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Based on review of Tennessee Code Annotated 63-7-103 (Tennessee Practice of Professional Nursing), review of medical staff bylaws, review of facility policy, medical record reviews, and interviews, the facility failed to provide a Medical Screening Examination (MSE) by a Qualified Medical Provider (QMP) for 2 patients (#29 and #30) of 30 Emergency Department (ED) patients reviewed.

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

Based on review of facility policy, review of medical staff bylaws, review of Tennessee Code Annotated 63-7-103 (Tennessee Practice of Professional Nursing), medical record review, and interviews, the facility failed to provide a Medical Screening Examination (MSE) by a Qualified Medical Provider (QMP) for 2 patients (#29 and #30) of 30 Emergency Department (ED) patients reviewed.

The findings included:

Review of the facility's "Initial Emergency Medical Screening" policy last reviewed 12/2016, revealed "...All patients presenting to...Emergency Department will receive an appropriate MSE...to determine whether or not an emergency medical condition [EMC] exists...The Initial Emergency Medical Screening will be provided by the Qualified Medical Personnel as approved by the Board of Trustees and Medical Staff..."

Review of the facility's "Emergency Screening and Stabilization/Transfer/250 Yard Rule and EMTALA" policy last reviewed 4/2017, revealed "...must provide for an appropriate Medical Screening Examination conducted by a physician or other QMP...to determine whether or not an Emergency Medical Condition exists...or with respect to a pregnant woman having contractions, whether the woman is in labor..."

Review of the facility's "Medical Screening of Obstetric Patients" policy last reviewed 12/2016, revealed "...Patients with Pregnancy of any gestational age who present to [name of hospital] will have a screening exam performed by a qualified provider...Patients < [less than] 20 weeks gestation are assessed through the Emergency Department...All patients > [greater than] 20 weeks gestation, presenting with OB related complaints will be directed to the Labor and Delivery area...The medical screening will take place in the Labor and Delivery area...A qualified Registered Nurse in Labor and Delivery...who has validated competency in Labor and Delivery skills and screening of OB [obstetric] patients may perform medical screening exams on an outpatient basis...Following assessment and examination of the patient, the RN will notify the patient's physician of the findings of her exam. Based on these findings the physician will determine disposition and give an appropriate order..."

Review of the facility's "BYLAWS OF THE MEDICAL - DENTAL STAFF..." last reviewed/revised April 2016, revealed "...Qualified Medical Personnel which includes MDs [Medical Doctor], DOs [Doctor of Osteopathic Medicine], Nurse Practitioners...and Obstetric Registered Nurses [RN]..."

Review of the Tennessee Code Annotated 63-7-103 revealed "...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 #29 presented to the Labor Delivery department on 9/20/17 at 2:35 PM for complaint of "...PELVIC PRESSURE...UC [uterine contractions]..." and was 38.5 estimated gestational age (EGA). Further review revealed the patient was placed on a fetal monitor by the RN #1 at 3:40 PM (1 hour and 5 minutes after arrival). Continued review revealed the patient was provided a vaginal exam by the RN at 4:02 PM and the assessment was "...Dilatation...3.5 [centimeters]...Effacement...50 [%]...Station...-2..." Continued review revealed the patient was discharged home in stable condition on 9/20/17 at 4:28 PM. Further review revealed no documentation of the patient was provided a MSE by any QMP other than the RN.

Medical record review revealed Patient #30 presented to the Labor and Delivery department on 9/23/17 at 1:30 PM with complaint of "...sharp right lower abdomen pain..." and was 38.1 weeks EGA. Further review revealed the patient was placed on the fetal monitor by a RN #1 at 1:30 PM. Continued review revealed Patient #30's vital signs on arrival were: blood pressure 123/68 and heart rate 107. Further review revealed there was no documentation regarding dilatation, effacement, station, or presentation. Continued review revealed the triage assessment was charted by the RN at 9:28 PM (8 hours after arrival). Further review revealed the patient was discharged home in stable condition on 9/23/17 at 10:01 PM (8.5 hours after arrival). Further review revealed the patient's blood pressure was not reassessed between the time of arrival and the time of discharge. Continued review revealed no documentation the patient was provided a MSE by any QMP other than a RN.

Review of the personnel file for RN #1 revealed the RN completed an Intermediate Fetal Monitoring Course on 9/23/15 and a labor and delivery core competency course in 2016 at the facility.

Interview with RN #2 on 10/11/17 at 1:00 PM, in the Labor and Delivery Nurses Station, confirmed Patient #29 and Patient #30's MSE were provided by a RN and there was no documentation either patient was seen by a QMP other than RN#1.

Interview with the Chief Nursing Officer (CNO) on 10/11/17 at 2:00 PM, in the CNO's office, confirmed Patient #29 and Patient #30's MSE was provided by a RN and there was no documentation either patient was seen by a QMP other than RN #1.