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PHYSICIANS REGIONAL MEDICAL CENTER 7565 DANNAHER WAY POWELL POWELL, TN 37849 July 22, 2013
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on medical record review, review of facility policy, and interview, the facility failed to provide stabilizing treatment for one patient (#19) and failed to provide an appropriate transfer for one patient (#4) of twenty sampled patients.

The findings included:

Please refer to A-2407 for failing to provide stabilizing treatment.

Please refer to A-2409 for failing to provide appropriate transfer.
VIOLATION: STABILIZING TREATMENT Tag No: A2407
Based on medical record review, review of facility policy and/or protocols, and interview, the facility failed to provide stabilizing treatment for one patient (#19) of twenty sampled patients.

The findings included:

Medical record review revealed the patient presented to the facility (Hospital #1's) emergency room on July 6, 2013.

Medical record review of ER Physician (Medical Doctor - M.D.#3) Documentation, dated July 7, 2013, revealed, "...Arrival Date : 07/06/2013 Time: (11:52 p.m.)..."

Medical record review of an Emergency History and Physical dated July 6, 2013, at 11:55 p.m., revealed, "...presents to the emergency department with nausea, vomiting...began/occurred at (5:00 p.m.)...Pertinent negatives: abdominal pain...out of insulin and has been taking (patient's) sister's insulin...last had 12 units at (1:00 p.m.)...Positive for hyperglycemia...nausea, vomiting...Awake, alert, with orientation to person, place, time, and situation...Respirations: normal..."

Medical record review of a Triage assessment dated July 6, 2013, at 11:56 p.m., revealed, "...appears ill...Reports vomiting, since 5 pm. (p.m.)..."

Medical record review of a physician's order dated July 6, 2013, at 11:56 p.m., revealed, "Cbc (CBC-Complete Blood Count)...CMP (Comprehensive Metabolic Panel)..."

Medical record review of a Blood Glucose result dated July 7, 2013, at 12:04 a.m., revealed, "Hi (too high to be read by glucometer) Ranges: Critical Glucose Levels: Adult <50 mg/dl or >400 mg/dl (milligrams/deciliter)..."

Medical record review of a nurse's note dated July 7, 2013, at 12:05 p.m., revealed, "Notified ED (Emergency Department) physician of HI blood sugar."

Medical record review of the ER record revealed, "...Medications Ordered on Admission Insulin Regular Human 10 units...IVP...Given At 07/07 (12:07 a.m.)...NS (Normal Saline)...1000 ml (milliliters)...IV bolus...Given At 07/07 (12:12 a.m.)...NS...1000 ml...Given At 07/07 (12:14 a.m.)."

Medical record review of a laboratory report dated July 7, 2013, revealed, "...(collected at 12:05 a.m.) WBC (white blood cells) 25.7 (3.7-10.7)...Glucose 819* Appearance of Sample Mkd (Marked) Hemolysis*...K (potassium) 6.7 (3.5-5.2)...CO2 <12 (22-33)...Sample Hemolyzed. May Interfere With Results..."

Medical record review revealed no documentation regarding physician orders for insulin or normal saline following the laboratory report.

Medical record review of a physician's order dated July 7, 2013, at 12:41 a.m., revealed, "Comprehensive Metabolic PNL (Panel)..."

Medical record review of the ER record dated July 7, 2013, revealed, "...Outcome: (1:11 a.m.) Discharge ordered by MD..."

Medical record review of Discharge Instructions signed by the patient revealed, "...Arrival Date: Saturday, July 6, 2013...Care provided by: (M.D. #3)...Prescriptions Zofran Lantus Novolin R..."

Medical record review of the ER record revealed, "Prescriptions...Lantus 100 unit/ml Subcutaneous Solution Inject 35 unit...2 times per day; Quantity: 1 vial Novolin R 100 unit/ml Injection Solution Inject 1 unit by INTRAVENOUS route as directed per sliding scale: Quantity: 1 vial."

Medical record review of a physician's order dated July 7, 2013, at 1:26 a.m., revealed, "Comprehensive Metabolic PNL...Ordered: 07/07 (12:41 a.m.)...Canceled: 07/07 (1:26 a.m.)...Reason for Cancellation: PATIENT discharged ."

Medical record review of the ER record dated July 7, 2013, revealed, "...Outcome...(1:28 a.m.) discharged to bus station by cab...(1:30 a.m.) Patient left the ED."


Review of a Specimen Rejection Criteria dated January 1986, revealed, "A laboratory specimen is only as good as the specimen provided. At times, laboratory specimens must be rejected and recollect specimens to yield accurate results. Reasons for Specimen Rejection...The specimen is hemolyzed...Emergency department personnel will be notified when a specimen is rejected and a recollect scheduled... Phlebotomy staff will be notified of the need for a stat (immediate) recollect in Emergency Department (ED)...Phlebotomist...will respond to ED for recollect...Regardless of whether compromised specimen results are given or not, a recollect specimen will be obtained and processed in the lab. This is necessary to rule out the possibility of in vivo (in living organism) hemolysis by the patient. In addition, for patient safety, an optimal specimen should be utilized to obtain valid patient test results..."

Review of a facility policy titled "Emergency Medical Treatment and Labor Act (EMTALA) most recently revised October 9, 2012, 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, including ancillary services routinely available to the Emergency Department, prior to discharge or transfer....Emergency Medical Condition (EMC)...means...A medical condition manifesting itself by acute symptoms of sufficient severity...such that absence of immediate medical attention could reasonably be expected to result in...Placing the health of the individual...in serious jeopardy...Serious impairment to bodily functions...Serious dysfunction of any bodily organ or part...Any individual with respect to whom the hospital has determined that an (EMC) exists will be provided further medical examination and treatment as may be necessary to stabilize the (EMC)..."

Interview with the Lab Team Leader on July 16, 2013, at 9:40 a.m., in an administration conference room and the presence of the Vice President of Emergency Services, revealed the most significant result of hemolysis of a specimen was elevated potassium levels. Continued interview revealed hemolysis resulted in slightly elevated BUN (Blood Urea Nitrogen) and creatinine levels. She stated, "...Others (test results) it shouldn't effect much. Should have a repeat CMP with hemolysis. Our policy is to get a repeat unless the physician says no. (It) could be the patient left before we could get second (specimen) drawn. (Patient's specimen) was collected at 12:05 a.m. It usually takes twenty to thirty minutes delay from collection til (until) we get it in the lab. Will take about forty-five minutes to run (tests) in the lab."

Interview with M.D. #3 (the ED's Medical Director) in an administration conference room and the presence of the Vice President of Emergency Services, on July 16, 2013, at 10:55 a.m., revealed blood glucose was usually more than 450 when a glucometer result was "HI" and the practice was to give ten units of insulin with the reading of "HI." He stated, "...CO2 of 12 a good chance the patient will be acidotic. If that was the case give fluids. Sugar (blood glucose) should be rechecked. We don't send to lab, but with hemolysis the lab will come do second check...I can't find recheck of blood sugar in the chart but I'm sure it was...When told (blood glucose is) 819 usually recheck (within) an hour of getting insulin..." Continued interview revealed the patient was known to him from prior visits to the ER and he stated, "I would not send a patient home with a glucose of 819. (Patient) would have been admitted ..."

Review of a Cumulative Summary of the patient's laboratory results provided by and interview with the Lab Team Leader on July 16, 2013, at approximately 12:10 p.m., in an administration conference room, confirmed the CMP ordered by the physician on July 7, 2013, at 12:41 a.m., had not been completed.

Interview with the Vice President of Emergency Services on July 16, 2013, at 12:15 p.m., in an administration conference room and the presence of the Quality Officer, confirmed the medical record contained no information to indicate the patient's blood glucose was rechecked before discharge.

Interview with the Quality Officer on July 16, 2013, at 12:32 p.m., in an administration conference room and the presence of the Vice President of Emergency Services, confirmed the facility failed to recheck the patient's blood glucose level, with a known blood glucose of 819, prior to discharge of the patient.

Interview with the emergency room Director on July 17, 2013, at 12:40 a.m., in an administration conference room and the presence of the Vice President of Emergency Services, revealed the nurse assigned to a patient was responsible for verifying the completion of physician orders prior to discharge of a patient. She stated, "The doctor usually checks to see if patient is improving, etc. to establish if patient can discharge."



Medical record review revealed the patient presented to Hospital #2's emergency room on July 7, 2013.

Medical record review of ER Physician (M.D. #4) Documentation dated July 7, 2013, at 9:43 a.m., revealed, "Presentation...Mother states: brought to ER by mother...pt (patient) was at another hospital today and was released and was at a bus station found lethargic. presented to the ER lethargic required noxious stimuli to arouse pt. pt has labored at 33 deep respirations noted. pt does not repond to tactile or verbal stimuli...Acuity...Emergent..."

Medical record review of an Emergency Department History and Physical dated July 7, 2013, revealed, "...9:46 (a.m)...presents to ED (Emergency Department)...with complaints of Unresponsive...(10:48 (a.m.) Pertinent positives: lightheadedness, shortness of breath, Pertinent negatives: abdominal pain, nausea, vomiting...alert but confused...(10:51 (a.m.) has been recently seen by a physician: in the hospital (Hospital #1)...earlier today, yesterday...symptoms became worse just prior to arrival."

Medical record review of a laboratory report dated July 7, 2013, revealed, "Collected (9:44 a.m.), revealed, "PH 6.810 LL (critical low) (7.350-7.450) PCO2 8.5 LL (35.0-45.0)...HC03 (bicarbonate) 1.3 (23.0-29.0)..."

Medical record review of a laboratory report dated July 7, 2013, revealed, "...collected at (9:45 a.m.) Potassium 7.0 HH (Critical High) (3.5-5.1)...CO2 <5.0 LL (22.0-30.0) Glucose 737 HH (70-110)...White Blood Count 44.12 HH..."

Medical record review of a Hospital (#2) Intensive Care Unit History and Physical dated July 7, 2013, at 1:28 p.m., revealed, "...came to the emergency room in critical condition with diabetic ketoacidosis (DKA) and suspsected aspiration pneumonia...seen and treated at...(Hospital #1)...last night...for the same and was discharged ...is in severe DKA at this time and will be moved to the intensive care unit...very critically ill...Final Admitting Diagnoses...Severe diabetic ketoacidosis...Severe metabolic acidosis...Aspiration pneumonia is suspected...Severe leukocytosis...Sepsis with possible septic shock..."

Medical record review of a nurse's note dated July 11, 2013, at 12:00 p.m., revealed, "Pt discharge(d) to home...prescription F/U (follow-up) appointment...made...verbalz understd (verbalized understanding..."

Medical record review of a Discharge Summary dated July 11, 2013, revealed, "...Discharge Diagnosis (ES)...Type 1 diabetes with severe diabetic ketoacidosis...Aspiration pneumonia...Metabolic acidosis, multifactorial, including (DKA) and sepsis...Dehydration, resolved at discharge...Nausea and vomiting secondary to gastroparesis...(DKA) responded to aggessive hydration and the (DKA) protocol, in which we transitioned to the Lantus insulin twice daily (patient) is prescribed from...home physician...will be allowed to be discharged home today...is having no nausea or vomiting, asked to be discharged home, and it is not unreasonable due to (patient's) condition..."

Interview with M.D. #3 on July 17, 2013, at 1:10 p.m., in an administration conference room and the presence of the Vice President of Emergency Services, revealed the prescription for intravenous insulin was an error and his practice was to discharge a patient when blood glucose was less than 300. He confirmed the facility failed to provide stablizing treatment to Patient #19 prior to discharge on July 7, 2013.

C/O: #
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
Based on medical record review, review of facility policy, and interview, the facility failed to provide an appropriate transfer for one patient (#4) of twenty sampled patients.

The findings included:

Patient #4 presented to the facility's emergency room (ER) on April 6, 2013.

Medical record review of a History and Physical dated April 6, 2013, revealed, "...presents to ER via walk-in with complaints of neck injury...tongue numbness, left ankle pain...Neck: positive for pain with movement, pain at rest..."

Medical record review of a CT (Computerized Tomography) Scan report dated April 6, 2013, revealed, "...Impression: Right articular pillar and junction with lamina fracture at C (cervical) 7 verterbral body displaced by 2 mm (millimeters). Posterior C3 spinous process fracture...Bilateral pedicle fractures at C2..."

Medical record review of an ankle x-ray report dated April 6, 2013, revealed, "...Impression: Positive for nondisplaced medial and lateral malleolar fractures."

Medical record review of a physician's (Medical Doctor - M.D. #1) progress note dated April 6, 2013, at 7:00 p.m., revealed, "...I had a detailed discussion with the patient and/or guardian regarding...the need to transfer to another facility...does not immediately have the required specialist..." Continued review revealed no documentation regarding identification of the specialty required.

Medical record review of a Disposition Summary dated April 6, 2013, at 7:04 p.m., revealed, "Transfer ordered...Reason for transfer: Orthopedics..."

Medical record review of a Physician Certification and Patient Consent for Transfer Form dated April 6, 2013, at 7:06 p.m., revealed, "This is to certify that I, (Patient #4)...have given my consent to or have requested transfer to (Hospital #3) under the care of ( M.D. #2)... have been informed that this transfer is necessary...Reason for Transfer: Hospital does not have capacity or capability to provide necessary care...In need of treatment/service not available here. Specify: (space was blank)..." Continued review revealed no documentation regarding the patient and/or a family member's signature and included, "...Risks of Transfer Explained to Patient: Yes Benefits of Transfer Explained to Patient: specialized care..." Continued review revealed no documentation regarding specific risks of transfer.

Medical record review of a nurse's note dated April 6, 2013, at 7:11 p.m., revealed, "...Family remains at bedside and has been updated on status of patient's condition..."

Medical record review of a nurse's note dated April 6, 2013, at 7:26 p.m., revealed, "Transferred by EMS (Emergency Medical Services) ground to (Hospital #2)...Discharge instructions given to patient, family...Instructed on need for transfer Demonstrated understanding of instructions..."


Review of a facility policy titled "Emergency Medical Treatment and Labor Act (EMTALA) most recently revised October 9, 2012, 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...an appropriate transfer, if necessary...An appropriate transfer is one in which...the hospital's Emergency Department...provides medical treatment within its capacity...and...the medical facility that will receive the transfer has been contacted directly...has agreed to accept the transfer and to provide appropriate medical treatment...and...sends with the patient originals or copies of all medical records related to the emergency condition...informed written consents and certifications..."

Interview with the Vice President for Emergency Services on July 16, 2013, at 1:25 p.m., in an administrative conference room, confirmed the facility failed to appropriately transfer Patient #4 on April 6, 2013.