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TENNOVA HEALTHCARE-LAFOLLETT MEDICAL CENTER 923 EAST CENTRAL AVENUE LA FOLLETTE, TN 37766 Aug. 23, 2013
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on review of facility policy, medical record review, and interview, the facility failed to provide appropriate transfer for ten patients (#3, #4, #5, #6, #7, #9, #10, #12, #13, #17) of twelve patients reviewed for transfer.

The findings included:

Refer to A-2409 for failure to provide appropriate transfer.
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
Based on review of facility policy, medical record review, and interview, the facility failed to provide an appropriate transfer for eight patients (#3, #4, #5, #6, #7, #9, #13, #17) of twelve patients reviewed for transfer.

The findings included:

Review of facility policy titled "Emergency Medical Treatment and Active Labor Act (EMTALA) Policy" dated September 15, 2008, revealed, "...Any individual who comes to the hospital's Dedicated Emergency Department...and on whose behalf a request is made for examination or treatment for a medical condition will be provided with...any necessary treatment to stabilize an emergency medical condition within the capabilities of the staff and facilities...prior to discharge or transfer...any necessary treatment to stabilize an emergency medical condition within the capabilities of the staff and facilities...prior to discharge or transfer...an appropriate transfer, if necessary...An appropriate transfer is one in which the hospital's Emergency Department...provides medical treatment within its capability...the medical facility that will receive the transfer has been contacted directly, has confirmed that it has available space and qualified personnel for treatment, and has agreed to accept the transfer and to provide appropriate medical treatment...Capabilities of the staff of a facility means the level of care that the personnel of the hospital can provide within the training and scope of their professional licenses...Labor means the process of childbirth beginning with the latent or early phase of labor and continuing through the delivery of the placenta. A woman experiencing contractions is considered to be in true labor unless a physician...certifies that, after a reasonable time of observation, the woman is in false labor..."


Patient #3 presented to the facility's emergency room (ER) on June 23, 2013, at 12:56 p.m.

Medical record review of a History and Physical dated June 23, 2013, revealed, "...(1:55 p.m.)...complaint of High Blood Sugar...(1:57 p.m.)...patient has Down's and MR (Mental Retardation)...positive for fatigue, malaise, poor PO (oral) intake...polydipsia, polyphagia, polyuria...(2:02 p.m.)...appears smells of ketones..."

Medical record review of a physician's progress note dated August 13, 2013, at 3:09 p.m. revealed, "...I feel the patient has limited communication skills, uncontrolled diabetes with ketoacidosis (metabolic acidosis), Renal insufficiency and indeterminate troponin so will consider transferring to tertiary care."

Medical record review of a Physician Certification and Patient Consent for Transfer Form revealed no documentation regarding the risks and/or benefits of the transfer.

Interview with the ER's Assistant Manager on August 20, 2013, at 1:15 p.m., in a conference room, confirmed the facility failed to provide an appropriate transfer for Patient #3.


Patient #4 presented to the facility's ER on June 24, 2013, at 10:17 a.m.

Medical record review of a History and Physical dated June 24, 2013, at 10:59 a.m., revealed, "...complaints of Back Pain...acute...decreased range of motion, and weakness...symptoms began 4 days ago...has metastatic cancer of rectum..."

Medical record review of a physician progress note dated June 24, 2013, at 3:50 p.m., revealed, "Physician consultation...a recommendation for transfer for higher level of care is made."

Medical record review of a Physician Certification and Patient Consent for Transfer Form dated June 24, 2013, and signed by M.D. #2, revealed no documentation regarding the risks and/or benefits of the transfer.

Interview with the ER's Assistant Manager on August 20, 2013, at 1:40 p.m., in a conference room, confirmed the facility failed to provide an appropriate transfer for Patient #4.


Patient #5 presented to the facility's ER on June 29, 2013, at 8:01 p.m.

Medical record review of a History and Physical dated June 29, 2013, at 8:22 p.m., revealed, "...presents with a burn..."

Medical record review of a physician's progress note authored by Doctor of Osteopathy (D.O. #1) dated June 29, 2013, at 9:35 p.m., revealed, "...spoke with PA (Physician's Assistant #1) who is arranging air transport to (Hospital #3)...and will accept pt (patient) for transfer."

Medical record review of a progress note dated June 29, 2013, at 10:48 p.m., not authored by a physician, revealed, "Pt is now being transferred to (Hospital #4)...accepted by M.D. #3."

Medical record review of a Physician Certification and Patient Consent for Transfer Form not dated or timed by the physician revealed no documentation regarding the reason for the transfer or identification of the risks and/or benefits of the transfer.

Interview with the Risk Manager on August 20, 2013, at 2:00 p.m., in a conference room, confirmed the progress note written at 10:48 p.m. regarding contact with Hospital #4 and acceptance of patient in transfer was not authored by a physician. Continued interview confirmed the facility failed to provide an appropriate transfer for Patient #5.


Patient #6 presented to the facility's ER on June 29, 2013, at 5:45 p.m.

Medical record review of a History and Physical dated June 29, 2013, at 5:46 p.m., revealed, "...complaints of Trauma...was struck by a car...Exam: (5:51 p.m.)...Basilar skull fracture findings: the patient does not have obvious signs of a basilar skull fracture..."

Medical record review of a Disposition Summary authored by M.D. #2 and dated June 29, 2013, at 5:27 p.m., revealed, "Transfer ordered to (Hospital #2). Diagnosis are Laceration - traumatic, interior upper lip separated from gum line and bone, Calcaneus Fracture - R (right), Ankle Sprain - R, Alcohol Intoxication...Reason for transfer: Trauma- Higher Level of Care..."

Medical record review of a physician's progress note authored by M.D. #2 and dated June 29, 2013, at 5:55 p.m., revealed, "...care is transferred to (D.O. #1)."

Medical record review of a Physician Certification and Patient Consent for Transfer Form dated June 29, 2013, revealed no documentation regarding the risks and/or benefits of the transfer or the signature of a physician.

Interview with the Assistant Manager of the ER on August 20, 2013, at 2:33 p.m., in a conference room, confirmed the facility failed to provide an appropriate transfer for Patient #6.


Patient #7 presented to the facility's ER on July 3, 2013, at 12:26 p.m.

Medical record review of a History and Physical dated July 3, 2013, at 1:26 p.m, revealed, "...complaints of Chest Pain...located primarily in the substernal area..."

Medical record review of a physician progress note authored by M.D. #2 and dated July 3, 2013, at 1:33 p.m., revealed, "...(facility) does not immediately have the required specialist...mildly improved after treatment, and as a result, I will transfer patient....(M.D. #4) was called at (1:33 p.m.), was contacted at (1:33 p.m.)...after a discussion of the case, a recommendation for transfer for higher level of care is made."

Review of a Physician Certification and Patient Consent for Transfer Form dated July 3, 2013, revealed the risks and/or benefits were not identified.

Interview with the Risk Manager on August 20, 2013, at 2:30 p.m., in a conference room, confirmed the facility failed to provide an appropriate transfer for Patient #7.


Patient #9 presented to the facility's ER on July 10, 2013, at 4:04 p.m.

Medical record review of a History and Physical dated July 10, 2013, at 6:03 p.m., revealed, "...nausea, vomiting...states...is diabetic but does not check...blood sugar every day..."

Medical record review of a Disposition Summary dated July 10, 2013, at 6:10 p.m., revealed, "Transfer ordered to Other Acute Care Facility. Diagnosis (diagnoses) are Diabetic Ketoacidosis, Type 1 Uncontrolled, Substance Abuse...Reason for transfer: Pediatrics...Accepting physician is (M.D. #5)..."

Medical record review of a Physician Certification and Patient Consent for Transfer Form dated July 10, 2013, signed by M.D. #6 (Medical Director of the Emergency Department), revealed the risks and/or benefits were not identified, stability/instability of patient's condition was not identified, and included, "...Permission by (patient's mother) via phone..."

Medical record review of a Documentation of Transfer (Addendum to Physician's Certification and Patient's Consent/Request for Transfer) dated July 10, 2013, revealed, "...Family/Significant Other present at Transfer: Father..."

Interview with the Risk Manager on August 21, 2013, at 10:20 a.m., in a conference room, confirmed the facility failed to provide an appropriate transfer for Patient #9.

Patient #13 presented to the facility's ER on July 31, 2013, at 1:16 a.m.

Medical record review of a physician's progress note (M.D. #10) dated July 31, 2013, at 1:27 a.m., revealed, "Patient medically screened."

Medical record review of a nurse's note dated July 31, 2013, at 1:30 a.m., revealed, "Presenting complaint...states (patient) is 39 weeks pregnant with contractions approx (approximately) 15 minutes apart...Acuity: ESI (Emergency Severity Index) 2 (on a scale of 1-5, 1=highest acuity)..."

Medical record review of a physician's progress note (M.D. #10) dated July 31, 2013, at 1:32 a.m., revealed, "ER care complete, transfer ordered by MD."

Medical record review of M.D. #10's Disposition Summary dated July 31, 2013, at 1:32 a.m., revealed, "Transfer ordered to (Hospital #2). Diagnosis is Active Labor, Term. Reason for transfer: Obstetrics...Symptoms are unchanged."

Medical record review of a nurse's note dated July 31, 2013, at 1:37 a.m., revealed, "...Pain Reassessment: remains unchanged...Patient awaiting physician at this time..."

Medical record review of a Physician Certification and Patient Consent for Transfer Form signed by M.D. #10 and dated July 31, 2013, at 1:50 a.m., revealed the accepting facility contact person was not identified. Continued review revealed the identity of the person to whom report was called was blank.

Medical record review revealed no documentation regarding a nurse's or physician's assessment between 1:37 a.m. and transfer at 2:03 a.m. on July 31, 2013.

Medical record review of a Justification of Medical Necessity for Ambulance Transportation dated July 31, 2013, revealed, "...Type of Ambulance Transportation...Emergency..."

Medical record review of a nurse's note dated July 31, 2013, at 2:03 a.m., revealed, "Transferred to: by EMS (Emergency Medical Services) ground (Hospital #2)..."

Medical record review a History and Physical dated July 31, 2013, at 8:35 a.m., revealed, "...presents to ER via walk-in with complaints of Term Labor...with possible uterine contractions, and last 10 second(s), nausea, and vomiting. The estimated gestational age is 39 weeks..."

Review of the medical record and interview with the Medical Director of the Emergency Department, on August 21, 2013, at 2:40 p.m., in a conference room and the presence of the Risk Manager and the Assistant Manager of the ER, revealed the medical record had insufficient documentation to determine the patient's stability for transfer. The Medical Director confirmed the facility failed to provide an appropriate transfer for Patient #13.


Patient #17 presented to the facility's ER on August 13, 2013, at 1:20 a.m.

Medical record review of a History and Physical dated August 13, 2013, at 1:23 a.m., revealed, "...complaints of Term Labor...EMS states that...contractions are 3-4 minutes apart and that they last for 45 seconds...Patient states that...expected due date is August 29th..."

Medical record review of the ER Record dated August 13, 2013, revealed, "...ED (Emergency Department) Course...(3:19 a.m.) vaginal delivery of preterm neonate, placenta, Performed by...MD (Medical Doctor #1)..."

Medical record review of a Physician Certification and Patient Consent for Transfer Form signed by M.D. #1 and dated August 13, 2013, revealed no documentation regarding a reason for the transfer or identification of the risks and/or benefits of the transfer. Continued review revealed no signature of the patient or a patient representative and included, "Pt has had Demerol (pain medication). verbalized need to transfer."

Medical record review of a nurse's note dated August 13, 2013, at 6:30 a.m., revealed, "Transferred...to (Hospital #6)..."

Interview with the Risk Manager on August 21, 2013, at 12:20 p.m., in a conference room, confirmed the facility failed to provide an appropriate transfer for Patient #17.