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Based on hospital Emergency Medical Treatment and Labor Act (EMTALA) policy, Medical Staff By-Laws, Ambulance Patient Care Record, medical record review, observation and interview, the facility failed to provide continuing monitoring according to the patient's needs after the Medical Screening Exam (MSE) was initiated to determine if an Emergency Medical Condition (EMC) existed for 1 of 22 (Patient #4) sampled patients reviewed.

Refer to findings in deficiency A-2406.

Based on hospital EMTALA (Emergency Medical Treatment and Labor Act) policy, Medical Staff By-Laws, Triage Guidelines, Ambulance Patient Care Record, medical record review, observation and interview, the facility failed to provide continuing monitoring according to the patients' needs after the Medical Screening Exam (MSE) was initiated to determine if an Emergency Medical Condition (EMC) existed for 1 of 22 (Patient #4) sampled patients reviewed.

The findings included:

1. Review of the Bylaws, Rules and Regulations and Policies of the Medical Staff for (name of Hospital #2) revealed, "...Part II: Rules and Regulations A. Medical Screening Examinations (MSE) When a patient presents to the [name of Hospital #2] seeking treatment, a MSE will be done in accordance with the Emergency Medical Treatment and Active Labor Act (EMTALA) ..."

2. Review of the EMTALA Policy revealed, "...Persons on [name of Hospital #2] property requesting or appearing to need emergency medical treatment, will be treated in the following manner.
If a person presents to a dedicated emergency department (DED), including [name of ED location], Trauma, L&D, or Burn ED: A qualified medical personnel (QMP) will perform a medical screening exam (MSE) per Patient Triage Policy ... Purpose: To ensure that all patients presenting to [name of Hospital #2] requesting emergency treatment receive an appropriate MSE to determine whether or not an emergency condition (EMC) exists ... Process: Medical Screening Exam (MSE) An MSE consists of an assessment and any ancillary test (based on the patient's chief complaint) necessary to determine if an emergency medical condition (EMC) exists. This may be a brief history and physical or may require complex ancillary studies and procedures (such as lab test, fetal monitoring, electrocardiogram [EKG], or radiology procedures) ....NOTE: When the provider begins the medical screening exam, he/she will indicate the time by activating the screening exam indicator within the [name of electronic medical record company]. The medical screening examination will be used to determine if an emergency medical condition exist and the process will not be considered complete until final disposition of the patient is performed by the provider which may include but is not limited to admission, transfer or discharge ... Appropriate Transfer to [name of Hospital #2] since [name of Hospital #2] operates specialized facilities and services (Burn, Trauma, and Newborn Centers), it will not refuse to accept an appropriate transfer of a patient requiring those services, unless no beds are available, diagnostic capability is unavailable or operating rooms are at capacity in any specialized services area..."

3. Review of the Triage Guidelines provided by Hospital #2 revealed, "Policy: Triage is an essential function of an Emergency Department (ED). Triage is the first interaction a patient has in the Emergency Department. The aim is to ensure that patients are treated in order of clinical urgency. Purpose: The goal of triage is to expedite patient care by prompt and accurate assessment, which prioritizes patients into levels, resulting in appropriate response levels for medical evaluating and treatment. The triage clinician is responsible for stratifying and monitoring the level of acuity of patients admitted through the triage area...In addition, the triage clinician is responsible for updating the appropriate provider of changes in patient conditions while waiting to be seen. The triage clinician works closely with the Patient Care Coordinator (PCC)/Charge Nurse to coordinate patient care...Process: ... 2. The triage nurse will facilitate the timely transport of patients to the appropriate treatment area, prioritizing beds for Level 1 and 2 arrivals... 9. Patients categorized as (level 3) remaining in the waiting room, will be reassessed every two (2) hours or as condition warrants. All changes and reassessments are documented in the patient record..."

4. Medical record review for Patient (Pt) #4 revealed the patient presented to Hospital #1 via private vehicle with chief complaint of gunshot wound (GSW) to flank. He arrived at 2:25 AM on 7/23/16, was triaged at 2:27 AM and classified acuity level N-1-Emergent. The Emergency Department Medical Doctor (ED MD) note documented, "The patient came to ED with GSW to RLA [right lower abdomen] patient stated shot at home, stated he was walking to his home after work from his vehicle when he heard gunshots and ran to his home. Patient was stuck in the right flank and exited. His VS [vital signs] were BP [blood pressure] 207/96, P [pulse] 101." The wound documentation revealed, "wounds: rt [right] flank, puncture wound, size and depth (length 1 cm [centimeter], width 1 cm) shape irregular, characteristics; bleeding, margin discrete, color pink, discharge bloody ...Alert and oriented to person, place, time and situation." Lab was within normal limits. An abdominal (abd) and pelvis Computerized Tomography (CT) with contrast at 2:44 AM revealed, "...soft tissue injury is seen over the right hip, however no ballistic fragment is identified ...Impression: No acute findings in the chest, abdomen or pelvis ...Pelvis x-ray: no acute fracture, dislocation, no abnormality ...Chest x-ray at 2:31 AM revealed no acute cardiopulmonary findings ...Abd x ray revealed no acute findings."

The ED physician, MD #3, noted the patient's condition was stable and disposition was medically cleared, transfer to other location and patient accepted by (staff member at Hospital #2). The patient was administered Morphine and Zofran IVP at 2:33 AM. A Physician Certification of Medical Necessity for Ambulance Transfer documented "shock trauma ...GSW RLQ [Right Lower Quadrant]" When the patient departed the ED at 3:41 AM to Hospital #2 via ambulance, his VS were BP 141/83, P 92 O2 Sat (oxygen blood saturation) 96% pain scale of 8/10.

Review of the (Name of ambulance service) Patient Care Record revealed the ambulance crew picked up Pt #4 from Hospital #1 at 3:43 AM on 7/23/16 and arrived at Hospital #2 at 3:56 AM. A narrative assessment by the Emergency Medical Technician-Paramedic (EMT-P) revealed, "[Name of ambulance] responded lights and sirens to [Hospital #1]ER for the transport of a pt to [Hospital #2] Trauma for higher level of care.. Pt had 2 GSW on his RLQ.. entry and exit wounds...arrived on scene to find a 21 yom [year old male] laying in the bed.. Pt was alert and moved to the stretcher.. Pt secured down with straps x 5 rails up x 2..Pt denies any past medical history.. Pt alert oriented x 4 ..Skin warm and dry.. HEENT [head, ears, eyes, nose and throat] clear.. Pt had clear lung sounds with equal rise and fall of the chest.. Pt had GSW x 2 RLQ with entry and exit wounds.. Pain 5/10 on pain scale.. ER staff stated no major organs were hit. Bleeding was controlled.. Pt had good PMS/ROM [pulse motor sensor/range of motion]in all 4 extremities.. Pt sinus rhythm on the cardiac monitor.. Pts vitals within normal limits for the pt.. Pt transported on a cardiac monitor. Pt had NS [normal saline] bolus en route to [Hospital #2] ... Pt was given pain meds prior to transport by ER staff. Pt had 3 liters (NS) prior to EMS [Emergency Medical Services] arrival ... Pt transported lights and sirens to [Hospital #2] trauma where upon arrival pt was taken inside and triage. Due to extended offload time, pt care was transferred to Paramedic [EMT-P #3]. Report was given to the nurse... Signatures were obtained ... Nurse assumed for care ...[name of ambulance unit] went back in services. Patient transferred call closed at 9:45 AM."

Review of the ED record from (Hospital #2) revealed the patient presented on 7/23/16 at 4:01 AM. Nurse #1 documented, "04:01 CCA/ST [Critical Care Assessment/Shock Trauma] Arrival time: 04:01. Presenting complaint: Pt transfer from [Hospital #1] for GSW RLQ and R lower pelvis posteriorly. No metallic fragments seen on the x-rays and the CT's were pending. (advised of extended off-load). Transition of care: acute care hospital. Care prior to arrival: See EMS report. Mechanism of Injury: GSW. Trauma events details: Injury occurred in the state of Tennessee Injury occurred July 23, 2016 Injury occurred at 2:06.

04:01: Acuity: ESI [Emergency Severity Index] 3 Urgent [ESI-3= Requires 2 or more ES resources (see resource table). This category is moderate risk for patient waiting to be seen. The patient condition is stable, but treatment should be provided as soon as possible to relieve distress and pain. In assigning this acuity, the nurse should consider that the patient may need a simple study or procedure. The patient should be reassessed every 2 hours while waiting... Resource table: Lab (blood and urine), EKG, x-rays, Magnetic Resonance Imaging (MRI), CT scans, ultrasound, angiography, Intravenous (IV) fluids (hydration), IV or Intramuscular (IM) medications, nebulized medications, Speciality Consultations, Simple procedure: 1 resource (laceration repair, urinary catheter), Complex procedure: 2 resources (conscious sedation).]
04:01 Method of arrival: Ambulance: [name of ambulance unit]."

Vital signs were documented at 4:10 AM by Medical Care Technician (MCT) #1 with BP 144/84, P 78 O2 Sat 97%. The next set of vital signs were documented at 9:58 AM by MCT #2 with BP 121/64 P 72 O2 Sat 100%.
At 10:00 AM Nurse #2 documented, "EMS off Load time: 9:35. Arm band placed on right arm Wrist ..."

The ED Course documented,
"04:06 Patient arrived in ED
04:40 [MD #1], MD is PHCP [Primary Health Care Provider]
04:40 [MD #4], MD is Attending Physician
05:47 Triage is completed
07:35 PHCP role handed off by [MD #1]MD
07:35 [MD #2], MD is PHCP
09:45 Patient Interventions: Patient place in exam room on stretcher. Cardiac monitor on. NIBP on. Pulse ox on. Patient has correct arm band on for positive identification. Wrist Call light in reach. Yes Place in gown. Bed in low position, Valuables/Clothing left with patient. Spinal precautions Instructions Provided Side rails up x 1. Family updated by nurse.
09:50 Wound care located on anterior aspect of right lateral abdomen and posterior aspect of right lateral abdomen Patient tolerated well. Was irrigated with NS x 2 liters dressed with 4 x 4 s, to GSW x 2."

At 10:12, Nurse #2 documented, "Condition: stable Discharged to home ambulatory, with family. Instructed on discharge instructions, medication usage, follow up and referral plans, wound care, no drinking with medication, no driving heavy equipment, Discharge instructions given to patient, Prescriptions given x 1, demonstrated understanding of instructions, medications, Verbalized understanding IV discontinued ..."

Review of the Physician Documentation revealed at 4:40 AM "Patient medically screened" by MD #1. There was no other physician documentation until 9:20 AM, MD #1 documented the HPI (history physical interview), "This 21 yrs old African American Male presents to Ed via Ambulance with complaints of GSW to Back, GSW to Abdomen..." A Review of Symptoms (ROS) was documented at 9:22 AM with "Positive for GSW wounds x 2 to the R flank ..."

At 9:23 AM, MD #1 documented, "Exam: ...This is a well developed, well nourished patient who is awake, alert and in no acute distress ..." The next note was at 9:58 AM by MD #2 which documented, "Counseling: I had a detailed discussion with the patient and/or support person the historical points, exam findings and any diagnostic results supporting the discharge/admit diagnosis, I had a detailed discussion with the patient and/or support person the need for outpatient follow up. Data Reviewed: vital signs ..."
At 10:10 AM the patient's IV's were discontinued by Nurse #2. A discharge order was written by MD #2 at 10:00 AM.

There was no additional lab, radiological reports or medications administered to the patient while he was at Hospital #2.

5. On 8/1/16 at 2:45 PM a tour of Hospital #2 Trauma Unit was conducted. The unit consisted of 13 bays in the Critical Care Assessment (CCA) area and 2 Shock Trauma (ST) Rooms. The nurses station was centrally located in the CCA with a view of all 13 bays and the walls to the double closed doors leading to the ST rooms.

6. During an interview on 8/1/16 at 2:45 PM in the hallway of the CCA, the Interim Nurse Manager of the CCA/ST unit was asked if the MD goes to the ambulance or "the wall" to do an MSE? She stated, "We have 13 beds, census maybe over 13 and may off load to the wall, (indicating the wall along the entrance to the CCA). If we can take one of our stretchers, we will, if we can't, they stay on the EMS stretcher ...When they get here they are our patient ... we do vital signs and a primary assessment ... " She was asked what is extended off load? She replied, "We try to give EMS a heads up when the patient flow may be impeded. When we are getting bottlenecked, we will call in report to [Ambulance Coordination Unit] ...the nursing staff is responsible for patient documentation while on extended off-load."

7. On 8/1/16 at 3:20 PM, EMT-P #2 who transferred Patient #4 from Hospital #1 to Hospital #2 was interviewed via telephone. EMT-P #2 stated,"... arrived at [name of hospital #2]... sat on the wall until another crew came to relieve me around 9:30 AM...". EMT-P #2 stated it took about an hour before a doctor came by. We had 3 doctors come by and look at him. I don't recall names, 2 students first, then the older male doctor came by and said we're gonna flush and send you home but they never did." EMT-P #2 stated he did not recall vital signs or assessments being done. There were 4 other stretchers in front of them. The doctor said every bed was full except for one.

8. On 8/2/16 at 8:10 AM in the Administrative Conference Room, MCT #1 verified vital signs should be done within 30 minutes to an hour after arrival if on the wall stating , "...I report to the Patient Care Coordinator [PCC] if abnormal. Vital signs are charted in the computer." MCT #1 verified she remembered (Name of Patient #4) stating she charted in the computer every time she obtained vital signs, if she was busy another technician was taking vital signs too. MCT #1 verified only one set of vital signs were documented at 4:10 AM for Pt. #4.


9. During an interview on 8/2/16 at 8:21 AM in the Administrative Conference Room, Nurse #1 was given a copy of Patient #4's ED record. Nurse #1 stated she recalled Patient #4 and she had completed the ESI-3 triage assignment on 7/23/16. She stated she reviewed the transferring hospital's documentation and the vitals completed by the MCT to assign the ESI-3. She stated, "...we make every effort to get them off [EMS] stretcher..." She stated the ER was full when Patient #4 was triaged so he was left on the EMS stretcher in the hallway. She stated, "He [Patient #4] was sitting on ambulance stretcher where I could see him...we put people in the hall...when I say people are on the wall, line ambulances so I can see; if we have a trauma that leaves me to watch all of CCA and [patients] on the wall..." She stated she had informed the EMS medics when the patient was accepted they were experiencing extended offload due to high patient volume. When asked what the procedure was for patient's "on the wall" Nurse #1 stated, " We try to do vitals every 2 hours, if diaphoretic or blood pressure is off, we do more often...goal is every 2 hours..." Nurse # 1 reviewed Patient #4's record, at the time of this interview, and verified the vitals were documented at 4:10 AM and again at 9:58 AM. Nurse #1 stated. " These [vitals] should have been done more often."

10. During an interview on 8/2/16 at 8:50 AM in the Administrative Conference Room, MD #1 stated, "Every patient that comes through trauma doors gets an MSE to make sure no life threatening injuries. If deemed stable, they can wait for a space available ... " The surveyor asked what a MSE consisted of and MD #1 stated, " Talk to patient, stable airway, heart/lung, no obvious bleeding, ask what happened. " The surveyor asked if the MSE was done at 4:01 AM (as indicated on the record) or at 9:20 AM (when HPI was completed)? MD #1 stated, "It was done when he came in ...He was very stable, transferred from another hospital after screening him, he was stable ... "

11. During an interview via telephone on 8/2/16 at 9:02 AM, EMT-P #1 stated, When we arrived at [named Hospital #2] we walked in with the stretcher, gave the patient information to the lady to register and we were told to go wait in the hallway . He stated," One or two stretchers were on the wall in CCA... We were in a separate hall from Shock Trauma... we stayed in the hall for 6-7 hours." He stated, "I had him on the monitors and was taking VS..." The EMT-P #1 further stated, "... someone came out and looked at his wounds and said it did not hit any major organs...the lady who registered him, [later identified as MCT #1] came out after about an hour and took VS on all the patients [on the wall]... this was my first time to be stuck on the wall..." The surveyors asked him to clarify where he was located with Patient #4, for the extended wait time. He stated, "We were on the other side of the double doors that only the hospital personnel has a code." When asked if he was in view of the nurse's station in the CCA area, he stated "No."

12. During an interview in the Administrative Conference Room on 8/2/16 at 9:15 AM, Nurse #2 stated, "...any patient on out property is out patient...If a patient can't be off loaded...We try to get vital signs, assess in an hour but try for within 30 minutes after arrival and then we try to do VS every 2 hours..." He stated when patients can't be off loaded they [ED Staff] rely on Medics to let them know if there are any changes with the patient. He verified he was the charge nurse and came on duty at 7AM when Patinet #4 was in the ED awaiting offloading. He stated, " We had 18 Patients in our 13 bay ED. I had 6 nurses....Patient #4 had not been checked in yet and no one had assumed care..." He stated," I reported to the Chief (MD)who had reviewed the CT and determined the patient only needed wound care." Nurse #2 verified the patient was off loaded from the EMS stretcher at 9:35 AM. He further verified no vitals were documented after the inital assessment at 4:10 AM until he was offloaded at 9:35 AM.

Nurse #2 diagrammed for the surveyors the Trauma ED. Per his diagram the Patient #4 was located, not in the CCA, not in vision of the nurse's station, but through 2 sets of locked double doors, in the hallway by Trauma OR and the Blood Bank.