HospitalInspections.org

For documentation purposes:

Facility A is Parkridge East Hospital (a satellite facility of Parkridge Medical Center) located at 941 Spring Creek Road, Chattanooga, TN 37412.

Facility B is Erlanger Medical Center located at 975 East Third Street, Chattanooga, TN 37403 (located 6 miles from Facility A).

Based on review of facility policy, review of facility Medical Staff Rules and Regulations, review of the Tennessee Nurse Practice Act, medical record review, review of facility investigation, and interview, the facility failed to provide a medical screening examination (MSE) by a qualified medical provider (QMP) for 1 patient (#29) and failed to prevent a delay in treatment for 1 patient (#27) of 35 medical records reviewed.

Refer to A-2406
Refer to A-2408

Based on facility policy review, review of facility Medical Staff Rules and Regulations, review of Tennessee Nurse Practice Act, medical record review, and interview, the facility failed to provide a medical screening examination (MSE) for 1 patient (#29) of 35 medical records 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 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 [qualified medical providers) may perform an MSE if licensed and certified, approved by the hospital's governing board...QMP's 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 [fetal monitoring training]...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 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 were permitted to complete Medical Screening Examinations under the Tennessee Nurse Practice Act.

Medical record review revealed Patient #29 presented to Facility A on 8/3/17 at 3:39 AM at 38 weeks gestation with complaints of contractions and a pain score of 6 (severe pain). Further review revealed a vaginal examination and fetal heart monitoring was done by a Registered Nurse (RN). Further review revealed no documentation the patient was provided a MSE by a physician, physician's assistant (PA), or advanced practice nurse (APN) prior to being discharged home at 5:30 AM.

Medical record revealed Patient #29 returned to Facility A on 8/3/17 at 3:06 PM (9 hours and 36 minutes later) for complaint of contractions with a pain score of 9 (severe pain). Further review revealed a vaginal examination and fetal heart monitoring was done by a RN. Further review revealed no documentation the patient was provided a MSE by a physician, PA, or an APN prior to being discharged home on 8/3/17 at 5:30 PM.

Interview with Facility A's Women's Service Director on 9/6/17 at 4:00 PM, in the conference room, revealed some Obstetrics (OB) patients who present in labor are not seen by a physician, PA, or APN, and are only seen by a RN. Continued interview confirmed OB RNs provide a MSE for patients in possible labor and "...a Hospitalist...laborist..." is available every night from 7:00 PM to 7:00 AM and every weekend from 7:00 PM Friday to 7:00 AM on Monday. Further interview confirmed a MSE was not provided by a licensed physician, PA, or APN.

Based on review of facility policy, medical record review, review of facility investigation, and interview, the facility failed to prevent a delay in treatment for 1 patient (#27) of 35 medical records reviewed.

The findings included:

Review of facility policy "On-call Pay" dated 1/1/14, revealed "...designated on-call employees must be available to be reached electronically or by phone and must be able to report to work within thirty [30] minutes of being contacted..."

Medical record review revealed Patient #27 was admitted to the Emergency Department (ED) at Facility A on 7/29/17 at 3:47 AM with complaints of right lower quadrant pain for 2 weeks. Further review revealed the patient had reported the onset of symptoms started on 7/15/17 and were not getting better and had a pain score of 9 [indicating severe pain]. Continued review revealed her Last Menstrual Period (LMP) was 9/1/15 and she had been on Depo-Provera (injections to prevent pregnancy). Further review revealed the patient was transferred to Facility B on 7/29/17 at 9:33 AM (5 hours and 14 minutes later).

Medical record review of an Emergency Provider Report at Facility A dated 7/29/17 at 3:49 AM revealed the patient was evaluated by the ED physician. Further review revealed "...abdominal pain, nausea...urinary frequency...pain for 2 weeks...slowly worse...nausea..."

Medical record review of a Laboratory Results Interpretation report from Facility A dated 7/29/17 at 4:25 AM revealed a Positive Pregnancy test.

Medical record review of an Emergency Patient Record at Facility A dated 7/29/17 at 4:35 AM revealed the Ultra Sound (US) Tech was called for a transvaginal ultrasound (pelvic ultrasound) order. Further review revealed "...called [named US tech]...no answer...left message on her voice mail..."

Medical record review of an Emergency Patient Record at Facility A dated 7/29/17 at 4:37AM revealed "...no call back from...US Tech...re-paged..."

Medical record review of an Emergency Patient Record at Facility A dated 7/29/17 at 4:41 AM revealed "...no call back from [named] US Tech...re-paged..."

Medical record review of an Emergency Patient Record at Facility A dated 7/29/17 at 5:05 AM revealed "...no call back from [named US Tech]...re-paged..."

Medical record review of an Emergency Patient Record at Facility A dated 7/29/17 at 5:05 AM revealed "...Nursing supervisor was notified of the multiple attempts to contact US Tech to no avail [no success]. Advised that following US Tech's shift begins at 7:00 AM MD [Medical Doctor] notified..."

Medical record review of an Emergency Patient Record at Facility A dated 7/29/17 at 5:11 AM revealed "...no call back from US Tech...re-paged..."

Medical record review of an Emergency Patient Record at Facility A dated 7/29/17 at 7:06 AM revealed "...[named US Tech] in US called and std [stated] she is here and will be down to get patient in just a few minutes..."

Medical record review of an Ultrasound Transvaginal report at Facility A revealed the US was completed on 7/29/17 at 7:30 AM (3 hours and 5 minutes after the US was ordered).

Medical record review of an Ultrasound Transvaginal report at Facility A dated 7/29/17 at 8:04 AM revealed the report was signed by [named radiologist]. Further review revealed "...impression...a live ectopic [outside the uterus] pregnancy at 9 weeks and 5 days of the right ovary...recommend stat Obstetrics and Gynecology [OB/GYN] consultation..."

Medical record review of an Emergency Provider Report at Facility A dated 7/29/17 at 8:05 AM revealed the ED physician contacted the on-call OB/GYN physician for Facility A. Continued review revealed the patient requested to be transferred to Facility B because her OB physician was located there.

Medical record review of an Emergency Medical Condition (EMC) form at Facility A dated 7/29/17 revealed the patient was transferred to Facility B at 9:33 AM with a diagnosis of a live ectopic pregnancy via ambulance.

Review of a facility investigation report from Facility A dated 8/11/17 revealed "...ED Director and Assistant Chief Nursing Officer [ACNO] were made aware of patient issue r/t [related to] call received from Facility B with concern about patient transfer...delay in u/s [ultrasound] and direction provided...the delay in u/s [ultrasound] tech response was a schedule issue/confusion with tech who was sick and the covering technician..." Further review revealed "...review of patient medical record: 7/29/17:
3:47 AM: patient arrived in ED
4:00 AM: triaged with pain of 9. Right Lower Quadrant [RLQ] pain x [times] 2 weeks. Much worse that day with nausea and vomiting
4:30 AM: transvaginal u/s ordered. Positive Pregnancy Test
U/S tech paged at 4:37 AM, 4:41 AM, 5:05 AM. Nursing supervisor notified at 5:05 AM. Advised that following US tech shift begins at 7:00 AM. MD notified.
7:06 AM: US tech on site and on way to get patient
8:00 AM: transvaginal u/s interpretation...live ectopic pregnancy at 9 weeks 5 days of the right ovary. Recommend stat [now] OB/GYN consultation.
8:05 AM: [named ED physician] and [named on-call OB/GYN] phone conversation
8:10 AM: pain 9 (scale of 1-10, indicating intense pain)
9:33 AM: pt. transferred to Facility B by EMS [emergency medical services]..."

Medical record review of an Operative Report from Facility B dated 7/29/17 at 1:44 PM revealed "...procedure: diagnostic laparoscopy [surgical procedure in which a fiber optic instrument is inserted through the abdominal wall to view the organs in the abdomen or to permit a surgical procedure]...partial omentectomy [surgical procedure to remove thin fold of abdominal tissue]..."

Interview with the Director of Imagining Services at Facility A on 9/6/17 at 11:10 AM, in the conference room, confirmed "...the US technicians are on call after 11:00 PM...the technician had notified me on Thursday [7/28/17] that she had strep throat and could not return to work...the schedule technician thought she was on call for the main hospital [not Facility A]...did not realize she was on call for [Facility A]...they had called her 3 times...the order was put in at 4:31 AM and the US was completed at 7:13 AM by the day shift US technician..." Further interview revealed "...they are responsible for their own schedules..."

Telephone interview with the ED Medical Director at Facility A on 9/6/17 at 11:00 AM revealed the patient presented to the ED on 7/29/17 with a chief complaint of RLQ pain. Further interview revealed "...I saw the patient around 4:00 AM...she had no idea she was pregnant...her HCG came back elevated which indicated she was pregnant...after we got her labs back I ordered an Ultrasound to rule out an ectopic pregnancy..." Further interview confirmed "...there was a delay in the getting the US...the test was done around 7:30 AM which did reveal an ectopic pregnancy..."

Telephone interview with ED Physician #2 at Facility A on 9/6/17 at 11:30 AM confirmed "...the patient came in with RLQ pain...her HCG [Human chorionic gonadotropin] [hormone produced during pregnancy] was positive indicating she was pregnant...the US was performed after I came in and showed a 9 week 5 day old right ovarian ectopic pregnancy...she said she had an OB/GYN physician at [Facility B] and had seen the physician to get her birth control...wanted to go to [Facility B]...the patient was very stable...no acute abdomen...""

Interview with the Cooperate Risk Manager at Facility A on 9/7/17 at 9:50 AM, in the conference room, revealed "...I was notified about the patient and the delay in getting the US...the technician did not realize she was on-call for Facility A and had not got anyone to cover for her due to sickness...they called her 3 times then they got in touch with the day shift technician who performed the US..." Continued interview confirmed "...the delay in the US has been discussed and referred to the department manager for follow up...the nursing supervisor was notified by the ED staff...further calls to the US staff were made and the day shift technician did the US as soon as she got in the facility..." Further interview revealed "...we discussed the delay in obtaining the US with our ED Medical Director and CMO [Chief Medical Officer]..."

Interview with the Chief Nursing Officer (CNO) on 9/7/17 at 10:00 AM, in the conference room, revealed "...I was notified by the RM [Risk Manager] regarding the US and the patient's transfer..." Further interview confirmed "...there was a delay in getting the US..."