HospitalInspections.org

Based on review of facility policy, medical record review, and interviews, the facility failed to provide a Medical Screening Examination by a Qualified Medical Provider for 6 patients (#3, #4, #6, #7, #12 and #33) and failed to provide an appropriate transfer for 1 patient (#3) of 38 Emergency Department patients reviewed.

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

Refer to 2409 for failure to provide appropriate transfer.

Based on facility policy reviews, review of medical staff guidelines, review of the state nurse practice act, medical record reviews, and interviews, the facility failed to provide an appropriate Medical Screening Examination (MSE) for 6 (#3, #4, #6, #7, #12 and #33) patients of 38 Emergency Department (ED) patients reviewed.

The findings included:

Review of facility A's policy titled EMTALA EXAM, effective date 3/1997, revealed "...Upon arrival to the Emergency Department treatment area patients will have a medical screening exam by the ED Physician or Physician's Assistant...the purpose of the medical screening exam will be to determine the presence or absence of an emergency medical condition..."

Review of the facility A's policy titled OBSTETRICAL (OB) PATIENTS PRESENTING TO THE EMERGENCY DEPARTMENT, effective date 10/2001, revealed "...If the Obstetrical patient is 20 weeks or greater gestation she will be assigned to the Labor and Delivery Department for a medical screening exam...All patients will recieve a medical screening exam in Labor and Delivery by their obstetrical provider, the obstetrician on-call or an obstetrical Registered Nurse..."

Review of the facility A's MEDICAL STAFF GUIDELINES, effective date 10/29/99 revealed "...The Obstetrical RN [Registered Nurse] may perform the OB medical screening exam..."

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 presribed 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.

Review of the ED Log revealed Patient #3 presented to the ED at facility A on 7/24/16 at 1630 with a complaint of pelvic pain and cramping. She was 38 weeks pregnant. According to the medical record there was an OB MD on call and there was also an NP who was 2 hours away. The NP indicated she would meet the patient at Facility 2. The patient was discharged to drive to facility 2 in her POV in order to see the ARNP in an unstable condition. She was discharged in an unstable condition to drive herself to hospital two. Further medical record review revealed no documentation the patient was provided a MSE by a Physician, Advanced Practice Nurse, Physician's Assistant, or other Qualified Medical Provider (QMP). Additionally, patient #3 failed to transferred appropriately.


Review of the ED Log revealed Patient #4 presented to the ED at facility A on 7/26/16 at 4:32 AM with a complaint of possible labor. The patient did not see a physician or a NP, did not have a Medical Screening and was discharged from the hospital in an unstable condition. There was an OB on-call who was contacted by phone, but did not see the patient. Continued medical record review revealed the patient was discharged home on 7/26/16 at 12:17 PM. in an unstable condition. Further medical record review revealed no documentation the patient was provided a MSE by a Physician, Advanced Practice Nurse, Physician's Assistant, or other Qualified Medical Provider (QMP).

Review of the ED Log revealed Patient #6 presented to the ED at facility A on 7/2/16 at 2:50 AM for a complaint of possible labor. Further medical record review revealed patient was triaged in the ED and monitored. She did not see a physician or a NP and her OB MD was not notified and did not come to the ED. Further medical record review revealed no documentation the patient was provided a MSE by a Physician, Advanced Practice Nurse, Physician's Assistant, or other QMP and she was discharged from the hospital in an unstable condition.

Review of the ED Log revealed Patient #7 presented to the ED at facility A on 7/24/16 at 10:56 PM for a complaint of pregnant with contractions. Further medical record review revealed the patient was assessed by a OB RN at 11:15 PM. Continued medical record review revealed the patient was monitored in the ED for approximately 14 hours and was discharged home on 7/25/16 at 1:28 AM in an unstable condition. Further medical record review revealed no documentation the patient was provided a MSE by a Physician, Advanced Practice Nurse, Physician's Assistantor, other QMP.

Review of the ED Log revealed Patient #12 presented to the ED at facility A on 4/3/16, at 9:52 PM for complaint of 7 months pregnant with abdominal pain, back pain urinary frequency and a concern for pre-term labor. The patient was monitored in the ED for approximately 12 hours. Continued medical record review revealed the patient was discharged home on 4/3/16 at 11:20 PM. in an unstable condition. Further medical record review revealed no documentation the patient was provided a MSE by a Physician, Advanced Practice Nurse, Physician's Assistant, or other QMP and she was discharged from the hospital in an unstable condition.

Review of the ED Log revealed Patient #33 presented to the ED at facility A on 9/11/16, at 2325 for complaint of abdominal pain, premature rupture of membranes and a concern for pre-term labor. There was a physician order to transfer the patient to facility #2. Further medical record review revealed no documentation the patient was provided a MSE by a Physician, Advanced Practice Nurse, Physician's Assistant, or other QMP and she was discharged from the hospital in an unstable condition. The patient was not stable for transfer.
This patient did not receive a MSE, stabilizing ttreatment or appropriate transfer.

Interview with RN #1 (Obstetric RN at facility A) on 10/24/16 at 3:24 PM, in the Business Manager's Office, confirmed some OB patients are not examined by a Physician, Advanced Practice Nurse, Physician's Assistant, or other QMP prior to discharge. Further interview with RN #1 revealed the physicians can view the fetal/maternal monitor strips and vital signs via the computer at their office or home and the physicians have the capabilitity to document in the computer charts from outside the facility.

Interview with RN #2 (Obstetric RN at facility A) on 10/25/16 at 8:09 AM, in the Business Manager's Office, confirmed all OB patients who present to the facility are not examined by a Physician, Advanced Practice Nurse, Physician's Assistant, or other QMP prior to discharge. Further interview with RN #2 revealed the physicians can view the fetal/maternal monitor strips and vital signs via the computer at their office or home and the have the capability to document in the computer charts from outside the facility.

Interview with Physician #2 at facility A, on 10/25/16 at 9:24 AM, in the ED Physician's work station, revealed OB patients over 20 weeks gestation who present with possible labor or other OB complaints are not examined by the ED Physicians but are transported to OB for assessment of their OB problems. Further interview with Physician #2 revealed OB patients are seen by the ED Physician only if they have a non-obstetrical problem or complaint.

Interview with the Director of Nursing (DON) at facility A on 10/25/16 at 4:30 PM, in the Business Manager's Office, revealed OB patients over 20 weeks gestation who present to the ED are provided a MSE by an obstetric RN in accordance with the facility's policies and medical staff guidelines. Further interview confirmed the OB physicians view the fetal/monitor strips, nurses notes, diagnostic tests, and document in the chart via tele-medicine from outside the facility and give the RN orders and instructions regarding the treatment and disposition of patients. Further interview confirmed not all OB patients are provided a MSE by a Physician, Advanced Practice Nurse, Physician's Assistant, or other QMP. Further interview confirmed there is no documentation of a MSE for patients #4, #6, #7, and #12 by a Physician, Advanced Practice Nurse, Physician's Assistant, or other QMP.


.

Based on facility policy review, medical record review, and interviews, the facility failed to appropriately transfer one (#3) patient of 38 Emergency Department (ED) patients reviewed.

The findings included:

Review of facility A policy titled Transfer (Acute Care, Extended Care, Emergency Services) effective date March 1997, revealed "...The patient or appropriate family member or legal guardian must give written consent, following an explanation of risks and benefits of the transfer by the physician...a completed Transfer Authorization Form shall be enclosed in an envelope to be sent with the patient...PATIENTS MAY NOT BE TRANSFERRED BY PRIVATE VEHICLE..."

Review of the facility A ED Daily Log Detail dated 7/24/16 at 4:14 PM, revealed Patient #3 presented to the ED with a chief complaint of possible labor. Continued review revealed the patient's disposition was discharged home.

Review of the medical record for Patient #3 revealed the patient presented to the ED at facility A on 7/24/16 at 4:14 PM for complaint of "...38 WEEKS AND FOUR DAYS PREGNANT. PELVIC PRESSURE WITH CRAMPING..." Further medical record review revealed the patient was triaged in the ED on 7/24/16 at 4:15 PM and moved to OB (Obstetric Department) at 4:16 PM. Continued medical record review revealed on 7/24/16 at 4:25 PM the patient was "...admitted to LDR [labor and delivery room] 2..." and was placed on the Fetal Heart Monitor at 4:30 PM. Further medical record review of a note written by Physician #1 dated 7/24/16 at 7:35 PM revealed "...Pt STILL 3 cm [centimeters] CNM [Certified Nurse Midwife at facility B] CONTACTED. PT WILL BE TRANSPORTED TO WWMC [facility B] BY FAMILY. SHE IS ACCEPTED BY CNM [facility B] ON CALL..." Continued medical record review revealed no documentation of a completed transfer form, a request for transfer in writing indicating the risk and benefits of the transfer, and no signature of the physician certifying the medical benefits of the transfer outweigh the risks of the transfer.

Review of the medical record for Patient #3 from facility B dated 7/24/15 at 8:10 PM revealed "...Was sent here [facility B] by car from [facility A] after being evaluated for labor and told she was in active labor..." Further medical record review revealed the patient delivered on 7/25/16 at 4:31 AM at facility B.

Interview with Registered Nurse (RN) #1 at facility A on 10/24/16 at 3:24 PM, in the Business Office Managers Office, confirmed Patient #3 arrived in the Labor and Delivery Unit (L&D) on 7/24/16 (uncertain of time) from the Emergency Department. Further interview revealed RN #1 stated the patient was assessed by an RN to determine if she was in labor. Continued interview confirmed RN #1 notified the on call OB Physician (Physician #1) of the patient's arrival. Further interview confirmed RN #1 was told to call [facility B] to determine who the nurse midwife on call was. Continued interview confirmed RN #1 contacted the nurse midwife on call for facility B and the midwife stated she was about 2 hours away. Further interview confirmed the nurse midwife was told facility A's Obstetric staff would monitor the patient until the nurse midwife arrived at facility B and if the patient's cervix did not change facility A's staff would send the patient to facility B.

Interview with Physician #1 at facility A on 10/24/16 at 3:53 PM, in the Business Office Managers Office, confirmed he was the Obstetrician on-call when Patient #3 presented to the ED on 7/24/16. Further interview with Physician #1 confirmed he did not remember if he came to facility A and saw the patient. Continued interview with Physician #1 revealed the patient's cervix was dilated to 3 centimeters and she was experiencing "some contractions" when she came to the hospital. Further interview confirmed Physician #1 thought the patient was in latent labor (first stage of labor) and Patient #3's cervix had not changed when the midwife notified facility A she was at facility B. Continued interview with Physician #1 revealed he instructed the L&D nurses to transfer the patient to facility B.

Interview with RN #2 at facility A on 10/25/16 at 8:09 AM, in the Business Office Managers Office, confirmed she remembered caring for Patient #3 in L&D on 7/24/16. Continued interview revealed Patient #3 was receiving intravenous fluids and antibiotics when RN #2 reported to work at 7:00 PM on 7/24/16. Further interview confirmed Patient #3's cervix was assessed and had dilated to 3 centimeters (cm). Continued interview revealed the nurse midwife called the L&D unit at facility A and wanted to see the patient at facility B. Further interview revealed Patient #3's cervix was checked and had not changed (dilated further) and she was sent to facility B. Continued interview with RN #2 revealed no copies of the chart or other information from the patient's treatment at facility A was sent with the patient or to facility B. Further interview revealed a transfer form was not completed because the patient was discharged from facility A. Continued interview with RN #2 confirmed the patient was instructed to go immediately to facility B when discharged and the patient left facility A in a car driven by her husband.

Interview with RN #3 at facility B on 10/26/16 at 9:00 AM, in the conference room, revealed staff from facility A had called the center after hours and told RN #3 "...Our [facility B] patient had showed up there and thought she was in labor..." Continued interview revealed facility A "...had wanted [Patient #3] to go to [facility B]...because she was our patient..." Continued interview with RN #3 revealed the nurse from facility A told her Patient #3 was in active labor. Further interview revealed Patient #3 was discharged and sent to facility B without any medical records or other paperwork from facility A. Continued interview revealed Patient #3 arrived at facility B in a car driven by the patient's husband.

Interview with Patient #3 by telephone on 10/25/16 at 4:50 PM confirmed the patient presented to the ED at facility A on 7/24/16 "...around 4:30 [PM]..." Further interview revealed "...I was having contractions...would have liked to delivered there [facility A] but they would not let me...the doctor would not let me deliver there...said they did not have my records...I would have liked to have had it [baby] there if they let me..." Further interview revealed "...I was 4 centimeters when I left...the nurse told me I was 4 when I left...they sent me to the birthing center [facility B]...they were supposed to give me my chart but they didn't...they didn't give me any paperwork to take..." Further interview confirmed the patient was sent from facility A to go directly to facility B by private vehicle.

Interview with the Director of Nurses (DON) at facility A on 10/25/16 at 3:45 PM, in the Business Manager's Office, confirmed there was no Transfer Authorization Form in Patient #3's medical record because the patient had been discharged on 7/24/16 and not transferred.




.