review of a Physician's Admission History and Physical record from Hospital C dated 6/4/17 at 7:27 PM revealed "...pt. [patient] c/o [complaints of] pain since 11:00 AM today. Seen @ [at] [Hospital A] and d/c [discharged]. [Patient #1] Then went to [Hospital B], found to be 8-9 cms dilated and transferred here for evaluation..." Further review revealed "...assessment and plan: 22 y/o [year old] female @ 23/4 weeks with PTL [premature labor]. Will admit for Magnesium tocolysis [medication used to stop labor], Celestone [steroid medication used to stop labor], Ampicillin/Azithromycin [antibiotics]. [Named Physician] to evaluate with USG [ultrasound] to see if cervical tissue remains for rescue cerclage [procedure to hold the cervix closed]..."

Medical record review of a Labor and Delivery Flowsheet from Hospital C dated 6/4/17 at 7:52 PM revealed "...[named physician] explaining to patient the need for emergency C-Section [surgical delivery of a baby] at this time d/t [due to] baby being breech and pt. completely dilated; pt. in agreement..."

Medical record review of an Operative Report from Hospital C dated 6/4/17 9:41 PM revealed "...preterm labor, advance cervical dilatation with no measurable cervix, membranes ballooning into the vagina and breech presentation..." Further review at 8:31 PM revealed "...the infant was delivered atraumatically from the breech presentation..." Continued review revealed the infant was transferred to Hospital D.

Medical record review of a Discharge Summary from Hospital C dated 6/7/17 at 9:00 AM revealed "...22 year old female...EDC [estimated date of conception] is 9/27/17, 23 weeks and 4 days gestation. The patient had complaints on 6/4/17 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] for evaluation.

Telephone interview with Patient #1 on 12/13/18 at 2:40 PM revealed the patient walked into the ED at Hospital A on 6/4/17 at approximately 1:00 PM. Continued interview revealed she was seen by a nurse and complained of being 23 weeks pregnant and having severe abdominal pain all day. Further interview revealed the nurse put a monitor on her stomach, but did not examine her vagina or genitalia. Continued interview revealed she did not see any provider other than the nurse and was discharged home with instructions to take Tylenol for pain. Further interview revealed she went home for a short while, but was too uncomfortable, so she went to the ED at Hospital B. Continued interview revealed she told the nurse at Hospital B about her visit to Hospital A and that she had not had a vaginal exam or urinalysis done while she was there and also advised the nurse that she was only seen by a nurse at Hospital A. Further interview revealed Patient #1 was transported from Hospital B to Hospital C by ambulance on 6/4/17, was given anesthesia, and delivered her baby by caesarean section (C-Section). Continued interview revealed the baby was transferred to Hospital D and expired the morning of 6/5/17.

Interview with OB Physician #1 at Hospital C on 12/18/18 at 3:25 PM, in the conference room, revealed Patient #1 was transferred from Hospital B because the patient was 8-9 cm dilated, 100% effaced, had bulging membranes, and was in pre-term labor. Further interview revealed "...I accepted the patient as a transfer from [Hospital B]...the patient had presented to [Hospital A] that same day and according to the medical record she was discharged from [Hospital A] on 6/4/17..."

In summary, Patient #1's medical record at Hospital C contained documentation that the patient was only assessed by a RN while at Hospital A and also contained documentation that the patient advised the staff Hospital B that she did not receive a vaginal exam or urinalysis while at Hospital A.

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 2 patients (#21 and #30) of 34 Emergency Department (ED) patients reviewed.

The findings included:

Review of the Medical Staff Rules and Regulations, last revised 3/2018, revealed "...Emergency Services: the screening of individuals seeking emergency medical care in the Emergency Department, for the purpose of determining whether the individual has an emergency medical condition that requires stabilizing treatment, shall be done by the Emergency Department physician, or by the appropriately credentialed Physician Assistant and/or Nurse Practitioner, privileged to perform medical screening examinations... 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 Medical Screening of the Obstetrical Patient dated 2/2015, revealed "...it is the policy of this hospital to provide medical screening examination to all obstetrical patients presenting for unscheduled obstetrical evaluation, testing or services within the capabilities of the Obstetrical Unit and the ancillary services routinely available to the Obstetrical Unit, including the use of on-call physicians..." Further review revealed "...Qualified Obstetrical Evaluator: a Registered Nurse with at least 2 years experience as a full time nurse in an Obstetrical Department of this or equivalent hospital 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..."

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 and continuing through the delivery of the placenta. 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, 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. An MSE is an ongoing process that begins with triage...Qualified Medical Professional [QMP] means an individual who has been determined by the Hospitals Governing Body and authorized by hospital by-laws and regulations to conduct a MSE....Stabilized: means with respect to an EMC that no material deterioration of condition is likely, with reasonable medical probability, to result from or occur...with respect to woman in labor that the woman has delivered the child and the placenta..." 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 per standardized protocols if the nature of the individuals request for examination and treatment is 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 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 #21 was admitted to the Obstetric (OB) Triage Unit on 12/3/18 at 9:40 PM with a complaint of Decreased Fetal Movements and 36 weeks pregnant with twins.

Medical record review of a nurse's OB triage record dated 12/3/18 at 10:17 AM revealed Patient #21 was assessed by an RN. Further review revealed "...pt. [patient] c/o [complaints of] decreased [fetal] movement...notified MD [medical doctor] of fetal heart rate tracing is reactive for both babies, pt. has no c/o pain, [baby] kick count is adequate..." Continued review revealed "...order received for pt. discharge [home]..." Further review revealed no documentation the patient had a MSE by any provider other than the RN.

Medical record review revealed Patient #30 was admitted to the OB Triage Unit on 7/8/18 at 10:24 PM with complaints of contractions and the estimated date of delivery was 7/14/18 (approximately 39 weeks pregnant).

Medical record review of a nurse's OB Triage record dated 7/8/18 at 10:24 PM revealed the patient was assessed by an RN. Further review revealed "...[11:37 PM] called provider...informed MD of pt. presented with ctx [contractions] 3 minutes apart, efm [external fetal monitoring] 8-10 minutes apart, slight change in cervix from last OV [observation], reactive NST [nonstress test], new orders received..." Further review revealed the patient was discharged home on 7/8/18. Further review revealed no documentation the patient had a MSE by any provider other than the RN.

Interview with the Nurse Manager on 12/19/18 at 9:30 AM, in the conference room, confirmed Patient #21 and Patient #30 had MSEs provided by a RN and confirmed the patients were not seen by any other providers prior to discharged from Hospital C.