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Based on review of facility policy, review of Tennessee Code Annotated 63-7-103 (Tennessee Practice of Professional Nursing), review of medical staff rules and regulations, medical record review, and interviews, the facility failed to provide a Medical Screening Examination by a Qualified Medical Provider for 2 patients (#34 and #37) of 37 patients reviewed, and failed to accept the appropriate transfer of 1 patient (#4) when the facility had the capacity and capability to treat the patient.

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

Refer to 2411 for failure to accept an appropriate transfer.

Based on review of facility policy, review of medical staff rules and regulations, review of Tennessee Code Annotated 63-7-103 (Tennessee Practice of Professional Nursing), medical record reviews, and interviews, the facility failed to provide a Medical Screening Examination (MSE) by a Qualified Medical Person (QMP) for 2 patients (#34 and #37) of 37 patients reviewed.

The findings included:

Review of facility policy "EMTALA - Tennessee Medical Screening Examination and Stabilization" dated 06/2017 revealed, "...hospital must provide an appropriate MSE within the capability of the hospital's emergency department...to any individual, including a pregnant woman having contractions...Only the following individuals may perform an MSE...A qualified physician with appropriate privileges...Other qualified licensed independent practitioner (LIP) with appropriate competencies and privileges...A qualified staff member who...is functioning within the scope of his or her license and in compliance with state law and appropriate practice acts...QMPs may perform an MSE if licensed and certified, approved by the hospital's governing board...QMPs in the labor and delivery DED [designated emergency department] may be appropriately-approved RNs [Registered Nurse]..."

Review of facility policy "Labor and Delivery Medical Screening" approved 09/2016 revealed, "...In the Labor and Delivery setting, emergency medical screening examinations may be performed by...a Labor and Delivery Registered Nurse [RN] who has completed the Qualified Medical Provider (QMP) competencies...It is permissible for a Labor and Delivery Registered Nurse to conduct an emergency labor screening examination on a patient of 20 weeks gestation or greater utilizing the Obstetrical Medical Screening Tool..."

Review of "Medical Staff Rules and Regulations - 2017" dated 03/2017 revealed, "...qualified medical person provides medical screening...Qualified Medical Person or Personnel - means an individual other than a licensed physician who is certified in one of the following categories...Registered Nurse in Perinatal Services..."

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 revealed the Code did not specify Registered Nurses were permitted to complete Medical Screening Examinations under the Tennessee Nurse Practice Act.

Medical record review revealed Patient #34 presented to the facility's East campus on 7/3/17 at 2:26 PM with complaint of 37 weeks pregnant with contractions. Further review of the medical record revealed the patient was assessed by an RN with fetal heart monitoring and a vaginal exam being provided by an RN. Further review of the medical record revealed no documentation of the patient being provided a MSE by a physician, physician's assistant (PA), or advanced practice nurse (APN) prior to being discharged home at 4:47 PM. Further review of the medical record revealed the patient returned to the facility on 7/3/17 at 11:59 PM for complaint of labor and elevated blood pressure. Further review of the medical record revealed the patient was admitted to the hospital and delivered her baby on 7/4/17 at 6:01 AM.

Medical record review revealed Patient #37 presented to the facility's East campus on 6/25/17 at 2:15 AM for complaint of being 36 weeks pregnant with contractions. Further review of the medical record revealed the patient was assessed by an RN with a vaginal exam and fetal heart monitoring being provided by an RN. Further medical review revealed no documentation of the patient being provided a MSE by a physician, PA, or APN prior to being discharged home on 6/25/17 at 10:40 AM. Further review of the medical record revealed the patient returned to the facility on 7/6/17 at 8:15 AM and delivered her baby on 7/6/17 at 12:43 PM.

Interview with the Womens Service Director on 8/1/17 at 11:42 AM, in the Labor and Delivery classroom at the facility's East campus, confirmed on the first 7/3/17 visit, Patient #34 was not provided a MSE by a physician, PA, or APN. Further interview confirmed Patient #34 was assessed by an RN only during the first 7/3/17 visit. Further interview revealed pregnant patients presenting in possible labor to the facility's East campus may routinely be provided a MSE by an RN only. Further interview revealed the East campus provides 24 hour labor and delivery (L&D) services and has a physician that specializes in L&D in the hospital each night from 7:00 PM to 7:00 AM and every weekend from Friday at 7:00 PM to Monday at 7:00 AM.

Interview with the Womens Service Director on 8/1/17 at 11:58 AM, in the Labor and Delivery classroom at the facility's East campus, confirmed on the 6/25/17 visit Patient #37 was not provided a MSE by a physician, PA, or APN. Further interview confirmed Patient #37 was assessed by an RN only during the 6/25/17 visit.

Based on review of facility policies, review of Medical Staff Rules and Regulations 2017, review of a facility letter, review of medical records, review of an audio recording, and interviews, the facility failed to accept an appropriate transfer of 1 patient (#4) of 37 patients reviewed.

The findings included:

Review of facility policy "EMTALA-Transfer Policy" approved 03/2016 revealed, "...A hospital with specialized capabilities...shall accept from a transferring hospital an appropriate transfer of an individual with an EMC [Emergency Medical Condition] who requires specialized capabilities if the receiving hospital has the capacity to treat the individual..."

Review of the facility policy "EMTALA-Provisions of On-Call Coverage" approved 01/2017 revealed, "...The on-call physician does not have the authority to refuse an appropriate transfer on the behalf of the facility...Only the CEO [Chief Executive Officer], Administrator-on-Call ("AOC"), or a hospital leader who routinely takes administrative call has the authority to verify that the facility does not have the capability and capacity to accept a transfer. Any transfer request which may be declined must first be reviewed with this individual before a final decision to refuse acceptance is made. This requirement applies to all transfer requests..."

Review of Medical Staff Rules and Regulations - 2017 dated 3/2017 revealed, "...Each medical staff member shall comply with the hospital EMTALA policies..."

Review of a letter from the facility dated 7/7/17 revealed, "...Parkridge Medical Center...may constitute a potential violation of the Emergency Medical Treatment and Labor Act (EMTALA) as Parkridge unintentionally misrepresented that the hospital did not have the capability to accept the transfer of a patient...On June 5, 2017 at 7:44 PM...[Facility B] contacted Tristar Transfer Center to request the transfer of [Patient #4] who was diagnosed with a ST-Elevated Myocardial Infarction (STEMI) [heart attack]...[Facility B] indicated cardiology services were not available at their facility and reported the patient requested to be transferred to Parkridge...the on-call cardiologist [MD #1] questioned the transfer to Parkridge, asking if [Facility C] had been contacted and also noting that he did not believe that Parkridge had a helipad...The Transfer Center Representative also attempted to intercede and reported that Parkridge did have a helipad...the On-Call Cardiologist continued to advise that it would be best to transfer the Patient to [Facility C] again indicating he did not believe Parkridge had a helipad...Parkridge's Intake Center Representative contacted Parkridge Administration and confirmed that Parkridge did have a helipad..." Further review of the letter revealed the facility believed this incident was a possible violation of EMTALA requirements and implemented these interventions to prevent additional violations:

A. On June 5, 2017, the On-Call Cardiologist was advised that the hospital did have a helipad and that declining the transfer request of the Patient was inappropriate. This information was also re-iterated via email to the On-Call Cardiologist on July 5, 2017.

B. The On-Call Cardiologist was not paid for call coverage on June 5, 2017, as a result of the inappropriate declination of the transfer request.

C. On June 8, 2017, the Division Ethics and Compliance Officer discussed the incident with the Transfer Center Director, specifically regarding the importance of immediately notifying the AOC prior to any official potential declinations.

D. On June 13, 2017, the On-Call Cardiologist was also reminded of the hospital's EMTALA obligations, noting that all transfer requests must be accepted unless Parkridge does not have the capability and capacity to provide the requested care.

E. On June 13, 2017, the On-Call Cardiologist was advised that according to Parkridge policy, on-call physicians do not have the authority to decline transfer requests, as the AOC should be contacted to make the final determination as to whether Parkridge has the capability and capacity to accept or deny a transfer request.

F. On July 5, 2017, a letter was sent to all on-call physicians reminding the physicians of Parkridge's EMTALA policies and advising that on-call physicians do not have the authority to decline transfer requests, as the CEO or AOC should be contacted to make the final determination as to whether Parkridge has the capability and capacity to accept or deny a transfer request.

G. On July 7, 2017, this incident was reported by Parkridge to the Tennessee Bureau of Health Licensure and Registration.

H. The On-Call Cardiologist was assigned an EMTALA educational course with a required completion date of July 31, 2017.

Review of the medical record from Facility B revealed Patient #4 presented to the ED there on 6/5/17 at 7:32 PM with complaint of chest pain. Further review of the medical record physician's notes dated 6/5/17 revealed, "...Primary Impression: Acute ST segment elevation myocardial infarction [heart attack]..." Further review of the medical record revealed nurses notes on 6/5/17 at 7:50 PM which stated, "...AIR EVAC [helicopter ambulance] CALLED AT THIS TIME..." Further review of the nurses notes revealed, "...[MD #1/On-Call Cardiologist at Facility A] REPORTS THAT PT [patient] NEEDS TO GO TO [Facility C] AND TO CALL AND SET UP ACCEPTANCE THERE..." Further review of nurses notes revealed the patient left Facility B on 6/5/17 by Air Ambulance at 8:20 PM transferred to Facility C.

Review of the medical record from Facility C revealed Patient #4 was admitted there on 6/5/17 at 9:42 PM by air ambulance with diagnosis of ST-Elevated Myocardial Infarction (heart attack). Further review of the record revealed air ambulance notes dated 6/5/17 at 9:19 PM which stated, "...patient initially requested transfer to [Facility A] however the ED staff states they were unable to obtain acceptance...[Facility C] was contacted and accepted..." Further review of the medical record revealed the patient had a Cardiac Catheterization (a tiny flexible tube is inserted in the blood vessels of the heart for diagnosis and treatment) performed on 6/5/17 at 10:11 PM. Further review of the medical record revealed the patient was monitored overnight in Facility C's Intensive Care Unit and then moved to a step-down unit. Further review of the medical record revealed the patient was discharged home in stable condition on 6/7/17.

Review of an undated and untimed audio recording of a telephone conversation between Facility A's Transfer Center Staff (TCS) and MD #1 revealed, "...[TCS] They are going to fly him...[MD #1] Where are they landing?...[TCS] at the helipad...[MD #1] Which helipad?...[TCS] at [Facility A] you all have one somewhere...[MD #1] I don't know where it is...[MD #1] [Facility C] has a helipad..." Further review of this recording revealed a telephone conversation between TCS and Facility A's nursing office (NO) which revealed, "...[TCS] where is your helipad?...[NO] Behind the hospital...[TCS] Doctor [MD #1] is telling them that you don't have a helipad...he denied a transfer for a STEMI [heart attack]...[NO] He can't deny it for that, we have a helipad...[TCS] He conferenced the physician at [Facility B] and he denied accepting..."

Physician (MD) #1 was interviewed by telephone on 7/31/17 at 1:30 PM. MD #1 confirmed he was the cardiologist on-call at Facility A on 6/5/17, and he remembers Patient #4's requested transfer on that date. MD #1 stated "...I did not refuse to accept the patient...I told them I did not think [Facility A] had a helipad and I thought it would be better if he was taken to [Facility C]...it was because I did not know we had a helipad here...I called them back to accept the transfer, but the patient had already been transferred to [Facility C]...I have never refused to accept a transfer...I could have treated him here but I thought there was no place for the helicopter to land with him...I never knew we had a helipad here..."

Interview with the Administrator On-Call (AOC #1) on 7/27/17 at 12:15 AM, in Facility A's Quality Department's conference room, revealed she was the AOC on duty on 6/5/17 and she remembers the attempted transfer of Patient #4 from Facility B to Facility A on 6/5/17. AOC #1 stated she was called by the transfer center employee who told her, "...[MD #1] had denied acceptance of a transfer from [Facility B] because we do not have a place to land the helicopter..." AOC #1 stated she told the transfer center "...'we will accept the patient,' but he had already denied it...the patient had been sent to [Facility C] already..." Further interview revealed MD #1 should not have denied acceptance of a transfer without consulting and involving the AOC. Further interview with AOC #1 revealed, "...This should have come to the AOC...the physicians are not supposed to deny a transfer without the AOC being involved..." Further interview with AOC #1 revealed Facility A had a helipad, and had both the capacity and capability to treat Patient #4 on 6/5/17.

Interview with the Chief Operating Officer and the Ethics and Compliance Director on 7/31/17 at 2:11 PM, in Facility A's Quality Management conference room, revealed the Facility has implemented the following corrective actions and as a result this was considered a past non compliance.