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Based on review of facility policy, review of Medical Staff Bylaws, medical record reviews, and interviews, the facility failed to provide an appropriate Medical Screening Examination (MSE) and stabilizing treatment within it's capabilities for 1 patient (Patient #2) with Abdominal Pain of 36 patients review. The facility's failure resulted in Patient #2 traveling 27 miles by private vehicle in severe pain to obtain diagnosis and treatment for his Emergency Medical Condition (EMC).

The findings included:

Patient #2 presented to the Emergency Department (ED) at Hospital A's West Campus on 6/10/2021 at 1:08 AM with a complaint of severe lower abdominal pain and the patient rated his pain as a 4 (on the pain scale of 1-10 with level 10 being the most severe pain). Patient #2 had a history of Diverticulitis (inflammation of abnormal pouches which can develop on the lining of the large intestine). The patient was seen by an ED physician and laboratory tests and a Computed Tomography (CT) of the Abdomen were ordered. The patient's white blood count was 12.8 (normal 5.0 to 10.8, elevated typically means infection or inflammation in the body). The CT of the Abdomen showed "...Possible enteritis. Recommend clinical correlation [clinical correlation recommended usually indicates inadequate clinical information was provided, or there was an unexpected finding requiring clinical assessment]. If mechanical obstruction is a concern clinically recommend followup plain film examination in 4-6 hours..." Patient #2 was re-evaluated by the physician and diagnostic tests were discussed. Patient #2 was discharged home from Hospital A 6/10/2021 at 2:31 AM with instructions to "...FOLLOWUP WITH PCP [primary care physician] 2-3 DAYS..." The patient left Hospital A on 6/10/2021 at 2:41 AM.

Patient #2 then presented to the ED at Hospital B on 6/10/2021 at 4:29 AM (1 hour 50 minutes after leaving Hospital A's ED) with a complaint of abdominal pain. The patient rated his pain as an "11." Review of an ED Provider's Note dated 6/10/2021 at 4:48 AM showed "...presents today for evaluation of abdominal pain. Location of abdominal pain is diffuse but more pronounced on the right lower quadrant...description of the pain is sharp...uncomfortable appearing male...there is abdominal tenderness in the left lower quadrant...Abdomen moderately tender to palpation. Peritonitis is present...peritonitis is present on exam..." Patient #2 was taken to the operating room that afternoon for robotic small bowel resection and was discharged home from Hospital B on 6/14/2021.

Refer to A2406 and A2407.

Based on facility policy reviews, review of Medical Staff Bylaws, medical record reviews, and interviews, the facility failed to provide an appropriate Medical Screening Examination (MSE) within the capabilities of the hospital to diagnose the Emergency Medical Condition (EMC) of 1 patient (Patient #2) with Abdominal Pain of 36 Emergency Department (ED) patients reviewed. The facility's failure to complete an appropriate MSE led to a delay in diagnosis of Patient #2's EMC.

The findings included:

Review of the facility's policy titled "EMTALA [Emergency Medical Treatment and Labor Act] - Tennessee Medical Screening Examination & Stabilization," approved 6/2017 revealed, "...An EMTALA obligation is triggered when an individual comes to a Dedicated Emergency Department (DED) and...the individual or a representative acting on the individual's behalf requests an examination or treatment for a medical condition...then an appropriate MSE, within the capabilities of the Hospital's DED...including ancillary services routinely available...shall be performed..."

Review of the facility's "Medical Staff Rules and Regulations - 2019" approved 4/2020 revealed "...A physician/APP [Advanced Practice Provider] or qualified medical person provides medical screening and determines the scope of assessment and care for patients in need of emergency care..."

Review of the Patient #2's medical record at Hospital A showed the patient presented to the ED at the facility's West Campus Emergency Department (ED) on 6/10/2021 at 1:08 AM for complaint of severe lower abdominal pain. Continued review revealed the patient stated his pain was severe and he rated his pain as a 4 (on a scale of 1-10 with 10 being the most severe pain). Continued review revealed the patient's vital signs at 1:17 AM were "...Pain 4...Temperature F: 97.8 [normal is 97 to 99]...Pulse: 89 [normal is 60 to 100]....Blood pressure: 146/98 [normal is less than 120/80]... Continued review revealed the nurse re-assessed the patient's vital signs at 2:40 AM and they were documented as "...Temperature F: 98.0...Pulse 78...Blood Pressure: 136/99..." Further review revealed Patient #2's pain was not re-assessed after 1:17 AM.

Review of a physician's "EMERGENCY PROVIDER REPORT" at Hospital A dated 6/10/2021 revealed Physician #1 began the MSE of Patient #2 at 1:10 AM. Continued review revealed "...Chief Complaint: Abdominal pain...PT [patient] PRESENTS C/O [complaining of] ONE HOUR OF DIFFUSE [wide spread] ABDOMINAL PAIN A/W [also with] NAUSEA...PT HAS PMH [past medical history] DIVERTICULITIS [inflammation of abnormal pouches which can develop on the lining of the large intestine]...IN MODERATE DISTRESS SECONDARY TO PAIN...Abdomen/GI [gastro-intestinal] Atraumatic, Soft, No guarding, No rebound, BS [bowel sounds] normoactive [normal], No distention, No hernia, No palpable mass, DIFFUSE TENDERNESS..." The ED physician ordered laboratory tests and a Computed Tomography (CT) of the Abdomen for Patient #2.

Review of the laboratory results at Hospital A dated 6/10/2021 at 1:40 revealed Patient #2's White Blood Count was 12.8 (normal 5.0 to 10.8, elevated typically means infection or inflammation in the body).

Review of the CT of the Abdomen for Patient #2 at Hospital A dated 6/10/2021 at 1:45 AM revealed "...Possible enteritis. Recommend clinical correlation [usually indicates inadequate clinical information was provided, or there was an unexpected finding requiring clinical assessment] If mechanical obstruction is a concern clinically recommend followup plain film examination in 4-6 hours..."

Review of Physician #1's re-assessment of Patient #1 dated 6/10/2021, not timed, revealed "...discussed lab and ct findings with pt...pt has had some improvement...abd [abdomen] remains soft...no vomiting will d/c [discharge] with pcp [primary care physician] followup..." Continued review revealed the patient was discharged home from Hospital A on 6/10/2021 at 2:31 AM with instructions to "...FOLLOWUP WITH PCP [primary care physician] 2-3 DAYS..." Continued review reveled the patient left the facility on 6/10/2021 at 2:41 AM.

Review of the medical record at Hospital B showed Patient #2 presented to the ED 6/10/2021 at 4:29 AM (1 hour 50 minutes after leaving Hospital A's ED).

Review of ED Triage Notes at Hospital B dated 6/10/2021 at 4:39 AM revealed "...Pt. arrived to triage desk via wheelchair. C/o of abd [abdominal] pain...Says pain is '11/10' [indicating severe pain/more severe than the 1-10 scale indicates]..." Continued review revealed the patient's vital signs were "...Temp: 98.2...Heart Rate: 106...B/P [blood pressure]: 113/70..."

Review of an ED Provider Note at Hospital B dated 6/10/2021 at 4:48 AM revealed "...presents today for evaluation of abdominal pain. Location of abdominal pain is diffuse but more pronounced on the right lower quadrant...Patient stated he felt every bump on the rolled [road] on route to the emergency room...description of the pain is sharp...uncomfortable appearing male...there is abdominal tenderness in the left lower quadrant...Abdomen moderately tender to palpation. Peritonitis is present...peritonitis is present on exam. Patient's history of presentation and exam warrants evaluation with blood work-up, EKG and 1 set troponin [laboratory test for heart attack], and CT of abdomen and pelvis..."

Review of a laboratory report at Hospital B dated 6/10/2021 at 5:42 AM revealed Patient #2's white blood count was 20.

Review of an ED Provider Note at Hospital B dated 6/10/2021 at 7:32 AM revealed "...The patient fulfills septic [life threatening response to infection] criteria with a pulse of 106 and white count of 20,900. I have started septic protocol..."

Review of Radiology Report of a CT Abdomen and Pelvis with Contrast at Hospital B dated 6/10/2021, not timed, revealed "...Focal inflammatory changes surrounding a blind-ending pouch arising from the small bowel in the midabdomen concerning for a Meckel's diverticulitis..."

Review of an ED Provider Note at Hospital B dated 6/10/2021 at 8:12 AM revealed "...CT Scan is back and suggest Meckel's diverticulitis [a rare disease involving an infected pouch on the lining of the small intestine] per the radiologist. I have paged on surgery..."

Review of General Surgery Operative Note at Hospital B dated 6/10/2021 at 1:16 PM revealed Patient #2 had a Robotic Abdominal Exploration and a Small Bowel Resection and Intracorporeal Anastomosis (surgical removal of a section of bowel and reattachment of the bowel ends). Continued review of the operative note revealed "...the small bowel was run until the inflamed diverticulum was identified...used to amputate the distal and proximal small bowel...Purulence [pus] was noted in the pelvis and this was all removed..."

Review of a discharge summary for Patient #2 at Hospital B dated 6/14/2021, not timed, revealed "...presented on 6/10 [6/10/2021] with acute abdominal pain and CT scan was concerning for Meckel's diverticulitis. Patient was taken to the operating room that afternoon for robotic small bowel resection...Patient was discharged home with plans for follow-up...in 2 weeks..." Continued review revealed Patient #2 was discharged home from Hospital B in good condition on 6/14/2021 at 3:42 PM.

During a telephone interview on 6/22/2021 at 12:53 PM, Physician #1 stated she was on duty at Hospital A's ED on 6/10/2021 and she remembered Patient #1. Physician #1 stated she examined the patient and did not find any evidence the patient was having an acute abdominal problem requiring surgery or emergency interventions. Continued interview revealed the patient did not have severe pain or severe abdominal tenderness, and his diagnostic tests did not show any evidence of acute disease. Continued interview revealed there were no acute problems found with the patient's CT Scan and laboratory tests and she believed the patient was stable for discharge. Physician #1 stated she examined the patient prior to discharge and he had no signs or symptoms of an acute surgical abdomen. Continued interview revealed the patient's condition had improved while he was in the ED and the physician believed the patient was stable for discharge and did not have an emergency medical condition. Physician #1 confirmed she did not consult the general surgeon or gastroenterologist on call regarding Patient #2 and she did not transfer the patient to the main campus ED.

During a telephone interview on 6/23/2021 at 8:45 AM, Patient#2 stated he presented to Hospital A's ED on 6/9/2021 around midnight. The patient stated his pain was very severe and that he told the ED staff his pain severity was above a 1-10 scale and was a 15-20 level of pain. Continued interview revealed he was treated with morphine for pain and he told staff it was not helping. The patient stated he continued to complain of severe pain. Patient #2 stated x-rays and a CT scan without contrast was performed on the patient. The patient stated he was told he might have a virus and to go home and put a hot towel to his abdomen. Continued interview revealed he told the ED staff that his pain was still very severe and unrelieved at discharge. Patient #2 stated he went directly to Hospital B by private vehicle for further treatment and at Hospital B he had a CT scan with contrast and was told he had a ruptured bowel. The patient stated he was taken to the operating room immediately after his CT Scan.

During an interview on 6/23/2021 at 11:00 AM, Hospital A's Vice President of Quality stated the facility has a general surgeon and a gastroenterologist on call daily for additional consults, assessments, and treatments for ED patients. Continued interview revealed consults with on-call specialists are requested by the ED physician when the ED physician determines a consult is needed.

Based on facility policy reviews, medical record reviews, and interviews the facility failed to provide stabilizing treatment within the capabilities of the hospital to treat the Emergency Medical Condition (EMC) of 1 patient (Patient #2) patient with Abdominal Pain of 36 patients reviewed. The facility's failure resulted in Patient #2's seeking further medical treatment at Hospital B located 29 miles from Hospital A.

The findings included:

Review of the facility's policy titled "EMTALA - Tennessee Medical Screening Examination & Stabilization" approved 6/2017 revealed, "...if an EMC is determined to exist, the individual will be provided necessary stabilizing treatment, within the capacity and capability of the facility..."

Review of the Patient #2's medical record at Hospital A showed the patient presented to the ED at the facility's West Campus Emergency Department (ED) on 6/10/2021 at 1:08 AM for complaint of severe lower abdominal pain. Continued review revealed the patient stated his pain was severe and he rated his pain as a 4 (on a scale of 1-10 with 10 being the most severe pain). Continued review revealed the patient's vital signs at 1:17 AM were "...Pain 4...Temperature F: 97.8 [normal is 97 to 99]...Pulse: 89 [normal is 60 to 100]....Blood pressure: 146/98 [normal is less than 120/80]... Continued review revealed the nurse re-assessed the patient's vital signs at 2:40 AM and they were documented as "...Temperature F: 98.0...Pulse 78...Blood Pressure: 136/99..." Further review revealed Patient #2's pain was not re-assessed after 1:17 AM.

Review of a physician's "EMERGENCY PROVIDER REPORT" at Hospital A dated 6/10/2021 revealed Physician #1 began the MSE of Patient #2 at 1:10 AM. Continued review revealed "...Chief Complaint: Abdominal pain...PT [patient] PRESENTS C/O [complaining of] ONE HOUR OF DIFFUSE [wide spread] ABDOMINAL PAIN A/W [also with] NAUSEA...PT HAS PMH [past medical history] DIVERTICULITIS [inflammation of abnormal pouches which can develop on the lining of the large intestine]...IN MODERATE DISTRESS SECONDARY TO PAIN...Abdomen/GI [gastro-intestinal] Atraumatic, Soft, No guarding, No rebound, BS [bowel sounds] normoactive [normal], No distention, No hernia, No palpable mass, DIFFUSE TENDERNESS..." The ED physician ordered laboratory tests and a Computed Tomography (CT) of the Abdomen for Patient #2.

Review of the medical record at Hospital B showed Patient #2 presented to the ED 6/10/2021 at 4:29 AM (1 hour 50 minutes after leaving Hospital A's ED).

Review of ED Triage Notes at Hospital B dated 6/10/2021 at 4:39 AM revealed "...Pt. arrived to triage desk via wheelchair. C/o of abed [abdominal] pain...Says pain is '11/10' [indicating severe pain/more severe than the 1-10 scale indicates]..." Continued review revealed the patient's vital signs were "...Temp: 98.2...Heart Rate: 106...B/P [blood pressure]: 113/70..."

Review of an ED Provider's Note at Hospital B dated 6/10/2021 at 4:48 AM revealed "...presents today for evaluation of abdominal pain. Location of abdominal pain is diffuse but more pronounced on the right lower quadrant...Patient stated he felt every bump on the rolled [road] on route to the emergency room...description of the pain is sharp...uncomfortable appearing male...there is abdominal tenderness in the left lower quadrant...Abdomen moderately tender to palpation. Peritonitis is present...peritonitis is present on exam..."

Review of Radiology Report of a CT Abdomen and Pelvis with Contrast at Hospital B dated 6/10/2021, not timed, revealed "...Focal inflammatory changes surrounding a blind-ending pouch arising from the small bowel in the midabdomen concerning for a Meckel's diverticulitis..."

Review of an ED Provider's Note at Hospital B dated 6/10/2021 at 8:12 AM revealed "...CT Scan is back and suggest Meckel's diverticulitis [a rare disease involving an infected pouch on the lining of the small intestine] per the radiologist. I have paged on surgery..."

Review of General Surgery Operative Note at Hospital B dated 6/10/2021 at 1:16 PM revealed Patient #2 had a Robotic Abdominal Exploration and a Small Bowel Resection and Intracorporeal Anastomosis (surgical removal of a section of bowel and reattachment of the bowel ends). Continued review of the operative note revealed "...the small bowel was run until the inflamed diverticulum was identified...used to amputate the distal and proximal small bowel...Purulence [pus] was noted in the pelvis and this was all removed..."

During a telephone interview on 6/22/2021 at 12:53 PM, Physician #1 stated she was on duty at Hospital A's ED on 6/10/2021 and she remembered Patient #1. Physician #1 stated she examined the patient and did not find any evidence the patient was having an acute abdominal problem requiring surgery or emergency interventions. Continued interview revealed the patient did not have severe pain or severe abdominal tenderness, and his diagnostic tests did not show any evidence of acute disease and she believed the patient was stable for discharge. Physician #1 stated she examined the patient prior to discharge and he had no signs or symptoms of an acute surgical abdomen. Continued interview revealed the patient's condition had improved and the physician felt the patient did not have an emergency medical condition. Physician #1 confirmed she did not consult the general surgeon or gastroenterologist on call and she did not transfer the patient to the main campus ED.

During a telephone interview on 6/23/2021 at 8:45 AM, Patient#2 stated he presented to Hospital A's ED on 6/9/2021 around midnight. The patient stated his pain was very severe and that he told the ED staff his pain severity was above a 1-10 scale and was a 15-20 level of pain. Continued interview revealed he was treated with morphine for pain and he told staff it was not helping. The patient stated he continued to complain of severe pain. The patient stated he was told he might have a virus and to go home and put a hot towel to his abdomen. Continued interview revealed he told the ED staff that his pain was still very severe and unrelieved at discharge. Patient #2 stated he went directly to Hospital B by private vehicle for further treatment and at Hospital B he had a CT scan with contrast and was told he had a ruptured bowel. The patient stated he was taken to the operating room immediately after his CT Scan.