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PHYSICIANS REGIONAL MEDICAL CENTER 7565 DANNAHER WAY POWELL POWELL, TN 37849 Aug. 25, 2017
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on review of facility policy, medical record review, and interview, the facility failed to provide a Medical Screening Examination for 1 patient (#1) of 30 patients reviewed.

The findings included:

Refer to A-2406 for failure to provide a medical screening examination.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policy, review of facility bylaws, review of the Emergency Department (ED) Central Logs, review of ED bed capacity reports, review of ED average patient flow logs, review of ED staffing logs, medical record review, and interview, the facility failed to provide a Medical Screening Examination for 1 patient (#1) of 30 patients reviewed.

The findings included:

Review of facility policy "EMTALA Medical Screening Stabilization Policy," last revised 9/1/13, revealed "...when an individual comes, by himself or herself, with another person, or by EMS [Emergency Medical Services] to the Dedicated Emergency Department of the Hospital and a request is made...the hospital must provide an appropriate Medical Screening Examination within the capacity of the Hospital (including ancillary services routinely available in the Dedicated Emergency Department and emergency services offered at outpatient departments or facilities) to determine whether an Emergency Medical Condition exists, or within respect to a pregnant woman having contractions, whether the woman is in active labor..."

Review of facility bylaws "Emergency Medical Screening, Treatment," Transfer, [and] On-Call Roster Policy," not dated, revealed "...Any individual who presents to the Emergency Department...for care shall be provided with a medical screening examination...All patients shall be examined by qualified medical personnel...defined as a physician...licensed physician assistants..."

Review of the ED Central Logs revealed Patient #1 presented to Facility A on 5/27/17 at 7:07 AM with a chief complaint of nausea, vomiting, and bloody stools. Further review revealed the patient left the ED at 8:07 AM (1 hour later).

Review of Facility A's ED Bed Capacity report revealed the ED had 20 patient rooms and on 5/27/17 all of the ED rooms were occupied by patients.

Review of the Average Patient Flow Report for Facility A dated 5/27/17 revealed the patient census for the ED was:
6:00 AM: 22 patients
7:00 AM: 22 patients
8:00 AM: 26 patients
9:00 AM: 30 patients

Review of Facility A nurse staffing log dated 5/27/17 revealed:
6:00 AM: 3 Registered Nurses (RN)
7:00 AM: 3 RN's
8:00 AM: 3 RN's
9:00 AM: 4 RN's
Continued review revealed the Charge Nurse was one of the 3 RNs and also had a patient assignment on 5/27/17 between 7:00 AM and 9:00 AM. Further review revealed no additional staff was listed on the staffing log as on call or available as needed for a high volume of patients in the ED.

Medical record review revealed the Inpatient/Outpatient Conditions of Admission and Consent to Medical Treatment form was signed by the patient on 5/27/16 at 7:10 AM.

Medical record review of an ED Disposition Summary from Facility A dated 5/27/17 at 8:09 AM revealed "...patient left the facility before triage...not evaluated by a provider...patient left due to wait time..." Further review revealed "...outcome: eloped...chief complaint: nausea/vomiting/diarrhea, bloody stools..."

Medical record review revealed the patient did not receive a nursing triage assessment or a medical screening examination (MSE) by a Qualified Medical Provider (QMP) while the patient was in the ED at Facility A.

Medical record review revealed Patient #1 presented to Facility B's ED on 5/27/17 at 5:43 PM for complaints of rectal bleeding.

Medical record review of an ED Nursing Triage Record from Facility B revealed "...nausea, vomiting since last night [5/26/17] states diarrhea is bloody with fresh red blood..." Further review revealed the patient's vital signs were as follows: Blood Pressure (BP) 127/66 (within normal limits), Pulse 82 (within normal limits), Respirations 18 (within normal limits), and Oxygen Saturation 98% (within normal limits). Continued review revealed the patients pain score was 5 (on a scale of 1 to 10, with 10 being the worst pain). Further review revealed "...no acute distress...abdomen: normal nondistended..."

Medical record review of an ED Physicians Record at Facility B dated 5/27/17 at 5:52 PM revealed "...pt. [patient] presents to the ED c/o [complaints of] rectal bleeding onset around 11:00 AM today. The pt. states the BM [bowel movement] is grainy and bright red with some clots...pt. states she had issues like this in the past...states yesterday she noted near syncope [passing out], diarrhea, lethargy, n/v [nausea and vomiting] and ABD [abdominal] pain...reports the diarrhea episodes are frequent and large in quantity...states the amount of blood is large as well with each movement...states she has had polyps in the past..." Further review revealed "...pt. appears to be in no acute distress...abdomen: bowel sounds are increased in the epigastrium...no guarding...no rebound tenderness...stool is grossly positive for blood...stool content was clear and mucousy with slight pink tinge..." Further review revealed "...primary diagnosis: lower gastrointestinal hemorrhage...colitis [inflammation of the colon]..." Continued review revealed the physician ordered the following laboratory tests: Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), Prothrombin Time (PT, blood test to check for bleeding), and an International Normalized Ratio (INR, blood test used to check blood clotting time).

Medical record review of the laboratory results from Facility B dated 5/27/17 revealed Patient #1's White Blood Count (WBC, cells used to fight infection) was 16.5 (normal 3.8-10.7).

Medical record review of the ED Medication Administration Record for Patient #1 dated 5/27/17 revealed the patient received the following medications while in the ED at Facility B: Protonix (medication to decrease high levels of stomach acid) 40 milligrams (mg) intravenous (IV); Normal Saline (IV solution) 1000 milliliter (ml); Rocephin (antibiotic) 1 gram (gm) IV; and Flagyl (antibiotic) 500 mg IV.

Medical record review of an ED Physicians Progress Note from Facility B dated 5/27/17 at 8:55 PM revealed "...rechecked pt...d/w [discussed with] the pt. about the ED findings and the plan for observation....d/w the pt. about the importance of staying for further observation/evaluation and the pt. understanding and agrees..." Further review revealed the ED Physician consulted with the Hospitalist and the decision was made to admit Patient #1 to Facility B.

Medical record review of an Admission History and Physical from Facility B dated 5/27/17 at 9:14 PM revealed "...history of hypertension [elevated blood pressure], [DIAGNOSES REDACTED] [elevated blood lipids] and gastroesophageal reflux [GERD] disease who presented to the ED with bright red blood per rectum. She had been feeling well up until yesterday evening. Around 11:00 PM [5/26/17] she felt like she was about to have diarrhea. She sat down and developed nausea and vomiting. She threw up multiple times but denies any blood in it...Denies any significantly large clots. She had multiple episodes of diarrhea...she does endorse abdominal cramps in the epigastric area...crampy pain..." Further review revealed "...when she presented to the ED she was found to have leukocytosis [elevated white blood counts] and colitis [inflammation of the inner lining of the stomach] on CT [computed tomography]..." Further review revealed "...impression: colitis, bright red blood per rectum, abdominal pain, nausea and vomiting, leukocytosis, dizziness and lethargy [periods of weakness]...will be placed in hospital...for the colitis we will place her on Rocephin and Flagyl...will ask gastrointestinal to see her...electrolyte replacement [salts or minerals that conduct electrical impulses in the body] protocols and pain medication and antiemetics [medication used for nausea] as needed..."

Medical record review of a Gastroenterology Consult from Facility B dated 5/28/17 at 1:31 PM revealed "...[AGE] year old female who probably has ischemic colitis [inflammation or injury of the large intestine from decreased blood supply] or infectious colitis [inflammation of the colon]. I do favor ischemic colitis due to distribution of colitis on the CT scan. Certainly she appears to be doing well. Her bowel is not at risk for necrosis [death of tissues]. I could continue antibiotics as well as clear liquids. If she continues to bleed, then certainly we will decide on proceeding for colonoscopy [test to visualize the inner lining of the intestines] tomorrow..."

Medical record review of a Discharge Summary from Facility B dated 5/30/17 at 2:45 PM revealed "...CT scan of the abdomen and pelvis showed moderate colitis involving the transverse colon [middle part of the large intestine] to the level of the proximal sigmoid colon [lower part of the intestine]. The patient had rectal bleeding up until two nights ago. She has not had any further rectal bleeding...was evaluated by gastroenterology on 5/28/17 for hematochezia [blood in the stool]...felt like it was the case of ischemic colitis versus infectious colitis and he did favor ischemic colitis due to the distribution on the CT scan...he felt like this ischemic colitis could be secondary to chronic constipation...he recommended clear liquids until she follow up with [named Gastrointestinal physician]..." Further review revealed "...the patient does not want to go back to [Facility A]...has requested that she follow up with [another Gastrointestinal physician]..." Further review revealed "...at present she is resting comfortably...denies any nausea, vomiting, headache, fever or chills...her abdominal pain is improving...no further hematochezia since two nights ago. She is stable at the time of discharge..."

Interview with ED Registration Clerk #1 at Facility A on 8/24/17 at 4:00 PM, in the ED lounge, revealed the clerk registered the patient into the ED on 5/27/17. Further interview revealed "...she [Patient #1] signed the consent forms at 7:10 AM...if she had been in any acute distress I would have called for a nurse to come and check her..."

Interview with ED Registered Nurse (RN) #1 at Facility A, on 8/24/17 at 4:10 PM, in the ED lounge, revealed "...I went to the lobby to take the patient back to the ED for triage at 8:09 [AM] and she was not there...she had left prior to triage..." Further interview revealed "...there is not an assigned triage nurse during that time...we bring the patients back to the ED for triage and we do the pull to full [patients are triaged in an ED room until all ED beds are full]...we can triage the patients in the triage room but most of the time we just bring them back to a room..." Further interview revealed "...I do not remember the patient but I do remember going out to call for her at 8:09 [AM] and she was not in the lobby...I documented she left due to the wait time..." Continued interview revealed "...each nurse has an assigned zone in the ED and in the morning between 7:00 [AM] and 9:00 [AM] the charge nurse will have a zone also...when your zone has an empty space that nurse goes out and gets the patients in the lobby who are waiting to be seen...for any emergencies then one of us would assess the patient and bring the patient and find a room for the patient..."

Interview with ED Physician #1 at Facility A on 8/24/17 at 4:05 PM, in the ED Nurses Station, revealed "...all patients who come into the ED and request a medical screening evaluation should receive an examination...sometimes they do not stay to be seen..." Further interview revealed "...it looks like the patient came in on 5/27/17...it looks like she was not triaged nor did not receive a medical screening examination...it looks like she left before either one was completed..."

Interview with the ED Medical Director at Facility A, on 8/24/17 at 4:15 PM, in the ED lounge, revealed "...any patient who comes to the ED and requests an examination should receive a medical screening...sometimes patients do come into the ED and leave prior to a triage or a medical screening...we try to prevent that from happening..." Further interview confirmed "...it looks like the patient came into the ED and left prior to a triage or medical screening...she left less than an hour after she presented to the ED..."

Interview with the ED Nurse Manager at Facility A on 8/25/17 at 8:05 AM, in the Administration Conference room, revealed "...the ED was full on 5/27/17 at 7:00 [AM]...the capacity numbers show we had 22 patients in the ED and we have 20 rooms...there were 3 RN's scheduled for the dayshift from 7:00 [AM] to 9:00 [AM]...another nurse came in at 9:00 [AM]..." Continued interview confirmed the patient did not receive a triage or a medical screening examination.

Telephone interview with Patient #1 on 8/29/17 at 2:50 PM revealed the patient was not evaluated by a nurse or a physician and the lobby was empty. Continued interview revealed after an hour and another patient was taken back into the ED around 8:00 AM, before her, she and her husband left the ED.