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Based on review of facility policy, medical record review, and interview, the facility failed to provide an appropriate and ongoing medical screening examination for 1 (Pt #20) patient of 20 Emergency Department (ED) patients reviewed.

For documentation purposes:
Facility A: Cookeville Regional Medical Center is located at 1 Medical Center Blvd, Cookeville, TN.

Facility B: Ascension Saint Thomas Highlands is located at 401 Sewell Dr, Sparta, TN.

The findings include:

Patient (Pt) #20 entered Hospital A's ED on 9/19/2024 at 7:54 PM with complaints of fever and not being able to hold anything down after having 4 wisdom teeth removed 3 days prior. She reported her temperature being 101°F (Fahrenheit). Her temperature on admission was 99°F. Lab work was completed but no radiological testing was completed. On the physician's assessment, it does not show an assessment was completed inside the patient's mouth. Pt #20 was discharged 9/19/2024 at 11:37 PM. On 9/22/2024, Pt #20 presented to Hospital B's ED where she had a CT scan which showed "Postoperative changes related to recent extraction of all 4 wisdom teeth. There is early organizing fluid collection within the left temporalis muscle lateral to the left maxillary sinus measuring 2.5cm x 1.2cm x 1.5cm- possibly early abscess... Induration of subcutaneous fat along the let platysma."

Please refer to findings at A 2406

Based on review of facility policy, review of a grievance report, medical record review, and interview, the facility failed to provide an appropriate and ongoing medical screening examination for 1 patient (#20) of 20 Emergency Department (ED) patients reviewed.

The findings include:

Review of the facility's policy, "Emergency Medial Treatment and Active Labor Policy," revised 7/2023, showed "...any individual who comes to [name of the medical center] requesting emergency services is entitled to and will receive a Medial Screening Examination performed by the individuals qualified to perform such examination to determine whether an Emergency Medical Condition exists...Capability and/or Capabilities refer to the hospital's physical space. Equipment, supplies and services...including ancillary services that the hospital provides...Comes to the Emergency Department with respect to an individual requesting examination and treatment means that the individual is on the hospital property...Emergency Medical Condition means a medical condition manifesting itself by acute symptoms of sufficient severity [including severe pain]...such that the absences of immediate medical attention could reasonably be expected to result in placing the health of the individual...in serious jeopardy, serious impairment to bodily functions...Medical Screening Examination 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 done within the facilities capabilities and available personnel...Stable for Discharge...patient is stable for discharge when, within reasonable clinical confidence, it is determined that the patient has reached the point where his/her continued care, including diagnostic work-up and/or treatment, could reasonable be performed as an outpatient or later as an inpatient...How To Provide the Medical Screening Examination...The Medical Screening Examination shall include both a generalized and a focused assessment based on the patient's chief complaint, with the intent to determine the presence of absence of an Emergency Medical Condition...Depending on the patient's presenting symptoms, the Medical Screening Examination represents a spectrum ranging from a simple process involving only a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures such as, but not limited to...clinical laboratory tests, CT scans and other diagnostic tests and procedures..."

Medical record review of an ED Summary Report dated 9/19/2024 at 7:54 PM, showed patient (Pt) #20 presented to the ED. Review showed at 8:02 PM, triage was completed with complaints of "...4 wisdom teeth removed and was prescribed clindamycin (an antibiotic) and hasn't been able to hold it down, reports that she has had a fever...reporting 101°F (Fahrenheit)." Chief complaint listed as "fever." An ESI (Emergency Severity Index) of 3 was given (has the potential to increase in severity if not treated). Vital signs were temperature 99°F, heart rate 98, and blood pressure 138/77. Pt #20's pain level was a 7 out of 10.

Medical record review of the Daily Focus Assessment Report dated 9/19/2024 at 8:11 PM, showed an assessment for Pt #20 was completed by RN (Registered Nurse) #1 "...appearance uncomfortable...pain location in teeth, quality aching, and duration is continuous...throat pain...abdomen soft, round, nausea/vomiting...known or suspected infection..."

Medical record review of the Medical Screening Exam (MSE) dated 9/19/2024 at 8:16 PM, showed a MSE was performed for Pt #20 and the patient presented with "nausea, vomiting, and fever since wisdom teeth extraction on Monday [3 days prior]."

Medical record review of an ED Summary Report dated 9/19/2024 at 8:45 PM, showed the following abnormal laboratory results:
Neutrophils = 85.2% (reference range 40-70%) - (a type of white blood cell that shows
up first in fighting infections).
Absolute Neutrophils = 7.19 uL (reference range 1.56-6.13) - (total # of neutrophils-
high level indicates too many neutrophils being produced which could be from an
infection).
Absolute Lymphocytes = 0.68 uL (reference range 1.18-3.74 uL) - (total # of
lymphocytes, a low level could indicate an autoimmune disorder or from medications).

Medical record review of ED (physician) orders dated 9/19/2024 at 10:02 PM, showed an order for clindamycin (arrived at the ED on this antibiotic post teeth extraction) was placed.

Medical record review of the ED Provider Note dated 9/19/2024 at 10:03 PM, showed Provider #1 saw Pt #20, "Patient...presented to the ED with complaint of fever, nausea and vomiting...reports that she had a recent dental extraction...reports she was started on clindamycin...has had vomiting since...denies abdominal discomfort...medical decision-making- patient seen and examined, monitored for acute changes...chemistry ordered that was normal. CBC...was normal...was given IV fluids, Reglan and Toradol...observed in the ED... remained stable...no radiographs or EKG ordered at this time...discussed with patient...patient remained stable and discharged..." The assessment showed "...present illness vomiting...fever, chills, nausea, and vomiting...throat pain...mouth pain...no abdominal pain, nausea vomiting..." The assessment did not include an examination of Pt #20's post-surgical mouth.

Medical record review of an ED Summary Report dated 9/19/2024 at 10:32 PM, showed Pt #20's pain level was an 8 out of 10.

Medical record review of ED visit at Hospital B on 9/21/2024 at 9:42 PM showed Pt #20 arrived with complaints of "...worsening facial pain and swelling...has had increasing pain and swelling to left jaw and face...today was rinsing with Chlorhexidine [antiseptic] and noticed drainage of purulence [pus]...able to open mouth slightly but some degree of trismus [difficulty to open mouth]...postoperative changes with pretty significant swelling to left side and I am unable to fully visualize surgical site...patient with slight leukocytosis [elevated white blood cells] but no fever here..." Pt #20's WBC (white blood cell) was 12/L (normal range 40-11.5 u/L). Review showed a CT scan (Computed Tomography) was completed 9/22/2024 at 12:12 AM, and showed "Postoperative changes related to recent extraction of all 4 wisdom teeth. There is an early organizing fluid collection within the left temporalis muscle [fan shaped muscle at the side of the head] lateral [beside] the maxillary sinus [below the eye] measuring 2.5 cm [centimeters] x 1.2 cm x 1.5 cm. Possibly early abscess [collection of pus from bacteria causing infection]. There is induration [thickening of tissue] of the subcutaneous fat [below the skin] along the left platysma [muscle around the neck]."

Review of a grievance report dated 10/29/2024 at 4:06 PM showed Pt #20 filed a grievance with Hospital A and complained of "...pain, nausea, vomiting, and vision changes after 4 wisdom teeth were removed on 9/16/2024...she stated (Physician #1) never performed an assessment...He didn't look in the mouth...she went to [Hospital B] 2 days later and was diagnosed with an abscess in her temple..." As part of the grievance investigation, an email was sent to the ED Medical Director who spoke with Physician #1. A response from Physician #1 was sent on 11/6/2024 at 3:41 PM, "I did do an exam of the mouth because I had to find an otoscope...I felt the neck and it didn't elicit any pain...the abdomen was the main complaint...did feel the nausea and vomiting was from the clindamycin...I have documented a better oral exam though she was more concerned with nausea...no facial swelling...I hope she didn't have a bad outcome...a temporal abscess is a pretty rare diagnosis following a dental extraction."

During a telephone interview on 2/26/2025 at 6:07 AM, with Physician #1, he stated he does remember Pt #20's visit. He stated he had "no suspicion of an abscess...Her main concern was nausea and vomiting, even in triage. She said she had a procedure 4 days prior. She did not have any complaints of a headache. If a patient comes in with a suspected dental injury or problem, the hospital does not have an oral surgeon on staff. We must call another hospital with an oral surgeon and would need to transfer the patient. I do not feel a transfer was necessary." He stated he did look in her mouth because he had to find an otoscope...He stated he "didn't see any increased swelling." His assessment documentation on the mouth which said, "throat pain...mouth pain" was reviewed with Physician #1 and he stated, "I should have documented I looked in her mouth." He stated an X-ray or CT scan (Computed Tomography) was not a standard test for complaints like this. He discussed the patient's pain level and stated, "she had recent oral surgery so pain would be expected."

During an interview on 2/26/2025 at 9:55 AM, with RN #1 showed she cared for Pt #20 on the night shift. She stated she "vaguely remembered" Pt #20, "She was upset and yelling because she was not being immediately seen and said we didn't care. I don't recall if she complained of pain. I don't think I was present during the Provider exam. I would have documented if I looked into her mouth. If a patient comes in with a fever our protocol is screening for sepsis, and they will have a CBC [complete blood count] and blood cultures completed. We do not have a protocol for dental pain, but we do have one for pain. I do not generally see a CT scan routinely completed with dental issues..."