HospitalInspections.org

Based on review of facility policy, review of Medical Staff Rules and Regulations, medical record review, and interviews the facility failed to provide an appropriate Medical Screening Examination (MSE) for one patient (#17) who presented to the Emergency Department (ED) for treatment; and failed to ensure physician signature to authenticate the verbal order for transfer for one patient (#19) of 31 medical records reviewed.

The findings included:

Patient #17 was admitted to the facility's ED on 3/16/2023 at 7:39 PM with 8 weeks gestation and nausea and vomiting. The patient was triaged at 8:03 PM and no vital signs were documented for the patient. A Medical Screening Examination was initiated and diagnostic testing was performed which showed no acute findings. She was given intravenous fluids and Zofran (medication for nausea). The ED Physician documented "see nurses notes for vital signs".

There were no vital signs documented for the patient during the patient's admission. The patient was discharged home with diagnosis of hyperemesis gravidarum. The facility's policy showed vital signs were to be included in the triage process to assist with proper diagnosis and treatment for the patient.

Patient #19 was admitted facility's ED on 3/31/2023 at 12:56 PM with abdominal pain. A medical screening examination was completed to include laboratory and radiology diagnostic testing. Diagnostic testing showed acute appendicitis. The transfer form showed the patient had been accepted at Facility C. The Physicians Certification form showed a verbal order for transfer from the ED Physician to the Registered Nurse. The ED Physician had not authenticated the verbal order to ensure an appropriate transfer to Facility C.

Refer to A-2406 and A-2409

Based on review of facility policy, medical record review, and interviews, the facility failed to provide an appropriate Medical Screening Examination (MSE), that included vital signs, for one patient (#17) who was admitted to the Emergency Department (ED) for evaluation of 31 records reviewed.

The findings included:

Review of facility policy "Emergency Medical Treatment and Active Labor Act (EMTALA) policy, last revised 2/5/2021, showed "...the triage nurse takes and documents vital signs, along with any other relevant observations, and assigns an acuity level [ESI-Emergency Severity Index level] that dictates the order in which the patient will be seen...Medical Screening Examination (MSE) is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether or not an emergency medical condition exists...such screening must be performed by a qualified medical personnel...the MSE is an ongoing process, and the medical records must reflect continued monitoring based on the patient's needs and must continue until the patient is either stabilized, admitted to the hospital, or appropriately transferred..."

Review of facility policy "ED Patient Assessment and Reassessment Policy" last revised 7/20/2021 showed "...all patient (including pediatric patients age 17 and under) who present to the Emergency Department for treatment will receive a thorough assessment to the chief complaint. Definition: triage assessment- is a focused assessment to the chief complaint; vital signs with O2 [oxygen] saturation, onset of symptoms, pain assessment, age, date of birth...discharge, transfer, or admission reassessment-before leaving the Emergency Department each patient will be reassessed for [1] change or improvement in condition [2] pain, [3] understanding of discharge care, transfer or admission, repeat vital signs to include cardiac rhythm and pulse ox [oxygen saturation] as indicated..."

Medical record review showed Patient #17 was admitted to the facility on 3/16/2023 at 7:39 PM with nausea and vomiting. The patient was 8 weeks pregnant. She was discharged at 10:34 PM.

Medical record review of an ED Nursing Triage record dated 3/16/2023 at 8:03 PM showed the patient presented with nausea and vomiting for two days and she was 8 weeks pregnant. There was no documentation of vital signs for the patient during her admission. The patient was triaged with an ESI score of a 3 indicating urgent needs.

Medical record review of an ED Physicians record dated 3/16/2023 at 8:14 PM showed the patient presented with nausea and vomiting with pregnancy for the past 2 days. The patient was Gravida (number of pregnancies) 5, Para (number of live births) 4 and she was 4-8 weeks pregnant. Her physical examination showed no acute findings. The ED Physician documented "...see nurses notes for vital signs..." There was no documentation of vital signs.

Medical record review of an ED Physicians Discharge Note dated 3/16/2023 at 10:20 PM showed the patient's diagnosis included Hyperemesis Gravidarum (severe nausea and vomiting during pregnancy).

Medical record review of the discharge instructions dated 3/16/2023 at 10:34 PM showed the patient was given instructions related to Hyperemesis Gravidarum and the patient signed the discharge instructions. There were no vital signs documented.

During a telephone interview on 7/19/2023 at 2:10 PM, Licensed Practical Nurse (LPN) #1 stated she had completed the patient's triage on 3/16/2023. The vital signs were normally completed during the initial triage for the patients and there was a "hard stop" if the vital signs were not documented but the staff can override the hard stop. She stated she did not remember the patient. She confirmed the patient's vital signs were not documented in the medical record during the triage process or upon discharge.

During an interview on 7/19/2023 at 3:00 PM, the ED Nurse Manager and the Chief Nursing Officer (CNO), stated vital signs were part of the initial triage process and should be documented in the nursing triage record. They confirmed there were no vital signs documented in the medical record for Patient #17 during the patient's visit on 3/16/2023.

During a telephone interview on 7/20/2023 at 8:35 AM, ED Physician #1 stated he evaluated the patient on 3/16/2023 and the patient complained of nausea and vomiting for 2 days. The patient was in her first trimester of pregnancy. ED Physician #1 stated "...the vital signs were obtained in the triage process and were normally documented in the nursing triage record. I documented to see the nurses notes but did not notice they were not recorded...I should have made sure they were documented in the record. The vital signs would be considered part of the medical screening..."

Based on review of facility policy, review of Medical Staff Rules and Regulations, medical record review, and interviews the facility failed to ensure the Emergency Department (ED) physician had authenticated the transfer verbal order for one patient (#19) of 31 medical records reviewed.

The findings included:

Review of facility policy "Emergency Medical Treatment and Active Labor Act (EMTALA), last revised 2/5/2021 showed "...[B] any transfer of an individual with an EMC [Emergency Medical Condition] must be initiated by a physicians order with the appropriate certification...the individual must be informed of the risks versus the benefits of the transfer...[C] documentation of transfer; appropriate transfer documentation...must be included in the patient's medical record. In addition, the ED staff including the certifying physician, must complete Memorandum of Transfer [MOT] including all required signatures, dates and times...certification of risks versus benefits; the transferring physician must provide a complete picture of the benefits to be expected from appropriate care at the receiving hospital, such as higher level of care, specialists available, and the risks associated with the transfer, including the time away from an acute care setting necessary to effect the transfer. While checkboxes is permitted, the physician should also include written, individualized risk and benefits in the space marked 'other'. In addition, vital signs taken immediately prior to transfer should be noted on the MOT..."

Review of facility policy "Verbal Orders" last revised 6/20/2023, showed "...2.3.1; verbal and telephone orders may be accepted by a healthcare provider as defined in their scope of practice and must be authenticated [verified] and countersigned by the prescribing practitioner or other responsible practitioner within the time period specified by medical staff bylaws, state and federal regulations..."

Review of the facility's Medical Staff Rules and Regulations (no date) showed "...2.15 [a] verbal orders are discouraged except in emergency situation...the practitioner who gave the verbal order or another responsible practitioner [who is credentialed and granted privileges to write order] who is responsible for the care of the patient shall authenticate and date any order, including but not limited to medication orders, as soon as possible, such as during the next patient visit, and in no case longer then forty-eight [48] hours from dictating the verbal order..."

Medical record review showed Patient #19 was admitted to the ED on 3/31/2023 at 12:56 PM with complaints of abdominal pain. He was transferred to Facility C at 5:56 PM.

Medical record review of an ED Nursing Triage record dated 3/31/2023 at 1:07 PM showed the patient presented to the ED after he was evaluated in an Urgent Care facility with possible appendicitis. The patient had RLQ (right lower quadrant) pain for 2 days. His vital signs were as follows: Blood Pressure 115/80, Pulse 115, respirations 18, and temperature 97.6 degrees Fahrenheit. He was triaged with an ESI score of a 3 indicating urgent needs.

Medical record review of an ED Physicians record dated 3/31/2023 at 1:26 PM showed the patient presented with right lower quadrant abdominal pain and nausea. The patient was evaluated at an Urgent Care Center and was sent to the ED for further evaluation. The patient's physical examination showed pain to the RLQ with guarding and no rebound tenderness. Diagnostic testing included the following: CBC, CMP, Computed Tomography (CT) of the abdomen and pelvis, and a UA. Laboratory diagnostic testing showed no acute findings. A CT of the abdomen and pelvis dated 3/31/2023 at 2:33 PM showed "...suspicious for appendicitis..."

Medical record review of an ED Physicians note dated 3/31/2023 at 3:33 PM showed the patient was diagnosed with acute appendicitis. He was given a 500 ml (milliliter) bolus of Normal Saline, Flagyl (antibiotic) 1000 mg IV (intravenous) and Rocephin (antibiotic) 2000 mg (milligram) IV. The patient's status was discussed with the ED Physician at Facility C who agreed to accept the patient for transfer.

Medical record review of an EMTALA transfer form dated 3/31/2023 at 3:35 PM showed the physicians certification for transfer was signed by the RN and "...v/o [verbal order] [named ED Physician #2], MD..." The physician's certification verbal order was not signed by the ED Physician to ensure the risk and benefits were discussed with the patient/family and an emergency medical condition existed for transfer to a higher level of care.

Medical record review of a discharge disposition dated 3/31/2023 at 5:56 PM showed the patient was transferred to East Tennessee Children's Hospital by Emergency Medical Services (EMS).

During an interview on 7/19/2023 at 11:54 AM the Chief Nursing Officer (CNO) confirmed the verbal order was written on the physician's certification transfer form by the nurse on 3/31/2023 and the verbal order was not authenticated by the ED Provider.

During an interview on 7/19/2023 at 11:30 AM, RN #2 stated the ED was very busy on 3/31/2023 and she was in the ED assisting the staff with patient care. Normally the ED Provider signed the physician's certification for transfer. RN #2 stated "...I am not sure, but I think EMS came to get the patient and we were trying to get the patient out, so I talked to [ED Physician #2] who was with another patient, and she said to go ahead and sign the verbal order on the transfer form so they could take the patient to [Facility C]..."

During an interview on 7/26/2023 at 10:45 AM, ED Physician #2 confirmed the verbal order was not authenticated related to the verbal order for transfer. ED Physician #2 stated normally medical records sent electronic notification for the physician to sign the verbal order but she had not received the notification.