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REGIONAL ONE HEALTH 877 JEFFERSON AVENUE MEMPHIS, TN 38103 Sept. 28, 2016
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on facility policy, transfer agreement, Ambulance Patient Care Record, medical record review and interview, the hospital emergency department (ED) delayed moving patients from an Emergency Medical Services (EMS) stretcher and care to an ED bed and care for 1 of 20 (Patient #4) patients reviewed. Based on interviews, the hospital failed to ensure the ED nursing were knowledgeable of EMTALA rules applying to all patients who are on the property of the hospital.

The findings included:

1. Review of the facility policy, "Triage Guidelines" revealed, "Triage is an essential function of an Emergency Department (ED). Triage is the first interaction a patient has in the Emergency Department. The aim is to ensure that patients are treated in order of clinical urgency... The goal of triage is to expedite patients care by prompt and accurate assessment, which prioritizes patient into levels, resulting in appropriate response levels for medical evaluation and treatment...The triage nurse will facilitate the timely transport of patients to the appropriate treatment area, prioritizing beds for Level 1 and 2 arrivals...Patients categorized as (Level 3) remaining in the waiting room, will be reassessed every two (2) hours or as condition warrants..."

2. Medical record review from Hospital #2 revealed Patient #4 was involved in a motor vehicle collision on 9/19/16 at approximately 6:00 PM. The patient was unconscious when EMS arrived at the scene. The ED physician ordered a Computerized Tomography (CT) of the abdomen and pelvis which revealed, "...Abnormal free fluid in the pelvis. I [Medical Doctor (MD) #3] am uncertain of the etiology. However, this finding is abnormal in a young male..." The ED physician documented, "...9/19/2016 11:52:00 PM, [MD #1], phone call, consult, SBAR [situation background assessment recommendation] given, abnormal CT results discussed, [MD #1] agrees to admit pt [patient] to [Hospital #1]...Condition: Guarded...Pt transferred to [Hospital #1] due to abnormal CT results..."

Review of the EMS record revealed Patient #4 was transferred from Hospital #2 to Hospital #1 Trauma ED by EMS on 9/20/16 at 12:45 AM for higher level of care due to abnormal CT results.

The EMS record documented Patient #4 complained of abdominal pain to the right lower quadrant and rated the pain as a 6 on a 1 to 10 scale. EMS documented, "...Clinical Impression...Primary Impression...Traumatic injury...Chief Complaint...Abd [abdominal] pain...Patient's Level of Distress...Severe...Signs & Symptoms...Pain-Abdominal..." EMS arrived at Hospital #1 on 9/20/16 at 1:01 AM. EMS documented, "...ON ARRIVAL PT [patient] ASSESSED AND ADVISED TO WAIT IN HALLWAY AREA DUE TO ER [emergency room ] OVERCROWDING. AFTER SEVERAL HOURS PT WAS MOVED TO BED IN ER. PT CARE TX [transferred] TO STAFF WITH PT ALERT AND PT COMPLAINS OF INCREASED PAIN SINCE ARRIVAL AT ER. PT NOW RATES PAIN A 9..."

Review of Hospital #1's medical record revealed Patient #4 arrived at the ED by EMS on 9/20/16 at 1:05 AM. ED MD #2 documented the medical screening exam was completed by on 9/20/16 at 1:57 AM. MD #2 ordered Morphine 4 mg IVP at 2:12 PM but canceled the order. There was no documentation why the order for Morphine was canceled.

MD #2 ordered a CT of the chest and abdomen with Intravenously (IV) contrast on 9/20/16 at 2:34 AM which was completed and dictated at 5:34 AM. MD #2 documented in the review of systems at 2:36 AM that the patient experienced neck, back and abdominal pain. There was no further assessments from the physician or nurse until 3:50 AM.

MD #2 ordered a CT of the pelvis with contrast on 9/20/16 at 6:34 AM which was completed and dictated at 11:28 AM.

On 9/20/16 at 3:45 AM, Nurse #2 completed the triage and assessed Patient #4 at an acuity level of 3 Urgent. This was 2 hours and 30 minutes after the patient had arrived to Hospital #1's ED. At 3:50 PM Nurse #2 was designated as Patient #4's primary nurse, and patient #4 was placed in an exam room and transferred from the EMS stretcher and care to an ED bed, 2 hours and 45 minutes after arriving to Hospital #1's ED.

On 9/20/16 at 3:50 AM Nurse #2 documented vital signs and assessed Patient #4 for pain. Patient #4 complained of neck and abdominal pain and rated it as an 8 on a 1 to 10 scale. Nurse #2 administered Morphine 8 mg IVP at 3:57 AM and reassessed the pain level at 4:30 AM which was rated as a 6 on a 1 to 10 scale. Nurse #2 administered Morphine 8 mg IVP at 5:46 AM and assessed Patient #4's pain level at 6:32 AM as a 4 on a 1 to 10 scale. The ED nurses administered Morphine 2 mg IVP at 12:05 PM and Morphine 2 mg at 7:25 PM with no pain assessment documented prior to the administration of the medication or no pain reassessment following the medication.

The CT of the chest and abdomen with contrast revealed, "...Too small to characterize centrilobular nodules throughout the left lower lobe. This may represent contusion or inflammatory process in appropriate clinical setting...No pneumothorax...Hyperemic gastric and [DIAGNOSES REDACTED] mucosa...Centrilobular emphysematous changes involving the bilateral lung apices...Diminutive right ninth rib with adjacent metallic debris, likely sequela of remote trauma and possible partial rib resection..."

The CT of the pelvis with contrast dictated on 9/20/16 at 11:28 AM revealed, "...Small amount of free pelvic fluid of intermediate density. The liver is incompletely imaged and there appears to be a small amount of fluid around the edge of the liver that was not present on the prior CT. This could represent subtle liver injury..."

The patient left the ED on 9/21/16 at 12:22 AM when he was admitted to the medical/surgical unit with a diagnosis of [DIAGNOSES REDACTED]

3. During an interview on 9/26/16 at 1:05 PM in the Administrative Conference Room, the Clinical Outcome Nurse stated the initial vital signs and a physical assessment of an ED patient were supposed to be completed and documented within one hour of arrival to the ED by the nursing staff. The Clinical Outcome Nurse stated the initial physical assessment was documented in the Nurse's Notes under the heading, "Primary Survey." The Clinical Outcome Nurse confirmed Patient #4 arrived in the ED at 1:05 AM and that the first physical assessment was not documented until 3:50 AM. The Clinical Outcome Nurse confirmed the first physical assessment was not documented within the one hour timeframe according to hospital policy.

During an interview on 9/27/16 at 8:41 AM in the Administrative Conference Room, Nurse #2 stated, "...Technically, they become our patient when they are on our grounds. EMS is technically responsible until on our stretcher...I picked the patient [Patient #4] up at 3:50 AM...We treated his pain when he came off the stretcher [off-loaded from EMS stretcher]... If a patient is in the back hall on EMS stretcher, someone takes VS - unspoken rules to eyeball patient even when EMS is still with patient..."

During an interview on 9/27/16 at 9:37 AM in the Administrative Conference Room, Nurse #1 stated. "...briefly recall this patient [Patient #4]...if on Critical Advisory and overflowing, could have stayed on [EMS] stretcher... Any free personnel can take a patient to CT scan. Would like EMT [emergency medical technician] to stay with them until they are off-loaded, until we assume care..."

During an interview on 9/27/16 at 11:05 AM in the Administrative Conference Room, MD #2 stated, "I kind of remember this patient...car accident, abdominal pain, he was outside [found outside] the car...2:36 AM I documented a review of systems...I remember it was not severe pain...I placed an order [for Morphine] then decided he didn't need it and switched it later." He further stated he had evaluated patients on EMS stretchers in the past.

During an interview via telephone on 9/27/16 at 1:22 PM, EMT #1 stated, "We came to [Hospital #1], extremely busy night...When we got to [Hospital #1] there were 2-3 stretchers in the hallway and both Shock Trauma rooms were full. Our patient was stable, his VS were stable and he was in pain. When we came into the the ED, we waited about 30-45 minutes in the hallway, then we were moved to hallway by the Burn Center. When we first came in the ED, the nurse assessed the patient, no VS were taken right then and [Nurse #1] asked the patient questions. After about 20-30 minutes, we moved to another hallway [back hallway]..."

During an interview on 9/28/16 at 11:27 AM in the conference room, MD #1 stated, "...I was told over the phone the patient had abdominal trauma from a car accident and had free fluid which indicated abdominal trauma...I took the call while I was in OR [operating room]..." MD #1 confirmed she was the Chief Resident and had accepted the transfer of Patient #4 from another hospital. When asked how she would be informed if the hospital was on diversion, MD #1 stated, "...I don't know sometimes...sometimes the attending [physician] will tell me or [named dispatch company] will tell me..."