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.

METRO NASHVILLE GENERAL HOSPITAL 1818 ALBION STREET NASHVILLE, TN 37208 March 9, 2011
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
INTAKE #TN 650

Based on 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 appropriate Medical Screening Examination (MSE) within the capabilities of the hospital ED for in order to determine if an emergency medical or psychiatric condition existed in order to provide appropriate treatment for such conditions to ensure the patients were stabilized prior to being discharged from the DED for 6 of 25 (Patients #2, 4, 5, 7, 20 and 25) sampled patients.
Refer to findings in deficiency V2406
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on policy review, hospital By-laws Rules and Regulations, medical records review and interview, it was determined the hospital failed to ensure all patients presenting to the dedicated emergency department (DED) received an appropriate medical screening examination (MSE) according to hospital policies and within the capabilities of the hospital to determine if a medical or psychiatric medical emergency existed in order to ensure all emergency medical and psychiatric conditions were treated and patients were stabilized for 6 of 25 (Patients #2, 4, 5, 7, 20 and 25) sampled patients.

The findings included:

1. Review of the hospital's policy, "Emergency Medical Treatment and Labor Act", documented, "...When an individual comes to [Hospital #1], and a request is made for emergency care, [Hospital #1] must provide an appropriate Medical Screening Examination within the capability of the facility emergency department whether an emergency medical condition exists...Appendix A...capabilities refer to (1) The hospital's physical space, equipment, supplies and services...including ancillary services that the facility provides. (2) The capabilities of the facility's staff mean the level of care that the hospital's personnel can provide within the training and scope of their professional license..."

Review of the hospital's policy, "Disruptive Behavior Hospital-wide", documented, "...Patient Disruptive Behavior...Disruptive behavior by a patient must be reported by calling a supervisor, the Administrator on Duty, the compliance hotline or by entering an electronic incident report...Employees will attempt to manage disruptive behavior and minimize risk by using the following techniques: remain calm, maintain eye contact (to the extent it seems safe (noting that to some people appear aggressive), maintain a safe distance, remove audiences, encourage the patient to relocate to a more appropriate/safe environment, allow the patient to vent, listen empathetically, exhibit a willingness to help, set limits and calmly convey the expectation that the patient will control his/her own behavior, and calling in assistance if unable to de-escalate the situation...Disruptive behavior that rises to the level in which an employee feels that he/she or other persons are in danger of harm should be reported to Security immediately...Once any immediate danger or threat is under control, security will contact the house supervisor, facilities director, or administrator on duty to communicate the circumstances of the situation...An incident report will be filed by security or the supervisor handling the situation..."

Review of the hospital's "Medical Staff By-laws Rules and Regulations", documented, "..."Psychiatric/Substance-Abuse Services: Emergency Department - Patients that present to the Emergency Department with psychiatric, drug and alcohol conditions will be screened medically and those without associated medical problems will be referred to appropriate Behavioral Health Consultant or Agency for evaluation and referral for appropriate treatment of their acute major psychiatric illness..."

2. Medical record review for Patient #2 documented the patient came to the ED on 1/11/10 at 1418 with complaints of abdominal pain. The triage nurse documented at 1448 the patient complained for the past 2 days he/she had experienced constant abdominal pain, moderate in severity, radiating to the back along with fever, chills and vomiting.

ED Physician #1 documented at 1458 the patient complained of vomiting and abdominal pain "currently quite severe." ED Physician #1 documented upon examination that the patient had a "normal pelvic examination...cervix non-tender..."

Review of the X-ray report dated 1/11/10 at 5:04 PM documented, "...Artifact from clothing overlies the pelvic on the upright abdominal image..."

The patient received Toradol and Phenergan intravenously (IV) for pain and vomiting and was discharged home at 1926 with the diagnosis of Pelvic Inflammatory Disease (PID).

During an interview on 3/8/11 at 3:15 PM, ED Physician #1 stated the artifact from the clothing should have been removed in order to perform a conclusive X-ray. ED Physician #1 offered no explanation as to why the X-ray was not repeated without the artifact from the clothing. ED Physician #1 verified a Complete Blood Count (CBC) test had not been obtained during the patient's ED visit. ED Physician #1 stated, "We usually are more intense and provide more services on re-visits to the ED"

On 1/13/10 at 2025 Patient #2 came to the ED a second time with complaints of abdominal pain. The Computerized Tomography (CT) scan of the abdomen dated 1/13/10 at 9:53 PM documented, "...There is a dilated fluid-filled appendix which measures 16 millimeters in greatest diameter...Periappendiceal inflammatory stranding is noted. The findings are suggestive of acute appendicitis. Small amount of fluid is noted in the cul-de-sac..." The patient's CBC report obtained during the re-visit dated 1/13/10 documented the patient's White Blood Cell (WBC) count was elevated at 16.3 (normal being 4.5 - 10.0).

During an interview on 3/8/11 at 3:15 PM, ED Physician #1 was asked to explain the findings of the above CT scan. ED Physician #1 stated the CT scan documented the patient had "acute appendicitis with perforation."

3. Medical record review for Patient #4 documented the patient came to the ED on 2/21/10 at 1226 with complaints of right eye pain. The patient's pain was documented as an 8 on a scale of 1 - 10, with 10 being the most painful. At 1307 the triage nurse documented, using the Snellan eye chart, the patient's vision in the left eye was 20/30 and "unable to visual chart right eye". ED Physician #2 performed a MSE at 1315 and documented the patient complained of right eye pain with a history of drainage from the right eye that was associated with blurred vision and was painful when the patient blinked. The patient was discharged at 1335 with Gentamycin antibiotic eye drops for a diagnosis of Conjunctivitis.

On 2/23/10 at 1137 Patient #4 returned to the ED with complaints of right eye pain. The patient's pain was documented as a 10 on a scale of 1 - 10, with 10 being the most painful. At 1252 the triage nurse documented, "unable to obtain visual acuity due to pt (patient) unable to open eyes for exam" ED Physician #1 performed a MSE at 1252 and documented the patient complained of right eye pain, exacerbated with blinking, describes the pain as a foreign body sensation. The patient was diagnosed with a "large corneal abrasion affecting the right central cornea" The patient was discharged at 1513 with Gentamycin antibiotic eye ointment and medication for pain.

On 2/27/10 at 1221 Patient #4 again returned to the ED with complaints of right eye pain. The pain was documented a 10 on a scale of 1 - 10, with 10 being the most painful. The triage nurse documented, using the Snellan eye chart, the patient's vision in the right eye was 20/200 and the left eye was 20/200. The nurse documented "drainage noted in right eye" ED Physician #2 documented at 1243 the patient, "c/o (complains of) severe right eye pain x (times) 10 days. States this is the 3rd (third) visit here for the same and it is getting worse" A nurse's note documented at 1258, "Pt (patient) yelling from rm (room) 12 requesting medication for pain...Pt c/o pain to left eye...Drops applied to affected eye to help numb the pain...Pt refuses to open eye so that MD (doctor) may look at eye...Pt states, "I will just leave" encouraged pt to stay so that eye may be examined. Pt is hostile and continues to yell loudly, while placing his hand in my face. Security now at bedside. Pt refuses to be seen at this time. Escorted from ED by hospital security..."
Review of an Against Medical Advice Form (AMA) form dated 2/27/10 at 1357 documented, "Patient refused to sign... Pt was yelling and trying to hit nurses. Pt escorted out of ER [ED] per security."

The facility failed to provide the patient with a medical screening that included a complete eye exam, that would include a visual acuity test, flourescence staining, occular pressures measured and a consult with an eye specialist.

Review of a letter dated 7/30/10 addressed "To Whom It May Concern" depicting the address of the hospital at the bottom of the page documented, "As of this date the document Leaving Against Medical Advice dated 2/27/10 has not been scanned into [Patient #4] medical record."

During an interview on 3/8/11 at 2:36 PM, when questioned as to what was the hospital policy to ensure patients were stable enough to be escorted from the hospital's ED prior to receiving a MSE, the Director of Risk Management stated the hospital did not have a policy on what to do with patients who were escorted out of the ED prior to receiving a MSE and treatment.

During an interview on 3/8/11 at 2:12 PM, the Hospital Security Director stated, "Normally escort people who become verbally or physically aggressive, try not to escort anyone off property." The Security Director stated the security personnel will not escort anyone from the ED unless the ED physician directs them to escort the patient from the ED. The Security Director stated if a patient was escorted from the ED an Incident Report should be completed. The Security Director verified there was no documentation an Incident report had been completed for this patient.

During a telephone interview on 3/9/11 at 10:40 AM, ED Physician #2 verified he/she was working in the ED on 2/27/10. ED Physician #2 stated he/she heard a commotion in Patient #4's room. The ED Physician stated he/she entered the patient's room and the patient was cursing. The ED Physician stated he/she attempted to exam the patient and the patient continued to curse and refused to be examined. The ED Physician stated he/she left the room because the patient did not want to be examined. The ED Physician verified he/she did not see the patient hit at or threaten anyone. The ED Physician denied asking security to escort the patient from the ED. The ED Physician verified he/she did not ask assistance from the other ED Physicians working that day.

During a telephone interview on 3/9/11 at 3:07 PM, the Registered Nurse (RN) assigned to Patient #4 on 2/27/10, verified that he/she had worked in the ED on that day. The RN stated he/she had walked into the Patient #4's room and the patient was sleeping. The RN stated it was difficult to awaken the patient and the patient "seemed startled and aggravated" when he/she woke up. The RN stated the patient "arose" out of the bed swinging his arms. The RN stated he/she was not hit by the patient and did not feel the patient was intentionally trying to hit her/him. The RN stated the patient was "aggravated" and kept changing his/her mind about receiving treatment in the ED. The RN stated he/she did not call security and was unsure why the patient was escorted out of the ED. The RN verified he/she did not notify the ED Supervisor about the patient incident and had not completed an Incident Report.

During an interview on 3/9/11 at 4:12 PM, Patient #4 verified he/she had come to the ED on 2/27/10 with complaints of eye pain. The Patient stated that he/she yelled for some pain medications and the ED Physician, RN and 2 Security Officers presented in his/her room. The patient stated, "They tried to look at my eye, when they touched it I couldn't bear it, so they deemed me combative." The patient denied refusing to be examined. The patient denied refusing to sign an AMA form. The Patient denied hitting at or striking anyone. The Patient stated he/she was escorted out of the hospital's ED without treatment.

Review of Patient #4's ED medical record for Hospital #2 dated 3/2/10 documented the patient came to the ED at 1940 with complaints of right eye pain documented as a 10 on a scale of 1 - 10, with 10 being the most painful. The MSE documented the patient's right eye was red and painful, the patient had "zero vision" and was "unable to see" in the right eye. The MSE documented the patient's intraocular pressure was 51 (normal being 10 - 20). The clinical impression was documented as, "Decreased vision Glaucoma - acute." The MSE documented, "...Pt needs transfer to ophtho (ophthalmology) care tonight." Case Manager notes dated 3/2/10 documented at 2300, Assisted with transfer... [Physician #6] accepted patient... to see in office tonight..." The transfer form documented the patient was "unstable" but required a "higher level of care and was transferred to Facility #3 by EMS at 2300."

As a comparison, medical record review was performed for Patient #5 which documented the patient came to the ED on 1/1/10 at 1655 with complaints of right eye pain. The triage nurse documented the pain as 5 on a scale of 1 - 10, with 10 being the most painful. The nurse's notes documented at 1742, "Security with pt... Pt is being unruly." ED Physician #3 documented he/she performed the MSE examination at 1733 and the patient was discharged at 1750.

During an interview on 3/8/11 at 2:39 PM, the Director of Risk Management verified documentation revealed Patient #5 had inappropriate behaviors while in the hospital's ED and required Security personnel to accompany the patient. The Director of Risk Management did not have answers as to why Patient #5 had received a MSE and treatment and Patient #4 had been escorted out of the ED prior to receiving a MSE and treatment.

4. Medical record review for Patient #7 documented the Patient came to the ED on 3/10/10 at 1320 with complaints of right leg pain with edema, back pain and cramping. The triage nurse documented the patient's pain was a 7 on a scale of 1 - 10, with 10 being the most painful. Review of the Doppler Sonogram dated 3/10/10 at 4:18 documented, "...Consistent with acute Deep Vein Thrombosis (DVT). The above findings were discussed with [ED Physician #4] in the emergency department on 3/10/10 at approximately 4:30 PM"

Review of the MSE documented Patient #7 was examined by ED Physician #1 and discharged at 1740 with a diagnosis of edema.

During an interview on 3/8/11 at 3:26 PM, ED Physician #1 stated he/she had stepped out of the ED briefly when Radiology had called the results of the Doppler Sonogram report. ED Physician #1 stated ED Physician #4 took the report and wrote on a piece of the paper the results were "superficial phlebitis". ED Physician #1 verified he/she did not call Radiology or view the Doppler Sonogram report prior to discharging the patient from the ED.

During an interview on 3/9/11 at 10:35 AM, ED Physician #4 verified he/she had received the Doppler Sonogram report from Radiology on 3/10/10 regarding Patient #7. ED Physician #4 stated he/she wrote on a piece of the paper the patient had "thrombosis" and placed the paper on ED Physician's #1 computer. ED Physician #4 stated he/she later verified with ED Physician #1 that he/she had seen the Doppler Sonogram results report. ED Physician #4 verified he/she did not document in the patient's medical record the results of the Doppler Sonogram report.

On 3/12/10 at 0517 Patient #7 returned to the ED with complaints of chest pain, shortness of breath (SOB) generalized pain and inflammation affecting the shin. The pain was documented as a 10 on a scale of 1 - 10, with 10 being the most painful. The MSE documented the patient's D-Dimer results were elevated at 16.68 (a normal D-Dimer result of less than 0.49 is considered negative for DVT). The patient was admitted to the hospital with a diagnosis of DVT.

5. Medical record review for Patient #20 documented the patient was carried into the ED, by their spouse, on 8/3/10 at 1036 with the complaint of overdose with Xanax. The MSE conducted at 1130 by ED Physician #2 documented, "...Severely lethargic. Presents with an altered level of consciousness...Patient is poorly responsive...Has access to sedating medications...The history suggests ingestion of several substances or drugs, which reportedly include: seroquel and Xanax...No available psychiatric history or unusual behavior...Patient is not responding to verbal stimuli. Unable to reliably assess patient's judgement..." At 1712 ED Physician #2 documented, "Patient is waking up and is very coherent...She is being discharged in stable condition in company of her [spouse]. The ED RN documented at 1719, "...Patient discharged from the department...left by self..." There was no documentation ED Physician #2 followed the hospital's By-laws Rules and Regulations and referred the patient to appropriate Behavioral Health Consultants or Agency.

6. Medical record review for Patient #25 documented the patient (MDS) dated [DATE] at 0011 due to a drug overdose. ED Physician #5 performed a MSE and documented, "...pt brought in per EMS (Emergency Medical Services) for apparent overdose on Tramadol x (times) 50 + (plus) pills & (and) 6 beer this evening about 30 min (minutes) PT (prior to) arrival of EMS: pt's family states that this isn't' the first time the pt has done this; pt AAO x 3 (awake, alert and oriented) & answering questions appropriately...History of significant underlying depression..." At 0015 ED Physician #5 completed a "Certificate of Need For Emergency Involuntary Admission Under Title 33 Chapter 6 Part 4 Tennessee Code Annotated" form which documented, "...h/o (history of) Depression and previous overdose...reports became suicidal today and took an overdose of Tramadol...poor judgement...has been drinking alcohol as well...needs inpatient treatment for safety of self..." At 0125 ED Physician #5 documented, "...Unable to reliably assess patient's judgment...Flat affect, angry" At 0148 the patient's care was transferred to ED Physician #3. There was no documentation ED Physician #3 examined the patient. At 0718 the patient's care was transferred to ED Physician #2. ED Physician #2 documented at 1200, "Patient re-evaluated and now saying that she was drinking when she took those pills. She says that she is not suicidal and does not plan to kill herself..." The patient was discharged home at 1220. There was no documentation why the patient was not Involuntarily admitted as ordered by ED Physician #5.

On 11/29/10 at 1937 Patient #25 returned to the ED by EMS with Cardiopulmonary resuscitation (CPR) in progress. The patient's drug screen dated 11/29/10 at 2000 documented the patient had a positive drug screen for Phencyclidine (Angel Dust). At 2024 Patient #25 was admitted to the Intensive Care Unit with the diagnosis of coma, unresponsiveness and respiratory arrest. The patient expired 11/30/10.