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SAINT THOMAS MIDTOWN HOSPITAL 2000 CHURCH ST NASHVILLE, TN 37236 July 20, 2017
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on review of facility policy, review of Tennessee Code Annotated 63-7-103 (Tennessee Practice of Professional Nursing), review of Medical Staff Rules and Regulations, medical record review, and interviews, the facility failed to provide a Medical Screening Examination by a Qualified Medical Provider for 3 patients (#27, #33, and #34) of 37 patients reviewed.

Refer to 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 Tennessee Code Annotated 63-7-103 (Tennessee Practice of Professional Nursing), review of Medical Staff Rules and Regulations, medical record reviews, and interviews, the facility failed to provide a Medical Screening Examination (MSE) by a Qualified Medical Person (QMP) for 3 patients (#27, #33, and #34) of 37 patients reviewed.

The findings included:

Review of facility policy "Screening, Transfer, and Acceptance of Patients with a Possible Emergency Medical Condition (EMTALA)" policy effective date 01/1995, revealed "...The hospital shall provide a medical screening evaluation for an individual who...comes to another (non-emergency department) area of the hospital or on the hospital propery and requests examination or treatment for what may be an emergency medical condition...The medical screening examination shall be performed by a physician or a Qualified Medical Person as designated by the governing body or Medical Staff Bylaws..."

Review of facility policy "Admission Procedure to Labor and Delivery" policy effective date 08/2001, revealed "...OB [obstetrics] Quick Look should be completed by an RN [Registered Nurse] and is to be documented..."

Review of the Tennessee Code Annotated 63-7-103 "...Title 63 Professions of the Healing Arts...Nursing...General Provisions..." dated 2016, revealed "...professional nursing includes...(A) Responsible supervision of a patient...(B) Promotion, restoration and maintenance of health or prevention of illness of others...(C) Counseling, managing, supervising and teaching of others...(D) Administration of medications and treatments as presribed by a licensed physician...or nurse authorized to prescribe...(E) Application of such nursing procedures as involve understanding of cause and effect...(F) Nursing management of illness, injury or infirmity...(b) the practice of professional nursing does not include acts of medical diagnosis or the development of a medical plan or care..." Continued review did not specify Registered Nurses were permitted to complete Medical Screening Examinations under the Tennessee Nurse Practice Act.

Review of "MEDICAL STAFF RULES AND REGULATIONS" DATED 6/28/16 revealed, "...A Medical Screening Examination ("MSE")...may be provided by a Physician or by an individual who is designated as a Qualified Medical Person ("QMP") by either the Department of Emergency Medicine or the Department of Obstetrics and Gynecology...Designated QMPs are limited to providing MSEs in accordance with written protocols..." The Medical Staff Rules and Regulations failed to define and/or designate that Labor and Delivery Nurses were qualified to perform medical screening examinations, and make the determination as to whether or not an emergency medical condition exists.

Medical record review revealed Patient #27 presented to the hospital's Labor and Delivery (OB) department on 7/5/17 at 1:40 PM for complaints of nausea and vomiting for 11 days, vaginal discharge, and contractions. Further review revealed the patient's vital signs were checked by a Registered Nurse (RN) and the patient was placed on a fetal monitor. Further review revealed the patient was discharged at 7/5/17 at 3:15 PM with a discharge order "...To home not in active labor to f/u [follow up] with MD [Medical Doctor]..." Further review revealed the patient was assessed by the RN but no documentation that a Medical Screening Examination (MSE) was provided by physician, a physcian's assistant, an advance practices nurse, or a Qualified Medical Person (QMP).

Medical record review revealed Patient #33 presented to the facility's OB department on 5/5/17 at 4:23 PM with complaint of 39 weeks pregnant with contractions. Further review revealed the patient was assessed by a RN who placed the patient on a fetal monitor, assessed the patient's cervix, and took the patient's vital signs. Further review revealed the RN contacted the physician by telephone on 5/5/17 at 6:43 PM and received orders to "...discharge home..." Further review revealed the patient was discharged home on 5/5/17 at 6:50 PM. Further review revealed no documentation the patient was provided a Medical Screening Examination (MSE) by a physician, a physician's assistant, an advanced practice nurse, or a Qualified Medical Person (QMP).

Medical record review revealed Patient #34 (MDS) dated [DATE] at 1:03 AM for complaint of 36 weeks pregnant with abdominal pain. Further review revealed the patient was assessed by a RN who placed the patient on the fetal monitor, assessed the patient's cervix, and monitored the patient's vital signs. Further review of discharge orders dated 5/7/17 at 2:20 AM revealed "...To home if not in labor..." Further review revealed no documentation the patient was provided a Medical Screening Examination (MSE) by physician, a physician's assistant, an advanced practice nurse, or a Qualified Medical Person (QMP).

Interview with RN #1 and RN #2 (Nurse Managers of the Labor and Delivery Unit) and RN #3 (OB staff nurse) on 7/19/17 at 1:14 PM, in the Administration Conference Room, confirmed Patients #27, #33, and #34 were not provided an MSE by a physician, a physcian's assistant, or an advanced practice nurse. Further interview confirmed the patients were assessed by an RN. Continued interview revealed OB patients presenting for assessment of possible labor are provided a "Quick Look" assessment by a RN to determine if the patient is in labor. Further interview confirmed patients who present with a complaint of possible labor are not seen by a physician, a physician's assistant, or an advanced practice nurse/midwife, but are only assessed by a RN who contacts a physician or midwife by telephone.