The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

PERRY COMMUNITY HOSPITAL 2718 SQUIRREL HOLLOW DRIVE LINDEN, TN 37096 Nov. 17, 2011
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
An unannounced onsite EMTALA investigation began on November 15, 2011 and continued through November 17, 2011 for complaint numbered, TN 928. A determination of Immediate Jeopardy was reached and was based on record reviews and interviews which revealed the hospital failed to provide within its capabilities a medical screening examination sufficient to determine whether an emergency medical condition existed and additionally failed to stabilize emergency room patients prior to discharge.

Based on review of the Tennessee State Board of Nursing Rules & Regulations, document review, policy review, review of the hospital's By-laws Rules and Regulations, medical record review and interview, it was determined the hospital failed to ensure the Dedicated Emergency Department (DED) provided an adequate Medical Screening Examination (MSE) within the capabilities of the hospital DED in order to determine if an emergency medical condition existed. Failure of the hospital to provide an appropriate MSE resulted in the hospital's inability to have a definitive determination of an emergency medical condition and the inability to provide treatment for such conditions based on the MSE and to ensure patients were stabilized prior to being discharged from the DED for 16 of 24 (Patients #3, 6, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22 and 23) sampled patients.



Refer to findings in deficiency A2406 and A2407
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on policy review, document review, record review and interview, it was determined the hospital failed to ensure all patients presenting to the Dedicated Emergency Department (DED) seeking medical attention received an adequate medical screening examination (MSE) to determine if an emergency medical condition existed. Failure to provide oversight to ensure qualified individuals performed adequate assessments led to patients being treated and released without having determined the source and severity of their illness or injury, therefore, the appropriateness of the treatment and disposition could not be determined due to the lack of definitive evidence an emergency medical condition did or did not exist for 16 of 24 (Patients #3, 6,11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22 and 23) sampled DED patients.

The findings included:

1. Review of the hospital's By-Laws Rules and Regulations addendum dated 1/17/07 documented, "...All patients presented to the emergency room will be medically screened by qualified medical personnel to determine whether an emergency condition exists. This screening may be done by a Physician, Nurse Practitioner, Physician's Assistant, or a qualified Registered Nurse with advanced training. This may include but is not limited to, (ACLS, PALS, BLS) and/or emergency room experience." There was no documentation of criteria approved to evidence, if met, that an RN was qualified to perform MSE.

Review of the personnel files for the Registered Nurses (RN) identified as responsible for performing MSE revealed the files did not contain evidence of any criteria having been established, evaluated and found to be met to evidence that the RN had been deemed qualified to perform this function.

2. Review of the hospital's policy, "Emergency Medical Treatment", documented, "Any individual who comes to the emergency department and requests examination or treatment for a medical condition is entitled to and will receive an appropriate medical screening examination...The medical screening examination is an ongoing process based on the patient's needs and continue until the patient is either stabilized or appropriately transferred... The medical screening examination shall include both a generalized assessment and a focused assessment...A medical screening examination is not an isolated event. It is an on-going process. The record must reflect continued monitoring according to the patient's needs and must continue until he/she is stabilized or appropriately transferred. There should be evidence of this evaluation prior to discharge or transfer along with documentation of the process...When non-physician personnel perform the medical screening examinations, screening protocols that outline the examination and/or diagnostics workup required to determine if an emergency medical condition exits should be developed and approved by the hospital's medical staff. These protocols will normally be complaint specific and will be limited to those presented complaints that lend themselves to screening by such non-physician personnel... Emergency medical condition... A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain and/or symptoms of substance abuse)..."

During an interview on 11/9/11 at 9:00 AM, when questioned if the DED RNs who performed the MSE used a complaint specific protocol to determine if an emergency medical condition existed the ED Supervisor stated, "We do not have the protocols"

3. Review of the DED staff meeting minutes dated 6/27/11 documented an issue had been identified with patients who had presented to the DED and had not been seen by physicians and practitioners. The meeting minutes documented the physicians and practitioners would be allowed to document on the patient's DED records even if they had not seen the patients.

4. During an interview on 11/15/11 at 1:25 PM, the DED Supervisor verified a zero (o) with a strike through the middle placed in the area designated for recording the physician's arrival to the DED meant the patient was not seen by the physician. When shown a medical record with this symbol but also having documentation indicating an assessment was performed, a diagnosis made and a signature present, the DED Director stated the physician had come to the DED and documented on the patient's record and that the physician was not saying he had seen the patient he was just documenting an assessment.

During an interview in the DED on 11/15/11 at 1:50 PM, the DED Supervisor was asked if there had been an identified pattern with any physician or practitioner not physically assessing emergency department patients. The DED Supervisor stated she had identified a pattern with Physician #1. The surveyor asked the DED Supervisor if there were instances when Physician #1 was in the building and did not come to see the DED patient. Her answer was, "Yes ma'am."

During an interview on 11/16/11 at 12:30 PM the DED Supervisor stated the documentation on the patients's DED records and Central Logs verified those patients had not been seen by Physician #1 while the patients were in the DED.

5. During an interview on 11/16/11 at 9:20 AM the Director of Clinical Services verified the words "Not Seen" meant the patient was not seen by the physician.

6. During an interview on 11/16/11 at 9:40 AM the Director of Nursing (DON) verified a zero with a strike through the middle meant the patient was not seen.

7. During a telephone interview on 11/17/11 at 8:55 AM, Physician #1 stated he did at times examine patients somewhere else such as the hallway of the hospital and stated, "I check them briefly" then go to the DED and write on the chart but "it may be the next day or some little bit later... it's a common thing..." When the surveyor sought clarification by asking if sometimes when patients were examined they were no longer in the DED, Physician #1 stated he did examinations in the DED "Most of the time." When questioned as to what "not seen" on the patient's DED record meant, Physician #1 stated, "We do see them from time to time inpatient and outpatient..." Additionally Physician #1 stated, "They [patients] want their shot or they will leave."

8. Review of the hospital's "Medical Screening Exam" form documented a check box format numbered 1 - 20 with an area on the last page to write additional notes. The check boxes were titled, General, Nutrition, Psychosocial, Functional Status, Fall Risk Assessment, Barrier to Learning, Pain Assessment, Respiratory, Cardiovascular, Endocrine, Neurological, Gastrointestinal, GU/GYN [genitourinary/gynecological], Integumentary, Eyes, Musculoskeletal, Suspected Abuse, Suicidal Risk, Past Medical History and Past Surgeries.

9. Review of the DED patient log revealed patients #3, 6, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22 and 23 were documented as not having been seen by the physician or practitioner.

10. Medical record review for Patient #21 documented the patient (MDS) dated [DATE] at 0600 complaining of a headache from being assaulted. The triage nurse documented at 0600 the patient stated she has had a migraine headache for 3 days and experienced 3 seizures that morning prior to coming to the DED. Review of the MSE form documented an assessment initiated by the RN on 8/18/11 at 0605 and revealed the RN documented the patient complained of head pain rating a 10 on a scale of 1-10 with 10 being the most painful. The RN documented, "the patient appears sedated, some difficulty with speech... friend states she fell on everything..." On page 3 of the form under Nurses Notes the Licensed Practical Nurse (LPN) documented at 0650, "Pt [Patient] states her 'daughter and the man that brought me here hit me' ...abrasion noted to bridge of nose... 0656 requested from patient a urine specimen, patient to BR [bathroom] per self, when pt exited BR she was carrying a urine specimen cup with clear liquid inside, Patient states 'I tried to pee but can't' asked pt if she could void at all in a few minutes, Pt states, 'If I could drink some water maybe I could', pt removed lid from specimen cup and drank the contents therein 0710 I&O [In & Out] cath [catherization] performed to obtain urine specimen..." There was no documentation of further assessment of the patient to determine if an emergency medical condition existed. There was no documentation the RN used a complaint specific protocol in order to determine if an emergency medical condition existed. Review of the results of the urine sample documented the patient was positive for barbiturates, benzodiazepine, cannabinoids and opiate. Despite the ED form documenting the patient was not seen by the physician, a summary of information was documented in the space for physical examination and a diagnosis of migraine headache and multiple illicit substance use was documented on the form by Physician #1. The patient was administered Toradol IM at 0710 and was discharged home at 0835. There was no documentation of assessment for the patient's chief complaints which brought her to the DED, including seizures, falls, assaults and illicit drug use.

11. Medical record review for Patient #22 documented the patient (MDS) dated [DATE] at 0630 with complaints of pain and redness in the left eye. The triage nurse documented at 0630 the patient stated he was building a building and had a possible foreign body in his eye. The patient rated his eye pain a 6 on a scale of 1-10 with 10 being the most painful. Review of the MSE form documented an assessment was initiated by the RN on 8/14/11 at 0630 and revealed the RN documented the patient stated he had been building with wood the day before and suspected wood had gotten into his eye. On the MSE form in the area for pain assessment the RN documented the patient had pain in the left eye rating a 6. There was no further documentation of an assessment of the patient's eye and the patient's pain to determine if an emergency medical condition existed. There was no documentation the RN used a complaint specific protocol in order to determine if an emergency medical condition existed. There was no documentation the DED physician examined the patient's eye. Despite the DED form documentation the patient was not seen by the physician, a summary of information was documented in the space for physical examination and a diagnosis of foreign body with corneal abrasion was documented on the form by Physician #1. The patient was administered eye ointment at 0640 and was discharged home with an eye patch at 0705. There was no documentation of referral to an eye specialist for evaluation/treatment of the left eye injury.

12. Medical record review for Patient #3 documented the patient arrived by ambulance to the DED on 10/23/11 at 2140 with complaints of a migraine headache rating the pain an 8 on a scale of 1-10 with 10 being the most painful. The patient also complained of nausea. Review of the MSE form documented an assessment was initiated by the RN on 10/23/11 at 2140 and revealed the RN documented under the area for pain assessment the patient had a headache rating the pain an 8 and "seen in ER [DED] earlier today, given Nubain 5 mg with some relief...". The RN documented the patient had been treated by emergency medical services (EMS) with intravenous Zofran and Nubain Intramuscularly (IM) prior to this hospital visit at 1830. There was no further documentation of an assessment of the patient's pain to determine if an emergency medical condition existed. There was no documentation the RN used a complaint specific protocol in order to determine if an emergency medical condition existed. Despite the ED form documenting the patient was not seen by the physician, a summary of information was documented in the space for physical examination and a diagnosis of migraine headache was documented on the form by Physician #1. The patient was administered Nubain and Phenergan Intravenously (IV) at 2145 and was discharged at 2230.

13. Medical record review for Patient #6 documented the patient was admitted on [DATE] at 1820 with complaints of a headache rating a 10 on a scale of 1 - 10 with 10 being the most painful. The patient also complained of nausea. The RN documented the patient had been treated with Nubain and Phenergan Intramuscularly (IM) prior to this hospital visit and now the patient complained the headache and nausea were worse. Review of the MSE form documented an assessment was initiated by the RN on 11/6/11 at 1825 and revealed the RN documented the patient had a headache rating a "10/10." There was no further documentation of an assessment of the patient's pain to determine if an emergency medical condition existed. There was no documentation the RN used a complaint specific form to rule out an emergency medical condition. There was no documentation the DED physician had examined the patient. Despite the ED form documenting the patient was not seen by Physician #1, Nubain and Phenergan IM were administered at 1835 and the patient was discharged home at 1850.

14. Medical record review for Patient #11 documented the patient was admitted on [DATE] at 1015 with complaints of lower back and left shoulder pain rating a 9 on a scale of 1-10 with 10 being the most painful. Review of the MSE form documented an assessment was initiated by the RN on 10/11/11 at 1020 and revealed the RN documented in the area for pain assessment the patient had low back and left shoulder pain rating a 9. There was no further documentation of an assessment of the patient's pain to determine if an emergency medical condition existed. There was no documentation the RN used a complaint specific protocol in order to determine if an emergency medical condition existed. Despite the ED form documenting the patient was not seen by the physician, a summary of information was documented in the space for physical examination and a diagnosis of Exacerbation of low back pain and right shoulder pain (even though the patient complained of left shoulder pain) was documented on the form by Physician #1. The patient was administered Vistaril IM at 1020 and was discharged home at 1030.

On 10/17/11 at 0330 Patient #11 presented a second time to the DED with complaints of lower back and left shoulder pain rating a 6 on a scale of 10 with 10 being the most painful. The MSE form documented an assessment was initiated by the RN on 10/17/11 at 0330 and revealed the RN documented in the area for pain assessment the patient had left shoulder pain rating a 6. The form documented the patient stated he had run out of pain medication earlier that day. Physician #1 was notified at 0335 and ordered 2 Lortab 10 milligram tablets to be dispensed to the patient to take home. There was no further assessment of the patient's pain to determine if an emergency medical condition existed. There was no documentation the RN used a complaint specific protocol in order to determine if an emergency medical condition existed. Despite the ED form documenting the patient was not seen by the physician, the patient was dispensed two 10 milligram (mg) Lortab at 0335 by the RN and discharged home at 0400.

15. Medical record review for Patient #12 documented the patient was admitted on [DATE] at 0725 with complaints of headache rating 6 on a scale of 1-10 with 10 being the most painful. The patient also complained of nausea. The RN documented the patient had taken Imitrex and Zofran prior to arrival in the DED at 0300. Review of the MSE form documented an assessment was initiated by the RN on 10/29/11 at 0730 and revealed the RN documented in the area for pain assessment the patient complained of a headache rating the pain a 6, sound and light made the pain worse and Imitrex helped the pain some. There was no further documentation of an assessment of the patient's pain to determine if an emergency medical condition existed. There was no documentation the RN used a complaint specific protocol in order to determine if an emergency medical condition existed. Despite the ED form documenting the patient was not seen by the physician, a summary of information was documented in the space for physical examination and a diagnosis of migraine headache was documented on the form by Physician #1. The patient was administered Nubain and Phenergan IM at 0750 and discharged home at 0805.

16. Medical record review for Patient #13 documented the patient (MDS) dated [DATE] at 0335 with complaints of right jaw pain radiating to the ear. The pain was rated a 10 on a scale of 1 - 10 with 10 being the most painful. Review of the MSE form documented an assessment was initiated by the RN on 10/31/11 at 0335 and revealed the RN documented in the area for pain assessment the patient complained of right back molar and right ear pain rating a "10+" and the patient had tried oragel and Motrin without any relief. There was no further assessment of the patient's pain to determine if an emergency medical condition existed. There was no documentation the RN used a complaint specific protocol in order to determine if an emergency medical condition existed. Despite the ED form documenting the patient was not seen by the physician, a summary of information was documented in the space for physical examination and a diagnosis of broken right lower molar was documented on the form by Physician #1. The patient was administered Nubain and Phenergan IM at 0350 and was repeated at 0420. The patient was discharged home at 0545. There was no referral to a Dentist for evaluation/treatment of right jaw pain.

17. Medical record review for Patient #14 documented the patient (MDS) dated [DATE] at 2315 with complaints of lower back pain rating the pain a 9 on a scale of 1 -10 with 10 being the most painful. Review of the MSE form documented an assessment was initiated by the RN on 11/9/11 at 2320 and revealed the RN documented the patient complained of low back pain rating the pain a 9 and a history of chronic low back pain. There was no further assessment of the patient's pain to determine if an emergency medical condition existed. Despite the ED form documenting the patient was not seen by the physician, a summary of information was documented in the space for physical examination and a diagnosis of exacerbation of low back pain was documented on the form by Physician #1. The patient was administered Nubain, Phenergan and Robaxin IM at 2340 and was discharged home at 2358.

18. Medical record review for Patient #15 documented the patient (MDS) dated [DATE] at 1215 with complaints of upset stomach. Review of the MSE form documented an assessment was initiated by the RN on 11/6/1/1 at 1220 and revealed the RN documented the patient complained of nausea,vomiting and diarrhea since mid-night and had experienced these same symptoms 2 weeks ago. The RN documented on the MSE form the patient experienced abdominal pain when vomiting, lumbar pain and had a sore throat from vomiting. On the MSE form in the area by pain assessment the RN documented "denies pain" There was no further assessment of the patient's symptoms to determine if an emergency medical condition existed. There was no documentation the RN used a complaint specific protocol in order to determine if an emergency medical condition existed. Despite the ED form documenting the patient was not seen by the physician, a summary of information was documented in the space for physical examination ans a diagnosis of Gastritis was documented on the form by Physician #1. The patient was administered Pepcid and a "GI Cocktail" at 1240 and was was discharged home at 1300.

19. Medical record review for Patient #16 documented the patient (MDS) dated [DATE] at 0100 with complaints of an abscessed tooth. Review of the MSE form documented an assessment was initiated by the RN on 11/6/11 at 0105 and revealed the RN documented in the area for pain assessment the patient complained of right jaw pain rating the pain a 10. There was no documentation of an assessment of the patient's mouth, jaw and teeth. There was no documentation of further assessment to determine if an emergency medical condition existed. There was no documentation the RN used a complaint specific protocol in order to determine if an emergency medical condition existed. Despite the ED form documenting the patient was not seen by the physician, a summary of information was documented in the space for physical examination and a diagnosis of gastritis was documented on the form by Physician #1. The patient was administered Nubain and Phenergan IM at 0115 and was discharged home at 0130. There was no referral to a Dentist for evaluation/treatment of complaints of an abscessed tooth.

20. Medical record review for Patient #17 documented the patient was admitted on [DATE] at 1700 with complaints of feet pain and complained he was out of his medication Lyrica. Review of the MSE form documented an assessment was initiated by the RN on 10/13/11 at 1655 and revealed the RN documented in the area of pain assessment the patient complained of a pain of rating 10. Documented under Nurses Notes was the patient's complaints of feet pain, history of neuropathy, out of his medication and history of exposure to Agent Orange. There was no documentation of further assessment of the pain to determine if an emergency medical condition existed. There was no documentation the RN used a complaint specific protocol in order to determine if an emergency medical condition existed. Despite the ED form documenting the patient was not seen by the physician, a summary of information was documented in the space for physical examination and a diagnosis of neuropathic pain both feet was documented on the form. The patient was dispensed four Lyrica 150 mg by the RN (no time documented) and was discharged at 1730.

21. Medical record review for Patient #18 documented the patient (MDS) dated [DATE] at 0350 with complaints of right hip and leg pain rating the pain a 10 on a scale 1-10 with 10 being most painful. Review of the MSE form documented an assessment was initiated by the RN on 9/13/11 at 0355 and revealed the RN documented in the area for pain assessment the patient complained of right lower leg pain rating the pain a 10. There was no further documentation of an assessment of the patient's leg and pain to determine if an emergency medical condition existed. There was no documentation the RN used a complaint specific protocol to determine if an emergency medical condition existed, Despite the ED form documenting the patient was not seen by the practitioner (Physician Assistant), Demerol, Phenergan and Benadryl IM were administered to the patient at 0415 and was the patient was discharged at 0435.

22. Medical record review for Patient #19 documented the patient was admitted on [DATE] at 2315 with complaints of a migraine with pain rated 9 on a scale of 1-10 with 10 being the most painful. The patient also complained of anxiety due to the recent death of her ex-husband. Review of the MSE form documented an assessment was initiated by the RN on 7/3/11 at 1315 and the RN documented the patient had taken Imitrex early that day without pain relief. There was no documentation of further assessment of the patient's pain to determine if an emergency medical condition existed. There was no documentation the RN used a complaint specific protocol in order to determine if an emergency medical condition existed. The RN documented she contacted Physician #2 who gave an order for IM medication. Despite the ED log documenting the patient was not seen and the form being blank in the area for time of physician arrival, a summary of information was documented in the space for physical aexamination and a diagnosis of cephalgia and anxiety was documented by Physician #2. The patient was administered Nubain and Phenergan IM at 2330 and discharged home at 2345.

23. Medical record for patient #20 documented the patient was admitted on [DATE] at 0300 with complaints of acid reflux, nausea, vomiting and diarrhea with abdominal pain rating the pain a 7 on a scale of 1-10 with 10 being the most painful. The triage nurse documented the patient stated he had recently drank spring water that smelled funny and the symptoms had been present for 5 days since that time. Review of the MSE form documented an assessment was initiated by the RN on 7/15/11 at 0300 and revealed the RN documented in the area for pain assessment the patient complained of abdominal pain for 5 days, rating the pain a 7, pain is worse when the patient drinks cold water, nothing relieves the patient's pain and the patient had not eaten for 5 days. The RN documented the patient complained of "smothering" when in the supine position and has had several episodes of incontinence. Nurses Notes documented the patient was seen in the emergency department at another hospital the last 2 nights for the same complaint. Physician #1 was contacted and gave orders for treatment. There was no documentation of further assessment of the patient to determine if an emergency medical condition existed. There was no documentation the RN used a complaint specific protocol in order to determine if an emergency medical condition existed. Despite the ED form documenting the patient was not seen by the physician, a summary of information was documented in the space for physical examination and a diagnosis of gastroenteritis was documented on the form by Physician #1. The patient was administered Zofran IV at 0330, Flagyl IV at 0335 and Cipro IV at 0400 The RN dispensed (3) Cipro 500 mg and (3) Flagyl 250 mg at 0445 and the patient was discharged home at 0500. The patient's complaints of "smothering" when in the supine position and incontinence were not assessed. There was no documentation that patient was referred their to attending physician for continued complaints.

24. Medical record review for Patient #23 documented the patient (MDS) dated [DATE] at 0120 with complaints of back pain. Review of the triage note dated 9/21/11 at 0120 documented the patient complained of back pain rating the pain a 10 on a scale of 1-10 with 10 being the most painful. Review of the MSE form documented an assessment was initiated by the RN on 9/21/11 at 0124 and revealed the RN documented the patient complained of back pain with a pain scale rating of 10. There was no further documentation of an assessment of the patient's pain to determine if an emergency medical condition existed. There was no documentation the RN used a complaint specific protocol in order to determine if an emergency medical condition existed. Despite the ED form documenting the patient was not seen by the physician, a summary of information was documented in the space for physical examination and a diagnosis of exacerbation of back pain was documented on the form by Physician #1. The patient was administered Nubain and Phenergan IM at 0145 and was discharged home at 0200.

The hospital failed to provide patients seeking medical attention with an appropriate MSE to determine if an emergency medical condition existed, failed to ensure staff working in the DED possessed required skills and competencies necessary to assess patients and failed to ensure protocols were developed and used to assist non-physician personal with performing adequate MSE to determine if an emergency medical condition existed.
VIOLATION: STABILIZING TREATMENT Tag No: A2407
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review, policy review, record review and interview, it was determined the hospital failed to ensure Dedicated Emergency Department (DED) staff possessed the necessary skills and qualifications to perform assessments, therefore, it could not be determined the patient received appropriate treatment and stabilization prior to being discharged home for 16 of 24 (Patients # 3, 6, 9, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, and 23) sampled patients.

The findings included:

1. Review of the hospital's policy, " Emergency Medical Treatment (EMTALA) Policy", documented, "...A medical screening examination is not an isolated event. It is an on-going process. The record must reflect continued monitoring according to the patient's needs and must continue until he/she is stabilized or appropriately transferred. There should be evidence of this evaluation prior to discharge or transfer along with documentation of the process... A patient will be deemed stabilized if the treating physician attending to the patient in the hospital has determined within reasonable clinical confidence that the emergency medical condition has resolved."

2. Review of the Rules of The Tennessee Board of Nursing documented, "Standards of Nursing Practice for the Registered Nurse ...The Registered Nurse shall ...Conduct and document nursing assessments ...Evaluate the responses of individuals ...Communicate accurately in writing and orally with recipients of nursing care and other professionals ...Delegate to another only those nursing measures which that person is prepared or qualified to perform.."

Review of the Tennessee Board of Nursing Position Statements reaffirmed February 2009 documented, "It is apparent from these rules the interpretation of the standard of care for the licensed practical nurse in terms of assessment is that the individual is not prepared educationally in the basic vocational program with the requisite scientific skills to expand his or her practice to assessment of patients, formulation of a plan of care, or evaluation of the plan of care developed by the registered nurse..."

3. Review of the hospital's By-Laws Rules and Regulations addendum dated 1/17/07 documented, "...All patients presented to the emergency room will be medically screened by qualified medical personnel to determine whether an emergency condition exists. This screening may be done by a Physician, Nurse Practitioner, Physician's Assistant, or a qualified Registered Nurse with advanced training. This may include but is not limited to, (ACLS, PALS, BLS) and/or emergency room experience." There was no documentation of criteria approved to evidence, if met, that an RN was qualified to perform MSE.

Review of the personnel files for the Registered Nurses (RN) identified as responsible for performing MSE revealed the files did not contain evidence of any criteria having been established, evaluated and found to be met to evidence that the RN had been deemed qualified to perform this function.

4. Medical record review for Patient #3 documented the patient was admitted on [DATE] at 2140 with complaints of migraine headache rating a 8 on a scale of 1-10 with 10 being the most painful. The patient also complained of nausea. The RN documented the patient had been treated by emergency medical services with intravenous Zofran and Nubain IM prior to this hospital visit at 1830. The patient was administered Nubain IV and Phenergan IM at 2145 and discharged at 2230. There was no documentation of continued monitoring and assessment of the patient's pain by the RN or physician (MD). There was no documentation of a RN or MD assessment of the patient to determine if the patient had been stabilized prior to being discharged home.

5. Medical record review for Patient #6 documented the patient (MDS) dated [DATE] at 1820 with complaints of nausea and a headache rating the pain a 10 on a scale of 1 - 10 with 10 being the most painful. The RN documented the patient had been treated with Nubain and Phenergan Intramuscular (IM) prior to this hospital visit and now the patient complained the headache and nausea were worse. The patient was administered Nubain and Phenergan IM at 1835 and discharged home at 1850. There was no documentation of continued monitoring and assessment of the patient's pain and nausea by a RN or MD. There was no documentation of a RN or MD assessment of the patient to determine if the patient had been stabilized prior to being discharged home.

6. Medical record review for Patient #9 documented the patient was admitted on [DATE] at 0115 with complaints of epigastric pain rating a 6 on a scale of 1-10 with 10 being the most painful. The RN documented the patient had no prior treatment. The patient was administered Reglan, Pepcid and a gastrointestinal (GI) cocktail by mouth at 0135 and discharged home at 0200. There was no documentation of continued monitoring and assessment of the patient's pain by a RN or a MD. There was no documentation of a RN or MD assessment of the patient to determine if the patient had been stabilized prior to being discharged home.

7. Medical record review for Patient #11 documented the patient was admitted on [DATE] at 1015 with complaints of lower back and left shoulder pain rating a 9 on a scale of 1-10 with 10 being the most painful. The patient was administered Vistaril IM at 1020 and discharged home at 1030. There was no documentation of continued monitoring and assessment of the patient's pain by a RN or a MD. There was no documentation of a RN or MD assessment of the patient to determine if the patient had been stabilized prior to being discharged home.

Patient #11 presented a second time to the DED on 10/17/11 at 0330 with complaints of lower back and left shoulder pain rating a 6 on a scale of 10, with 10 being the most painful. The patient was dispensed two 10 milligram (mg) Lortab at 0335 by the RN and discharged home at 0400. There was no documentation of continued monitoring and assessment of the patient's pain by a RN or a MD. There was no documentation of a RN or MD assessment of the patient to determine if the patient had been stabilized prior to being discharged home.

8. Medical record review for Patient #12 documented the patient was admitted on [DATE] at 0725 with complaints of headache rating 6 on a scale of 1-10 with 10 being the most painful. The patient also complained of nausea. The RN documented the patient had taken Imitrex and Zofran prior to arrival in the DED at 0300. The patient was administered Nubain and Phenergan IM at 0750 and discharged home at 0805. There was no documentation of continued monitoring and assessment of the patient's pain and nausea by a RN or a MD. There was no documentation of a RN or MD assessment of the patient to determine if the patient had been stabilized prior to being discharged home.

9. Medical record review for Patient #13 documented the patient (MDS) dated [DATE] at 0335 with complaints of right jaw pain radiating to the ear. The pain was rated a 10 on a scale of 1 - 10 with 10 being the most painful. The MSE form dated 10/31/11 at 0335 documented the patient had right back molar and right ear pain rating "10+". The patient was administered Nubain and Phenergan IM at 0350 and it was repeated at 0420. At 0545 the patient was discharged home. There was no documentation of continued monitoring and assessment of the patient's pain by a RN or a MD. There was no documentation of a RN or MD assessment of the patient to determine if the patient had been stabilized prior to being discharged home.

10. Medical record review for Patient #14 documented the patient (MDS) dated [DATE] at 2315 with complaints of lower back pain rating the pain a 9 on a scale of 1 -10 with 10 being the most painful. The MSE form dated 11/9/11 at 2320 documented the patient had back pain rated at a 9. The patient was administered Nubain, Phenergan and Robaxin IM at 2340 and was discharged home at 2358. There was no documentation of continued monitoring and assessment of the patient's pain by a RN or a MD. There was no documentation of a RN or MD assessment of the patient to determine if the patient had been stabilized prior to being discharged home.

11. Medical record review for Patient #15 documented the patient (MDS) dated [DATE] at 1215 with complaints of an upset stomach. The MSE form dated 11/6/11 at 1220 documented the patient experienced abdominal pain when vomiting, had a sore throat from vomiting and lumbar pain. The MSE documented the patient complained of vomiting since mid-night and had experienced these same symptoms 2 weeks ago. The patient was administered Pepcid and a "GI Cocktail" at 1240 and was discharged home at 1300. There was no documentation of continued monitoring and assessment of the patient's pain and vomiting by a RN or a MD. There was no documentation of a RN or MD assessment of the patient to determine if the patient had been stabilized prior to being discharged home.

12. Medical record review for Patient #16 documented the patient (MDS) dated [DATE] at 0100 with complaints of an abscess tooth. The MSE form dated 11/6/11 at 0100 documented the patient complained of right jaw pain rating the pain a 10. There was no documentation of an assessment of the patient's mouth, jaw and teeth. The patient was administered Nubain and Phenergan IM at 0115 and discharged home at 0130. There was no documentation of continued monitoring and assessment of the patient's pain by a RN or a MD. There was no documentation of a RN or MD assessment of the patient to determine if the patient had been stabilized prior to being discharged home.

13. Medical record review for Patient #17 documented the patient was admitted on [DATE] at 1700 with complaints of feet pain. The pain rating scale was not completed at triage. At 1655 the RN documented the patient's pain as 10. The patient was dispensed four (4) Lyrica 150 mg by the RN (no time documented) and was discharged home at 1730. There was no documentation of continued monitoring and assessment of the patient's pain by a RN or a MD. There was no documentation of a RN or MD assessment of the patient to determine if the patient had been stabilized prior to being discharged home.

14. Medical record review for Patient #18 documented the patient was admitted on [DATE] at 0350 with complaint of leg and hip pain. The triage nurse documented the pain as 10 on a scale of 1-10 with 10 being the worst pain. The patient was administered Demerol, Phenergan and Benadryl IM at 0415 and was discharged home at 0435. There was no documentation of continued monitoring and assessment of the patient's pain by a RN or a MD. There was no documentation of a RN or MD evaluation of the patient to determine if the patient had been stabilized prior to being discharged home.

15. Medical record review for Patient #19 documented the patient was admitted on [DATE] at 2315 with complaint of migraine with pain rated 9 on a scale of 1-10 with 10 being the most painful. The patient also complained of anxiety and a recent death of her ex-husband. The RN documented the patient had taken Imitrex earlier in the day with no relief. The patient was administered Nubain and Phenergan IM at 2330 and discharged home at 2345. There was no documentation of continued monitoring and assessment of the patient's pain by a RN or a MD. There was no documentation of a RN or MD evaluation of the patient to determine if the patient had been stabilized prior to being discharged home.

16. Medical record for patient #20 documented the patient was admitted on [DATE] at 0300 with complaint of acid reflux and nausea and vomiting, with a pain rating of 7 on a scale of 1-10 with 10 being the most painful. The triage nurse documented the symptoms had been present for 5 days. The patient was administered Zofran IV at 0330, Cipro IV at 0400 and Flagyl IV at 0335. The RN dispensed (3) Cipro 500 mg and (3) Flagyl 250 mg at 0445. The patient was discharged home at 0500. There was no documentation of continued monitoring and assessment of the patient's pain or nausea by a RN or a MD. There was no documentation of a RN or MD evaluation of the patient to determine if the patient had been stabilized prior to being discharged home.

17. Medical record review for Patient #21 documented the patient (MDS) dated [DATE] at 0600 complaining of a headache from being assaulted. The triage nurse documented at 0600 the patient stated she has had a migraine headache for 3 days and experienced 3 seizures that morning prior to coming to the DED. The MSE form dated 8/18/11 at 0105 documented the patient appeared sedated, had difficulty speaking and complained she had been attacked. An urine sample was obtained and revealed the patient was positive for barbiturates, benzodiazepine, cannabinoids and opiate. The patient was administered Toradol IM at 0710 and discharged home at 0835. There was no documentation of continued monitoring and assessment of the patient by a RN or a MD. There was no documentation of a RN or MD evaluation of the patient to determine if the patient had been stabilized prior to being discharged home.

18. Medical record review for Patient #22 documented the patient (MDS) dated [DATE] at 0630 with complaints of pain and redness in the left eye. The patient rated his eye pain a 6 on a scale of 1 - 10 with 10 being the most painful. The MSE form dated 11/6/11 at 0105 documented the patient stated he had been building a house the day before and suspected wood had gotten into his eye. The patient was administered eye drops, eye ointment and a patch to wear. The patient was discharged at 0705. There was no documentation of continued monitoring and assessment of the patient's eye by a RN or a MD. There was no documentation of a RN or MD evaluation of the patient to determine if the patient had been stabilized prior to being discharged home.

19. Medical record review for Patient #23 documented the patient (MDS) dated [DATE] at 0120 with complaints of back pain rating the pain a 0 on a scale of 1 - 10 with 10 being the most painful. The MSE form dated 9/21/11 st 0124 documented the patient complained of back pain and rated the pain a 10. The patient was administered Nubain and Phenergan IM at 0145. There was no documentation of a further MSE to determine if an emergency medical condition existed. The patient was discharged at 0200. There was no documentation of continued monitoring and assessment of the patient's pain by a RN or a MD. There was no documentation of a RN or MD evaluation of the patient to determine if the patient had been stabilized prior to being discharged home.

20. During an interview in the conference room on 11/16/11 at 8:50 AM, the ED night supervisor was asked if Patient #26 was seen by the physician she stated, " I wasn't aware he wasn't seen, I go assess patient and go back to the floor if it is not a critical patient " When asked if she worked the floor at night in addition to working as night supervisor in the ED, she stated, "Yes." The surveyor asked if the LPN on duty conducted the discharge assessment and the night supervisor stated, "Vital signs are done by the LPN." When asked who determines the patient is stable for discharge, she stated, "I assume the doctor tells give meds and discharge home ...LPN discharges...".